Burns II

Dr Jayan Man Shrestha

Plastic Surgery unit

Dept of surgery
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Inhalation injury

Inhalation of hot gases and the products of combustion

injure various parts of the respiratory tract
absorption of the products of combustion
may lead to serious local or systemic toxic
effects.
Inhalation injury increases mortality in all burns.
(Worsens by 40%)
Inhalation injury is most likely to be associated with
burns of the head and neck
30% of patients with burns to the face have an inhalation
injury.
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Classification of
Inhalation Injury

1. Airway Injury Above the Larynx

2. Airway Injury Below the Larynx
3. Systemic Intoxication Injuries

A irway Injury Above The

Larynx

burn produced by the inhalation of HOT

GASES (enclosed space /trapped in a fire /
inhalation of steam)
same pathophysiological changes as
thermal injury
Inflammatory mediators cause oedema of
the tissues - obstruction initially /later loss
of the protective functions of the mucosa.
Respiratory obstruction at the time of
maximal wound oedema (between 12 and
36 hours).

A irway Injury Above The

Larynx

burn to the neck skin may aggravate this

obstruction by producing neck oedema.
- much more likely in children who have
relatively narrow airways and short necks

The upper respiratory tract has such an

efficient ability to conduct heat away that it
is only after
extreme heat exposure that pure heat
damage to the lower respiratory tract
occurs.
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A irway Injury Below The

Larynx

burns produced by the inhalation of the products of

combustion.
Fires produce oxidation and reduction of compounds
containing carbon, sulphur, phosphorus and nitrogen.
chemical compounds - carbon monoxide and
dioxide / cyanide /hydrogen chloride / hydrogen
fluoride / hydrogen bromide. Acids and alkalis
produced when these compounds dissolve in the
water chemical burn
the particles of soot produce damage to the alveolus.

Systemic Intoxication
Injury

Systemic toxicity follows absorption

of carbon monoxide, hydrogen
cyanide, hydrofluoric acid,
phosgene and ammonia
The two most important
intoxications - carbon
monoxide and cyanide

Carbon monoxide
poisoning

Carbon monoxide (CO) - colourless

and odourless gas
diffuses rapidly into the blood
stream, combines very readily with
Hb (240 times greater affinity for
Hb than O2)
Combines with Hb to form COHb.

Carbon monoxide
poisoning

COHb dissociates less readily than

oxyhaemoglobin - tissue anoxia occurs.
COHb dissociates slowly - having a half
life of 250 minutes in a patient
breathing room air, and 40 minutes in
a patient breathing 100% oxygen.
CO also binds with great affinity to
intracellular cytochrome abnormal
cellular functioning
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Carbon monoxide
poisoning

Patients - confused and disorientated

skin colouration - cherry red

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Diagnosis Of Inhalation
Injury

At the scene severe resp distress early

death
increasing respiratory obstruction,
occurring over several hours thermal
injury above the larynx repeatedly
assessed
Increasing abnormalities in oxygenation as
shown by increasing restlessness and
confusion
- injury below the larynx / CO poisoning
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Diagnosis

Hx of enclosed space / explosion of petrol

or gas fire
Burns to Mouth, Nose and Pharynx
Singed Nasal Hairs / eyelashes / eyebrows
Sputum containing Soot Productive Cough
Change of Voice, Hoarse Brassy Cough
Respiratory Difficulty - Inspiratory
stridor / tracheal tug / rib retraction /
indrawing of Supraclavicular Fossae /
Flaring of Alar Nasae
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Diagnosis

CO systemic toxicity
Confusion , altered conciousness
Blood - COHb

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Treatment of inhalation
injury

all patients with burns be given

humidified oxygen by mask at least >12
litres per minute
close observation - early and rapidly
progressive respiratory obstruction
likely
increasing airway obstruction must be
secured by endotracheal intubation.
If in doubt - intubate
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Treatment of inhalation
injury

Hypoxia due to injury below larynx

Oxygen by mask / Intubation

/ Intermittent Positive Pressure Ventilation

Systemic intoxication
protection of unconcious patient
100% oxygen by mask / intubation/ IPPV

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ELECTRIC BURNS

Low voltage ( <1000 volts )

High voltage ( >1000 volts )
Conversion of electrical energy to
heat is governed by Ohms law
C= V/R current in amperes
Joules Law- J= C2RT

relation between current and heat

production
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Electric burnscont

Bone offers the most resistance

Current takes the shortest path

Arc injury is very deep

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Electric cont..

Flash burn
Contact injury

Extremities / body
parts

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Renal- ARF, Myoglobinuria

Cardiac arrest, VT, AF, SVT, RBBB
CNS- convulsions, coma, paraplegia
Abdomen- Splenic injury
Skeletal injury due to fall.

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MANAGEMENT

General

ABCDE

Fluid therapy
Mannitol
NaHCO3

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Cardiac monitoring
( CPK-MB)

Conduction of electrical current

through the mediastinum
Dangerous arrhythmias - up to 24
hours after injury / require
continuous ECG monitoring for that
time.
pre-existing myocardial disease

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