Burn and burn management

DR.KHADIJA EL.RABIE
MBBCh , MD
Plastic and reconstruction surgeon
 Introduction

Pathophysiolo Classification
gy
Conte
nt

Complications
Management

Estimate of
burn size
 Introduction

Definition of Burn
-Coagulative necrosis of the
skin due to exposure to
abnormal physical and
chemical agent
The functions of the skin include:
o Temperature regulation
o Sensory interface
o Immune response
o Protection from bacterial invasion
o Control of fluid loss
o Metabolic function
o Psycho-social function
Introduction

Friction
Wet Heat
Burn

Radiation Dry Heat

ElectricityChemicals
Causative Agents
 Wet Heat

Commonest type of burn

Friction injury
Burn
1-Water

2-Steam
Radiation Dry Heat
3-fat-oil

ElectricityChemicals ( the max temperature u

can hold in your hand
without throwing the object
away is 60 degrees).
 Dry Heat

1-Flame : e.g. matches,

Friction cigarettes, gas .
Wet Heat
Burn
2-Domestic appliances
e.g.: irons.
Radiation

ElectricityChemicals
 Chemicals

1-It can be acid or alkali.

Friction
Wet Heat 2-Degree of injury depends
Burn on strength of agent, its
concentration and duration
of contact with skin.
Radiation Dry Heat
3-Risk of absorption and
systemic effect.

4-Risk of inhalation of
Electricity fumes.
 Chemicals

Indicators of inhalation
Friction injury:
Wet Heat
Burn
•In closed space
•Head, Face, Neck or Chest
Radiation Dry Heat burn
•Singed Nasal hair or
eyebrow
•Hoarseness, tachypnea
Electricity •Nasal/Oral mucosa red or
dry
•Soot around mouth or
nose
•Coughing up black sputum
 ElectricalEffects depend on:
1-Amount of electricity
(Voltage)
2-Nature of current (AC or
Friction DC)
Wet Heat
Burn 3-Area of contact
4-Duration of contact

Radiation Dry Heat -Dry skin has high

resistance.
-Wet or sweaty skin has
low resistance
Chemicals
in electrical burns there is
an entery wound (small)
and an exit wound (large)
 Radiation

1-UV light from sun or

Friction sunbeds (the
Wet Heat
Burn commonest)
2-Usually superficial
but may be
Dry Heat
widespread.
3-Post radiotherapy.

ElectricityChemicals
 Friction
Burns

•E.g RTA When the victim is

pulled out of the car ,
Wet Heat Slides over the road.

Radiation Dry Heat

ElectricityChemicals
 Pathophysiology
 Local Effect:
 Three Zones within a
major burn
▪ Zone of coagulation
-devitalized,
necrotic, white, no
circulation
▪ Zone of stasis
-may covert to full
thickness, mottled
red
▪ Zone of Hyperemia
-outer rim, good
blood flow, red
 Pathophysiology
 Systemic Effect:
▪ The release of cytokines and other inflammatory
mediators at the site of injury has a systemic effect
once the burn reaches 30% of total body surface
area.

▪ Cardiovascular changes—Capillary permeability is

increased, leading to loss of intravascular proteins
and fluids into the interstitial compartment., result in
systemic hypotension and end organ hypoperfusion.

▪ .Immunological changes—Non-specific down

regulation of the immune response occurs, affecting
Classification-depth of the
burn
Classification
destruction of
epidermis.
1 Superficial burns 1st degree
 Very painful, dry, red
burns due to dilation of
2Superficial partial-thickness 2 nd
degree dermal capillaries,
which blanch with
pressure. They usually
3 Deep partial-thickness 2nd degree take 3 to 7 days to
heal without scarring.
4 Full thickness 3rd degree The most common
type of first-degree
5 4th degree burn is sunburn. First-
degree burns are
limited to the
epidermis, or upper
layers of skin.
Classification
Involve epidermis
& superficial portion
of dermis.
1 Superficial burns 1st degree

Typically, they
2Superficial partial-thickness 2 nd
degree blister with clear
fluid and are moist,
red, weeping burns
3 Deep partial-thickness 2nd degree
which blanch with
pressure .
4 Full thickness 3rd degree
They heal in 7 to
5 4th degree 21 days.

 Scarring is usually
confined to changes
Classification
Extend to reticular
dermis.

Bloody blistering
1 Superficial burns 1st degree
which are non
blanching which could
2Superficial partial-thickness 2 nd
degree be wet or waxy.

Their color may

3 Deep partial-thickness 2nd degree range from patchy,
cheesy white to red.
4 Full thickness 3rd degree Less painful than
superficial partial
5 4th degree thickness burn.

They take over 21

days to heal and
scarring may be
Classification
Whole of the dermis .
It is Painless, dry,
1 Superficial burns 1st degree hard leathery.
Capillary refill will be
absent .
2Superficial partial-thickness 2 nd
degree
 May see coagulated
vessels.
3 Deep partial-thickness 2nd degree Skin grafts are
necessary.
4 Full thickness 3rd degree Charred with eschar
which is black, grey,
5 4th degree white or cherry red in
colour, hairs not
attached, may see
thrombosed veins.
Classification

1 Superficial burns 1st degree

It is a life
threatening injuries.
2Superficial partial-thickness 2 nd
degree
Extends through
skin, subcutaneous
3 Deep partial-thickness 2nd degree tissue and into
underlying muscle
and bone.
4 Full thickness 3rd degree
Dry, painless.
5 4th degree
 Estimation of burn size
 Rule of nines 4.5
4.5
▪ Also known as
Wallace’s rule of 9.
▪ The most common
method, but not the
18 18
best. 9 9
▪ It is different in 4.5 4.5 4.5
children due to their 1
different surface 18 18
area, they have 9 9 9 9 1
bigger head and
small limbs in 7 7 7
proportion to their
trunk
 Estimation of burn size
 Lund an Browder
Chart
▪ The best and most
accurate method.
▪ It considers the
variation of the
surface area
. according to the age.
▪ Only partial and full
thickness burns are
included in this
estimate of burn
size.
Estimation of burn size
• Ruleof Palms:
Good for
estimating small
patches of burn
wound
Burn Unit Referral Criteria
 Greater than 15% burns in an adult, and more than 10% burns in a
child .

 Inhalation injury.

 Any full thickness or deep dermal burn .

 Burns of special regions: face, hands, perineum.

 Circumferential burns .

 Associated trauma or significant pre-burn illness: e.g. diabetes .

 Any patients with burns and concomitant trauma (e.g., fractures).

 Management
 Resuscitation primary survey
 ABC’s

a) Airway: ensure adequate airway.

b)Breathing:
▪ Circumferential burns of neck or chest may constrict breathing.
▪ Strider or difficulty breathing indicates endotracheal intubation
or ventilation .
▪ Prophylactic endotracheal / nasotracheal I ntubation in case of:
inhalation Injury.
supraglottic obstruction.
extensive burns > 60%.
deep facial burns. facial fracture. Closed head injury with
unconsciousness.
c)Circulation:
Monitor : pulse, BP, failure to maintain adequate circulation may be
the initial response by medical personnel should include the
:following
Consider burn patient as a multiple trauma patient until determined
otherwise

1. Primary survey

•Airway maintenance with cervical spine control Rapid airway

compromise
•Breathing and ventilation Beware of
inhalational injury
•Circulation with haemorrhage control Fluid
replacement
•Disability and evaluation of neurological status
Compartment Syndrome
•Exposure with environmental control
Percentage area of burn
Management
 History
 The cause
 Time and place
 Age
 Any chronic illnesses, e.g. DM,
HTN..etc
 Immunization for tetanus ( open
wounds), we give immunoglobulin
for patients who have never been
 Management
 Exam.
 Expose patient TOTALLY, remove
any burned clothing.
 Examine generally.
 Suspect any associated injury.
 Examine locally at the site of burn:
Assess depth (degree) &
calculate the size of burn.
 Management
 Monitor the resuscitation
by IV fluids:
 Fluid replacement is the
prime object of initial burn
treatment.
 IV resuscitation is required
for any burn patient with; To assess fluid
requirement we need
more than 10% of body to identify:
surface in children
1. Time of burn
or more than 15% of body 2. Patient weight
surface in adult. 3. %TBSA involved

 Assess fluid requirement.

 Resuscitation Formulas
 Parkland’s formula:
 Using Ringer's lactate solution

4ml ringer's lactate x body weight x % of burn

= total fluids for 24 hours

▪ Give half of the calculated total fluid in first 8.

▪ Second and third 8 hrs, give one fourth.

 In the 2nd day u give colloids..and plasma

protein factors..and potassium
Management
 Maintenance fluid:
 For adult ; 2-3 liters/day

 For children
A- first 10 kg
100cc/kg
B- from 10-20kg
50cc/kg
C- above 20kg
Management
 Dressing:
 The aim of the burn dressing is
to keep the wound clean and
dry, and prevent infection
 Two types.
Management
Leave it exposed
Just put ointment
such as Flamazine
(silver
sulphadiazine
cream or Mebo ).
Used for face or Open Method
limbs burns (the Dressi
limb should
elevated to reduce
be ng
edema).
Silver
Types
Sulphadiazine is for
pseudomonas & not
to apply on face
( very irritant !) 
use MEBO instead .
Be careful for
silver allergy( they
Management

Closed Method Open Method

Dressi
ng
Types
Management
The burn is
cleansed with
antiseptic solution
Covered with silver
sulphadiazine cream
(antibacterial).
 Non adherent
Closed Method
Dressi layer of gauze.
Absorbent layer
ng Cotton wool
Change the
Types dressing daily or as
often as necessary.
On each dressing
change, remove any
loose tissue.
Always use Closed
dressing except :
Management
 Supportive Care
 Physiotherapy:
from the first day.

 Analgesia:
Methadone.
IV morphine for acute pain
▪ Don't give analgesia in cases of intracranial or intra
abdominal injury (we have to exclude them first) 
coz it will mask them.
Burn Complication
 Infection: most serious complication (pneumonia)

 GI complications: Curling ulcer in 12% of all burn patients (prevented by

prophylactic antiacids and H2 blockers)

 Respiratory complication: major cause of death in burned patient.

 Hyperkalaemia in the 1st 24 hr because the destruction of RBCs.

In the 2nd day there will be hypokalemia due to potassium loss in the urine.

 Suppurative thrombphlebitis(change iv position in the first 72hours)

 Circumferential burn relived by escharotomy

 Cataract.

 Late Complications:

▪ Dyspigmentation .
▪ Wound contracture.
Thank You
Any Questions