A burn is a type of injury to skin, or other tissues, caused by heat, cold, electricity, chemicals, friction, or radiation. Most burns are due to heat from hot liquids, solids, or fire. While rates are similar for males and females the underlying causes often differ.

1. BURN
Presented by:
Mr. Abhay Rajpoot

2. ANATOMY OF SKIN
The skin is the largest organ of the body, with a total area of about 20 square
feet. The skin protects us from microbes and the elements, helps regulate body
temperature, and permits the sensations of touch, heat, and cold.
Skin has three layers:
 The epidermis, the outermost layer of skin, provides a waterproof barrier
and creates our skin tone.
 The dermis, beneath the epidermis, contains tough connective tissue, hair
follicles, and sweat glands.
 The deeper subcutaneous tissue (hypodermis) is made of fat and connective
tissue

4. INTRODUCTION
 Burns are tissue damage that results from heat, overexposure to the sun or
other radiation, or chemical or electrical contact. Burns can be minor
medical problems or life-threatening emergencies.
 The treatment of burns depends on the location and severity of the
damage. Sunburns and small scalds can usually be treated at home. Deep or
widespread burns need immediate medical attention.

5. DEFINITION
 Burns is defined as a wound caused by exogenous agent leading to
coagulative necrosis of the tissue.
 A burn is a type of injury to skin, or other tissues, caused by heat, cold,
electricity, chemicals, friction, or radiation. Most burns are due to heat
from hot liquids, solids, or fire

6. CAUSES
 Thermal Burns
 Dry heat
Contact burn
Flame burn
 Moist heat- Scald burn
 Smoke and inhalational injury
 Chemical Burns- acids & alkali
 Electrical burns- High & low voltage
 Cold Burns- frostbite
 Radiation

7. Thermal Burns
 Heat changes the molecular structure of tissue
Causing Dena turion of proteins
 Extent of burn damage depends on
–Temperature of agent
–Amount of heat
–Duration of contact

8. THE EFFECTS OF THE BURNS ARE INFLUENCED BY
THE:
1.Intensity of the energy
2.Duration of exposure
3.Type of tissue injured

9. CLASSIFICATION OF BURNS
 First degree—injury localized to the epidermis
 Superficial second degree—injury to the epidermis and superficial papillary
dermis
 Deep second degree—injury through the epidermis and deep up to reticular
dermis
 Third degree—full-thickness injury through the epidermis and dermis into
subcutaneous fat
 Fourth degree—injury through the skin and subcutaneous fat into
underlying muscle or bone

10. CLASSIFICATION OF BURNS
SUPERFICIAL BURN : 1ST DEGREE BURN
• Reddened skin
• Pain at burn site
• Involves only epidermis
• Blanch to touch
• Have an in-tact epidermal barrier
• Do not result in scarring
• Examples : Sun-burn, minor scald from a kitchen accident
• Treatment is aimed at comfort with topical soothing agents +/- NSAIDs

12. PARTIAL-THICKNESS BURN: 2ND DEGREE BURN
• Intense pain
• White to red skin
• Blisters
• Involves epidermis & papillary layer of dermis
• Spares hair follicles, sweat glands etc.
• Erythematous & blanch to touch
• Very painful/sensitive.
• No or minimal scarring.
• Spontaneously re-epithelialize from retained epidermal structures in 7-14 days

13. DEEP SECOND DEGREE BURN
• Injury to deeper layers of dermis –reticular dermis
• Appears pale & mottled
• Do not blanch to touch
• Capillary return sluggish or absent
• Less painful, remain painful to pinprick
• Takes 14 to 35 days to heal byre-epithelialisation from hair follicles
& sweat gland, keratinocytes often with severe scarring
• Contractures possible• Require excision & skin grafting

14. FULL-THICKNESS BURN:3RD DEGREE BURN
• Dry, leathery skin(white, dark brown, or charred)
• Loss of sensation(little pain)
• All dermal layers/tissue maybe involved
• Always require surgery.
Fourth degree burn
• Involves structures beneath the skin- muscle, bone.

17. Depth of burn & causes Skin involvement symptoms Wound appearance Recuperative course
Superficial partial thickness
(similar to first degree)
Sunburn
Low-density flash
Epidermis;
possibly a portion of dermis
Tingling
Hyperesthesia
(supersensitivity
Pain that is soothed by
cooling
Reddened; blanches with
perssure;dry
Minimal or no edema
Possible blisters
Complete recovery within a
week; no scarring
peeling
Deep partial thickness(similar to
second degree)
Scalds
Flash flame
contact
Epidermis, upper dermis,
portion of deep dermis
Pain
Hyperesthesia
Sensitive to cold air
Blistered, mottled red base;
broken epidermis; weeping
surface
edema
Recovery in 2-4 wks
Some scarring &
depigmentation
contractures
Infection may convert it to
full thickness
Full-thickness (similar to
third degree)
Flame
Prolonged exposure to hot
liquids
Electric current
Chemical
contact
Epidermis, entire dermis, &
sometimes subcutaneous
tissue; may involve
connective tissue, muscle &
bone
Pain free
Shock
Hematuria & possibly
hemolysis
Possible entrance & exit
wounds (electrical burn)
Dry; pale white, leathery,
or charred
Broken skin with fat
exposed
edema
Eschar sloughs
grafting necessary
Scaring & loss of contour &
function;
Contractures
Loss of digits & extremity

18. PATHOPHYSIOLOGY

26. PATHOPHYSIOLOGY OF BURNS
• Fluid Shift
– Period of inflammatory response
– Vessels adjacent to burn injury dilate → ↑ capillary hydrostatic pressure and
↑ capillary permeability
– Continuous leak of plasma from intravascular space into interstitial space
– Associated imbalances of fluids, electrolytes and acid-base occur
–Haemoconcentration
-Lasts 24-36 hours

27. CONTI…
Fluid remobilization
– Capillary leak ceases and fluid shifts back into the circulation
– Restores fluid balance and renal perfusion
• Increased urine formation and diuresis
– Continued electrolyte imbalances
• Hyponatremia
• Hypokalaemia
– Haemodilution

28. CONTI…
SYSTEMIC CHANGES
• Cardiac
– Decreased cardiac output
• Pulmonary
– Respiratory insufficiency as a secondary process
– Can progress to respiratory failure
– Aggressive pulmonary toilet and oxygenation
• Gastrointestinal
– Decreased or absent motility (may need NG tube)
– Curling’s ulcer formation

29. CONTI…
•Metabolic
– Hypermetabolic state
• Increased oxygen and calorie requirements
• Increase in core body temperature
• Immunologic– Loss of protective barrier
– Increased risk of infection
– Suppression of humoral and cell mediated immune responses

30. ACUTE PHASE
• Clinical shock
• External loss of plasma
• Loss of circulating red cells
• Burn edema

31. SUB ACUTE PHASE
• Diuresis
• Clinical Anaemia
• Accelerated metabolic rate
• Nitrogen Disequilibrium
• Bone and joint changes
• Endocrine Disturbances
• Electrolyte and chemical imbalance
• Circulatory Derangements
• Loss of function of skin as an organ

32. BODY’S RESPONSE TO BURNS
• Emergent Phase (Stage 1)
– Pain response
– Catecholamine release
– Tachycardia, Tachypnea, Mild Hypertension, Mild Anxiety
• Fluid Shift Phase (Stage 2)
– Length 18-24 hours
– Begins after Emergent Phase
• Reaches peak in 6-8 hours
– Damaged cells initiate inflammatory response
• Increased blood flow to cells
• Shift of fluid from intravascular to extravascular space

33. • Hypermetabolic Phase (Stage 3)
–Last for days to weeks
–Large increase in the body’s need for nutrients as it repairs itself
• Resolution Phase (Stage 4)–Scar formation
–General rehabilitation and progression to normal function

34. Jackson’s Theory of Thermal Wounds
– Zone of Coagulation
• Area in a burn nearest the heat source that suffers the most damage
as evidenced by clotted blood and thrombosed blood vessels
– Zone of Stasis
• Area surrounding zone of coagulation characterized by decreased
blood flow.
– Zone of Hyperaemia
• Peripheral area around burn that has an increased blood flow

35. CONTI..
Severity is determined by:
–Depth of burn
–Extend of burn calculated in percent of total body surface (TBSA)
–Location of burn
–Patient risk factors

36. ASSESSMENT OF BURNS
• Rule of Nine
–Best used for large surface areas
–Expedient tool to measure extent of burn
• Rule of Palms–Best used for burns < 10% BSA

38. CONTI..
AREA OF PALM = 1% BODY SURFACE AREA

39. MANAGEMENT
Pre-hospital care (Emergent Phase)
• Ensure rescuer safety
• Stop the burning process: Stop, drop and roll
• Check for other injuries
A standard ABC (airway, breathing, circulation)check followed by a rapid secondary survey.
• Cool the burn wound:
Analgesia
Slows the delayed microvascular damage, Minimum of 10 min
Effective up to 1 hour after the burn injury
• Give oxygen
• Elevate

40. HOSPITAL CARE (ACUTE PHASE)
• A : Airway control.
• B :Breathing and ventilation.
• C :Circulation.
• D: Disability – neurological status.
• E :Exposure with environmental control.
• F :Fluid resuscitation.

41. THE CRITERIA FOR ACUTE ADMISSION TO A BURNS
UNIT
• 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

42. AIRWAY RECOGNITION OF THE POTENTIALLY BURNED
AIRWAY
• A history of being trapped in the presence of smoke or hot Gases
• Burns on the palate or nasal mucosa, or loss of all the hairs
• in the nose : Deep burns around the mouth and neck

43. CONTI..
Airway
• 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
Breathing
• Inhalational injury
• Thermal burn injury to the lower airway
• Metabolic poisoning: Carboxyhaemoglobin
• Mechanical block to breathing: Escharotomy

44. CONTI..
Circulation
• Maintain iv line with wide bore canula peripherally
• One central line
• Escharotomy of limbs if circulatory compromise in circumferential burns
Fluids for resuscitation
• In children with burns over 10% TBSA and adults with burns over 15% TBSA,
consider the need for intravenous fluid resuscitation
• If oral fluids are to be used, salt must be added
• Fluids needed can be calculated from a standard formula
• The key is to monitor urine output

45. CONTI..
Parkland Formula :
Total percentage body surface area × weight(kg) × 4 = volume (ml)
• Half this volume is given in the first 8 hours, and
• the second half is given in the subsequent 16hours.
• Crystalloid : Ringer lactate
• Hypertonic saline
• Human albumin solution
• Colloid resuscitation

46. Debridement
Types of debridement:
1. Auto debridement
2. Tangential excision (at the end of 1st week)
3. Staged primary debridement (1-3 days postburn).
This early debridement of dead tissue interrupt sand attenuates the systemic
inflammatory response and normalize immune function.

47. CONTI…
Analgesia
Acute
• Small superficial burns : simple oral analgesia, Topical cooling
• Large burns: intravenous opiates. Subacute
• Large burns: continuous analgesia is required, beginning with infusions
and continuing with oral tablets such as slow-release morphine.

48. CONTI…
Nutrition
• Burns patients need extra feeding
• A nasogastric tube should be used in all patients with burns over 15% of TBSA
• Removing the burn and achieving healing stops the catabolic drive.
Sutherland formula
• Children: 60 kcal/ kg + 35 kcal % TBSA
• Adults: 20 kcal /kg + 70 kcal % TBSA
Protein20% of energy, 1.5 to 2 g/kg protein/day

49. Tetanus prophylaxis
• Tetanus toxoid, 0.5 mL intramuscularly, if the last booster dose was more
than 5 years before the injury.
• If immunization status is unknown, human tetanus immunoglobulin 250 to
500units, I.M. plus tetanus toxoid in opposite side

50. Monitoring and control of infection
• Burns patients are immunocompromised
• They are susceptible to infection from many routes
• Sterile precautions must be rigorous
• Swabs should be taken regularly
• A rise in white blood cell count, thrombocytosis and increased
catabolism are warnings of infection
Topical treatment of deep burns
• 1% silver sulphadiazine cream
• 0.5% silver nitrate solution
• Mafenide acetate cream
• Serum nitrate, silver sulphadiazine and ceriumnitrate

51. Principles of dressings for burns
• Full-thickness and deep dermal burns need antibacterial dressings to
delay colonisation prior to surgery
• Superficial burns will heal and need simple dressings
• An optimal healing environment can make a difference to outcome in
borderline depth burns

52. Surgical treatment of deep burns
• Early debridement and grafting is the key to effectively treating
• deep partial- and full-thickness burns in a majority of cases
• Deep dermal burns need tangential shaving and split-skin grafting
• All but the smallest full-thickness burns need surgery
• Should be ready for significant blood loss
• Topical adrenaline reduces bleeding
• All burnt tissue needs to be excised

53. SURGICAL TREATMENT OF DEEP BURNS
 Proper dressing should be done
 Physiotherapy and splints are important in maintaining range of movement
and reducing joint contracture
 Breathing assistance
 Feeding tube
 Skin grafts. A skin graft is a surgical procedure in which sections of your own
healthy skin are used to replace the scar tissue caused by deep burns. Donor
skin from deceased donors or pigs can be used as a temporary solution.
 Plastic surgery. Plastic surgery (reconstruction) can improve the appearance
of burn scars and increase the flexibility of joints affected by scarring.

54. 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 is treated with pressure garments/Silicone patch(6-18 month)
 Pharmacological treatment of itch is important

55. COMPLICATION
 Bacterial infection, which may lead to a bloodstream infection (sepsis)
 Fluid loss, including low blood volume (hypovolemia)
 Dangerously low body temperature (hypothermia)
 Breathing problems from the intake of hot air or smoke
 Scars or ridged areas caused by an overgrowth of scar tissue (keloids)
 Bone and joint problems, such as when scar tissue causes the shortening
and tightening of skin, muscles or tendons (contractures)

56. PREVENTION
 Never leave items cooking on the stove unattended.
 Turn pot handles toward the rear of the stove.
 Don't carry or hold a child while cooking at the stove.
 Keep hot liquids out of the reach of children and pets.
 Keep electrical appliances away from water.
 Check the temperature of food before serving it to a child. Don't heat a baby's
bottle in the microwave.
 Never cook while wearing loose fitting clothes that could catch fire over the stove.
 If a small child is present, block his or her access to heat sources such as stoves,
outdoor grills, fireplaces and space heaters.
 Before placing a child in a car seat, check for hot straps or buckles.
 Unplug irons and similar devices when not in use. Store them out of reach of small
children.

57. NURSING MANAGEMENT
NURSING DIAGNOSIS
 Impaired Physical Mobility
 Deficient Knowledge
 Disturbed Body Image
 Fear/Anxiety
 Impaired Skin Integrity
 Imbalanced Nutrition: Less Than Body Requirements
 Risk for Ineffective Tissue Perfusion
 Acute Pain
 Risk for Infection
 Risk for Deficient Fluid Volume
 Risk for Ineffective Airway Clearance

58. ASSIGNMENT
ON
NCP On Burn Management