BURN

Dr. Bivek Pokhrel

Resident Medical Officer
Annapurna Neurological Institute
and Allied Sciences

Success lies not in achieving what you aim at, but in aiming at what you ought to achieve.
Introduction:

• Burn is a global public health problem associated

with significant morbidity and mortality, mostly in
low- and middle-income countries.

• Most of the burn victims in Nepal belong to the

working age group between 15–60 years old.

• Flame burns were found to be the most common

cause of burn injury followed by scald burns,
whereas scald burns were the most common cause
of burn injury among the pediatric population.
• Burn is a public health problem, accounting for an
estimated 265,000 deaths annually throughout the
world

• Five percent of disabilities at all age group in Nepal

are due to burns related injury.
THE PATHOPHYSIOLOGY OF BURN INJURY
Burns cause damage in a number of different ways,
but by far the most common organ affected is the
skin. However, burns can also damage the airway and
lungs, with life-threatening consequences.

Airway injuries occur when the face and neck are

burned.

Respiratory system injuries usually occur if a person is

trapped in a burning vehicle, house, car or aeroplane
and is forced to inhale the hot and poisonous gases.
Classification of Burn:
Depending on the thickness of the skin involved it can be
classified as:
• First Degree
• Second Degree
• Third Degree
• Fourth Degree
First degree:
• Epidermis looks red and painful with no blisters.
• Heals rapidly in 5-7 days by epithelialization without
scarring.

Second degree:
• The affected area is mottled, red, painful, with
blisters.
• Heals by epithelialization in 14-21 days.

 Superficial second degree burn heals, causing

pigmentation.
 Deep second degree burn heals, causing scarring,
and
Third degree:

•The affected area is charred, parchment like, painless

and insensitive, with thrombosis of superficial vessels.
It requires grafting.

•Charred, denatured, insensitive, contracted full

thickness burn is called as eschar. These wound must
heal by re-epithelialization from wound edge.

Fourth degree:
•Involves the underlying tissues—muscles and bones.
First Degree Burn
2nd Degree Burn
3rd Degree Burn
Calculation Of Burn:
 Clinical Features:

• History of Burn
• Pain, Burning, anxious status, Tachycardia, Fluid loss.
• Features of shock in case of severe burn.
• Massive Oedema (due to altered pressure gradient)
• Cardiac Dysfunction is due to:
 Hypovolemia
 Release of Cardiac Depressants
 Hormonal Causes (CA, Vasopressin, Angiotensin's)

• Renal Changes is d/t max. ADH secretion to cause max. water

Retention. Release of Aldosterone to cause max. reabsorption
of Na.
 Myoglobin released from muscles (in case of electric injury or
often from eschar) is most injurious to kidneys.
• Pulmonary Changes are d/t Altered Ventilation-Perfusion
Ratio.
 ARDS
 Aspiration
 Septicemia

• GIT changes are due to:

 Acute gastric dilatation which occurs in 2-4 days.
 Paralytic ileus due to electrolyte loss
 Curling’s Ulcer
 Cholestasis and Hepatic damage.
 Ac. Acalculous Cholecystitis and Ac. Pancreatitis

• Metabolic Changes (Hyper metabolism, Negative N2 balance,

Electrolyte imbalance, Def. of Vitamins, Metabolic Acidosis
due to hypoxia and lactic acidosis)
Sepsis in Burn Patient:

• Focus may be at Burn site, catheter site, Cannula site or

Respiratory infection.
• Low immunity, Loss of protein and IGs, Loss of barrier(skin)
• Opportunistic Infection
• Infection are most commonly due to:
 Streptococci (Beta hemolytic- most common)
 Pseudomonas
 Staphylococci
 Other Gram Negative
 Candida albicans

• May lead to Toxic Shock Syndrome

Management of Burns:

• First Aid:
 Stop the burning process and keep Patient safe
 Cool the area with tap Water by continuous irrigation for 20min

• Definitive Treatment:
 Maintain ABC
 Assess the % of Burn, degree and type.
 Sedation and proper analgesia
 Burn unit, barrier nursing, sterile clothes, aseptic methods.
 Most is the Fluid Resuscitation and prevention of secondary
infection.
Fluid Resuscitation:

There are many formulas to calculate the fluid replacement in

burn but the most important and useful one is the Parkland.

• Parkland Regime

4ml X Percentage of Burn X Body Wt.

24 Hours

• Maximum % considered is 50%.

• Half the volume is given in 1st 8 hours and rest is given in
16 hours.
Evan’s Formula:

•In 1st 24 hours: Normal Saline 1mg/Kg/ % burns

•Colloids: 1ml/Kg/ % burns

•5% dextrose in water, 2000ml in adult.

•In 2nd 24 hours half the volume used in 1st 24 hours.

Fluids Used are NS, RL, Hartmann fluid, Plasma.

Ringer Lactate is the Fluid of Choice.

Supportive Managements:

•Urinary Catheterization
•TT injection
•Continuous monitoring of Vitals, Renal Function, Electrolytes.
•PPI or H2 Blocker to prevent stress ulcers.
•Ryle’s Tube to prevent aspiration
•Antibiotics to prevent secondary infection.
•In burns of oral cavity tracheostomy may be required to maintain
airway.
•TPN is required for faster recovery.
•Tracheostomy/ Intubation
•Intensive Nursing care.
• Dressing in regular interval under anesthesia using paraffin
gauze, hydrocolloids, plastic films, etc.

• Open method with application of Silver sulfadiazine.

• Closed Method is to protect the wound, reduce pain.

• Tangential excision of burn wound with skin grafting can be

done within 48 hours in a Pt. with less than 25% burn.

• In burns of head and neck region, exposure treatment is

advised.