for medical students

1. Presentation on :
Burns: Assessment & Management
Swornim Gyawali
Intern GMC
2010 batch

2. Outline
• Objective
• Introduction
• Type of Burn injury
• Classification of Burns
• Pathophysiology of Burns
• Assessment of the Burn wound
• Management of Burns
– Primary
– Secondary
• Complications of Burn Injuries

3. Objectives
• At end of this presentation we be able to
know
1. definition and causes of Burn injuries
2. Types and classification of burns
3. pathophysiology of burns
4. Management of a patient who sustained
burn injury
5.Complications of burns

4. 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

5. Types of Burn Injury
• Thermal
Flame : fire injury
Scald : moist heat/steam
Flash : explosion
Contact : to hot surfaces

6. • Cold exposure (frostbite)
Usually occurs in distal parts of the body
Common sites: Fingers, Toes, Nose and Ears
Severe Vasoconstriction & Decreased Blood flow
 Ischemia
• Chemical burns
 Cause progressive damage
 Acid produces tissue coagulative Necrosis.
 Alkaline burns generate colliquation Necrosis.
 Systemic absorption of some chemicals is life
threatening

7. • Electrical
 mechanisms of injury :
i. Electrical current injury
ii. Electrothermal burns from arcing current
iii. Flame burn caused by ignition of clothes
 Deep destruction of muscles  rhabdomyolysis
myoglobinuria ATN  ARF
• Inhalation Hot smoke
• Radiation sunburn

8. Pathophysiology of Burn
Local Changes
1. Burn causes coagulative necrosis of the epidermis and
underlying tissues
2. depth of injury: temperature & duration of exposure
area of cutaneous injury

9.  Systemic changes

10. Assessment of The Burn Wound
• 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

12. 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,

14. Assessment of The Burn Wound (cont’d)
• Total percentage of body surface area
(TBSA)
1. Lund-Browder chart

15. • Rule of Nines

18. Management; Primary Survey
Initial Intervention
 Airway maintenance with cervical
spine control
 Breathing and Ventilation
 Circulation with Haemorrhage Control
 Disability: Neurological Status
 Exposure with Environmental Control

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

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

21. Fluid resuscitation
American Burn Association's practice guidelines,
patient with greater than 15 percent total body
surface area (TBSA) non-superficial burns should
receive formal fluid resuscitation.
Fluid selection
Formulae
1. Parkland : 4ml x wt (Kg) x % TBSA burn
-Ringer’s lactate or Hartman solution
2. Evans :1ml x wt x %TBSA
3. Brooke :1.5ml x wt x %TBSA
4. Modified Brook:2ml x wt x % TBSA

22. Management; secondary Survey (cont’d)
• History
• Thorough physical examination
• Lab studies and monitoring
 CBC
 Electrolytes
 RFT
 Glucose
 Venous blood gas
 Caboxyhemoglobin
 Arterial blood gas
 Chest x-ray
 ECG

23. Management; Secondary Survey (cont’d)
Chemoprophylaxis
Tetanus immunization
Antibiotic
Wound management
 Wound dressing and care
 Escharotomy
 Chest - at the anterior axillary line
 Extremity - can be done at a bedside without
local anesthesia

25. 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

26. Nutritional Requirement Calculations
Curreri formula
• Age 16–59 years: (25)W + (40)TBSA
• Age 60+ years: (20)W + (65)TBSA
Sutherland formula
• Children: 60 kcal /kg + 35 kcal%TBSA
• Adults: 20 kcal /kg + 70 kcal%TBSA
Protein needs
• Greatest nitrogen losses between days 5 and
10
• 20% of kilocalories should be provided by
proteins

27. Burn Complications
1. INFECTION
2. Curling ulcer- stress ulcers
3. Contracture
4. Marjolin’s ulcer, Hypertrophic scar, keloid
Pschological aspect
• PTSD
• Flash backs
• Avoidance behavior
• Sleep disturbance

28. Minimizing complications
1. Hand washing before & after touching
each patient.
2. Aseptic techniques for dressing &
procedures
3. Early nutritional support
4. Early excision of deep burns
5. Use of topical antimicrobials
6. Early excision and grafting

29. Thank you !!!
• Queries ????

30. Refrences
1. SCHWARTZ :Principles of surgery ,9th
edi.2008
2. BAILEY & LOVE : Short practice of
surgery ,25th edi,2008
3. American Burn Association's practice
guidelines, 2012
4. Internet (pictures)
5. Medscape.com