Classification, Principles, assessment and management of burn

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Principles of Management of Burn Injury

Alazar BekeleAmanuel G/YonhannesAmanuel TeshaleAmelewerk Gonfa

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Outline• Objective• Introduction• Epidemiology• Type of Burn injury• Classification of Burns• Pathophysiology of Burns• Assessment of the Burn wound• Management of Burns• Primary• Secondary

• Complications of Burn Injuries• Prevention• Summary• References

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Objectives At the end of this seminar students we be able to know:• definition and causes of Burn injuries• The burden of the injury in our country• Types and classification of burns• Understand the pathophysiology of burns • Management of a patient who sustained burn injury• Complications of burns

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Introduction Definition• A burn is a coagulative destruction of the surface layers of the body.• It occur when some or all of the cells in the skin or other tissues are

destroyed by heat cold electricity Radiation Lightening caustic chemicals

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Epidemiology Worldwide,

Burns are the fourth most common type of trauma More than 90% of burns are caused by carelessness or ignorance &

are completely preventable About 90% of burns occurs in low and middle income countries Most burn injuries occur in domestic setting, with cooking as the

most common activity Armed conflicts increase the incidence of burns

In Ethiopia, Based on A community-based study by Kidanu E. Highest incidence = in children < 5 years of age Scald burn= 59 % and flame = 34 % 81 % of these burn injuries occurs in home Mortality rate= 11.5 %

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Epidemiology (cont’d) Age wise:

As with other forms of trauma, burns frequently affect children and young adults.o Children under 8 Scald Burnso In older children and adults flame-related Burns

(usually the result of house fires.)Work-related burns:

The most common burns in work places:1. Chemicals or hot liquids2. Electricity3. Molten or hot metals

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Epidemiology (cont’d)

• No one is immune to thermal injury• Demographic analysis shows four

high risk groups: The very young The very old The very unlucky The very careless

Flame 33%

Scald 30%

Contact 15%

Flash 10%

Electrical 5%

Radiation 1%

Friction 1%

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Types of Burn Injury1. Thermal

The depth of the burn injury is related to contact temperature, duration of contact of the external heat source, and the thickness of the skin.

o Flame: a burn injury by fire House fires, smoking related fires, improper use of flammable

liquids, automobile accidents, fall into open fire. o Scald: a burn injury by moist heat /steam.

Scalds from hot water are most common cause of burn.o Flash: explosion of natural gas ,gasoline & other flammable

liquids cause intense heat for a brief timeo Contact: direct conduction of heat from a hot surface to the

body.

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Types of Burn Injury (cont’d)2. Cold exposure (frostbite)

Damage occurs to the skin and underlying tissues when ice crystals puncture the cells or when they create a hypertonic tissue environment.

Usually occurs in distal parts of the body Common sites: Fingers, Toes, Nose and Ears

Severe Vasoconstriction & Decreased Blood flow Microvascular stasis Thrombus formation Microvasculature Emboli Ischemia

3. Chemical burns    It can cause

alteration of pH, disruption of cellular membranes, and direct toxic effects on metabolic processes.

Cause progressive damage until they are inactivated by reaction with the body tissue or diluted with water

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In addition to the duration of exposure, the nature of the agent will determine injury severity.

Acid produces tissue coagulative Necrosis. Alkaline burns generate colliquation Necrosis. Systemic absorption of some chemicals is life threatening.

4. Electrical Electrical energy is transformed into thermal injury as the

current passes through poorly conducting body tissues. mechanisms of injury :

i. Electrical current injuryii. Electrothermal burns from arcing currentiii. Flame burn caused by ignition of clothes

Deep destruction of muscles rhabdomyolysis myoglobinuria ATN ARF

Types of Burn Injury (cont’d)

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Types of Burn Injury (cont’d)5. Inhalation

Toxic products of combustion injure airway tissues and frequently occur with flash burns from fire and steam. Hot smoke usually burns only the pharynx while steam can

also burn the airway below the glottis. Carbon monoxide, which is produced from combustion,

impairs cellular respiration

6. Radiation Can be due to Radio frequency energy or ionizing radiation The most common type of radiation burn is the sunburn.Radiation burns are often associated with cancer due to the ability

of ionizing radiation to interact with and damage DNA.

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Pathophysiology of Burn1. Local Changes• Burn causes coagulative necrosis of the epidermis and

underlying tissues,• The depth injury depending on

the temperature to which the skin is exposed the duration of exposure. The specific heat of the causative agent also affects the

depth. o The skin provides a robust barrier to transfer of energy to

deeper tissues; o therefore, much of the injury is confined to this layer.o However, after the inciting focus is removed, the response of

local tissues can lead to injury in the deeper layers.

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The area of cutaneous injury has been divided into three zones:• Zone of Coagulation

The necrotic area of a burn where cells have been disrupted is termed the zone of coagulation.

This tissue is irreversibly damaged at the time of injury. • Zone of Stasis

The area immediately surrounding the necrotic zone has a moderate degree of insult with decreased tissue perfusion.

depending on the wound environment, can either survive or progress to coagulative necrosis.

• Zone of Hyperemiais characterized by vasodilation from inflammation

surrounding the burn wound.

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Pathophysiology of Burn (cont’d)2. Systemic changes

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Pathophysiology of Burn (cont’d)

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Pathophysiology of Burn (cont’d)The airway and lungs• Airway injuries occur when

the face and neck are burned or if a person is trapped in a burning material,

and is forced to inhale the hot and poisonous gases

• Warning signs of burns to the respiratory system Burns around the face and neck A history of being trapped in a burning room Change in voice Stridor

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Assessment of The Burn Wound1. Burn Depth Cutaneous burns are classified according to the depth of tissue

injury:1. superficial or epidermal (first-degree), 2. partial-thickness (second degree), or 3. full thickness (third degree). 4. Burns extending beneath the subcutaneous tissues and

involving fascia, muscle and/or bone are considered fourth degree

Burn wounds are not usually uniform in depth and many have a mixture of deep and superficial components.

A precise classification of the burn wound may be difficult and may require up to three weeks for a final determination.

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First degree (Superficial)

• Red, erythematous • Very sensitive to touch • Very painful • Usually moist • No blisters

Second degree (partial-thickness)

• Erythematous or whitish with a fibrinous exudate

• Wound base is sensitive to touch and Painful • Commonly have blisters • Surface may blanch to pressure

Third degree (Full thickness)

• Surface may be: White, Black, leathery, Pale or Bright red

• Generally anesthetic or hypoesthetic • Subdermal vessels do not blanch • No blisters • Hair easily pulled from its follicle

Fourth degree • Involves deep tissues including fascia, muscle, bone, and tendons

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Assessment of The Burn Wound (cont’d)2. Percent Body Surface Area Estimates The extent of burns is expressed as the total percentage of body

surface area (TBSA). • Superficial burns are not included in the TBSA burn assessment. • The location of partial-thickness and full-thickness burned areas are

recorded on a burn diagram. • Burns with an appearance compatible with either deep partial-

thickness or full-thickness are presumed to be full-thickness until accurate differentiation is possible.

• The two commonly used methods of assessing TBSA in adults are the Lund-Browder chart and "Rule of Nines,"

• whereas in children, the Lund-Browder chart is the recommended method because it takes into account the relative percentage of body surface area affected by growth.

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Lund-Browder methodAssessment of The Burn Wound (cont’d)

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Rule of Nines  For adult assessment, the most

expeditious method to estimate TBSA in adults is the "Rule of Nines“ Each leg represents 18 percent TBSA

Each arm represents 9 percent TBSA The anterior and posterior trunk

each represent 18 percent TBSA The head represents 9 percent TBSA

Assessment of The Burn Wound (cont’d)

Indications for Hospitalization for Burns Burns greater than 15% body surface area High-tension wire electrical burns Inhalation injury regardless of the size of body

surface area burn Inadequate home situation Suspected child abuse or neglect Burns to hands, feet, genitals

Assessment of The Burn Wound (cont’d)

Management; Primary SurveyInitial Intervention

Airway maintenance with cervical spine control Breathing and Ventilation Circulation with Haemorrhage Control Disability: Neurological Status Exposure with Environmental Control

Management; Primary Survey (cont’d)

Air way managementThe risk of inhalation injury increases with the extent of the burn and is present in two-thirds of patients with burns greater than 70 percent of the total body surface area (TBSA).Common signs of significant smoke inhalation injury• Persistent cough, stridor, or wheezing• Hoarseness• Deep facial or circumferential neck burns• Nares with inflammation or singed hair• Carbonaceous sputum or burnt matter in the mouth or nose

Management; Primary Survey (cont’d)• Blistering or edema of the oropharynx• Depressed mental status, including evidence of drug

or alcohol use• Respiratory distress• Hypoxia or hypercapnia• Elevated carbon monoxide and/or cyanide levels

Management; Primary Survey (cont’d)

Diagnostic tests and monitoring • Arterial blood gas• Chest x-ray• Serial peak expiratory flow rates (PEFR)• Pulse oximetry• Capnography• fiberoptic laryngoscopy and bronchoscopy

Management; Primary Survey (cont’d)

Treatment• Supplemental oxygen and airway protection• Close monitoring of fluid resuscitation• Mechanical ventilation• Inhaled nitric oxide• aerosolized heparin and N-acetylcysteine (NAC)

Management; Primary Survey (cont’d)Fluid resuscitation

According to the American Burn Association's practice guidelines, any patient with greater than 15 percent total body surface area (TBSA) non-superficial burns should receive formal fluid resuscitation.

Fluid selection Formulae1. Parkland : 4ml x wt (Kg) x % TBSA burn -Ringer’s lactate or Hartman solution2. Evans :1ml x wt x %TBSA3. Brooke :1.5ml x wt x %TBSA4. Modified Brook:2ml x wt x % TBSA 

Management; Primary Survey (cont’d)Monitoring fluid status

Monitoring urine output Clinical signs of volume statuslaboratory measurements:-mixed venous blood gas

and serum lactate concentrationinvasive monitoring:-central venous pressure

Blood transfusionRisk assessmenthemoconcentration

Management; secondary Survey (cont’d)History

what burned location of the fire if explosion occurred if the patient used alcohol or drugs if it is associated with trauma The AMPLE trauma history should be obtained

Management; Secondary Survey (cont’d)Thorough physical

examination Lab studies and monitoring CBCElectrolytes RFTGlucoseVenous blood gasCaboxyhemoglobin

Arterial blood gas Chest x-ray ECG Cyanide levels

Management; Secondary Survey (cont’d)

ChemoprophylaxisTetanus immunizationAntibiotic

Wound management Wound dressing and careEscharotomy

Chest - at the anterior axillary line Extremity - can be done at a bedside without local

anesthesia

Nutrition• Hypermetabolism develops as a response to injury• If TBSA >40%, lean body weight ↓ by 25% over the first 3

weeks • Patient with major burn needs high calorie in the form of:

CHO (50%), protein (20%) , fat (30%) and some vitamins & minerals

Nutrition (cont’d)

• A nasogastric tube should be used in all patients with burns over 15% of TBSA• Earlier paralytic ileus can be prevented.• Mucosal integrity is preserved.• ↓Risk of bacterial translocation

Nutritional Requirement CalculationsCurreri formula• Age 16–59 years: (25)W + (40)TBSA• Age 60+ years: (20)W + (65)TBSASutherland formula• Children: 60 kcal kg–1 + 35 kcal%TBSA• Adults: 20 kcal kg–1 + 70 kcal%TBSAProtein needs• Greatest nitrogen losses between days 5 and 10• 20% of kilocalories should be provided by proteins

Burn Complications 1. INFECTIONPredictors of infection : Burn size Age Inhalation injury

Burn Complications (cont’d)

2. Curling ulcer- stress ulcers3. Contracture 4. Marjolin’s ulcer, Hypertrophic scar, keloidPschological aspect• PTSD• Flash backs• Avoidance behavior• Sleep disturbanceSo all burn patient needs psychiatric evaluation and management.

Severe keloids

Minimizing complications1. Hand washing before & after touching each patient.2. Aseptic techniques for dressing & procedures3. Early nutritional support4. Early excision of deep burns5. Use of topical antimicrobials 6. Early excision and grafting

Prevention1. Implementing good health & safety regulations2. Educating the public3. Store gasoline and other flammable liquids out of reach of

children4. Stir the bath water with your hand to avoid hot spots 5. Do not use electrical appliances in or near showers6. Keep a fire extinguisher available

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Summary• A burn injury is a coagulative damage or destruction of skin and/or its

contents by Thermal, Chemical, Electrical Radiation energies or combinations

• Burns are the fourth most common type of trauma• Cutaneous burns are classified according to the depth of tissue injury.• Pathophysiology of burn is attributed to the local and systemic changes.• A thorough estimation of burn size is essential to guide therapy. The

extent of burns is expressed as the total percentage of body surface area (TBSA).

• The estimation of percent total body surface area includes partial-thickness, full-thickness, and fourth degree burns. Superficial burns are not included in the TBSA burn assessment.

• The most accurate method of assessment of TBSA burn in children and adults is the Lund-Browder chart.

• Primary and secondary surveys are crucial for the management of a patient with burn injury

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References1. SCHWARTZ :Principles of surgery ,9th edi.20082. BAILEY & LOVE : Short practice of surgery ,25th edi,20083. Oxford text book of surgery4. UpToDate 21.25. Sabiston text book of surgery 18th edition6. American Burn Association's practice guidelines, 2012

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