Burn ppt shashi

1. 1. Presenter: Dr. Shashi K. SinghModerater: Dr. Kumar Shrestha, Dr. Piyush,Dr.

Jainendra Chaudhary, Dr. Indra K. Jha
2. 2. • Burns is defined as a wound caused byexogenous agent leading to
coagulativenecrosis of the tissue.
3. 3. Causes• Thermal BurnsDry heatContact burnFlame burnMoist heat- Scald burnSmoke
and inhalational injury• Chemical Burns- acids & alkali• Electrical burns- High & low
voltage• Cold Burns- frostbite• Radiation
4. 4. Thermal Burns• Heat changes the molecular structure of tissueCausing Denaturion of
proteins• Extent of burn damage depends on–Temperature of agent–Amount of heat–
Duration of contact
5. 5. • The effects of the burns are influenced bythe:1.Intensity of the energy2.duration of
exposure3.type of tissue injured
6. 6. Pathophysiology of Burns• Fluid Shift– Period of inflammatory response– Vessels
adjacent to burn injury dilate → ↑ capillaryhydrostatic pressure and ↑ capillary
permeability– Continuous leak of plasma from intravascular space intointerstitial space–
Associated imbalances of fluids, electrolytes and acid-baseoccur– Hemoconcentration–
Lasts 24-36 hours
7. 7. • Fluid remobilization– Capillary leak ceases and fluid shifts back into thecirculation–
Restores fluid balance and renal perfusion• Increased urine formation and diuresis–
Continued electrolyte imbalances• Hyponatremia• Hypokalemia– Hemodilution
8. 8. SYSTEMIC CHANGES• Cardiac– Decreased cardiac output• Pulmonary– Respiratory
insufficiency as a secondary process– Can progress to respiratory failure– Aggressive
pulmonary toilet and oxygenation• Gastrointestinal– Decreased or absent motility (may
need NG tube)– Curling’s ulcer formation
9. 9. • Metabolic– Hypermetabolic state• Increased oxygen and calorie requirements•
Increase in core body temperature• Immunologic– Loss of protective barrier– Increased
risk of infection– Suppression of humoral and cell-mediated immuneresponses
10. 10. ACUTE PHASE• Clinical shock• External loss of plasma• Loss of circulating red cells•
Burn edema
11. 11. SUB ACUTE PHASE• Diuresis• Clinical Anemia• Accelerated metabolic rate•
Nitrogen Disequilibrium• Bone and joint changes• Endocrine Disturbances• Electrolyte
and chemical imbalance• Circulatory Derangements• Loss of of function of skin as an
organ
12. 12. Body’s Response to Burns• Emergent Phase (Stage 1)– Pain response–
Catecholamine release– Tachycardia, Tachypnea, Mild Hypertension, MildAnxiety• Fluid
Shift Phase (Stage 2)– Length 18-24 hours– Begins after Emergent Phase• Reaches
peak in 6-8 hours– Damaged cells initiate inflammatory response• Increased blood flow
to cells• Shift of fluid from intravascular to extravascular space– MASSIVE EDEMA
13. 13. • Hypermetabolic Phase (Stage 3)–Last for days to weeks–Large increase in the
body’s need fornutrients as it repairs itself• Resolution Phase (Stage 4)–Scar formation–
General rehabilitation and progression tonormal function
14. 14. Jackson’s Theory of Thermal Wounds• Jackson’s Theory of Thermal Wounds– Zone
of Coagulation• Area in a burn nearest the heat source that suffers the mostdamage as
evidenced by clotted blood and thrombosedblood vessels– Zone of Stasis• Area
surrounding zone of coagulation characterized bydecreased blood flow.– Zone of
Hyperemia• Peripheral area around burn that has an increased bloodflow
15. 15. Severity is determined by:–depth of burn–extend of burn calculated in percent of
totalbody surface (TBSA)–location of burn–patient risk factors
16. 16. CLASSIFICATION OF BURNS• First degree—injury localized to theepidermis•
Superficial second degree—injury to theepidermis and superficial papillary dermis• Deep
second degree—injury through theepidermis and deep upto reticular dermis• Third
degree—full-thickness injury through theepidermis and dermis into subcutaneous fat•
Fourth degree—injury through the skin andsubcutaneous fat into underlying muscle
orbone
17. 17. CLASSIFICATION OF BURNS
18. 18. Superficial Burn : 1st Degree Burn• Reddened skin• Pain at burn site• Involves only
epidermis• Blanch to touch• Have an in-tact epidermalbarrier• Do not result in scarring•
Examples : Sun-burn, minorscald from a kitchen accident• Treatment is aimed atcomfort
with topical soothingagents +/- NSAIDs
19. 19. Partial-Thickness Burn: 2nd DegreeBurn• Intense pain• White to red skin• Blisters•
Involves epidermis & papillarylayer of dermis• Spares hair follicles, sweatglands etc.•
Erythematous & blanch to touch• Very painful/sensitive.• No or minimal scarring.•
Spontaneously re-epithelializefrom retained epidermalstructures in 7-14 days
20. 20. Deep second degree burn• Injury to deeper layers of dermis –reticular dermis•
Appears pale & mottled• Do not blanch to touch• Capillary return sluggish or absent•
Less painful, remain painful to pinprick• Takes 14 to 35 days to heal byre-epithelialisation
from hairfollicles & sweat gland,keratinocytes often with severe scarring• Contractures
possible• Require excision & skin grafting
21. 21. Full-Thickness Burn:3rd Degree Burn• Dry, leathery skin(white, darkbrown,
orcharred)• Loss of sensation(little pain)• All dermallayers/tissue maybe involved• Always
requiresurgery.
22. 22. Fourth degree burn• Involves structures beneath the skin- muscle,bone.
23. 23. ASSESSMENT OF BURNS• Rule of Nine–Best used for large surface areas–
Expedient tool to measure extent of burn• Rule of Palms–Best used for burns < 10% BSA
24. 24. AREA OF PALM = 1% BODY SURFACE AREA
25. 25. ManagementPre-hospital care• Ensure rescuer safety• Stop the burning process:
Stop, drop and roll• Check for other injuries.A standard ABC (airway, breathing,
circulation)check followed by a rapid secondary survey.
26. 26. • Cool the burn wound:AnalgesiaSlows the delayed microvascular damage,Minimum
of 10 minEffective up to 1 hour after the burn injury• Give oxygen• Elevate
27. 27. Hospital care• A : Airway control.• B :Breathing and ventilation.• C :Circulation.• D:
Disability – neurological status.• E :Exposure with environmental control.• F :Fluid
resuscitation.
28. 28. The criteria for acute admission to a burns unit• Suspected airway or inhalational
injury• Any burn likely to require fluid resuscitation• Any burn likely to require surgery•
Patients with burns of any significance to the hands, face,feet or perineum• Patients
whose psychiatric or social background makes it• inadvisable to send them home• Any
suspicion of non-accidental injury• Any burn in a patient at the extremes of age• Any burn
with associated potentially serious sequelae• including high-tension electrical burns and
concentrated• hydrofluoric acid burns
29. 29. AirwayRecognition of the potentially burnedairway• A history of being trapped in the
presence ofsmoke or hot Gases• Burns on the palate or nasal mucosa, or loss ofall the
hairs• in the nose : Deep burns around the mouth andneck
30. 30. Airway• Burned airway• Early elective intubation is safest• Delay can make intubation
very difficultbecause of Swelling• Be ready to perform an emergencycricothyroidotomy if
intubation is delayed
31. 31. Breathing• Inhalational injury• Thermal burn injury to the lower airway• Metabolic
poisoning:Carboxyhaemoglobin• Mechanical block to breathing:Escharotomy
32. 32. Circulation• Maintain iv line with wide bore canulaperipherally• One central line•
Escharotomy of limbs if circulatorycompromise in circumferential burns
33. 33. Fluids for resuscitation• In children with burns over 10% TBSA andadults with burns
over 15% TBSA, considerthe need for intravenous fluid resuscitation• If oral fluids are to
be used, salt must be added• Fluids needed can be calculated from astandard formula•
The key is to monitor urine output
34. 34. • Parkland Formula:Total percentage body surface area × weight(kg) × 4 = volume
(ml)• Half this volume is given in the first 8 hours,and• the second half is given in the
subsequent 16hours.
35. 35. • Crystalloid : Ringer lactate• Hypertonic saline• Human albumin solution• Colloid
resuscitation
36. 36. • The commonest colloid-based formula is theMuir and Barclay formula:0.5 ×
percentage body surface area burnt ×weight = one portion;• Periods of 4/4/4, 6/6 and 12
hoursrespectively;• one portion to be given in each period.
37. 37. Assessment of adequacy of fluidreplacement• Urine output is most commonly used
parameter• Urine osmolarity is the most accurate parameter• U/O > 0.5-1.0 ml/kg/hr•
CVP 5-10 cm/H2O.• U/O > 2ml/kg/hr – sign of overhydration
38. 38. Fluid Resuscitation Complications• Overresuscitation complications:Poor tissue
perfusionCompartment syndromePulmonary edemaPleural effusionElectrolyte
abnormalities
39. 39. TREATING THE BURN WOUNDEscharotomy• Circumferential full-thickness burns to
thelimbs require emergency surgery.• The tourniquet effect of this injury is easilytreated
by incising the whole length of full-thickness burns..
40. 40. Escharotomy• Incise along medialand/or lateral surfaces.• Avoid bonyprominences.•
Avoid tendons, nerves,major vessels.
41. 41. Escharotomy• Upper limb: Mid-axial, anterior to the elbowmedially to avoid the ulnar
nerve• Hand : Midline in the digits. Release musclecompartments if tight.• Lower limb:
Mid-axial, Posterior to the anklemedially to avoid the saphenous vein• Chest: Down the
chest lateral to the nipples,across the chest below the clavicle and acrossthe chest at the
level of the xiphisternum
42. 42. Fasciotomy• Fascia = thick whitecovering of muscles.• Fasciotomy = fascia isincised
(and often overlyingskin)• Skin and fascia split opendue to underlying swelling.• Blood
flow to distal limb isimproved.• Muscle can be inspected forviability.
43. 43. Debridement• Types of debridement:1. Auto debridement.2. Tangential excision (at
the end of 1st week)3. Staged primary debridement (1-3 days postburn).This early
debridement of dead tissue interruptsand attenuates the systemic inflammatoryresponse
and normalize immune function.4. For deep circumferential burn, urgentescharotomy is
done
44. 44. BLISTERS• Intact blister- barrier to microbial invasion• Intact blister creates moist
environment hencemore rapid reepithelialization• More rapid angiogenesis• Rupture of
blisters under contaminatedconditions may increase infection rates
45. 45. BLISTERS• In the pre-hospital setting, there is no hurry toremove blisters.• Leaving
the blister intact initially is lesspainful and requires fewer dressing changes.• The blister
will either break on its own,or the fluid will be resorbed.
46. 46. • AnalgesiaAcute• Small superficial burns : simple oral analgesia,Topical cooling•
Large burns: intravenous opiates.Subacute• Large burns: continuous analgesia is
required,beginning with infusions and continuing with oraltablets such as slow-release
morphine.
47. 47. Nutrition• Burns patients need extra feeding• A nasogastric tube should be used in
allpatients with burns over 15% of TBSA• Removing the burn and achieving healingstops
the catabolic drive.
48. 48. NutritionSutherland formula• Children: 60 kcal/ kg + 35 kcal%TBSA• Adults: 20 kcal
/kg + 70 kcal%TBSAProtein20% of energy1.5 to 2 g/kg protein/day
49. 49. Tetanus prophylaxis• Tetanus toxoid, 0.5 mL intramuscularly, if thelast booster dose
was more than 5 years beforethe injury.• If immunization status is unknown,human
tetanus immunoglobulin 250 to 500units, I.M. plus tetanus toxoid in opposite side
50. 50. Monitoring and control of infection• Burns patients are immunocompromised• They
are susceptible to infection from manyroutes• Sterile precautions must be rigorous•
Swabs should be taken regularly• A rise in white blood cell count,thrombocytosis and
increased catabolism arewarnings of infection
51. 51. Topical treatment of deep burns• 1% silver sulphadiazine cream• 0.5% silver nitrate
solution• Mafenide acetate cream• Serum nitrate, silver sulphadiazine and ceriumnitrate
52. 52. Principles of dressings for burns• Full-thickness and deep dermal burns
needantibacterial dressings to delay colonisationprior to surgery• Superficial burns will
heal and need simpledressings• An optimal healing environment can make adifference to
outcome in borderline depthburns
53. 53. Surgical treatment of deep burns• Early debridement and grafting is the key to
effectivelytreating• deep partial- and full-thickness burns in a majority ofcases• Deep
dermal burns need tangential shaving and split-skin grafting• All but the smallest full-
thickness burns need surgery• Should be ready for significant blood loss• Topical
adrenaline reduces bleeding• All burnt tissue needs to be excised
54. 54. Surgical treatment of deep burns• Proper dressing should be done• Postoperative
management requires carefulevaluation of fluid balance and levels ofhaemoglobin.•
Physiotherapy and splints are important inmaintaining range of movement and
reducingjoint contracture
55. 55. Delayed reconstruction of burns• Eyelids must be treated before exposurekeratitis
arises• Transposition flaps and Z-plasties with orwithout tissue expansion are useful•
Full-thickness grafts and free flaps may beneeded for large or difficult areas• Hypertrophy
is treated with pressuregarments/Silicone patch(6-18 month)• Pharmacological treatment
of itch is important
56. 56. Chemical Burns
57. 57. Chemical BurnsAcids• Protein injury by hydrolysis.• Thermal injury is made with skin
contact.Alkali• Saponification of fat• Hygroscopic effect- dehydrates cells• Dissolves
proteins by creation of alkalineproteinates (hydroxide ions)
58. 58. Electrical Burns
59. 59. Electrical Burns• Greatest heat occurs at the points of resistance– Entrance and Exit
wounds– Dry skin = Greater resistance– Wet Skin = Less resistance• Longer the contact,
the greater the potential ofinjury– Increased damage inside body• Smaller the point of
contact, the moreconcentrated the energy, the greater the injury.
60. 60. • Electrical Current Flow–Tissue of Less Resistance• Blood vessels• Nerve–Tissue of
Greater Resistance• Muscle• Bone
61. 61. Results in………..–Serious vascular and nervous injury–Immobilization of muscles–
Flash burns– Late complications: cataracts, progressivedemyelinating neurologic loss
62. 62. – Assess patient• Entrance & Exit wounds• Remove clothing, jewelry, and leather
items• Treat any visible injuries– Thermal burns• ECG monitoring– Bradycardia,
Tachycardia, VF or Asystole– Treat cardiac & respiratory arrest– Aggressive airway,
ventilation, and circulatory management.• Consider Fluid bolus for serious burns– 20
ml/kg• Consider Sodium Bicarbonate: 1 mEq/kg• Consider Mannitol: 10 g
63. 63. Radiation burns• Local burns causing ulceration need excisionand vascularised flap
cover – usually with freeflaps• Systemic overdose needs supportive treatment
64. 64. Cold injuries• The damage is more difficult to define andslower to develop than
burns• Acute frostbite needs rapid rewarming, thenobservation• Delay surgery until
demarcation is clear
65. 65. THANKYOU