Full written

Acute burn Dr.muhammed naeem

Learning objectives
1-Classification of causes of burn
2-Proper assessment of depth of burn in the acute stage.
3-Assessment of percentage of TOTAL BURN SURFACE AREA ( %TBSA) according to
Wallace rule of nine.
4-Early diagnosis and management of inhalational injury.
5- Fluid resuscitation of acutely burned patient according to Parkland formula and
assessment of proper resuscitation .
6-Local care of burned wound.
7- Assessment the need for early surgical decompression of acutely burned patient

Introduction
The burn is depicted as a traumatic lesion provoked by several possible agents (thermal, chemical,
mechanical, or electrical) involving different skin layers to a certain degree.
Burns are one of the most devastating conditions encountered in medicine. The injury represents
an assault on all aspects of the patient, from the physical to the psychological. It affects all ages,
from babies to elderly people, and is a problem in both the developed and developing world. Most
of us have experienced the severe pain that even a small burn can bring. However the pain and
distress caused by a large burn are not limited to the immediate event. The visible physical and the
invisible psychological scars are long lasting and often lead to chronic disability.
Skin surface area is about 0.2–0.3m2 in the newborn and about 1.5–2.0m2 in the adult. Thickness
of epidermis from 0.05mm (eyelids) to 1mm (sole of the foot). Dermis is approximately 10×
thicker than epidermis site for site.

Causes of burn injury :

most common
1-Thermal burn : most common cause which may be caused by
-Scald
-Flash
-Flame
-Contact Advantage, limited to the area of contact

2-Chemical burn :
Alkalis (cause a liquefactive necrosis)
*more severe, liquefactive continuous deeply

1
 Acids (cause a coagulative necrosis)
Organic compounds
Phosphorus
3-Electrical burn :
Low voltage <1,000 V
High voltage >1,000 V
4-Radiation injury

Pathophysiology of burn injury

A. Thermal injury causes coagulation necrosis of the skin and underlying tissues to a variable
depth. Burn injury also exerts deleterious effects on all other organ systems.
B. Hemodynamic—The first 24-h postburn are characterized by decreased blood volume,
increased blood viscosity, and depressed cardiac output. Microvascular permeability is increased
directly by heat and indirectly by endogenous mediators. The diminished blood volume and
cardiac output cause oliguria, which may progress to acute renal failure. Numerous factors have
been reported to increase vascular permeability and leukocyte infiltration:
• Histamine
• Arachidonic acid metabolites (principally thromboxane A2 and the leukotrienes)
• Substance P
• Fibrin degradation product D
• Activated proteases
• Platelet-activating factor (PAF)
• Cytokines such as interleukin-1 (IL-1) and tumor necrosis factor (TNF)
C. Immune system—Humoral and cell-mediated immunity are both impaired and are manifested
as depressed levels of immunoglobulin, reduced activation of complement, and diminished
stimulation of lymphocyte proliferation and response.
D. Hematologic—There is immediate red blood cell destruction in direct proportion to the extent
of the burn, particularly third-degree burns. Endothelial injury may lead to release of
thromboplastins and to collagen exposure; the latter then initiates platelet adhesion, aggregation,
and contact activation of factor XII. Severe full-thickness burns induce consumption of
coagulation factors at the burn site, which contributes to the development of disseminated
intravascular coagulation (DIC).

2
E. Gastrointestinal—Ileus is universal in patients with burns of more than 25% total body surface
area (TBSA). Gastric and duodenal mucosal damage, secondary to focal ischemia, can be observed
as early as 3–5 h postburn. If the mucosa is unprotected, the early erosions may progress to frank
ulceration.
F. Endocrine—In the early postburn period, a catabolic endocrine pattern develops that is
characterized by elevated glucagon, cortisol, and catecholamine levels with depressed insulin and
triiodothyronine levels. These effect an increase in metabolic rate, glucose flow, and a negative
nitrogen balance. Their magnitude correlates with the size of the burn area.

Acute management of burn:

Without intervention, patients with serious burns die for three primary reasons. Burn shock in the
first day, respiratory failure in the following 3–5 days, and burn wound sepsis in subsequent weeks.
The initial management of a severely burnt patient is similar to that of any trauma patient. A
modified “advanced trauma life support” primary survey is performed, with particular emphasis
on assessment of the airway and breathing. The burn injury must not distract from this sequential
assessment, otherwise serious associated injuries may be missed.
-- Perform an ABCDEF primary survey
A—Airway with cervical spine control, B—Breathing,
C—Circulation, D—Neurological disability, E—Exposure with
Indications for hospital admission: The following are the admission criteria for all patients
with burn injuries according to the American Burn Association.
• Second- and third-degree burns greater than 10% of TBSA in patients under 10 or over 50
years of age
• Second-degree burns greater than 20% TBSA in other ages
• Third-degree burns greater than 5% TBSA in any age
• Significant burns of the face, hands, feet, genitalia, or perineum
• Significant electrical/lightning injuries
• Significant chemical burns
• Associated inhalation injury, concomitant mechanical trauma, or significant preexisting
medical illnesses
• Burns requiring special social, emotional, or long-term rehabilitative support, including cases
of suspected or actual child abuse

3
Evaluation of burn involves:
• Extent of burns (surface area): Although the classic “Wallace Rule of 9” is still followed in
many centers
The Wallace rule of nines
• Adult body surface area (BSA):
∘ 9% head and neck
∘ 9% each arm
∘ 18% anterior trunk
∘ 18% posterior trunk
∘ 18% each leg
∘ 1% perineum.
• BSA of children up to 1 year old is distributed differently:
∘ 18% head and neck
∘ 9% each arm
∘ 18% anterior trunk
∘ 18% posterior trunk
∘ 13.5% each leg
∘ 1% perineum.

4
– For each additional year of age up to age 10, 1% should be subtracted from the head and neck
and 0.5% added to each leg.
• Depth of burn injury is generally difficult to assess initially. It is sufficient to distinguish
between erythema and actual skin damage at the initial examination.
• First-degree burn—superficial burn that involves only the epidermis. The area is erythematous,
tender, and usually heals in less than 7 days.

• Second-degree burn—destruction of the epidermis and upper dermal layer. The skin is red,
blistered, and sensory nerve damage causes extreme pain.

• Third-degree burn—destruction of the epidermis and dermis. The area is white, leathery,
charred, and pain is absent due to destruction of sensory nerves

5
• Fourth-degree burn—destruction of skin, muscle, and bone.

Fluid resuscitation :
Fluid resuscitation is required for:
∘ Adults with burns >15% TBSA.
∘ Children with burns >10% TBSA.
Parkland formula
• 4 ml/kg/% burn of Hartmann’s solution in the first 24 hours after the burn.
∘ Half the fluid is given in the first 8 hours after injury.
∘ The second half is given in the next 16 hours.
• Hartmann’s solution contains:
Na+ 131 mmol/l
Cl− 111 mmol/l
Lactate 29 mmol/l
K+ 5 mmol/l
Ca2+ 2 mmol/l.
The rate of infusion is modified to meet specific end points of resuscitation:
∘ Urine output is the best indicator of tissue perfusion
– Aim for 0.5–1 ml/kg/h in adults; 1–1.5 ml/kg/h in children
– Double this after high-voltage electrical injuries.
∘ Other parameters to be monitored:
– Pulse, blood pressure, capillary refill
– Core–peripheral temperature gradient
– Respiratory rate

6
– Urine osmolality.
• Serial measures of arterial blood lactate and base excess also indicate adequacy of resuscitation.
Factors specific to children resuscitation
• Proportionately greater surface area than adults.
• Reduced physiological reserves.
∘ Because of this, children require additional maintenance fluid containing dextrose.
• Daily maintenance fluid requirement:
∘ 100 ml/kg for the first 10 kg body weight
∘ 50 ml/kg for the next 10 kg body weight
∘ 20 ml/kg for the remainder of the body weight
• Maintenance fluid is given enterally whenever possible.
Inhalation Injury
Inhalation injury—a chemical tracheobronchitis and acute pneumonitis—is caused by the
inhalation of smoke and other irritative products. In severe cases, it progresses to development of
adult respiratory distress syndrome (ARDS).
Typical Signs of Significant inhalational Injury
1. Singeing of nasal hair
2. Significant facial burns
3. Carbonaceous sputum
4. Hoarseness
5. Stridor swelling of upper airway

6. Carboxyhemoglobin level of more than 15% at 3 h postexposure is strong evidence of smoke

inhalation
Evaluation of inhalational injury
1. Chest x-ray and arterial blood gases are routinely obtained.
2. Fiberoptic bronchoscopy may be performed at bedside.
3. Xenon ventilation/perfusion scanning has been reasonably accurate in diagnosing inhalation
injury.

7
Treatment of inhalational injury
is mainly supportive with oxygen therapy Immediate treatment involves administering 100% oxygen.
Endotracheal intubation is necessary in some cases. Hyperbaric oxygen has been used in some units.

-Routine tetanus prophylaxis is employed in burned patient.

-There is no role for prophylactic systemic antibiotic therapy. Give antibiotics when there
are features of infections.
-Put NG tube and prescribe antacids :When the burn surface area is 25% or more of deep
burn, the patient is liable to develop paralytic ileus and stress gastro-dudenal erosions or
ulcers→ put NG tube and prescribe antacids.
-Frequent checking of PCV, S.electrolytes, and renal function tests
-Nutrition support: Give high calorie and high protein diet .In addition to Vitamins A and
C, Iron and Zinc suppliments.
- Psychlogical support.
-Rehabilitation and physiotherapy with early splinting of burned extremities and joints to
avoid post burn contractures.

Surgical decompression
• Deep dermal and full thickness burns are inelastic.
∘ Can cause distal limb ischemia if circumferential .
• Similarly, extensive involvement of the chest (or abdomen in a child) can impair ventilation.
• Constriction becomes worse once fluid resuscitation is begun.
• Escharotomy relieves this constriction.
∘ Usually done with electrocautery, because they tend to bleed.
• Fasciotomies usually required only for burns involving muscle, or high-voltage electrical

8
injuries.
• Escharotomies begin and end in unburnt or superficially burnt skin.
• Limb escharotomies are generally made in midaxial lines.
∘ Avoid the ulnar nerve at the elbow and common peroneal nerve at the knee.
• Chest escharotomies are made along the mid-axillary lines to the subcostal region.
∘ They are joined across the upper abdomen by a chevron incision parallel to the costal margin.
∘ This creates a mobile breastplate that moves with ventilation.
∘ The anesthetist can advise on the adequacy of chest escharotomy by a drop in ventilator airway
pressures.

Local Management of burn

1. Initial care involves debridement of necrotic tissue and open blisters, protection from the
environment, and edema reduction.
2. Enzymatic debridement is practiced in some centers.
3. Early excision of burn tissue provides better functional and aesthetic results. The post excision
wound is ideally covered with meshed split thickness autografts. Early staged excision should
begin on postburn day 3 in full thickness burn.
Types of burn wound excision:
Tangential excision: sequential removal of layers of eschar and necrotic tissue until a layer of
viable, bleeding tissue.
Fascial excision: excision of the burned tissue and subcutaneous tissue down to the layer of the
muscle fascia

9
 ‫نفس سجينة ال‬
skin graft

Water jet-powered VersaJet: useful for excision of concave surfaces of the hand and feet, as well
as for excision of the eyelids, ear, and nose

‫مي لو سالين كلش سريع يكص‬

Coverage of skin defect after burn wound excision

Skin graft: segment of tissue that transfer from one site of body (donor site) to another site
(recipient site) without its blood supply.
Types of skin graft :1. Full thickness skin graft: which consist of epidermis and full thickness of
dermis.
2. Split thickness skin graft: Which consist of epidermis and variable portion
of dermis, it described as thin, intermediate, and thick according to thickness of included dermis.
Skin substitutes: in cases of extensive burn wounds, the surface area burned may exceed the
available donor sites , so they need for a replacement for human skin until complete coverage with
autografts can occur

10
Pain control in burnt patients:
Background pain :Best treated with longer acting agents :MORPHIN
Procedural pain occurs during daily wound care and therapy. shorter acting agents are probably
best. use of short-acting benzodiazepines is favorable.

Avoid NSAID
Topical Agents used in local wound care of burn
• Silver sulfadiazine (1% Silvadene)—most commonly used agent. Active against most Gram-
positive and Gram-negative organisms. The “pseudoeschar” that forms over the burn can confuse
the inexperienced observer. Leukopenia can occur.
• Sulfamylon (Mafenide acetate)—has superior eschar penetration. Excellent choice for ears,
noses, and some electrical burns. It has the disadvantage of causing intense pain on application
and is associated with metabolic acidosis.
1%, twice daily
• Silver nitrate (0.5%)—effective as a prophylactic against Pseudomonas colonization.
Disadvantages include production of black stains, hyponatremia, and methemoglobinemia.
• Povidone iodine—not effective, inactivated by wound exudate

Management of out- patient burn

11
References
1-Handbook of plastic surgery , Arvind N.Padubidri, and Maria Siemionow, chapter 25; burn
pp :176-180.
2-Key Notes In Plastic Surgery ,2nd edition, Adrian Richards and Hywel Dafydd,chapter 8,
burn ,pp 490-516.
3-Stone's Plastic Surgery Facts and Figures ,3rd edition, chapter2 burn, pp 25-29.

12
 Slides

Acute burn
By : Dr.Muhammed Naeem
PLASTIC & RECONSTRUCTIVE SUEGERY
Learning objectives

• 1-Classification of causes of burn

• 2-Proper assessment of depth of burn in the acute stage.
• 3-Assessment of percentage of TOTAL BURN SURFACE AREA ( %TBSA)
according to Wallace rule of nine.
• 4-Early diagnosis and management of inhalational injury.
• 5- Fluid resuscitation of acutely burned patient according to Parkland
formula and assessment of proper resuscitation .
• 6-Local care of burned wound.
• 7- Assessment the need for early surgical decompression of acutely
burned patient
Causes of burn injury :
Most common
• 1-Thermal burn : most common cause which may be caused by
• -Scald
• -Flash
• -Flame
• -Contact Advantage, limited to the area of contact

• 2-Chemical burn :
*more severe, liquefactive continuous deeply
• Alkalis (cause a liquefactive necrosis)
• Acids (cause a coagulative necrosis)
• Organic compounds
• Phosphorus
• 3-Electrical burn :
• Low voltage <1,000 V
• High voltage >1,000 V
• 4-Radiation injury
Flame burn
Flash burn
Contact burn
Scald burn
Chemical burn
Radiation burn
 Pathophysiology of burn injury
• A. Thermal injury causes coagulation necrosis of the skin and underlying
tissues to a variable depth. Burn injury also exerts deleterious effects on all
other organ systems.
• B. Hemodynamic—The first 24-h postburn are characterized by decreased
blood volume, increased blood viscosity, and depressed cardiac output.
Microvascular permeability is increased directly by heat and indirectly by
endogenous mediators. The diminished blood volume and cardiac output
cause oliguria, which may progress to acute renal failure
• C. Immune system—Humoral and cell-mediated immunity are both
impaired and are manifested as depressed levels of immunoglobulin,
reduced activation of complement, and diminished stimulation of
lymphocyte proliferation and response
Zone of burn injury
 more than 20%

(fluid from intravascular compartment to

interstitium and extravascular compartment)

(Hypovolemic shock)

Occur in burn and non burn area

the cytokines in first h. of burn have negative inotropic effect on the
heart which can aggrevate the burn shock
Inhalation Injury ‫يستنشق هوا كلش حار‬

• Inhalation injury—a chemical tracheobronchitis and acute pneumonitis—is

caused by the inhalation of smoke and other irritative products. In severe
cases, it progresses to development of adult respiratory distress syndrome
(ARDS).
Typical Signs of Significant inhalational Injury
• 1. Singing of nasal hair
• 2. Significant facial burns
• 3. Carbonaceous sputum
• 4. Hoarseness
• 5. Stridor
• 6. Carboxyhemoglobin level of more than 15% at 3 h postexposure is strong
evidence of smoke inhalation
 Evaluation of inhalational injury
History : burn in closed spaces
• 1. Chest x-ray and arterial blood gases are routinely obtained.
• 2. Fiberoptic bronchoscopy may be performed at bedside.

The erythema of trachea with with sweety deposit

which usually is highly increasse the possibility of
inhalational injury in such patient
•
 Treatment of inhalational injury is mainly
supportive
**Which include oxygen therapy, extensive chest physiotherapy in addition to need
endotracheal intubation or tracheostomy
Antibiotics and steroids are not indicated for treatment of inhalational injury
Acute management of burn:
• Without intervention, patients with serious burns die for three primary
reasons. Burn shock in the first day, respiratory failure in the following
3–5 days, and burn wound sepsis in subsequent weeks.
• The initial management of a severely burnt patient is similar to that of
any trauma patient. A modified “advanced trauma life support”
primary survey is performed, with particular emphasis on assessment
of the airway and breathing. The burn injury must not distract from
this sequential assessment, otherwise serious associated injuries may
be missed.
Sun burn
very painful ‫بطبوطه‬
painless
• Fourth-degree burn—destruction of skin,
muscle, and bone.
• • Depth of burn injury is generally difficult to assess initially. It is sufficient
to distinguish between erythema and actual skin damage at the initial
examination.
• • First-degree burn—superficial burn that involves only the epidermis. The
area is erythematous, tender, and usually heals in less than 7 days.
• • Second-degree burn—destruction of the epidermis and upper dermal layer.
The skin is red, blistered, and sensory nerve damage causes extreme pain.
• • Third-degree burn—destruction of the epidermis and dermis. The area is
white, leathery, charred, and pain is absent due to destruction of sensory
nerves
• • Fourth-degree burn—destruction of skin, muscle, and bone.
• Extent of burns (surface area)
• The Wallace rule of nines
• • Adult body surface area (BSA):
• ∘ 9% head and neck
• ∘ 9% each arm
• ∘ 18% anterior trunk
• ∘ 18% posterior trunk
• ∘ 18% each leg
• ∘ 1% perineum.
• • BSA of children up to 1 year old is distributed differently:
• ∘ 18% head and neck
• ∘ 9% each arm
• ∘ 18% anterior trunk
• ∘ 18% posterior trunk
• ∘ 13.5% each leg
• ∘ 1% perineum.
• – For each additional year of age up to age 10, 1% should be subtracted from the head and neck and 0.5% added to each leg.
Indications for burn hospital admission: The following are the admission
criteria for all patients with burn injuries according to the American Burn
Association .
• • Second- and third-degree burns greater than 10% of TBSA in patients
under 10 or over 50 years of age
• • Second-degree burns greater than 20% TBSA in other ages
• • Third-degree burns greater than 5% TBSA in any age
• • Significant burns of the face, hands, feet, genitalia, or perineum
• • Significant electrical/lightning injuries
• • Significant chemical burns
• • Associated inhalation injury, concomitant mechanical trauma, or
significant preexisting medical illnesses
• • Burns requiring special social, emotional, or long-term rehabilitative
support, including cases of suspected or actual child abuse
Fluid resuscitation :
• Fluid resuscitation is required for:
• Adults with burns >15% TBSA.
• Children with burns >10% TBSA.
• Parkland formula
• 4 ml/kg/% burn of Hartmann’s solution in the first 24 hours after the
burn.
• Half the fluid is given in the first 8 hours after injury.
• The second half is given in the next 16 hours.
burn surface area
• ∘ children require additional maintenance fluid containing dextrose.
• • Daily maintenance fluid requirement: is giving according to weight of child
• ∘ 100 ml/kg for the first 10 kg body weight
• ∘ 50 ml/kg for the next 10 kg body weight
• ∘ 20 ml/kg for the remainder of the body weight
• • Maintenance fluid is given enterally whenever possible

**maintenance fluid is better to given orally rather

than through IV line
The goals of Burn management is not only the
survival of the victims but also to improve their
quality of life as much as possible
Surgical decompression
• Deep dermal and full thickness burns are inelastic.
• Can cause distal limb ischemia if circumferential .
• Similarly, extensive involvement of the chest (or abdomen in a child)
can impair ventilation.
• Constriction becomes worse once fluid resuscitation is begun.
• Escharotomy relieves this constriction.
• Usually done with electrocautery, because they tend to bleed.
• Fasciotomies usually required only for burns involving muscle, or
high-voltage electrical injuries.
Acute burn surgery
Early burn wound excision and skin grafting

skin graft ‫نفس سچينة ال‬

Out patient management of burn

should avoid NSAIDs

discussed in next slide

only if there is an evidence an infection

Local Management of burn
• Topical Agents used in local wound care of burn
• Silver sulfadiazine (1% Silvadene)—most commonly used agent. Active
against most Gram-positive and Gram-negative organisms. The
“pseudoeschar” that forms over the burn can confuse the inexperienced
observer. Leukopenia can occur.
• Sulfamylon (Mafenide acetate)—has superior eschar penetration. Excellent
choice for ears, noses, and some electrical burns. It has the disadvantage of
causing intense pain on application and is associated with metabolic
acidosis.
• Silver nitrate (0.5%)—effective as a prophylactic against Pseudomonas
colonization. Disadvantages include production of black stains,
hyponatremia, and methemoglobinemia.
*Any other drug these agents associated with side effect that should be
taken in consideration when use to avoid such side effect or complication
References
• 1-Handbook of plastic surgery , Arvind N.Padubidri, and Maria
Siemionow, chapter 25; burn pp :176-180.
• 2-Key Notes In Plastic Surgery ,2nd edition, Adrian Richards and
Hywel Dafydd,chapter 8, burn ,pp 490-516.
• 3-Stone's Plastic Surgery Facts and Figures ,3rd edition, chapter2
burn, pp 25-29.
(Very important
notes)