Burns Ulcers

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A burn is a type of injury to flesh caused by heat,

electricity, chemicals, light, radiation or friction. Most

burns only affect the skin (epidermal tissue and dermis).

Rarely, deeper tissues, such as muscle, bone, and bloodvessels can also be injured. Burns may be treated with first

aid, in an out-of-hospital setting, or may require more

specialized treatment such as those available at specialised

burn centers.


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1. Stage of neurogenic shock proves to be lethal. It

includes the fright, terror and hysterical reaction ofthe individual especially on the pain produced by the

irritation of nerve endings in the skin


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2. Stage of fluid loss first effect of burns is dilation

of capillaries and increasing permeability. Plasma

seeps out into the surrounding tissue to produce

blisters and edema. Fluid loss reduces the blood

volume, so that the blood becomes thicker, that the

volume of the cellular elements of the bloodincreases in relation to the volume of fluid (plasma)

of the blood. This change makes the circulation less

efficient. The loss of fluid volume is reflected in the

increasing hematocrit. Urinary output is reducedowing to fluid loss and hematocrit level is elevated or

hypovolemia hypotension decrease renal

perfusion and renal shutdown


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3. Stage of Burn slough and infection escharseparates from underlying viable tissue by formation

of slough this leaves a large open wound that is

usually infected. The infecting organism vary in the

upper part of the body often had colon bacilli as theinfecting organism. Infection, however, does not

occur suddenly, it probably begins soon after the

burn occurs and then gradually grows in the

sloughing tissue


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4

. Stage of Repair

repair of the burned area andsystemic repair


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Classification

Burns can be classified by mechanism ofinjury, depth, extent and associated injuries

and comorbidities.

Currently, burns are described according to the depth of

injury to the dermis and are loosely classified into first,

second, third and fourth degrees. This system was devised

by the French barber-surgeon Ambroise Pare and remainsin use today


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Nomenclature LayerInvolved

Appearance Texture Sensation Time ToHealing

Complications

First degreeEpider

mis

Redness

(erythema)Dry Painful

1wk or

lessNone


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NomenclatureLayer

InvolvedAppearance Texture Sensation

Time To

HealingComplications

Second

degree

(superficial

partial

thickness)

Extendsinto

superfic

ial

(papilla

ry)

dermis

Red with

clear

blister.

Blanches

withpressure

Moist Painful 2-3wks

Local

infection/

cellulitis

Distinguishing between the superficial-

thickness burn and the partial-thicknessburn is important, as the former may heal

spontaneously, whereas the latter often

requires surgical excision and skin grafting.


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NomenclatureLayer

Involved

Appearance Texture SensationTime To

Healing

Complications

Second

degree (deep

partial

thickness)

Extends

into deep

(reticular)

dermis

Red-and-

white with

bloody

blisters.

Lessblanching.

Moist Painful

Weeks -

may

progress

to third

degree

Scarring,

contractures

(may require

excision and

skin grafting)


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Complications

Third degree

(full

thickness)

Extends

through

entire

dermis

Stiff and

white/brown

Dry,

leatheryPainless

Requires

excision

Scarring,

contractures,

amputation


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Complications

Fourth

degree

Extends

through

skin,

subcutan

eous

tissue

and intounderlying

muscle

and bone

Charred

with escharDry Painless

Requires

excision

Amputation,significant

functional

impairment


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Burn severity

In order to determine the need for referral to a

specialised burn unit, the American Burn Association

devised a classification system to aid in the decision-

making process. Under this system, burns can be

classified as major, moderate and minor. This is

assessed based on a number of factors, including total

body surface area (TBSA) burnt, the involvement of

specific anatomical zones, age of the person and

associated injuries


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Major burns

Major burns are defined as:

y Age 10-50yrs: Partial thickness burns >25% TBSA

y Age 50: Partial thickness burns >20%TBSA

y Full thickness burns >10%

y Burns involving the hands, face, feet or perineum

y Burns that cross major joints

y Circumferential burns to any extremity

y Any burn associated with inhalational injury

y Electrical burns

y Burns associated with fractures or other trauma

y Burns in infants and the elderly

y Burns in persons at high-risk of developing

complications


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Moderate burns

Moderate burns are defined as:

y Age 10-50yrs: Partial thickness burns involving 15-

25% TBSA

y Age 50: Partial thickness burns involving 10-

20% TBSA

y Full thickness burns involving 2-10% TBSA


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Minor burns

Minor burns are:y Age 10-50yrs: Partial-thickness burns


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Burn surface area

Burns can also be assessed in terms of total body surface area

(TBSA), which is the percentage affected by partial thickness or fullthickness burns. First degree (erythema only, no blisters) burns are

not included in this estimation. The rule of nines is used as a quick

and useful way to estimate the affected TBSA. More accurate

estimation can be made using Lund & Browder charts which takeinto account the different proportions of body parts in adults and

children. The size of a person's hand print (palm and fingers) is

approximately 1% of their TBSA. The actual mean surface area is

0.8% so using 1% will slightly over estimate the size. Burns of 10%

in children or 15% in adults (or greater) are potentially lifethreatening injuries (because of the risk of hypovolaemic shock)

and should have formal fluid resuscitation and monitoring in a

burns unit.


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Causes ofBurns

Chemical - Most chemicals that cause chemical burns

are strong acids or bases. Chemical burns can be

caused by caustic chemical compounds such as

sodium hydroxide or silver nitrate, and acids such assulfuric acid. Hydrofluoric acid can cause damage

down to the bone and its burns are sometimes not

immediately evident


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Electrical burns are caused by either an electric shock

or an uncontrolled short circuit. (A burn from a hot,electrified heating element is not considered an

electrical burn.) Common occurrences of electrical

burns include workplace injuries, or being defibrillated

or cardioverted without a conductive gel. Lightning isalso a rare cause of electrical burns.


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Since normal physiology involves a vast number of applications

of electrical forces, ranging from neuromuscular signaling to

coordination of wound healing, biological systems are veryvulnerable to application of supraphysiologic electric fields.

Some electrocutions produce no external burns at all, as very

little current is required to cause fibrillation of the heart muscle.

Therefore, even when the injury does not involve any visible

tissue damage, electrical shock survivors may experience

significant internal injury. The internal injuries sustained may be

disproportionate to the size of the burns seen (if any), and the

extent of the damage is not always obvious. Such injuries may

lead to cardiac arrhythmias, cardiac arrest, and unexpected fallswith resultant fractures or dislocations


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Radiation burns are caused by protracted exposure to UV

light (as from the sun), tanning booths, radiation therapy

(in people undergoing cancer therapy), sunlamps,radioactive fallout, and X-rays. By far the most common

burn associated with radiation is sun exposure, specifically

two wavelengths of light UVA, and UVB, the latter being

more dangerous. Tanning booths also emit thesewavelengths and may cause similar damage to the skin

such as irritation, redness, swelling, and inflammation.

More severe cases of sun burn result in what is known as

sun poisoningor "heatstroke". Microwave burns arecaused by the thermal effects of microwave radiation.


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Management

First-aid treatment in the home: apply cold water

In the hospital most important goal of initial therapy

1.Solution: Ringers Lactate is the choice because it

most closely resembles the composition of the

extracellular fluid compartment

2.Dosage: 3-4 ml/KBW/%TBSA

3.S

chedule total quantity to be given in 24 hoursOne-half during the first 8 hours

The other during the next 16 hours


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Remove foreign adherent material b gentle washing withiodine-based solution or hexachlorophene and water,

then thoroughly rinsing with NSS

Shave hair from burned area and area immediatelysurrounding it

Excision of fragments of dead devitalized tissues


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Application of topical agents

1.Purpose: 0.5% silver nitrate unknown action; not very

popular because it stains the skin2.Gentamicin cream

3.Mafylon/Sulfamylon orSilver sulfadiazine (Silvadene)

the burn butter

1.purpose: to prevent bacterial invasion2.Method of application: applied evenly 1/8 inch in

thickness

3.Side effects

o Reduces buffering capacities of the blood because it

increases bicarbonate excretion (when bicarbonates are

broken down, they provide a heavy acid load).

Remember:Monitor pH level of blood

o Cause burning sensation for 20 minutes after application


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Dressing may (Closed method) or may not (open method)

be used. If closed method is used, dressings are changed

everydayWound debriment is done with each dressing change to

prevent eschar ( a tough coagulum of necrotic tissue).

Necrotic tissues are not only good media for bacteria,

but also promote growth of granulation tissues

Daily removal of dried cream by soaking in whirlpool

bathtub prior to debridement

Morphine sulfate, gr.1/4 relieve pain of second degreeburns

Use of Bradford frame for ease of turning and

maintenance of good body alignment


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Position flat on bed with legs extended specially during

the first 24-48 hours in order to:

1.Avoid postural shock because of fluid loss,

circulation to the head may become inadequate

2.Support healing of burn wounds

3.Prevent hip contractures

1.Proper splinting

2.Active and passive range of motion exercises

Grafting is done to minimize growth of granulation

tissues which results in contractures and ugly scars

1.Xenograft from animals

2.Homograft from other individuals

3.Autograft - oneself


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Burns Ulcers

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