BURNS FOR HOMOEOPATHIC STUDIENTS SURGERY

BURNS

1. BURNS

2.   Burn can be defined as  any injury that results from the direct contact or exposure to any thermal, chemical, electrical or radiation source . Or A burn is a wound in which there is coagulative necrosis of the tissue.

3. There are different degrees of burns. Your healthcare provider determines the seriousness (degree) of a burn based on the depth of the burn and the amount of affected skin. Burns can be painful. Left untreated, a burn can lead to infection.

4. THE VARIOUS TYPES OF BUMS 1. ORDINARY BURNS 2. SCALDS 3. ELECTRIC BURNS 4. CHEMICAL BURN 5. RADIATION BURNS 6. COLD BURNS

5. ORDINARY BURNS ORDINARY BURNS are usually caused by dry heat with fire, open flame, hot metal or aeroplane crash in civil life and bomb injuries in war time.

6. SCALDS SCALDS are caused by moist heat e.g. hot liquid or steam.

7. ELECTRIC BURNS Low-voltage electrical sources produce direct injury at the point of contact. Skin and subcutaneous tissue are involved most commonly, although muscle and bone beneath the cutaneous bum may be damaged.

8. High-voltage current not only causes direct injury at the point of contact but also damages tissues that conduct the electricity through the body. Tissue damage associated with electrical injury occurs when electrical energy is converted to thermal energy. The resulting injury is a thermal bum.

9. The skin gradually undergoes coagulation necrosis. At high voltages, skin resistance is initially overcome and the current flows through deep tissues in the body unimpeded. Except bone, these internal tissues act as a volume conductor offering little resistance to electrical flow.

10. Majority of electric bums are caused by high-voltage electric current. The peculiarity of electrical burns is that it causes minimal destruction of the skin. The skin is involved at 2 points — 1. At the point of contact with the electrical source and 2. At the site of exit at which the patient is grounded.

11. The magnitude of injury of the tissues between the point of entry and the point of exit of the electric current is directly related to the amount of electric current passing through.

12. The amount of damage also depends on the resistance of the tissues. The muscle , the nerve and blood vessels offer least resistance to the electric current and so sustain maximum amount of tissue damage.

13. But the skin offers considerable resistance and that is why cutaneous injury may be apparently small , although there may be considerable deep tissue destruction involving the upper and lower extremity musculatures.

14. However it should be remembered that electrical resistance of skin is markedly reduced by moisture , so ulcers are more often seen in the axilla and antecubital fossa in case of electrical bum of the upper extremity.

15. Electrical injury to the musculature is often associated with release of haemochromogens into the blood stream which are ultimately excreted through urine. So ' port-wine ' coloured urine is not unusual following major electrical injury.

16. CHEMICAL BURN CHEMICAL BURN is caused by strong acid or base which comes in contact with skin or any other tissue. The severity of the damage is directly related to the concentration of the chemical agent, the amount of agent and the duration of contact. Such bum injury tends to be deeper than it is assessed from outside. If the superficial slough is removed, the depth of the injury can be assessed.

17. RADIATION BURNS RADIATION BURNS are usually caused by X-rays or radium. This is in fact a type of inflammation of the skin which can be regarded as bum. This only occurs when the tissue has been irradiated beyond its tolerance limit.

18. Two types of radio dermatitis are usually seen: ACUTE RADIODERMATITIS 2. CHRONIC RADIODERMATITIS

19. ACUTE RADIODERMATITIS which presents the usual changes of acute inflammation with erythema , varying degrees of oedema and exfoliation. These usually develop on or about the 5th day. If the exposure dose is highly excessive, it may cause necrosis in both epidermis and dermis. In such cases a slough is formed, which on separation leaves a deep indolent ulcer.

20. CHRONIC RADIODERMATITIS May occur if small doses of irradiation are given for too long a time or if acute radio dermatitis has occurred a few years ago which may leave chronic radiodermatitis as legacy. In this condition the skin shows irregular pigmentation or depigmentation in certain areas, telangieactases and small indolent ulcers. Microscopically there may be atrophy and flattening of the epidermis, but the dermis becomes dense and sclerotic.

21. Skin appendages may disappear and the small cutaneous vessels may become dilated. The most important feature of this chronic radio-dermatitis is its liability to grow into cancers.

22. 6. COLD BURNS Are caused by exposure to cold which include freezing injuries (frostbite) or non-freezing cold injuries e.g. chilblain (localized painful erythema in the fingers, toes or ears produced by cold damp weather), trench foot (seen in soldiers due to prolonged exposure to extreme cold water combined with circulatory disturbances predisposed by tight clothing, garters or ill-fitting shoes) and immersion foot (a condition resembling trench foot occurring in shipwrecked persons who have spent protracted periods in waterlogged boats).

23. It is usually a concern in military populations, though it is being encountered increasingly in the civilian population with the rise in popularity of winter sports. Cold burns also cause coagulative necrosis of the tissue.

24. FROSTBITE FROSTBITE results in actual freezing of tissues with the formation of ice crystals. Mostly the skin and subcutaneous tissue of the hands, feet, ears and nose are affected. When these parts are exposed to low temperatures for prolonged period of time such injury may occur. Tissue necrosis following frostbite is related primarily to the mechanical effects of ice crystals, cellular dehydration and microvascular occlusion.

25. Crystals of ice appear both intra cellularly and extra cellularly in any tissue. As freezing progresses intracellular water shifts to the extracellular space and leads to intracellular dehydration with increase in intracellular concentrations of electrolytes, proteins and sugar. The resulting hyperosmolarity leads to denaturation of intracellular proteins. The skin is relatively resistant to these damaging effects, though other tissues like nerves, muscles and blood vessels are quite sensitive.

26. Clinical features of frostbite are described by various degrees: First-degree frostbite is hyperaemia and oedema of the skin without necrosis. Second-degree frostbite causes hyperaemia , vesicle formation and partial thickness necrosis of the skin. Third-degree frostbite causes necrosis of the entire skin thickness and may extend to a variable degree into the underlying subcutaneous tissue. Fourth-degree frostbite means necrosis of full thickness of the skin including subcutaneous tissue and all underlying structures including muscle and bone. This leads to gangrene of the affected part.

27. PATHOLOGY OF BUMS For advantage of description, pathological changes of bums are divided into 2 heads — I. Local changes and II. Systemic changes.

28. I. LOCAL CHANGES These can be described under 4 heads — Severity of bum, 2. The extent of bum, 3. Vascular changes and 4. Infection.

29. 1. SEVERITY OF BURN. Bums are classified into 3 grades or degrees according to the depth of necrosis. In first-degree bum there is simply hyperaemia of the skin with slight oedema of the epidermis. There is only microscopic destruction of the superficial layers of the epidermis, which are desquamated within a few days. It is of little clinical significance as the superficial layers of epithelium are soon replaced from the basal layers, so that there is no scarring.

30. First-degree burns rapidly heal if the patient avoids further exposure to source of heat. First-degree burns are not considered while estimating the magnitude of bum for purposes of planning intravenous fluid replacement.

31. In second-degree burns the entire thickness of the epidermis is destroyed. Blebs or vesicles are formed between the separating epidermis anddermis . Vesiculation is the hall mark of the second-degree burn. Second-degree bum is further subdivided into (a) Mild and (b) Severe varieties.

32. In mild cases enough epithelium is left in the hair follicles and dermal glands to provide new cells for resurfacing the burned area. In severe cases , there is not enough epithelium left, so that resurfacing of the burned area is not possible and skin grafting becomes necessary.

33. In third-degree burn there is complete destruction of the epidermis and dermis with irreversible destruction of dermal appendages and epithelial elements including the sensory nerves. Skin grafting becomes obligatory to cover the area.

34. ANOTHER TYPE OF CLASSIFICATION Another type of classification is in vogue to describe severity of bum. In this classification two degrees are considered — (a) partial thickness bum and (b) full thickness bum.

35. (a) Partial thickness burn Partial thickness burn is that type of bum in which the superficial layers of the skin e.g. the whole of epidermis and sometimes the superficial part of the dermis become destroyed. But there are enough epithelial cells surrounding the hair follicles or sweat glands from which regeneration may take place. So in partial-thickness bum, spontaneous regeneration of epithelium is expected and skin grafting is not necessary.

36. (b) Full thickness burn Full thickness burn: In this condition the whole thickness of the skin including the epidermis and the total depth of the dermis is destroyed. Spontaneous regeneration of epithelium is not possible, so development of scar tissue and contractures are inevitable unless skin grafting is performed in right time. As sensory nerves are also destroyed in full thickness bum, sensation is lost in full thickness burn and pin prick test (by firmly pressing a needle over the burned area) will be negative.

37. To the contrary sensation of the skin remains and pin prick test will be positive in partial thickness burn. It must be remembered that since skin varies in thickness in different parts of the body, application of the same intensity of heat for a given period of time will result in a burn which will vary in depth depending on the thickness of the skin in the local area and on the degree of development of the dermal appendages (sweat glands and hair follicles) and dermal papillae.

38. 2.EXTENT OF BURN EXTENT OF BURN.— The length and width of the bum wound is expressed as a percentage of the total surface area displaying either second or third-degree bum. The extent of burn is most commonly estimated by the ' rule of nines'.

39. 'Rule of nines' for estimating percentage of body surface involved in bums are as follows:— Anatomic area Percentage of body surface Head, face and neck 9% Right upper extremity 9% Left upper extremity 9% Right lower extremity (thigh - 9%, leg and foot - 9%) 18% Left lower extremity 18% Anterior trunk ( chest - 9%, abdomen - 9% ) 18% Posterior trunk ( upper half - 9%, lower half - 9% ) 18% External genitalia 1%. Above-mentioned 'rule of nines' is applicable only to the adults.

40. INFANTS AND CHILDREN The surface area of the head and neck of children is significantly larger than 9%. For example in one year old child the surface area associated with head is about 19% as compared to only 7% in adults. In contrast, each lower extremity represents only 13% of the total body surface area in these patients.

41. 3. VASCULAR CHANGES It is of great importance in the burnt area. Two main changes are noticed — There is dilatation of small vessels due to direct injury to the vessel walls and to local liberation of histamine. This increases blood flow to the injured part as seen in case of inflammation. This increased blood flow is not followed by stasis as happens in inflammation.

42. Capillary permeability is greatly increased. Due to this, plasma rich in protein pours out continuously in large amount. This exudate collects in blisters or begins to dry to form a dry brown crust which protects the wound. This crust separates in one or two weeks in case of superficial bums, but it takes longer times in case of deep bums.

43. 4. INFECTION Skin is sterilized. In case of first-degree bums the intact epidermis will act as barrier against infection. But in case of deep burns, if the crust which protects the raw wound is broken virulent organisms may enter the bum wound to cause severe infection. Moreover general malnutrition, loss of plasma and blood volume and anemia in extensive bums severely handicap the defense mechanism against infection.

44. Bacteriaemia and bacteriaemic shock are the second commonest cause of death in bum following oligaemic shock. This usually occurs between the second and third weeks.

45. SYSTEMIC CHANGES These can be conveniently described under four heads — 1. Shock. 2. Biochemical changes. 3. Changes in blood. 4. Systemic lesions.

46. 1. SHOCK This is the most important effect of bums. Various types of shock are come across in burns, but by far it is the oligaemic shock which is the most important and claims majority of lives following burns. (a) Oligaemic shock. (b) Neurogenic shock. (c) Cardiogenic shock. (d) Bacteriaemic shock

47. 2. BIOCHEMICAL CHANGES ( i ) Electrolyte imbalance. (ii) Hypoproteinaemia . (iii) Hyperglycemia. (iv) There will be rise in blood urea, N.P.N. and creatinine levels due to kidney damage in extensive bums.

48. 3. CHANGES IN BLOOD ( i ) Haemoconcentration . ii) Apparent increase in the number of red cell is also due to outpouring of plasma. (iii) Sludging of blood may occur due to intravascular agglutination of R.B.Cs. (iv) An abrupt fall in the eosinophil count during the first 12 hours is very characteristic of bums. (v) Aggregation of red cells, white cells and platelets is a common finding in burns. This increases blood viscosity.

49. In the course of 24 hours the count should begin to rise. Eosinophil count may give an indication to the prognosis of the case. A persistent eosinopenia , failure in the early rise after the initial drop and lack of late rise in the eosinophil count indicate bad prognosis.

50. (vi) Anaemia . (vii) A biphasic alteration of the coagulation system is also seen in burns.

51. 4. SYSTEMIC LESIONS ( i ) The liver may show numerous areas of focal necrosis. (ii) Kidney is often involved due to low blood perfusion. (iii) Adrenals become slightly enlarged and deeply congested. (iv)Gastric and duodenal mucosal changes indicative of focal ischaemia can be observed as early as 3 to 5 hours after bums. (v) Alterations of pulmonary function. (vi) A change in the endocrine pattern. (vii) Neurogenic changes are not commonly seen in burn injuries. (viii) Immunologic impairment

52. TREATMENT This is conveniently described under three headings — I. Treatment of shock, II. General treatment and III. Local treatment of bum wound.

53. I. TREATMENT OF SHOCK 1. Sedation 2. Fluid resuscitation 3. Maintenance of airway

54. II. GENERAL TREATMENT 1. Escharotomy and fasciotomy . 2. Tetanus prophylaxis 3. Antibiotics. 4. Nutritional support. 5. Gastric decompression. 6. Treatment of G. I. complications.

55. III. LOCAL TREATMENT 1. First-aid measures The patient should be immediately removed from source of heat. Cold clean water should be applied to the burned area immediately and is continued every 5 minutes.

56. 2. Burn wound care After proper resuscitation, attention should be directed to the burn wound. It should be cleansed with a surgical detergent and all loose nonviable skin should be trimmed away. The second-degree bums or partial thickness bums usually present as vesicular lesions. The overlying blister should be punctured and the upper nonviable skin is removed. Such debridement should usually be performed without anesthesia, but with tremendous aseptic care

57. At the time of wound cleansing, the entire wound should be inspected. Silver nitrate must be used soon after injury, before bacteria have proliferated on the wound. Majority of the topical antimicrobial agents appear to be equally effective in controlling burn wound infection when applied early before heavy colonization has occurred. The nonviable skin of the third-degree or whole thickness bum injury is known as the eschar . Usually the eschar remains tightly adherent to the underlying subcutaneous tissue and its removal may cause significant pain and severe haemorrage . 72

58. MANAGEMENT OF BURNS First Aid Stop the burning process and keep the patient away from the burning area. Cool the area with tap water by continuous irrigation for 20 minutes (not cold water as it can cause hypothermia).

59. Indications for admission in burns Any moderate and severe burns Airway burns of any type Burns in extremes of age All electrical/deep chemical burns

60. HOMOEOPATHIC TREATMENT

61. Primary Remedies Apis mellifica This remedy relieves pink, swollen skin with itching, burning pain improved by applying cold compresses. Cantharis This remedy relieves blisters from burns or friction . Urtica urens When a burn is mild and the primary symptoms are redness and stinging pain, this remedy often brings relief. It is often useful for sunburn when the pain is prickly and stinging.

62. Other Remedies Arnica This is a valuable first-aid remedy to help reduce pain and swelling and prevent the onset of shock after any injury. Another remedy that is more specific to the burn should be considered after  Arnica . Belladonna This relieves red, hot and painful skin from burns or sunburn. Calendula Ointment This remedy has a slight antiseptic action, speeds up the healing of damaged skin, and keeps the skin moisturized . Causticum If a burn is intensely painful and blisters seem to be forming, this remedy may help to bring relief. The person often feels more sad than restless from the pain. Rawness and soreness may develop in the injured area.  Causticum  is also helpful when pain remains in older burns, or when burns have not completely healed.

63. Other Remedies Hepar sulphuris calcareum This remedy is helpful for treating very sensitive and painful burns in people who are prone to infection. The person may feel extremely vulnerable and irritable, and may have chills or be very sensitive to cold. Hypericum This remedy is often helpful when the pain of a burn is intense and the nerves are extremely sensitive. Along with the usual discomfort of a burn, stabbing or shooting pains may be felt in the injured area. Phosphorus This remedy may be useful for the pain of electrical burns, on the way to medical care. (When electrical burns occur, the damaged area may look small on the surface, but be more extensive underneath; they should always be examined by a doctor.)

64. Other Remedies Calendula and Hypericum tinctures These tinctures (used topically in unpotentized herbal form) often is helpful in soothing burns and promoting tissue healing. Ten drops of either  Calendula  or  Hypericum  tincture, or both, may be mixed in an ounce of water and applied to the area several times per day.

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