BURNSBURNS

TYPE OF BURNTYPE OF BURN

Scalds Scalds Fat burnsFat burnsFlames burnsFlames burnsElectrical burnsElectrical burnsCold injury Cold injury Friction burnsFriction burnsIonizing radiationIonizing radiationChemical burnsChemical burns

EFFECTS OF BURN INJURYEFFECTS OF BURN INJURY

Local EffectsLocal Effects – results from destruction of – results from destruction of superficial tissues and inflammatory response of superficial tissues and inflammatory response of deeper tissues.deeper tissues.

Tissue damageTissue damage

Loss of barrier to infection.Loss of barrier to infection.

Fluid loss from surface.Fluid loss from surface.

Red cell destruction.Red cell destruction.

InflammationInflammation

Regional EffectsRegional Effects – Circulation (limb circulation may – Circulation (limb circulation may be compromised) be compromised)

EFFECTS OF BURN INJURYEFFECTS OF BURN INJURY

Systemic EffectsSystemic Effects – depend on its size. – depend on its size.Increase capillary permeability:Increase capillary permeability:

• OedemaOedema• Loss of circulating fluid volumeLoss of circulating fluid volume• Hypovolaemic shockHypovolaemic shock• Increase metabolic rate.Increase metabolic rate.• Multiple organ failure.Multiple organ failure.• Inhalation injuryInhalation injury• Systemic complications: Curling’s ulcer, Systemic complications: Curling’s ulcer,

septicemia, severe weight loss, UTI, DVT, septicemia, severe weight loss, UTI, DVT, pulmonary embolism.pulmonary embolism.

CLINICAL FEATURESCLINICAL FEATURES

Pain - > in superficial burns compared to Pain - > in superficial burns compared to deep burns.deep burns.

Acute anxietyAcute anxiety

Fluid loss & dehydrationFluid loss & dehydration

Local tissue oedemaLocal tissue oedema

ComaComa

CLASSIFICATION OF BURNSCLASSIFICATION OF BURNS

1.1. Partial Thickness BurnsPartial Thickness Burnsa)a) Superficial partial thickness burns: –Superficial partial thickness burns: –

Involve only epidermis and superficial Involve only epidermis and superficial dermis. dermis. Pain, swelling & fluid loss may be marked. Pain, swelling & fluid loss may be marked. Cells of epidermal appendages remain Cells of epidermal appendages remain intact.intact.Burn heals in <3weeks with perfect final Burn heals in <3weeks with perfect final cosmetic result. cosmetic result.

CLASSIFICATION OF BURNSCLASSIFICATION OF BURNS

b)b) Deep partial thickness burns:- Deep partial thickness burns:- Epidermis & much of the dermis are Epidermis & much of the dermis are destroyed.destroyed.Fewer intact epithelial cells in remaining Fewer intact epithelial cells in remaining appendages.appendages.Pain, swelling and fluid loss are marked.Pain, swelling and fluid loss are marked.Burn takes >3weeks to heal & often heals Burn takes >3weeks to heal & often heals with ugly hypertrophic scars.with ugly hypertrophic scars.May be complicated by infection.May be complicated by infection.

CLASSIFICATION OF BURNSCLASSIFICATION OF BURNS

2.2. Full Thickness Burns Full Thickness Burns Destroyed epidermis, dermis including Destroyed epidermis, dermis including the epidermal appendages.the epidermal appendages.Destroyed tissues undergo coagulative Destroyed tissues undergo coagulative necrosis and form eschar (a coagulum of necrosis and form eschar (a coagulum of dead tissue) which begins to lift after 2-3 dead tissue) which begins to lift after 2-3 weeks.weeks.Raw area need grafting for healing to Raw area need grafting for healing to prevent fibrosis and ugly contracture.prevent fibrosis and ugly contracture.

ASSESSMENT OF BURN AREAASSESSMENT OF BURN AREA

Use ‘Rule of Nines’ (do not apply to infant and Use ‘Rule of Nines’ (do not apply to infant and children)children)

Head – 9% Head – 9% Front – 2 X 9%Front – 2 X 9% Back – 2 X 9%Back – 2 X 9% Genitalia – 1%Genitalia – 1% Lower limb front & back – 2 X 9% respectivelyLower limb front & back – 2 X 9% respectively Upper limb – 9% each Upper limb – 9% each

ASSESSMENT OF BURN DEPTHASSESSMENT OF BURN DEPTH

Depends upon: Depends upon:

1.1. The temperature of the burning agentThe temperature of the burning agent

2.2. The mode of transmission of heatThe mode of transmission of heat

3.3. The duration of contactThe duration of contact

MANAGEMENTMANAGEMENT

1.1. First AidFirst AidStop the burning process.Stop the burning process.Cool the burn surface – irrigation with cold Cool the burn surface – irrigation with cold water with temperature of 8-15water with temperature of 8-15˚C.˚C.

2.2. Emergency examination & treatmentEmergency examination & treatmentA – airway maintenanceA – airway maintenanceB – breathingB – breathingC – circulation C – circulation D – disability: neurological statusD – disability: neurological statusE – exposure and environment control: keep warmE – exposure and environment control: keep warmF – fluid resuscitation: prevent shockF – fluid resuscitation: prevent shock

MANAGEMENTMANAGEMENT

3.3. Local management of burnsLocal management of burnsInitial cleansing & debridementInitial cleansing & debridementPrevention of contamination (Exposure, Prevention of contamination (Exposure, evaporative dressings, semi-occlusive & evaporative dressings, semi-occlusive & occlusive dressings, topical antibacterial, occlusive dressings, topical antibacterial, ‘biological dressings’) ‘biological dressings’) Relief of constrictionRelief of constrictionRestoration of epidermal coverRestoration of epidermal coverFunctional & cosmetic result Functional & cosmetic result

Fluid resuscitation in burnFluid resuscitation in burn

"fluid resuscitation," implies that fluids "fluid resuscitation," implies that fluids are being returned following a dramatic are being returned following a dramatic loss. loss.

More precisely, fluid resuscitation is More precisely, fluid resuscitation is intended to return cells to appropriate intended to return cells to appropriate volume and tonicity and to optimize end volume and tonicity and to optimize end diastolic volume with respect to Starling diastolic volume with respect to Starling mechanisms.mechanisms.

Fluid ManagementFluid Management

Adult – 15%Adult – 15% of body of body

Children – 10%Children – 10% involvementinvolvement

Hypovolemic shock – jeopardise OHypovolemic shock – jeopardise O22

transport- increase risk of tissue transport- increase risk of tissue hypoxia-organ failurehypoxia-organ failure

Burns of less than 10% of total body Burns of less than 10% of total body surface area (TBSA)surface area (TBSA)– Shock is unlikelyShock is unlikely– Therefore, intravenous resuscitation usually Therefore, intravenous resuscitation usually

unnecessaryunnecessary

Burn of 10-20% TBSABurn of 10-20% TBSA– Usually require IV infusion Usually require IV infusion – May require urethral catheterization, May require urethral catheterization,

particularly in elderly who are more particularly in elderly who are more susceptible to changes in fluid dynamicsusceptible to changes in fluid dynamic

– In very fit adult, may not require itIn very fit adult, may not require it

Burns of 20-30% TBSABurns of 20-30% TBSA– Require both an IV infusion and urethral Require both an IV infusion and urethral

catheterizationcatheterization– May be necessary to use central venous May be necessary to use central venous

cannulacannula

Burns greater than 30% TBSABurns greater than 30% TBSA– Insertion of central venous line is mandatory Insertion of central venous line is mandatory

in order to measure CVP and possibly in order to measure CVP and possibly provide access for adjuvant parenteral provide access for adjuvant parenteral nutrition laternutrition later

Muir & BarcleyMuir & Barcley

Fluid volume = Fluid volume = Body weight (kg) X % burnBody weight (kg) X % burn (ml) (ml) 22

Eg: 70kg man with 20% burnEg: 70kg man with 20% burn70kg X 20% 70kg X 20% = 700ml= 700ml

22

Fluid loss- most is at the 1st 12 hoursFluid loss- most is at the 1st 12 hours

- substantial loss at least - substantial loss at least

another 36 hoursanother 36 hours

- much is essentially plasma- much is essentially plasma

With this formula, the anticipated fluid loss in With this formula, the anticipated fluid loss in each of the three 4 hours period immediately each of the three 4 hours period immediately following the burn is half the product of the following the burn is half the product of the % area of burn and the body weight in kg.% area of burn and the body weight in kg.

700 ml for the every first three 4-hour 700 ml for the every first three 4-hour periodsperiods

After the first 12 hours, the same After the first 12 hours, the same volume (700ml) is administered in each volume (700ml) is administered in each of the next two 6-hour periodsof the next two 6-hour periods

And then again over the 12-hour And then again over the 12-hour periods (700ml). periods (700ml).

Formula is only as guideFormula is only as guide

Adequate resuscitation is monitored by Adequate resuscitation is monitored by regular clinical assessmentregular clinical assessment

The objective of treatment of shock The objective of treatment of shock should be to maintain:should be to maintain:

1.1. PR of < 120 bpmPR of < 120 bpm

2.2. A systolic between or above 120mmHg A systolic between or above 120mmHg

3.3. A steady CVP at between 5 an 8 cm HA steady CVP at between 5 an 8 cm H22OO

4.4. A urine flow rate between 50 A urine flow rate between 50 &100ml/hour&100ml/hour

Solution Of Choice In Burn Solution Of Choice In Burn PatientPatient

Plasma substitute (gelatin solution) as Plasma substitute (gelatin solution) as much of the fluid loss is essentially much of the fluid loss is essentially plasmaplasma

OrOr

4.5% human albumin4.5% human albumin

Isotonic electrolyte solution Isotonic electrolyte solution

eg. Hartmann’s solutioneg. Hartmann’s solution

COLLOIDCOLLOID

TypesTypes

Albumin 5% Albumin 5%

Fresh Frozen Plasma (FFP) Fresh Frozen Plasma (FFP)

Synthetic colloid (Hetastarch, Dextran 40 or 60) Synthetic colloid (Hetastarch, Dextran 40 or 60)

AdvantagesAdvantages

Remains in intravascular space for hours Remains in intravascular space for hours

DisadvantagesDisadvantages

Risk of sensitivity reactions Risk of sensitivity reactions

CRYSTALLOIDCRYSTALLOID

TypesTypesLactated Ringers Lactated Ringers Normal Saline Normal Saline AdvantagesAdvantages Inexpensive and readily available Inexpensive and readily available Does not result in allergic reactionDoes not result in allergic reactionDisadvantagesDisadvantages Only transiently expand the intravascular Only transiently expand the intravascular volume volume Only 25% remains in intravascular space Only 25% remains in intravascular space Requires infusion of 4-5x the deficit Requires infusion of 4-5x the deficit May result in pulmonary edema in critically ill May result in pulmonary edema in critically ill

PROGNOSISPROGNOSIS

Depends on:Depends on:

1.1. Age and general conditionAge and general condition

2.2. Extend of burnExtend of burn

3.3. Depth of burnDepth of burn

4.4. Site of burnSite of burn

5.5. Associated respiratory injuryAssociated respiratory injury