Burn classification and management

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BURN

BY DR BADAL KHAN PGR1SURGICAL UNIT 3 BMCH

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INTRODUCTION

Majorty of burns in children are SCALDS caused by accidents with kettles,pans,hot drinks and bath waterIn young males burn caused by experimenting With mathes and inflamable liquides

Electrical and chemical injuries occur in adults with Associated conditions such as mental disease, Epilepsy Alcohal and drug abuse

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ETIOLOGY OF BURNSDRY HEAT

FLAME

ELECTRICT CONTACT

CHEMICAL

FROSTBITE

IONIZING RADIATION

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CLASSIFICATION OF BURNS

1.Depending on the percentage of burns MILDo Partial thickness burns <15% in adults and <10% In children oro Full thickness <2%

o Can be treated on outpatient department

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Classification (cont…….

MODERATEoSecond degree burn of 15-25% burns

oThird degree burn between 2-10% burns

oBurns which are not involving eyes,ears

Face,hand,feet and perineum

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CLASSIFICATION (CONT……)

SEVEREoSecond degree burns more then 25% in adults and More then 20% in childrenoAll third degree burns more then 10%oAll electrical burns and inhalation burnsoBurns with fractureoBurns involving eyes,ears,feet,hands and perineum

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Classification(cont…..)

2.Depending on thickness of skin involved First degree Second degree Third degree Fourth degree Partial thickness burns

I. SuperficialII. deep

Full thickness burns

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CLASSIFICATION(CONT…..)

a.First degree Epidermiss looks red and painfull No blisters formation Heals rapidly In 5-7 days by epithelialization Without scarring

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Classification(cont…..)

b.2nd degree burnsaffected area is red,mottled,painfullBlister formationHeals in 14-21 days by epithelialization With scaring

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CLASSIFICATION(CONT……)

C.3rd degree burnsAffected area is painless and insensetive with Thrombosis of superficial vesselsIt requires graftingD.4th degree burnsIt involves underlying Tissues Muscles bones

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Degrees of burns.Partial thickness and full thickness discuss in asessment of burn

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Pathophysiology of burn injuryMost common organ affected is the skinBurn can also damage airways and lungs with life Threatening consequensesRespiratory system injuries occure if person trapped In a burning vehicle,house,car and is forced to inhale The hot and poisonous gasesHot gases burn the lining of airway above the larynx And lining start to swell later on block the airwaySteam causes damage to the lower airways,respiratory Epithelium swells and detach from bronchial tree

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Pathophysiology(cont……)

Metabolic poisoningCarbon monoxide is a product of incomplete combustion That is often produced by fires in a closed space is one of Many poisonous gasesCo binds to hb with an affinity of 240> O2 so block Transport Of O2Level of carboxyhaemoglobin in blood can be measureConc >10% dangerous and need treatment with pure Oxygen for more then 24hoursHydrogen cynide causes metabolic acidosis by interefering With mitochondrial respiration

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Inhalational injurycaused by mainute particles within thick smoke because Of their small size and are not filtered by the upper Airwayand are carried down to lung parenchymaStick to moist lining causes intense reaction in alveoliCauses chemical pneumonitis followed by oedema within Alveolar sac and dec gaseous exchangeBacterial pneumonia occures

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Inflamtion and circulatory changesBurn skin release of neuropeptides activation of Complement are intiated by stimulation of pain fibers and Alteration of proteins by heat

Activation of hageman factor alter archidonic acid Thrombin and kallikrein pathways

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At cellular levelComplement causes degranulation of mast cellsAttracts neutrophils which also degranulate and releases Large amount of free radicals and proteasesMast cells also releases TNF@ which act as chemotactic Agent to inflamatory cellsThese inflamatory factors alter permeability of bld vesselsLarge protein molecules can also escape with easeDamaged collagen and extravasated proteins oncotic Pressure further increase flow of water from intravascular To extravascular space

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PathophysiologyHeat causes coagulation necrosis of skin andsubcutaneous tissue.↓Release of vasoactive peptides↓Altered capillary permeability↓Loss of fluid → Severe hypovolaemia↓Decreased cardiac → Decreased myocardialoutput function↓Decreased renal blood → Oliguriaflow (Renal failure)↓Altered pulmonary resistance causing pulmonaryOedema infectionSystemic Inflammatory Response Syndrome (SIRS)↓Multi Organ Dysfunction Syndrome (MODS).

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ASSESSMENT OF BURNS

1.ASSESSING SIZEBurn size should be assessed in a controlled environmentTo avoid hypothermiaIn smaller burns just cut a piece a clean paper the size of patient ,s whole hand (digit and palm)which present 1% TBSAAnd match this to the areaAnother accurate way of measuring the size of burns is to drawThe burn on a LUND AND BROWDER CHART

Age in yrs

0 1 5 10 15 adult

A head 9 8 6 5 4 3

B thigh 2 3 4 4 4 4

C leg 2 2 3 3 3 3

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ASSESSMENT(CONT…..)RULE OF 9 (wallace,s rule of 9Each upper limb is 9% TBSAEach lower limb is 18% TBSATorso 18% each sideHead and neck 9%Perineum 1%In children head and neck is 18% andLower limb is 13.5% each=13.5*2=27%

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Rule of 9

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ASSESSMENT(CONT…..)2.Assessing depth from the historyBurning of human skin is temperature and time dependentIt takes 6 hours for skin maintained at 44c* for irreversible changesA surface teperature of 70c* for 1 second produce epidermaldestruction

Example of Exposure to hot water at 65c*45 second exposure produce full thickness burn15 second exposure produce deep partial thickness burn7 second exposure produce superficial partial thikness burn

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ASSESSMENT(CONT…..)a) Superficial partial thickness burns No deeper then papillary dermis Blister formation Loss of epidermis Capillary return visible When blanched Dermis is pink and moist Pin prick sensation normal Heal without scarring In 2 weeks Treatment is non surgical

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Superficial partial thickness burns

After 24 hours after burn After 2 weeks

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Superficial partial thickness burn after 3 monthsPigment returning

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ASSESSMENT(CONT…..)

b)Deep partial thickness burnDamage to deeper parts of dermisEpidermis is usually lostFixed capillary stainingColour does not blanch with pressureSensation is reducedPt is unable to distinguish sharp from blunt pressureTakes 3 or more weeks to heal without surgeryLeads to hypertrophic scarring

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ASSESSMENT(CONT…..)

c) Full thickness burnsWhole of the dermis destroyedHard and leathery feelNo capillary returnOften thrombosed vessels can be seen under The skinThese are completely anesthetisedNo pain and no bleeding

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Causes of death in burns

a. Hypovolaemia and shock

b. Renal failure

c. Pulmonary oedema and ARDS

d. Septicaemia

e. Multiorgan failure

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Full thickness burnWraped in cling film

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Deep partial thickness burntangential shaving to remove dead dermisDermis remove layer by layer untill bleeding

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Hypertrophic scarring following a deep dermal burn.After 3 or more weeks

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Management of burns

Management of burns is consist of prehospital care & hospital care

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Management of burnsPrehospital careStop the burning processStop,drop and roll is a good method of extinguishingFireCool the burn woundThis provide analgesia and slow the delayed micro--vascular damage which occure after a burn injuryCooling should be for minimum 10 mintues and up toOne hour to avoid hypothermiaGive oxygenGive oxygen especialy if there is altered level concious_-ness level

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Management of burnsElevateSitting a patient up with a burned airway may prove lifeSavingElevation of burned limbs reduce swelling and discomfortCheck for other injuriesA standard ABC check followed by a secondary surveyPatients burned in explosions may have head and spine injuriesAnd other life threatening problems

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Management of burns

Indications for admission in burnsSusected airway or inhalational injuryAny burn require fluide resusciationAny burn in extreme of agesAll electrical and chemical burnsAny burn which require surgeryBurn of any significance to hands,face,feet or perineumSuspicious of non accidental injury

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Management of burns

Hospital careAdmit the patientAirway controlBreathing and ventilationCirculationDisabilityExposure with environment controlFluid resuscitationAssess the %age,degree and type of burnKeep the patient in clean environmentSedation and proper analgesia

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Management of burnsA.AIRWAY CONTROL

Burned airway creates problems by swelling and can completely Occlude the airwaySecure airway with an endotracheal tube until swelling subsided which is Usually 48 hoursDelayed diagnosis of airway burn make difficult to intubate the Patient in presence of lyrangeal oedema so cricothyroidectomy Should be doneEarly intubation of suspected airway burn is the treatment of Choice in such patients

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Management of burnsB.BREATHINGA progressive increase in respiratory rate and effort ,anxietyRising pulse and confusion with decreasing o2 saturationThese symptoms take 24 hours to 5 days to appearTreatment starts as soon as possible includingPhysiotherapyNebulisersWarm humidified oxygen

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Management of burns

Fluide resuscitationIv volume must be maintained following a burn in order to provide sufficient circulation to perfuse not only the organs but also the peripheral tissues,especially damaged skinIv resuscitation is appropriate for any child with a burn greaterThen 10% and 15%for TBSA for adultsIf oral resuscitation is to be commenced then water is givenShould not be salt freeIt is appropriate to give oral rehydration with a solution such asDIORALYTE*Most common fluid used is ringer lactate

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Management of burnsFluid volume is relatively constant in proportion to the areaOf body burned therefore there are formulate that calculateThe approximate volume of fluid needed for the pt of a givenBody weight with a given %age of the body burnedFormulas to calculate the fluid replacement1.parkland regime (commonly used)4ML/%burn/kg body weight/24 hours4*50*60=12000ml in 24 hoursHalf this volume is given in the frist 8 hoursSecond half is given in the subsequent 16 hoursOthers1. Evan,s formula2. Muir and barclay3. Modified brook formula

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Management (cont…)

Fluids usedCrystalloid resuscitationRinger lactate is the most commonly used crystalloid These are as effective as colloids for maintaining intra--vascular volumeLess expensiveIn childrenDextrose saline given for maintanaince100ml/kg for 24 hours for frist 10kg50ml/kg for 24 hours for next 10kg20ml/kg for 24 hours for each kg above 20kg body weight

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Management (cont…)hypertonic saline it produces hyperosmolarity and hypernatremia

Reduces shift of intracellular water to extracellular space

AdvantagesInclude less tissue oedema and a resultant decrease inEscharotomies and intubations

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Management (cont…)Colloid resuscitationPlasma proteins are responsible for the inward oncoticPressure that counteracts the outward capillary hydrostaticPressure.Without proteins there will be oedemaProteins should be given after frist 12 hours of burn beforeThis time proteins will leak out of cellsGiven through muir and barclay formula0.5*%age bsa burn*weight=one portionPeriods of 4/4/4, 6/6, 12 hours respectivelyOne portion to b given in each period

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Management (cont…)

Monitoring of resuscitationThe key to monitoring of resuscitation is urinary outputOutput should be between 0.5ml and 1.0ml/kg/hourIf urine output is below this infusion rate should increaseBy 50%If still output is inadequate then a bolus of 10ml/kg given2ml/kg/hr urinary output signals decrease in the rate ofPerfusionHaematocrit measurement is a usefull tool in confirmingSuspected under or overhydration

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Management (cont…)Treating the burn woundDressingsParaffine guazeHydrocolloids (duoderm)Biological dressings synthetic (biobrane) natural (amniotic membrane)Full-thickness and deep dermal burns need antibacterialdressings to delay colonisation prior to surgeryOpen methodSilver sulfadiazine application without dressings commonly Used in burns of face,head and neck.Closed methodDressing done to soothen and to protect the woundTo reduce the painAs an absorbent

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Management (cont…)Treating the burn wound (cont……Tangential excisionCan be done within 48 hours with skin grafting in patients with less Then 25% burnUsually done in deep dermal burnsDead dermis is removed layer by layer Untill fresh bleeding occursLater skin grafting done

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Treating the burn wound (cont……Treating the burn wound (cont…… escharotomyCircumferential full-thickness burns to the limbs require emergencySurgeryThe tourniquet effect of this injuryis easily treated by incising the whole length of full-thicknessburns.This should be done in the mid-axial line, avoiding majorNervesThe burn needs to be cleaned and the size and depth need to be Full thickness burns and deep partial-thickness burns that will requireoperative treatment will need to be dressed with an antibacterialdressing to delay the onset of colonisation of the wound

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A full-thickness burn to the upper limb with a mid-axialescharotomy.The soot and debris have been washed off.

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Topical agent advantages problems

Silver sulfadiazine 1 %

-Antiseptic (G +ve and G –ve-Soothening, good penetration- Hydration and softening of eschar occurs

-Neutropenia, pseudoeschar-- Causes wound maceration

Sulfamylon – 5% -(Mafenide acetate)

Antipseudomonal, anticlostridial- Penetrates very well in to tissues

Very irritant,painfulCauses acidosis

Silver nitrate – 0.5% - Antiseptic Stains burn area

Povidone iodine (5%) - Used on

granulation tissue - after eschar separation

IrritantPainfullNot used in partialburns

Silver sulphadiazine and cerium nitrate

- Boosts cell mediated immunityand forms sterile eschar

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Additional aspects of treating burn patientAnalgesiaOral form of paracetamol and nsaids in superficial burnsIv opiates for large burnsIm should not be given in over 10% of TBSA as absorption is UnpredictableShort acting analgesia given before dressingEnergy balanceFeeding should start within 6 hrs of injury to reduce gut mucosal damage.Burns patients need extra feedingA nasogastric tube should be used in all patients with burns over 15%of TBSA and 10% in case of children Burn injuries are catabolic in the acute episode.Removing the burn and achieving healing stops the catabolic drive

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Additional aspects of treating burn patient

control of infectionPatients with major burns are immunocompromised,pathogenic and opportunistic bacteria and fungi enter via the burn wound,cathetars and iv linesThey have compromised local defences in the lungs and gut due to oedemaSterile precautions must be rigorous Swabs should be taken regularly A rise in white blood cell count, thrombocytosis and increased catabolism are warnings of infectionNursing carePhysiotherapyPsychological support

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SURGERY FOR THE ACUTE BURNAny deep partial-thickness and full-thickness burns exceptthose that are less than about 4 cm2, need surgeryA topical solution of 1:500 000 adrenaline also helps to reducebleeding,deep dermal burns, the top layer of dead dermis is shavedoff until punctate bleeding is observed and the dermis can beseen to be free of any small thrombosed vesselsFull-thickness burns require full-thickness excision of theSkinPostoperative management of these patients obviouslyrequires careful evaluation of fluid balance and levels of haemoglobin.

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Delayed reconstruction and scarmanagement

is common for large Full thickness burnsEyelids must be treated before exposure keratitis arises Transposition flaps and Z-plasties with or without tissueexpansion are useful Full-thickness grafts and free flaps may be needed for largeor difficult areas Hypertrophy is treated with pressure garments to be wornfor 6-18 monthsSmaller areas of hypertrophy, silicone patches will speedscar maturation,as will intralesional injection of steroid. Pharmacological treatment of itch is important

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Effects of burn Shock due to hypovolaemia Renal failure(toxins from burn&myoglobin) Pulmonary oedema,resp infections,ARDS,resp failureInfection by staph aureus,pseudomonas,klebsella leads toSepticemia Fungal and viral infections of dangerous type can occureGIT: Hypovolaemia, ischaemia of mucosa, erosivegastritis—Curling’s ulcer (seen in burns > 35%). Fluid and electrolyte imbalance.immunosuppression predisposes to severe opportunistic infection.Eschar formation and its problems like defectivecirculation, ischaemia when it is circumferential.Electrical injuries often cause fractures, majorinternal organ injury, convulsions.

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Effects of burn(cont…..)Inhalation burn causes pulmonary oedema,respiratory arrest, ARDS.Chemical injury causes severe GIT disturbances likeerosions, perforation, stricture oesophagus (alkali),pyloric stenosis (acid), mediastinal injury.Other problemsDVT, pulmonary embolismbed-sores,severe malnutrition with catabolic status, Toxic shock syndrome: It is a life-threatening exotoxin mediated disease caused byStaphylococcusaureus. It is common in children, presents withrashes, myalgia, diarrhoea, vomiting, and multiorganfailure with high mortality.

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Effects of burn(cont…..)

Development of contracture is a late problem. Itleads to ectropion, microstomia, disability ofdifferent joints, defective hand functions, growthretardation causing shortening

COMPLICATIONS OF BURNS CONTRACTUREEctropion of eyelid causing keratitis and cornealulcer.Disfigurement in face.Narrowing of mouth microstomia.Contracture in the neck causing restricted neck movements.Disability and nonfunctioning of joints due to contractureHypertrophic scar and keloid formation.

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COMPLICATIONS OF BURNS CONTRACTUREMarjolin’s ulcer

It is a very well-differentiated squamous cell carcinoma occurring in a scar ulcer due to repeated breakdown (unstable scar of long duration).• It is locally malignant.• As there are no lymphatics in the scar, so thereis no spread to lymph nodes.• As there are no nerves in the scar it is painless.• It has raised and everted edge with induration.• Biopsy confirms the diagnosis.TreatmentRadiotherapy is not given for Marjolin’s ulcer.Treatment is either wide excision or amputation. It is curable.Once it spreads out of the scar tissue it behaves likeany other squamous cell carcinoma and so can spread to regional lymph nodes

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Marjolin’s ulcer developed over burns contracture

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Contracture at different parts of body chest and neck

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Contracture at different parts of bodySevere contracture at knee joint causing deformity Contracture at face

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Complication of contracture

Hypertrophic scar Keloid formation

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Treatment of burn contracture

• Release of contracture surgically and use of skin graft or “Z” plasty or different flaps.

• Proper physiotherapy and rehabilitation is essential.

• Pressure garments to prevent hypertrophic scars.

• Management of itching in the scar using aloe vera, antihistamines and moisturizing creams.

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Prevention of development of contracture

• Joint exercise in full range during recovery period ofburns

• Pressure garments for a long period

• Topical silicon sheeting

• Saline expanders for scars

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NON THERMAL INJURIESElectrical burnsChemical burnCold injuriesIonising radiation

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Non thermal(cont……)

Electrical burns 1000vLow tension injuriesLow tension injuries do not have enough energy to cause Significant destructionEntry and exit points normally in the fingers suffers small Deep burns may damage underlying nerves and vesselsAc creates a tetany within muscles so patient unable to Release the device untill the power was turned offMay interfere with normal cardiac pacing and can cause Cardiac arrest

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Electrical burns(cont…..)

high tension injuries3 sources of damage

1) The flash2) The flame3) The current

When a high tension line is earthed it can arc over the ptAnd causes a flash burnExtremely rapid heating of the air causes an explosionThat propel the victim backwardIt is always a major burnThere is a wound of entry and wound of exitMajor internal organ injuries occuresConvulsions can develope

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ManagementDepending on injury it is managed accordinglyPatient should always be admitted and should be assessed by

i. ECGii. u/s abdomeniii. Chest x-ray iv. Ct scan head sometimesv. Cardiac enzyme analysis

Acidosis is common so bicarbonate infusion neededFractures and dislocations common so managed accordinglyRelease of myoglobin can cause renal tubular damage and renal Failure so manitol is used to prevent myoglobin induced renal failure (compartment syndrome)

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Wound of entry in an electric burn.Electric burn

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An exit wound of a high-tension injury,Amputation and cover with the lateral portion of the second toe.

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Chemical burnsThere are 70000 different chemicals in regular use within industryOccasionally these cause burnsThere are two aspects to a chemical injury

1. Physical destruction to the skin2. Systemic absorption

The initial management of any chemical injury is copious lavageWith water but some need to be remove physically eg.phosphorusA component of millitary devicesThe more common injuries are caused by either

1. Alkalis2. acids

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Chemical burns(cont…)

After copious lavage, the next step in themanagement of any chemical injury is to identify the chemicaland its concentration and to elucidate whether there is anyunderlying threat to the patient’s life if absorbed systemically

Alkali burns occur in oral cavity and oesophaguswhich leads to multiple oesophageal strictures.

Alkalisalkalis are more destructive and especially when come in contactWith eyesCommonly used alkalis are sodium hydroxide,lime,bleachThey cause fat sponification,fluide loss,release of alkali proteinase

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Chemical burns(cont…)

AcidsAcid burn occurs in skin, soft tissues and GIT. In GIT,Burns affecting the fingers and caused by dilute acid are relatively common.The initial management is with calcium gluconate gel topically severe burns or burns to large areas of the hand can be subsequently treated with Bier’s blocks containing calcium gluconate 10 per cent gelit is common in stomach either due to nitric acid or sulphuric acid which may lead to severe gastritis or pyloric stenosis.Other acids are formic acid, hydrofluoric acid.They cause metabolic acidosis, renal failure, ARDS, haemolysis.Acidaemia should be corrected by IV sodium bicarbonate.

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Cold injuries

Cold injuries are principally divided into two types1. Acute cold injuries from industries2. Frost bite

inflammatory reaction is not as marked.The tissue is more resistant to cold injury than to heat injuryThe assessment of depth of injury is more difficult,Frostbiteinjuries affect the peripheries in cold climatescold injury produces delayed microvascular damage similar to that of cardiac reperfusion injury.The initial treatment is with rapid rewarming in a bath at 42°C.The level of damage is difficult to assesssurgery usually does not play a role in its management

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Ionising radiationThese injuries can be divided into

1. Localised 2. Whole body exposure

The management of localised radiation damage is usually Conservative until the true extent of the tissue injury is apparent.If damage have caused an ulcer, then excision and coverage with vascularised tissue is required.A patient who has suffered whole-body irradiation and is sufferingFrom acute desquamation of the skin has received a lethal dose ofRadiation which can cause a particularly slow and unpleasant deathDose may be lethal and may not be lethalGiving iodine tablets, the management of these injuries is supportive

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THANKS

Burn classification and management

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