BURNS

CLASSIFICATION OF BURNS
Erythema red, dry skin that easily blanches then
rapidly refills
Superficial red moist wound that blanches and
rapidly refills
Superficial dermal pale, dry, blanching wound
that regains colour slowly
Deep dermal mottled cherry red and does not
blanch. The blood is thrombosed and fixed in
damaged capillaries in the deep dermal plexus
Full thickness dry, leathery or waxy, hard
wound that does not blanch. In extensive burns,
full thickness burns can be mistaken for unburnt
skin

3 ZONES OF MAJOR BURNS



1. Central zone of coagulation in the area of
maximum damage where skin cells are
irreversibly damage
2. Surrounded by zone of stasis characterized by
decreased tissue perfusion. Injured cell can
survive or die according to effectiveness of the
treatment.
3. The outer zone of erythema is superficial. Cells
here minimally injured and will recover in 7 days.
Is not included in clalculation of burnt area.

SYSTEMIC CHANGES
Systemic and 3
rd
space fluid losses lead to
hypovolaemia
Systemic inflammatory response occurs once
burns affect 30% of body surface area
Myocardial contractility becomes depressed
In smoke inhalation, bronchocontriction and
ARDS occur
Basal metabolic rate increases up to 3 fold
General capillary permeability is increased
Peripheral and splanchnic vasoconstriction occurs
Red cells are destroyed by burns
Sepsis is likely if burns become infected, leading
to organ failure and death
Organisms Strep pyogenes, Pseudomonas
aeruginosa

ELECTROCUTION BURNS
Voltage - determinant of the severity
Musle damage rhabdomyolysis and renal failure
Extent of burning is proportional to electrical
resistance through which current is transmitted
Bone offer highest resistance; current passes
through, bone become heated adjoining muscle
damage.
Fasciotomy to decompress muscle
compartment

CHEMICAL BURNS
Depends on agent, concentration, quantity and
duration of contact
Tend to be deep because corrosive continue to
act until fully removed
Alkalis tend to penetrate more deeply than acid

ASSESSMENT OF BURNED PATIENT

HISTORY
Source of burn
Temperature
Duration of contact
Inhalation of noxious gas

CALCULATING THE BURNED AREA



ASSESSING DEPTH OF BURN





1. Partial burns
1. Superficial
Affect the dermis

2. Superficial dermal
Destroy epidermis and upper layer of dermis;
blistering usually occurs. Burn may be
covered with soot or dirt (need removing)
and blister (deroofed to check base). Capillary
refill can be tested by pressure from sterile
cotton bud. A 21 g needle to test sensation
and bleeding; pain normally felt in superficial
dermal and bleeding is brisk.

3. Deep dermal
Destroy all of the epidermis and most of the
dermis, leaving only the skin adnexae, sweat
glands and some hair follicles. On needle
testing, bleeding is delayed and only non-
painful sensation is experienced.

2. Full thickness burns
Insensate and do not bleed on needling.



PRINCIPLE OF MANAGEMENT OF BURNS

First aid
Stop the burning process.
Remove heat source.
Active cooling immersing burned area in tepid water for
15 20 minutes

Analgesia
Cooling and covering burns
Larger burns opioids later NSAIDs

Dressings
PVC film sterils and forms a pliable, non adherent,
impermeable barrier which is transparent to allow
inspection.

MANAGEMENT OF BURNS OF SPECIFIC DEPTH
1. Superficial burns
Supportive therapy with regular analgesia and
dressing moist area

2. Superficial dermal burns
Exposed superficial nerves make these burns
particularly painful. Healing expected within 2
weeks from keratinocytes within sweat glands
and hair follicle. Treatment needs at least weekly
changing. If burns are still unhealed after 2
weeks, depth assessment was incorrect, should
refer to burns unit.

3. Deep dermal burns
Density of skin adnexae is less at this depth and
healing is slower and subject to contracture.
Some of these burns heal spontaneously if kept
warm, moist and free fro infection. If deep
dermal burns are extensive/ fuctionally/
cosmetically sensitive area, they are better
treated in burns unit by excision to a viable depth
and skin grafting within 5 days.

4. Full thickness burns
All regenerative elements in burned area have
been destroyed; without grafting, contraction
and distortion would be substantial. Ideally need
excision and grafting.



RESUSCITATION AND FLUID MANAGEMENT
Effective resuscitation maintain tissue perfusion
in the zone of stasis
Greates fluid is lost in the first 8-12 hours
Substantial fluid losses continue for at least
another 36 hours
Rapid boluses should not be given early on as
raised intravascular hydrostatic pressure drives it
rapidly out of the circulation





MANAGEMENT OF THE BURNS
Partial thickness re-epithelise spontaneously
Full thickness require excision and skin grafting
Grafting should be done within 5 days
Wound to be graft should be free from infection
Deep circumferential burns of the limbs and
thorax begin to contract early restrict blood
flow and respiratory movement
If excision not done early and these signs develop
escharotomy is performed.