BURNS

Ashkay
Anita
Collins
Kennie
 INTRODUCTION
Burns is defined as a wound caused by exogenous agents
leading to coagulative necrosis of the tissue.
Burns are uniquely visual injuries, and the ability to assess
burns by sight is an essential skill both for planning initial
burn care and for making decisions about such things as the
need for surgery, the presence of infection, and the extent
of scarring.
Human skin can tolerate temperatures up to 42-44 0 C (107-
111 0 F) but above these, the higher the temperature the
more severe the tissue destruction. Below 45 0 C (113 0 F),
resulting changes are reversible but >45 0 C, protein
damage exceeds the capacity of the cell to repair
 ANATOMY & PHYSIOLOGY OF THE SKIN

• The skin is the largest organ of the body, ranging in area

from 0.25 m2 in the newborn to 1.8 m2 in the adult.
 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
 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

The effects of the burns are influenced by the

• Intensity of the energy
• duration of exposure
• type of tissue injured
PATHOPHYSIOLOGY OF THERMAL 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
Pathophysiology of Thermal Burns
Cont’d
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
Pathophysiology
• Local Effects
• Almost all burns are colonized by bacteria
• Common pathogens that infect burn
wounds: MRSA, Pseudomonas, Klebsiella,
Acinetobacter, Candida
•
Eschars can cause constrictive effects.
• Significant eschar on chest or neck → restricts chest
excursion → asphyxia
• Systemic Effects
• Large (> 30% of the body surface area) and/or deep burns →
extensive tissue damage → 
• Release of cytokines and other inflammatory mediators (systemic
inflammatory response syndrome) 
• Evaporative fluid loss 
• Hemolysis, muscle damage
• Immunosuppression
• Hypermetabolic state with increased nutritional requirements
•
Inhalation of hot smoke and/or noxious gases→ inhalation injury
• Laryngeal edema 
• Carbon monoxide poisoning
Classification of
Burns
Classification of Burns
 Severity : the severity of a burn is assessed
based on the depth of burn,the amount of skin
involved in the burn and other associated
clinical features.

 Depth of Burn :Burns may also be classified

into Partial thickness and Full thickness,
depending on whether there is destruction of
the germinal epithelial layer of the skin.
 Further divided into four(4) degrees of severity.
Classification Cont’d

 1st Degree (Superficial Burn).

 Depth of Tissue Damage
Superficial layers of the epidermis
 Features
Erythema,Edematous,the burn wound
blanches on applying pressure and refills
rapidly.
 Sensation
Mild to moderate pain.
 Healing process
Healing occurs within 3-6 days without
scarring.
 2nd Degree-2A (superficial partial thickness burn)
 Depth of tissue damage
Epidermis and upper layers of the dermis; dermal
appendages (hair follicles, sweat, and sebaceous
glands are spared)
 Features
Erythema,Vesicles/bullae
The burn wound blanches on applying pressure and
refills slowly.
• Sensation
Severe pain.
• Healing process
Healing within 1–3 weeks with
hypopigmentation/hyperpigmentation but without
scarring
 2B (Deep partial-thickness burn)
 Depth of tissue damage
Deeper layers of the dermis
 Symptoms
Mottled skin with red and/or white
patches
Vesicles/bullae
The burn wound does not blanch on
applying pressure.
• Sensation
Pain is decreased.
 Healing process
Healing takes 3 weeks or longer and
results in scar formation.
 3rd degree (full thickness burn)
 Depth of tissue damage
Epidermis, dermis, and subcutaneous
tissue.
Most skin appendages are destroyed.
 Features
Tissue necrosis with black, white, or
gray leather-like skin (eschar)
No vesicles/bullae
The burn wound does not blanch on
applying pressure
• Sensation
May be less painful.
 Healing process
The burn does not heal by itself.
 4th degree
 Depth of tissue damage
Epidermis and all of dermis including
deeper structures (muscles, fat, fascia,
and bones)
 features
White,Charred tissue,thrombosed
vessels,blanching does not occur.
• Sensation
Not painful,although surrounding areas
of second degree burn are painful.
 Healing process
Does not heal,severe scarring and
contractures. The tissue is dead and
requires amputation.
Assessment

of Burns
Rule of Nine (Wallace Rule
of Nines)
Best used for large surface
areas.
 Lund and Browder
Chart
Best used for burns <10%
BSA.
Burn management
 INTIAL MANAGEMENT OF MAJOR INJURIES.

• An accurate history and examination of the patient and the burn is

vital. A systematic approach will ensure that key information is not
missed.
• HISTORY:
• Exact time and mechanism of the injury:
• (a) Type of burn, i.e scald, flame, electrical, chemical.
• (b) How was the person put out?
• (c) What first aid was carried out? If cooling was performed,
what with and for how long?
• Likelihood of concomitant injuries ((i.e. fall from
height, road traffic accident, explosion).
 Primary survey
• The initial management of a severely burnt patient is
similar to that of any trauma patient. A modified ATLS
primary survey is performed, with particular emphasis
being placed on assessment of the airway and breathing.
• A: Airway with cervical spine control

• The cervical spine should be protected unless it is

definitely not injured. Inhalation of hot gases will result in
a burn above the vocal cords; this burn will become
oedematous over the course of hours, especially after fluid
resuscitation has begun.If there is any concern about the
patency of the airway, then intubation is the safest policy.
 BREATHING
• All burn patients should receive 100% oxygen through a
non-rebreathing mask on presentation. There are several
mechanisms that can compromise respiration such as:
•  mechanical restriction of ventilation;
•  blast injury
•  smoke inhalation
•  carbon monoxide poisoning.
• Deep dermal or full-thickness circumferential burns of
the chest can limit chest excursion and prevent adequate
ventilation. This requires immediate escaharotomy
 C: circulation
• Intravenous access should be established with large-bore
cannula placed preferably through unburnt tissue. The
peripheral circulation must be checked. Any deep or
full-thickness circumferential extremity burns can act as
a tourniquet, especially once oedema secondary to fluid
resuscitation has begun. 

• D: neurological disability
• The patient’s score on the Glasgow Coma Scale should be
assessed. Patients may be confused due to hypoxia or
hypovolaemia.
 E: exposure with environment control
• It is very easy for the burn patient, especially children, to become
hypothermic. This leads to hypoperfusion and deepening of the burn
wound. The patient should be covered and warmed as soon as possible.
• FLUIDS:
• In children with burns over 10% of TBSA and in adults with burns over
15% of TBSA ,fluid resuscitation is required
• •If oral fluids must be used, salts should be added
• •Fluids can calculated from a standard formula ,key is to monitor urine
output.
• •PARKLAND FORMULA
• Total % body water*weight in kg *4=volume(ml)
• Half of this vol is given in the first 8hrs then the other half in the
subsequent 16hrs
 Further Management
• Full-thickness burn injuries should be covered with a
clean cloth, sheet, or sterile non-adhesive bandages if
possible, taking care not to disrupt blisters.
• For burned toes or fingers, separate with non-adhesive
dressing material.
• Eschar, or burned dead tissue, is present in many full-
thickness burns and is tan, brown, or black, leathery, and
non-elastic in texture.
• If it forms a band circumferentially around an extremity or
digit it can compromise blood flow by compression of
proximal blood vessels.
• This constriction may necessitate the need for
escharotomy; removal or scoring of the eschar, or
fasciotomy, opening of deep fascia and all compartments
to release pressure and regain blood flow or lung
expansion.
• Intake of adequate nutrition, with special attention to
proteins and calories, are essential to the healing process.
• As scars form, they may result in an overgrowth of scar
tissue or the development of keloid scars. These scars can
be restrictive and cause difficulty in regaining mobility and
function, especially over joint areas. The destruction of
tendons and ligaments and the development of scar tissue
can result in contractures that tighten and shorten skin,
muscles, or tendons, thus permanently preventing joints
from regaining proper alignment and position. Scar
management and surgical revision may be necessary to
regain functionality, as well as for aesthetic reasons.