Approach to a patient

with Burn

May, 2024
Objectives
• Define burn
• Identify types of burn and their cause
• Explain the body surface assessment techniques
• Describe the principles of managing a patient with burn injury
• Explain wound management techniques

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Outline
• Introduction to burn
• Review of anatomy and physiology of the skin
• Definition
• Classification of burn
• Body surface assessment
• Systemic effects of burn
• Evaluation and management of burn

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 Anatomy and physiology of skin
• The skin is the largest organ of the human body
• serves as a protective barrier between the internal organs and the
external environment.
• It is composed of three primary layers
 the epidermis
the dermis
the hypodermis

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• Epidermis
- The outermost layer of the skin
- primarily responsible for protection against the external
environment.

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• Dermis
- Structural support to the skin.
- is divided into two layers
- The papillary layer
- The reticular layer

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• Hypodermis
- Deepest layer
- Consists of fat cells and connective tissue
- Serves as insulator, cushion, energy storage and thermal regulator

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Definition of burn
• A burn is defined as coagulative destruction of the surface
layers of the body.
• Burns are commonly thought of as injury to the skin caused
by excessive heat. More broadly, burns result from traumatic
injuries to the skin or other tissues primarily caused by
thermal or other acute exposures
• WHO defines it as an injury to the skin or other organic tissue
primarily caused by heat or due to radiation, radioactivity,
electricity, friction or contact with chemicals

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Epidemiology
• According to WHO
- An estimated 180 000 deaths every year are caused by burns. The
vast majority occur in low- and middle-income countries.
- Non-fatal burns are a leading cause of morbidity, including prolonged
hospitalization, disfigurement and disability
- Females have slightly higher rates of death from burns compared to
males which is associated with open fire cooking, or inherently unsafe
cookstoves, which can ignite loose clothing.
- Burns are the fifth most common cause of non-fatal childhood
injuries.
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 Burn
Classification of Burn
Based on

Etiology Depth Severity

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Based on Aetiology
1. Thermal Burn
- Accounts for most burn cases.
- caused by:
∘ Scalding by hot liquids or gases
∘ Contact
∘ Flame
∘ Flash.
- Survival is largely determined by the burn’s TBSA and depth, and patient’s age
- There are several types of thermal burns

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1. Thermal burn
A. Scald burns
• a type of thermal burn caused by boiling water and steam
• the most common etiology in the very young and very old
• The degree of tissue necrosis depends on the temperature and
duration of application of the burning agent.
• Boiling water causes partial thickness burn in 0.1 seconds; full
thickness burn in 1 second.
• Prolonged contact with water at
50 ∘C can cause deep burns

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1. Thermal Burn
B. Flame/ contact burns
• sustained either from flame or from immediate contact with a hot
solid object.
• the most common mechanism of burns in adults in high-income
countries
• Associated with misuse of flammable liquids, automobile crashes and
ignition of clothing
• Higher mortality rate and longer length of stay
in hospital.

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1. Thermal Burn
C. Flash burns
• caused byexplosion of natural gas, gasoline and other flammable
liquids with and intense heat for a brief time.
• Clothing, unless it ignites, is protective against flash burns.
• gasoline is the most common liquid (63%) due to the use of gasoline
products for farming or recreational purposes (eg, bonfires, burning
leaves, boating, yard work).

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2. Chemical Burn

• By spill or splash of caustic substances which are found in bleach,

battery acid, fertilizers and disinfectants..
• Cause progressive damage until they are inactivated by reaction with
the body tissue or diluted with water.
• Chemical burns should be considered deep dermal or full-thickness
until proven otherwise.
• Alkali burns cause liquefative necrosis and allow deep penetration
• Acid burns coagulative necrosis limiting deep injuries

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3. Electrical burn
• results from electricity passing through the body causing rapid injury.
• The severity of damage is underestimated because the surface damage
is far more smaller than the damage of the deeper structures.
• In extreme cases, electricity can cause shock to the brain, strain to the
heart, and injury to other organs.
• Lightning strikes are also a cause of electrical burns, but this is a less
common event
• Electrical current enters a part of the body, such as the fingers or hand,
and proceeds through tissues with the lowest resistance to current and
finally leaves the body at a “grounded” area, typically the foot.

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3. Electrical burn
• During this exchange, the muscle is the major tissue through which the
current flows, and thus it sustains the most damage.
• Patients with electrical injuries are at risk for other injuries, such as being
thrown from the electrical jolt or falling from heights after disengaging
from the electrical current.

• Types
- Low voltage – less than 1000V. small, localized, deep burns
- High voltage – greater than 1000V. Cause varying degrees of cutaneous
burn at the entry and exit sites combined with hidden destruction of deep
tissue.

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4. Cold injury
• Cold burns are caused by direct contact with ice or an ice pack.
• Symptoms include numbness, blisters, and other symptoms
• Freezing of the water in skin cells forms ice crystals that damage the
skin cells
• Blood vessels constrict, reducing blood flow and delivery of oxygen to
the area
• Frost bite – prolonged exposure to extremely cold temperature
causing deep and permanent injury to both skin and bone.

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5. Radiation burn
• The radiation types of greatest concern are thermal radiation, radio
frequency energy, ultraviolet light and ionizing radiation.
• The most common type of radiation burn is a sunburn caused by UV
radiation.
• High exposure to X-rays during diagnostic medical imaging or
radiotherapy can also result in radiation burns.
• As the ionizing radiation interacts with cells within the body—
damaging them—the body responds to this damage, typically
resulting in erythema

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Based on depth
• First degree (Superficial)
• Second degree (Partial thickness)
- Superficial
- Deep
• Third degree (full thickness)
• Fourth degree

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1st Degree Burn
• Affect only the epidermis
• The burn site is red, painful, dry, blanch
with pressure (rapid refill)
• and has no blisters.
• Mild sunburn or a minor scald from a
kitchen accident are examples.
• Long-term tissue damage is rare, Heal in 4-
7 days without any scar.
• Treated by topical soothing agents

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2nd degree burn
A. Superficial partial thickness
burn
• present with redness, blanch
with pressure (slow refill),
blistering, painful and sensitive to
touch.
• Underlying dermis is pink and
moist
• heal within 1-2 weeks without
leaving significant scarring.
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 2nd degree burn
B. Deep Partial-Thickness Burns
• Both the epidermis and a significant portion of
the dermis are damaged.
• often appear mottled, with a white or waxy
color. They may have a dry, leathery texture.
• less painful compared to superficial burns as
they may damage the nerve endings.
• Blisters are less common or may not be present
at all in deep 2nd degree burns.
• Healing takes 3 weeks or more and may require
medical intervention
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3rd degree burn
• Full thickness burn
• charred or white, leathery
appearance.
• typically not painful initially
because the nerve endings have
been destroyed. However,
surrounding areas of partial-
thickness burns may cause pain.

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3rd degree burn
• The destruction of the skin
prevents the formation of fluid-
filled blisters that are commonly
seen in shallower burns.
• do not heal on their own and
require medical intervention.
• serious complications, including
infection, scarring, contractures
and long-term functional and
cosmetic impairments.

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4th degree burn
• extend beyond the deep layers of the skin and involve structures such
as muscles, tendons, or bones.
• These types of burns are extremely severe and require immediate
emergency medical attention.
• Black, charred appearance
• Common in electrical burn

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Based on severity
• This classification is based on TBSA, depth of injury, and age of the
patient.

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Burn Size (Body surface area assessment)
Wallace rule of nine -
- each upper extremity and the head and neck are 9% of the TBSA,

- the lower extremities and the anterior and posterior trunk are 18%
each,

- the perineum and genitalia are assumed to be 1% of the TBSA.

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Burn size
Another method of estimating smaller burns-
- equate the area of the open hand (the palm and the extended
fingers) of the patient as approximately 1% TBSA, then to transpose
that measurement visually onto the wound for a determination of its
size.

- helpful when evaluating splash burns and other burns of disparate

distribution.

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Children
- relatively larger portion of body surface area in the head and neck
and a relatively smaller surface area in the lower extremities.

Lund and Browder chart for children, where at birth

- the head represents 18% and the lower limbs 13.5% each
- each year 1% is subtracted from the head, 0.5% added to each lower
limb until the age of 10

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Lund and Browder chart

• 1. DETEMINE THE SEVERITY OF THE BURN

• 2. TO CALCULATE PATIENTS FLUID REQUIRMENT

• 3. DETRMINE HOSPITAL ADMISSION CRITERIA

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Systemic effects of Burn
• Inflammation and edema
• Shock reaction after burn
• Effect on the renal system
• Effect on the immune system
• Changes in the intestine
• Changes in peripheral circulation
• Injuries to the lungs and airways
• Hypermetabolism

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Inflammation and Edema
Burns induce a massive increase in inflammation in response to the injury,
in the wound first that is then generalized to all other tissues.
• release of neuropeptides and the activation of complement initiated by
the stimulation of pain fibres and the alteration of proteins by heat
• activation of Hageman factor initiates a number of protease-driven
cascades,
• altering the arachidonic acid, thrombin and kallikrein pathways.
• Fluid is lost from capillaries leading to edema
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shock reaction after burn
Burns produce an inflammatory reaction
• This leads to vastly increased vascular permeability
• Water, solutes and proteins move from the intra-vascular space to
extravascular space
• The volume of fluid lost is directly proportional to the area of the burn
• Above 15% of surface area, the loss of fluid produces shock requiring
resuscitation
(10% in extreme ages)

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Effect on the renal system
• decreased renal perfusion and GFR due to:
• decreased cardiac output, hypovolemia
• Stress induced hormones and mediators - angiotensin,
aldosterone, and vasopressin
result in oliguria, which, if left untreated, will cause acute tubular
necrosis and renal failure.
• Myoglobin released from muscles injures the kidneys.

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Effect on the immune system
• Cell-mediated immunity is significantly reduced in large burns -
bacterial and fungal infections.
• potential sources of infection:
• primarily from the burn wound and from the lung if this is injured,
• from any central venous lines, tracheostomies or urinary catheters present.

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Changes to the intestine
• Microvascular damage and ischemia to the gut mucosa.
• reduces gut motility and the absorption of food.
• Increases the translocation of gut bacteria - infection in large burns.
• Gut mucosal swelling, gastric stasis and peritoneal edema can cause
abdominal compartment syndrome,
• which splints the diaphragm and increases the airway pressures
needed for respiration

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Danger to peripheral circulation
• In full-thickness burns, the collagen fibres are coagulated.
• The normal elasticity of the skin is lost.
• acts as a tourniquet as the limb swells and will progress to limb-
threatening ischemia

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Injury to the airway and lungs
- Inhaled hot gases can cause supraglottic airway burns and laryngeal
oedema
- Inhaled steam can cause subglottic burns and loss of respiratory
epithelium
- Inhaled smoke particles can cause chemical pneumonitis and
respiratory failure
- Inhaled poisons, such as carbon monoxide, can cause metabolic
poisoning
- Full-thickness burns to the chest can cause mechanical blockage to rib
movement
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Hypermetabolism
• typically 3 to 4 days after injury, the condition of hypermetabolism
develops,
• Characterized by tachycardia, increased cardiac output, elevated
energy expenditure, increased oxygen consumption, and massive
proteolysis and lipolysis
• due in part to the release of catabolic hormones, such as
catecholamines, glucocorticoids, and insulin/glucagon

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• The ebb phase is characterized by low metabolic rate, hypothermia,
and low cardiac output,
• often temporally related to the onset of injury.
• Flow phase - high cardiac output and oxygen consumption
• duration of the catabolic flow phase is dependent on the type of
injury and the efficacy of therapeutic interventions
• anabolic flow phase - slow reaccumulation of protein and fat that
extends for even years after the injury

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complications of burn
• Systemic inflammatory response syndrome (SIRS) and sepsis
• Toxic shock syndrome (TSS)
• Toxin-mediated acute life-threatening illness.
• Usually caused by S. aureus or Group A Streptococcus (GAS).
• Features: pyrexia, rash, hypotension, MODS, desquamation of
palms and soles.
• Cardiovascular and respiratory complications

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Prognosis
• It depens on the following conditions:
• age, burn size, and inhalation injury
• coexistent trauma, pneumonia
• comorbidities such as pre-injury (HIV), metastatic cancer, and kidney or liver
disease

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Evaluation and managementof Burn

1. Pre-Hospital Care
2. Hospital Care
3. Management and prevention

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Pre-Hospital care
The principles of pre-hospital care
are:
• Ensure rescuer safety.
• Stop the burning process - Stop,
drop and roll
• Check for other injuries.
• Cool the burn wound.
• Give oxygen
• Elevate
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Hospital care
• The principles of managing an acute burn injury are
the same as in any acute trauma case, should be
approached in an ATLS-protocol.
Primary survey
• A->Airway control.
• B->Breathing and ventilation.
• C->Circulation.
• D->Disability – neurological status.
• E->Exposure with environmental control.

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Airway maintenance with cervical spine
protection
• The burned airway creates problems for the patient by swelling and, if
not managed proactively, can completely occlude the upper airway.
• Secure the airway with an endotracheal tube until the swelling has
subsided.
• The symptoms of laryngeal edema, such as change in voice, stridor,
anxiety and respiratory difficulty, are very late symptoms.
• Because of this, early intubation of suspected airway burn is the
treatment of choice in such patients.

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Cont.
• The time-frame from burn to airway occlusion is usually between 4
and 24 hours.
• The history is of inhalation of hot gases such as in a house or car fire.
• Clues on examination include blisters on the hard palate, burned
nasal mucosa and loss of all the hair in the nose, but perhaps the
most valuable signs are the presence of deep burns around the
mouth and in the neck.

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Breathing
• Any one trapped in a fire for more than a couple of minutes must be
observed for signs of smoke inhalation.
• Expose the chest to assess ventilation.
• The clinical features are a progressive increase in respiratory effort
and rate, rising pulse, anxiety and confusion and decreasing oxygen
saturation.
• Treatment starts as soon as this injury is suspected and the airway is
secure.

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 Circulation
• Control hemorrhage
• Monitor pulse and blood pressure
• Insert two large-bore cannulas.
• Profound hypovolemia is not caused by acute burns – other causes of
shock should be sought.

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 Disability
• Begin the assessment by determining the patient’s level of
consciousness using the AVPU method.
• A – Alert
• V – Responds to verbal stimuli
• P – Respond only to painful stimuli
• U – Unresponsive
• GCS is used to assess the depth and duration of coma and should be
used to follow the patient’s level of consciousness

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 Exposure
• Completely undress the patient, examine for major associated injuries
and maintain a warm environment.
• Exposure represent hypothermia, burns, and possible exposure to
chemical and radioactive substances and should be evaluated and
treated as the fifth priority in the primary survey.
• At the end of the primary survey, before continuing with the
secondary survey, the ABCDEs should be re-evaluated and confirmed.

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 Secondary survey

History
• The circumstances surrounding the injury can be very important to
the initial and ongoing care of the patient.
• Helps predict likelihood of inhalation injury, depth of burn, probability
of other injuries.

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For Flame injuries
• Did the fire occur inside or outside?
• Was the patient found inside a smoke-filled room?
• How did the patient escape?
• If the patient jumped out of a window, from what floor did he/she
jump?
• Were others killed at the scene?
• Did the clothes catch on fire?
• How long did it take to extinguish the flames?
• How were the flames extinguished?

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For Scalds
• What was the temperature of the liquid?
• What was the liquid?
• How much liquid was involved?
• Was the patient wearing clothes?
• How quickly were the patient’s clothes removed?
• How quickly was care sought

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For electrical injuries
• What kind of electricity was involved – high voltage/low voltage,
AC/DC?
• What was the duration of contact?
• Was the patient thrown or did he or she fall?
• Was there loss of consciousness?
• Associated flash
• Associated clothing fire

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For chemical injuries
• What chemical
• Length of time exposed to the chemical
• Specific antidotes used.
• Is there any evidence of ocular involvement?
• Is there any evidence of illegal activity?

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Medical History
 Allergies. Drug and/or environmental
Medications. Prescription, over-the-counter, herbal, illicit, alcohol.
Previous illness (diabetes, hypertension, cardic or renal disease,
seizure disorder, mental illness) or injury, past medical history,
pregnancy
Last meal or drink
Events/environment related to the injury
Tetanus and childhood immunizations

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Pre-burn Weight
• Adjusted fluid rates are based on the patient’s pre-burn weight.
• If the patient has received a large volume of fluid prior to calculating the
hourly fluids, obtain an estimated of the patient’s pre-injury weight from the
patient or family member if possible.

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“Head to Toe” Examination
Head/maxillo-facial
Cervical spine and neck
Chest
Abdomen
Perineum, genitalia
Back and buttocks
Musculoskeletal
Vascular
Neurological

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 Investigations
• CBC, BG,Rh, x match
• Serum chemistries/electrolytes (e.g., Na+, K+, CI-)
• serum albumin
• RFT (scr, BUN)
• Glucose levels
• Urinalysis for pregnancy, toxicology, and in diabetics
• Chest X-Rays,
• Arterial blood gases with Carboxyhemoglobin level
(Carbon Monoxide) if inhalation injury is suspected
• ECG – With all electrical burns or pre-existing
cardiac problems
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Management
Initial Assessment and Stabilization
Surgical intervention(escharotomy)
Nutritional Support
Prevention of sepsis
Wound Care and Dressing Techniques
Infection Control and Prevention
Pain Management and Psychological Support

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Management of burn
Initial Assessment and Stabilization is through pre-hospital care and
hospital care (primary and secondary survey.) and fluid resuscitation.

Fluid resuscitation
• Greatest fluid losses occur in the first 24 hours post-burn.
• Increased vascular permeability allows leak of fluid and proteins from
the intravascular to the interstitial compartment.
• Burn shock results from this fluid shift, coupled with myocardial
depression.

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• Fluid resuscitation is required for:
• Adults with burns >15% TBSA.
• Children with burns >10% TBSA.
• Fluid resuscitation is administered by one of the following regimes.
Parkland formula
• Hartmann’s solution (ringer’s lactate) contains:
• Na+ 131 mmol/l
• Cl− 111 mmol/l
• Lactate 29 mmol/l
• K+ 5 mmol/l
• Ca2+ 2 mmol/l.

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 Crystalloid sparing strategies
• Crystalloid solutions, contain water-soluble electrolytes including
sodium and chloride, lack proteins and insoluble molecules.
• Infusion of large volumes of crystalloid is associated with oedema,
increased total body sodium and abdominal compartment
syndrome.
• Albumin has been used in adults.
• Fresh frozen plasma (FFP) is often used in children.

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 Muir and Barclay
• Calculates the volume of human albumin solution to be given in
the first 36 hours following a burn.
• Each infusion volume is given as follows:
first 12 hours - 3 infusions at 4 hour intervals
second 12 hours - 2 infusions at 6 hour intervals
third 12 hours - 1 infusion

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Cont.
• Follow up is needed and the rate of infusion is modified to meet specific end
points of resuscitation as the formula is not always reliable:
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.
Pulse,
blood pressure,
capillary refill
Core–peripheral temperature gradient
Respiratory rate
Urine osmolality.

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comparison

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Complications of fluid resuscitation
Over-resuscitation
Under-resuscitation
• Generalized
• Hypovolemia edema
• Shock • Pulmonary
• Renal failure edema
• Ischemia- • Cerebral edema
reperfusion injury • Intestinal edema
• MODS. • Compartment
syndrome of
limbs and
abdomen.

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 Elevate the patient’s head and affected
extremities
• Unless contraindicated by spine immobilization, elevate the patient’s
head to 45 degrees.
• This will help minimize facial and airway edema and prevent
aspiration.
• Similarly, elevating the affected extremities reduces edema.

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 Monitoring Extremity Perfusion
• In constricting, circumferential extremity burns, edema developing in
the tissue under the burn eschar may gradually impair venous return.
• If this progresses to the point where capillary and arterial flows are
markedly reduced, ischemia and necrosis may result.
• Elevate the affected extremity to minimize swelling.
• An escharotomy is sometimes indicated to restore adequate
circulation.

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Sites of escharotomy incision with particular
attention over areas

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 Nutritional support
• Maintenance of body weight and lean body mass (muscle protein).
• Electrolyte and vitamin homeostasis.
• Nutritional requirements correlate with resting energy expenditure
(REE).

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Calorie requirements
• Calculating calorie requirements
• Curreri formula is popular in adult burns:
• (25 kcal x Wt(kg)) + (40 kcal x % TBSA) burn per day
• Galveston formula is used for children:
• 1500 kcal x BSA(msq) for maintenance + 1500 kcal x BSA(msq.) burn.
• Du Bois formula for BSA

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Body Surface Area

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Route of feeding
• Healthy patients with burns <20% TBSA satisfy nutritional requirements by oral feeding and
supplementary drinks.
• Larger burns, confused or malnourished patients are best treated with enteral feeding.
• Major burns >40% TBSA have higher risk of gastric stasis and require repeated periods of
fasting for theatre. For these patients, nasojejunal feeding tubes allow continuous feeding.

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Why avoid Parenteral nutrition?
Parenteral nutrition is avoided in burns because of its negative effects:
 Decreased liver function with fatty infiltration
 Reduced immune function
 Line sepsis
 Increased mortality

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 Prevention of sepsis

• Up to 75% of deaths in burn patients are attributable to sepsis.

• Burn wounds are rapidly colonized with bacteria from:
 environment,
 adjacent uninjured skin,
 bacteria located deep in uninjured hair follicles or sweat glands,
 hematogenous spread from the gut.

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 • Gram-positive bacteria, e.g. Staphylococcus aureus, usually colonize the wound first.
• Gram-negative bacteria take 5 days to reach significant levels.
• Strategies that help prevent sepsis:
 Infection control procedures with barrier nursing and hand washing.
 Regular bathing or showering – decreases surface bacterial counts.
 Prevention of catheter-related infection by regular changes of intravascular lines.
 Topical antimicrobial agents:

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 Wound care
• Burn wound surfaces are prone to rapid bacterial colonization with the potential for invasive
infection.
• Measures to reduce the likelihood of infection include
 good infection control practices,
 topical antimicrobial therapy, and
 burn wound debridement/excision,
 Wounds that become infected require systemic antimicrobial therapy, in addition to the
chosen regimen for local wound care.

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Debridement

• Debridement is the medical removal of dead, damaged, or infected tissue to improve the
healing potential of the remaining healthy tissue.
• Removal may be
• mechanical(irrigation) debridement
• surgical debridement
• enzymatic debridement
• autolytic debridement (self-digestion)
• biological debridement(maggot therapy) ..........certain species
• decreases the risk of infections.
• determine the depth of burn wounds with better accuracy
• Initial debridement can usually be accomplished with sterile saline soaked gauze.
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Dressing and Topical antimicrobial agents
The topical agent is applied to the wound, then covered with a
nonadherent dressing.
• Dressings must be changed frequently (e.g. twice daily).
• Commonly used topical agents include, silver sulfadiazine, bismuth-
impregnated petroleum gauze, mafenide, and chlorhexidine. Other
agents such as honey can be used.

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 Pain Management and Psychological
Support
Analgesia
Acute:
• Small burns, especially superficial burns
• Respond well to simple oral analgesia, paracetamol and non-steroidal anti-
inflammatory drugs
Subacute:
• In patients with large burns
• Continuous analgesia is required, beginning with infusions and continuing with oral
tablets
Psychological Support
• Rehabilitation and psychological counseling and therapy are vital.
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Indications for admission to burn center
• Burns involving the face, hands, feet, genitalia, perineum, or major joints
• Partial-thickness burns greater than 10% TBSA
• Third-degree burns in any age group
• Electrical burns, including lightning injury
• Chemical burns
• Suspected Inhalation injury
• Burn injury in patients with complicated pre-existing medical disorders
• Burned children in hospitals without qualified personnel for the care of children
• Burn injury in patients who will require special social, emotional, or
rehabilitative intervention
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Prevention of burn injury
Significant proportion of burns can be prevented by:

• Implementing good health & safety regulations

• Educating the public
• Safer household appliances

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References
• World Health Organization: WHO. (2023, October 13). Burns.
https://www.who.int/news-room/fact-sheets/detail/burns
• For images: Research gates, cleavland clinics

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 Thank you
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