Burn

Short Summery of Burn for MBBS Students

1. Dr. Md. Majedul Islam FCPS(Surgery) Burn

2. Burn Def: Thermal injury characterized by coagulation necrosis of the affected tissue.   Burn is caused by contact with Dry Heat(Fire) Moist Heat(Steam, hot liquid) Chemical(Acid or alkali) Electricity Radiation energy Electromagnetic energy

3. Classification Burns  can be  classified  by depth, mechanism of injury, extent, and associated injuries. The most commonly used  classification  is based on the depth of injury and extent

4. According to the depth( Bailey&Loves ) Superficial partial-thickness burns: goes no deeper than the papillary dermis . The clinical features are blistering and/or loss of the epidermis . The underlying dermis is pink and moist. The capillary return is clearly visible when blanched . Pinprick sensation is normal. This burns heal without residual scarring in 2 weeks. The treatment is non-surgical

5. Deep partial-thickness burn Involve damage to the deeper parts of the reticular dermis . Clinically , the epidermis is usually lost. The colour does not blanch with pressure under the examiner’s finger. Sensation is reduced, and the patient is unable to distinguish sharp from blunt pressure when examined with a needle . Deep dermal burns take 3 or more weeks to heal without surgery and usually lead to hypertrophic scarring.

6. Full-thickness burns The whole of the dermis is destroyed in these burns Clinically , they have a hard, leathery feel. There is no capillary return. Often, thrombosed vessels can be seen under the skin. These burns are completely anaesthetised : a needle can be stuck deep into the dermis without any pain or bleeding.

7. Traditionally 1. First Degree burn: only epidermis 2. Second Degree burn: Epidermis & part of dermis. 3. Third Degree Burn: Full thickness burn.

8. Features of burn 1 st Degree: erythema with minimal skin edema and minimal tissue damage, no systemic effect. Pain is the main symptom. healing without sacr . Usually caused by sunburn, scalding(moist heat). 2 nd Degree: Blister formation.Heal with minimal scarring. Remember: 2 nd degree burn converted into 3 rd degree burn when it is infected.

9. Feature of 3 rd Degree burn: White waxy appearance No blister Lack of sensation Heals by fibrosis with eventual contracture and deformities

10. Burn wound asessment Assessing the area of a burn The patient’s whole hand is 1 per cent TBSA, and is a useful guide in small burns The Lund and Browder chart The rule of nines

11. Complication of Burn Immediate Hypovolemia & shock with electrolyte imbalance. Renal failure laryngeal oedema , chemical alveolitis and respiratory failure in inhalation burn injury and also metabolic poisoning by Inhaled poisons, such as carbon monoxide Hypothermia Curling’s ulcer(Acute GIT ulcer) limb-threatening ischaemia (in circumferential limb burn)

12. Complication Contd Delayed: Wound infection Respiratory complication like pneumonia Renal failure Septicemia Late: Hypertrophic scar or keloid Post burn contracture or deformity Marjolin’s ulcer of the burn scar

13. Pathology of Shock in Burn Burns produce an inflammatory reaction This leads to vastly increased vascular permeability Water, solutes and proteins move from the intra- to the extravascular space The volume of fluid lost is directly proportional to the area of the burn Above 15 per cent of surface area, the loss of fluid produces shock

14. Dangers in a Burn Patient 1. Hypovolemia & shock(Mainly due to loss of plasma and fluid) 2. Multiple organ failure(Kidneys, liver and lungs) Sepsis Hypothermia

15. Management of burn patient Pre-hospital care The principles of pre-hospital care are: Ensure rescuer safety. Stop the burning process. Stop, drop and roll is a good method of extinguishing fire burning on a person . Check for other injuries. A standard ABC (airway, breathing, circulation ) check followed by a rapid secondary survey will ensure that no other significant injuries are missed. Cool the burn wound. This provides analgesia and slows the delayed microvascular damage that can occur after a burn Injury Elevate . Sitting a patient up with a burned airway may prove life-saving in the event of a delay in transfer to hospital care . Elevation of burned limbs will reduce swelling and discomfort .

16. Hospital Care Initial assessment: Take History of patient and burn(Type, site of burn, nature, any associated injury) Vitals(BP, Pulse, Resp rate, Temp) Extent(Rule of 9) & Depth of burn

17. Immediate Management Secure airway (specially for inhalational burn) Start I.V fluid, send blood for grouping and cross matching Immunization against Tetanus Relief of pain by analgesics(morphine or pathidine ) Blood Transfusion if available Antibiotic Anti ulcerant Local wound care

18. Fluid Resuscitation in Burn 1 st Twenty four(24) hous : Crystalloid solution(most commonly Ringers lactate. If not available the normal saline) Modified Parkland/Brooke formula: (2-4ml X Wt in Kg X %of burn in TBSA =1 st 24 hr ) Here Half fluid(50%) given in first 8 hours, then remaining half or 50% fluid in next 16 hours.

19. Second 24 Hours Colloid solution is added with crystalloid solution Brooke army formula for colloid solution: 0.5ml X Wt in kg X % of TBSA(Total body surface area) burned Colloid solution are : Plasma 4.5% Albumin Whole blood Dextran

20. Subsequent fluid therapy is adjusted by observing: State of hydration of the patient Urine output Measurement of serum electrolytes, blood urea and creatinine

21. For children In children, maintenance fluid must also be given with resuscitation. This is normally dextrose–saline given as follows: 100 mL /kg for 24 hours for the first 10 kg; 50 mL /kg for the next 10 kg; 20 mL /kg for 24 hours for each kilogram over 20 kg body weight .

22. Remember When IV fluid is given : In children with burns over 10 per cent TBSA and adults with burns over 15 per cent TBSA , consider the need for intravenous fluid resuscitation

23. Monitoring of a Burn Pt Vitals Urine Output(0.5ml/kg/hour) Central venous pressure(CVP) ABG(arterial blood gas analysis) Blood(electrolyte, creatinine , sugar,urea ,)

24. Local Wound Care Clean water or normal saline to wash the wound For superficial burn: Silver sulphadiazine cream then occlusive dressing to minimize exposure to air and to hasten re- epithelisation and to decrease pain For deep burn: debridement and skin grafting and splintage

25. Measure to prevent complication Dressing every alternate day for 3 week Escarotomy for deep or full thickness burn High protein diet Physiotherapy to prevent deformity or contracture Psychological support

26. Escharotomy Circumferential full-thickness burns to the limbs require emergency surgery. The tourniquet effect of this injury is easily treated by incising the whole length of full-thickness burns . This should be done in the mid-axial line, avoiding major nerves . One should remember that an escharotomy can cause a large amount of blood loss; therefore, adequate blood should be available for transfusion if required.

27. Escarotomy