BURN

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5330701566

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Skin

Epidermis

Dermis

Subcutaneous

Vascular supply

Subpapillary

Dermal

Subdermal

Skin Function

Protection

Sensation

Thermoregulation

Control of evaporation

Storage and synthesis

Absorption

Water resistance

Burn
Definition
Burn is a tissue injury
from thermal (heat or cold)
application or absorption of
physical energy of chemical
contact

Type of Burn

Thermal

Non-Thermal

Electrical

Chemical

Radiation

Cold

Thermal burn injury

PATHOPHYSIOLOGY

Local change
thermal injury causes coagulative
necrosis of the epidermis and
underlying tissues
the depth of injury dependent on
the

temperature

the

specific heat of the

causative agent

the

duration of exposure.

Systemic change

Circulation

Burns produce an inflammatory reaction

This leads to vastly increased vascular

permeability

Water, solutes and proteins move from the

intra- to the extravascular space

The volume of fluid lost is directly

proportional to the area of the burn.

Above 15 per cent of surface area, the loss

of fluid produces shock

Peripheral circulation : Limb-threatening

ischemia

Hematology

Acute hemolysis
Coagulopathy

GI

Microvascular damage and ischemia to the

gut mucosa

Reduce gut motility

Reduce food absorption

Increase bacterial translocation

Abdominal compartment syndrome

Immune system and infection

Significant reduced Cell-mediated immunity

Increase risk of bacterial and fungal

infection

Renal

Destroy renal tubule

Oliguria

Acute renal failure

Proteinuria

Injury to the airway and

lungs
Upper airway : Dangers of smoke, hot gas or steam
Upper airway : Dangers of smoke, hot gas or steam
inhalation

Inhaled hot gases

supraglottic airway burns

and laryngeal oedema

Inhaled steam

subglottic burns and loss

of respiratory epithelium

Inhaled smoke
particles

chemical alveolitis and

respiratory failure

Inhaled poisons

metabolic poisoning

Full-thickness
burns to the
chest

mechanical blockage to
rib movement

Injury to the airway and

lungs
Lower airway
Lower airway

Rare injury

Heat exchange mechanism at supraglottic airway

Steam
Large latent heat
of evaporation

Thermal damage to lower airway

RE rapidly swelling and detach
Cast
Obstruct main airway

MANGAEMENT

Immediate care of burn

Pre-hospital
Ensure
Stop

care

rescuer safety

the burning process

Check

for other injuries

Cool

the burn wound

Give

oxygen

Elevate

Immediate care of burn

Hospital care
Assessment

as trauma care

ABCDEF

A - Airway control

B - Breathing and resuscitation

C - Circulation

D - Disability - neurogenic status

E - Exposure with environmental

control, Elevate burn limb

F - Fluid resuscitation

Indication for admission

<Burn center referral
criteria>

ABCDEF
Airways :
Initial management of the burned airway
Early elective intubation is safest
Delay can make intubation very difficult because of
swelling
Be ready to perform an emergency cricothyroidotomy, if
intubation is delayed
Key : History + Early symptom

ABCDEF
Breathing:
Inhalation
Thermal

injuries

burn injury to the lower

airway
Metabolic

poisoning

Mechanical

block to breathing

Assessment of
the burn wound
Size
Depth

Burn depth

First degree burn

Epidermis

Redness

Dry

Painful Sensation

Take 1 wk to healing

1st degree burn

Superficial second degree

burns
No deeper than the papillary dermis
Blistering and or loss of the
epidermis

Pink and moist

Pinprick sensation is normal
Heal without residual scarring
in 2-3 wk

Deep second degree

burn

Deeper parts of the reticular dermis

The exposed dermis is not moist

Abundant fixed capillary staining

Sensation is reduced

Take 3 or more weeks to heal

without surgery and usually lead to
hypertrophic scarring and scar
contracture

2nd degree burn

Third degree burn

The whole of the dermis is

destroyed in these burns

Hard , leathery feel skin

Charred , black skin no capillary

return

Visible thrombosed vessels

Anesthetised skin

Treatment by skin graft

3rd degree burn

Fourth degree burn

Extends through skin,

subcutaneous tissue and into
underlying muscle and bone

Charred with eschar

Painless, Hard and dry skin

Amputation, significant functional

impairment

4th degree burn

Zone of injuries

Depth of burns

Fluid resuscitation

Intravenous fluid resuscitation

In

children with burns over 10 per

cent TBSA

In

adults with burns over 15 per cent

TBSA, consider the need for

If oral fluids are to be used, salt must

be added

Parkland formula
TBAS X Weight X 4 = volume(mL)

give in 1st 8
hours
give in 16
hours

Fluid resuscitation

Crystalloid resuscitation

Ringers lactate is the most common used

Children < 2yrs : add 5%dextros

Hypertonic saline

Colloid resuscitation
Protein

: after 12 hours

Monitoring of
resuscitation
depend on time, Urine output and MAP
Time
MAP

: leak close

: 60 mmHg

Urine

output

Adult

: 0.5-1 ml/kg/hr

Children

: 1-1.5 ml/kg/hr

If urine output is below this , increase infusion rate 50%

Sign of hypoperfusion , 10ml/kg iv bolus
If urine output >2 ml/kg/hr , decrease rate iv

Treating of burn wound

Escharotomy
Circumferential

full-thickness
burns to the limbs
Emergency

surgery
Incising

the whole
leghth of the full
thickness burn

Treating of burn wound

Early burn wound care

Wound dressing by NSS

Scrubbing

Debriment

First-degree wounds : no dressing and are treated with

topical salves to decrease pain and keep the skin moist.

Second-degree wounds : daily dressing changes with

topical antibiotics, cotton gauze, and elastic wraps.
Alternatively, the wounds can be treated with a
temporary biologic or synthetic covering to close the
wound.

Deep second- and third-degree wound : excision and

grafting for sizable burns

Treating of burn wound

Topical antimicrobial agent

1%

silver sulphadiazine cream

0.5%

silver nitrate solution

Mafenide
Serum

acetate cream

nitrate, silver sulphadiazine

and cerium nitrate

Surgery for acute burn wound

Escharectomy
Tangential
Fascial

excision

excision

Surgery for acute burn wound

For Deep partial-thickness and full-thickness

burns, except those that are less than about 4
cm2,

the anesthetist needs good control of the patient.

subcutaneous injection of a dilute solution of

adrenaline and tourniquet control

Deep dermal burns need tangential shaving and

split-skin grafting

Full-thickness burns require full-thickness excision

of the skin. the burn excision is down to viable fat.
Wherever possible, a skin graft should be applied
immediately.

Surgery for acute burn

wound
Postoperative

management

Requires careful evaluation of fluid

balance and levels of haemoglobin.

Physiotherapy

and splints are

important in maintaining range of
movement and reducing joint
contracture.

Analgesia
Acute
Small

burn : paracetamol ,
NSAIDs, Topical cooling

Large

burn : Intravenous opioids

Subacute
Large
Short

burn : continuous analgesia

acting analgesia before

dressing changes

Energy balance and nutrition

Nutritional
requireme
nt
NG tube

Adult with burn > 15 % TBSA

Children with burn >10 % TBSA

All patient with burn 20 % TBSA

Removing the burn and achieving healing

stops the catabolic drive

Complication of burn

Burn wound infection

Pneumonia

Sepsis

Fungal infection

Urinary tract infection

Curlings ulcer

Scar contracture

Hypertrophic scar

Deformity

Loss joint function

Physical therapy and

Rehabilitation
Physical
Prevent

therapy program
prolong immobilization

Splinting
Prevent

and Positioning

hypertrophic scar

Delayed reconstruction
and scar management

Delayed reconstruction of burns

Common for large full-thickness burn

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 is treated with pressure

garments

Pharmacological treatment of itch is

Non thermal burn injury

Electrical

Low-voltage injuries :

cause small, localized, deep burns.

They can cause cardiac arrest through pacing

interruption without significant direct
myocardial damage

High-voltage injuries :

damage by flash (external burn) and

conduction (internal burn).

Myocardium may be directly damaged

without pacing interruption

Limbs may need fasciotomy or amputation

Look for and treat acidosis and

Low-voltage injury

High-voltage injury

Chemical injury

More than 70000 different chemicals can cause

burn injury

Damage is from corrosion and poisoning

Copious lavage with water helps in most cases

Then identify the chemical and assess the risks

of absorption

Acids VS Alkalis

Radiation injury

Local
Ulceration
Tx:

excision and vascularised flap

cover, usually with free flaps

Systemic
Lethal

: particular slow unpleasant

death
Non-lethal

: systemic effects related

to gut mucosa and immune
dysfuction

Tx:

Supportive treatment

Reference

Thank you
for your
attention