BURNS

BY DR ESME IDUN-TAWIAH
OUTLINE
• INTRODUCTION
• EPIDEMIOLOGY
• CLASSIFICATION
• PATHOPHYSIOLOGY
• CLINICAL PRESENTATION
• INVESTIGATIONS
• MANAGEMENT
• COMPLICATIONS
• REFERENCES
INTRODUCTION
• Burn injury refers to tissue damage from various aetiologies causing
coagulative/liquefactive necrosis of cells
- Thermal
- Electrical
- Chemical
- Radiation
- Friction
EPIDEMIOLOGY
• Burns are estimated to cause approximately 180,000 deaths annually
worldwide with mostly in low-middle income countries
• Data from the Burns Registry of the Burns intensive Care unit of KATH
showed burns admissions being high amongst children (0-10 years)
with a mean TBSA distribution of 24-35%
• Mortality – 8.4% - 32% in the years 2009-2013
• Highest reports of the aetiology being Thermal burns
AETIOLOGY

ELECTRICAL BURNS CHEMICAL BURNS

AETIOLOGY
RADIATION
THERMAL BURNS
LAYERS OF THE SKIN
CLASSIFICATION
FIRST DEGREE/SUPERFICAL PARTIAL SECOND DEGREE/ DEEP PARTIAL
THICKNESS THICKNESS
CLASSIFICATION

THIRD DEGREE/FULL THICKNESS FOURTH DEGREE/ FULL THICKNESS

FULL THICKNESS BURNS
CLASSIFICATION OF BURNS
• By degrees
• 1st degree – epidermis
• 2nd degree – epidermis and dermis (superficial - papillary dermis; deep
– reticular dermis)
• 3rd degree – epidermis, dermis, and subcutaneous tissue
• 4th degree – muscle, joints and bone involved
CLASSIFICATIONS
TRADITIONAL CLASSICATION CONTEMPORARY RADICAL CLASSIFICATION
CLASSIFICATION

First Degree Superficial Partial Superficial Burns

Thickness (No surgical intervention
Erythema (5-7days healing) required)

Superficial
(Blistering, blanching with
healing in 3 weeks)
Second Degree
Deep Deep Partial Thickness Deep Burns
(Whitening, non- (Surgical Intervention
blanching, healing >/= 3 required)
weeks)

Third Degree Full Thickness

(Leathery and insensate)

Fourth Degree
Charred
 Estimation of Burn Surface Area (TBSA)
WALLACE’S RULE OF NINE LUND AND BROWDER’S CHART
PATHOLOGY/ PATHOPHYSIOLOGY OF
BURNS
• Tissue damage depends on temperature, exposure and duration
• Tissue damage is described by the Jacksonian model
• Inflammatory mediators – histamine, serotonin, prostaglandins,
thromboxane, kinins – cause increased capillary permeability
• Leakage of fluids from vessels into interstitial tissues; causes oedema
• Fluid loss is rapid in the first 8 hours; reduced after 24 to 48 hours;
when the integrity of the vessel wall is restored
Jackson’ Classification
SYSTEMIC EFFECTS
• Cardiovascular – Hypovolaemia, burn shock
• Renal – AKI
• Respiratory – Carbon monoxide inhalation, Direct thermal injury, Inhalation of
products of combustion, Pulmonary oedema
• GI – compromise of gut mucosa, curling ulcer
• CNS – restlessness, agitation
• Haematological - Anaemia – due to (1) direct destruction of rbcs (2) haemolysis from
initial injury (3) bone marrow depression (4) cutaneous loss from frequent changes
of dressings
• Immunosuppression – mechanical barrier, loss of immunoglobulins
• Metabolic changes - Hypermetabolism
CLINICAL PRESENTATION
• Demographics
• History of the accident – duration, exposure, temperature, fire in an
enclosed space, Patient lying unconscious in a building on fire, first aid
• Symptoms based on degree
• NB – management is a multidisciplinary care
• But first, Revive the patient!
INITIAL ASSESSMENT
• Principles of management – Revive, Restore, Repair, Rehabilitate
• Revive = Primary Survey
• Airway and cervical spine control - Signs – Soot around the mouth and
nose; singed facial and nasal hair; swollen upper airway, hoarse or
weak voice
• Breathing - brassy cough, respiratory difficulty
• Circulation – signs of burn shock
• Disability – restlessness
• Exposure – TBSA, weigh
Patient with inhalation injury
INVESTIGATIONS
• FBC, GXM
• BUE CREATININE
• LFTs
• ECG
• ARTERIAL BLOOD GASES
• WOUND SWAB
 MANAGEMENT
• Fluid replacement; Packland formula/ Brooke formula – Crystalloids, colloids, mannitol, NaHCO
• Pain management
• Catheter – urine monitoring 1ml/kg hourly for children, 30mls/hour for adults
• Monitor vitals half hourly
• Prophylactic antibiotics, PPIs
• Tetanus prophylaxis
• Escharotomy (if needed)
• Wound dressing/ splinting - silver sulphadiazine, silver nitrate, mafenide, flamacerium, povidone
iodine, honey
• Refer/ send to burns ICU – sev burns, face, joints, circum. chest/abdomen, perineum, hands
• Nutrition – NG tube help recover gut. (100j/kg + 160j/%TBSA, 240j/kg + 140j – energy), 2-3g/kg of
protein, RYG pills
• Physiotherapy
• Excision and Grafting
LANDMARKS OF ESCHAROTOMY
Escharotomy for Circumferential burns
COMPLICATIONS
• EARLY
- CVS - Hypovolemic shock
- Infection
- GI - Ulcers, paralytic ileus, liver damage
- Respiratory – Airway obstruction, Pneumonia, trachea-bronchitis,
atelectasis
- Renal – AKI, pyelonephritis, calculi
- Vascular – DVT, PE, thrombophlebitis, anemia – DIC
COMPLICATIONS
• LATE
- Chronic burn wound
- Hypertrophic/ Keloid scar
- Contracture
- Loss of body parts
- PTSD
- Dyschromic scar
- Burn scar metaplasia/ Marjolin’s ulcer
REFERENCES
• BAJA’s Principles and Practice of Surgery, 5th edition
• World Health Organization. World Health Organization. News letter,
August 2017. Burns. Available at
http://who.int/mediacentre/factsheets/fs365/en/
• Agbenorku, P., Aboah, K, et al. Epidemiological studies of burn
patients in a burn center in Ghana: any clues for prevention?. Burn
trauma 4, 21 (2016)
• Guo F, Zhou H, Wu J. et al. Jan 2021. Prospective Study on Energy
Expenditure in Patient with severe burns. JPEN J Parenter Enteral.
2021 Jan. 45 (1):146-51