This document discusses the assessment and management of burn injuries. It begins with an introduction to common causes of burns in children and adults. It then covers risk factors, types of burns, effects of burns, and classifications of burns based on depth and percentage of total body surface area affected. The pathophysiology of burns is explained. Assessment involves determining burn size, depth, and severity. Management involves initial first aid at the scene, and then hospital care which focuses on cooling burns, giving oxygen, and elevating injured areas. Causes of death from severe burns are also outlined.
2. 2
INTRODUCTION
Majorty of burns in childrenare SCALDScaused
by accidents with kettles,pans,hot drinks and
bath water
In young males burn causedbyexperimenting
With mathes and inflamable liquides
Electrical and chemical injuries occur in adultswith
Associated conditions suchasmental disease,
EpilepsyAlcohal and drug abuse
3. Risk Factors
Fire/Combustion
Firefighter
IndustrialWorker
Occupant of burning structures
Chemical Exposure
IndustrialWorker
Electrical Exposure
Electrician
Electrical Power DistributionWorker
6. Effects
Burn injury causes destruction of tissue, usually the skin,
from exposure to thermal extremes (either hot or cold),
electricity, chemicals, and/or radiation
The mucosa of the upper GI system (mouth, esophagus,
stomach) can be burned with ingestion of chemicals
The respiratory system can be damaged if hot gases, smoke, or
toxic chemical fumes are inhaled
Fat, muscle, bone, and peripheral nerves can be affected in
electrical injuries or prolonged thermal or chemical exposure
Skin damage can result in altered ability to sense pain, touch, and
temperature
7. Skin
Largest body organ. Much more than a
passive organ.
Protects underlying tissues from injury
Temperature regulation
Acts as water tight seal, keeping body fluids in
Sensory organ
8. Skin
Injuries to skin which result in loss, have
problems with:
Infection
Inability to maintain normal water balance
Inability to maintain body temperature
9. Skin
Two layers
Epidermis
Dermis
Epidermis
Outer cells are dead
Act as protection and
form water tight seal
10. Skin
Epidermis
Deeper layers divide to produce the stratum
corneum and also contain pigment to protect
against UV radiation
Dermis
Consists of tough, elastic connective tissue which
contains specialized structures
11. Skin
Dermis - Specialized Structures
Nerve endings
Blood vessels
Sweat glands
Oil glands - keep skin waterproof,usually
discharges around hair shafts
Hair follicles - produce hair from hair root or
papilla
Each follicle has a small muscle (arrectus pillorum)
which can pull the hair upright and cause goose flesh
13. Burn Classification - Depth
New terminology
Superficial: only
the epidermis
Superficial partial
thickness: epidermis
and dermis, excluding
all the dermal
appendages
Deep partial
thickness: epidermis
and most ofthe
dermis
Full thickness: epidermis
and all of the dermis
Old terminology
1st degree: only the
epidermis
2nd degree: epidermis and
dermis, excluding all the
dermal appendages
3rd degree: epidermis and all
of the dermis
4th degree: epidermis,
dermis, and subcutaneous
tissues (fat, muscle, bone,
and peripheral nerves)
14. Very painful, dry, red burns which blanch with pressure.
They usually take 3 to 7 days to heal without scarring.
Also known as first-degree burns.
The most common type of first-degree burn is sunburn.
15. Very painful burns sensitive to temperature change and air exposure.
More commonly referred to as second-degree burns.
Typically, they blister and are moist, red, weeping burns which blanch with pressure.
They heal in 7 to 21 days.
16. Blistering or easily unroofed burns which are wet or waxy dry, and are
painful to pressure.
Their color may range from patchy, cheesy white to red, and they do not
blanch with pressure.
17. Burns which cause the skin to be waxy white to a charred black and
tend to be painless.
Healing is very slow, if at all, and may require skin grafting.
18.
19. Burn Classifications
1st degree (Superficial burn)
Involves the epidermis
Characterized by reddening
Tenderness and Pain
Increased warmth
Edema may occur, but no blistering
Burn blanches under pressure
Example - sunburn
Usually heal in ~ 7 days
21. Burn Classifications
2nd degree
Damage extends through the epidermis and
involves the dermis.
Not enough to interfere with regeneration of the
epithelium
Moist, shiny appearance
Salmon pink to red color
Painful
Does not have to blister everytime
Usually heal in ~7-21 days
25. Burn Classifications
3rd degree
Both epidermis and dermis are destroyed with burning
into SQ fat
Thick, dry appearance
Pearly gray or charred black color
Painless - nerve endings are destroyed
Pain is due to intermixing of 2nd degree
May be minor bleeding
Cannot heal and require grafting
31. 3
1
CLASSIFICATION OF BURNS
Depending on the percentage of burns
MILD
o Partial thickness burns <15%in adults and <10%
In children
or
o Full thickness <2%
o Canbe treated on outpatient department
33. 3
3
CLASSIFICATION (CONT……)
SEVERE
oSeconddegree burns more then 25%in adults
and More then 20%in children
oAll third degree burns more then10%
oAll electrical burns and inhalation burns
oBurns with fracture
oBurns involving eyes,ears,feet,handsand
perineum
34. Pathophysiology of burn injury
34
Most common organ affected is the skin
Burn canalso damage airways and lungs with life
Threatening consequenses
Respiratory system injuries occure if person trapped
In a burning vehicle,house,car and is forced to inhale
Thehot and poisonous gases
Hot gasesburn the lining of airway above thelarynx
And lining start to swell later on block the airway
Steam causesdamage to the lowerairways,respiratory
Epithelium swells and detach from bronchialtree
35. Pathophysiology(cont……)
Metabolic poisoning
Carbon monoxide is a product of incomplete combustion
That is often produced by fires in a closed space is one of
Many poisonous gases
Cobinds to hb with an affinity of 240> O2soblock
Transport Of O2
Level of carboxyhaemoglobin in blood canbemeasure
Conc>10%dangerous and need treatment with pure
Oxygenfor more then 24hours
Hydrogen cynide causesmetabolic acidosis by interefering
with
1 mitochondrial respiration 13
36. Pathophysiology(cont……)
Inhalational injury
causedby minute particles within thick smokebecause
Of their small sizeand are not filtered by the upper
Airwayand are carried down to
lung parenchyma
Stick to moist liningcauses
intense reaction in alveoli
Causeschemical pneumonitis
followed by oedema within
Alveolar sacand dec gaseous
exchange
1
0/2
B
2/2
a
01
c
6
terial pneumonia occures
14
37. Pathophysiology(cont……)
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Inflamtion and circulatory changes
Burn skin release of neuropeptides activation of
Complement are intiated by stimulation of pain fibersand
Alteration of proteins byheat
Activation of hageman factor alter archidonicacid
Thrombin and kallikrein pathways
38. Pathophysiology(cont……)
10/22/2016 38
At cellular level
Complement causesdegranulation of mast cells
Attracts neutrophils which also degranulate and releases
Largeamount of free radicals andproteases
Mast cells also releases TNF@which act aschemotactic
Agent to inflamatory cells
Theseinflamatory factors alter permeability of bldvessels
Largeprotein molecules canalso escapewith ease
Damaged collagen and extravasated proteins oncotic
Pressurefurther increase flow of water fromintravascular
T
oextravascularspace
41. ASSESSMENT OF BURNS
ASSESSING SIZE
Burn sizeshould be assessedin acontrolled environment
T
o avoid hypothermia
In smaller burns just cut apiece aclean paper the sizeof
patient ,swhole hand (digit and palm)which present 1%TBSA
And match this to thearea
Another accurate way of measuring the size of burns is to draw
Theburn on a Ruleof9or LUND AND BROWDER CHART
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42. ASSESSMENT(CONT…..)
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RULEOF9 (wallace,s rule of9
Eachupper limb is 9%TBSA
Eachlower limb is 18%TBSA
Torso18%each side
Head and neck 9%
Perineum 1%
In children head and neck is 18%and
Lower limb is 13.5%each=13.5*2=27%
45. ASSESSMENT(CONT…..)
10/22/2016 45
2.Assessing depth from the history
Burning of human skin is temperature and timedependent
It takes 6 hours for skin maintained at 44c* for irreversible changes
Asurface teperature of 70c* for 1 second produceepidermal
destruction
example of exposure of hot water at 65 degree C temperature
45 second exposure produce full thicknessburn
15 second exposure produce deep partial thicknessburn
7 second exposure produce superficial partial thiknessburn
47. ASSESSMENT(CONT…..)
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a) Superficial partial thickness burns
No deeper then papillary dermis
Blister formation
Lossof epidermis
Capillary return visible
When blanched
Dermis is pink and moist
Pin prick sensation normal
Heal without scarring
In 2 weeks
Treatment is non surgical
50. ASSESSMENT(CONT…..)
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b)Deep partial thickness burn
Damageto deeper parts ofdermis
Epidermis is usually lost
Fixedcapillary staining
Colour does not blanch with pressure
Sensation is reduced
Pt is unable todistinguish sharp from blunt pressure
T
akes3 or more weeks to heal without surgery
Leadsto hypertrophic scarring
63. Management of burns
Prehospital care
Stop the burning process
Stop,drop and roll is agood method of extinguishing
Fire
Cool the burn wound
Thisprovide analgesia and slow the delayed micro-
-vascular damage which occure after aburn injury
Cooling should be for minimum 10 mintues and up to
Onehour to avoidhypothermia
Give oxygen
Giveoxygen especialy if there is altered conciousness_
level 32
64. Management of burns
64
Elevate
Sitting apatient up with aburned airway may provelife
Saving
Elevation of burned limbs reduce swelling anddiscomfort
Check for other injuries
AstandardABCcheck followed by asecondarysurvey
Patients burned in explosions may have head and spineinjuries
And other life threateningproblems
65. Management of burns
65
Indications for admission in burns
Susectedairway or inhalational injury
Any burn require fluide resusciation
Any burn in extreme of ages
All electrical and chemicalburns
Any burn which require surgery
Burn of any significance to hands,face,feet orperineum
Suspiciousof non accidentalinjury
69. Management of burns
69
Hospital care
Admit the patient
Airway control
Breathing and ventilation
Circulation
Disability
Exposure with environmentcontrol
Fluid resuscitation
Assessthe %age,degreeand type of burn
Keepthe patient in cleanenvironment
Sedation and proper analgesia
70. Management of burns
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A.AIRWAY CONTROL
Burned airway creates problems by swelling and cancompletely
Occlude the airway
Secureairway with an endotracheal tubeuntil
swelling subsided which is Usually 48hours
Delayed diagnosis of airway burn make difficult to intubate the
Patient in presence of lyrangeal oedema socricothyroidectomy
Should be done
Early intubation of suspected airway burn is the treatment of
Choice in suchpatients
71. Management of burns
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B.BREATHING
Aprogressive increase in respiratory rate and effort,anxiety
Risingpulse and confusion with decreasing o2saturation
Thesesymptoms take 24 hours to 5 daysto appear
Treatment starts assoon aspossible including
Physiotherapy
Nebulisers
Warm humidified oxygen
72. Management of burns
10/22/2016 72
Fluide resuscitation
Iv volume must be maintained following aburn in order to
provide sufficient circulation to perfuse not only the organs but
also the peripheral tissues,especially damagedskin
Iv resuscitation is appropriate for any child withaburn greater
Then 10%and 15%for TBSAfor adults
If oral resuscitation is to be commenced then water is given
Should not be saltfree
It is appropriate to give oral rehydration with asolution such as
DIORALYTE*
Most common fluid used is ringer lactate
73. Management of burns
Fluid volume is relatively constant in proportion to the area
Of body burned therefore there are formulate that calculate
The approximate volume of fluid needed for the pt of agiven
Body weight with agiven %ageof the bodyburned
Formulas to calculate the fluid replacement
1.parkland regime (commonly used)
4ML/%burn/kg body weight/24 hours
4*50*60=12000ml in 24hours
Half this volume is given in the frist 8 hours
Secondhalf is given in the subsequent 16hours
Others
1. Evan,s formula
2. Muir and barclay
10/223/2.016Modified brook formula 39
74.
75. Management (cont…)
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Fluids used
Crystalloid resuscitation
Ringer lactate is the most commonly usedcrystalloid
Theseare aseffective ascolloids for maintaining intra-
-vascular volume
Lessexpensive
In children
Dextrose saline given for maintanaince
100ml/kg for 24 hours for frist10kg
50ml/kg for 24 hours fornext 10kg
20ml/kg for 24 hours for each kgabove 20kg bodyweight
76. Management (cont…)
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hypertonic saline
it produces hyperosmolarity andhypernatremia
Reducesshift of intracellular water to extracellular space
Advantages
Include less tissue oedema and aresultant decrease in
Escharotomies and intubations
77. Management (cont…)
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Colloid resuscitation
Plasmaproteins are responsible for the inward oncotic
Pressure that counteracts the outward capillaryhydrostatic
Pressure.
Without proteins there willbe oedema
Proteins should be given after frist 12 hours of burn before
This time proteins will leak out of cells
Given through muir and barclay formula
0.5*%agebsa burn*weight=one portion
Periods of 4/4/4, 6/6,12 hours respectively
Oneportion to b given ineach period
78. Management (cont…)
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Monitoring of resuscitation
Thekey to monitoring of resuscitation is urinaryoutput
Output should be between 0.5ml and1.0ml/kg/hour
If urine output is below this infusion rate should increase
By50%
If still output is inadequate then abolus of 10ml/kggiven
2ml/kg/hr urinary output signals decrease in the rate of
Perfusion
Haematocrit measurement is ausefull tool in confirming
Suspected under or overhydration
79. Management (cont…)
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44
Asan absorbent
Treating the burn wound
Dressings
Paraffine guaze
Hydrocolloids (duoderm)
Biological dressings
synthetic (biobrane)
natural (amniotic membrane)
Full-thickness and deep dermal burns needantibacterial
dressings to delay colonisation prior tosurgery
Open method
Silver sulfadiazine application without dressingscommonly
Usedin burns of face,head andneck.
Closed method
Dressing done to soothen and to protect the wound
T
oreduce thepain
80. Management (cont…)
10/22/2016
Treating the burn wound (cont……
Tangential excision
Canbe done within 48 hours with skin grafting in patients with less
Then 25% burn
Usually done in deep
dermal burns
Deaddermis is removed
layer by layer Untill fresh
bleeding occurs
Later skin grafting done
45
81. Treating the burn wound
(cont……
Treating the burn wound (cont……
escharotomy
Circumferential full-thickness burns tothe limbs require emergency
Surgery
Thetourniquet effect of thisinjury
is easily treated by incising the whole length of full-thickness
burns.
Thisshould be done in the mid-axial line,avoiding major
Nerves
Theburn needs to be cleaned and the sizeand depth need tobe
Full thickness burns and deep partial-thickness burns thatwill
requireoperative treatment will need to be dressed with an
antibacterialdressing to delay the onset of colonisation of the
wo1
0
u/
2
2
n/
2
d0
1
6 46
82.
83. Afull-thickness burn to the upper limb with a mid-axial
escharotomy.
Thesoot and debris have been washedoff.
10/22/2016 83
84. 10/22/2016 84
Topicalagent advantages problems
Silver sulfadiazine 1 -Antiseptic (G+ve -Neutropenia,
% and G–ve pseudoeschar
-Soothening, good -- Causeswound
penetration maceration
- Hydration and
softening of eschar
occurs
Sulfamylon – 5%- Antipseudomonal, Very irritant,painful
(Mafenide acetate) anticlostridial Causesacidosis
- Penetrates very
well in to tissues
Silver nitrate –0.5% -Antiseptic Stainsburn area
Povidone iodine Irritant
(5%) - Usedon Painfull
granulation tissue - Not used in partial
after eschar burns
separation
Silver sulphadiazine - Boostscell
and cerium nitrate mediated immunity
and forms sterile
eschar
85. Additional aspects of treating
burn patient
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Analgesia
Oral form of paracetamol and nsaids insuperficial burns
Iv opiates for largeburns
Im should not be given in over 10%of TBSAasabsorption is
Unpredictable
Short acting analgesia given beforedressing
Energy balance
Feeding should start within 6 hrs of injury to reduce gut mucosal damag
Burns patients need extra feeding
Anasogastric tube should be used in all patients withburns over 15%
of TBSAand 10%in caseofchildren
Burn injuries are catabolic in theacute episode.
Removing the burn and achieving healing stops thecatabolic drive
86. Additional aspects of treating
burn patient
control of infection
Patients with major burns areimmunocompromised,
pathogenic and opportunistic bacteria and fungi enter via theburn
wound,cathetars and iv lines
Theyhave compromised local defences in the lungs and gut dueto
oedema
Sterile precautions must berigorous
Swabsshould be taken regularly
Arise in white blood cell count, thrombocytosisand
increased catabolism are warnings of infection
Nursing care
Physiotherapy
Psy
10c
/2h
2/2o
016
logical support 50
87. SURGERY FORTHEACUTEBURN
10/22/2016 87
Any deep partial-thickness and full-thickness burnsexcept
those that are less than about 4 cm2, needsurgery
Atopical solution of 1:500 000 adrenaline also helps toreduce
bleeding,
deep dermal burns, the top layer of dead dermisis shaved
off untilpunctate bleeding is observed and the dermis can be
seento be free of any small thrombosedvessels
Full-thickness burns require full-thickness excision ofthe
Skin
Postoperative management of these patientsobviously
requires careful evaluation of fluid balance and levels ofhaemoglobin.
88. Delayed reconstruction and scar
management
10/22/2016 88
is common for large Full thicknessburns
Eyelids must be treated before exposure keratitisarises
Transposition flaps and Z-plasties with or withouttissue
expansion are useful
Full-thickness grafts and free flaps may be needed forlarge
or difficult areas
Hypertrophy is treated with pressure garments tobe worn
for 6-18months
Smaller areas of hypertrophy, silicone patches will speed
scar maturation,as will intralesional injection of steroid.
Pharmacological treatment of itchis important
89. Pediatric Burns
Thin skin
increases severity of burning relative to adults
Large surface/volume ratio
rapid fluid loss
increased heat loss hypothermia
Delicate balance between dehydration and
over hydration
Immature immunological response sepsis
Always consider possibility of child abuse
91. Complication of burn
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Shockdue to hypovolaemia
Renalfailure(toxins from burn&myoglobin)
Pulmonary oedema,resp infections,ARDS,resp failure
Infection by staph aureus,pseudomonas,klebsella leadsto
Septicemia
Fungaland viral infections of dangerous type canoccure
GIT
:Hypovolaemia, ischaemia of mucosa,erosive
gastritis—Curling’s ulcer (seen in burns >35%).
Fluid and electrolyte imbalance.
immunosuppression predisposes to severe opportunistic infection.
Escharformation and its problems likedefective
circulation, ischaemia when it is circumferential.
Electrical injuries often causefractures,major
internal organ injury, convulsions.
92. Complications (cont…..)
10/22/2016
. 92
Inhalation burn causespulmonary oedema,
respiratory arrest,ARDS.
Chemical injury causessevere GITdisturbances like
erosions, perforation, stricture oesophagus (alkali),
pyloric stenosis (acid), mediastinalinjury.
Other problems
DVT,pulmonaryembolism
bed-sores,
severe malnutrition with catabolicstatus,
Toxic shock syndrome:
It is a life-threatening exotoxin mediated disease causedby
Staphylococcusaureus. It is common in children, presentswith
rashes, myalgia, diarrhoea, vomiting, andmultiorgan
failure with highmortality
93. Complications (cont…..)
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Development of contracture is alate problem.It
leads to ectropion, microstomia, disability of
different joints, defective hand functions, growth
retardation causingshortening
COMPLICATIONS OFBURNSCONTRACTURE
Ectropion of eyelid causing keratitis andcorneal
ulcer.
Disfigurement in face.
Narrowing of mouthmicrostomia.
Contracture in the neck causing restricted neckmovements.
Disability and nonfunctioning of joints due to contracture
Hypertrophic scarand keloid formation.
94. COMPLICATIONS OFBURNS CONTRACTURE
Marjolin’s ulcer
It is avery well-differentiated squamous cell carcinoma
occurring in ascarulcer due to repeated breakdown(unstable
scar of longduration).
•It is locallymalignant.
•Asthere are no lymphatics in the scar,sothere
is no spread to lymphnodes.
• Asthere are no nerves in the scar itis painless.
•It hasraised and everted edge with induration.
•Biopsy confirms the diagnosis.
Treatment
Radiotherapy is not given forMarjolin’sulcer
.
Treatment is either wide excision or amputation. It is curable.
Once it spreads out of the scar tissue it behaves like
any other squamous cell carcinoma and socanspreadto
10/22/20r1e6gional lymphnodes 56
99. Treatment of burn
contracture
10/22/2016 99
• Releaseof contracture surgically and useof skingraft
or “Z” plasty or differentflaps.
• Proper physiotherapy and rehabilitation is essential.
• Pressuregarments to prevent hypertrophicscars.
• Management of itching in the scarusing aloevera,
antihistamines and moisturizing creams.
100. Prevention of developmentof
contracture
10/22/2016 100
•Joint exercise in full range during recovery periodof
burns
• Pressuregarments for along period
•Topical silicon sheeting
•Saline expanders for scars
102. Non thermal(cont……)
10/22/2016 102
Electrical burns 1000v
Low tension injuries
Low tension injuries do not have enough energy to cause
Significant destruction
Entry and exit points normally in the fingers suffers small
Deepburns may damage underlying nerves and vessels
Accreates atetany within musclessopatient unable to
Releasethe device untill the power wasturnedoff
May interfere with normal cardiac pacing and cancause
Cardiac arrest
103. Electrical
burns(cont…..)
high tension injuries
3 sources of damage
1) The flash
2) The flame
3) The current
When ahigh tension line is earthed itcanarc over the pt
And causesaflash burn
Extremely rapid heating of the aircausesan explosion
That propel the victimbackward
It is always amajor burn
There is awound of entry and wound ofexit
Major internal organ injuriesoccures
Convulsions candevelope
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104. Electrical
burns(cont…..)
Management
Depending on injury it is managedaccordingly
Patient should always be admitted and should be assessedby
i. ECG
ii. u/s abdomen
iii. Chestx-ray
iv. Ctscanhead sometimes
v. Cardiac enzyme analysis
Acidosis is common sobicarbonate infusion needed
Fractures and dislocations common somanaged accordingly
Releaseof myoglobin cancauserenal tubular damage andrenal
Failure somanitol is used to prevent myoglobin inducedrenal
failure (compartment syndrome)
10/22/2016 66
105. Wound of entry in anelectricburn.
Electric burn
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107. Chemical
burns
10/22/2016 107
There are 70000 different chemicals in regular usewithinindustry
Occasionally these causeburns
There are two aspects to achemicalinjury
1. Physicaldestruction to theskin
2. Systemicabsorption
Theinitial management of any chemical injury is copious lavage
With water but some need tobe remove physically eg.phosphorus
Acomponent of millitary devices
Themore common injuries are causedbyeither
1. Alkalis
2. acids
108. Chemical burns(cont…)
10/22/2016 108
Alkalis
alkalis are more destructive and especially when come incontact
With eyes
Commonly used alkalis are sodium hydroxide,lime,bleach
Theycausefat sponification,fluide loss,release of alkali proteinase
Alkali burns occur in oral cavity andoesophagus
which leads to multiple oesophagealstrictures.
After copious lavage, the next step in themanagement of any
chemical injury is toidentify the chemical
and its concentration and to elucidate whether there is any
underlying threat to the patient’s life if absorbed systemically
109. Acidaemia should be corrected by IVsodiumbicarbonate.
10/22/2016
Chemical burns(cont…)
109
Acids
Acid burn occurs in skin, soft tissues and GIT
.In GIT
,
Burns affecting the fingers and causedby dilute acid arerelatively
common.
Theinitial management is with calcium gluconate geltopically
severe burns or burns to large areas of the hand canbe
subsequently treated with Bier’s blocks containing calcium
gluconate 10 per centgel
it is common in stomach either due to nitric acid or sulphuric acid
which may lead tosevere gastritis or pyloric stenosis.
Other acids are formic acid, hydrofluoricacid.
Theycausemetabolic acidosis, renal failure, ARDS,haemolysis.
110. Cold injuries
inflammatory reactionisnot asmarked.
Thetissueismoreresistanttocoldinjurythantoheatinjury
Theassessmentof depth of injuryismoredifficult,
Frostbite
injuries affectthe peripheriesincoldclimates
coldinjury producesdelayedmicrovasculardamagesimilarto
that of cardiacreperfusioninjury.
Theinitial treatmentiswith rapidrewarminginabathat42°C.
Thelevelof damageisdifficult toassess
surgery
usuallydoesnot playarole in itsmanagement
Cold injuries are principally divided into twotypes
1. Acute cold injuries fromindustries
2. Frost bite
72
111. Ionising
radiation
111
Theseinjuries canbe divided into
1. Localised
2. Whole body exposure
Themanagement of localised radiation damage is usually
Conservative until the true extent of the tissue injury is apparent.
If damage have causedan ulcer, then excision and coveragewith
vascularised tissue is required.
Apatient who hassuffered whole-body irradiation and issuffering
From acute desquamation of the skin hasreceived alethal dose of
Radiation which cancauseaparticularly slow and unpleasantdeath
Dosemay be lethal and may not belethal
Giving iodine tablets, the management of these injuries is supportive