seminar; SPHMMC

1. Principles of Management of Burn Injury
Alazar Bekele
Amanuel G/Yonhannes
Amanuel Teshale
Amelewerk Gonfa
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2. Outline
• Objective
• Introduction
• Epidemiology
• Type of Burn injury
• Classification of Burns
• Pathophysiology of Burns
• Assessment of the Burn wound
• Management of Burns
• Primary
• Secondary
• Complications of Burn Injuries
• Prevention
• Summary
• References 2

3. Objectives
At the end of this seminar students we be able to know:
• definition and causes of Burn injuries
• The burden of the injury in our country
• Types and classification of burns
• Understand the pathophysiology of burns
• Management of a patient who sustained burn injury
• Complications of burns
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4. Introduction
 Definition
• A burn is a coagulative destruction of the surface layers of the body.
• It occur when some or all of the cells in the skin or other tissues are
destroyed by
 heat
 cold
 electricity
 Radiation
 Lightening
 caustic chemicals
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5. Epidemiology
 Worldwide,
 Burns are the fourth most common type of trauma
 More than 90% of burns are caused by carelessness or ignorance
& are completely preventable
 About 90% of burns occurs in low and middle income countries
 Most burn injuries occur in domestic setting, with cooking as the
most common activity
 Armed conflicts increase the incidence of burns
 In Ethiopia, Based on A community-based study by Kidanu E.
 Highest incidence = in children < 5 years of age
 Scald burn= 59 % and flame = 34 %
 81 % of these burn injuries occurs in home
 Mortality rate= 11.5 %
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6. Epidemiology (cont’d)
 Age wise:
 As with other forms of trauma, burns frequently affect
children and young adults.
o Children under 8  Scald Burns
o In older children and adults  flame-related Burns
(usually the result of house fires.)
Work-related burns:
 The most common burns in work places:
1. Chemicals or hot liquids
2. Electricity
3. Molten or hot metals
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7. Epidemiology (cont’d)
• No one is immune to thermal
injury
• Demographic analysis shows four
high risk groups:
 The very young
 The very old
 The very unlucky
 The very careless
Flame 33%
Scald 30%
Contact 15%
Flash 10%
Electrical 5%
Radiation 1%
Friction 1%
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8. Types of Burn Injury
1.Thermal
 The depth of the burn injury is related to
 contact temperature,
 duration of contact of the external heat source, and
 the thickness of the skin.
o Flame: a burn injury by fire
 House fires, smoking related fires, improper use of flammable
liquids, automobile accidents, fall into open fire.
o Scald: a burn injury by moist heat /steam.
 Scalds from hot water are most common cause of burn.
o Flash: explosion of natural gas ,gasoline & other flammable
liquids cause intense heat for a brief time
o Contact: direct conduction of heat from a hot surface to the
body. 8

9. Types of Burn Injury (cont’d)
2. Cold exposure (frostbite)
Damage occurs to the skin and underlying tissues when ice
crystals puncture the cells or when they create a hypertonic
tissue environment.
Usually occurs in distal parts of the body
 Common sites: Fingers, Toes, Nose and Ears
Severe Vasoconstriction & Decreased Blood flow  Microvascular
stasis  Thrombus formation  Microvasculature Emboli 
Ischemia
3. Chemical burns
 It can cause
 alteration of pH,
 disruption of cellular membranes, and
 direct toxic effects on metabolic processes. 9

10.  In addition to the duration of exposure, the nature of the agent
will determine injury severity.
 Acid produces tissue coagulative Necrosis.
 Alkaline burns generate colliquation Necrosis.
 Systemic absorption of some chemicals is life
threatening.
4. Electrical
 Electrical energy is transformed into thermal injury as the
current passes through poorly conducting body tissues.
 mechanisms of injury :
i. Electrical current injury
ii. Electrothermal burns from arcing current
iii. Flame burn caused by ignition of clothes
 Deep destruction of muscles  rhabdomyolysis
myoglobinuria ATN  ARF
Types of Burn Injury (cont’d)
10

11. Types of Burn Injury (cont’d)
5. Inhalation
 Toxic products of combustion injure airway tissues and frequently
occur with flash burns from fire and steam.
 Hot smoke usually burns only the pharynx while steam can
also burn the airway below the glottis.
 Carbon monoxide, which is produced from combustion,
impairs cellular respiration
6. Radiation
 Can be due to Radio frequency energy or ionizing radiation
 The most common type of radiation burn is the sunburn.
 Radiation burns are often associated with cancer due to the
ability of ionizing radiation to interact with and damage DNA.
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12. Pathophysiology of Burn
1.Local Changes
• Burn causes coagulative necrosis of the epidermis and
underlying tissues,
• The depth injury depending on
 the temperature to which the skin is exposed
 the duration of exposure.
 The specific heat of the causative agent also affects the
depth.
o The skin provides a robust barrier to transfer of energy to
deeper tissues;
o therefore, much of the injury is confined to this layer.
o However, after the inciting focus is removed, the response of
local tissues can lead to injury in the deeper layers. 12

13.  The area of cutaneous injury has been divided into three zones:
• Zone of Coagulation
The necrotic area of a burn where cells have been disrupted is
termed the zone of coagulation.
This tissue is irreversibly damaged at the time of injury.
• Zone of Stasis
The area immediately surrounding the necrotic zone has a
moderate degree of insult with decreased tissue perfusion.
depending on the wound environment, can either survive or
progress to coagulative necrosis.
• Zone of Hyperemia
is characterized by vasodilation from inflammation surrounding
the burn wound.
13

14. Pathophysiology of Burn (cont’d)
2. Systemic changes
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15. Pathophysiology of Burn (cont’d)
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16. Pathophysiology of Burn (cont’d)
The airway and lungs
• Airway injuries occur when
 the face and neck are burned or
 if a person is trapped in a burning material,
and is forced to inhale the hot and poisonous
gases
• Warning signs of burns to the respiratory system
 Burns around the face and neck
 A history of being trapped in a burning room
 Change in voice
 Stridor
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17. Assessment of The Burn Wound
1.Burn Depth
 Cutaneous burns are classified according to the depth of tissue
injury:
1. superficial or epidermal (first-degree),
2. partial-thickness (second degree), or
3. full thickness (third degree).
4. Burns extending beneath the subcutaneous tissues
and involving fascia, muscle and/or bone are
considered fourth degree
 Burn wounds are not usually uniform in depth and many have a
mixture of deep and superficial components.
 A precise classification of the burn wound may be difficult
and may require up to three weeks for a final
determination. 17

18. 18

19. First degree
(Superficial)
• Red, erythematous
• Very sensitive to touch
• Very painful
• Usually moist
• No blisters
Second degree
(partial-
thickness)
• Erythematous or whitish with a fibrinous
exudate
• Wound base is sensitive to touch and
Painful
• Commonly have blisters
• Surface may blanch to pressure
Third degree
(Full thickness)
• Surface may be: White, Black, leathery,
Pale or Bright red
• Generally anesthetic or hypoesthetic
• Subdermal vessels do not blanch
• No blisters
• Hair easily pulled from its follicle 19

20. 20

21. Assessment of The Burn Wound (cont’d)
2. Percent Body Surface Area Estimates
 The extent of burns is expressed as the total percentage of body
surface area (TBSA).
• Superficial burns are not included in the TBSA burn assessment.
• The location of partial-thickness and full-thickness burned areas
are recorded on a burn diagram.
• Burns with an appearance compatible with either deep partial-
thickness or full-thickness are presumed to be full-thickness until
accurate differentiation is possible.
• The two commonly used methods of assessing TBSA in adults are
the Lund-Browder chart and "Rule of Nines,"
• whereas in children, the Lund-Browder chart is the recommended
method because it takes into account the relative percentage of
body surface area affected by growth.
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22. Lund-Browdermethod
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Assessment of The Burn Wound (cont’d)

23. Rule of Nines
For adult assessment, the most
expeditious method to estimate TBSA
in adults is the "Rule of Nines“
 Each leg represents 18 percent
TBSA
 Each arm represents 9 percent TBSA
 The anterior and posterior trunk
each represent 18 percent TBSA
 The head represents 9 percent TBSA
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Assessment of The Burn Wound (cont’d)

24. Indications for Hospitalization for Burns
 Burns greater than 15% body surface area
 High-tension wire electrical burns
 Inhalation injury regardless of the size of body
surface area burn
 Inadequate home situation
 Suspected child abuse or neglect
 Burns to hands, feet, genitals
Assessment of The Burn Wound (cont’d)

25. Management; Primary Survey
Initial Intervention
 Airway maintenance with cervical spine control
 Breathing and Ventilation
 Circulation with Haemorrhage Control
 Disability: Neurological Status
 Exposure with Environmental Control

26. Management; Primary Survey (cont’d)
Air way management
The risk of inhalation injury increases with the extent of the burn
and is present in two-thirds of patients with burns greater than 70
percent of the total body surface area (TBSA).
Common signs of significant smoke inhalation injury
• Persistent cough, stridor, or wheezing
• Hoarseness
• Deep facial or circumferential neck burns
• Nares with inflammation or singed hair
• Carbonaceous sputum or burnt matter in the mouth
or nose

27. Management; Primary Survey (cont’d)
• Blistering or edema of the oropharynx
• Depressed mental status, including evidence of drug
or alcohol use
• Respiratory distress
• Hypoxia or hypercapnia
• Elevated carbon monoxide and/or cyanide levels

28. Management; Primary Survey (cont’d)
Diagnostic tests and monitoring
• Arterial blood gas
• Chest x-ray
• Serial peak expiratory flow rates (PEFR)
• Pulse oximetry
• Capnography
• fiberoptic laryngoscopy and bronchoscopy

29. Management; Primary Survey (cont’d)
Treatment
• Supplemental oxygen and airway protection
• Close monitoring of fluid resuscitation
• Mechanical ventilation
• Inhaled nitric oxide
• aerosolized heparin and N-acetylcysteine (NAC)

30. Management; Primary Survey (cont’d)
Fluid resuscitation
According to the American Burn Association's practice
guidelines, any patient with greater than 15 percent total body
surface area (TBSA) non-superficial burns should receive formal
fluid resuscitation.
Fluid selection
Formulae
1. Parkland : 4ml x wt (Kg) x % TBSA burn
-Ringer’s lactate or Hartman solution
2. Evans :1ml x wt x %TBSA
3. Brooke :1.5ml x wt x %TBSA
4. Modified Brook:2ml x wt x % TBSA

31. Management; Primary Survey (cont’d)
Monitoring fluid status
Monitoring urine output
Clinical signs of volume status
laboratory measurements:-mixed venous blood gas
and serum lactate concentration
invasive monitoring:-central venous pressure
Blood transfusion
Risk assessment
hemoconcentration

32. Management; secondary Survey (cont’d)
History
what burned
 location of the fire
 if explosion occurred
 if the patient used alcohol or drugs
 if it is associated with trauma
 The AMPLE trauma history should be obtained

33. Management; Secondary Survey (cont’d)
Thorough physical
examination
Lab studies and
monitoring
CBC
Electrolytes
RFT
Glucose
Venous blood gas
Caboxyhemoglobin
 Arterial blood gas
 Chest x-ray
 ECG
 Cyanide levels

34. Management; Secondary Survey (cont’d)
Chemoprophylaxis
Tetanus immunization
Antibiotic
Wound management
Wound dressing and care
Escharotomy
 Chest - at the anterior axillary line
 Extremity - can be done at a bedside without local
anesthesia

37. Nutrition
• Hypermetabolism develops as a response to injury
• If TBSA >40%, lean body weight ↓ by 25% over the first 3
weeks
• Patient with major burn needs high calorie in the form of:
CHO (50%), protein (20%) , fat (30%) and some
vitamins & minerals

38. Nutrition (cont’d)
• A nasogastric tube should be used in all patients with burns
over 15% of TBSA
• Earlier paralytic ileus can be prevented.
• Mucosal integrity is preserved.
• ↓Risk of bacterial translocation

39. Nutritional Requirement Calculations
Curreri formula
• Age 16–59 years: (25)W + (40)TBSA
• Age 60+ years: (20)W + (65)TBSA
Sutherland formula
• Children: 60 kcal kg–1 + 35 kcal%TBSA
• Adults: 20 kcal kg–1 + 70 kcal%TBSA
Protein needs
• Greatest nitrogen losses between days 5 and 10
• 20% of kilocalories should be provided by proteins

40. Burn Complications
1. INFECTION
Predictors of infection :
Burn size
Age
Inhalation injury

41. Burn Complications (cont’d)
2. Curling ulcer- stress ulcers
3. Contracture
4. Marjolin’s ulcer, Hypertrophic scar, keloid
Pschological aspect
• PTSD
• Flash backs
• Avoidance behavior
• Sleep disturbance
So all burn patient needs psychiatric evaluation and
management.

42. Severe keloids

43. Minimizing complications
1. Hand washing before & after touching each patient.
2. Aseptic techniques for dressing & procedures
3. Early nutritional support
4. Early excision of deep burns
5. Use of topical antimicrobials
6. Early excision and grafting

44. Prevention
1. Implementing good health & safety regulations
2. Educating the public
3. Store gasoline and other flammable liquids out of reach of
children
4. Stir the bath water with your hand to avoid hot spots
5. Do not use electrical appliances in or near showers
6. Keep a fire extinguisher available

45. Summary
• A burn injury is a coagulative damage or destruction of skin
and/or its contents by Thermal, Chemical, Electrical Radiation
energies or combinations
• Burns are the fourth most common type of trauma
• Cutaneous burns are classified according to the depth of tissue
injury.
• Pathophysiology of burn is attributed to the local and systemic
changes.
• A thorough estimation of burn size is essential to guide therapy.
The extent of burns is expressed as the total percentage of body
surface area (TBSA).
• The estimation of percent total body surface area includes
partial-thickness, full-thickness, and fourth degree burns.
Superficial burns are not included in the TBSA burn assessment.
• The most accurate method of assessment of TBSA burn in
children and adults is the Lund-Browder chart. 45

46. References
1. SCHWARTZ :Principles of surgery ,9th edi.2008
2. BAILEY & LOVE : Short practice of surgery ,25th edi,2008
3. Oxford text book of surgery
4. UpToDate 21.2
5. Sabiston text book of surgery 18th edition
6. American Burn Association's practice guidelines, 2012
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47. • Thanks ☺
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