BURN

PRESENTED BY- Jemal yimam

Jibril Berhanu
Kalkidan zenebe
Objectives
To understand burn , the risk factors and its etiologic agent

To know Classifications of burn and importance of it

To know how to asses the area and depth of burn

To understand the path physiology of burn

To know complications of burn

To be able to know how to manage burn and also the indications for
surgery

To be able to know how to take history and investigate patients with

burn
DEFINITION:
Burn: is coagulative necrosis of the epidermis and underlying
tissue that most commonly results from the transfer of
heat energy.
Death from burn occur in bimodal distribution
immediately after injury
weeks later as a result of multiorgan failure
two-thirds of burn occur at home
75% of all burn related death occur in house due to house fire
young adults flammable liquids
toddlers-hot liquid
Significant % in children is due to child abuse
 Risk factors
low socio-economic status
unsafe environment
Criteria for referral to burn center
partial thickness burn >10% of TBSA
burns involving face , hands , feet , genitalia ,
perinium or major joints
Any full thickness burn
electrical burns
chemical burns
inhalation burns
 Burns in patients with pre-exiting medical
disorders

Any patient with concomitant burn and trauma(

fracture)

burned children in hospitals without qualified

personnel or equipment
Burns requiring special social, emotional or long
term rehabilitation
 BASED ON CAUSES
To be able to address proper treatment

THERMAL
Scald
Flame
Flash
Contact
Inhalation injury
RADIATON
ELECTRICAL
CHEMICAL
 Thermal burns : induce cellular damage
primarily by transfer of energy and coagulative
necrosis
A. SCALD BURNS
contact from hot water are the most common
cause of burn
Depth is proportional to temperature, duration of
contact & thickness of skin
B. FLAME BURNS
Next most common
House fires, smoking related fires, improper use of
flammable liquids, automobile accidents, ignition of
clothing from stoves or space heaters, fall into open
fire or space heater
C.FLASH BURNS
Explosion of natural gas, propane, gasoline
& other flammable liquids
Depth depends on the amount and type of fuel
May be associated with thermal damage to the upper
airway
D. CONTACT BURNS
Result from contact with hot metals, plastic, glass or hot coals
Limited in extent & very deep
 Chemical burns
Could be - accidentally, occupational, assault
The degree of tissue damage, as well as the level of toxicity , is
determined by:
-chemical nature of the agent
- concentration of the agent
- duration of skin contact Causative agents
Alkali, burns are more dangerous than acidic burns-
-lime,KOH,NaOH, bleach ,cement(calcium oxide)
-may penetrate deep
- mechanisms
Acids-may be more superficial,eschar formation
-induce thermal injury
-formic acid, hydrofluoric acid , Hcl
Other organic and inorganic chemicals
-hydrocarbons
 Electrical burns
current: Alternating(AC)
Direct(DC)
Tissues:- high resistance -tendon, fat, bone
Intermediate resistant- skin
lowest resistance mucous membrane,
nerves, blood vessels, and muscles
sources of injury
1. low-voltage < 1000 volt of current
no transmission to deeper tissues
household current (110-220 V)
mouth (oral commissure)
2. high-voltage>1000 volt of current
cutaneous burn at the entry and exit sites, combined with hidden
destruction of deep tissue
3. Lightning strike
 RADIATION BURNS - burns associated with
nuclear blasts, uv-light, x-rays, cancer radiotherapy
 CLASSIFICAION
BASED ON DEPTH OF INJURY

1. 1st Degree (superficial)

2. 2nd Degree(partial thickness)
2.1,Superficial 2.2,Deep
3. 3rd degree (Full thickness)
4. 4th Degree
 Based on depth
1st degree burn ( superficial )
confined to the dermis
painful , erythematous , blanchable to
touch
heal within a weak
self limited
e.g;-sun burn &minor scald

 2nd degree burn (partial thickness)

involves dermis
-superficial 2nd degree burn
epidermis and superficial portion of dermis
painful , erythematous , blanch to touch , blister
formation
heal in seven fourteen days
may result in slight skin discoloration
e.g;-scald injury & flash flame burns
 Deep 2nd degree burn
epidermis and most of dermis involves
doesnt blanch touch
less sensitive to light touch but
remain painful to pinprick
re-epitheliaze in 14-35 days or progress to 3rd degree
burn
forms severe scar
 3rd degree burn ( full thickness )
involves all epidermis and dermis with
subcutaneous tissue
no dermal & epidermal appendages remain
characterized by hard leathery eschar that is
painless and black , white or cherry red
requires skin grafting to timely
heal by re-epithelialization from wound edges
 4th degree burn
involves full-thickness of dermis and epiderms to
extend into muscle , bone & brain tissue
e.g -high voltage electric injury
-severe thermal burns
 Based on severity of the burn:
depth of burn
burned body surface area
associated conditions
medical problems
trauma
Critical burn creteria
3rd degree burn > 10% of BSA
2nd degree burn > 30% of BSA
>20% in pediatrics
respiratory injury
hands , feet , face or genitalia
electrical and chemical burns
complicated burn by trauma
underlying health problems
 Moderate burn criteria
3rd degree 2-10% BSA
2nd degree 15-30% BSA
10-20% in pediatrics
without complicating factors
excluding hands , face ,feet or genitalia
 Minor burn criteria
3rd degree <2% BSA
2nd degree <15% BSA
1st degree <20% BSA
<10% in pediatrics
 PATHOPHYSIOLOGY OF BURNS
Can be
Local change
-zone of coagulation
- zone of stasis
-zone of hyperemia

Systemic change
-cardiovascular change
-respiratory change
-gastrointestinal changes
-renal changes
- metabolic change
-immunological change
-hematological changes
 Areas of cutaneous injuries are classified as
zone of coagulation
-occur at the point of maximum injury
-irreversible tissue loss

zone of stasis
-characterized by decreased tissue perfusion
-high risk of progression to coagulative necrosis

zone of hyperemi
-the outer most zone
-characterized by tissue perfusion increased b/c of VD
-
 SUSCEPTIBILITY TO
SEPTICEMIA INFECTIONS

HYPOVOLEMIA HYPOTHERMIA
Affects mostly skin. However, burns can also
damage the airways & lungs, with life threatening
consequence. Airway injuries when the face &
neck are burned.in burning vehicle..inhaling
hot & poisonous gases.
Warning signs of burns to the respiratory system
are- burns around the face & neck, a history of
being trapped in a burning room, change in voice
& stridor.
 Physical burn Injury to the airway above the
larynx
Inhaled hot gases can cause supraglottic
airway burns & laryngeal edema.
Inhaled steam can cause supraglottic burns &
loss of respiratory epithelium.
Inhaled smoke particles can cause chemical
alveolitis & respiratory failure.
Inhaled poisons, such as carbonmonoxide,
can cause metabolic poisoning.
Full-thickness burns to the chest can cause
mechanical blockage to rib movement.
 Physical burn Injury to the airway below the
larynx
Rare, however, Steam has a large latent heat of
evaporation & can cause thermal damage to the
lower airway.
Metabolic Poisoning
COformed in the fire has 240 times more
affinity than Oxygen for hemoglobin.
Carboxyhemoglobin.>10% needs pure
treatment with pure oxygen for more than 24
hours. Death occurs with concentration 60%.
Hydrogen Cyanide..interfers with mitochondrial
respiration causing metabolic acidosis.
 Inhalational Injury
..Can cause alveolitis, bacterial pneumonitis,
presence or absence has significant impact on
mortality of patients.
Mechanical block on rib movement-Burned skin is
very stiff & thick.
Inflammation & Circulatory changes
Burns produce an inflammatory reaction (Mast
cell & Neutrophils degranulate.TNF
produce).The activation of Hagman Factor
initiates a number of protease-driven cascades,
a,l,tering the arachidonic acid, thrombin &
kalirikien pathways.
LOSS OF IV FLUID
 This leads to vastly increased vascular
permeability.
Water, solutes & proteins moves from the
intra to the extravascular space.
The volume of fluid lost is directly
proportional to the area of the burn.
Above 15% of surface area, the loss of fluid
produces shock.
 Other life threatening events with major burns
Cell Mediated Immunity is significantly reduced in large
burns, leaving them more susceptible to bacterial &
fungal infections.
Sites are lung, burn wound, tracheostomy & urethral
catheterization.
Changes to the Intestine
The inflammatory stimulus & shock can cause
microvascular damage ischemia to the gut mucosa.
This reduces gut motility & can prevent the absorption
of food. Failure of enteral in a patient with burn is a life
threatening complication.
 Gut bacterial translocation Gastric
stasis, peritoneal edema
Abdominal compartment syndrome
Splint of diaphram Increase in
airway pressure for respiration.
Circumferential burns may compromise
blood supply.
Major determinants of the outcome of a burn
1.Percentage of surface area involved.
2.Depth of burn.
3.Presence of an Inhalational Injury.
 Assessment of a burn wound
Assessing size
Burn size needs to be formally assessed in a
controlled environment. This allows the area
to be exposed & any soot or debris washed
off. Care should be taken not to cause
hypothermia during this stage.
Burn size
estimates the extent of injury.
Rule of nines
In adults
Body parts TBSA
Each upper extremity 9%

head and neck 9%

Each lower extremities 18%
anterior trunk 18%
posterior trunk 18%
perineum and genitalia 1%

Infants -21% of TBSA - -> head and neck

-13% of TBSA - -> each leg
o which incrementally approaches the
adult proportions with increasing
 The patients whole hand is 1% TBSA, & is a
useful guide in small burns, which maps out
the percentage of TBSA of sections of our
anatomy.
The Lund & Browder chart is useful in large
burns which maps out the percentage of TBSA
of sections of our anatomy.
 Assessing the depth from history
It takes hot water at 650 c, exposure for 45
sec will produce a full thickness burn, for 15
sec a deep partial thickness burn & for 7 sec a
superficial partial thickness burn.
INVESTIGATIONS
BLOOD COMPLETE PICTURE
CROSS MATCH
X-RAYS
URINE ANALYSIS
ECG
RFTs
ELECTROLYTES
Management
 Management
IMMEDIATE CARE OF THE BURNED PATIENT
Pre hospital care
Hospital care
TREATING THE BURNED WOUND
Conservative management
surgical treatment
 Pre-hospital care
Stop the burning process
Check for other injuries
Cool the burn wound
Give oxygen
Elevate
The criteria for acute admission to a burns unit
Suspected airway or inhalational injury
Any burn likely to require fluid resuscitation
Any burn likely to require surgery
Patients with burns of any significance to the hands, face,feet or
perineum
Patients whose psychiatric or social background makes it
inadvisable to send them home
Any suspicion of non-accidental injury
Any burn in a patient at the extremes of age
Any burn with associated potentially serious sequelae
including high-tension electrical burns and concentrated
hydrofluoric acid burns
Major determinants of the outcome of a burn
Percentage surface area involved
Depth of burns
Presence of an inhalational injury
 Hospital care
Airway and Breathing
Assess for potential airway involvement
o burn occur in an enclosed structure or explosion
o hoarseness, stridor, facial burns, singed facial hair
o expectoration of carbonaceous sputum
Endotracheal intubation Initial management
Cricothyroidectomy Delay
 Cont
increase in respiratory effort and rate
rising pulse, anxiety and confusion
Decreasing oxygen saturation
Circulatory Status
o Burns do not cause rapid onset of hypovolemic
shock
o If shock is present, look for other injuries
o Circumferential burns may cause decreased
perfusion to extremity
 FLUID RESUSCITATION
The principle of fluid resuscitation is two maintain intravascular fluid
following burn
In children with burns over 10% TBSA and adults with
burns over 15% TBSA, consider the need for intravenous fluid

If oral fluids are to be used, salt must be added

Fluids needed can be calculated from a standard formula

Parkland formula %BSA weight (kg) 4 = volume

Half this volume is given in the first 8 hours, and

the second half is given in the subsequent 16 h
ours
here are three types of fluid used.
Ringers lactate or Hartmanns solution
albumin solution or fresh-frozen plasma,
Hypertonic
. saline
.
 Monitoring of resuscitation
The key is to monitor urine output
hematocrit measurement
acidbase balance
 Wound care
Each wound is dressed with an appropriate covering
that serves several function
protects the damaged epithelium
provide splinting action
reduce evaporative heat loss
minimize cold stress
provide comfort over the painfull wound
 Wound dressing
1 Antimicrobial dressing ;-
Use Topical antibiotic
- silver sulfadiazine cream
- mafenide cream
- Silver nitrate solution

2 Synthetic and Biologic Dressings

These coverings include allograft (cadaver ), xenograft (pig
skin),Transcyte, Integra Biobrane
 Excision and Grafting

Excision
In deep dermal burns, the top layer of dead dermis is shaved
off until punctate bleeding is observed and the dermis can be
seen
to be free of any small thrombosed vessels also
Full-thickness burns require full-thickness excision of
the skin then
Zimmer instrument Watson blade, and Weck blade
 Timing of excision :
2 types
1. Facial excision :include the burn , sc fat to
the level of investing fascia
2. Tangential (sequential) excision :by
sequentially removing thin slices of burned
tissue until a viable bed remains
 Grafting
Deep second- and third-degree burns do not heal in timely fashion without auto
grafting

Grafting
split-thickness skin graft

Full-thickness skin grafts

meshed
Flap
 ADDITIONAL ASPECTS OF TREATING THE
BURNED PATIENT

Analgesia & Tetanus prophylaxis

Energy balance and nutrition
Burns patients need extra feeding
A nasogastric tube should be used in all patients
with burns over 15% of TBSA
Removing the burn and achieving healing stops the
catabolic drive
Physiotherapy
 REFERENCE
Bailey &loves short practice of surgery ,25th
ed.
Sabiston textbook of surgery,18th ed.
Schewartz manual surgery, 8th ed
uptodate