Burns and its management

1. BY Dr. RITESH DHANBHAR

2. Burns is defined as a wound caused by exogenous agent
leading to coagulative necrosis of the tissue.

3. Causes
• Thermal Burns
Dry heat
Contact burn
Flame burn
Moist heat- Scald burn
Smoke and inhalational injury
• Chemical Burns- acids & alkali
• Electrical burns- High & low voltage
• Cold Burns- frostbite
• Radiation
• Sun Burns

4. classification
1. Depending on the Percentage of Burns:
(a) Mild:
Partial thickness burn less than 15% in adult or less than
10% in children or full thickness less than 2%.
(b) Moderate:
Second degree 15-25% burns in adult or 10-20% in
children or third degree 2-10% burns.
(c) Major:
Second degree >25% burns in adult or >20% burns in
children or third degree >10% burns or burns involving
eyes, ears, feet, hand, perineum. All inhalational and
electrical burns.

5. Classification
2. Depending on Thickness of Skin Involved:
(a)First degree:
injury localized to the epidermis.
(b) Second Degree:
i) Superficial second degree: injury to the epidermis and superficial
papillary dermis.
ii) Deep second degree: injury through the epidermis and deep upto
reticular dermis.
(c) Third degree:
full-thickness injury through the epidermis and dermis into
subcutaneous fat.
(d) Fourth degree:
injury through the skin and subcutaneous fat into underlying muscle
or bone.

7. Clinical Features:
i) First degree burns:
• Reddened skin
• Pain at burn site
• Involves only epidermis
• Blanch to touch
• Have an in-tact epidermalbarrier
• Do not result in scarring
• Examples : Sun-burn, minorscald from a kitchen
accident

8. Clinical Features
ii) Superficial 2nd Degree Burns :
• Intense pain
• White to red skin
• Blisters
• Involves epidermis & papillary layer of dermis
• Spares hair follicles, sweatglands etc
.• Erythematous & blanch to touch
• Very painful/sensitive
.• No or minimal scarring.
• Spontaneously re-epithelialization from retained
epidermal structures in 7-14 days
Second Degree Burns

9. Clinical Features
iii) Deep second degree burns:
• Injury to deeper layers of dermis, i.e, reticular dermis.
• Appears pale & mottled.
• Do not blanch to touch.
• Capillary return sluggish or absent.
• Less painful, remain painful to pinprick.
• Takes 14 to 35 days to heal by re-epithelialization from
hair follicles & sweat gland, keratinocytes often with severe
scarring.
• Contractures possible.

10. Clinical Features
iv) 3rd Degree Burn:
• Dry, leathery skin (white, dark brown, or charred).
• Loss of sensation (little pain).
• All dermal layers/tissue maybe involved.
v) Fourth degree burn:
• Involves structures beneath the skin- muscle,bone.

11. Third Degree Burns
Fourth Degree Burns

12. Assessment Of Burns
1) Wallace Rule of Nine:

13. Assessment Of Burns
2) Lund & browler chart: Each part of body is indivially
assessed for involment of burns

14. Pathophysiology
i) Local Changes:
Thermal injury causes coagulative necrosis of
epidermis and underlying tissue, with depth of injury
dependent on temperature to which skin is exposed,
the specific heat of causative agent, duration of
exposure.

15. Pathophysiology
The area of cutaneous or superficial injury has been
divided into three zones:
(a)Zone of coagulation:
Necrotic area of burn where cells are disrupted.
(b) Zone of satsis:
Its area surrounding zone of coagulation where
vessel leakage & vessel damage present
(c)Zone of hyeremia
It is area where Vasodilation & inflammation is
present.

16. Systemic changes
 Cardiac:
Decreased cardiac output.
• Pulmonary:
Respiratory insufficiency as a secondary process.
Can progress to respiratory failure.
• Gastrointestinal:
Decreased or absent GI motility.
Curling’s ulcer formation.

17. Systemic Changes
• Metabolic:
Hypermetabolic state.
Increased oxygen and calorie requirements.
Increase in core body temperature.
• Immunologic:
Loss of protective barrier.
Increased risk of infection.
Suppression of humoral and cell-mediated
immuneresponses.

18. MANAGEMENT

19. First Aid:
1. Stop the burning process.
2. Cool the area with tap water with continuous
irrigation for 20 minutes.
Indications Of Admission in Burns:
1. Moderate and severe burns.
2. Airway burns of any type.
3. Burns in extremes of age.
4. All electrical or deep chemical burns.

20. Management
Definitive Treatment:
1. Maintain airway, breathing, circulation (ABC).
2. Sedation and analgesia.
3. Assessment of percentage, degree and type of burn
and accordingly fluid management.
4. Chemoprophylaxis: tetanus toxoid antibiotics and
local antiseptics.
5. Ryle’s tube insertion initially for aspiration and later
for feeding.

21. Fluid Resuscitation
 Formulas to calculate fluid replacement;
1. Parkland Regimen:
 Total Fluid replacement in 24 hours =
4ml per % of burn per kg body weight.
 Half of the volume is given in first 8 hours, rest is
given in next 16 hours.

22. Fluid Resuscitation
2. Muir and Burclay Regimen:
For colloid after 12-24 hours.
1 Ration = % burns × body weight in kg/ 2.
3 Rations given in 1st 12 hours.
2 Rations given next 12 hours.
1 Ration given in next 12 hours.
3. Galveston Regimen (Paediatric):
5000ml/m² burn area + 1500ml/m² total BSA.

23. Fluid Resuscitation
 Fluids used:
Ringer lactate is the fluid of choice.
Blood is transfused after 48 hours.
In 1st 24 hours only crystalloids should be given.
After 24 hours colloids like plasma, gelatin, dextran,
hetastarch are used at the rate of 0.35-0.5 ml/kg/% of
burns.
Urine output should be 30-50 ml/hr.
 Hourly TPR charting.

24. Local Management
1.Open Method:
Application of silver sulphadiazine without any dressings
commonly used in burns of face and neck.
Mefenide acetate & silver nitrare can be used.
2.Closed Method:
With dressings done to soothen and protect wound, to
reduce pain and as an absorbent.
3.Tangential excision:
Skin grafting can be done within 48 hours with less than
25% burns

25. Wound coverage
In 3 weeks the area granulate well & split skin grafting is
done (SSG, Thiersch graft ).
For wider area Mesh split skin graft is used.
In case of eschar, escharotomy is done to prevent
compression of vessels.
Cultured skin graft.

26. Complications Of Burns
 Eschar: It is a charred, denatured, full thickness, deep
burns with contracted dermis.
Escharotomy:
•Incise along medial and/or lateral surfaces.
• Avoid bonyprominences.
• Avoid tendons, nerves , major vessels.

27. Complications Of Burns
 Contracture:
Disorganised over formation of compact collagen
( three times than normal) causes hypertrophic scar finally
leading to contracture.
 Classification of Contracture in Neck ( BM Achauer)
1. Mild : Inability to see ceiling.
2. Moderate: Flexion possible but not extension.
3. Severe: Fully contracted in flexed position with pull on
lower lip.
4. Extensive: Mentosternal adhesions.

28. Complications of burns
 Complications of contracture:
1. Ectropion
2. Disfigurement of face.
3. Microstomia.
4. Hypertrophic scar and keloid formation.
5. Marjolin’s ulcer.
 Treatment:
1. Z- Plasty
2. Random cutaneous flap, microvascular free flap,
faciocutaneous flap.
3. Physiotherapy.
4. Pressure garments.

29. Chemical Burns
 Acids
• Protein injury by hydrolysis.
.• Thermal injury is made with skin contact.
 Alkali
• Saponification of fat.
• Hygroscopic effect- dehydrates cells.
• Dissolves proteins by creation of alkaline proteinates (hydroxide
ions).
 Treatment:
Late neutralization with antidote done by 0.2% acetic acid in
alkali burns, sodium bicarbonate or calcium gluconate for acid
burns.

30. Electrical Burns
• Greatest heat occurs at the points of resistance, i.e, at
Entrance and Exit wounds. Dry skin = Greater
resistance– Wet Skin = Less resistance
• Longer the contact, the greater the potential of injury
• Smaller the point of contact, the more concentrated the
energy, the greater the injury.
Treatment:
Assess Entrance & Exit wounds.
• Remove clothing, jewelry, and leather items.
• Treat any visible injuries.

31. Radiation Burns
• Local burns causing ulceration need excision and
vascularised flap cover – usually with free flaps.
• Systemic overdose needs supportive treatment
• The damage is more difficult to define and slower to
develop than burns.
• Acute frost bite needs rapid rewarming, then
observation.
• Delay surgery until demarcation is clear.

32. Cold Burns
• The damage is more difficult to define and slower to
develop than burns.
• Acute frostbite needs rapid rewarming, then
observation.
• Delay surgery until demarcation is clear.

33. THANK YOU !!!