Burn traumaBurn trauma. . Pathogenesis. Diagnostic Pathogenesis. Diagnostic

criteria. Clinic.criteria. Clinic.

20122012

In In GreekGreek mythologymythology, , PrometheusPrometheus is a is a

TitanTitan known for known for stolstolinging firefire from from

ZeusZeus and g and giivvinging it it to to mortalsmortals for their for their

use.use.

Burn isBurn is Burn injuries are caused by a Burn injuries are caused by a

variety of sources, including variety of sources, including dry heat (flame), moist heat dry heat (flame), moist heat (scald, by hot liquids), (scald, by hot liquids), contact with hot surfaces, contact with hot surfaces, chemicals, electricity, and chemicals, electricity, and ionizing radiation. The ionizing radiation. The causative agent of the injury causative agent of the injury affects both the prognosis affects both the prognosis and the treatment.and the treatment.

According to this, there are According to this, there are thermal, chemical, electrical, thermal, chemical, electrical, contact, radiation, sun contact, radiation, sun burns.burns.

Among surgical diseases Among surgical diseases burns take 2 %.burns take 2 %.

Pathogenesis Pathogenesis

The tissue destruction caused by a The tissue destruction caused by a burn injury can cause many local and burn injury can cause many local and systemic problems, including fluid systemic problems, including fluid and protein losses, sepsis, and and protein losses, sepsis, and disturbances of the metabolic, disturbances of the metabolic, endocrine, respiratory, cardiac, endocrine, respiratory, cardiac, hematological, and immune systems. hematological, and immune systems. Complex of these disturbances is Complex of these disturbances is

called called burn disease.burn disease.

Burn diseaseBurn diseaseappears in case of burns of more appears in case of burns of more

than 10-15% of body area in adults than 10-15% of body area in adults and and

5-7% in children5-7% in children Burn shock (24-72 hours and more)Burn shock (24-72 hours and more)

Acute burn toxemiaAcute burn toxemia

Burn septic toxemia (lasts till the all Burn septic toxemia (lasts till the all wounds will be closed by autografts)wounds will be closed by autografts)

Recovery period ( 12 months and Recovery period ( 12 months and more)more)

Pathogenesis of the development of burn Pathogenesis of the development of burn shockshock

traumatictraumatic

hypovolemichypovolemic

hypercoagulativehypercoagulative

painpain

Pathogenesis of the development of burn shockPathogenesis of the development of burn shock

PainPain

CNSCNS

adrenalinadrenalin

αα-adrenoreceptors-adrenoreceptors of precappilaresof precappilares

spasm of spasm of precappilaresprecappilares

s-m of hypo perfusion of organs ands-m of hypo perfusion of organs and tissuestissues

Pathogenesis of the development of burn shockPathogenesis of the development of burn shock

decreasing of oxygen, going to organs and tissuesdecreasing of oxygen, going to organs and tissues

acidosisacidosis

blocking ofblocking of αα--adrenoreceptors of precapillarsadrenoreceptors of precapillars

paretic dilation of precapillarsparetic dilation of precapillars

increased capillary permeability (capillary leak syndrome)increased capillary permeability (capillary leak syndrome)

increased capillary hydrostatic pressure increased capillary hydrostatic pressure

NORMAL BLOOD CAPILLARYNORMAL BLOOD CAPILLARY POSTBURN BLOOD POSTBURN BLOOD CAPILLARYCAPILLARY

Water molecule

Water is the smallest molecule that can pass through the capillary pores.

Protein molecule

Permeability is increased, which allows large molecules such as proteins to pass through the capillary pores easily.

The vascular capillary response to burn injury - fluid shift (capillary leak capillary leak

syndrome)syndrome)

liquid part of liquid part of blood to tissuesblood to tissues

Pathogenesis of the development of burn shockPathogenesis of the development of burn shock

Local inflammatory answerLocal inflammatory answer SystemicSystemic inflammatory answerinflammatory answer

toto 15% 15% of burnsof burns more than 15% of burnsmore than 15% of burns

changes in veins changes in veins

of para necrotic of para necrotic

zonezone

Injury of endothelium Injury of endothelium by by ferments of granulocytesferments of granulocytes

liquid part of liquid part of

blood to tissuesblood to tissues

edema, blistersedema, blisters

increasing amount of inflammatory increasing amount of inflammatory

inhalationsinhalations

influence on veins of interior influence on veins of interior

organsorgans

staying of blood in staying of blood in capillariescapillaries

edema of organsedema of organs

Clinic of burn shockClinic of burn shock

Generalized edema

Slow or no gastric motility. Decreased bowel sounds. Abdominal distention Nausea and vomiting Beginning ulceration of gastrointestinal mucosa. Translocation of ranslocation of microorganisms to microorganisms to vesselsvessels

Central nervous system disorders (exaltation, depression)

acute cardio-vessel acute cardio-vessel insufficiencyinsufficiency – – mainmain

reasonreason of deathof death ((developsdevelops during during 1-2 1-2

hourshours))

In urine cylinders,it’s dark red, anuria

RestrictiveRestrictive respiratory respiratory insufficiencyinsufficiency - - hypoxiahypoxia

Concentration Concentration of blood,of blood, hyper hyper coagulation, coagulation, DVSDVS onon 2-3 2-3 dayday

Pathogenesis of the development of Pathogenesis of the development of

acute burn toxemiaacute burn toxemia

The inflammatory responses The inflammatory responses gradually subside 24 to 36 hours gradually subside 24 to 36 hours after the injury, and the capillary leak after the injury, and the capillary leak abates. Fluid shifts back into the abates. Fluid shifts back into the circulation. But with toxic substances circulation. But with toxic substances from metabolism of necrotic tissues. from metabolism of necrotic tissues. Endogen intoxication - Endogen intoxication - period of period of acute burn toxemiaacute burn toxemia (from few hours (from few hours or days after the trauma) or days after the trauma)

disorders of CNSdisorders of CNS, , depressing, inversion of depressing, inversion of sleepingsleeping, , psychosispsychosis;;

hyperthermiahyperthermia;; tachycardia, hypotensiontachycardia, hypotension;; polyuriapolyuria ( (cylinders, leucocytes, cylinders, leucocytes,

erythrocytes in urineerythrocytes in urine);); dynamic impassabilitydynamic impassability;; decreasing of protein level in blooddecreasing of protein level in blood;; leukocytosisleukocytosis, , left shiftleft shift..

Clinic of acute burn toxemiaClinic of acute burn toxemia

Main criterions of Main criterions of burnsburns

area (%)area (%)depth (I,II,III,IV)depth (I,II,III,IV)severity (units)severity (units)

Determination of burn areaDetermination of burn area

Rule of 9Rule of 9

Rule of palmRule of palm

Dolinin’s Dolinin’s schemescheme

Skin structure Skin structure

Classification of burns Classification of burns according to the depthaccording to the depth

Classification of burns Classification of burns according to the depthaccording to the depth

superficial-thickness woundssuperficial-thickness wounds partial-thickness wounds (separated partial-thickness wounds (separated

into superficial and deep subgroups)into superficial and deep subgroups) full-thickness woundsfull-thickness wounds deep full-thickness woundsdeep full-thickness wounds

Classification of burns Classification of burns according to the depthaccording to the depth

I stage – epidermal burnI stage – epidermal burn II stage – dermal superficial burnII stage – dermal superficial burn III stage – dermal deep burnIII stage – dermal deep burn IV stage – under fascia burnIV stage – under fascia burn

Determination of burn depthDetermination of burn depth

II II IV IV

IIIIII

The American Burn Association (ABA) describes burns as The American Burn Association (ABA) describes burns as minor, moderate, or major depending on the depth, minor, moderate, or major depending on the depth,

extent, and location extent, and location

MINOR BURNSMINOR BURNS Deep partial-thickness burns <15% TBSA Full-thickness burns <2% TBSA No Deep partial-thickness burns <15% TBSA Full-thickness burns <2% TBSA No

burns of eyes, ears, face, hands, feet, or perineum No electrical burns No burns of eyes, ears, face, hands, feet, or perineum No electrical burns No inhalation injury No complicated concomitant injuryinhalation injury No complicated concomitant injury

Patient is under 60 yr and has no chronic cardiac, pulmonary, or endocrine Patient is under 60 yr and has no chronic cardiac, pulmonary, or endocrine disorderdisorder

MODERATE BURNSMODERATE BURNS Deep partial-thickness burns 15%-25% TBSA Full-thickness burns 2%-10% Deep partial-thickness burns 15%-25% TBSA Full-thickness burns 2%-10%

TBSA No burns of eyes, ears, face, hands, feet, or perineum No electrical TBSA No burns of eyes, ears, face, hands, feet, or perineum No electrical burns No inhalation injury No complicated concomitant injuryburns No inhalation injury No complicated concomitant injury

Patient is under 60 yr and has no chronic cardiac, pulmonary, or endocrine Patient is under 60 yr and has no chronic cardiac, pulmonary, or endocrine disorderdisorder

MAJOR BURNSMAJOR BURNS Partial-thickness burns >25% TBSAPartial-thickness burns >25% TBSA Full-thickness burns >10%Full-thickness burns >10% Any burn involving the eyes, ears, face, hands, feet, perineumAny burn involving the eyes, ears, face, hands, feet, perineum Electrical injuryElectrical injury Inhalation injuryInhalation injury Client over 60 yr of ageClient over 60 yr of age Burn is complicated with other injuries (e.g., fractures)Burn is complicated with other injuries (e.g., fractures) Client has cardiac, pulmonary, or other chronic metabolic disordersClient has cardiac, pulmonary, or other chronic metabolic disorders

Methods of burn depth Methods of burn depth determination determination

1) 1) primary examinationprimary examination : : - color of epidermis and derma ( epidermis - red or pink in case of - color of epidermis and derma ( epidermis - red or pink in case of

I,II stages, white or yellow or black in case of deep burns ; derma – I,II stages, white or yellow or black in case of deep burns ; derma – red in II stage, pail in IIIA, grey in IIIB)red in II stage, pail in IIIA, grey in IIIB)

- edema- edema - vesicles- vesicles - is or not necrosis (IIIB, IV)- is or not necrosis (IIIB, IV) 2) 2) needle testneedle test ( hyper aesthesia in II st., superficial hypoaestesia in ( hyper aesthesia in II st., superficial hypoaestesia in

case of IIIAst. and so on)case of IIIAst. and so on) 3) 3) application of wet gauzeapplication of wet gauze with special solutions (spiritus) with special solutions (spiritus) 4) 4) depilation testdepilation test ( painful in 1,2,3Ast., easy, without pain in case ( painful in 1,2,3Ast., easy, without pain in case

of deep burns)of deep burns) 5) 5) instrumental methodsinstrumental methods:: a) usage of radioactive isotopesa) usage of radioactive isotopes b) impedance measuringb) impedance measuring c) thermographyc) thermography d) infrared zondingd) infrared zonding e) histological and biochemical methodse) histological and biochemical methods

ВВurn’s severityurn’s severity rule of “hundreds”rule of “hundreds” is used (age in years + total area of is used (age in years + total area of

burns in %)burns in %)

Frank’s indexFrank’s index is more exact. (FI= Area of superficial is more exact. (FI= Area of superficial burns + 3 * area of deep burns)burns + 3 * area of deep burns)

Lesion Severity Index.Lesion Severity Index. (LSI) is the most exact . (LSI) is the most exact .LSI = Area of I-IIst. +2 area of IIIA st. + 3 area of IIIB st.+ LSI = Area of I-IIst. +2 area of IIIA st. + 3 area of IIIB st.+

4 area of IV st.+ age coefficient (factor)+ factor of 4 area of IV st.+ age coefficient (factor)+ factor of respiratory burnsrespiratory burns

The age factor : every year more then 60 is 1 unitThe age factor : every year more then 60 is 1 unitThe factor of respiratory burns :The factor of respiratory burns :- if there is a light degree = 15 units (respiratory disorders - if there is a light degree = 15 units (respiratory disorders

are not fixed);are not fixed);- if middle degree = 30 units (respiratory disorders are - if middle degree = 30 units (respiratory disorders are

fixed first 6-12 hours after trauma);fixed first 6-12 hours after trauma);- if severe degree = 45 units (respiratory insufficiency - if severe degree = 45 units (respiratory insufficiency

from the moment of burn is fixed)from the moment of burn is fixed)Prognosis of burns is favorable, if LSI is not more than 30 Prognosis of burns is favorable, if LSI is not more than 30

unit, is relatively favorable, if 30-60 un., is doubtful – unit, is relatively favorable, if 30-60 un., is doubtful – 61-90 units , unfavorable – more than 90 units.61-90 units , unfavorable – more than 90 units.

Burn shockBurn shock EasyEasy burnburn shock - LSI from 10 up to 30 shock - LSI from 10 up to 30 unitsunits, ,

lasts 24-36 lasts 24-36 h, Hb is 151-160, normal diuresis.h, Hb is 151-160, normal diuresis.

MediumMedium burnburn shock - LSI from 31 up to 60 shock - LSI from 31 up to 60 unitsunits

lasts from 36 up to 48 lasts from 36 up to 48 h, Hb 161-170, diuresis h, Hb 161-170, diuresis is decreased, urine is concentratedis decreased, urine is concentrated

SevereSevere burnburn shock - LSI from 61 up to 90 shock - LSI from 61 up to 90 unitsunits.., ,

lasts up to 64 lasts up to 64 h,h, Hb 171-190, oligouria to Hb 171-190, oligouria to 30ml/hour30ml/hour

The most severeThe most severe burnburn shock – LSI > 90 units, shock – LSI > 90 units, lastslasts up to 72 hours, Hb more than 190, up to 72 hours, Hb more than 190,

anuria.anuria.

Respiratory burnsRespiratory burns

Such diagnosis we can suggest ifSuch diagnosis we can suggest if:: Patient got the burn in the close Patient got the burn in the close

roomroom The burn is caused by the steam , The burn is caused by the steam ,

flame or during explosion flame or during explosion Patients cloth was in a firePatients cloth was in a fire There are burns of chest, neck and There are burns of chest, neck and

faceface

Respiratory burnsRespiratory burns Proofs of the respiratory burns areProofs of the respiratory burns are:: There are burns of the nose, lips, tongueThere are burns of the nose, lips, tongue Nose hair is burnedNose hair is burned Interior organs of the mouth are injuredInterior organs of the mouth are injured Problems with the voiceProblems with the voice Cyanosis, disorders of breezingCyanosis, disorders of breezing Mechanical asphyxiaMechanical asphyxia Dates of consultation of otorynolaryngologistDates of consultation of otorynolaryngologist X-ray examinationX-ray examination Fiberoptic bronchoscopy Fiberoptic bronchoscopy Arterial blood gas determinationArterial blood gas determination Pulmonary function testsPulmonary function tests

Respiratory burnsRespiratory burns

There are 3 degrees of respiratory There are 3 degrees of respiratory burnsburns::

light: there are no respiratory light: there are no respiratory disorders during the first day after disorders during the first day after traumatrauma

medium: respiratory disorders are medium: respiratory disorders are during first 6-12 hours after burnduring first 6-12 hours after burn

severe: respiratory insufficiency from severe: respiratory insufficiency from the moment of the burnthe moment of the burn

Formulation of the Formulation of the diagnosis in case of burnsdiagnosis in case of burns

1. The word ‘burn’1. The word ‘burn’ 2. The etiological factor: flame, hot water, steam, 2. The etiological factor: flame, hot water, steam,

acid…acid… 3. The stage of burn ( I, II, III, IV)3. The stage of burn ( I, II, III, IV) 4. The burn area in % (area of deep burns is 4. The burn area in % (area of deep burns is

putting in brackets)putting in brackets) 5. Injured organs, areas.5. Injured organs, areas. 6. Accompanying injuries that deal with the action 6. Accompanying injuries that deal with the action

of thermal agent ( respiratory burns, carbon of thermal agent ( respiratory burns, carbon monoxide poisoning )monoxide poisoning )

7. Dates about burn shock with it’s degree or 7. Dates about burn shock with it’s degree or another period of the burn disease ( toxemia, another period of the burn disease ( toxemia, septic toxemia, recovery)septic toxemia, recovery)

8. LSI (lesion severity index)8. LSI (lesion severity index) 9. Complications9. Complications 10. Accompanying traumas and diseases10. Accompanying traumas and diseases

The clinical diagnosisThe clinical diagnosis:: Burn by the fire I and II st. 25% Burn by the fire I and II st. 25% of face, neck, right upper limb, of face, neck, right upper limb,

chest.chest. Respiratory burn of light Respiratory burn of light

degree. Burn shock, medium degree. Burn shock, medium degree.degree.

LSI – 40 units.LSI – 40 units.Accompanying diagnosis: Accompanying diagnosis:

Stomach ulcer.Stomach ulcer.

Thank Thank you you

for your for your attentioattentio

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