BURNS

Dr.P.Viswakumar, M.S
Assistant Professor of Surgery,
Dept of General Surgery,
PSGIMSR,
Coimbatore-4.
 Key Facts
An estimated 265 000 deaths every year are
caused by burns the vast majority occur in
low- and middle-income countries.
Non-fatal burn injuries are a leading cause of
morbidity.
Burns occur mainly in the home and
workplace.
Burns are preventable.
 What is a Burn?
A burn is an injury to the skin or
other organic tissue primarily
caused by heat or due to
radiation, radioactivity, electricity,
friction or contact with
chemicals.
Burn Classification
 Causes
Flamedamage from superheated oxidized
air
Scalddamage from contact with hot liquids
Contactdamage from contact with hot or
cold solid materials
Chemicalscontact with noxious chemicals
Electricityconduction of electrical current
through tissues
 Depths
First degreeinjury localized to the epidermis
Superficial second degreeinjury to the
epidermis and superficial dermis
Deep second degreeinjury through the
epidermis and deep into the dermis
Third degreefull-thickness injury through the
epidermis and dermis into subcutaneous fat
Fourth degreeinjury through the skin and
subcutaneous fat into underlying muscle or
bone
First Degree Second Degree

Third Degree Fourth Degree

 Pathology Underlying Burns
Skin is the largest organ on the human body,
provides a staunch barrier in the transfer of
energy to deeper tissues.
Once the inciting focus is removed, however,
the response of local tissues can lead to injury
in the deeper layers.
The area of cutaneous or superficial injury has
been divided into three zoneszone of
coagulation, zone of stasis, and zone of
hyperemia
 Fire/Flames,Contact with hot liquids,hot/cold
solid materials induce cellular damage via
transfer of energy directly leads to coagulation
necrosis.
Chemical and electrical burns cause injury via
cell memberane damage in addition to
thermal injury.
Depth of Injury depends on 3 factors
1) Temperature at which skin exposed
2) Casuative agents
3) Duration of Exposure.
 Systemic Effects of Burns
Severe burns covering more than 40% of the
TBSA are typically followed by a period of
stress, inflammation, and hypermetabolism .
Characterized by a hyperdynamic circulatory
response with increased body temperature,
glycolysis, proteolysis, lipolysis, and futile
substrate cycling.
Their severity, length, and magnitude are
unique for burn patients.
 Post Burn Metabolic Phenomena
Two Distinct phase of metabolic changes observed
in post burns.
The first phase occurs within the first 48 hours of
injury and has been called the ebb phase.
Characterized by decrease in cardiac output,
oxygen consumption, and metabolic rate, as well
as impaired glucose tolerance associated with its
hyperglycemic state.
These metabolic variables gradually increase
within the first 5 days postinjury to a plateau
phase (the flow phase).
Time Post burn
 Post Burn Squela
Cardiac out put increases by 1.5 times
Liver size increases by 225%
Muscle protein is degraded much faster than it is
synthesized.
The net protein loss causes loss of lean body mass
and severe muscle wasting.
10% loss Immune Dysfunction
20% loss Decrease wound healing
30% loss Increased risk of Pneumonia &
Pressure sores
40% loss Death
 Renal Drecresed GFR and Renal blood flow
and can lead to ATN if left untreated
The gastrointestinal response to burn is
highlighted by mucosal atrophy, changes in
digestive absorption, and increased intestinal
permeability.
Burns cause a global depression in immune
function.
Great risk for a number of infectious
complications, including bacterial wound
infection, pneumonia, and fungal and viral
infections.
Assessment & Management
of Burn patients
Assesment of Burn Size
Assesment of Depth and Degree
 Basic Management
Prehospital management
 Remove the person from source and burning
process must be stopped.
Addressing Inhalation injury with 100%
oxygen
Remove heated source like
rings,bracelet,Chain,Watches,etc.
Pouring water with room temperature
advisable only upto 15 min beyond which it
can lead to hypothermia.
 Initial Assessment
By Primary and Secondary Survey.
In Primary survey immediate life threatening
conditions are identified and treated
In Secondary survey head to foot examination are
carried out.
Exposure to heated gas and smoke leads to airway
injury which in turn manifest as airway
edema,hoarseness of voice.
Airway injury must be suspected with facial burns,
singed nasal hairs, carbonaceous sputum, and
tachypnea
 BP monitoring in burn patient ?

Initial Wound Care :

Aim is to protect wound from environmental
exposure by clean dry dressing.
Avoid damp dressing
Cover with blanket to prevent hypothermia
The first step in diminishing pain is to cover
the wounds to prevent contact to exposed
nerve endings.
 Resuscitation
Adequate resuscitation of the burn patient
depends on the establishment and
maintenance of reliable IV access.
Ringer lactate is always prefered solution of
resuscitation.
Initial resuscitation volume is calculated with
body weight and TSBA
Eg., (80Kg x 40% TBSA)/8 = 400mL/hr
 Resuscitation Formulas

FORMULA CRYSTALLOID COLLOID FREE WATER

4 mL/kg per %
Parkland None None
TBSA burn
1.5 mL/kg/% 0.5 mL/kg per
Brooke 2.0 liters
TBSA burn % TBSA burn
5000 mL/m 2
Galveston burned area +
2 None None
(pediatric) 1500 mL/m
total area
 Escharotomies
Deep 2nd and 3rd degree burn encompass
exterimities.
Compromise vascular flow to the peripherals.
Recognized by numbness and tingling in the
limb and increased pain in the digits.
If tissue pressure >40 mm Hg requires
escharotomy.
Specific Treatment
Specific treatment part
Addresses
Inhalation injury
Local Wound care
 Inhalation Injury
Approximately 80% of fire-related deaths
result not from burns, but from inhalation of
the toxic products of combustion.
Overall mortality rate was about 25-50% if
burn patient requires more than 1 wk
ventilatory support.
Early diagnosis of bronchopulmonary injury is
therefore critical for survival.
 Bronchoscopic findings
Airway edema,
Inflammation,
Mucosal necrosis,
Presence of soot and charring in the airway,
Tissue sloughing,
Carbonaceous material in the airway.
Early intubation is required if features of Airway
edema seen as it ll increase in first 24 hours.
 Criteria for Intubation
CRITERIA VALUE

Pa o 2 (mm Hg) <60

Pa co 2 (mm Hg) >50 (acutely)

Pa o 2 /F io 2 ratio <200

Respiratory, ventilatory
Impending
failure

Upper airway edema Severe

 Treatment of Inhalation Injury
TREATMENT TIME, DOSAGE, METHOD

Bronchodilator (e.g., Albuterol) q2h

5000 to 10,000 U with 3 mL

Nebulized heparin
normal saline q4h

Nebulized acetylcysteine 20%, 3 mL q4h

Hypertonic saline Induce effective coughing

Racemic epinephrine Reduce mucosal edema

 Wound Care
Treatment depends on the characteristics and size
of the wound.
All treatments are aimed at rapid and painless
healing.
Wound thoroughly cleaned and adequately
debrided.
Clean dressing to address two functions of Skin
1) As Barrier from environmental infection
2) Prevention of thermal/water loss through
exposed wound.
 Wound Care
First and superfiscial second degree needs
topical oinment and pain killers.
Deep 2nd and 3rd requires excision and
grafting.
DRESSINGS ADVANTAGES AND DISADVANTAGES
Antimicrobial Salves
Broad-spectrum antimicrobial; painless and
easy to use; does not penetrate eschar; may
Silver sulfadiazine (Silvadene)
leave black tattoos from silver ion; mild
inhibition of epithelialization

Broad-spectrum antimicrobial; penetrates

eschar; may cause pain in sensate skin; wide
Mafenide acetate (Sulfamylon)
application may cause metabolic acidosis;
mild inhibition of epithelialization

Ease of application; painless; antimicrobial

Bacitracin
spectrum not as wide as above agents
Ease of application; painless; antimicrobial
Neomycin
spectrum not as wide
Ease of application; painless; antimicrobial
Polymyxin B
spectrum not as wide
Effective in inhibiting most fungal growth;
Nystatin (Mycostatin) cannot be used in combination with mafenide
acetate
More effective staphylococcal coverage; does
Mupirocin (Bactroban)
not inhibit epithelialization; expensive
Antimicrobial Soaks

Effective against all microorganisms;

stains contacted areas; leaches
Silver nitrate 0.5%
sodium from wounds; may cause
methemoglobinemia

Wide antibacterial coverage; no

fungal coverage; painful on
Mafenide acetate 5% application to sensate wound; wide
application associated with
metabolic acidosis

Effective against almost all microbes,

Sodium hypochlorite 0.025% (Dakins
particularly gram-positive organisms;
solution)
mildly inhibits epithelialization

Effective against most organisms,

Acetic acid 0.25% particularly gram-negative ones;
mildly inhibits epithelialization
Synthetic Coverings
Provides a moisture barrier;
inexpensive; decreased wound pain;
OpSite use complicated by accumulation of
transudate and exudate, requiring
removal; no antimicrobial properties
Provides a wound barrier; associated
with decreased pain; use
Biobrane complicated by accumulation of
exudate, risking invasive wound
infection; no antimicrobial properties
Provides a wound barrier; decreased
pain; accelerated wound healing; use
Transcyte
complicated by accumulation of
exudate; no antimicrobial properties
Provides complete wound closure
and leaves a dermal equivalent;
Integra
sporadic take rates; no antimicrobial
 Burn Wound Coverage
Biologic Coverings

Completely closes the wound;

provides some immunologic
Xenograft (pig skin)
benefits; must be removed or
allowed to slough

Provides all the normal

functions of skin; can leave a
Allograft (homograft, cadaver
dermal equivalent; epithelium
skin)
must be removed or allowed to
slough
Burn wound Excision
Tangential Excision:
Requires repeated shavings for deep,partial
and full thickness burns.
0.005 0.010 inch excision carried.
Full thickness Excision :
0.015 to 0.030 inch thickness.
Fascial Excision :
Reserved for burns extending down through
the fat into muscle, where the patient presents
late with large infected wounds and life-
threatening invasive fungal infections.
Multiorgan Failure and Death
 Nutritional Support
MAINTENANCE BURN WOUND

AGE GROUP NEEDS NEEDS

Infants (0-12 mo) 2100 kcal/% TBSA 1000 kcal/% TBSA

burned/24 hr burned/24 hr

Children (1-12 yr) 1800 kcal/% TBSA 1300 kcal/% TBSA

burned/24 hr burned/24 hr
Adolescents (12-
1500 kcal/% TBSA 1500 kcal/% TBSA
18 yr)
burned/24 hr burned/24 hr
 Pharmacologic Support
Recombinant Human Growth Hormone.
Insulin-Like Growth Factor
Oxandrolone
Propranolol
Insulin
Metformin
 Electrical Burn
Of all burn patients admitted, 3% to 5% are
injured from electrical contact.
Electrical current enters a part of the body, such
as the fingers or hand, and proceeds through
tissues with the lowest resistance to current,
generally the nerves, blood vessels, and muscles.
The skin has a relatively high resistance to
electrical current and is therefore mostly spared.
Heat generated by the transfer of electrical
current and passage of the current itself then
injures the tissues.
 The muscle is the major tissue through which the
current flows, and thus it sustains the most
damage.
Injuries are divided into high- and low-voltage
injuries.
Low-voltage injury is similar to thermal burns
without transmission to the deeper tissues.
The syndrome of high-voltage injury consists of
varying degrees of cutaneous burn at the entry and
exit sites, combined with hidden destruction of
deep tissue .
Address Cardiac derangement.
The key to managing patients with an electrical
injury lies in the treatment of the wound.
Chemical Burns
 Burns Referral
Patients with the following criteria should be referred
to a designated burn center:
1. Partial-thickness burns more than 10% of the TBSA
2. Burns involving the face, hands, feet, genitalia,
perineum, and/or major joints
3. Any full-thickness burn
4. Electrical burns, including lightning injury
5. Chemical burns
6. Inhalation injury
7. Burns in patients with preexisting medical
disorders that could complicate management,
prolong recovery, or affect outcome
 8. Any patient with burns and concomitant trauma
(e.g., fractures) in which the burn injury poses the
greater immediate risk of morbidity and mortality. In
these cases, if the trauma poses the greater
immediate risk, the patient may be initially stabilized
in a trauma center before being transferred to a burn
unit. Physician judgment is necessary in these cases
and should be in conjunction with the regional
medical control plan and triage protocols.
9. Burned children in hospitals without qualified
personnel or equipment to care for children
10. Burns in patients who will require special social,
emotional, or long-term rehabilitative intervention.
Take Home message
 The treatment of burns is complex.
Minor injuries can be treated in the
community by knowledgeable physicians.
Moderate and severe injuries, however,
require treatment in dedicated facilities.
Burn injury treatment depends on the depth
and total body surface area affected.
Early systemic response would be dampening
of all responses and followed
hypermetabolism.
 Early fluid resuscitation with adequate fluids
and addressing inhalation injury saves lots of
life.
Addressing wound comes second after initial
resuscitation with adequate covering of wound.
Main aim of wound care to protect body from
infection and hypothermia.
Early wound excision and grafting prevents
wound contracture.
Electrical burns- High voltage burns addressed
in multidimentional way.
Chemical burns Alkali and Acids treated
differently.
Thank you