1. Presenter: Dr. Shashi K. Singh
Moderater: Dr. Kumar Shrestha, Dr. Piyush,
Dr. Jainendra Chaudhary, Dr. Indra K. Jha

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

4. Thermal Burns
• Heat changes the molecular structure of tissue
Causing Denaturion of proteins
• Extent of burn damage depends on
–Temperature of agent
–Amount of heat
–Duration of contact

5. • The effects of the burns are influenced by
the:
1.Intensity of the energy
2.duration of exposure
3.type of tissue injured

6. Pathophysiology of Burns
• Fluid Shift
– Period of inflammatory response
– Vessels adjacent to burn injury dilate → ↑ capillary
hydrostatic pressure and ↑ capillary permeability
– Continuous leak of plasma from intravascular space into
interstitial space
– Associated imbalances of fluids, electrolytes and acid-base
occur
– Hemoconcentration
– Lasts 24-36 hours

7. • Fluid remobilization
– Capillary leak ceases and fluid shifts back into the
circulation
– Restores fluid balance and renal perfusion
• Increased urine formation and diuresis
– Continued electrolyte imbalances
• Hyponatremia
• Hypokalemia
– Hemodilution

8. SYSTEMIC CHANGES
• Cardiac
– Decreased cardiac output
• Pulmonary
– Respiratory insufficiency as a secondary process
– Can progress to respiratory failure
– Aggressive pulmonary toilet and oxygenation
• Gastrointestinal
– Decreased or absent motility (may need NG tube)
– Curling’s ulcer formation

9. • 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 immune
responses

10. ACUTE PHASE
• Clinical shock
• External loss of plasma
• Loss of circulating red cells
• Burn edema

11. SUB ACUTE PHASE
• Diuresis
• Clinical Anemia
• Accelerated metabolic rate
• Nitrogen Disequilibrium
• Bone and joint changes
• Endocrine Disturbances
• Electrolyte and chemical imbalance
• Circulatory Derangements
• Loss of of function of skin as an organ

12. Body’s Response to Burns
• Emergent Phase (Stage 1)
– Pain response
– Catecholamine release
– Tachycardia, Tachypnea, Mild Hypertension, Mild
Anxiety
• Fluid Shift Phase (Stage 2)
– Length 18-24 hours
– Begins after Emergent Phase
• Reaches peak in 6-8 hours
– Damaged cells initiate inflammatory response
• Increased blood flow to cells
• Shift of fluid from intravascular to extravascular space
– MASSIVE EDEMA

13. • Hypermetabolic Phase (Stage 3)
–Last for days to weeks
–Large increase in the body’s need for
nutrients as it repairs itself
• Resolution Phase (Stage 4)
–Scar formation
–General rehabilitation and progression to
normal function

14. Jackson’s Theory of Thermal Wounds
• Jackson’s Theory of Thermal Wounds
– Zone of Coagulation
• Area in a burn nearest the heat source that suffers the most
damage as evidenced by clotted blood and thrombosed
blood vessels
– Zone of Stasis
• Area surrounding zone of coagulation characterized by
decreased blood flow.
– Zone of Hyperemia
• Peripheral area around burn that has an increased blood
flow

16. Severity is determined by:
–depth of burn
–extend of burn calculated in percent of total
body surface (TBSA)
–location of burn
–patient risk factors

17. CLASSIFICATION OF BURNS
• First degree—injury localized to the
epidermis
• Superficial second degree—injury to the
epidermis and superficial papillary dermis
• Deep second degree—injury through the
epidermis and deep upto reticular dermis
• Third degree—full-thickness injury through the
epidermis and dermis into subcutaneous fat
• Fourth degree—injury through the skin and
subcutaneous fat into underlying muscle or
bone

18. CLASSIFICATION OF BURNS

19. Superficial Burn : 1st Degree Burn
• Reddened skin
• Pain at burn site
• Involves only epidermis
• Blanch to touch
• Have an in-tact epidermal
barrier
• Do not result in scarring
• Examples : Sun-burn, minor
scald from a kitchen accident
• Treatment is aimed at
comfort with topical soothing
agents +/- NSAIDs

20. Partial-Thickness Burn: 2nd Degree
Burn
• Intense pain
• White to red skin
• Blisters
• Involves epidermis & papillary
layer of dermis
• Spares hair follicles, sweat
glands etc.
• Erythematous & blanch to touch
• Very painful/sensitive.
• No or minimal scarring.
• Spontaneously re-epithelialize
from retained epidermal
structures in 7-14 days

21. Deep second degree burn
• Injury to deeper layers of dermis –
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-epithelialisation from hair
follicles & sweat gland,
keratinocytes often with severe scarring
• Contractures possible
• Require excision & skin grafting

22. Full-Thickness Burn:3rd Degree Burn
• Dry, leathery skin
(white, dark
brown, or
charred)
• Loss of sensation
(little pain)
• All dermal
layers/tissue may
be involved
• Always require
surgery.

23. Fourth degree burn
• Involves structures beneath the skin- muscle,
bone.

25. ASSESSMENT OF BURNS
• Rule of Nine
–Best used for large surface areas
–Expedient tool to measure extent of burn
• Rule of Palms
–Best used for burns < 10% BSA

27. AREA OF PALM = 1% BODY SURFACE AREA

29. Management
Pre-hospital care
• Ensure rescuer safety
• Stop the burning process: Stop, drop and roll
• Check for other injuries.
A standard ABC (airway, breathing, circulation)
check followed by a rapid secondary survey.

30. • Cool the burn wound:
Analgesia
Slows the delayed microvascular damage,
Minimum of 10 min
Effective up to 1 hour after the burn injury
• Give oxygen
• Elevate

31. Hospital care
• A : Airway control.
• B :Breathing and ventilation.
• C :Circulation.
• D: Disability – neurological status.
• E :Exposure with environmental control.
• F :Fluid resuscitation.

32. The criteria for acute admission to a burns unit
• Suspected airway or inhalational injury
• Any burn likely to require fluid resuscitation
• Any burn likely to require surgery
• Patients with burns of any significance to the hands, face,
feet or perineum
• Patients whose psychiatric or social background makes it
• inadvisable to send them home
• Any suspicion of non-accidental injury
• Any burn in a patient at the extremes of age
• Any burn with associated potentially serious sequelae
• including high-tension electrical burns and concentrated
• hydrofluoric acid burns

33. Airway
Recognition of the potentially burned
airway
• A history of being trapped in the presence of
smoke or hot Gases
• Burns on the palate or nasal mucosa, or loss of
all the hairs
• in the nose : Deep burns around the mouth and
neck

34. Airway
• Burned airway
• Early elective intubation is safest
• Delay can make intubation very difficult
because of Swelling
• Be ready to perform an emergency
cricothyroidotomy if intubation is delayed

35. Breathing
• Inhalational injury
• Thermal burn injury to the lower airway
• Metabolic poisoning:Carboxyhaemoglobin
• Mechanical block to breathing:Escharotomy

36. Circulation
• Maintain iv line with wide bore canula
peripherally
• One central line
• Escharotomy of limbs if circulatory
compromise in circumferential burns

37. Fluids for resuscitation
• In children with burns over 10% TBSA and
adults with burns over 15% TBSA, consider
the need for intravenous fluid resuscitation
• If oral fluids are to be used, salt must be added
• Fluids needed can be calculated from a
standard formula
• The key is to monitor urine output

38. • Parkland Formula:
Total percentage body surface area × weight
(kg) × 4 = volume (ml)
• Half this volume is given in the first 8 hours,
and
• the second half is given in the subsequent 16
hours.

39. • Crystalloid : Ringer lactate
• Hypertonic saline
• Human albumin solution
• Colloid resuscitation

40. • The commonest colloid-based formula is the
Muir and Barclay formula:
0.5 × percentage body surface area burnt ×
weight = one portion;
• Periods of 4/4/4, 6/6 and 12 hours
respectively;
• one portion to be given in each period.

41. Assessment of adequacy of fluid
replacement
• Urine output is most commonly used parameter
• Urine osmolarity is the most accurate parameter
• U/O > 0.5-1.0 ml/kg/hr
• CVP 5-10 cm/H2O.
• U/O > 2ml/kg/hr – sign of overhydration

42. Fluid Resuscitation Complications
• Overresuscitation complications:
Poor tissue perfusion
Compartment syndrome
Pulmonary edema
Pleural effusion
Electrolyte abnormalities

43. TREATING THE BURN WOUND
Escharotomy
• Circumferential full-thickness burns to the
limbs require emergency surgery.
• The tourniquet effect of this injury is easily
treated by incising the whole length of full-
thickness burns.
.

44. Escharotomy
• Incise along medial
and/or lateral surfaces.
• Avoid bony
prominences.
• Avoid tendons, nerves,
major vessels.

45. Escharotomy
• Upper limb: Mid-axial, anterior to the elbow
medially to avoid the ulnar nerve
• Hand : Midline in the digits. Release muscle
compartments if tight.
• Lower limb: Mid-axial, Posterior to the ankle
medially to avoid the saphenous vein
• Chest: Down the chest lateral to the nipples,
across the chest below the clavicle and across
the chest at the level of the xiphisternum

47. Fasciotomy
• Fascia = thick white
covering of muscles.
• Fasciotomy = fascia is
incised (and often overlying
skin)
• Skin and fascia split open
due to underlying swelling.
• Blood flow to distal limb is
improved.
• Muscle can be inspected for
viability.

48. Debridement
• Types of debridement:
1. Auto debridement.
2. Tangential excision (at the end of 1st week)
3. Staged primary debridement (1-3 days post
burn).
This early debridement of dead tissue interrupts
and attenuates the systemic inflammatory
response and normalize immune function.
4. For deep circumferential burn, urgent
escharotomy is done

49. BLISTERS
• Intact blister- barrier to microbial invasion
• Intact blister creates moist environment hence
more rapid reepithelialization
• More rapid angiogenesis
• Rupture of blisters under contaminated
conditions may increase infection rates

50. BLISTERS
• In the pre-hospital setting, there is no hurry to
remove blisters.
• Leaving the blister intact initially is less
painful and requires fewer dressing changes.
• The blister will either break on its own,
or the fluid will be resorbed.

51. • Analgesia
Acute
• Small superficial burns : simple oral analgesia,
Topical cooling
• Large burns: intravenous opiates.
Subacute
• Large burns: continuous analgesia is required,
beginning with infusions and continuing with oral
tablets such as slow-release morphine.

52. Nutrition
• Burns patients need extra feeding
• A nasogastric tube should be used in all
patients with burns over 15% of TBSA
• Removing the burn and achieving healing
stops the catabolic drive.

53. Nutrition
Sutherland formula
• Children: 60 kcal/ kg + 35 kcal%TBSA
• Adults: 20 kcal /kg + 70 kcal%TBSA
Protein
20% of energy
1.5 to 2 g/kg protein/day

54. Tetanus prophylaxis
• Tetanus toxoid, 0.5 mL intramuscularly, if the
last booster dose was more than 5 years before
the injury.
• If immunization status is unknown,
human tetanus immunoglobulin 250 to 500
units, I.M. plus tetanus toxoid in opposite side

55. Monitoring and control of infection
• Burns patients are immunocompromised
• They are susceptible to infection from many
routes
• Sterile precautions must be rigorous
• Swabs should be taken regularly
• A rise in white blood cell count,
thrombocytosis and increased catabolism are
warnings of infection

56. Topical treatment of deep burns
• 1% silver sulphadiazine cream
• 0.5% silver nitrate solution
• Mafenide acetate cream
• Serum nitrate, silver sulphadiazine and cerium
nitrate

57. Principles of dressings for burns
• Full-thickness and deep dermal burns need
antibacterial dressings to delay colonisation
prior to surgery
• Superficial burns will heal and need simple
dressings
• An optimal healing environment can make a
difference to outcome in borderline depth
burns

58. Surgical treatment of deep burns
• Early debridement and grafting is the key to effectively
treating
• deep partial- and full-thickness burns in a majority of
cases
• Deep dermal burns need tangential shaving and split-
skin grafting
• All but the smallest full-thickness burns need surgery
• Should be ready for significant blood loss
• Topical adrenaline reduces bleeding
• All burnt tissue needs to be excised

59. Surgical treatment of deep burns
• Proper dressing should be done
• Postoperative management requires careful
evaluation of fluid balance and levels of
haemoglobin.
• Physiotherapy and splints are important in
maintaining range of movement and reducing
joint contracture

60. Delayed reconstruction of burns
• Eyelids must be treated before exposure
keratitis arises
• Transposition flaps and Z-plasties with or
without tissue expansion are useful
• Full-thickness grafts and free flaps may be
needed for large or difficult areas
• Hypertrophy is treated with pressure
garments/Silicone patch(6-18 month)
• Pharmacological treatment of itch is important

61. Chemical Burns

62. 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)

64. Electrical Burns

65. Electrical Burns
• Greatest heat occurs at the points of resistance
– Entrance and Exit wounds
– Dry skin = Greater resistance
– Wet Skin = Less resistance
• Longer the contact, the greater the potential of
injury
– Increased damage inside body
• Smaller the point of contact, the more
concentrated the energy, the greater the injury.

66. • Electrical Current Flow
–Tissue of Less Resistance
• Blood vessels
• Nerve
–Tissue of Greater Resistance
• Muscle
• Bone

67. Results in………..
–Serious vascular and nervous injury
–Immobilization of muscles
–Flash burns
– Late complications: cataracts, progressive
demyelinating neurologic loss

68. – Assess patient
• Entrance & Exit wounds
• Remove clothing, jewelry, and leather items
• Treat any visible injuries
– Thermal burns
• ECG monitoring
– Bradycardia, Tachycardia, VF or Asystole
– Treat cardiac & respiratory arrest
– Aggressive airway, ventilation, and circulatory management.
• Consider Fluid bolus for serious burns
– 20 ml/kg
• Consider Sodium Bicarbonate: 1 mEq/kg
• Consider Mannitol: 10 g

69. Radiation burns
• Local burns causing ulceration need excision
and vascularised flap cover – usually with free
flaps
• Systemic overdose needs supportive treatment

70. Cold injuries
• 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

71. THANKYOU