Presentation on severe skin burns at a district hospital. Adaption is made for under resourced hospitals in developing countries.

1. Burns: Assessment & Management
Dr Christian van Rij @ 8th and 15th April 2010

3. Structure Presentation
Background
• Definition/Causes
• Epidemiology
• Pathology
Assessment
• TSAB
• Burn Thickness
• Lab investigations
Treatment
• ATLS Approach
• Skin Treatment
• Special sites
• Supportive Tx
• African Adaption
• Reconstructive Tx

4. Definition Burns
Injury to the body surface caused by
• Thermal
• Electricity
• Chemicals
• Light / Radiation
Flames
55%
Chemical or
Electrical
5%
Scalds
40%
Burn causes in the UK (2004)

5. Thermal Injuries
• Flames:
– majority in adult
• Contact
– object too hot / contact too long
• Scalds
– hot fluids and gases

6. Electrical Burns
• Domestic current:
– Alternating nature can cause arrhythmias
• High tension injuries:
– Mainly voltage determent (severe > 1000V)
– Severe burns between entry & exit point
• Flash injuries
– No current through the body but heat from the
nearby discharge cause superficial skin burns

7. UV-Radiation Burns
• UV-Radiation damages DNA of superficial cells
– Temporary damage
– Benign alterations
– Malignancies
• Dark skin protects
– But malignancies are later detected
and often more aggressive

8. Ionizing Radiation
• Can detach electrons from molecules
– Penetrates deep → lesions deeper than skin only
• Causes DNA damage / Acute Radiation Syndrome
– If patient survives often cancers & birth defects

9. Chemical Burns
• Burns tend to be deep as the corrosive agent
continues until completely removed
• Alkalis tend to penetrate deeper and cause
worse burns than acids
• Some chemicals need to be treated with specific
neutralizing agents:
– Chromic acid or Dichromate salts with Sodium Hyposulphite
– Hydrofluoric acid with Calcium Gluconate 10%
– But do not treat an alkali burn with an acid or vice versa!

10. Consider non-accidental injury
Indicative are:
• Injury pattern:
– Burn of soles, palms, genitalia, buttocks, perineum
or when only upper limps are affected
– Symmetrical burns of uniform depth
– No splash marks in a scald injury
• History
– Inconsistent story
– Lack of guilt or concern

11. Epidemiology

12. DALY by Fires per 100,000 people
WHO Disease and injury country estimates, 2009

13. Age Distribution Patients
< 5 yr
20%
5-14 yr
10%
15-64 yr
60%
> 65 yr
10%
2004 UK setting

14. Prognostication in major burns
• Aggressive treatment for someone with a non-
survivable injury is inhumane
• A patient with a survivable injury should be
treated as optimal as possible
• Prognostic Burn Index: a very crude estimate of
mortality involving adding age + TBSA
– Not yet evaluated in a prospective large trial
– Need to evaluate each patient individually

15. Main Determents of Mortality
Death
Increasing
Burn Size
Inhalation
Trauma
Increasing
Age
Infection

16. Burn patient Pathology

17. Jackson’s burn zones
• Zone of coagulation
• Zone of stasis: potentially salvageable
• Zone of Hyperemia

18. Systemic Complications
• When the burn reaches >30% of TBSA
• Sites
– Cardiovascular -> shock & electrolyte imbalances
– Respiratory -> Bronchoconstriction / RDS
– Metabolic -> 3x increase in basal metabolic rate
– Immunological -> down regulation immune response
– Local: compromising constrictions

19. Burn Assessment
Anamnesis, TSAB, Burn thickness

20. History Taking
• Do it early as later you might not be able
• Exact mechanism
• Exact timing
• Exact injury
• Suspicion previous injury / non-accidental burn

21. Total Body Surface Area Burned
Superficial epithelial burned areas should not be
included, it can be mentioned separately
Three methods to make estimation of TBSAB:
1. Hand Surface
2. Wallace Chart: Rule of Nines
3. Lund and Browder Chart

22. TBSAB: Hand Surface Area
• Surface hand palm & fingers is ± 0,8%
– Bit smaller in morbid obese patients
• For estimation of burns sizes:
– Less than 15% TBSA, or
– More than 85% TBSA
± 0,8%
TBSA
S.Hettiaratchy, R.Papini; Initial management of a major burn: II - assessment and resuscitation; BMJ 2004;329:101–3

23. TBSAB: Wallace Chart - Rule of 9s
• Easiest to remember
• Anterior & Posterior
part of limbs together
• Adapted version for
children: Less accurate

24. TBSAB: Lund & Browder Chart
• Bit more extensive but
more accurate
• Separate Anterior &
Posterior percentages
• Especially in children
the best solution

25. Histology Skin
Stratum Cornea
Stratum Lucidum
Stratum Granulosum
Stratum Spinosum
Stratum Basale
Epidermis
Dermis
Papillary region
Reticular region
Subcutaneous Tissue
or Hypodermis

26. Burn Deepness: Superficial (epidermal)
• 1st Degree
• Brisk bleeding on pin prick
• Painful
• Caucasians: Red color
• Africans: Darkening
• Blanching on pressure
with brisk return of color
• Sometimes small blisters
• No scar will develop

27. Burn Deepness: Superficial Dermal
• Superficial 2nd degree
• Brisk bleeding on pin prick
• Painful
• Caucasian: Red color
• Africans: Light Brown / Red
• Blanching on pressure but
with slow return of color
• Blisters common
• Sometimes Scars

28. Burn Deepness: Deep Dermal
• Deep 2nd degree
• Delayed bleeding on prick
• Dull sensation
• Dry red / bit white color
• No blanching on pressure
• No blisters
• Gives scarring

29. Burn Deepness: Full Thickness
• 3rd degree
• No bleeding on pin prick
• No sensation
• Dry white color or Leathery
• No blanching on pressure
• Gives severe scarring

30. Burn Deepness: Overview
Assessment Epidermal /
Superficial / 1
Superficial
Dermal / 2A
Deep Dermal /
2B
Full thickness /
3
Bleeding on prick Brisk Brisk Delayed None
Sensation Painful Painful Dull None
Appearance Red / Dark Bit whiter Cherry Red White leathery
Blanching to
pressure
Yes, brisk
return
Yes, slow
return
No No
When underlying muscles or bones are affected, sometimes this
is called a 4th degree burn; but this is not official nomenclature.

31. Scald burns assessment is difficult
• Non-scald burn: deepness extends in layers
• Scald burn: give scattered pattern of deepness
– Seems only superficial dermis is affected, but the
deeper arterial plexus might already got thromboses
Brans TA, et al; Histopathological evaluation of scalds and contact burns in the pig model. Burns 1994:20 Suppl 1:S48-51

32. Additional investigations
• General Laboratory
– Full blood count; packed cell volume; urea;
electrolytes; clotting screen; blood group; crossmatch
• Electrical injuries
– 12 lead electrocardiography
– Cardiac enzymes
• Inhalational injuries
– Chest x-ray
– Arterial blood gas analysis

33. Advanced Trauma Life Support Approach
Oxygenation and Circulation

34. Airway with cervical spine control
• Inhalation of hot gases results in a airway at risk
– Look for inhalation trauma indicators
– Becomes oedematoes over next hours, especially
after starting fluid resuscitation
– Inspection Oropharinx by anaesthesist required
– Indications for intubation:
• Erythema or swelling of the oropharynx
• Change in voice with hoarseness or harsh cough
• Stridor, tachypnoea, or dyspnea

35. Breathing problems
• Mechanical restriction due to chest eschars
• Blast injury
• Smoke as direct irritant to the lungs
• CO inhalation results in Carboxyhaemoglobin
• All patients should receive 100% O2 through
humidified non-rebreathing mask at admission

36. Circulation: Fluid management
• Resuscitation goal:
– To maintain tissue perfusion to the zone of stasis
– To achieve proper organ perfusion
• How much?
– Too little fluids causes poor perfusion & hypoxia
– Too much fluids causes oedema which will again
result in poor perfusion & hypoxia
– Should be based on physiological parameters

37. Parkland Schedule for Resuscitation
• 4ml (crystalloids) × TBSAB(%) × weight(kg)
– Give 50% in the first 8 hours following the trauma
– Give remaining 50% in the next 16 hours
– High tension electrical & airway burns require more
• Consider to add the daily maintenance fluid
• Sodium chloride solution should be avoided as
it can cause hyperchloraemic metabolic acidosis

38. Circulation: Escharotomy
• Resuscitation can increase wound
oedema and swelling beneath
non-elelastic burnt tissue
• Raised tissue pressure can impair
circulation
• Escharotomy may be required

39. Neurological Disability
• Other trauma is often forgotten:
– E.g. falling from height after high tension injury
• Confusion can be due to:
– Hypoxia
– Hypovolemia
– Head Trauma
– Septicemia
– Psychological shock

40. Pain Control
• Burns are very painful
• Combined analgesics reduces need for
increasing narcotic doses for breakthrough pain
• Don't give IM drugs if TBSAB > 10% as
absorption is then unpredictable
• Lorazepam has recently been found to lessen
burn pain, largely by treating acute anxiety

41. Expose with Environmental control
• Top to toe on front & back should be examined
• Patients (children) become easily hypothermic
– Will lead to hypoperfusion of the zone of stasis
causing extension of the zone of coagulation

42. Treatment of the burned skin
1st aid to skin, skin toilet, grafting, strictures, keloid

43. 1st Aid to the burned skin
• Skin cooling:
– Remove all non-sticking clothing
– Prompt irrigation with tap water for 20 minutes
– Chemical burns require longer rinsing (up to 24h)
– Do not use very cold water as it causes
vasoconstriction worsening tissue ischemia
– Prevent hypothermia

44. 1st Aid to the burned skin
• Dressing
– Helps relieve pain and keeps the area clean
– Moist environment fastens wound healing
– After 48h again, then every 3-4 days (unless soaked)
• Types:
– Continuously water soaked gauzes
– Paraffin or Vaseline gauzes
– Transparent Polyvinylchloride film
– Silver sulfadiazine gauzes (only after wound assessment)

45. Epidermal burns
• Analgesia usually only requirement treatment
• Healing occurs rapidly within a week with
regeneration from undamaged keratinocytes

46. Superficial Dermal Burns
• Healing within 2 weeks by keratinocytes from
the sweat glands & hair follicles
• Progression to deeper is unlikely if the wound is
kept moist
• Elevate the affected limb for 48h

47. Deroofing Blisters: controversial
• Pro Deroofing
– Allows burn depth assessment
– Blister fluid is a medium for bacterial growth
– Blister fluid suppresses immunity (an in-vitro study)
• Contra Deroofing
– Intact blisters acts as a sterile stratum spongiosum
• ‘Consensus’: large blisters to be deroofed

48. Deep Dermal burns
• Most difficult to assess: reexamine after 48h
• Lower density of skin adnexae → slower healing
• Associated with contractures / keloid
• Excise to a viable depth in cosmetic/large areas
• Dress non-adhesively and elevate

49. Full Thickness Burns
• Spontaneous healing only from edges
• Necrosis should be excised
• If primary excision and closure is not possible:
– Grafts or Transposition flaps

50. Skin Grafting
• Type of graft:
– Meshed thin/thick split graft
– Full thickness (pinch) graft
– Thicker is better for graft site;
but worse for donor site
• Grafts have no blood supply
– Do not graft where no
granulation can occurs; like
cartilage, bone or naked tendon

51. Skin Grafting Technique

52. Skin Grafting Technique

53. Skin grafting as a priority
Make the mistake of grafting too
often instead of too little
If you wait too long:
– Granulation tissue will be older
making grafts take less well
– Prolonged fibrosis will give worse
scars and contractures
Consider priority areas first

54. Flap translocations
• The transfer whole thickness skin with intact
blood supply
• Flaps should be considered
– If very quick closing of the skin deficit is crucial
– If reconstruction of underlying structures is needed
– If at the site split skin grafts are unlikely to take

55. Flap Types
• Free Flap
– The blood supply is isolated, disconnected, then
reconnected at a remote site
• Perforator Flaps:
– Flaps in which tissues are isolated on small
perforating vessels that run from major vessels to
supply the surface
• Composite Flaps:
– Composed of various tissues and transferred
together; often skin with bone or muscle

56. Flap Types
• Random Flap:
– Local transposition ignoring blood vessel paths
– Length to width ratio not more than 1 ½ :1
• Axial Flaps:
– Local transposition respecting blood vessel paths
– Longer flaps with length to width ratio of 6:1
• Pedicled or Islanded Flap
– Have a very narrow base around stalk of supplying
vessels around which it can be rotated

57. Random Flap subtypes
• Advancement flap
• Rotation flap
• Bilobed flap
• Bipedicle flap
• Z-plasty
• Y-V-plasty
Often used for contraction release

58. New Developments
• Cultured epithelial autografts
– Can be applied as suspension after one week, or
– As sheet after three weeks
– Can be combined with a mesh grafts to improve
cosmetic results
• Vacuum-assisted closure
• Skin traction techniques

59. Special Sites
Face, Ears, Hands and Feet

60. Facial skin burns
• Clean face with diluted chlorohexidine bd
• Apply cream (such as liquid paraffin) every hour
• Sleep with pillows to minimize oedema
• Men: shave daily
• Use unmeshed skin grafts only
• Priority: Eye lids must be able to be closed

61. Covering the cornea is an emergency
Options:
1. Fill cornea temporarily with CAF ointment 6h
2. Make relaxation incisions (esp. for upper lid)
3. Early inlay split skin graft
4. Temporary tarsorrhaphy
Caution:
• Do not use steroids
• Do not apply gauzes to the cornea (it rubs)

62. Burns to the Cornea
• Examine the cornea early (swelling comes quick)
– Usually the cornea is not burned but eyelids only
– Use fluorescein to look for ulcers
• Treatment corneal burn:
– If hazy cornea: apply CAF and atropine eye drops
– If punctae or canaliculae are damaged: pass a style or
indwelling suture through them to keep them open
– If palpebral & ocular conjunctivae stick together:
separate them with a glass rod

63. Ear burns
• Inflammation of the cartilage can occur when
the skin has already healed
• Symptoms: acutely painful, red and tender
• Necrotic cartilage will infect and slough;
taking down the finely shaped skin

64. Removing necrotic cartilage
• Incise outer border ear
• Remove any non resilient yellow cartilage
• Reexamine after 24h to remove new necrosis
• Keep it moist with saline
• Don’t bend cartilage

65. Burned Hands
• Dorsal hand burns are complicated
• Refer burned tendons, bone, cartilage and joints
• Exposed joints usually require amputation or
arthrodesis (in a functional position)
• Thick burns to finger often need escharotomy
• Excising/grafting hand/foot burns is a priority!

66. Burned Hand or Feet
• Raise his hand high to minimize oedema
• Moist plastic bag method best way of dressing
– It keeps the fingers moist, mobile, painless
– Daily wash his hand and apply antiseptic like silver
• Physiotherapy and splinting in position of safety
are needed to prevent stiffening & contractures
– Dynamic splinting or night splinting

67. Supportive Treatment
Antibiotics, Nutrition, Psychology

68. Systemic Antibiotic Prophylaxis
• Meta-analysis could not really confirm benefit:
– Only proven benefit with huge quantities of triple Tx
– Prophylaxis before surgery might be beneficial
• Burn units: known for Resistance development
→ Systemic antibiotics only for established
infections with the smallest spectrum possible
→ Topical antimicrobials are advised
Avni T, Levcovich A, et al; Prophylactic antibiotics for burns patients: systematic review and meta-analysis. BMJ 2010;340:c241c

69. Nutritional importance
• Prevent catabolic state: an anabolic state is
required for healing
• (Small) injuries can triple basal metabolic rate
– Associated with hyperpyrexia
• Splachnic hypoperfusion decreases absorption
and motility

70. Management hypermetabolic response
• Reduce heat loss by environmental conditioning
• Ensure quick closure of wounds
• Early recognition and treatment of infection
• Early enteral feeding

71. Physiotherapy
• Elevation, Splinting and Exercises improve
outcome very significantly
• Needs to start on day one, given on daily basis
• Splinting essential to prevent contractures

72. Nursing Tasks
• Positioning
• Regular dressings
• Encouraging exercises
• Encouraging proper feeding
• Psychosocial support
• Monitoring
• Administering drugs

73. Psychological characteristics
Challenges
• Pain
• Anxiety (acute stress /
PTS disorder)
• Depression
• Sleep disturbance
• Increase of premorbid
psychopathology
• Grief
Treatments
• Drug management of
anxiety, depression
sleeplessness and pain
• Brief counselling
• Teach non-drug
approaches to pain
management

74. Staring
“The way we choose to interpret
and perceive stares will influence
our ability to cope with them”
“By strengthening our social
skills, we can overcome the
challenge of looking different”
“Remember, you are in control
and not the person staring:
become conscious of your own
behavior”
Why people are staring
Compassioned
Concern
Curious
Overwhelmed
by trauma
Rude
Amy Acton, burn survivor, www.phoenix-society.org

75. Adaption to our Africa Setting
Non-specialized staff, Limited equipment and drugs

76. Patient Case

77. 4 possible approaches
1. Early excision followed by
– Dressing and early grafting, or
– Flap Application
2. Occlusive dressing
3. Air dried dressing
4. Soaked dressing
Commonly practiced in
well resourced and
specialized settings
(discussed above)
Advocated for an
under-resourced or
non-specialized setting

78. 1: Early Excision and grafting
• Excise necrotic tissue (within 3/7) and graft it
directly (within 3/7) before it becomes infected
• You must be sure the burn is full thickness
• Severe bleeding is the main danger
– Have adrenalin injections and transfusion at hand

79. 2: Occlusive Dressing

80. 2: Occlusive Dressing
• For non full thickness burns
• Dressing burn wound >2cm thick
– Sealing the wound to prevent bacteria reaching it
• Assuming the burn made the wound sterile, and
• Dressing is applied aseptically immediately, and
• Wound fluids are absorbed before reaching the surface
– Leave undisturbed and new skin has grown after 10/7
! Done badly this dressing is a disaster !

81. 3: Open / Air-dried method

82. 3: Open / Air-dried method
• A dried crust is an effective barrier
– Air will dry the wound and is barely contaminative
– Use bed cradles as clothes & flies contaminate
– Wound fluids must be removed to get a dry crust
– Regular application of povidon iodine is advocated
• If an eschar / slough needs to come off, you
might change to soaked dressings
• Be aware of hypothermia

83. 4: Water Soaked Dressing
• Put gauzes over the wound and keep it
constantly wet with half strength saline hourly
– Pouring from a jug with a Macintosh under the burn
– Immersing the burn in a (daily refreshed) bucket
• Patient should exercise while immersed for 20 minutes bd
• Sloughs on a deep burn will usually separate on
the 12th day and be ready for grafting on the
15th to 17th day

84. 4: Water Soaked Dressing
• Advantages:
– Reduces hospital time compared to the dry method
– Is painless, easy and cheap
– Suitable for superficial as well as deep burns
– Eschars will turn to Sloughs and will separate early
• Disadvantages:
– Not easy on the thorax in adults
– Difficult to combine with splinting
– Caution for hypothermia

85. Slough and Eschars
• Slough & Eschars: a thick layer of dead tissue:
– Sloughs are moist, soft and stinking
– Eschars are dry, hard and dark
• Eschars can impair circulation → Escharotomy
• Eschars can protect against infection
• If infected they should be removed directly:
– under an antibiotic cover
– if bleeding is excessive, consider removing in stages

86. Other considerations for adaption
• Systemic Antibiotics
– Also in Africa no evidence of a prophylactic benefit
– Resistance development is not less common, while
– Spread of resistant bacteria is much more likely due
to limited isolation
• Blisters
– Some argue that “due to less hygienic environment
you should also keep larger blisters intact”

87. Reconstruction Surgery
Contractures and Keloids

88. Contractures

89. Preventing Contractures
• Prevent full thickness burns
• Make grafting joints a priority
– Graft early on a thin layer of granulation to prevent
extensive (contracture forming) fibrosis
– Use unmeshed full thickness grafts at joints
– Place grafts across the joints
• Splinting is effective against grafting
– But it can stiffen a joint if applied 24h
– Serial casting are not effective for burn contractures

90. Skin expansion

91. Incision Releases for wide contractures

92. Z-Plasty for narrow contractures

93. Z-Plasties combined to gain effect

94. Y to V Plasty

95. Hypertrophic / Keloid Scarring
• Keloid: hypertrophic scarring outside area burnt
• Influenced by many factors
• Pressure garments are the primary intervention
• Other options:
– Special contact media (e.g. silicone gel)
– Moisturizing creams
– Massage
– Surgery

96. Following up a burn survivor
• Healed burns will be sensitive; are often
dry/scaly and may have pigment changes
• Use moisturizer cream
• Sun protection for 6-12 months
• Pruritis is common:
– Massage with aqueous creams like Aloe Vera
– Antihistamines and analgesics can help
• Psychological / Social assessment

97. Questions and Discussion
What can we implement/improve at our Hospital?

98. References
• ABC of Burns;
– BMJ Books; 1 Ed.; 2005; ISBN: 978-0727917874
• Emergency and early management of burns and scalds
– Enoch S; BMJ 2009;338:b1037
• Prophylactic antibiotics for burns patients:
systematic review and meta-analysis;
– Avni T, et al; BMJ 2010;340:c241
• Primary Surgery; Volume Two;
– King M; Chapter 58; 1st ed; 1993
• Bailey & Love’s Short practice of Surgery:
– Williams N; Chapter 28-29; 25th ed; 2008