Burn

for medical students

1. Presentation on : Burns: Assessment & Management Swornim Gyawali Intern GMC 2010 batch

2. Outline Objective Introduction Type of Burn injury Classification of Burns Pathophysiology of Burns Assessment of the Burn wound Management of Burns Primary Secondary Complications of Burn Injuries

3. Objectives At end of this presentation we be able to know 1. definition and causes of Burn injuries 2. Types and classification of burns 3. pathophysiology of burns 4. Management of a patient who sustained burn injury 5.Complications of burns

4. Introduction Definition A burn is a coagulative destruction of the surface layers of the body. It occur when some or all of the cells in the skin or other tissues are destroyed by heat cold electricity Radiation Lightening caustic chemicals

5. Types of Burn Injury Thermal Flame : fire injury Scald : moist heat/stea m Flash : explosion Contact : to hot surfaces

6. Cold exposure (frostbite ) Usually occurs in distal parts of the body Common sites: Fingers, Toes, Nose and Ears Severe Vasoconstriction & Decreased Blood flow  Ischemia Chemical burns Cause progressive damage Acid produces tissue coagulative Necrosis . Alkaline burns generate colliquation Necrosis . Systemic absorption of some chemicals is life threatening

7. Electrical mechanisms of injury : Electrical current injury Electrothermal burns from arcing current Flame burn caused by ignition of clothes Deep destruction of muscles  rhabdomyolysis  myoglobinuria  ATN  ARF Inhalation Hot smoke Radiation sunburn

8. Pathophysiology of Burn Local Changes Burn causes coagulative necrosis of the epidermis and underlying tissues depth of injury: temperature & duration of exposure area of cutaneous injury

9. Systemic changes

10. Assessment of The Burn Wound Burn Depth Cutaneous burns are classified according to the depth of tissue injury: superficial or epidermal (first-degree), partial-thickness (second degree), or full thickness (third degree). Burns extending beneath the subcutaneous tissues and involving fascia, muscle and/or bone are considered fourth degree

11. First degree (Superficial) Red, erythematous Very sensitive to touch Very painful Usually moist No blisters Second degree (partial-thickness) Erythematous or whitish with a fibrinous exudate Wound base is sensitive to touch and Painful Commonly have blisters Surface may blanch to pressure Third degree (Full thickness) Surface may be: White, Black, leathery, Pale or Bright red Generally anesthetic or hypoesthetic Subdermal vessels do not blanch No blisters Hair easily pulled from its follicle Fourth degree Involves deep tissues including fascia, muscle, bone, and tendons

12. Assessment of The Burn Wound (cont’d) T otal percentage of body surface area (TBSA) Lund-Browder chart

13. Rule of Nines

14. Management; Primary Survey Initial Intervention Airway maintenance with cervical spine control Breathing and Ventilation Circulation with Haemorrhage Control Disability: Neurological Status Exposure with Environmental Control

15. Diagnostic tests and monitoring Arterial blood gas Chest x-ray Serial peak expiratory flow rates (PEFR) Pulse oximetry Capnography fiberoptic laryngoscopy and bronchoscopy

16. Treatment Supplemental oxygen and airway protection Close monitoring of fluid resuscitation Mechanical ventilation Inhaled nitric oxide aerosolized heparin and N- acetylcysteine (NAC)

17. Fluid resuscitation American Burn Association's practice guidelines, patient with greater than 15 percent total body surface area (TBSA) non-superficial burns should receive formal fluid resuscitation. Fluid selection Formulae 1. Parkland : 4ml x wt (Kg) x % TBSA burn -Ringer’s lactate or Hartman solution 2. Evans :1ml x wt x %TBSA 3. Brooke :1.5ml x wt x %TBSA 4. Modified Brook:2ml x wt x % TBSA 

18. Management; secondary Survey (cont’d) History Thorough physical examination Lab studies and monitoring CBC Electrolytes RFT Glucose Venous blood gas Caboxyhemoglobin Arterial blood gas Chest x-ray ECG

19. Management; Secondary Survey (cont’d) Chemoprophylaxis Tetanus immunization Antibiotic Wound management Wound dressing and care Escharotomy Chest - at the anterior axillary line Extremity - can be done at a bedside without local anesthesia

20. Nutrition Hypermetabolism develops as a response to injury If TBSA >40%, lean body weight ↓ by 25% over the first 3 weeks Patient with major burn needs high calorie in the form of: CHO (50%), protein (20%) , fat (30%) and some vitamins & minerals

21. Nutritional Requirement Calculations Curreri formula Age 16–59 years: (25)W + (40)TBSA Age 60+ years: (20)W + (65)TBSA Sutherland formula Children: 60 kcal /kg + 35 kcal%TBSA Adults: 20 kcal /kg + 70 kcal%TBSA Protein needs Greatest nitrogen losses between days 5 and 10 20% of kilocalories should be provided by proteins

22. Burn Complications 1. INFECTION 2. Curling ulcer- stress ulcers 3. Contracture 4. Marjolin’s ulcer, Hypertrophic scar, keloid Pschological aspect PTSD Flash backs Avoidance behavior Sleep disturbance

23. Minimizing complications Hand washing before & after touching each patient. Aseptic techniques for dressing & procedures Early nutritional support Early excision of deep burns Use of topical antimicrobials Early excision and grafting

24. Thank you !!! Queries ????

25. Refrences SCHWARTZ :Principles of surgery ,9th edi.2008 BAILEY & LOVE : Short practice of surgery ,25th edi,2008 3. American Burn Association's practice guidelines , 2012 4. Internet (pictures) 5. Medscape.com