BURNS

Prepared by: Joan Nyaga

MCM; BSC CO
DEFINITION

• Burn- Tissue injury caused by thermal, radiation, chemical, or electrical contact

resulting in protein denaturation, loss of intravascular fluid volume due to
increased vascular permeability and oedema.
• Injury due to a sudden drastic change of temperature leading to tissue damage
ETIOLOGY OF BURNS

• Use the pneumonic – CHEMICAL

• C-Chemical e.g acids, Alkali
• H- heat- scalds due to burns from hot water, hot oil, open flame burn,
• E- electrical
• M-mechanical e.g friction
• I- ionizing radiation
• C- cellular eg bacterial
• A- antibody- antigen (Allergic reactions)
• L- light eg UV rays
• Others- frostbite
PERSONS AT RISK OF BURNS

• 1.Extremes of age - the very young (<4yrs) or very old (>50yrs)

• 2.Those whose ability to protect themselves is impaired or prone to accidents

Alcoholics, Sick, paraplegics ,diabetics, psychiatric, patients and patients of convulsive
disorders
• 3.The unlucky - Innocent bystander

• 4.The careless - Storing petrol in the house, adding paraffin to a lit stove, smoking in bed,
working close to high tension electric wires
• 5. Electrical engineers-

• 6. Industrial chemical workers

• 7. LPG cooking gas workers

CLASSIFICATION OF BURNS

• They can be classified in three ways

Mechanism of injury
Depth of injury
According to the size of burn
CLASSIFICATION OF BURNS ACCORDING TO
THE MECHANISM OF INJURY.
• 1.Thermal
• Open flames and Hot liquid are most common (heat usually ≥15-45°C)
• 2.Caustic chemicals or acids (may show little signs or symptoms for the first
few days) Mechanisms of injury: Extravasation-Due to drug leakage into
tissues e.g. All Cytotoxics, Sulphur drugs, Potassium drugs ,bismuth drugs
Causes Inflammation, vesicles; Skin necrosis may occur within24hrs &
Gangrene secondary to vascular spasm in 2-3days.
• Contact injury
• Paraffin : Types of injury
• -Local chemical reaction
• -Thermal injuries
• -Inhalational injuries (chemical pneumonitis and bronchospasm)
• -Systemic poisoning
• Acids - Cause severe superficial coagulative necrosis. Burning stops within 1-
2hrs for HCL & H2SO4 & 7-14days for HOCL - Amount ingested does not
contribute to extent of injury.
• -Initial mx-pour a lot of water for long 1-2 hours, dress with clean material and
control pain. Can Excise area to prevent continued reaction.
• Usually the graft take is very disappointing
• saponification (Fat +alkali) , hydrolyzing structural proteins & dissolving cells
along it's course thus amount ingested contributes to extent of injury. The burn
runs for 7-14 days.
Management
• Generously irrigate with fluid for 1-2 hours & Dress in gauze soaked in NS or Ice
2-3hrly.
• DO NOT try to neutralize the chemical.
• Can excise the area to prevent continued reaction
 3. Electricity
Types of electric injuries
 Low voltage - <1000 volts
 High voltage and ->1000 volts
 Very high voltage- Very high voltage include injury from the grid and lightening
injuries
 NOTE ; electric burns have entry and exit points.
• Main injuries are for electrical burns;
• -Myonecrosis, Renal failure and Heart arrhythmia
• -Myonecrosis lead Myoglobinuria causing to Renal failure with very little
damage to overlying skin.
• -Arching burn -Occur around joints due to burn at joint surrounded by two areas
of conductance.
• -Side flash-Very high voltage burns due to lightening.
• -Body resistance is about 500ohms.Current of 1 ampere is required to cause
cardiac asystole this usually does not occur with domestic electric burns
because the voltage is about 240V giving current of approx. O.5 A.
• -Thus TBSA is NOT an index for resuscitation. IV fluids are titrated against the
volume of urine & specific gravity (1.010).
• Usually X2 the physiological requirements (3L/24hrs) of the patient.
• -In microwave injuries, the area is normal looking but anaesthetic due to
depolarization of nerves
• -Flash burns occur in technicians & may resemble open flame burns

• Mx - Give plenty of fluids

• -Alkalinizing the urine and administration of mannitol aid in Flushing the

myoglobin from the kidney
• -Do fasciotomy of muscle compartment to avoid Compartment syndrome. Normal
pressure is 30mmHg
• -Debride after 3-4days
• 4.Frostbite
• 5.Mechanical (Frictional) burns
CLASSIFICATION OF BURNS ACCORDING
TO THE DEPTH OF INJURIES
• Depth of burn proportional to;
 Temperature applied

 Duration of contact

 Thickness of the skin

 Heat capacity of the agent

 Transfer coefficient

 The specific heat and conductivity of the local tissues

• The depth of injury determines formation of scar tissue.

1st degree- epidermis
2nd degree- Superficial 2nd degree- epidermis + upper 1/3 of dermis

-Deep 2nd degree burns- epidermis + upper 2/3 of dermis.

3rd degree- epidermis + dermis + subcutaneous tissues
4th degree – muscle involvement
5th degree- bone involvement
1st Degree Burns;
• -Epidermis only involved -Commonly caused by UV light or very short flash or
flame exposure .
• Skin is red, dry & hypersensitive thus painful
• -No treatment except analgesia.
• -Leaves no scarring on healing
• 2nd Degree Burns;

Superficial 2nd Degree

• -Epidermis + Upper ⅓ of Dermis
• -Commonly caused by scald (spill or splash)
• -Red, moist, weeping, cob blisters that Blanche with pressure
• -Painful - due to nerve exposure, & heals from 10-14days
• -Leaves no scarring on healing but there is potential pigment changes
 Deep 2nd Degree
• -Epidermis + Upper ⅔ of Dermis
• -Commonly caused by scald, flame, chemicals, oil & grease
• -Cheesy white, wet or waxy dry.
• -Healing takes 14-21days
• -Severe scarring & risk of contractures
 3rd degree burns (full thickness burns)
-Full Epidermis + Dermis are destroyed leaving no cells to heal and extends to the subcutaneous
tissue.
• -Commonly caused by scald, steam, flame, chemicals, oil, grease & high voltage electricity

• -Grey to charred & black, insensate, contracted, pale, leathery tissue

• -Severe scarring & high risk of contractures

4th Degree Burns

• Muscle involvement

5th Degree Burns

• Bone involvement - Especially in epileptics who convulse during burning
CLASSIFICATION OF BURNS BASED ON SIZE
OF BURNS
Minor burn Moderate Severe burn
burn

BSA in young <10% 10-15% >15%

or old
BSA in Adults <15% 15-25% >25%
3rd degree <1% 2-5% >5%
burns
Treatment Outpatient Inpatient Burn unit/ ICU
Size of burns -Determines extent of fluid loss.
• Wallace Rule of Nines – used in Adults to estimate BSA (Body surface Area)
• ii)American Burn Association Burn Severity score
• iii)Lund-Browder Chart for estimating the extent of burns in Children
• Zones of a burn wound

1.Centre-coagulate necrosis
2. Immediate area-zone of stasis
3.Further-zone of hyperemia
Depth of wound estimation
Clinical- Apperance, Pin prick test, use of dye
Imaging-U/S,MRI
• Major or Severe Burns also includes;

1. High voltage Electrical burns

2. Significant burn to face, eyes, ears, fingers, feet, joints, or genitalia
3. Significant associated injuries e.g. fractures & other major trauma
4. Inhalational Injuries
INHALATION BURNS

• Inhalational injury is Classified as supraglotic ,subglotic , or Global

• Causes upper airway obstruction secondary to; -Reflex Laryngospasm –Oedema -Sloughing of the mucosa ,
reduced clearance blockage and infection( Pneumonia)

Clinical presentation
• -History of having been injured in an enclosed space e.g. house, motor vehicle
• -Physical examination
• 1) Facial burns
• 2) Soot in nasopharynx
• 3) Respiratory distress- Tachypnoea - ≥25 breaths/min, Stridor, flaring of alae nasae
• 4) Coughing up carbonaceous sputum/soot
• 5) Hoarseness of voice (will indicate vocal cord swelling)
• 1) Admit patient to High dependency care or ICU

• 2) Intubate earliest opportunity to avoid difficulty once edema sets in. Tracheostomy is indicated in
the first several days for patients who are expected to require ventilatory support for a few weeks or more.
If the neck is burned, excision and grafting followed by tracheostomy is indicated in order to improve
pulmonary toilet.
• 3) Give 100% O2 by Mask or Endotracheal tube in serious inhalational injury. Should be moist the
humidity will help loosen the secretions and prevent drying of the airway;
• 4) Bronchodilators by aerosol or aminophylline intravenously may help if wheezing is due to reflex
bronchospasm.
• 5) Suction /lavage of bronchial secretions (bronchial toilet)

• 6) Chest physiotherapy with postural drainage is also required.

• 7) Bronchoscopy to evaluate extent of inhalational injury at same time do bronchial toile

• 8) Investigation-Measure carboxyhaemoglobin; With 100% O2, t½ of CO Hb
falls from 250mins to 40mins
• Others investigations
•  BGA
•  Hb
•  CXR.
• NB Pulse oximetry - Unreliable (may be normal
• Patient need about 10-15 % more of IV fluid calculated)
ADMISSION CRITERIA

• Indications for Admission

• A. Cause;

• 1)Electrical burns including lightning injuries

• 2)Chemical burns with serious threat of function or cosmetic impairment

• B)Severity;

• 1) Moderate & Severe burns

• 2) 3rd & 4th Degree burns regardless of TBSA

• 3) Non-healing burns after 14-21days

ADMISSION CRITERIA

• C)Anatomical location;
• 1)Head, neck, hands, soles, Perineum
• 2)Circumferential limb burns
• 3)Burns to the back
• 4) All inhalational injuries
ADMISSION CRITERIA

• D) Patients factors

• 1)Extremes of age (<4yrs & >50yrs)

• 2)Burns of both limbs in an Obese patient

• 3)Pregnancy

• 4)Any burn with concomitant trauma in which the injury poses the greatest risk of
morbidity or mortality
• 5)Burn injuries with pre-existing medical disorders that could complicate
management, prolong recovery or affect mortality e.g. Diabetes and
Hypertension, Epilepsy, Blind or Deaf, Infection, Renal problems
CASUALTY AND WARD MGT OF BURNS

• Casualty and Ward Management Goals

• A. The first 48hrs - All efforts are towards resuscitation & saving lives
• B.48hrs -6months- Prevention of complications
• C.>6months- Reconstructive surgery, Rehabilitation, Training
• The first 48hrs
• On arrival at casualty
• 1.Primary Survey - Airway with cervical spine control (Look out or & manage
inhalational injury),Breathing , Circulation & hemorrhage control, Disability & Exposure
• At this point -IV access large bore -Central Venous Pressure Monitor (CVP)
• -Urethral catheterization- urine Output monitoring- do not forget fluid input output
charting
• -NG tube
• -Endotracheal intubation if inhalational burn
• 2. Secondary Survey
 -History of the burn- take a meticulous history paying attention to details
 -Physical examination from head toe
 - Calculation of the BSA

• 3.Medical Management
• i) IV Fluids resuscitation
• For Moderate & Major/Severe Burns
• -Parkland's Formula
• 4mL/Kg /TBSA
• -Crystalloids: Ringers Lactate or Hartmann's solution, NS -Give ½ within 8hrs
since the burn occurred and the rest in the next 16hrs (most fluid loss occur 8-
12 hours after the burn)
• -Give ~50% more in electrical burns & inhalational injury
Monitoring of fluid therapy
• 1-Adequate resuscitation is measured by urine output; (best guide)
• Adults - 30-50mls/hr and Children - 0.5-1ml/Kg/hr
• -Increase rate of infusion if the urine is less than 20ml/hr and decrease rate of
infusion if the urine output greater than 60ml/hr because of risk of pulmonary
oedema especially in inhalational injury
• -However in electrical burns aim for 100ml /hr of urine to flush the kidney.
Alkalization of the urine by adding sodium bicarbonate to the IV fluid increases
the solubility and clearance rate of myoglobin in the urine
• -Hemaglobinuria suggest deep burn hence flush the kidney with increased
fluids and mannitol
• -Decrease in BP and urine output suggest need for colloids but a decrease in
urine output but normal BP suggest need for crystalloids
• 2- Pulse and BP recording .Pulse should be less than 120/minute
• 3-State of patient should be calm
• 4--Frequent chest auscultation to detect pulmonary oedema
• 5-Cerebral oedema especially in children may occur during fluid therapy
• 6-If possible CVP line is best guide for avoiding over infusion
• 7-Evaluate treatment every 3-4 hours
Causes of inadequate fluid resuscitation in a burns patient
• Inaccurate estimate of burn size,
• Undiagnosed inhalational injury
• Concomitant traumatic injury,
• Cardiac dysfunction,
• Refractory shock,
• Mathematic miscalculation
OTHER FLUID CALCULATION FORMULARS

• 1.Evans Formula

• 2ml/Kg/TBSA

NB -TBSA only up to 50 %
• -Total fluid given as mixture of colloids and crystalloids in the ration of 1:1.

• Colloid include, blood and blood products- plasma, albumin dextrans, Gelatins as haemacele
and Gelofulsine
• Crystalloids are Normal Saline, Hartmans solutions

• -Add 2000ml(2L) of 5% dextrose for insensible losses

• -Half of all the fluids given I the 1st 8 hrs since occurrence of burn and the rest in next 16 hours

• -After 24 hours give half of the fluids (1ml/kg/BSA) plus the 2 of 5 % dextrose.
2.Brook Army formula
• 2ml/Kg/TBSA

• NB -TBSA only up to 50 %

• -Total fluid given as mixture of crystalloids and colloids in the ration of 1.5:0.5 respectively

• -Colloid include plasma, blood, dextrans, albumin 34

• -Crystalloids are Saline, Hartmans solutions

• -Add 2000ml(2L) of 5% dextrose for insensible losses

• -Half of all the fluids given in the 1st 8 hrs since occurrence of burn and the rest in next 16 hours

• -After 24 hours give half of the fluids (1ml/kg/BSA) plus the 2L of 5 % dextrose.
• ii)Analgesics
• Give opiate analgesics IV (IM is ineffective erratic absorption); NSAIDS
• iii)PPI or H2 Blocker
• Protection from Curling's Ulcers (duodenal ulcers which occur in burn patients)
• iv)Tetanus toxoid
• v) Prophylactic antibiotics If TBSA >15%
• If less do M/C and sensitivity before antibiotic administration
• vi) Optional Drugs
• -DVT prophylaxis in lower limb burns
• -Tetracycline eye ointment for Face burns
• -Insulin if Diabetic or hypertensive control if hypertensive
• Wound care
• i)Remove all necrotic tissue & debris
• ii)Rupture blisters except those on the palms & soles of feet and those >1cm in diameter. Can do early escharectomy
and grafting
• iii)Wash wound with soap & water or normal saline
• iv)Apply topical antibiotic e.g. -Silver sulphadiazine (S/E - thrombocytopenia, leucopoenia,
• rash-sulfonamide sensitivity)
• -0.5% Silver Nitrate - Stains tissues & can cause hypochloraemic alkalosis & hyponatraemia; Good for grafts
• -Mafenide 10% - can penetrate tissue & eschar. Good for infected wounds & eschars. very painful on application;
carbonic
• anhydrase inhibition causing metabolic acidosis; sulfonamide sensitivity rash
• Dermazine concortion- silver sulphur diazine, zinc, phenytoin sodium, antibiotic
• v) Dressing

• Open Dressing - No dressing applied

• Exposure Dressing - Apply soothant e.g. Vaseline

• Occlusive dressing e.g. for small superficial previously debridedwounds

• Apply non-stick material e.g. Bactigras

• -Apply 3-5 layers of dry material e.g. gauze

• -Cover with crepe bandage

• -Change after 3days & then daily up to day 21. If there is no healing, consider skin grafting.

• -Silver sulfadiazine/transparent polythene bags for hands

• -Skin grafting e.g. for frictional burns.

• Indications for occlusive dressing
• -If the burn is oozing too much
• -If there is risk of infection
• -Children
• -If co-morbid conditions present
• -Joints
• -Patient's comfort
• 48hrs - 6months Management is based on complication

• control

• Escharotomies

• Surgical division of constricting eschars (scab formed especially after a burn).

• Indications;

•  3rd & 4th Degree Burns

•  Circumferential burns - may compromise distal extremity blood flow. Performed on

the midlateral or medial aspects of limbs, chest burns that would impair respiration
• Escharectomy
• Surgical –Tangential excision
• Medical –Use of mafenide , soaking with NS
COMPLICATIONS OF BURNS

• Instant complications
• 1.Inhalational injury
• 2.Dehydraion
• Immediate-hours
• 1.Haemorrhage
• 2.Airway obstruction
• 3.Circulatory collapse
• Early complications-days
• 1.Anaemia
Haemorrhage (Wound, GIT)
Thermal injury to RBCs
• 2.Electrolyte imbalances
•  Severe burns decrease Na in circualation but total body Na is increased.
•  Hyperkalemia
• 3.Infection;
•  0-7days - Contamination
•  >7 days – Sepsis
• 4. ARDS-inflammatory response
• Renal failure
• Deep venous thrombosis
• Myonecrosis
• Chronic ulcer.
• After 6months - Reconstructive surgery, Training &

• Rehabilitation

• -Physiotherapy - Splint at night & Motion during the day

•  To control pain

•  Reduce oedema & swelling

•  To protect the wound

•  To minimize cosmetic defects

•  To maximise patient's function

• -Start physiotherapy from day after escharotomy- do it 5 times a week. At night do nocturnal
splintage and for sleep comfort and avoid contractures
COMPLICATIONS OF BURNS

1. Hypertrophic scars - Itchy, Hyperaemic, Uncomfortable

2. Keloids - A keloid is a true tumour arising from the connective tissue
elements of the dermis.
• By definition, keloids grow beyond the margins of the original injury or scar; in
some instances, they may grow to enormous size.
• Mx - Local injection of Steroids & Bleomycin, Excision & Superficial irradiation

3. Contractures
4. Marjolin's ulcer - SCC developing in old burn site