06.A BURN INJURY-DR PHILLIP BMC 1.ppt

BURN

1. BURNINJURY
Dr Phillipo Leo Chalya
M.D. [Dar]; M.MED surg [Mak]
Surgeon Specialist -BMC

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DEFINITION
Burn injury can be defined as bodily
injury resulting from exposure to heat,
cold, chemical, electricity or radiation
Burn causes coagulation necrosis of the
skin and underlying tissues

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EPIDEMIOLOGY
Incidence
Burn injury constitutes a major health
problem allover the world affecting
approximately 1% of the world
population each year
In the United States, approximately 2.4
million burn injuries are reported every
year
In TZ burn injury is one of the
commonest form of trauma

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Morbidity / mortality
Burn injury contributes significantly to
high morbidity and mortality
Patients with extensive burns frequently
die, and for those with less severe
injuries, physical recovery is slow and
painful
In addition to physical damage caused
by burns, patients also may suffer
emotional and psychological problem

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Age
Age incidence depends on the type of
burn
Scald is common in children < 5 year of
age while flame, electrical and chemical
burn injuries are common in adult

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Sex
Sex distribution depends on the place of
burn
Domestic burn injury is common in
females while occupational and
recreational burns are common in males

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Race
No racial predilection exists in burn
injuries

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ETIOLOGY
Thermal injuries
–Scald
–Flame
–Contact
Chemical injuries
Electrical injuries
Radiation injuries
Cold injuries

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Mechanism of injury
Depends on the causes
–Thermal injuries
•Scald
•Flame
•Contact
–Chemical injuries
–Electrical injuries
–Radiation injuries
–Cold injuries

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Thermal injuries
Scalds
–About 70% of burns in children are caused
by scalds
–They also often occur in elderly people
–The common mechanisms are spilling hot
drinks or liquids or being exposed to hot
bathing water
–Scalds tend to cause superficial to
superficial dermal burns

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Flame
–Flame burns comprise 50% of adult burns
–They are often associated with inhalational injury
and other associated injuries
–Flame burns tend to be deep dermal or full
thickness
Contact
–In order to get a burn from direct contact, the object
touched must either have been extremely hot or the
contact was abnormally long
–The latter is a more common reason, and these
types of burns are commonly seen in people with
epilepsy or those who misuse alcohol or drugs
–They are also seen in elderly people after a loss of
consciousness
–Contact burns tend to be deep dermal or full
thickness

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Electrical injuries
Account for 3-4% of burn admissions
An electric current will travel through the
body from one point to another, creating
"entry" and "exit" points
The tissue between these two points can be
damaged by the current
The amount of heat generated, and hence the
level of tissue damage, is equal to
0.24x(voltage)
2
xresistance
The voltage is therefore the main determinant
of the degree of tissue damage

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Electrocution injuries can be divided into two
categories:-
–Low voltage injuries
•Considered to be anything <1000 volts
•This includes domestic electrical supply
–High voltage injuries
•Can be further divided into:-
–True high tension injuries
•Caused by high voltage current passing through the body
•> 1000V
•There is extensive tissue damage and often limb loss
•There is usually a large amount of soft and bony tissue
necrosis
•Muscle damage gives rise to rhabdomyolysis, and renal
failure may occur with these injuries
–Lighting injuries
•Caused by exposure to an extremely high voltage
current
•Result from an ultra high tension
A particular concern after an electrical injury is
the need for cardiac monitoring

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Chemical injuries
Chemical injuries are usually as a result
of industrial accidents but may occur
with household chemical products
Chemical burn may also occur as a
result of assault
These burns tend to be deep, as the
corrosive agent continues to cause
coagulative necrosis until completely
removed
Alkalis tend to penetrate deeper and
cause worse burns than acids

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Radiation injuries
These burns are frequently caused by
ultraviolet rays from the sun and nuclear
sources

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Cold injuries
Results from exposure to extremely cold
→tissue necrosis

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CLASSIFICATION
According to the type [causes] of burn
–Thermal burn
•Scald
•Flame burn
•Contact burn
–Electrical burn
–Chemical burn
–Radiation burn
–Cold burn

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According to body site burned
–Facial burn
–Head & neck
–Trunk
–Limbs
–Perineal burn etc
According to burn depth
–Superficial burn
•Epidemal
•Dermal
–Deep burn
•Dermal
•Full thickness
–Mixed burn

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According to the degree of tissue injury
–First degree burn
–Second degree burn
–Third degree burn
–Fourth degree burn
According to the Size/Extent of Burn
Injury
–Total body surface area (TBSA) burned
According to the severity of burn
–Minor burn
–Moderate burn
–Major burn

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PATHOPHYSIOLOGY
Burn injuries result in:-
–local response
–systemic response

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A. Local responses
Divided into three zones of a burn
which were described by Jackson in 1947
→Jackson’s zones of burn wound
These zones include:-
–Zone of coagulation
–Zone of stasis/ischaemia
–Zone of hyperamia

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Jackson's burns zones

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a. Zone of coagulation
This occurs at the point of maximum
damage
In this zone there is irreversible tissue
loss due to coagulation of the
constituent proteins

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b. Zone of stasis /ischemia
The zone of stasis is characterized by decreased
tissue perfusion
The tissue in this zone is potentially salvageable
The main aim of burns resuscitation is to
increase tissue perfusion here and prevent any
damage becoming irreversible
Additional insults—such as prolonged
hypotension, infection, or edema—can convert
this zone into an area of complete tissue loss

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c. Zone of hyperaemia
In this outermost zone tissue perfusion
is increased
The tissue here will invariably recover
unless there is severe sepsis or
prolonged hypoperfusion

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B. Systemic response
The release of cytokines and other
inflammatory mediators at the site of
injury has a systemic effect once the
burn reaches 30% of total body surface
area

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a. Cardiovascular changes
Capillary permeability is increased,
leading to loss of intravascular proteins
and fluids into the interstitial
compartment
Peripheral and splanchnic
vasoconstriction occurs
Myocardial contractility is decreased,
possibly due to release of tumor necrosis
factor

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Cardiac output decreases due to loss of
intravascular volume
These changes, coupled with fluid loss
from the burn wound, result in systemic
hypotension and end organ
hypoperfusion

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b. Respiratory changes
Inflammatory mediators cause
bronchoconstriction, and in severe
burns adult respiratory distress
syndrome can occur
Pulmonary dysfunction may occur as
result of:-
–Inhalation injury
–Aspiration
–Shock
–Upper airway injury/edema
–Circumferential thoracic eschar → RLD
Hypovolemia may cause V/Q mismatch

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c. Gastrointestinal changes
Characterized by mucosal atrophy,
changes in the digestive absorption and
intestinal permiability
Burn also causes reduced glucose,
amino acids and fatty acids
Stress (curling’s) ulcer
Acute pseudo-obstruction of the colon
–massive colonic dilation without organic
cause
Acalculous cholecystitis

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d. Renal changes
Uncommon, but can result from:
–prolonged hypotension due to hypovolemia
–myoglobin release from damaged
muscle/tissue
–hemoglobinuria from heat-induced
BV & CO RBF GFR:-
–Release of Angiotensin II, aldosterone,
vasopresinfurther reduction of RBF &
GFRARF
–Oliguria ATN & ARF

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e. CNS Changes
CNS dysfunction in up to 14% of burn
patients
–most had >50% BSA involvement
Hypoxia most common etiology
–smoke inhalation, pulmonary edema,
pneumonia

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f. Haematological changes
Mild thrombocytopenia (sequestration)
early, followed by thrombocytosis (2-4x
normal) by end of the first week
Persistant thrombocytopenia associated
with poor prognosis--suspect sepsis
DIC with generalized bleeding can
occur
–shock, sepsis, hypoxia, reperfusion

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g. Immunologic Changes
Loss of Skin as an organ of host
defense→:-
–Loss of keratin layers which act as physical
barrier tobacterial invasion→wound
sepsis
–Loss of stratum corneum containing of
unsaturated free fatty acid film which is
bacteriostatic and fungistatic
Cellular Immune Function
–Several circulating mediators in burn
patient sera suppress normal lymphocyte
function
–CD4 count

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Humoral Immune Function
–immunoglobulin levels decreased
proportional to burn size
–leakage of IgG & IgA from the circulation,
fibronectin depletion, impaired
opsonization
Phagocyte Function
–early granulocytopenia common
–diminished chemotactic responsiveness
•diffuse endothelial cell activation, and adhesion
molecule overexpression
–decreased oxygen radical production, with
impaired bactericidal activity
–PMN margination/aggregation

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h. Metabolic changes
Metabolic changes in burn injury occur
in 2 phases:-
–Ebb phase
–Flow phase
•Catabolic phase
•Anabolic [recovery phase]

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Ebb phase
Occurs during the 1
st
24 hours
Characterized by MR, hypothermia,
CO & oxygen consumption

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Flow phase
Subdivided into 3 phases:-
–Catabolic phase
–Anabolic phase

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a. Catabolic phase
Occurs after 24 hours after burn injury
Characterized by:-
–↑ Cardiac output
–↑ Oxygen consumption
–↑ Heat production [hyperthermia]
–↑ BMR
–Hyperglycemia
–Proteolysis
–Peripheral lipolysis
Mediated through release of catabolic
hormones [ i.e. catecholamines,
glucocorticoids,glucagon etc ] and other
chemical mediators e.g. cytokines, lipid
mediators etc

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b. Anabolic phase
Also called recovery phase
Characterized by:-
–Slow re-accumulation of protein and fat
–This phase continues for weeks to months
after injury

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Clinical presentation
History
Physical examination
–General
–Systemic
–Local

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History
Patient characteristics
–Age
–Sex
History of injury
–Time of burn
–Place of burn
–Nature of injury
•Intentional
•Unintentional
•Undetermined

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Type of burn
–Thermal
–Chemical
–Electrical
–Radiation
–Cold
Mechanism of injury
Associated injuries
Associated inhalation injuries
Associated clothing iginition
Whether first aid measures was done at
the site of accident

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Physical examination
General
–Body weight
–Shock
–Level of consciousness
–Dyspnoea
–In pain
–Restless ±gasping
–Anaemic
–Dehydration
–Etc

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Systemic examination
–Cardiovascular system
–Respiratory system
–PA
–CNS
Local examination [assessment of burn
wound]
–Body region burned
–Extent of burn
–Burn depth
–Severity of burn

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a. Body region burned
Head / neck
Upper limbs
Trunk
Lower limbs
Genitalia / Perineal areas

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b. Extent of burn [%TBSA]
Size of a Burn Injury
–Total Body Surface Area (TBSA) Burned
•Palmar Method
–A quick method to evaluate scattered or localized burns
–Client’s palm = 1 % TBSA
•Rule of Nines
–A quick method to evaluate the extent of burns
–Major body surface areas divided into multiples of nine
–Modified version for children and infants (Rule of
Sevens )
•Lund-Browder Method
–Most Accurate; based on age (growth)
–Can be used for the adult, children & infants

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c. Burn depth
Superficial (First Degree)
Partial Thickness
–Superficial ( Second Degree)
–Deep ( Second Degree)
Full Thickness ( Third Degree)
Deep-Full Thickness (4
th
degree)

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i. Superficial (First Degree)
Involves the epidermis
–Wound Appearance:
•Red to pink (light skin)
•Mild edema
•Dry and no blistering
•Pain / hypersensitivity to touch
–i.e. Classic sunburn
•Desquamation occurs 2-3 days
–Wound Healing
•Wound Healing spontaneous
•Duration 3 to 5 days
•No scarring / other complications

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Superficial-1
st
Degree Burns

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ii. Superficial -2
nd
Degree Burns
Involves upper 1/3 of dermis
–Wound Appearance:
•Red to pink
•Wet and weeping wounds
•Thin-walled, fluid-filled blisters
•Mild to moderate edema
•Extremely painful
–Wound Healing:
•In 2 weeks (spontaneous)
•Minimal scarring; minor pigment discoloration
may occur

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Superficial -2
nd
Degree Burns

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iii. Deep 2
nd
Degree Burns
Wound Appearance:
–Mottled: Red, pink, to white surface
–Moist
–No blisters
–Moderate edema
–Painful; usually less severe than superficial 2
nd
Degree
Wound Healing:
–May heal spontaneously 2-6 weeks
–If so Hypertrophic scarring / formation of
contractures
Wound Management:
–Treatment of choice: surgical excision & skin
grafting

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Deep 2
nd
Degree Burns
(10
th
day post-burn)
Deep 2nd Degree

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iv. Full-Thickness Burns (3
rd
degree)
Involves the entire epidermis and dermis
–Wound Appearance:
•Dry, leathery and rigid
•+ Eschar (hard and in-elastic)
•Red, white, yellow, brown or black
•Severe edema ( ? Escharotomy in limbs, chest)
•Painless & insensitive to palpation
–Wound Healing:
•No spontaneous healing;
weeks to months with graft
–Wound Management:
•Surgical excision & skin grafting

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v. Deep, Full-Thickness Burns
Extends beyond the skin to include
muscle, tendons & possibly bone.
–Wound Appearance:
•Black (dry, dull and charred)
•Eschar tissue: hard, in-elastic
•No edema
•Painless & insensitive to palpation
–Wound Healing:
•No spontaneous healing; weeks to months with
graft
–Wound Management:
•Surgical excision & skin grafting
•Frequently requires amputation if extremity
involved

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iv. Full-Thickness Burns
3rd Degree
5th to 6th Degree

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d. Severity of burn
Severity is determined by:-
–Type of burn
–Depth of burn injury
–Total body surface (TBSA) burned
–Location of burn( face, hands, feet and perineum are
considered severe !! )
–Patient’s Age
–Presences of other preexisting medical
conditions
–Presence of associated injuries
–Complications ( Inhalation , Hypothermia , Shock )

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Severity classified as follows:-
–Minor
–Moderate
–Major

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i. Minor burn injury
Characterized by:-
–<10% in adult
–< 5% <10 yo >50 yo
–< 2% full thickness
–No associated injuries, no complications,
no pre-morbid illness, no circumferential
burns, not involving the hands, face,
perineum
Minor burn needs outpatient
management

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ii. Moderate burns
Moderate –admit
–10 -20 % in adult
–5 -10 % <10 yo >50 yo
–High voltage, suspected inhalation,
circumferential or susceptibility to
infection

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iii. Major burns
Second and third-degree burns greater than
10% body surface area (BSA) in patients
under 10 or over 50 years of age
Second and third-degree burns greater than
20% BSA in patients between 10 and 50 years
of age
Second and third-degree burns with serious
threat to functional and cosmetic impairment
that involve the face, hands, feet, genitalia,
perineum, and other major joints
Third-degree burns greater than 5% BSA
Specialized injuries such as electrical burns,
including lightning and chemical burns, with
serious threat of functional or cosmetic
impairment

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Significant inhalation injuries
Circumferential burns of the extremities
or the chest
Pre-existing medical disorders that
complicate management, prolong
recovery, or affect mortality
Concomitant trauma in which the burn
injury poses the greatest risk of
mortality

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WORK UP
Lab studies
–Serum creatinine
–Serum electrolytes
–WBC + ESR
Imaging studies
–CXR
Endoscopic studies
–Bronchoscopy

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management
Objectives of management
Burn team
Criteria for admission
Phases of management

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Objectives of management
To prevent fluid and electrolyte
imbalance
Rapid and painless healing
To prevent complications
Rehabilitation

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Burn team
Consistsof multidisciplinary group whose
individual skills are complementary to each
other
Includes:-
–Surgeons –reconstructive (plastic), General or
trauma surgeon, Paediatric surgeon
–Nurses
–Anesthetist
–ICU team
–Physiotherapist
–Occupational therapist
–Social workers
–Psychologists
–Psychiatrist
–Dietitians

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Criteria for admission
Type of burn
–Electrical
–Chemical
–Lightening
%TSBA
–>15% in adult
–>10% in children
Body site affected: face, hands, perineum,
genitalia
Complications-inhalation burn
Pre-existing illness –renal diseases, Diabetes
mellitus, respiratory diseases
Circumferential burns of the limbs or chest

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Phases of management
As in all trauma patients the mgt of
burn injury is divided into 5 phases
according to ATLS (Advanced Trauma
Life Support)
Phase I: Primary survey phase
Phase II: Resuscitation phase
Phase III :Secondary survey phase
Phase IV: Supportive care phase
Phase V: Definitive treatment phase

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Phase I: Primary survey phase
Aim: to identify life threatening
conditions
The life threatening conditions include:
–A=Airway
–B=Breathing
–C=Circulation
–D=Disability-neurological status
–E=Exposure
This should go hand in hand with the
phase II

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Phase II: Resuscitation phase
Aim: to treat the immediately life
threatening condition
Airway –secure airway & Immobilize the
cervical spine
Breathing –optimize ventilation
Circulation-establish i.v. access
Disability-assess neurological deficit
Expose the patient to avoid missed injury
Fluid therapy

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Airway
A clear patent and functional airway
should be established
This can be achieved by:-
–Use of airways
–Proper position of the patient
–Endotracheal intubation
–Ambubags
–Tracheostomy

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Breathing / Ventilation
Make sure the patient is breathing
properly
Achieved by:-
–Use of oxygen masks
–Mechanical ventilators

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Disability: Neurological Status
Establishlevel of consciousness
–A= Alert
–V= Response to Vocal stimuli
–P= Response to Painful stimuli
–U= Unresponsive
Examine the pupillary response to light
Be aware of hypoxemia and shock can
cause level of consciousness

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Exposure with Environmentcontrol
Remove all clothing and jewellery
Keep the patient warm

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Fluid resuscitation
Fluid replacement
Fluid maintenance

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Fluid replacement
Fluid replacement is important to replace fluid loss
ad treat shock
i.v. should be administered through a wide bore
canula
The volume of fluid to be given is calculated as
follows:-
= 2-4ml x %TBSA x kg of body weight
The type of fluid to be given in the 1
st
24 hrs is
Crystalloid
½ of the calculated fluid is given in the 1
st
8 hrs, and
the remaining half is distributed over remaining
sixteenth hrs
Calculation fluid commences at time of injury not at
admission

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Fluid maintenance
At the end of 24 hours, colloid infusion
is begun at a rate of 0.5 mlx(total burn
surface area (%))x(body weight (kg)),
and maintenance crystalloid (usually
dextrose-saline) is continued at a rate of
1.5 mlx(burn area)x(body weight)
The end point to aim for is a urine
output of 0.5-1.0 ml/kg/hour in adults
and 1.0-1.5 ml/kg/hour in children.

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Phase III :Secondary survey
phase
Not started until phase I &II are
complete
This include:-
History
Physical examination
Investigations as above

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Phase IV: Supportive care phase
Analgesics-iv narcotics
Systemic antibiotics against ß-
hemolytic streptococcus
Tetanus toxoid
Nasogastric tube for patients with >
25%TBSA
Monitor
–vital signs
–Input /output
Urethral catheterization
Nutrition support

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Phase V: Definitive treatment
phase (Wound care)
Depends on the characteristics and size
of the wound
–Conservative treatment
–Surgical treatment

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Conservative treatment
Indicated for superficial 1
st
and 2
nd
degree burn
Involves:-
–Wound dressing
–Topical antimicrobial agents

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a. Wound dressing
The dressing shouldserve thefollowing
fx:-
–Protect the damaged epithelium,
minimizing bacterial ad fungal
colonization (protective fx)
–Provide splinting action tomaintain the
desired position of function (splinting fx)
–Occlusive to reduce evaporative heat loss
and minimize cold tress
–Provide comfort over the painful wound
The choice of dressing is based on the
characteristics of the wound

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Sterile Dressing
Several layers dressings
Special Considerations:
–Joint area lightly wrapped to allow mobility
–Facial wounds maybe left open to air, kept
moist
–Circumferential burns: wrap distal to
proximal
–All fingers and toes should be wrapped
separately
–Splints applied over dressings
–Functional positions maintained; not always
comfortable

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b. Antimicrobial Agent
Apply an Antimicrobial Agent
–Silverex
•Broad spectrum , Ideal choice.
–Silvadene
•Broad spectrum; the most common agent used
–Sulfamylon
•Penetrates eschar for invasive wound infections
•Painful burns for approximately 20 minutes after applied
–Acticoat (antimicrobal occlusive dressing)
•A silver impregnated gauze that can be left in place for 5
days
•Moist with sterile water only; remoisten every 3-4 hours

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Surgical treatment
Escharotomy
Skin grafting

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a. Escharotomy
Indicated for patients with
circumferential burns of the limbs, neck
or chest causing distal circulatory and
respiratory impairment respectively
Only the burnt tissue is divided, not any
underlying fascia, differentiating this
procedure from a fasciotomy
Incisions are made along the midlateral
or medial aspects of the limbs, avoiding
any underlying structures

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Escharotomy in a leg with a circumferential deep dermal burn

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For the chest, longitudinal incisions are
made down each mid-axillary line to the
subcostal region
The lines are joined up by a chevron
incision running parallel to the
subcostal margin
This creates a mobile breastplate that
moves with ventilation
Escharotomies are best done with
electrocautery, as they tend to bleed

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Diagram of escharotomies for the chest

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Although they are an urgent procedure,
escharotomies are best done in an
operating theatre by experienced staff

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b. Skin grafting
Skin grafting is done for deep 2
nd
degree
and other full-thickness burns
Can be:-
–Permanent
–Temporary

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i. Permanent Skin Grafts
Two types:
–Autografts
–Cultured Epithelial Autografts (CEA)

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ii. Temporary Skin Grafts
Why temporary ??
–Clients with large amounts of TBSA burned do
not have enough donor sites.
–Available donor sites are used first, but in large
burns not enough to cover all burn wounds.
–While waiting for donor site to heal so it can be
reused a temporary covering is needed.
Types of temporary Skin Grafts
–Biosynthetic
–Artificial Skins
–Synthetic

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a. Autograft
Harvested from client
Non-antigenic
Less expensive
Decreased risk of infection
Can utilize meshing to cover large area
Negatives: lack of sites and painful

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b. Cultured Epithelial Autografts
(CEA)
A small piece of client’s skin is harvested and
grown in a culture medium
Takes 3 weeks to grow enough for the
first graft
Very fragile; immobile for 10 days post
grafting
Great for limited donor sites
Negatives: very expensive; poor long term
cosmetic results and skin remains fragile for
years

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1. Biosynthetic Temporary Skin
Grafts
Homograft
Heterograft

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a. Homograft
AKA Allograft
Live or cadaver human donors
Fairly expensive
Best infection control of all biologic
coverings
Negatives:
–Risk of disease transmission (i.e. HBV &
HIV)
–Antigenic: body rejects in 2 weeks
–Not always available
–Storage problems

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b. Heterograft
AKA Xenograft
Graft between 2 different species
–i.e. Porcine (pig) most common
Fresh, frozen or freeze-dried (longer
shelf life)
Amendable to meshing & antimicrobial
impregnation
Antigenic: body rejects 3-4 days
Fairly inexpensive
Negatives: Higher risk of infection

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2. Artificial Skins
Transcyte
–A collagen based dressing impregnated
with newborn fibroblasts
Integra
–A collagen based product that helps form a
“neodermis” on which to skin graft

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3. Synthetic
Any non-biologic dressing that will help
prevent fluid & heat loss
–Biobrane, Xeroform or Beta Glucan
collagen matrix

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Donor Site: Wound Considerations
The donor site is often the most painful
aspect for the post-operative client
–We have created a brand new wound !!
–Variety of products are used for donor
sites.
•Most are left place for 24 hours and then left
open to air
–Donor sites usually heal in 7-10 days

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Complications
Ca be classified as:-
–Early Complications
–Late Complications

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a.Early Complications
Fluid / Electrolyte imbalance
Hypovolaemic shock
Thermoregulation dysfunction
Acute renal failure
Inhalation injury
Burn wound sepsis/Systemic infection
Anemia
Stress ulcers /Curling ulcers
Acute gastric/colonic dilatation
Cardiopulmonary failure
Myocardial infarction

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b. Late Complications
Contractures
Keloids
Hypertrophic scars
Marjolin’s ulcer
Acalculous Cholecystitis

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Prognosis
The prognostic factors for burns are
classified as follows:-
–Patient characteristics
–Circumstancesof the injury
–Characteristics of burn wound
–Treatment parameters

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Patient characteristics
Age
Sex
Pre-existing illness
HIV status

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Circumstancesof the injury
Nature of the injury
Type of burn
Timing in seeking medical care
Associated injuries
Associated burning of clothes
Inhalation injury
First-aid measures taken at the site of
accident

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Clinical characteristics of burn
wound
Body regions burned
% total surface area burnt (%TSAB)
Burn depth
Severity of burn
Burn wound sepsis

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Treatment parameters
Resuscitative measures
Definitive treatment

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Prevention
1
st
–risk factors
2
nd
–early treatment
3
rd
–rehabilitation

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