BURNHardik MainiPharm.D Chitkara university

Burn is defined as a wound caused by an exogenous agent leading to coagulated necrosis of the tissue.

TYPES OF

BURNSTHERMAL BURNS CHEMICAL BURNSELECTRICAL BURNSCOLD BURNSRADIATIONS

THERMAL BURNS

Scald burn Most frequent in home injuries like hot water , liquids and food are most common cause.

Temperature above than 136˚F causes burn.

Temperature less than 111˚F tolerated for long periods

CHEMICAL

BURN Common in industries and factories but can occur at homes also.

Caused by concentrated acids or alkalis.

Acids are more common than alkali.

ELECTRICAL BURNWorse than other

types of burn with entry and exit wounds.

May stop the heart and depress the respiratory system.

May cause thrombosis and cataracts.

RADIATION

BURNSCause due to radiations

Radioactive explosions.

X-Rays.Nuclear bomb explosions.

P’PHYSIOLOGY

OF BURNSFLUID SHIFTPeriod of inflammatory response.Vessels adjacent to burn injury dilates – inc. hydrostatic pressure and inc. capillary permeability.

Continuous leak of plasma from intravascular space to interstitial space.

Associated imbalances of fluids, electrolytes and acid-base occur.

HemoconcentrationLasts 24-36 hours.

P’PHYSIOLOGY

OF BURNSFLUID REMOBILIZATIONCapillary leak ceases and fluid shifts back into the circulation.

Restores renal perfusion and fluid balance.

Increase urine formation and diuresis.Continued electrolyte imbalances.HyponatremiaHypokalemiahemodilution

BODY’S RESPONSE TO BURN.

Emergent phase (STAGE 1)Pain responseCatecholamine responseTachycardia ,tachypnea , mild hypertension , mild anxiety

BODY’S RESPONSE TO BURN.

FLUID SHIFT PHASE (STAGE 2)Length 18-24 hours.Begins after emergent phaseReaches peak level in 6-8 hours.

Damaged cells initiate inflammatory response.

Increased blood flow to cellsShift of fluid from intravascularto extravascular space

Massive edema

BODY’S RESPONSE TO BURN.

HYPERMETABOLIC PHASE ( STAGE 3)

Last for days to weeksLarge increase in body’s need for nutrients as it repairs itself

RESOLUTION PHASE (STAGE 4)Scar formationGeneral rehabilitation and progression to normal function.

CLASSIFICATION OF BURNSFIRST DEGREE

SUPERFICIAL SECOND DEGREE

DEEP SECOND DEGREETHIRD DEGREEFOURTH DEGREE

1ST DEGREE BURN

Reddened skinPain at burn siteInvolves only epidermisBlanch to touchHave an intact epidermal barrier

Do not result in scaringEG: sunburn , minor accidentTreatment with topical soothing agents or NSAIDS

2ND DEGREE BURNS

Intense skinWhite to red skinBlisters Involves dermis and papillary layers of dermis

Spares hair follicles , sweat glands etc.

Erythematous and blanch to touch.Very painful/sensitive.No or minimal scarringSpontaneously re-epithelize from retained epidermal structures in 7-14 days.

DEEP SECOND DEGREE BURN

Injury to deeper layers of dermis-reticular dermis

Appear pale and mottledDo not blanch to touchCapillary return sluggish or absent.

Take 13 to 45 days to healRequires excision or skin grafting.

3RD DEGREE BURN

Dry, leathery skin (white , dark , brown or charred)

Loss of sensation (little pain)

All dermal layers/tissues may be involved.

Always require surgery.

4TH DEGREE BURNInvolves structure

beneath the skin-muscle , bone

ASSESEMENT OF BURNSRULE OF NINES

Best used for large surface areas

Expedient tool to measure extent of burn•RULE OF PALMSBest used for burns <10 % BSA

MANAGEMENTPRE HOSPITAL CARE

Ensure rescuer safetyStop the burning process : stop , drop and fall.

Check for other injuries A standard ABC (AIRWAY , BREATHING , CIRCULATION) check followed by a rapid secondary survey.

MANAGEMENT

Cool the burnt woundGive oxygenElevateGive analgesic

HOSPITAL CARE

A : Airway controlB : Breathing and ventilationC : CirculationD : Disability – neurological status

E : exposure with environmental control

F : fluid resuscitation

AIRWAYRECOGNISATION OF THE

POTENTIALLY BURNED AIRWAYA history of being trapped in the presence of smoke and 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.

AIRWAYBurned 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.

BREATHINGInhalation injury

Thermal burn injury to the lower airway.

Metabolic pathway:carboxy hemoglobin

Mechanical block to breathing: escharotomy

CIRCULATIONMaintain iv line with

wide bore cannula 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 needs for iv 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 unit output.

FLUIDS FOR

RESUSCITATION

PARKLAND FORMULA % TBSA ×Weight (KG)×4 = Volume (ml)

Half this volume is given in first eight hours.

Second half is given in the subsequent 16 hours.

Crystalloid : ringer lactateHypertonic saline Human albumin solutionColloid resuscitation

NUTRITIONBurnt patient need

extra feedingA nasogastric tube should be used in all patients with burn over 15% of TBSA

Removing the burn and achieving healing stops the catabolic drive.

NUTRITIONSUTHERAND FORMULA

Children : 60 kcal/kg +35 %kcal TBSA

Adults : 20 kcal/kg +70 %kcal TBSA•PROTEIN20% of energy1.5 to 2 g/kg protein/day

MONITORING AND

CONTROL OF INFECTION

Burn patients are immunocompromised.

They are susceptible to infections through many routes.

Sterile precautions should be taken.

Swabs should be used regularly.

A rise in WBC count ,thrombocytosis, and increase catabolism are warnings of infections.

TOPICAL TREATMENT OF DEEP

BURNS 1% silver sulphadiazine cream.

0.5% silver nitrate solution.

Mafenide acetate cream.Serum nitrate, silver sulphadiazine and cerium nitrate.

PRINCIPLES OF

DRESSINGS FOR BURNS

Full – thickness and deep dermal burns need antibacterial dressings to delay colonization prior to surgery.

Superficial burns will heal and require simple dressings.

An optimal healing environment can make a difference to outcome in borderline depth burns.