Burns - Types, Clinical Features & Management

This topic is very important for MBBS Students as for sure it will be reflecting upon in the theoretical as well as clinical aspect. They should be familiar with the clinical findings of a burn patient, to differentiate among them the stages of burns as well as to calculate the fluid requirements accordingly. This topic covers above all aspects of burns.....

1. Prof. U.Murali.
Burns

2. Learning Objectives
▪Classify the types of Burns.
▪Explain the pathophysiology, clinical features & effects of burns.
▪Identify the assessment methods of a burn's patient.
▪Identify the immediate care measures of a burn's patient.
▪Mention the fluid resuscitative methods in treating burns patient.
▪Outline the general measures in treating a burns patient.
▪Describe the treatment aspects of Sup. & Deep dermal burns.
▪Differentiate between electric burns & chemical burns.

3. Introduction
▪A burn is an injury caused by thermal, chemical,
electrical, (or) radiation energy.
▪ A scald is a burn caused by contact with a hot liquid
(or) steam, but the term 'burn' is often used to
include scalds.

4. Introduction
Thermal Injury Others
-Scald – hot liquids
-Flame burns
-Flash burns – exp. Gas / Alcohol
-Contact burns – hot metals
-Electrical injury
-Chemical burns
-Cold injury
-Ionizing Radiation
-Sun burns

6. Classification of Burns
2. Depth of Skin - Involved
▪1st degree
▪2nd degree
▪3rd degree
▪4th degree
▪Injury localized to Epidermis
▪Epidermis + Dermis
▪Epidermis + Dermis + Sub. Cut. Fat
▪Underlying tissues

7. Classification of Burns
3. Thickness of Skin - Involved
▪Superficial
▪Partial thickness
[SP / DP]
▪Full thickness
▪1
st
degree
▪2
nd
degree
▪2
nd
degree
▪3
rd
degree

8. Heat = Coag. necrosis of skin & sub cut. tissue
Release – vasoactive peptides
Altered capillary permeability
Loss of fluid → Severe hypovolemia
↓Cardiac output → Myo. Function ↓
Pulm.edema ↓ Renal blood flow → Oliguria

SIRS
↓
MODS
Pathophysiology of Burns

Infection

10. C/F - First Degree Burns
▪Skin - red, glistening,
painful, absence of
blisters and brisk capillary
refill.
▪Not life-threatening and
normally heal within a
week without scarring.

11. ▪Involves - Papillary dermis
▪Pale pink (or) mottled appearance
with blisters.
▪Sensation – normal / painful.
▪Brisk capillary refill.
▪Heal in 2-3 weeks with minimal
scarring and full functional
recovery.
C/F - Second Degree – Sup P T Burns

12. ▪Involves -Reticular dermis
▪Dry, whitish blotchy red, doesn't
blanch.
▪No capillary refill and reduced (or)
absent sensation.
▪3-8 weeks to heal with scarring,
may require surgical treatment for
functional recovery.
C/F - Second Degree – Deep P T Burns

13. ▪Whole dermis – All layers.
▪Charred black, hard leathery feel.
▪Absent capillary refill and absent
sensation.
▪Thrombosis of veins is seen.
▪Requires surgical repair and
grafting.
C/F - Third Degree – F T Burns

15. 15

16. Burn zones [Jackson’s]

18. Effects of Burn Injury
Major Others
-Shock – Hypovolemia - > 15% TBSA
-Fluid & Electrolyte imbalance
-Infection – Staph/Strep/Pseudo/Fungi
-GIT: ileus/ero. gastritis/Curling’s ulcer
-Pulm. edema/ARDS/Resp. failure
-Renal failure
-UTI / DVT
-Bedsores
-Post-burn immunosuppre.
-Malnutrition
-Contracture

20. Outcome – Major Determinants
▪ Percentage surface area involved
▪ Depth of burns
▪ Presence of an inhalational injury
▪Age & comorbidities of the patient

22. Area – Lund & Browder Chart

23. Area – Wallace’s – “ Rule of 9 ”

27. Burn causes – Likely depth
Cause of burn Probable depth of burn
Scald Superficial – Can be deep
Flash Burns Deep Dermal to FT
Flame Burns Mixed deep dermal + Full thickness
Alkali Burns Deep dermal [or] Full thickness
Acid Burns Weak – Superficial / Strong – Deep dermal
Electric Burns Full thickness

28. Inhalation Injury – Dangers
▪Inhaled hot gases – upper airway burns & laryngeal oedema
▪Inhaled steam - subglottic burns and loss of respiratory
epithelium
▪Inhaled smoke particles - chemical alveolitis, pulm.edema,
ARDS and respiratory failure
▪Inhaled poisons, such as carbon-monoxide (CO), can cause
metabolic poisoning - > 10% is dangerous
▪Full-thickness burns to the chest can cause mechanical
blockage to rib movement.

30. Inhalation Injury – Warning Signs
RECOGNITION / ASSESSMENT INITIAL MANAGEMENT

▪A history of being trapped in the presence of
smoke or hot gases – in enclosed space.
▪Burns on the palate or nasal mucosa, or loss of
all the hairs in the nose – blistering in mouth.
▪Deep burns around the mouth and neck.
▪Presents as Hoarseness of voice / Stridor.
▪Early elective intubation is safest
▪Delay can make intubation very
difficult due to swelling
▪Be ready to perform an emergency
cricothyroidotomy if intubation is
delayed

32. Immediate [Pre-hospital Care]
▪Remove from source of injury
▪Clothing to be removed
▪Cool the burn wound – 10 - 20mts –
no cold H2o
▪Check for other injury
▪Cleaning & Chemoprophylaxis
▪Ensure rescuer safety

33. Hospital Care
▪A – Airway / Assessment
▪B – Breathing & Ventilation
▪C – Circulation
▪D – Disability
▪E – Exposure
▪F – Fluid resuscitation
▪G – Girth ( Circumference )
▪H – Hand
▪I – Inhalation injury

34. Criteria – For Admission
▪Airway burns of any type
▪Burns in extremes of age
▪Burns requiring FR & Surgery
▪Burns of any significance to the hands,
face, feet or perineum
▪Pts. social background is not good
▪All electric / deep chemical burns

35. Fluid Resuscitation
▪Children > 10% TBSA / Adults > 15%
TBSA
▪IV access - Central vein access
▪Ringer lactate (or) Hartmann’s
solution is the fluid of choice
▪Others – Colloid & Hypertonic saline
▪Use - Resuscitation formulas
▪Monitor – Urine output –
{0.5-1ml/kg/hour | 30-60 ml/hour}

36. Fluids used
▪First 24 hours = Crystalloids – given = Saline, RL, Hartmann’s fluid
( PASS THROUGH CAPILLARY WALL EASILY & ALSO REPLICATES THE
OSMOLALITY OF PLASMA)
▪After 24 hrs up to 30 – 48 hrs = Colloids - Albumin, Dextran , Haemaccel
( TO COMPENSATE PLASMA LOSS )
▪Blood transfusion – after 48 hours

37. Parkland Formula – Commonly used
▪4ml x % burn x weight (kg) = volume [ml] - 24 hours
▪Max. % considered = 50%
▪First 8 hours ½ of vol. – Rest in next 16 hours = 24 hours
▪Next 24 hours = ½ of first day fluids

39. Fluids – Children - DNS
▪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.

40. Muir & Barclay Formula – Colloids
▪0.5 x % burn x wt.kg = 1 portion
▪3 portions = first - 12 hours
(4 hours once)
▪2 portions = second - 12 hours
(6 hours once)
▪1 portion = third (every 12 hrs once)

41. Other General Measures
▪Monitoring the patient – T/P/R/BP
▪Catheterization – Monitor urine output
▪Tetanus toxoid / H2 blockers
▪NGT – Enteral feeding - > 20%
▪Antibiotics – Culture
▪TPN – If necessary
▪Monitor – In Intensive care unit

42. ▪ No intramuscular,
subcutaneous injections.
▪Small burns – Paracetamol,
NSAID.
▪Large burns - Intravenous
opiates.
▪Intensive nursing care.
▪Physiotherapy – elevation,
splintage's, exercise.
▪Psychological – counseling.
Analgesia + Supportive Measures

43. Sup.Dermal & Partial Thickness burns
▪Heal – irrespective of dressing
▪SSD – Dressing – Very effective
▪Simple dressings –
Vaseline gauze
Silicon sheet / Hydrocolloids
▪Biological
Natural – Aminio.memb
Synthetic – Biobrane

44. Eschar - Treatment
▪Charred, denatured, full thickness
deep burns with contracted dermis.
▪Circumferential eschar – Limbs, Neck
& thorax – effect on respiration &
peripheral circulation.
↓
▪Tourniquet like-effect –causing
compartment syndrome - limbs
↓
▪Incising the whole length of full
thickness burns in different areas -
Escharotomy

47. Full Thickness & Deep dermal burns
▪1% silver sulphadiazine cream
▪0.5% silver nitrate solution
▪Sulfamylon - Mafenide acetate
cream
▪Cerum nitrate

49. Surgery – Deep Dermal burns
▪Within 48 hours - < 25% burns.
▪Called as – Tangential excision & SSG
▪Dead dermis - removed layer by layer until
fresh bleeding occurs.
▪Topical adrenaline (DILUTED) reduces
bleeding.
▪All burnt tissue needs to be excised.
▪Stable cover should be applied at once to
reduce burn load – SSG.

52. Electrical Burns
▪L TV – < 1000 Volts - injuries cause small,
localized, deep burns – Entry & Exit points.
▪HTV – > 1000 Volts - damage by flash / flame.
▪May have I O – injuries – GIT / Thorax & #
▪Look for and treat acidosis and myoglobinuria
– renal failure.
▪Assessed – ECG / Cardiac enzyme / C. Monitor.
▪Treated accordingly – Bicarbonate infusion,
Mannitol, fasciotomies & amputation.
▪Death – due to cardiac arrhythmias – VF

55. Chemical Burns
▪Acid burn occurs in skin, soft tissues and GIT
– H2SO4 / HNO3 – H. Fluoric acid.
▪Alkali burns occur in oral cavity and
oesophagus – NaOH / KOH / Cement.
▪Damage is from corrosion and poisoning.
▪Initial treatment is dilution with water
(Hydrotherapy).
▪Neutralization is done LATE, if required by
0.2% acetic acid in alkali burns;
sodium bicarbonate, calcium gluconate
10% gel, topical ziphrin solution in acid
burns.

57. References

58. To Summarize
▪Classification of burns & their clinical features.
▪Pathophysiology & Effects of burns.
▪Various assessment methods of a burns patient.
▪Calculate the fluid requirements in a burns injury.
▪Recognizing & Initial management of inhalation injury due to burns.
▪Medical & Surgical treatment of burns patient.
▪Difference between electrical & chemical burns.

59. Question Time
▪Classify burns & Identify the burn zones.
▪Explain the pathophysiology of burns.
▪Enumerate 4 differences between SPT & DPT burns.
▪Name 4 dangers & 4 warning signs of inhalation injury due to burns.
▪Mention the assessment & Fluid R methods in a burn's patient.
▪List any 4 criteria to admit a burns patient.
▪Write a note on Escharotomy.

60. High-voltage electrical injuries are likely to
cause the most extensive injury to –
▪A Muscle.
▪B Nerves.
▪C Skin.
▪D Fat.

61. A 1-year-old child weighing 10 kg arrives at the
casualty after sustaining 15% burn injury. Which one
of the following is the most appropriate fluid
advice on the first day for the above child? –
▪A 500 ml of Dextrose saline / day.
▪B 1000 ml of Dextrose saline / day.
▪C 1500 ml of Dextrose saline / day.
▪D 2000 ml of Dextrose saline / day.

62. In a patient with the burn wound extending into the
epidermis & superficial dermal layer without
involving deep dermis would present with all the
following features, except –
▪A Pale pink appearance.
▪B Usually painful.
▪C Often blister formation.
▪D Absent capillary refill.

63. In a 50 kg adult, how much of fluid should be
given in the first 8 hours in burns of 40%? –
▪A 2 liters.
▪B 4 liters.
▪C 6 liters.
▪D 8 liters.

64. While working in the school laboratory, concentrated
alkali falls on a student’s hand. The immediate
treatment should be –
▪A Wash with water.
▪B Wash with dilute acid.
▪C Mop the hand with a dry cloth.
▪D Pack the hand in ice until shifted to a hospital.

65. What will be the % of burns, if both sides of
the legs, the groin and the front of chest &
abdomen were involved in a 25-year-old man? –
▪A 35%.
▪B 45%.
▪C 55%.
▪D 65%.

66. “ Surgical Triad ”
Measure thrice, think twice, cut once.
Thank U

67. BURNS
Breathing & Body image
Urine Output
Rule of nines & Resuscitation
Nutrition
Shock & Silverdiazine