Management of burn

1. DR A H ELKASHIF

2. 
-Burns cause damage in a number of
different ways, but by far the most common
organ affected is the skin.

However, burns can also damage the airway
and lungs
-The hot gases can physically burn the
nose, mouth, tongue, palate and larynx—--
swelling—blockage of airway.

3. 
■ Burns around the face and neck

■ A history of being trapped in a burning
room

■ Change in voice

■ Stridor

4. Dangers of smoke, hot gas or steam inhalation
■ Inhaled hot gases can cause supraglottic airway burns and
laryngeal oedema
■ Inhaled steam can cause subglottic burns and loss of
respiratory epithelium
■ Inhaled smoke particles can cause chemical alveolitis and
respiratory failure
■ Inhaled poisons, such as carbon monoxide, can cause
metabolic poisoning
■ Full-thickness burns to the chest can cause mechanical
blockage to rib movement.

5. .
- Carbon monoxide(CO) binds to Hb with an affinity more
than 200
.blocks the transport of oxygen
.
times greater than that of
oxygen
-Carboxyhaemoglobin in the bloodstream can be
measured. Concentrations above 10 % are dangerous and
need treatment with pure oxygen for more than 24 hours.
-Death occurs with concentrations around 60 %.

6. INFLAMMATION AND CIRCULATORY CHANGES
-circulatory changes following burn are more
complex
-The overall effect of these changes is to produce a
net flow
of water, solutes and proteins from the
intravascular to the
extravascular space
what is the importance of measuring the
TBSA?
(
(total body surface area
It dictates the size of inflammatory reaction and therefore the amount
of fluid needed to control shock

7. 
■ Burns produce an inflammatory reaction

■ This leads to increased vascular
permeability

■ Water, solutes and proteins move from the
intra- to the extravascular space

■ The volume of fluid lost is directly
proportional to the area of the burn

■ Above 15 per cent of surface area, the loss
of fluid produces shock

8. Other complications of burns
■ Infection from the burn site, lungs,
gut, lines and catheters
■ Malabsorption from the gut
■ Circumferential burns may
compromise circulation to a limb

9. Pre-hospital care

10. 1.Ensure rescuer safety.
2. Stop the burning process.
3. Check for other injuries. A standard ABC
(airway,
breathing, circulation).
4. Cool the burn wound.
5. Give oxygen.
6. Elevate.

11. Hospital care
The principles of managing an
acute burn injury are the same as in
any acute trauma case

12. •
A, Airway control
•
B, Breathing and ventilation
•
C, Circulation
•
D, Disability – neurological
status
•
E, Exposure with environmental
control
F, Fluid
resuscitation

13. Major determinants of the outcome of a
burn
■ Percentage surface area involved
■ Depth of burns
■ Presence of an inhalational injury

14. Initial management of the burned airway
■ Early elective intubation is safest
■ Delay can make intubation very difficult
because of swelling
■ Be ready to perform an emergency
cricothyroidotomy, if intubation is delayed
Mechanical block to breathing-----escharotomy.

15. Recognition of the potentially burned airway
■ A history of being trapped in the presence
of smoke or hot gases
■ Burns on the palate or nasal mucosa, or
loss of all the hairs in the nose
■ Deep burns around the mouth and neck

16. The criteria for acute admission to a burn
unit.
-Suspected airway or inhalational injury
-Any burn require fluid
resuscitation
-Any burn require surgery
-burns to the hands, face, feet or perineum .
-burn in a patient at the extremes of age
-burn with associated potentially serious
sequelae, including high-tension electrical
burns and concentrated hydrofluoric acid
burns

17. ASSESSMENT OF THE BURN
WOUND
Assessing the area of a burn
■ The patient’s whole hand is 1 per cent TBSA, and is a
useful
guide in small burns
■ The Lund and Browder chart is useful in larger burns
■ The rule of nines is adequate for a first approximation
only
Assessing the depth of a burn
■ The history is important – temperature, time and burning
material
■ Superficial burns have capillary filling
■ Deep partial-thickness burns do not blanch, but have some
sensation
■ Full-thickness burns feel leathery and have no sensation

18. Superficial partial-thickness burns
The damage in these burns goes no
deeper than the papillary dermis.
The clinical features are blistering
and/or loss of the epidermis. The
underlying dermis is pink and moist.
The capillary return is clearly visible
when blanched. Pinprick sensation is
normal.
Superficial partial-thickness burns heal
without residual scarring in 2 weeks.
The treatment is non-surgical

19. Deep partial-thickness burn
-Damage to the deeper parts of the reticular
dermis . Clinically, the epidermis is usually
lost. The exposed dermis is not as moist as
that in a superficial burn.
-
-often abundant fixed capillary staining.
Thecolour does not blanch with pressure .
-
- sensation is reduced, the patient is
unable to distinguish sharp from blunt
pressure when examined with a needle.
Deep dermal burns take 3 or more weeks to
heal without surgery and usually lead to
hypertrophic scarring.

20. Full-thickness burns
The whole of the dermis is destroyed in
these burns .
Clinically, they have a hard, leathery
feel. The appearance can vary from that
similar to the patient’s normal skin to
charred black, depending upon the
intensity of the heat. There is no
capillary return. Often, thrombosed
vessels can be seen under the skin.
These burns are completely
anaesthetised.

21. Fluids for resuscitation
■ In children with burns over 10 per cent
TBSA and adults with burns over 15 per cent
TBSA, consider the need for intravenous fluid
resuscitation
■ If oral fluids are to be used, salt must be
added
■ Fluids needed can be calculated from a
standard formula
■ The key is to monitor urine output

22. There are three types of fluid used.
1.Ringer’s lactate or Hartmann’s
solution
2.human albumin solution or fresh-
frozen plasma
3.hypertonic saline.

23. Parkland formula. This calculates the
fluid to be replaced in the first 24 hours
total percentage body surface area× wt.
(kg)× 4 = volume (mL).
-Half this volume is given in the first 8
hours and the second half is given in the
subsequent 16 hours.

24. 

Circumferential full-thickness burns to the
limbs require emergency surgery___

25. Principles of dressings for burns
■ Full-thickness and deep dermal burns
need antibacterial
dressings to delay colonisation prior to
surgery
■ Superficial burns will heal and need simple
dressings
■ An optimal healing environment can make
a difference to
outcome in borderline depth burns

26. Analgesia
Burns patients need extra feeding
Burns patients are immunocompromised
They are susceptible to infection from many
routes
Physiotherapy

27. SURGERY FOR THE ACUTE BURN
WOUND
Any deep partial-thickness and full-
thickness burns, except
those that are less than about 4cm2,
need surgery

28. Surgical treatment of deep burns
■ Deep dermal burns need tangential shaving and
split-skin
grafting
■ All but the smallest full-thickness burns need
surgery
■ The anaesthetist needs to be ready for
significant blood loss
■ Topical adrenaline reduces bleeding
■ All burnt tissue needs to be excised
■ Stable cover, permanent or temporary, should be
applied at
once to reduce burn load

29. Delayed reconstruction of burns
■ Eyelids must be treated before exposure
keratitis arises.
■ Transposition flaps and Z-plasties with or
without tissue expansion are useful.
■ Full-thickness grafts and free flaps may be
needed for large or difficult areas.
■ Hypertrophy is treated with pressure
.garments
■ Pharmacological treatment of itch is
important.

30. Initial cleaning of the burn wound
-Washing the burn wound with chlorhexidine solution is
ideal for this purpose.
-For initial management of minor burns that are
superficial or
partial thickness, dressings with a non-adherent material,
such
as Vaseline-impregnated gauze are sufficient.
-These dressings are left in place for 5 days and healed
after 7–10 days. ----Various topical creams and
ointments have been used for the treatment of minor
burns.
- petroleum gauze.
-Silver sulphadiazine (1 per cent)
-or Flamazine

31. Burns that are being managed conservatively
should be healed within 3 weeks. If there are no
signs of re-epithelialisation in this time, the
wound requires debridement and grafting
Electrical burns
■ Low-voltage injuries cause small, localised, deep burns
■ They can cause cardiac arrest through pacing interruption
without significant direct myocardial damage
■ High-voltage injuries damage by flash (external burn) and
conduction (internal burn)
■ Myocardium may be directly damaged without pacing
interruption
■ Limbs may need fasciotomies or amputation
■ Look for and treat acidosis and myoglobinuri

32. Radiation burns
■ Local burns causing ulceration need
excision and
vascularised flap cover, usually with free
flaps
■ Systemic overdose needs supportive
treatment

33. Chemical burns
■ Damage is from corrosion and poisoning
■ Copious lavage with water helps in most cases
■ Then identify the chemical and assess the risks of
absorption