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Burns are tissue injuries caused by thermal, radiation, chemical, or electrical contact resulting in protein denaturation, loss of intravascular fluid volume due to increased vascular permeability and edema.
Chemical, Thermal, Electrical, Mechanical, Radiation, Frostbite
1.Extremes of age - the very young (<4yrs) or very old (>50yrs)
2. Those whose ability to protect themselves is impaired or prone to accidents Alcoholics, Sick, paraplegics, diabetics, psychiatric patients and patients of convulsive disorders
3.The unlucky - Innocent bystander
4.The careless - Storing petrol in the house, adding paraffin to a lit stove, smoking in bed, working close to high tension electric wires
Skin is the largest organ of the body. It is 0.025 m² in children and 1.8m² in adults. It has 3 major tissue layers.
This is the outermost layer, the epidermis, is composed of stratified epithelium.
The epidermis has two components, an outer layer of anucleate cornified cells (stratum corneum) that covers inner layers of viable cells (Malpighian layers) from which the cornified surface cells arise by differentiation.
The stratum corneum acts as a barrier to impede the entrance of microorganisms and toxic substances while allowing the body to retain water and electrolytes. Malpighian layers provide continuous production of cornified cells.
Malpighian layers can be further subdivided into the germinal basal cell layer, stratum spinosum, and stratum granulosum
Beneath the epidermis is the dermis, which is composed of a dense fibroelastic connective-tissue stroma containing collagen and elastic fibers and an extracellular gel termed ground substance.
The dermal layer contains an extensive vascular and nerve network, special glands, and appendages that communicate with the overlying epidermis.
The dermis is divided into two parts.
The third layer of skin is subcutaneous tissue, which is composed primarily of areolar and fatty connective tissue. This layer shows great regional variations in thickness and adipose content. It contains skin appendages, glands, and hair follicles
1.Protect entry of micro-organism
2,.Protect against UV light
3.Vitamin D synthesis
4. Homeostasis-Thermoregulation and prevent excess water loss
5.Cosmesis, beauty and identification-finger prints
Tissue damage due to the above agents leads to the release of vasoactive substances e.g. prostaglandins, histamines, oxygen radicals, leukotrienes, and platelet-activating factors. These substances cause microvascular instability with increased capillary permeability for the first 24-36hours of fluid shift to the extravascular compartment and edema. This leads to decreased right atrial filling pressures decreased cardiac output and Shock.
The body tries to compensate for these physiological changes by
If the process goes uncorrected;
Irreversible shock occurs as an end-stage with falling Blood pressure, cardiac output and pulse rate.
In patients with serious burns, the release of catecholamines, vasopressin, and angiotensin causes peripheral and splanchnic bed vasoconstriction that can compromise in-organ perfusion
Myocardial contractility also may be reduced by the release of inflammatory cytokine TNF-alpha
In deep third-degree burns, hemolysis may be encountered, necessitating blood transfusions to restore blood loss
A decrease in pulmonary function can occur in severely burned patients without evidence of inhalation injury from the bronchoconstriction caused by humoral factors, such as histamine, serotonin, and thromboxane A2.
A decrease in lung and tissue compliance is a manifestation of this reduction in pulmonary function.
Burned skin exhibits an increased evaporative water loss associated with an obligatory concurrent heat loss, which leads to dehydration and hypothermia.
1.Thermal
Open flames and Hot liquid are most common (heat usually ≥15-45°C).
2.Caustic chemicals or acids (may show little signs or symptoms for the first few days).
Extravasation
Due to drug leakage into tissues e.g. All Cytotoxics, Sulphur drugs, Potassium drugs, bismuth drugs: They cause Inflammation and vesicles; Skin necrosis may occur within 24 hours and Gangrene secondary to vascular spasm in 2-3days.
Management is by prevention and close monitoring, IV line in the forearm and flush line well.
Once it occurs –stop drugs and Apply normal saline gauze and change every 2 hours
Contact injury
Types of contact injury include:
-Local chemical reaction
-Thermal injuries
-Inhalational injuries (chemical pneumonitis and bronchospasm)
-Systemic poisoning
Acids - cause severe superficial coagulative necrosis. Burning stops within 1-2 hours for hydrochloric acid and sulphuric acid & 7-14 days for HOCL
The amount ingested does not contribute to the extent of the injury.
Initial management is to pour a lot of water for long 1-2 hours, dress with clean material and control pain.
You can excise area to prevent a continued reaction
-Usually, the graft take is very disappointing
Alkali - Causes deep liquefactive necrosis - penetrate tissue by saponification (Fat +alkali) , hydrolyzing structural proteins & dissolving cells along its course thus amount ingested contributes to the extent of the injury. The burn runs for 7-14 days.
Management - Generously irrigate with fluid for 1-2 hours & Dress in gauze soaked in NS or Ice 2-3hrly.
DO NOT try to neutralize the chemical.
Exercise the area to prevent a continued reaction.
3.Electricity
Types of electricity are: low voltage, high voltage, and very high voltage
Low voltage is <1000 volts while high voltage is > 1000 volts. Very high voltage include injury from the grid and lightning injuries
Electrical burns have entry and exit points.
Main injuries are
-Myonecrosis, Renal failure, and heart arrhythmia
-Myonecrosis leads Myoglobinuria causing to Renal failure with very little damage to overlying skin.
-Arching burn -Occur around joints due to burning at joint surrounded by two areas of conductance.
-Side flash-Very high voltage burns due to lightening.
-Body resistance is about 500ohms. A current of 1 ampere is required to cause cardiac asystole this usually does not occur with domestic electric burns because the voltage is about 240V giving current of approx. O.5 A.
Thus Total body surface area (TBSA) is NOT an index for resuscitation. IV fluids are titrated against the volume of urine & specific gravity (1.010). Usually, double the physiological requirements (3L/24hrs) of the patient.
-In microwave injuries, the area is normal-looking but anesthetic due to depolarization of nerves.
-Flash burns occur in technicians & may resemble open flame burns.
Management is by giving plenty of fluids.
Alkalinizing the urine and administration of mannitol aid in flushing the myoglobin from the kidney.
Do fasciotomy of the muscle compartment to avoid Compartment syndrome. Normal pressure is 30mmHg
Debride after 3-4 days
4.Frostbite
5.Mechanical (Frictional) burns
6.Radiation injury
Depth of burn is proportional to;
The depth of injury determines the formation of scar tissue.
1st Degree Burns;
In the first degree, the epidermis is the only part involved.
Commonly caused by UV light or very short flash or flame exposure. Skin is red, dry & hypersensitive thus painful.
No treatment except analgesia.
Leaves no scarring on healing.
2nd Degree Burns;
Superficial 2nd Degree
Epidermis plus the upper third ( ⅓) of Dermis are involved.
Commonly caused by scald (spill or splash).
Red, moist, weeping, cause blisters that Blanche with pressure.
Painful due to nerve exposure and heals from 10-14 days.
Leaves no scarring on healing but there are potential pigment changes
Deep 2nd Degree
Epidermis upper two thirds ( ⅔) of Dermis are involved.
Commonly caused by scald, flame, chemicals, oil & grease.
Cheesy white, wet or waxy dry; Does not Blanche with pressure
Healing takes 14-21 days
There are severe scarring and risk of contractures.
3rd Degree Burns (Full Thickness Burns);
Full Epidermis + Dermis are destroyed leaving no cells to heal and extend to the subcutaneous tissue.
Commonly caused by scald, steam, flame, chemicals, oil, grease & high voltage electricity.
Grey to charred & black, insensate, contracted, pale, leathery tissue
Severe scarring & high risk of contractures
4th Degree Burns
Muscle involvement
5th Degree Burns
Bone involvement - Especially in epileptics who convulse during burning
Determines the extent of fluid loss.
i)Wallace Rule of Nines - used in Adults to estimate BSA (Body Surface Area)
ii)American Burns Association Severity
iii) Lund-Browder Chart for estimating the extent of burns in Children.
1.Center-coagulate necrosis
2.Immediate area-zone of stasis
3.Further-zone of hyperemia
Clinical Appearance, Pinprick test, use of dye.
Imaging by ultrasound or MRI.
Classified as supraglottic, subglottic , or Global
Causes upper airway obstruction secondary to;
Reflex Laryngospasm
Edema
Sloughing of the mucosa, reduced clearance blockage and infection( Pneumonia)
Clinical presentation
History of having been injured in an enclosed space e.g. house, motor vehicle
Physical examination
1) Admit patient to High dependency care or ICU
2) Intubate the earliest opportunity to avoid difficulty once edema sets in.
Tracheostomy is indicated in the first several days for patients who are expected to require ventilatory support for a few weeks or more.
If the neck is burned, excision and grafting followed by tracheostomy is indicated in order to improve pulmonary toilet.
3) Give 100% O2 by Mask or Endotracheal tube in serious inhalational injury. Should be moist the humidity will help loosen the secretions and prevent drying of the airway;
4) Bronchodilators by aerosol or aminophylline intravenously may help if wheezing is due to reflex bronchospasm.
5) Suction /lavage of bronchial secretions (bronchial toilet)
6) Chest physiotherapy with postural drainage is also required.
7) Bronchoscopy to evaluate the extent of the inhalational injury at the same time do bronchial toilet
8) Investigation-Measure carboxyhemoglobin; With 100% O2, t½ of CO Hb falls from 250mins to 40mins
Others investigations
NB:-Pulse oximetry is unreliable (may be normal) and patients need about 10-15 % more of IV fluid calculated.
Electric burns - turn off mains before touching the patient
If the victim's clothes are on fire - Stop, Drop & Roll. Can cover with a blanket to put off the fire
Cool burned area of skin for 5-10mins (running water, cool compress or towel, immersion in cold water)
After 10mins, dry area & keep the patient warm to avoid hypothermia
Drink lots of fluids - Sweetened water with a pinch of salt PRN
Analgesics ± Anti-inflammatories e.g. Ibuprofen or Acetaminophen
Cover burn with a cool sterile dressing
Call Emergency services
DO NOT break or drain the blisters
DO NOT remove/ peel-off stuck clothing
Cool burned area of skin for 5-10mins (running water, cool compress or towel, immersion in cold water)
Once immersed in cool water, carefully remove clothing & jewelry on the burnt area
After 10mins, dry area & keep the patient warm to avoid hypothermia
Evaluate for signs of shock & treat accordingly
Elevate burnt area if possible
Cover burn with cool sterile dressing - DO NOT apply ointment, lotion or anything.
A) Cause;
1)Electrical burns including lightning injuries
2)Chemical burns with a serious threat of function or cosmetic impairment
B) Severity;
1) Moderate & Severe burns
2) 3rd & 4th Degree burns regardless of TBSA
3) Non-healing burns after 14-21 days
C) Anatomical location;
1)Head, neck, hands, soles, Perineum
2)Circumferential limb burns
3)Burns to the back
4) All inhalational injuries
D) Patient factors;
1) Extremes of age (<4yrs & >50yrs).
2) Burns of both limbs in an Obese patient.
3) Pregnancy.
4) Any burn with concomitant trauma in which the injury poses the greatest risk of morbidity or mortality.
5) Burn injuries with pre-existing medical disorders that could complicate management, prolong recovery or affect mortality e.g.
The first 48 hours
All efforts are towards resuscitation & saving lives
48 hours -6 months
Aim to prevent complications
More than 6 months
Reconstructive surgery, Rehabilitation, Training
On arrival at casualty
1.Primary Survey
Airway with cervical spine control (Look out for & manage inhalational injury), Breathing, Circulation & hemorrhage control, Disability & Exposure
At this point insert a large-bore intravenous cannula.
Central Venous Pressure Monitor (CVP)
Urethral catheterization
Nasogastric tube.
Endotracheal intubation if an inhalational burn
2.Secondary Survey
History of the burn
Physical examination from the head toe - Calculation of the BSA
3.Medical Management
4. IV Fluids
For Moderate & Major/Severe Burns use the following common formulas to estimate the required fluids.
4mL /Kg / Total body surface area
Crystalloids: Ringers Lactate or Hartmann's solution, NS
Give ½ within 8 hours since the burn occurred and the rest in the next 16 hours(most fluid losses occur 8-12 hours after the burn)
Give ~50% more in electrical burns & inhalational injury
1-Monitoring of fluid therapy
Adequate resuscitation is measured by urine output; (best guide).
In adults - 30-50mls/hr and Children - 0.5-1ml /Kg/hr.
Increase rate of infusion if the urine is less than 20ml/hr and decrease rate of infusion if the urine output greater than 60ml/hr because of the risk of pulmonary edema especially in inhalational injury
However, in electrical burns aim for 100ml /hr of urine to flush the kidney. Alkalization of the urine by adding sodium bicarbonate to the IV fluid increases the solubility and clearance rate of myoglobin in the urine
Hemoglobinuria suggest deep burn hence flush the kidney with increased fluids and mannitol
A decrease in BP and urine output suggest the need for colloids but a decrease in urine output but normal BP suggest need for crystalloids
2- Pulse and BP recording. The pulse should be less than 120/minute
3-State of the patient should be calm
4--Frequent chest auscultation to detect pulmonary edema
5-Cerebral edema, especially in children, may occur during fluid therapy
6-If possible CVP line is the best to guide for avoiding over infusion
7-Evaluate treatment every 3-4 hours
Causes of inadequate fluid resuscitation in a burns patient
An inaccurate estimate of burn size, Undiagnosed
1.Evans Formula
2ml/Kg/total body surface area
NB-TBSA only up to 50 %
The total fluid is given as a mixture of colloids and crystalloids in the ration of 1:1.
Colloid include blood and blood products- plasma, albumin, dextrans, Gelatins as haemacele and Gelofulsine
Crystalloids are Normal Saline, Hartmans solutions
Add 2000ml(2L) of 5% dextrose for insensible losses
Half of all the fluids given in the 1st 8 hrs since the occurrence of burn and the rest in the next 16 hours
After 24 hours give half of the fluids (1ml/kg/BSA) plus the 2L of 5 % dextrose.
2.Brook Army formula
2ml/Kg/total body surface area
NB-TBSA only up to 50 %
The total fluid is given as a mixture of crystalloids and colloids in the ratio of 1.5:0.5 respectively
Colloid include plasma, blood, dextrans, albumin
Crystalloids are Saline, Hartmans solutions
Add 2000ml(2L) of 5% dextrose for insensible losses
Half of all the fluids given I the 1st 8 hrs since the occurrence of burn and the rest in next 16 hours
After 24 hours give half of the fluids (1ml/kg/BSA) plus the 2L of 5 % dextrose.
ii)Analgesics
Give opiate analgesics IV (IM is ineffective erratic absorption); NSAIDs
iii)PPI or H2 Blocker
protection from Curling's Ulcers (duodenal ulcers which occur in burned patients)
iv)Tetanus toxoid
v) Prophylactic antibiotics If TBSA >15%
If less do M/C and sensitivity before antibiotic administration
vi) Optional Drugs
DVT prophylaxis in lower limb burns
Tetracycline eye ointment for Face burns
Insulin if Diabetic or hypertensive control if hypertensive
i)Remove all necrotic tissue & debris
ii)Rupture blisters except those on the palms & soles of feet and those>1cm in diameter. Can do early escharotomy and grafting
iii)Wash wound with soap & water or normal saline
iv)Apply topical antibiotic e.g.
Silver sulphadiazine (Side effects are thrombocytopenia, leucopenia, rash-sulfonamide sensitivity)
0.5% Silver Nitrate - Stains tissues & can cause hypochloraemic alkalosis & hyponatremia; Good for grafts
Mafenide 10% - can penetrate tissue & eschar. Good for infected wounds & eschars. very painful on application
Neosporin or Bacitracin - Good for facial burns as they are not toxic to the eyes
OR - Apply antibiotic-impregnated material
Dressing
Open Dressing - No dressing applied
Exposure Dressing - Apply soothant e.g. Vaseline
Occlusive dressing e.g. for small superficial previously debrided wounds
Apply non-stick material e.g. Bactigras
Apply 3-5 layers of dry material e.g. gauze
Cover with crepe bandage
Change after 3days & then daily up to day 21. If there is no healing, consider skin grafting.
Silver sulfadiazine/transparent polythene bags for hands
Skin grafting e.g. for frictional burns.
Indications for occlusive dressing
If wounds don’t heal between 21-30 days. Skin graft immediately for a frictional burn. It encourages healing.
Graft-any tissue removed from one anatomical part of the body to the recipient floor and its survival depends on the floor. (blood transfusion is not a graft)
Flap-(Pediculated graft) –removed with own blood supply.
Any part of the body can donate except the perineum and below the eyes.
Skin graft types: Spit thickness and Full-thickness grafts
1st 24 hours –graft survives by osmosis
Next 48 hours Neovascularization.Beyond its take or non-take (rejected)
The donor site kept dressed for 10-14 days.
Grafting across joints should apply splints to facilitate take
Biological dressing
-Amniotic membrane
-A graft from mother allograft which is rejected in 2 weeks but left in situ as a biological graft.
Face burns
Intubate patient & do temporary tarsorrhaphy (suturing eyelids together).
Whistling and blowing mouth for physiotherapy
In neck burns
A pillow is placed under the patients head to hyperextend the neck
The pillow below the shoulders to prevent contractures
Chest wall burns
2nd and 3rd-degree burns do occlusive dressing
Do escharotomy for any scar constricting respiratory movements-Do a checker-box release
Upper limb burns
Should be nursed elevated at 45° to reduce edema
Escharotomy lateral and medial also in the web spaces
Patient on a bed with a pillow between his shoulders to carbonic anhydrase inhibition causing metabolic acidosis; sulfonamide sensitivity rash
Start physiotherapy from the day after escharotomy- do it 5 times a week. At night do nocturnal splinting and for sleep comfort and avoid contractures
Lower limbs
Encourage movements to avoid DVT.
NB If ≥80% TBSA - Supervised Neglect
Nutritional support
Curreri formula - 25KCal/Kg + (40KCal * %TBSA)
Because burn injury causes a hypermetabolic state that is characterized by a dramatic increase in resting energy expenditure, nutritional support is essential, especially via the enteral route, to reduce intestinal villous atrophy
48 hours - 6 months Management is based on complication control
Escharotomies
Surgical division of constricting eschars (scab formed especially after a burn).
Indications;
Escharectomy
Surgical –Tangential excision
Medical –Use of mafenide, soaking with NS
After 6months - Reconstructive surgery, Training & Rehabilitation
Physiotherapy - Splint at night & Motion during the day
Occupational therapy - To rehabilitate the patient back into a functional living
Psychiatric rehabilitation
Instant complications
Immediate-hours
1.Hemorrhage
2.Airway obstruction
3.Circulatory collapse
1 month - 1year
Hypertrophic scars which are itchy, Hyperaemic, and uncomfortable.
Over 1 year
Keloids. A keloid is a true tumor arising from the connective tissue elements of the dermis. keloids grow beyond the margins of the original injury or scar; in some instances, they may grow to enormous size.
Management is by local injection of Steroids & Bleomycin, Excision & Superficial irradiation
Contractures
10 years
Marjolin's ulcer developing in the old burn site
Fluid and electrolyte imbalances
Severe burns decrease sodium in circulation but total body sodium is increased.
Hyperkalemia
Shock, dehydration due to increased fluid loss
Infection;
0-7 days - Contamination
>7 days – Sepsis
GIT;
1. Burns secondary to swallowing corrosive substances heal by fibrosis with the formation of strictures in esophagus Contractures of the esophagus lead to the obliteration of the angle of HIS, GERD more acid irritation & burns which cause more scarring & contractures
Nissen fundoplication is done to break the cycle.
2. Curling's ulcers may cause GIT bleeding
3.Pseudo-intestinal obstruction (paralytic ileus) on the third to the fourth day
4. Diarrhoea secondary to Ileal atrophy in the 7th-8th day; Diarrhoea may also be due to the drugs
5. Pancreatitis
6. Acalculous cholecystitis
7. Ogilvie's syndrome
Respiratory
Genitourinary
Skin
Musculoskeletal
Eye
Hematological
All burn patients put on haematinic and anti-helminth drugs.
Other hematological complications- Leucopenia and thrombocytopenia, DIC.
Multiple organ failure
CNS
CVS-Shock, Arrhythmia, tachycardia, Cardiac arrest.
1.Patient's age
2. Pre-existing medical conditions e.g. Cardiac, Pulmonary, Renal dysfunction
3.Presence of Inhalational injury
3.Size and Depth of Burn
4.Concomitant Injuries
5.Etiology of burn