MANAGEMENT OF BURNS

NANDANA -082021100066
THRUPTHI - 082021100070
VAISHNAVI- 082021100073
TOPIC Classification of burns

Assessment of burns
LEARNING Injury various systems
OUTCOMES Outline the fluid resuscitative methods of burns

Evaluate the definitive local management of

burns

Surgery for a ute burn wound

Discuss about the effects of Non - thermal burn

injury
CLASSIFICATION AND ASSESSMENT
OF BURN
Classification of burns
Depending on the thickness of the skin involved (1)

1. First degree: epidermis is red and painful without blisters, heals in 5-7
days by epithelialisation without scarring
2. Second degree: area is red, mottled, painful with blisters, heals with
epithelialisation in 14-21 days
3. Third degree: area is charred, parchment like painless and insensitive,
thrombosis of superficial veins, grafting is required
Eschar ; Charred, denatured, insensitive, contracted full thickness burn
4.Fourth degree: Underlying tissue is involved
Classification of burns
Depending on the thickness of the skin involved (2)

1. Superficial partial thickness burns

2. Deep partial thickness burns
3. Full thickness burns
Classification of burns
Assessment of the burn wound
Assessing size

Burn size needs to be formally

assessed in a controlled environment.
An accurate way of measuring the size
of burns is to draw the burn on a Lund
and Browder chart, which maps out
the percentage TBSA (total body
surface area) of sections of our
anatomy
The ‘rule of nines’, which states that
each upper limb is 9% TBSA, each
lower limb 18%, the torso 18%, each
side and the head and neck 9%
Assessment of the burn wound
Assessing depth

Burns are temperature and time dependent

It takes 6 hours for skin at 44 C to suffer irreversible changes but 1
second at 70 C for epidermal destruction
Injury to the airway and lungs
Physical burn injury to the airway above the larynx

Hot gases can physically burn the nose, mouth and tongue, palate and
larynx
The linings of the structures will start to swell and may interfere with
the larynx and block the airway
Physical burn injury to the airway below the larynx

Thermal damage can cause the respiratory epithelium to rapidly swell

and detach from the bronchial tree and create casts which can block
the upper airways
Injury to the airway and lungs
Metabolic poisoning
Carbon monoxide: altered consciousness, lethal at concentration of
60%

Inhalational injury
Minute particles are carried down to the lung parenchyma, they stick
to the moist lining and cause an intense reaction to the alveoli
Causing edema within the alveolar sacs and decreasing gaseous
exchange
Injury to the airway and lungs
Mechanical block on rib movement

Thick and stiff burnt skin can physically stop the ribs moving if there
is a large full thickness burn across the chest
Inflammatory and circulatory changes
Burned skin activates a web of inflammatory cascades
The stimulation of pain fibers cause the release of neuropeptides and
activates the complement system
Complement causes the degranulation of mast cells and coats the
protien altered by the burn attracting neutrophils which degranulate
releasing free radicals and proteases leading to further damage to the
tissue
Cytokines like TNF-alpha are released which act as chemotactic
factors and cause release of secondary cytokines
These inflammatory factors alter the permeability of blood vessels
Inflammatory and circulatory changes
Heat causes coagulation necrosis of skin and subcutaneous tissue
↓
Release of vasoactive peptides
↓
Altered capillary permeability
↓
Loss of fluid → Severe hypovolaemia
↓
Decreased cardiac output
↓
Decreased renal blood flow
(Renal failure)
Altered pulmonary resistance causing pulmonary oedema
↓
In case of infection
↓
Systemic inflammatory response syndrome (SIRS)
Other life threatening events
Immune system
Cell mediated immunity is reduced in large burns - more susceptible
to bacterial and fungal infections
Gastrointestinal system
Microvascular damage and ischemia to the gut mucosa
Reduced gut motility and prevents the absorption of food
Peripheral circulation
Elasticity of skin is lost, a full thickness burn will act as a tourniquet as
the limb swells which can proceed to limb ischemia if untreated
Immediate care of the burn patient
Criteria for acute admission
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
FLUID RESUSCITATVE METHODS OF
BURNS
Fluids resuscitation
The resuscitation volume is constant to the area of the body burned
The resuscitation volume is divided into two;
- The first half is given for the first 8 hours
- The second half is given to the rest 16 hours

oral rehydration intravenous rehydration

The oral solution given must Indicated in children with burn
not be salt-free >10% TBSA
oral rehydration with a Indicated in adults with burns
solution such as Dioralyte®. of
15% - 30% TBSA
Resuscitation volume

The volume needed in resuscitation is relatively

constant with the total body surface area (TBSA) burned

Parkland’s formula
calculate ideal amount of fluid required to rehydrate and prevent further
damage to burn patients
TOTAL PERCENTAGE BODY SURFACE AREA × WEIGHT (KG) × 4 = VOLUME (ML)
 TYPES OF FLUIDS USED

Ringer’s lactate Human Albumin Solution Hypertonic saline

contains lactate which buffer (HAS) reducing fluid shifts,
metabolic acidosis in the early volume expander in the burns decreasing tissue
post- burn phase shock resuscitation edema,
to correct hypoalbuminemia in causing fewer
the chronic period attendant
complications
 Crystalloid Resuscitation Colloid Resuscitation
as effective as colloids for maintaining plasma proteins are responsible for
intravascular volume the inward oncotic pressure which
non-burnt capillaries still sieve counteracts the outward capillary
proteins normally even when the large hydrostatic pressure
protein molecules leak out of proteins are given after the first 12
capillaries which is involved in burn hours of burns
injury
Pros: Pros:
less expensive remains intravascular
non- allergic
molecules are small enough to freely Cons:
cross capillary walls expensive
Cons: risk of anaphylaxis
higher volume is required
risk of edema
do not stay intravascular
 Monitoring of Resuscitation

1. urine output should be between 0.5-1.0 mL/kg body

weight per hour
if the output is below, the infusion rate should
increase by 50%
inadequate urine output and hypoperfusion: bolus of
10mL/kg body weight is given
2. acid-base balance appropriate in larger, more
complex burns
3. hematocrit measurement is useful in confirming
suspected under or over-hydration
DEFINITIVE AND LOCAL
MANAGEMENT OF BURNS
CHRONOLOGY OF MANAGEMENT OF BURNS
IMMEDIATE CARE
HOSPITAL CARE
ASSESSMENT
WOUND MANAGEMENT
IMMEDIATE CARE HOSPITAL CARE
Ensure safety Airway control
Stop burning process Breathing and ventilation
Check for other injuries Circulation
Cool the burn wound Disability- neurological status
Give oxygen Exposure to environmental
Elevate control
Fluid resuscitation
ASSESSMENT OF WOUND WOUND MANAGEMENT
Escharotomy (Only full thickness
burn)
Wound Dressing
Wound debridement and grafting
Escharotomy
An emergency procedure done to restore perfusion and allow adequate
ventilation
Mostly in circumferential full-thickness burns to the limbs
This should be done in the mid-axial line, avoiding major nerves
can cause a large amount of blood loss; thus adequate blood should be
available for transfusion
Wound Dressing
Full thickness burns and obvious deep dermal wounds
Dressing with nanocrystalline silver:
1. Silver sulphadiazine cream (1%)
2. Silver nitrate solution (0.5%)
3. Mafenide acetate cream
4. Silver sulphadiazine and cerium nitrate

Superficial partial thickness wounds and mixed depth wounds

1. Simplest way to treat superficial
wounds is by exposure and need
simple dressings
2. Full thickness and deep dermal burns
need antibacterial dressing to delay
colonisation prior surgery
Wound debriment and Grafting
Debridement is a process of removing dead skin that is exposed to burn
In some severe cases, the burn excision can be down to viable fat thus
wherever possible a skin graft is applied immediately.
With large burns- synthetic dermis or homografts provide temporary
cover
- allow complete excision of the wound
- reduces the burn load on the patient
ADDITIONAL ASPECTS OF TREATING THE BURNED
PATIENTS
ANALGESIA
Acute
small and superficial burns shows good prognosis to simple oral analgesia
large burns: intravenous opiates
Subacute
In large burns
infusions----> oral tablets
ENERGY BALANCE & NUTRITION
Any adult with a burn greater than 15% and children with a burn 10% of
TBSA
Patients with burns of 20% or greater nasogastric tube is given
In acute episode burn injuries are catabolic
Excision and stable coverage of burn wounds are significant in reversing
catabolic state of the person
MONITORING AND CONTROL OF INFECTIONS
Patients with large burns are immunocompromised and have
compromised local defence in the lungs and gut
Swabs are taken regularly to ensure any infection
Sterile precautions must be rigorous
A rise in WBC, thrombocytosis and increased catabolism are warnings of
infection
NURSING CARE
taking care of patient’s hygiene and baths
Nursing care provides psychological impact on the patient and their
family
Physiotherapy
helps in reducing swelling and improve the outcome
Psychological
Non-pharmacological approaches to pain control, such as hypnosis and
relaxation, can be effective
Educate and provide support to family members.
SURGERY FOR THE ACUTE BURN WOUND
Deep partial-thickness and full-thickness burns need surgery
burns of indeterminate depth should be reassessed
Deep dermal burns need tangential shaving and split skin grafting
Topical adrenaline reduces bleeding
All burnt tissue needs to be excised
Stable cover, permanent or temporary , should be applied at once to reduce
burn load
DELAYED RECONSTRUCTION OF BURNS
Eyelids must be treated before exposure keratitis arises
Transposition flaps and Z-plasties with or without tissue expansion are useful
Full thickness grafts and free flaps may be needed for large or difficult areas
Hypertrophy treated with pressure garments
Pharmacological treatment of itch is important
MINOR BURNS/OUTPATIENT BURNS
LOCAL BURN WOUND CARE
BLISTERS
Uncertainty on blister removal or to leave intact has been a subject of debate:
Suppresses immune function
Retards chemotaxis and intracellular killling
Provide medium for bacterial growth
Leaving blisters intact could act as sterile stratum spongiosum

INITIAL CLEANING OF WOUNDS

Washing burn wound with chlorhexidine solution
Topical Agents

Non adherent material - vaseline impregnated

gauze or Mepitel used for dressing
dressing left in place for 5 days
topical agents like silver sulphadiazine 1% or
Flamazine
Avoid in pregnancy, nursing mother and infant less
than 2 months because high risk of kernicterus
Dressing of Minor Burn Wounds

Aim:
▪Reduce pain
▪Protect and isolate burn wound
1. First layer:
▪Vaseline gauze or
▪Non adherent dressing (Mepitel)
2. Gauze or Kerlix wrap about with firm intactness
without impeding circulation
3. Wound is bandaged
Synthetic burn wound dressings:
▪Biobrane
▪Duoderm (Hydrocolloid dressings)
Advantages of synthetic burn:
▪Reduces dressing pain
▪Improved healing rate
▪Outpatient appointment reduced
▪Cost effective
 Biobrane® Duoderm®
Type Bilaminar dressing Hydrocolloid dressing
Material Inner layer: non bulky
▪ Knitted nylon threads
coated with porcine collagen
Outer layer:
▪Rubberised silicone
impervious to gases,
impermeable to fluids and
bacteria
Applied in Fresh burn wounds (<24hrs): Burn wounds to be kept in
Sensate position for 48-72hrs
Capillary blanching
and refill
After blister removal

Uses Prevent entry of fluids and

provide moist environment
Maintain moist bacterial
and re-epithialises burn
environment
wound
 Healing of Burn
Wounds
Conservative management of burn wounds
renders healing within 3 weeks
Absence of reepithelialisation during the
period
Wound requires debridement and grafting
 Infection
Transformation for aggressive management:
▪Superficial burn!
▪Partial thickness burn!
▪Deep partial thickness burn
Tackled with combination of:
▪Topical and
▪Systemic agents
▪Debridement
▪Skin grafting
 Itching
Aetiology: Therapeutic agents:
▪Histamine ▪Cyproheptadine
▪Endopeptides ▪Loratidine
Successful treatment: ▪Topical doxepin cream
▪Antihistamines
▪Analgesics
▪Moisturising creams
▪Aloe vera
▪Antibiotics
▪Gabapentin (severe itch)
 Traumatic Index

Healed burn wounds are vulnerable to develop traumatic

blisters due to fragile new epithelium
Management:
▪ Non adherent dressings
▪ Regular moisturization
 Effects of Nonthermal Burn
Injuries Classification
1.Electrical injuries
a.Low tension injuries
b.High tension injuries
2.Chemical injuries
3.Ionising radiation injury
4.Cold injuries
a.Acute cold injuries
b.Frost bite
 1. Electrical injuries
ELECTRICAL LOW VOLTAGE HIGH VOLTAGE
INJURIES INJURIES INJURIES
Aetiology 3 sources of
impairment:
Flash
Flame
Current

Character Insufficient energy to Sufficient current to

destroy notable quantities destroy subcutaneous
of subcutaneous tissue tissue and muscles
 ELECTRICAL LOW VOLTAGE HIGH VOLTAGE
INJURIES INJURIES INJURIES
Small localised deep Direct myocardial
Effects
burns damage without pacing
Cardiac arrest via disruption
pacing disruption Compartment
without marked direct syndrome resulting
myocardial damage from damage of
Little damage to underlying muscles
underlying nerve and Secretion of
tendon myoglobins causing
Tetany myoglobinuria .
 Limbs require:
Treatment Resuscitation
Fasciotomies or
Amputation .
Treatment of
myoglobinuria :
Resuscitation with
maintainence of high
urine output upto
2ml/kg body weight per
hr biocarbonate
boluses for acidosis.
Primary amputation
(a) An exit wound of a high-tension (b) Amputation and cover with the lateral
injury, with a dead big toe and portion of the second toe
significant damage to the medial
portion of the second toe.
 2. Chemical Injuries
Burns within the chemical industry by 70000 different chemicals in
regular use

Management:
Lavage with copious water, except: Phosphorus and elemental sodium
These substances need to physically removed with forceps
Identify Chemical and its concentration to elucidate whether any
underlying threat to patients life if absorbed systemic threat
Hydrofluoric acid- Topical calcium gluconate gel
Severe burns - Component of Bier’s blocks, Calcium gluconate 10% gel
Acute early excision in >50% burns
Delayed stage split skin graft of hydrofluoric acid wounds
Effects
Burns with >50%:
- Hypocalcaemia
- Subsequent arrhythmias
Physical damage to cutaneous tissue
Poisoning in systemic absorption
 3. Ionising Radiation Injury
Classification
Classification based on regional
exposure:
Whole body
Localised
Management

Conservative to the extent of apparent tissue injury

Excision of ulcer and vascularized tissue coverage
Vascularised flap cover using free flaps Iodine
tablets
Supportive management
Effects
Whole body irradiation causing acute
desquamation of the skin
Slow unpleasant death to lethal doses of
radiation
4. Cold Injuries
Classification
Industrial injuries result in acute cold injuries
Frost bite
Effects
Liquid nitrogen exposure causes destruction of
epidermis and dermis
No marked inflammatory reaction due to tissue
resistant to cold than heat injury
Delayed microvascular destruction
Conservative surgery
Management
Rapid rewarming bath at 42°C
References
Bailey and Love’s short practice of surgery 27th edition