Burn Injuries. Epidemiology b Tissue injury caused by thermal, electrical, or chemical agents b Can...

Burn InjuriesBurn Injuries

EpidemiologyEpidemiology Tissue injury caused by thermal, Tissue injury caused by thermal,

electrical, or chemical agentselectrical, or chemical agents Can be fatal, disfiguring, or Can be fatal, disfiguring, or

incapacitatingincapacitating ~ 1.25 million burn injuries per year~ 1.25 million burn injuries per year

• 45,000 hospitalized per year45,000 hospitalized per year• 4500 die per year (3750 from housefires)4500 die per year (3750 from housefires)

3rd largest cause of accidental death 3rd largest cause of accidental death

Anatomy and Physiology Anatomy and Physiology of Skinof Skin

SkinSkin

Largest body organ. Much more Largest body organ. Much more than a passive organ.than a passive organ.• Protects underlying tissues from injuryProtects underlying tissues from injury• Temperature regulationTemperature regulation• Acts as water tight seal, keeping body Acts as water tight seal, keeping body

fluids influids in• Sensory organSensory organ

SkinSkin

EpidermisEpidermis• Outer cells are dead Act as Outer cells are dead Act as

protection and form water protection and form water tight sealtight seal

• Deeper layers divide to Deeper layers divide to produce the stratum corneum produce the stratum corneum and also contain pigment to and also contain pigment to protect against UV radiationprotect against UV radiation

Skin Skin

DermisDermis• Consists of tough, elastic connective tissue Consists of tough, elastic connective tissue

which contains specialized structureswhich contains specialized structures Dermis - Specialized StructuresDermis - Specialized Structures

• Nerve endingsNerve endings• Blood vesselsBlood vessels• Sweat glandsSweat glands• Oil glands - keep skin waterproof, usually Oil glands - keep skin waterproof, usually

discharges around hair shaftsdischarges around hair shafts• Hair follicles - produce hair from hair root or Hair follicles - produce hair from hair root or

papillapapilla– Each follicle has a small muscle (arrectus pillorum) which can pull Each follicle has a small muscle (arrectus pillorum) which can pull

the hair upright and cause goose fleshthe hair upright and cause goose flesh


( I ) Burn Injuries ( I ) Burn Injuries Classifications according to Classifications according to causecause Thermal burnThermal burn

• Extensive and deeper part > superficial partExtensive and deeper part > superficial part Scald burnScald burn

• Boiling water or vapourBoiling water or vapour• superficial part > deeper part superficial part > deeper part

Chemical burnChemical burn• By Acid or alkali and it is a very deep burnBy Acid or alkali and it is a very deep burn

Electrical burnElectrical burn• Severest and associated with cerebral Severest and associated with cerebral

irritation and cardiac standstillirritation and cardiac standstill Radiation burn it is a deep burnRadiation burn it is a deep burn


Potential complicationsPotential complications• Fluid and Electrolyte loss Fluid and Electrolyte loss

HypovolemiaHypovolemia• Hypothermia, Infection, AcidosisHypothermia, Infection, Acidosis catecholamine release, catecholamine release,

vasoconstrictionvasoconstriction• Renal or hepatic failureRenal or hepatic failure• Formation of escharFormation of eschar• Complications of circumferential burnComplications of circumferential burn

Burn ClassificationsBurn Classifications

1st degree (Superficial burn)1st degree (Superficial burn)• Involves the epidermisInvolves the epidermis• Characterized by Characterized by

– Surface ----- Dry and Tenderness Surface ----- Dry and Tenderness

– Edema may occur, but no blisteringEdema may occur, but no blistering

– Mottled redMottled red

– Burn blanches under pressureBurn blanches under pressure

• Example – sunburnExample – sunburn• Usually heal in ~ 7 daysUsually heal in ~ 7 days


First Degree BurnFirst Degree Burn(Superficial Burn)(Superficial Burn)


2nd degree2nd degree• Damage extends through the epidermis and Damage extends through the epidermis and

involves the dermis.involves the dermis.• Not enough to interfere with regeneration of Not enough to interfere with regeneration of

the epitheliumthe epithelium• Surface Moist, shiny appearance and PainfulSurface Moist, shiny appearance and Painful• Vesicles or bullae contain opalescent fluidVesicles or bullae contain opalescent fluid• Mottled white after rupture of bullae with Mottled white after rupture of bullae with

coagulated albumincoagulated albumin• Salmon pink to red colorSalmon pink to red color• Usually heal in ~7-21 daysUsually heal in ~7-21 days


)) 2nd Degree Burn2nd Degree Burn(Partial Thickness Burn(Partial Thickness Burn

2nd Degree Burn2nd Degree Burn(Partial Thickness Burn)(Partial Thickness Burn)


3rd degree3rd degree• Both epidermis and dermis are destroyed Both epidermis and dermis are destroyed

with burning into SC fatwith burning into SC fat• Thick, dry appearanceThick, dry appearance• Pearly gray or charred black colorPearly gray or charred black color• Painless - nerve endings are destroyedPainless - nerve endings are destroyed• Pain is due to intermixing of 2nd degreePain is due to intermixing of 2nd degree• May be minor bleedingMay be minor bleeding• Cannot heal and require graftingCannot heal and require grafting

( 2) Depth Classification( 2) Depth Classification

Superficial (1st degree) Superficial (1st degree) Partial thickness (2nd degree)Partial thickness (2nd degree)

• Superficial 2nd degree (no need Superficial 2nd degree (no need for graft)for graft)

• Deep 2nd degree (need for graft)Deep 2nd degree (need for graft) Full thickness (3rd degree)Full thickness (3rd degree)

Full thickness burnFull thickness burn


3rd Degree Burn3rd Degree Burn(Full Thickness burn)(Full Thickness burn)



1st degree 1st degree (Superficial (Superficial

burn)burn)

2nd degree2nd degree 3rd degree3rd degree

InvolveInvolve Involves the Involves the epidermisepidermis

epidermis and epidermis and the dermis.the dermis.

Both epidermis and Both epidermis and dermis are dermis are destroyed with destroyed with burning into SC fatburning into SC fat

ClinicallClinicallyy

Surface ----- Dry Surface ----- Dry and Tenderness and Tenderness

Edema may Edema may occur, but no occur, but no blisteringblistering

Mottled redMottled red

Burn blanches Burn blanches under pressureunder pressure

Example - Example - sunburnsunburn

Surface Moist, Surface Moist, shiny shiny appearance and appearance and PainfulPainful

Vesicles or Vesicles or bullae contain bullae contain opalescent fluidopalescent fluid

Mottled white Mottled white after rupture of after rupture of bullae with bullae with coagulated coagulated albuminalbumin

Thick, dry Thick, dry appearanceappearance

Painless - nerve Painless - nerve endings are endings are destroyeddestroyed

No vesiclesNo vesicles

Pearly gray or Pearly gray or charred black colorcharred black color

May be minor May be minor bleedingbleeding

HealingHealing Usually heal Usually heal in ~ 7 daysin ~ 7 days

Usually heal in Usually heal in ~7-21 days~7-21 days

Cannot heal and Cannot heal and require graftingrequire grafting


Often it is not possible to predict Often it is not possible to predict the exact depth of a burn in the the exact depth of a burn in the acute phase. acute phase.

Some 2nd degree burns will Some 2nd degree burns will convert to 3rd when infection sets convert to 3rd when infection sets in. in.

When in doubt call it 3rd degree.When in doubt call it 3rd degree.

to predict the exact depth of to predict the exact depth of a burna burn

Methylene blueMethylene blue Sensation testsSensation tests Causative agentCausative agent ThermographyThermography Appearance of the lesionAppearance of the lesion

(III) Burn Classifications (III) Burn Classifications according to Critical or notaccording to Critical or not

Extremities of ageExtremities of age Site in the face, neck, genitalia Site in the face, neck, genitalia

perineum, hands and feetperineum, hands and feet Cause either electrical or chemicalCause either electrical or chemical Respiratory tract obstruction or Respiratory tract obstruction or

edemaedema

(IV) Body Surface Area (IV) Body Surface Area EstimationEstimation

Body Surface Area Body Surface Area EstimationEstimation

Burn Patient SeverityBurn Patient Severity

SeveritySeverity ChildrenChildren AdultAdult

MinorMinor SuperficiaSuperficiall

< 5%< 5% <10 %<10 %

DeepDeep < 2 %< 2 % < 5 %< 5 %

ModerateModerate SuperficiaSuperficiall

5 -15 %5 -15 % 10 - 25 10 - 25 %%

DeepDeep 2 – 5 %2 – 5 % 5 – 10 %5 – 10 %

SeverSever SuperficiaSuperficiall

>15 %>15 % > 25 %> 25 %

DeepDeep > 5 %> 5 % > 10 %> 10 %

Thermal Burn Injury Thermal Burn Injury PathophysiologyPathophysiology

Emergent phaseEmergent phase• Response to pain Response to pain catecholamine release catecholamine release

Fluid shift phaseFluid shift phase• massive shift of fluid - intravascular massive shift of fluid - intravascular

extravascularextravascular Hypermetabolic phaseHypermetabolic phase

demand for nutrients demand for nutrients repair tissue repair tissue damagedamage

Resolution phaseResolution phase• scar tissue and remodeling of tissuescar tissue and remodeling of tissue

Thermal Burn Injury Thermal Burn Injury PathophysiologyPathophysiology

Jackson’s Thermal Wound TheoryJackson’s Thermal Wound Theory Zone of CoagulationZone of Coagulation

• area nearest burn area nearest burn • cell membranes rupture, clotted blood and cell membranes rupture, clotted blood and

thrombosed vesselsthrombosed vessels Zone of StasisZone of Stasis

• area surrounding zone of coagulation area surrounding zone of coagulation • inflammation, decreased blood flowinflammation, decreased blood flow

Zone of HyperemiaZone of Hyperemia• peripheral area of burnperipheral area of burn• limited inflammation, increased blood flowlimited inflammation, increased blood flow

Assessment & Assessment & Management - Thermal Management - Thermal InjuryInjury

( I ) First aid in the burn sit( I ) First aid in the burn sit Remove to safe area, if possibleRemove to safe area, if possible Stop the burning processStop the burning process

• Extinguish fire - cool smoldering areasExtinguish fire - cool smoldering areas• Remove clothing and jewelryRemove clothing and jewelry• Cut around areas where clothing is Cut around areas where clothing is

stuck to skinstuck to skin• Cool adherent substances (Tar, Plastic)Cool adherent substances (Tar, Plastic)

Sedation Sedation Transport to hospitalTransport to hospital

(II) Initial hospital (II) Initial hospital managementmanagement Airway and BreathingAirway and Breathing

• Assess for potential airway Assess for potential airway involvementinvolvement

• Assist ventilations as neededAssist ventilations as needed• 100% oxygen via NRB 100% oxygen via NRB • Respiratory rates are unreliable due to Respiratory rates are unreliable due to

toxic combustion product’stoxic combustion product’s• Be prepared to intubate early if patient Be prepared to intubate early if patient

has inhalation injurieshas inhalation injuries

(II) Initial hospital (II) Initial hospital managementmanagement Circulatory StatusCirculatory Status

• Burns do not cause rapid onset of Burns do not cause rapid onset of hypovolemic shockhypovolemic shock

• If shock is present, look for other If shock is present, look for other injuriesinjuries

• Circumferential burns may cause Circumferential burns may cause decreased perfusion to extremitydecreased perfusion to extremity

(II) Initial hospital (II) Initial hospital managementmanagement

OtherOther• Analgesia & AntibioticsAnalgesia & Antibiotics• Anti-tetanic serumAnti-tetanic serum• Fluid Therapy after transfer to burn Fluid Therapy after transfer to burn

unitunit• Assess Burn Surface Area & Associated Assess Burn Surface Area & Associated

InjuriesInjuries

(III) Fluid Therapy in burn (III) Fluid Therapy in burn unitunit

Consider Fluid Therapy Consider Fluid Therapy AmountAmount TypeType RouteRoute

• Minor oralMinor oral• Moderate and sever IVModerate and sever IV

Rate of administrationRate of administration

Amount of Fluid Therapy Amount of Fluid Therapy

Evans formulaEvans formula In the first 24 hourIn the first 24 hour

• Body weight X % of surface area burnt X 2Body weight X % of surface area burnt X 2• + Basic requirements 2500 cc+ Basic requirements 2500 cc

In the second 24 hourIn the second 24 hour• Body weight X % of surface area burnt X 1Body weight X % of surface area burnt X 1• + Basic requirements 2500 cc+ Basic requirements 2500 cc

In the 3In the 3rdrd day day• Basic requirements 2500 ccBasic requirements 2500 cc

Type of Fluid TherapyType of Fluid Therapy

ColloidColloid CrystalloidsCrystalloids BloodBlood Basic requirement are given as glucose 5 %Basic requirement are given as glucose 5 %

ColloidColloid CrystalloiCrystalloidsds

BloodBlood

MinorMinor 1/21/2 1/21/2 nono

ModerateModerate 1/21/2 1/21/2 nono

SeverSever 1/41/4 1/21/2 1/41/4

Rate of administrationRate of administration

CrystalloiCrystalloidsds

ColloidColloid Basic Basic requirrequir

11stst 8 8 hourshours

1/21/2 1/21/2 1/31/3

22ndnd 8 8 hourshours

1/41/4 1/41/4 1/31/3

33rdrd 8 8 hourshours

1/41/4 1/41/4 1/31/3

44thth 8 8 hourshours

1/31/3 1/31/3 1/31/3


1/31/3 1/31/3 1/31/3


1/31/3 1/31/3 1/31/3

(IV) Treat Burn Wound (IV) Treat Burn Wound (initial)(initial)

Low priority - After ABC’s and initiation of Low priority - After ABC’s and initiation of IV’sIV’s

Do not rupture blistersDo not rupture blisters Cover with sterile dressingsCover with sterile dressings

• Moist: Controversial, limit to small areas Moist: Controversial, limit to small areas (<10%) or limit time of application(<10%) or limit time of application

• Dry: Use for larger areas due to concern for Dry: Use for larger areas due to concern for hypothermiahypothermia

• Cover with burn sheetCover with burn sheet No “Goo” on burn unless directed by No “Goo” on burn unless directed by

burn centerburn center

(IV) Treat Burn Wound (IV) Treat Burn Wound (Exposure Dressing)(Exposure Dressing)

Based on that bacteria well not Based on that bacteria well not grow or dry coagulumgrow or dry coagulum

IndicationsIndications•Burn around orificesBurn around orifices•Non circumferential burnsNon circumferential burns•Extensive burnsExtensive burns


The patient is completely bared The patient is completely bared in in

Clean bed sheetsClean bed sheets Room temp 20 – 22Room temp 20 – 22 Minimal humidityMinimal humidity Away from air currentAway from air current UVL to sterilize atmosphereUVL to sterilize atmosphere Suction pumpSuction pump Part elevation to decrease edemaPart elevation to decrease edema


Superficial burnSuperficial burn•A crust is formed due to A crust is formed due to

evaporation of oozing plasmaevaporation of oozing plasma•Epithelium grow below it and Epithelium grow below it and

began to separate after 10 began to separate after 10 days and complete after 14 days and complete after 14 daysdays


Deep burnDeep burn• An eschar is formed which is a An eschar is formed which is a

coagulative necrosis of dead skincoagulative necrosis of dead skin• Began to separate after 2 weeks but Began to separate after 2 weeks but

complete separation need interferencecomplete separation need interference• Methods of esharectomyMethods of esharectomy

– PhysicalPhysical– SurgicalSurgical– enzymaticenzymatic

IV) Treat Burn Wound IV) Treat Burn Wound (closure Dressing)(closure Dressing)

IndicationsIndications• Hands and mobile partsHands and mobile parts• Circumferential burnCircumferential burn• After escharectomyAfter escharectomy• In children and uncooperative patientsIn children and uncooperative patients

TechniqueTechnique• Cleaning with salineCleaning with saline• Silver sulphadiazineSilver sulphadiazine• Layer of suratulle ( vaslinzed gauze)Layer of suratulle ( vaslinzed gauze)• Fulffed cotton gaugeFulffed cotton gauge• Cotton wool and creep bandageCotton wool and creep bandage

Inhalation InjuryInhalation Injury

Anticipate respiratory problems:Anticipate respiratory problems:• Head, Face, Neck or ChestHead, Face, Neck or Chest• Nasal or eyebrow hairs are singedNasal or eyebrow hairs are singed• Hoarseness, tachypnea, drooling presentHoarseness, tachypnea, drooling present• Loss of consciousness in burned areaLoss of consciousness in burned area• Nasal/Oral mucosa red or dryNasal/Oral mucosa red or dry• Soot in mouth or noseSoot in mouth or nose• Coughing up black sputumCoughing up black sputum• an enclosed burning area (e.g. small an enclosed burning area (e.g. small

apartment)apartment)

Inhalation InjuryInhalation Injury

Burned or exposed to products of Burned or exposed to products of combustion in closed spacecombustion in closed space

Cough present, especially if Cough present, especially if productive of carbonaceous sputumproductive of carbonaceous sputum

Any patient in fire has potential of Any patient in fire has potential of hypoxia and Carbon monoxide hypoxia and Carbon monoxide poisoningpoisoning

Inhalation Injury Inhalation Injury

Supraglottic InjurySupraglottic Injury• Susceptible to injury from high Susceptible to injury from high

temperaturestemperatures• May result in immediate edema of May result in immediate edema of

pharynx and larynxpharynx and larynx– Brassy coughBrassy cough– StridorStridor– HoarsenessHoarseness– Carbonaceous sputumCarbonaceous sputum– Facial burnsFacial burns

Inhalation Injury Inhalation Injury

Subglottic InjurySubglottic Injury• Rare injuryRare injury• Injury to Lung parenchymaInjury to Lung parenchyma• Usually due to superheated steam, Usually due to superheated steam,

aspiration of scalding liquid, or aspiration of scalding liquid, or inhalation of toxic chemicalsinhalation of toxic chemicals

• May be immediate but usually delayedMay be immediate but usually delayed– Wheezing or CracklesWheezing or Crackles– Productive coughProductive cough– BronchospasmBronchospasm

Inhalation injuryInhalation injury

Other ConsiderationsOther Considerations• Toxic gas inhalationToxic gas inhalation• Smoke inhalationSmoke inhalation• Carbon Monoxide poisoningCarbon Monoxide poisoning• Thiocyanate poisoningThiocyanate poisoning• Thermal burnsThermal burns• Chemical burnsChemical burns

Inhalation Injury Inhalation Injury ManagementManagement

Airway, Oxygenation and VentilationAirway, Oxygenation and Ventilation• Assess for airway edema early and oftenAssess for airway edema early and often• Consider early intubation, RSIConsider early intubation, RSI• When in doubt oxygenate and ventilateWhen in doubt oxygenate and ventilate• High flow oxygenHigh flow oxygen• Bronchodilators may be considered if Bronchodilators may be considered if

bronchospasm presentbronchospasm present• Diuretics not appropriate for pulmonary Diuretics not appropriate for pulmonary

edemaedema


CirculationCirculation• Treat for Shock (rare)Treat for Shock (rare)• IV AccessIV Access

– large bore, multiple IVslarge bore, multiple IVs

– Titrate fluids to maintain systolic BP and perfusionTitrate fluids to maintain systolic BP and perfusion


Other ConsiderationsOther Considerations• Assess for other Burns and InjuriesAssess for other Burns and Injuries• Treat burn soft tissue injuryTreat burn soft tissue injury• Treat associated inhalation injury/poisoningTreat associated inhalation injury/poisoning

– Cyanide poisoning antidote kitCyanide poisoning antidote kit– Positive pressure ventilationPositive pressure ventilation– Hyperbaric chamber (carbon monoxide poisoningHyperbaric chamber (carbon monoxide poisoning))

Transport considerationsTransport considerations• Burn CenterBurn Center• Hyperbaric chamberHyperbaric chamber

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