BURNS

Definition
Types (etiology)
Degrees (classification)
Pathophysiology (local & systemic )
Burn assessment ( 9, palm, browder)
Managemnt ( Emergent, acute, rehablitation)
Reconstructive surgeries
Burn
Definition

A burn is a coagulative destruction of the surface layers of the

body that occur when some or all of the cells in the skin or
other tissues are destroyed by:
 Heat

 Cold

 Electricity

 Radiation

 Chemicals
Causes

Thermal
burns

Inhalation Chemical
injuries burns

Electrical Radiation
burns burns
Types of Burn Injury

 Depending upon etiology :

Thermal

 Flame : Fire injury

Contd.
Chemical burns

 Acid produces tissue Necrosis

(accidental cell death due to

ischemia )
Contd.

Electrical

 Electrical current injury

Contd.

Inhalation: Hot smoke

Radiation: sunburn
Contd.

 Depending upon degree:

 First degree
 Second degree
 Third degree
 Fourth degree
Contd.

 First degree/ Superficial burns

 Involves only epidermis

 Epidermis looks red and painful

 No blisters formation, dry texture

 Heals rapidly in 5-7 days by

epithelialization without scarring

Contd.

 2nd degree burns

 Superficial partial thickness burns (Papillary dermis)

 Very painful, redness with clear blisters, moist texture

 Blanches with pressure

 Heal in less than 2-3 weeks

Contd.

 2nd degree burns

 Deep partial thickness burns (Reticular dermis)

 Yellow or white, less blanching, fairly dry in texture, feeling

of pressure and discomfort, heal with in 3-8 weeks

Contd.

 3rd degree burns/ Full thickness burns

 Extends throughout the dermis

 Stiff and white- brown in color, no blanching

 Leathery texture, painless sensation

 Healing time is prolonged (may be months or years,

sometimes incomplete)
Contd.

 4th degree burns

 It involves underlying tissues,

muscles and bones.
 Black in color, eschar is present

 Painless and texture is dry

Degree 1st Degree 2nd Degree 2nd Degree 3rd Degree 4th Degree
of Burn Partial Deep Burns
Thickness

Involve Epidermis Epidermis + E+ D E+D+Subcut E+D+S+muscle

ment Dermis tissue s, tendons &
bone

Appeara
nce

Sympto Pain ++ Pain ++++ Painful -less Painless,insensit No Edema

ms & severe ive, Severe
Signs Edema

Healing 3-5 days , 2 weeks, min 2-6 weeks No spontaneous No spontaneous

spontaneou scarring, scarring / healing healing
s minimal formation of
No discolouration contractures
Scarring
Superficial (1st-degree)

Superficial partial thickness (2nd-

degree)

Deep partial thickness (2nd-degree)

Full thickness (3rd-
degree)

4th-degree
TBSA
1. Rule of nine: Best used for large surface area

 Head and neck 9%

 Each upper limb is 9 + 9 = 18%

 Each lower limb is 18 + 18 = 36%

 Chest and abdomen 18%

 Back 18%

 Perineum 1%

In children head and neck is 18% and lower limb is 13.5%

Rule of Nine
Contd.
2. Palm method:
 Best used for burns less than 10 %
 Used for irregular or splash burns

Patient’s entire hand area is 1%.

Clean piece of paper is cut to the

size of hand and through that

percentage of burns is assessed.
SEVERITY OF BURNS
It is determined by:-
Depth – first, second (partial thickness),third
degree(full thickness).
Extent- %age of TBSA.
Age – the very young & very old have a poor
prognosis; the prognosis alters for adults after age 45.
Area of the body burned – face, hands, feet,
perineum, & circumferential burns require special care.
Inhalation injury.
MANAGEMENT OF BURNS
Phases of burn care
25
Phase Duration Priorities
Emergent or From onset of injury to  First aid
immediate completion of fluid  Prevention of shock
resuscitative resuscitation  Prevention of respiratory distress
 Detection and treatment of injuries
 Wound assessment and initial care

Acute From beginning to near  Wound care and closure

completion of wound  Prevention or treatment of
closure complications, including infection
 Nutritional support
Rehabilitation From major wound  Prevention of scars and contractures
closure to return to  Physical, occupational, and vocational
individual’s optimal rehabilitation
level of physical and  Functional and cosmetic reconstruction
psychosocial  Psychosocial counseling
adjustment
Emergent phase
Emergent phase
*Immediate problem is fluid loss, edema, reduced blood
flow (fluid and electrolyte shifts)
Goals:
1. Secure airway
2. Support circulation by fluid replacement
3. Keep the client comfortable with analgesics
4. Prevent infection through wound care
5. Maintain body temperature
6. Provide emotional support
IV FLUID THERAPY

Clients with burns involving 15% to 20% of the TBSA

require IV fluid
Purpose is to prevent shock by maintaining adequate
circulating blood fluid volume
Severe burn requires large fluid loads in a short time to
maintain blood flow to vital organs
 Contd..

Fluid replacement formulas are calculated from the time of

injury and not from the time of arrival at the hospital

Diuretics should not be given to increase urine output.

Maximal Sterile Barriers
Secure IV Line
Weight of Patient
Estimation of Size of Burn
Start Fluid Resuscitation
Fluid Requirements

The projected fluid requirements for the first 24 hours are

calculated based on the extent of the burn injury.

Some combination of fluid categories may be used:

 Colloids (whole blood, plasma, and plasma expanders)

 Crystalloids/electrolytes (sodium chloride or lactated

Ringer’s solution).
Oral resuscitation can be successful in adults with less than

20% TBSA and children with less than 10% to 15% TBSA.
Contd.

Lactated Ringers - preferred solution

Contains Na+ - restoration of Na+ loss is essential

Contd.
 Consensus (Parkland) Formula:

Used to calculate a range for resuscitative phase fluid replacement in

the first 24 hours when the fluid shifts and the risk for hypovolemic
shock is the greatest.

Formula:
Pt wt. in KG X % Area burned X 2mL = Minimum fluid volume/24

hours
Then determine the maximum fluid volume/24hours as follows:

Pt wt in KG X % Area burned X 4mL = Maximum fluid

Contd.
Modified Parkland formula

Initial 24 hours: RL 3-4 ml X kg X % burn (adults)

Next 24 hours: Begin colloid infusion of 5% albumin

Resuscitation Solutions

Colloids- Albumin, Dextran

Crystalloids- RL, d5%,

NS, Hypertonic Saline
ACUTE PHASE
MANAGEMENT
 ACUTE PHASE OF BURN INJURY
• Lasts until wound closure is complete
• Care is directed toward continued assessment and
maintenance of the cardiovascular and respiratory
system
• Pneumonia is a concern which can result in
respiratory failure requiring mechanical
ventilation
• Infection (Topical antibiotics – Silvadene )
ACUTE PHASE OF BURN INJURY

• Tetanus Toxoid
• Weight daily without dressings or splints and
compare to pre-burn weight
• A 2% loss of body weight indicates a mild
deficit
• A 10% or greater weight loss requires
modification of calorie intake
• Monitor for signs of infection
LOCAL AND SYSTEMIC SIGNS OF
INFECTION- GRAM NEGATIVE BACTERIA

May led to septic shock

Conversion of a partial-thickness injury to a full-

thickness injury
Ulceration of health skin at the burn site

Erythematous, nodular lesions in uninvolved skin

Excessive burn wound drainage

Odor
Contd..

Sloughing of grafts

Altered level of consciousness

Changes in vital signs

Oliguria

GI dysfunction such as diarrhea, vomiting

Neurological status

All patients must be assessed for responsiveness with

GCS, they may be confused because of hypoxia or

hypovolemia.
wound care

Hydrotherapy:
 Shower, bed baths or clear water spray
 Maintain appropriate water and room temperature
 Limit duration to 20-30 minutes
 Don’t burst blisters, aspirate them!!!
 Trim hair around wound;
 Dry with towel; pat dry, don’t rub!
 Clean unburned skin and hair
Treating the burn wound
Dressings
47

Paraffin gauze dressings

Hydrocolloids (duoderm)

Full-thickness and deep dermal burns need antibacterial

dressings to delay colonization prior to surgery
Contd.

Open method 48

Silver sulfadiazine application without dressings commonly

Used in burns of face, head and neck.
Closed method
Dressing done to soothen and to protect the wound
To reduce the pain
As an absorbent
Infection Control
 Tetanus prophylaxis

 Antibiotics

 Topical therapy:

 0.5% Silver nitrate dressing

 Mafenide acetate cream
 Silver sulfadiazine cream
 Povidone-iodine ointment
 Gentamicin cream or ointment
Pain Relief and Adjustment

 Important to provide adequate analgesia, anxiolytics

and psychological support to:

 Family support to patient throughout grieving process

and help to accept long-term changes in appearance

Nutritional Support
 Burn wounds consume large amounts of energy and requires massive amounts of

nutrition to promote wound healing

 Monitoring Nutritional Status

 Weekly albumin levels

 Daily weight

 High protein diet is recommended for wound healing and

enhancement of host defense mechanisms
 Intake of Vit. c, Vit. A and high calorie diet is also recommended


Rehabilitative Phase
management
Surgical Management
 Skin Grafting:

 Closure of burn wound

 Spontaneous wound healing would take months for even a

small full-thickness burn

 Wound needs to be covered to prevent infection, loss of heat,

fluid and electrolytes

 Therefore, skin grafting is done for most full-thickness burns

(can be permanent or temporary )

Burn Rehabilitation

To attain the objective of optimal long-term function,

rehabilitation efforts must begin at the onset of burn care.

Physical and occupational therapists
Contd.

The following are the 3 principle priorities for the burn

therapist in the acute setting:
Performing passive ROM

Splinting and anti-deformity positioning

Establishing a long-term relationship with the patient and

family members to ensure compliance with therapy goals

Performing ROM

Passive ROM is best performed twice daily, with the

therapist taking all joints through a full ROM.

The therapist must be sensitive to the patient's pain,

anxiety, wound status, and extremity perfusion.

Performing ROM often can be timed to coincide with

dressing changes and wound cleansing, thereby

minimizing the need for medication.
Anti-deformity Positioning

Proper anti-deformity positioning minimizes the

shortening of tendons, collateral ligaments, and joint
capsules and reduces the contractures
These contractures generally are associated with the flexed

position of comfort
Splinting can be done according to the type of burn and

deformity suspected
Fully abduction with horizontal adduction of 15°–20° of the arms
A pillow or cushion can be added under the shoulder to allow fully
extension of neck
The hips should be kept fully extended and abducted when wounds involve the hips and
perineum
Foam pads or splints should be used to prevent planter flexion
caused by Achilles tendon or scar contracture
Comprehensive scar management
Active scars appear as red, raised and rigid with feeling like

tight, itching and pain.

 Hypertrophic scars around joints may hamper
mobilization and result in deformity when contracted.
To date, there is no single therapeutic strategy that can avoid

hypertrophic scar formation completely.

Contd.

Pressure therapy, positioning, splinting, ROM training,

and therapeutic exercises are irreplaceable treatments,

which can prevent, inhibit and improve scar proliferation
and contractures, as well as soften scar and alleviate
accompanied symptoms
Pressure therapy
The most commonly used products include pressure

garments, pressure pads, elastic bandages, rigid

transparent facemasks, and splints
Scar massage

Deep and firm massage can help to resolve this problem.

Exercises accompanied with scar massage can also help to

increase ROM
Deep and circular massage can also help re-alignment of

collagen fibres during scar formation.

 Scar massage is also a way to desensitize newly healed skin

and might promote sensory recovery.

Complications of Burn Injury

Infection

Hypovolemia

Dangerously low body temperature.

Respiratory Failure

Scarring

Bone and joint problems ( Contractures

Psychological aspects of burn

Along with the physical pain of burns and the treatments ,

patients also may face psychological stressors, such as:
Changes in body image

Depression

Family problems

Financial concerns

Memories of the accident