BURNS

By Sittie Azisah M. Puting and Harold Nkume

Surgical interns VCMC

Objectives

PART 1
Anatomy

Overview
Classification of
Burns
Estimation of Burns
(Depth & %)
Categories & Zones

PART 2
Pathophysiology
Initial

Evaluation
Resuscitation
Post-Resuscitation

Anatomy
Adult skin surface 1.5-2.0 m2 (0.2-0.3 in
newborns); largest organ
Skin thickness 1-2 mm; peaks age 30-40;
M> F
Functions include:
protection
regulation
Sensation

Wounding affects all the functions of the

skin.

Layers of the Skin

CLASSIFICATION OF BURNS

THERMAL
Flame: most common cause
for hospital admission of
burns , highest mortality.
Contact
Scald burn

ELECTRICAL
4% of U.S. hospital admissions
Cardiac arrhythmias
compartment syndromes
rhabdomyolysis

Differences between true high tension burn and flash burn

CLASSIFICATION OF BURNS

CHEMICAL
Remove

the toxic substance from the patient

Irrigation of the affected area with water for a minimum
of 30 minutes,
in cases of concrete powder or powdered forms of lye,
should be swept from the patient

Formic acid: hemolysis and hemoglobinuria

Hydrofluoric acid: hypocalcemia
Topical

Calcium gluconate onto wounds and IV

administration of calcium gluconate for systemic
symptoms

Chemical burn due to spillage of sulphuric acid

Estimating Burn Depth &

Percentage

Burn wounds are commonly classified as

superficial(first-degree),
partial-thickness

(second-degree),
Full-thickness(third-degree),
fourth-degree burns, which affect underlying soft
tissue.

Partial-thickness burns are further classified as

superficial

partial-thickness
deep partial-thickness burns by depth of involved
dermis.

Categories of Burns

FIRST-DEGREE BURNS are

Painful
do

not blister,

SECOND-DEGREE BURNS
have dermal involvement
extremely painful
with weeping and blisters,

THIRD DEGREE BURNS are

leathery,
Painless,
non-blanching

Categories of Burns 4th

degree
-

Fourth-degree burn is usually associated with

lethal injury.
Extend beyond the subcutaneous tissue,
involving the muscle, fascia, and bone.
Occasionally termed transmural burns, these
injuries often are associated with complete
transection of an extremity.

Area of Burn Rule of 9s

Area of Burns
- Pediatric

A 42 year old male has circumferential

burns of both his legs and genitals.
What percentage of his body is burned?

ANSWER:

37

A one year old child has second

degree burns on both palms and third
degree burns on her chest and abdomen.
What percent of total body surface area
burned(rule of 9s) would you report to a
burn center?

20

Three Zones Of Tissue Injury

Following Burn Injury

Zone of coagulation
the

most severely burned portion

center of the wound
Irreversible tissue loss due to coagulation
sometimes necrotic like a third- or fourth-degree
burn, and will need excision and grafting.

Zone of stasis
Peripheral

to zone of coagulation
Decreased tissue perfusion
Tissue-salvageable
Variable degrees of vasoconstriction and resultant
ischemia, much like a second-degree burn

Zone of hyperemia
Outermost

zone
Tissue perfusion is increased
will heal with minimal or no scarring
most like a superficial or first-degree burn

Zone of
Hyperemia

Zone of
Ischemia

Zone of
Coagulation

PROGNOSIS

The Baux score (mortality risk equals age plus

%TBSA) used to predict mortality in burns.
Age and %TBSA: the strongest predictors of
mortality
Age and burn size, as well as inhalation injury:
the most robust indicators for burn mortality.
Age even as a single variable strongly predicts
mortality in burns

In-hospital mortality in elderly burn patients is

a function of age regardless of other
comorbidities.
In nonelderly patients, comorbidities influence
mortality and length of stay.
Variables with the highest predictive value
for mortality are:
age,
%TBSA,
inhalation injury,
coexistent trauma,

Grading of Burn Wounds

Mild: < 5% TBSA

Moderate: 5-15% TBSA
Severe: > 15% (95% of burns seen)
May require Burn Unit care because of
potential for disability despite small TBSA (face,
hands, feet, perineum)

Pathophysiology of Burns

Cell damage and death causes vasoactive mediator

release:
Histamines
Thromboxanes
Cytokines
Increasing capillary permeability causes edema, third
spacing and dehydration
Possible obstruction to circulation (compartment
syndrome) and/or airway

Burn Edema and Inflammation

Generalized edema found in burns > 30%

TBSA
Heat directly damages vessels and causes
permeability
+
Heat activates complement histamine
release and more permeability thrombosis
and coagulation systems

Systemic Response to Burn

Injury

Accelerated fluid loss 2 leaky capillaries

Host resistance to infection
Multisystem Organ Failure
Infections in burns <20% TBSA are well
tolerated.
> 40% TBSA with infection has very low survival
rate
Initially CO, subsequent hypermetabolic state
w/ doubling of CO in 24 48 hours

Inhalation Injury

Heat dispersed in upper airways leads to edema

Cooled smoke and toxins carried distally
Increased blood flow to bronchial arteries
causes edema
Increased lung neutrophils mediators of
lung damage release proteases and
oxygen free radicals (ROS)
Exudate in upper airways formation of fibrin
casts

Stages of Inhalation Injury

Stage 1 acute pulmonary insufficiency

Signs of pulmonary failure at presentation

Stage 2 72-96 hrs after presentation (ARDS

picture)
extravasation of water
Hypoxemia
Lobar infiltrates

Stage 3 bronchopneumonia
Early Staph pneumonia (frequently PCN resistant)
Late - Pseudomonas

Inhalation Injury

Bronchoscopy:
- erythema
- intraglottic soot
- ulceration

INITIAL EVALUATION
Four crucial assessments:
Airway management,
Evaluation of other injuries,
Estimation of burn size,
Diagnosis of CO and cyanide poisoning

PRIMARY SURVEY

Stop the burning

ABCDE
Large-bore peripheral intravenous (IV)
catheters placed
Fluid resuscitation should be initiated
Larger than 40% TBSA two large bore IVs
(placement through burned skin is safe)
Severely burned: Central venous access
provide information on volume status

Burns <15% can usually hydrate orally

Burns larger than 15% in pediatric patients
may

require intraosseous access if venous

access cannot be attained

RESUSCITATION

The most commonly used formula, the

Parkland or Baxter formula,
consists

of 3 to 4 mL/kg/% burn of lactated

Ringers
half is given during the first 8 hours after burn
the remaining half is given over the subsequent
16 hours.

Continuation of fluid volumes depends on:

the time since injury,
urine output,
and mean arterial pressure (MAP).

Children under 20 kg
do

not have sufficient glycogen stores to maintain

an adequate glucose level in response to the
inflammatory response.
simplest approach is to deliver a weight-based
maintenance IV fluid with glucose
supplementation in addition to the calculated
resuscitation fluid with lactated Ringers

Blood pressure and urine output

MAP

of 60 mmHg ensures optimal end-organ

perfusion.

urine

output 30 mL/h in adults and1

to 1.5

mL/kg/h in pediatric patients

serum lactate to be a better predictor of
mortality in severe burns
base deficit predicts eventual organ
dysfunction and mortality.

Choice of IVF

Colloid:

fluid volumes
may decrease associated complications
such as intra-abdominal hypertension
may

decrease overall

Hypertonic solutions,
transiently

decrease initial resuscitation volumes,

downside of causing hyperchloremic

acidosis

Adjuncts

High-dose ascorbic acid (vitamin C)

decreases

fluid volume requirements

ameliorates respiratory embarrassment during
resuscitation.

Plasmapheresis
also

decreases fluid requirements in patients who

require higher volumes than predicted to maintain
adequate urine output and MAP.
filters out inflammatory mediators, thus
decreasing ongoing vasodilation and capillary
leak.

bedside thoracic ultrasound

increasing

makes

utility in surgical ICUs

rapid, noninvasive assessments

during acute changes in clinical
condition.
In burn patients for evaluation of volume
status,
gross assessment of cardiac function,
and
diagnosis of pneumothorax.

Other measures

100% oxygen
Sodium thiosulfate, hydroxocobalamin, and
100% oxygen

Serious burn requiring

referral to burn centre

Partial-thickness burns greater than 10% TBSA

Any burn in the very young, the elderly or the infirm
Any full thickness burn
Burns of special regions: face, hands, feet, perineum,
major joints
Third-degree burns in any age group
Electrical burns, including lightning injury

Serious burn requiring

referral to burn centre
Inhalation injury, Chemical burns
Associated trauma or significant pre-burn
illness: e.g. diabetes
Burned children in hospitals without
qualified personnel for the care of children
Burn injury in patients who will require
special social, emotional, or rehabilitative
intervention

Transfusion

blood transfusions should be used only when

there is an apparent physiologic need

Postresuscitation Period

Day 3 until 95% wound closure

Hyperdynamic, febrile, protein catabolic state
Release of more inflammatory mediators, cortisol,
glucagon, catecholamines, bacteria from wound
High risk of infection and pain
Remove non-viable tissue or close wounds to avoid
sepsis
Nutritional support essential
Maintain and support body temperature with high
ambient temps and humidity

Recovery Period

95% wound closure until 1 year post-injury

Continued catabolism and risk of non-healing
wound
Anticipate septic events, treat complications,
and continue nutritional support

TREATMENT OF THE BURN

WOUND

Silver sulfadiazine (prophylactic against infection)

Mafenide acetate (can be used with grafts)
Silver nitrate (broad spectrum)
Dakins solution (0.5% sodium hypochlorite
Solution)
Topical ointments: bacitracin, neomycin, and
polymyxin B(For smaller burns or larger burns that are
nearly healed)
Meshed skin grafts
Mupirocin for new burns
Silver-impregnated dressings: Acticoat,Aquacel,
Mepilex
Biologic membranes such as Biobrane (only on fresh

SURGERY

Escharotomies with or without fasciotomy

Excision and grafting
repeated

tangential slices using a Watson or

Goulian blade until viable, diffusely bleeding
tissue remains