BURN INJURY

Definition: Thermal Injury resulting into

coagulative necrosis mostly involving the skin.
Skin-complex organ with vital functions for
survival- hence extensive burn injury is more of a
systemic rather than localized disease.
Incidence: In Tz not established but risks can be
reduced by improving social circumstances,
housing and industrial safety.

Aetiology
Hot steam (scald)& liquids(boiling water, tea,
porridge, cooking oil); naked flames(paraffin stove
explosion, burning clothes- housefire, etc.); electrical
burns; chemical burns; radiation(eg sunburn).
In our environment, the majority are due to domestic
accidents esp. in children living in poor inner city
areas rather than in rural communities.
Beware of burn injury-cause of child abuse-suspect if
circumstances of burn accident seem incongruous
with clinical findings.

Pathophysiology
Burn injury results from transfer of heat to the
body either by direct contact or indirectly from a
radiant source.
Extent and depth( parameters of severity) of tissue
injury depend on:
temperature of source
duration of contact(PTB at 55deg.C&at 75C
in <1 sec.&FTB in 10s)
conductivity potential of involved tissues

Pathophysiology
Extent expressed in percentage of total BSA.
Adults-Wallaces Rule of 9s( Each upper limb9%, each lower limb-18%, Head and neck-9%,
Ant. Trunk-18%, Post Trunk-18%, Perineum &
Genitalia-1%). For smaller burn areas, can use the
patients palm as equivalent of 1%.
For children use special charts eg. Lund &
Browder chart.

Pathophysiology
Depth of injury was formerly measured in degrees but is now
obsolete. It is now graded as follows:
Superficial Partial thickness burn: Skin epithelium and superficial
dermis involved sparring the dermal appendages. Injury
manifests as an erythema with slight blistering eg. Due to
sunburn or scalds (hot steam).
Deep Partial thickness burn: Skin epithelium and most part of
dermis involved sparring few dermal appendages(sweat glands
and hair follicles). Considerable blistering and peeling of skin
eg.due to boiling fluids.
Deep Full thickness burn: Entire thickness of skin and its adnexae
is destroyed eg. Due to naked flames or electricity burns.

Pathophysiology
Depth of burns can be difficult to estimate
clinically as there is lot of overlap and can vary at
different sites on the body. The measurement can
however be assisted by various techniques
including use of ultrasound, laser Doppler,
thermography, Inj. of dyes and surgical biopsy.
All categories of burns are painful.
Measurement of extent and depth of burns gives
guidance to management and predicts prognosis.

Pathophysiology
Thermal injury-coagulation necrosis-immediate
pathophysiological changes occur both locally and
systemically as the skin is the largest organ in the
body and plays a critical role in maintenance of
body homeostasis.
Severe thermally injured skin- colossal loss of
fluids and electrolytes from the intravascular
compartment-hypovolaemic shock with
impending multiple organ failure if situation is not
corrected.

Pathophysiology
The markedly increased vascular( capillary)
permeability occurs at the site of burn injury and in
the microcirculation distant to the burn. Humorally
mediated-vasoactive peptides eg. Histamine,
bradykinin, 5-HT, PG E&F, leukotrienes,
complement system C5a and lysosomal components.
Capillary permeability is maximal in the first 8 hours
and declines over 36hrs post burn. After 24hrs,major
loss is in form of burn exudate at wound site(isotonic
to plasma)

Pathophysiology
Enormous fluid & electrolytes loss causes
increased HCT, haemoconcentration,
hypovolaemic shock and anuria.
Crystalloids only are given to maintain GFR in the
first 24hrs post-burn to avoid hypovolaemic shock.
Avoid excessive hypotonic solution(eg. Plain
dextrose) to avoid pulmonary oedema.
Effective transcapillary filtration pressure is also
increased resulting in tissue oedema.

Pathophysiology
The burn exudates cause protein loss and is good
medium for bacterial growth which proliferate on
the surface and in the hair follicles.
Degree of wound infection is proportional to
extent of burn and possible complications are
hypoproteinaemia, hyperpyrexia,
hypermetabolism(2-3 times the BMR),
septicaemia, bronchopneumonia & pyelonephritis.

Pathophysiology
Extensive deep burns reduce the humoral and
cellular defences of the body to bacteria and
therefore early(following resuscitation) tangential
surgical excision of the surface dead tissue
followed by skin grafting largely prevents wound
infection and has considerably reduced the
morbidity & mortality in extensive burn injury.
Equipped Blood and skin bank facilities are
essential.

Pathophysiology
Extensive burn wounds results in heat loss
from the surface with consequent
hypothermia esp. in children.
Also the high evaporative heat loss
necessitates higher calorie demand eg.>30%
burn requires twice the normal requirements
of calories/24hrs i.e. 200kcal/kg body wt.
orally/parenterally.

Pathophysiology
Anaemia in burns is due to direct destruction of rbcs by
heat at site of burn and accumulation of rbcs within the
burn itself, increased fragility and lysis in the circulation
over 48-72hrs postburn and haemoglobinuria.
The stress may result in gastric erosion or curlings ulcer
which may bleed.
Sepsis also contributes to anaemia.
However, due to early haemoconcentration and increased
viscosity affecting tissue perfusion, blood transfusion if
required is given on the 3rd day onwards preferably in form
of packed cells at 10mls/kg body wt. to keep HCT > 0.35.

Management
First aid measures to be taken at scene of accident include
ensuring airway, breathing and circulation is under
control.
Remove all clothing possible and cool the body for 10
mins. pouring water from a hose-pipe or in a bath tub or
buckets of water.
Then cover patient with blanket to avoid hypothermia and
refer to hospital.
If due to electrocution, ensure power supply is
disconnected before assisting the patient.

Management
Assessment and resuscitation in the A & E dept.
according to ATLS protocol and transfer to ward or
burn unit if available. Intubation is necessary if
patient develops respiratory failure due to:
a) Acute airway obstruction: oral or laryngeal
oedema.
b) Inability to handle secretions due to inhalation
injury.
c) Lower airway inhalation injury with respiratory
failure.

Management
Our Policy for admission:
Adult with 15% or more BSA burnt
Children with 10% or more BSA burnt.
Other indicators include smaller extent burns involving
hands, face, feet and joint surfaces (to avoid contractures
developing).
Circumferential burns of limbs or digits may compromise
blood supply distally due to eschar formation.
Facial burns from naked flames may be complicated by
respiratory distress due to inhalation of noxious fumes.

Management
Estimate extent and depth of burn injury, the former is essential
to calculate fluid requirements for resuscitation.
The body weight is measured(or estimated) and self-retaining
urethral catheter inserted to asses the resusc.CVP line is more
accurate.
Tetanus prophylaxis is instituted. Toxoid given if patient has
been immunized in the past 3yrs. Non-immunized patients
receive toxin-antitoxin (TAT) and immune globulin.
H2 receptor antagonist(Cimetidine/ Ranitidine) and/or Proton
pump inhibitor eg.Pantocid-given iv
Narcotic analgesic (Pethidine/Morphine) to counter pain,
anxiety, restlessness.

Management
Resuscitation: Involves carefully monitored fluid and
electrolyte replacement to correct or prevent state of
burn shock. It also includes replacement of continuing
losses and maintenance fluids without overloading the
circulation and prevention of tissue oedema.
A large bore cannula/venesection is essential.
Many formulae available eg. Muir and Barclay(UK),
Evans, Brook, Parklands Hosp. Etc. We use the
Modified Brooke Army Hospital formula (similar to
the ATLS protocol) to calculate fluid replacement

Management
Adult: 2ml/kg/% burn in first 24 hrs. Ringers lactate or
N/Saline; half of the calculated vol. given in the first 8hrs
of burn injury and the remaining half in the next 16hrs.
Period commences from time of burn injury-not
admission.
For >50% burn, initially calculate as 50% to avoid fluid
overload, then assess urine output(or CVP) and add fluids
accordingly.
Monitor S. electrolytes, blood gases and HCT.
Maintenance fluids (Metabolic water): 2000mls of 5%
Dextrose in 24hrs(adults).

Management
Children: 3ml/kg/% burn in first 24hrs using
crystalloids for replacement.
Maintenance fluids: 5% Dextrose amount tailored
according to body weight:

-Up to 10kg: 100mls/kg

-11 to 20kg : 1000mls+50mls/kg for every kg.

above 10kg.

-21kg to adult: 1500mls+20mls/kg for every

kg. above 20kg.

Management
Second 24hrs:
Adult: Half the calculated dose in the first 24 hrs
i.e. 1ml/kg/% burn. Half of this i.e. 0.5ml/kg/%
burn is colloid(dextran, plasmagel, plasma,
albumin) and the remaining half is crystalloid.
Children: Total vol. is 1.5ml/kg/% burn. i.e.
0.75ml/kg/% burn colloid and the remaining
crystalloid.
Maintenance fluid(Adult & Children)same as in 1 st
24 hrs.

Management

Monitoring Resuscitation:
1.Patients gen. condition to exclude clin features of shock.
2. Hourly vital signs-Pulse, BP, etc (ECG monitor)
3. Hourly Urine output-most important (Adult: 30-50ml/hr;
Children: 0.5-lml/kg/hr).
4. HCT estimation-measures degree of hydration(N: 0.35)
5. Serum electrolytes and blood gases. Danger of hyponatraemia if
excessive free water administration. Hypokalaemia may occur
during diuretic phase (2-3 day).
6.CVP monitoring more reliable than BP.
Swan-Ganz catheter assesses cardiac function and is most reliable
(measures Pulmonary Capillary Wedge Pressure).

Management
Burn Wound Management: In the wd or Burn unit.
Open method-No dressing used-Obsolete.
Closed (occlusive) method- Dressings used- is
recommended as it protects the wound from being
contaminated by the environment and minimizes
evaporative loss.
Wound is cleaned with copious saline and povidone
iodine, debrided to remove all dirt, dead tissues and
blisters and then dressed with povidone iodine or topical
antibacterial agents eg. Silver sulphadiazine (Flamazine,
Silverex powder or cream) Sofratulle, Phenytoin powder.

Management
Dressings changed daily or on alternate days
depending on the wounds progress.
Escharotomy (incise skin to subcutaneous fat-not
faciotomy) is necessary for circumferential
wounds of limbs compromising the distal
circulation or respiration in case of chest burn
wound.
Elevation of involved limbs reduces swelling and
improves perfusion (check with pulse oximeter).

Management
Chemical burns- pour copious amount of water and
saline/povidone iodine and then dress.
Electricity burns- require 24hr cardiac monitoring and
measurement of isoenzymes.
Deep full thickness burns require excision and skin grafting
after resuscitaton. Up to 20% burns can be excised at a time
as there is considerable blood loss during procedure.
Early physiotherapy to prevent burn contracture is essential.
Pressure garments - used to prevent hypertrophic scars and
disfigurement.

Management
Skin Grafting: Indications include when deep burns
are excised following resuscitation;
deep burns treated conservatively and form good
granulation tissue are covered with split skin grafts.
Infected burn wounds treated with antibiotics and
dressings and then become clean granulating
wounds are grafted.
Burn contractures are also released and then
covered with split or full-thickness grafts.

Management
Systemic antibiotics: Use of systemic antibiotics as
prophylaxis in burn patients is controversial and our
recommendation is to use it only in established clinical
infection to avoid development of resistant strains in
the burn unit. Need to exclude malaria in case of fever;
wound discharge need to be cultured and antibiotic
sensitivity determined.
Systemic antibiotics is also recommended as
prophylaxis whenever a surgical procedure is done
including wound excision, escharotomy and skin
grafting.

Management
Severe sepsis can give rise to Systemic
Inflammatory Response Syndrome
(SIRS) or multiple organ dysfunction
syndrome whereby there is release of
inflammatory mediators & cytokines
resulting the patient to go into hypotension,
develop tachycardia, oliguria, myocardial
depression and respiratory failure requiring
to be managed with a ventilator.

Management
Nutritional Management: Hypermetabolism in burns
necessitates protein and calorie replacement-the
proportion varies with extent of burn.
Should begin as soon as possible preferably
parenterally.
As we have no such facilities, we need to encourage
oral nutrition including use of naso-gastric tube
feeding with the assistance of a dietician.
Ensure adequate vitamins and trace element
supplements.

Complications
Immediate: 1. Fluid and Electrolyte imbalancehypovolaemic shock
2. Acute Renal Failure-extensive burns
3. Local wound sepsis-common-septicaemia/SIRS
4. Paralytic ileus-acute gastric dilatation-insert
N-G tube
5. Anaemia
6. Respiratory failure-smoke inhalation/CO intoxication
7. Curlings ulcer with gastric erosions-due to stress,
anoxia & hypovolaemia

Complications
Late:

1. Hypertrophic scars
2. Keloids
3. Contracture deformity
4. Marjolins ulcers (malignancy)

Any Questions/Comments