Principle and management of burn injury.pdf

Principle and management of burn injuries

1. PRINCIPLE AND
MANAGEMENT
OF BURN
INJURY
Fatin Syafiqah binti
sharizal

2. Burn is a type of coagulative necrosis caused by heat, transferred
from a source→to the body.
The most common organ affected is the skinwhichinvolve2
layer
1)the thin, outer epidermis
2)the thicker, deeper dermis.
However, burns can also damage the airwayand lungs, with life-
threatening consequences.
Types
-Thermal (Flame)
-Hot liquids (scalding)
-Chemical (acid, alkalis, corrosives)
-Electrical and lightning
-Radiation
-Inhalation
-Friction (abrasion)

3. ANATOMY OF
SKIN
Epidermis
-Outermost layerofskin
-Protective layer
Dermis
Contain bloodvessel,glandandnerve
ending
Temperature regulation
Sweat mechanism
Presentation title 3

4. PATHOPHYSIOLOGY
OF BURN

5. •Zone of Coagulation:occurs at the point of maximum
damage i.e.the nearest point to the heat source. There is
irreversible tissue necrosis here due to coagulation of
proteins.
•Zone of Stasis: surrounding the zone of coagulation, this
area is characterisedby decreased tissue perfusion. It is
damaged but potentially viable. If the burn is managed
correctlyit has the potential to be salvaged, otherwise it
could evolve into an area of necrosis.
•Zone of Hyperaemia:the outermost zone as its name
suggests is where there is increased tissue perfusion. This
is a reversible zone.
Aim ofresuscitation : increase the perfusion on zone of
stasis
Pathophysiology Local response
Jacksons Burn wound model
5

6. 6
Pathophysiology –Systemic
•The release of cytokines and other inflammatory mediators at the
site of injury has a systemic effect once the burn reaches20-30%of
total body surface area.
•Cardiovascular changes –Capillary permeability is increased,
leading to loss of intravascular proteins and fluid into the interstitial
compartment. Peripheral and splanchnic vasoconstriction occurs.
Myocardial contractility is decreased. These changes, coupled with
fluid loss from the burn wound, result in systemic hypotension and
end-organ hypoperfusion.
•Respiratory changes –Inflammatory mediators cause
bronchoconstriction, and in severe burns, adult respiratory distress
syndrome can occur.
•Metabolic changes –The basal metabolic rate increases up to
three times its original rate. This, coupled with splanchnic
hypoperfusion, necessitates early and aggressive enteral feeding to
decrease catabolism
•Immunological changes –Non-specific down regulation of the
immune response occurs, affecting both cell mediated and humoral
pathways.

7. 1) EXTEND OF
BURN
1)Rule of Nines
-Divides the body surface into areas of 9%or
multiples of 9%, with the exception ofthe
perineum 1%.
-Additionally small burns may be estimated by
using the palmarsurface (fingers and palm) of
patient’s hand 1% body surface area.
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8. Presentation title 9
•Lund and Browder Chart–This is a more
accurate method, especially in children,
•maps out the % TBSA based on
sections of anatomy.
•It also takes into accountdifferent
proportional body surface area
according to age.

9. Presentation title 10
•Palmar Surface-For small
burns, the patient's palm
surface (excluding the fingers)
represents approximately 0.5%
of their body surface area, and
the hand surface (including
the palm and fingers)
represents about 1% of their
body surface area.

10. 2) DEPTH OF
BURN
Burn depth is classified into superficial, partial
(some, but not all layers of the skin are injured) vs
full thickness(all layers of the skin are injured).

13. SEVERE BURN WHEN , if they have any of the
following;
•>10% TBSA in children (<10 years old) or elderly
(>50 years old)
•>20% TBSA in adults
•>5% full thickness
•high-voltage electrical burns
•significant burns to the face, eyes, ears, joints, or
genitalia

14. MANAGEMENT OF BURN

15. HOSPITAL CARE
Airways
Suspect inhalation injury if patient has:
-Respiratory distress (dyspnoea, stridor,
wheeze).
-voice changes
-signs of upper airway oedema
-deep facial burns
-sooty sputum
-a history of burn in enclosed space
-raised СОНЬ level
Need to consider early intubation
Breathing
-Administer oxygen.
-Expose the chest and ensure that chest expansion is
adequate and bilaterally equal.
-Palpate for crepitus and abnormalities such as rib fractures.
-Auscultate for breath sounds bilaterally.
-Ventilate via a bag and mask or intubate the patient if
necessary.
-Monitor respiratory rate; beware if rate is <10 or >20 per
minute.
-Pulse oximeter monitor.
Beware circumferential deep dermal or full thickness chest
burns –is escharotomy required?
-Consider carbon monoxide poisoning, non-burnt skin may
be cherry pink in colourin a non-breathing patient

16. Circulation
Insert 2 large bore of branulato unburnt skin
Take full set of blood (fbcrp, lftastck , coag,
consider drug toxicology
Assess crt(centrally and peripherally to burnt
and non-burnt areas)
Longer CRT indicates poor perfusion due to
hypotension, hypovolaemiaor need for
escharotomy on that limb
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17. Presentation title 19
Disability: neurological status
Establish level of consciousness: GCS score
Examine pupil response to light for reaction and size.
Be alert for restlessness and decreased levels of
consciousness –hypoxaemia, carbon monoxide
intoxication, shock, alcohol, drugs and analgesia influence
Exposure, environmental control and estimate burn
size
Remove all clothing and jewellery.
Keep patient warm, prevent hypothermia
Log roll patient, remove wet sheets and examine posterior
surfaces for burns and other injuries.
Estimate total body surface area (TBSA) %

18. FLUID
RESUSITATION
Who need fluid resuscitation ?
In children with burns > 10% TBSA and adults
with burns > 20% TBSA
AIM : URINE OUTPUT
Children 1ml/kg/hr
Adult 0.5ml/kg/hr

19. Presentation title 21
Parkland formula : fluid to be replaced in the first 24
hours
4ml ×weight (kg) ×TBSA % = volume (mL)
Half of the total volume given over the first 8 hours
the second halfof the total volume given over next 16 hours.
Example:
*REMEMBER THAT THE FLUID RESUSCITATION FORMULA FOR BURNS IS ONLY AN
ESTIMATE AND THE PATIENT MAY NEED MORE OR LESS FLUID BASED ON VITAL
SIGNS, URINE OUTPUT, OTHER INJURIES OR OTHER MEDICAL CONDITIONS
70 kg x30% TBSA x 4ml = 8400 mL HMsolution in the first 24
hours with 4200 mL of that total in the first 8 hours

20. Presentation title 22
In children maintenance fluid must also be given.
This is normally dextrose-saline given as Holliday-Segar formula:
4 mL/kg/Hror100 mL/kg/day for the first 10 kg;
2 mL/kg/Hror50 mL/kg/day for the next 10 kg;
1 mL/kg/Hror20 mL/kg/day for each kilogram over 20 kg body
weight.

21. Assessment of Adequate Fluid
Resuscitation
1.Urine output -maintain 1-3 mls/kg/hour
2.Pulse rate / blood pressure / respiratory rate
3.Peripheral colourand capillary return
4.Temperature
5.Blood investigations -Hemoglobin,
ElectrolytesMonitorfluid input / output closely
6.Insert urinary catheter (CBD) in burns > 10%
TBSA -to monitor hourly urine output
23Signs of Underhydration
1.Low urine output
2.Poor peripheral colourand capillary
return
3.Restlessness and confusion
4.Vomiting
Signs of Overhydration
1.Excessive urine output
2.Generalized oedema
3.Pulmonary oedema
4.Increase blood pressure
IV Albumin-Albumin is NOT necessary in 1* 48 hours-After 48 hours,
-infuse IV Albumin if serum albumin < 25 g/Dl
Use IV Albumin 25% at 4 ml/kg daily,
infuse over 5 hours for 3 days together with IV Lasix 0.5-1 mg/kg in
between transfusion
-Monitor serum albumin level
-Note: The above resuscitation formula is only a guideline. Changes
may be needed based on clinical response of patient.

22. PAIN MANAGEMENT
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23. Presentation title 25

24. WHO NEED TO TRANSFER TO
BURN UNIT
Presentation title 26
The American Burn Association recommends burn center referrals
for patients with:
•partial thickness burns greater than 10% total body surface area
•full thickness burns
•burns of the face, hands, feet, genitalia, or major joints
•chemical burns, electrical, or lighting strike injuries
•significant inhalation injuries
•burns in patients with multiple medical disorders
•burns in patients with associated traumatic injuries

25. BURN WOUND
MANAGEMENT
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26. PRINCIPLE OF WOUND CARE
Infection control + Early wound closure + Adequate nutritional support + Exercise
To maintain an ideal wound environment, the wound should be kept warm and moist as cells
function best at body temperature and in high humidity:
1.Avoid exposing the wound to cooling temperature or appliances.
2.Avoid leaving wounds exposed for lengthy periods.
3.Use wound cleansing solution at body temperature.
Wound bed should also be free from excess exudate, as large amounts of fluid can cause maceration of
granular and surrounding tissue and provides an ideal culture medium for bacteria. Dressing should
therefore be chosen that prevent dehydration of the wound bed, rehydrate wounds as necessary,
absorb exudate and maintain body temperature.

27. EXAMPLE OF WOUND
DRESSING

28. SURGERY
PROCEDURE THAT MAY BE NEEDED
FOR PATIENT
-Escharotomy orfasciotomy
-Wound debridment
-Skin grafting

29. WHAT IS
ESCHAROTOMY
Eschar is stiff, dead skin tissue caused by
deep partial-thickness and full-thickness
burns.
-Circumferential eschar on a limb
constricts distal circulation, and eschar
on the thorax constricts respiration.
-Escharotomy is surgical incision through
the eschar to release the constriction,
thereby restoring distal circulation and
allowing for adequate ventilation.
31
Indications for Burn Escharotomy
•Absent distal arterial flow as determined with a
Doppler ultrasonic flow meter in the absence of
systemic hypotension
•An oxygen saturation below 95% in the distal
end of the extremity as shown by pulse oximetry
in the absence of systemic hypoxia
•Impending or established respiratory
compromise due to circumferential torso or neck
burns

30. Presentation title 32
The dashed lines are the preferred escharotomy incision
sites. The bold lines are areas where vascular structures
and nerves may be damaged by escharotomy incisions.

31. WOUND
DEBRIDEMENT
Shouldbe done as early as possible
For thinsloughordeathtissue,mayalso
use autolytic agent for dressing

32. SKIN GRAFTING
Decide as early as possible wound for Split Skin
Graft (SSG) , preferably less than 2 weeks
Donor site
-Use thigh if possiblefollow by leg
-Harvest skinusingdermatome
Recipient site
-All hypergranulationtissue need to remove /
scraped off
-Prepare healtywoundbed

33. SPLIT
SKIN GRAF
-unmeshedifadequateskin
available
-Meshed 1:3 or 1:5 if necessary
-Secure with stapler , suture or
glue
-Wound inspection
-Recipient sitePOD5
-Donor site POD 10
-Stapler removalPOD7

34. NUTRITION
Nutrition support is an important compenentof burn management
Aim to
1.Promote optimal wound healing and recovery from burn injury
2.Decrease the risk of metabolic complications associated with
feeding
3.Provide nutrients to promote normal growth and development
Oral Intake
Started as soon as possible, If unable to take orally then to give via
enteral feeding
Enteral Feeding
-with burn injuries > 10% TBSA, Feeding will start after completing 24
hours of Parkland fluid resuscitation. Feeds given via perfusorfeeding.
Regime depending on dietician's orders
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35. PHYSIOTHERAPY
Aim for early physiotherapy
•keep the joints moving
• Reduce or prevent the joint tightening up (joint
contracture)
• Keep the muscles working for normal movement
• Prevent or reduce scars
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OCCUPATIONAL THERAPY
It is focused on the prevention of deformity and return
backto do daily living activities
Aim is to:
1.To prevent contractures & deformity
2.To reduce/ prevent hypertrophic scarring
3.To prevent loss of ROM
4.To achieve the maximal self-care independence
possible
5.To provide psychological support
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