Burn Injury and introduction & physiology

BURN INJURY
Dr Phillipo Leo Chalya
M.D. [Dar]; M.MED surg [Mak]
Surgeon Specialist - BMC

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DEFINITION
Burn injury can be defined as bodily
injury resulting from exposure to heat,
cold, chemical, electricity or radiation
Burn causes coagulation necrosis of the
skin and underlying tissues

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EPIDEMIOLOGY
Incidence
Burn injury constitutes a major health
problem allover the world affecting
approximately 1% of the world
population each year
In the United States, approximately 2.4
million burn injuries are reported every
year
In TZ burn injury is one of the
commonest form of trauma

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Morbidity / mortality
Burn injury contributes significantly to
high morbidity and mortality
Patients with extensive burns frequently
die, and for those with less severe
injuries, physical recovery is slow and
painful
In addition to physical damage caused
by burns, patients also may suffer
emotional and psychological problem

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Age
Age incidence depends on the type of
burn
Scald is common in children < 5 year of
age while flame, electrical and chemical
burn injuries are common in adult

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Sex
Sex distribution depends on the place of
burn
Domestic burn injury is common in
females while occupational and
recreational burns are common in males

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Race
No racial predilection exists in burn
injuries

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ETIOLOGY
Thermal injuries
– Scald
– Flame
– Contact
Chemical injuries
Electrical injuries
Radiation injuries
Cold injuries

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Mechanism of injury
Depends on the causes
– Thermal injuries
• Scald
• Flame
• Contact
– Chemical injuries
– Electrical injuries
– Radiation injuries
– Cold injuries

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Thermal injuries
Scalds
– About 70% of burns in children are caused
by scalds
– They also often occur in elderly people
– The common mechanisms are spilling hot
drinks or liquids or being exposed to hot
bathing water
– Scalds tend to cause superficial to
superficial dermal burns

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 Flame
– Flame burns comprise 50% of adult burns
– They are often associated with inhalational injury
and other associated injuries
– Flame burns tend to be deep dermal or full
thickness
 Contact
– In order to get a burn from direct contact, the object
touched must either have been extremely hot or the
contact was abnormally long
– The latter is a more common reason, and these
types of burns are commonly seen in people with
epilepsy or those who misuse alcohol or drugs
– They are also seen in elderly people after a loss of
consciousness
– Contact burns tend to be deep dermal or full
thickness

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Electrical injuries
 Account for 3-4% of burn admissions
 An electric current will travel through the
body from one point to another, creating
"entry" and "exit" points
 The tissue between these two points can be
damaged by the current
 The amount of heat generated, and hence the
level of tissue damage, is equal to
0.24x(voltage)2xresistance
 The voltage is therefore the main determinant
of the degree of tissue damage

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 Electrocution injuries can be divided into two
categories:-
– Low voltage injuries
• Considered to be anything <1000 volts
• This includes domestic electrical supply
– High voltage injuries
• Can be further divided into:-
– True high tension injuries
• Caused by high voltage current passing through the body
• > 1000V
• There is extensive tissue damage and often limb loss
• There is usually a large amount of soft and bony tissue
necrosis
• Muscle damage gives rise to rhabdomyolysis, and renal
failure may occur with these injuries
– Lighting injuries
• Caused by exposure to an extremely high voltage
current
• Result from an ultra high tension
 A particular concern after an electrical injury is
the need for cardiac monitoring

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Chemical injuries
Chemical injuries are usually as a result
of industrial accidents but may occur
with household chemical products
Chemical burn may also occur as a
result of assault
These burns tend to be deep, as the
corrosive agent continues to cause
coagulative necrosis until completely
removed
Alkalis tend to penetrate deeper and
cause worse burns than acids

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Radiation injuries
These burns are frequently caused by
ultraviolet rays from the sun and nuclear
sources

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Cold injuries
Results from exposure to extremely cold
→tissue necrosis

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CLASSIFICATION
According to the type [causes] of burn
– Thermal burn
• Scald
• Flame burn
• Contact burn
– Electrical burn
– Chemical burn
– Radiation burn
– Cold burn

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According to body site burned
– Facial burn
– Head & neck
– Trunk
– Limbs
– Perineal burn etc
According to burn depth
– Superficial burn
• Epidemal
• Dermal
– Deep burn
• Dermal
• Full thickness
– Mixed burn

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According to the degree of tissue injury
– First degree burn
– Second degree burn
– Third degree burn
– Fourth degree burn
According to the Size/Extent of Burn
Injury
– Total body surface area (TBSA) burned
According to the severity of burn
– Minor burn
– Moderate burn
– Major burn

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PATHOPHYSIOLOGY
Burn injuries result in:-
– local response
– systemic response

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A. Local responses
Divided into three zones of a burn
which were described by Jackson in
1947 →Jackson’s zones of burn wound
These zones include:-
– Zone of coagulation
– Zone of stasis/ischaemia
– Zone of hyperamia

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Jackson's burns zones

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a. Zone of coagulation
This occurs at the point of maximum
damage
In this zone there is irreversible tissue
loss due to coagulation of the
constituent proteins

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b. Zone of stasis /ischemia
 The zone of stasis is characterized by decreased
tissue perfusion
 The tissue in this zone is potentially salvageable
 The main aim of burns resuscitation is to
increase tissue perfusion here and prevent any
damage becoming irreversible
 Additional insults—such as prolonged
hypotension, infection, or edema—can convert
this zone into an area of complete tissue loss

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c. Zone of hyperaemia
In this outermost zone tissue perfusion
is increased
The tissue here will invariably recover
unless there is severe sepsis or
prolonged hypoperfusion

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B. Systemic response
The release of cytokines and other
inflammatory mediators at the site of
injury has a systemic effect once the
burn reaches 30% of total body surface
area

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a. Cardiovascular changes
Capillary permeability is increased,
leading to loss of intravascular proteins
and fluids into the interstitial
compartment
Peripheral and splanchnic
vasoconstriction occurs
Myocardial contractility is decreased,
possibly due to release of tumor necrosis
factor

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Cardiac output decreases due to loss of
intravascular volume
These changes, coupled with fluid loss
from the burn wound, result in systemic
hypotension and end organ
hypoperfusion

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b. Respiratory changes
Inflammatory mediators cause
bronchoconstriction, and in severe
burns adult respiratory distress
syndrome can occur
Pulmonary dysfunction may occur as
result of:-
– Inhalation injury
– Aspiration
– Shock
– Upper airway injury/edema
– Circumferential thoracic eschar → RLD
Hypovolemia may cause V/Q mismatch

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c. Gastrointestinal changes
Characterized by mucosal atrophy,
changes in the digestive absorption and
 intestinal permiability
Burn also causes reduced glucose,
amino acids and fatty acids
Stress (curling’s) ulcer
Acute pseudo-obstruction of the colon
– massive colonic dilation without organic
cause
Acalculous cholecystitis

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d. Renal changes
Uncommon, but can result from:
– prolonged hypotension due to hypovolemia
– myoglobin release from damaged
muscle/tissue
– hemoglobinuria from heat-induced
 BV & CO  RBF GFR:-
– Release of Angiotensin II, aldosterone,
vasopresinfurther reduction of RBF &
GFRARF
– Oliguria ATN & ARF

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e. CNS Changes
CNS dysfunction in up to 14% of burn
patients
– most had >50% BSA involvement
Hypoxia most common etiology
– smoke inhalation, pulmonary edema,
pneumonia

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f. Haematological changes
Mild thrombocytopenia (sequestration)
early, followed by thrombocytosis (2-4x
normal) by end of the first week
Persistant thrombocytopenia associated
with poor prognosis--suspect sepsis
DIC with generalized bleeding can
occur
– shock, sepsis, hypoxia, reperfusion

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g. Immunologic Changes
Loss of Skin as an organ of host
defense→:-
– Loss of keratin layers which act as physical
barrier to bacterial invasion →wound
sepsis
– Loss of stratum corneum containing of
unsaturated free fatty acid film which is
bacteriostatic and fungistatic
 Cellular Immune Function
– Several circulating mediators in burn
patient sera suppress normal lymphocyte
function
– CD4 count

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Humoral Immune Function
– immunoglobulin levels decreased
proportional to burn size
– leakage of IgG & IgA from the circulation,
fibronectin depletion, impaired
opsonization
Phagocyte Function
– early granulocytopenia common
– diminished chemotactic responsiveness
• diffuse endothelial cell activation, and adhesion
molecule overexpression
– decreased oxygen radical production, with
impaired bactericidal activity
– PMN margination/aggregation

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h. Metabolic changes
Metabolic changes in burn injury occur
in 2 phases:-
– Ebb phase
– Flow phase
• Catabolic phase
• Anabolic [recovery phase]

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Ebb phase
Occurs during the 1st 24 hours
Characterized by  MR, hypothermia,
CO &  oxygen consumption

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Flow phase
Subdivided into 3 phases:-
– Catabolic phase
– Anabolic phase

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a. Catabolic phase
 Occurs after 24 hours after burn injury
 Characterized by:-
– ↑ Cardiac output
– ↑ Oxygen consumption
– ↑ Heat production [hyperthermia]
– ↑ BMR
– Hyperglycemia
– Proteolysis
– Peripheral lipolysis
 Mediated through release of catabolic
hormones [ i.e. catecholamines,
glucocorticoids, glucagon etc ] and other
chemical mediators e.g. cytokines, lipid
mediators etc

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b. Anabolic phase
Also called recovery phase
Characterized by:-
– Slow re-accumulation of protein and fat
– This phase continues for weeks to months
after injury

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Clinical presentation
History
Physical examination
– General
– Systemic
– Local

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History
Patient characteristics
– Age
– Sex
History of injury
– Time of burn
– Place of burn
– Nature of injury
• Intentional
• Unintentional
• Undetermined

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Type of burn
– Thermal
– Chemical
– Electrical
– Radiation
– Cold
Mechanism of injury
Associated injuries
Associated inhalation injuries
Associated clothing iginition
Whether first aid measures was done at
the site of accident

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Physical examination
General
– Body weight
– Shock
– Level of consciousness
– Dyspnoea
– In pain
– Restless ± gasping
– Anaemic
– Dehydration
– Etc

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Systemic examination
– Cardiovascular system
– Respiratory system
– PA
– CNS
Local examination [assessment of burn
wound]
– Body region burned
– Extent of burn
– Burn depth
– Severity of burn

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a. Body region burned
Head / neck
Upper limbs
Trunk
Lower limbs
Genitalia / Perineal areas

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b. Extent of burn [%TBSA]
Size of a Burn Injury
– Total Body Surface Area (TBSA) Burned
• Palmar Method
– A quick method to evaluate scattered or localized burns
– Client’s palm = 1 % TBSA
• Rule of Nines
– A quick method to evaluate the extent of burns
– Major body surface areas divided into multiples of nine
– Modified version for children and infants (Rule of
Sevens )
• Lund-Browder Method
– Most Accurate; based on age (growth)
– Can be used for the adult, children & infants

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c. Burn depth
 Superficial (First Degree)
 Partial Thickness
– Superficial ( Second Degree)
– Deep ( Second Degree)
 Full Thickness ( Third Degree)
 Deep-Full Thickness (4th degree)

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i. Superficial (First Degree)
Involves the epidermis
– Wound Appearance:
• Red to pink (light skin)
• Mild edema
• Dry and no blistering
• Pain / hypersensitivity to touch
– i.e. Classic sunburn
• Desquamation occurs 2-3 days
– Wound Healing
• Wound Healing spontaneous
• Duration 3 to 5 days
• No scarring / other complications

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Superficial-1st Degree Burns

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ii. Superficial - 2nd Degree Burns
 Involves upper 1/3 of dermis
• Red to pink
• Wet and weeping wounds
• Thin-walled, fluid-filled blisters
• Mild to moderate edema
• Extremely painful
– Wound Healing:
• In 2 weeks (spontaneous)
• Minimal scarring; minor pigment discoloration
may occur

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Superficial - 2nd Degree Burns

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iii. Deep 2nd Degree Burns
Wound Appearance:
– Mottled: Red, pink, to white surface
– Moist
– No blisters
– Moderate edema
– Painful; usually less severe than superficial 2nd
Degree
Wound Healing:
– May heal spontaneously 2-6 weeks
– If so Hypertrophic scarring / formation of
contractures
Wound Management:
– Treatment of choice: surgical excision & skin
grafting

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Deep 2nd Degree Burns
(10th day post-burn)
Deep 2nd Degree

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iv. Full-Thickness Burns (3rd degree)
Involves the entire epidermis and dermis
• Dry, leathery and rigid
• + Eschar (hard and in-elastic)
• Red, white, yellow, brown or black
• Severe edema ( ? Escharotomy in limbs, chest)
• Painless & insensitive to palpation
– Wound Healing:
• No spontaneous healing;
weeks to months with graft
– Wound Management:
• Surgical excision & skin grafting

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v. Deep, Full-Thickness Burns
Extends beyond the skin to include
muscle, tendons & possibly bone.
• Black (dry, dull and charred)
• Eschar tissue: hard, in-elastic
• No edema
• Painless & insensitive to palpation
– Wound Healing:
• No spontaneous healing; weeks to months with
graft
– Wound Management:
• Surgical excision & skin grafting
• Frequently requires amputation if extremity
involved

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iv. Full-Thickness Burns
3rd Degree
5th to 6th Degree

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d. Severity of burn
Severity is determined by:-
– Type of burn
– Depth of burn injury
– Total body surface (TBSA) burned
– Location of burn( face, hands, feet and perineum are
considered severe !! )
– Patient’s Age
– Presences of other preexisting medical
conditions
– Presence of associated injuries
– Complications ( Inhalation , Hypothermia , Shock )

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Severity classified as follows:-
– Minor
– Moderate
– Major

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i. Minor burn injury
Characterized by:-
– <10% in adult
– < 5% <10 yo >50 yo
– < 2% full thickness
– No associated injuries, no complications,
no pre-morbid illness, no circumferential
burns, not involving the hands, face,
perineum
Minor burn needs outpatient
management

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ii. Moderate burns
Moderate – admit
– 10 - 20 % in adult
– 5 - 10 % <10 yo >50 yo
– High voltage, suspected inhalation,
circumferential or susceptibility to
infection

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iii. Major burns
 Second and third-degree burns greater than
10% body surface area (BSA) in patients under
10 or over 50 years of age
 Second and third-degree burns greater than
20% BSA in patients between 10 and 50 years
of age
 Second and third-degree burns with serious
threat to functional and cosmetic impairment
that involve the face, hands, feet, genitalia,
perineum, and other major joints
 Third-degree burns greater than 5% BSA
 Specialized injuries such as electrical burns,
including lightning and chemical burns, with
serious threat of functional or cosmetic
impairment

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Significant inhalation injuries
Circumferential burns of the extremities
or the chest
Pre-existing medical disorders that
complicate management, prolong
recovery, or affect mortality
Concomitant trauma in which the burn
injury poses the greatest risk of
mortality

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WORK UP
Lab studies
– Serum creatinine
– Serum electrolytes
– WBC + ESR
Imaging studies
– CXR
Endoscopic studies
– Bronchoscopy

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management
Objectives of management
Burn team
Criteria for admission
Phases of management

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Objectives of management
To prevent fluid and electrolyte
imbalance
Rapid and painless healing
To prevent complications
Rehabilitation

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Burn team
 Consists of multidisciplinary group whose
individual skills are complementary to each
other
 Includes:-
– Surgeons –reconstructive (plastic), General or
trauma surgeon, Paediatric surgeon
– Nurses
– Anesthetist
– ICU team
– Physiotherapist
– Occupational therapist
– Social workers
– Psychologists
– Psychiatrist
– Dietitians

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Criteria for admission
 Type of burn
– Electrical
– Chemical
– Lightening
 %TSBA
– >15% in adult
– >10% in children
 Body site affected: face, hands, perineum,
genitalia
 Complications- inhalation burn
 Pre-existing illness – renal diseases, Diabetes
mellitus, respiratory diseases
 Circumferential burns of the limbs or chest

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Phases of management
As in all trauma patients the mgt of
burn injury is divided into 5 phases
according to ATLS (Advanced Trauma
Life Support)
 Phase I: Primary survey phase
 Phase II: Resuscitation phase
 Phase III :Secondary survey phase
 Phase IV: Supportive care phase
 Phase V: Definitive treatment phase

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Phase I: Primary survey phase
Aim: to identify life threatening
conditions
The life threatening conditions include:
– A=Airway
– B=Breathing
– C=Circulation
– D=Disability- neurological status
– E=Exposure
This should go hand in hand with the
phase II

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Phase II: Resuscitation phase
Aim: to treat the immediately life
threatening condition
 Airway –secure airway & Immobilize the
cervical spine
 Breathing – optimize ventilation
 Circulation- establish i.v. access
 Disability- assess neurological deficit
 Expose the patient to avoid missed injury
 Fluid therapy

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Airway
A clear patent and functional airway
should be established
This can be achieved by:-
– Use of airways
– Proper position of the patient
– Endotracheal intubation
– Ambubags
– Tracheostomy

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Breathing / Ventilation
Make sure the patient is breathing
properly
Achieved by:-
– Use of oxygen masks
– Mechanical ventilators

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Disability: Neurological Status
Establish level of consciousness
– A= Alert
– V= Response to Vocal stimuli
– P= Response to Painful stimuli
– U= Unresponsive
Examine the pupillary response to light
Be aware of hypoxemia and shock can
cause  level of consciousness

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Exposure with Environment control
Remove all clothing and jewellery
Keep the patient warm

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Fluid resuscitation
Fluid replacement
Fluid maintenance

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Fluid replacement
 Fluid replacement is important to replace fluid loss ad
treat shock
 i.v. should be administered through a wide bore
canula
 The volume of fluid to be given is calculated as
follows:-
= 2-4ml x %TBSA x kg of body weight
 The type of fluid to be given in the 1st 24 hrs is
Crystalloid
 ½ of the calculated fluid is given in the 1st 8 hrs, and
the remaining half is distributed over remaining
sixteenth hrs
 Calculation fluid commences at time of injury not at
admission

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Fluid maintenance
At the end of 24 hours, colloid infusion
is begun at a rate of 0.5 mlx(total burn
surface area (%))x(body weight (kg)),
and maintenance crystalloid (usually
dextrose-saline) is continued at a rate of
1.5 mlx(burn area)x(body weight)
The end point to aim for is a urine
output of 0.5-1.0 ml/kg/hour in adults
and 1.0-1.5 ml/kg/hour in children.

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Phase III :Secondary survey
phase
Not started until phase I &II are
complete
This include:-
 History
 Physical examination
 Investigations as above

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Phase IV: Supportive care phase
Analgesics-iv narcotics
Systemic antibiotics against ß-
hemolytic streptococcus
Tetanus toxoid
Nasogastric tube for patients with >
25%TBSA
Monitor
– vital signs
– Input /output
Urethral catheterization
Nutrition support

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Phase V: Definitive treatment
phase (Wound care)
Depends on the characteristics and size
of the wound
– Conservative treatment
– Surgical treatment

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Conservative treatment
Indicated for superficial 1st and 2nd
degree burn
Involves:-
– Wound dressing
– Topical antimicrobial agents

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a. Wound dressing
The dressing should serve the following
fx:-
– Protect the damaged epithelium,
minimizing bacterial ad fungal
colonization (protective fx)
– Provide splinting action to maintain the
desired position of function (splinting fx)
– Occlusive to reduce evaporative heat loss
and minimize cold tress
– Provide comfort over the painful wound
The choice of dressing is based on the
characteristics of the wound

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Sterile Dressing
Several layers dressings
Special Considerations:
– Joint area lightly wrapped to allow mobility
– Facial wounds maybe left open to air, kept
moist
– Circumferential burns: wrap distal to
proximal
– All fingers and toes should be wrapped
separately
– Splints applied over dressings
– Functional positions maintained; not always
comfortable

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b. Antimicrobial Agent
Apply an Antimicrobial Agent
– Silverex
• Broad spectrum , Ideal choice.
– Silvadene
• Broad spectrum; the most common agent used
– Sulfamylon
• Penetrates eschar for invasive wound infections
• Painful burns for approximately 20 minutes after applied
– Acticoat (antimicrobal occlusive dressing)
• A silver impregnated gauze that can be left in place for 5
days
• Moist with sterile water only; remoisten every 3-4 hours

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Surgical treatment
Escharotomy
Skin grafting

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a. Escharotomy
Indicated for patients with
circumferential burns of the limbs, neck
or chest causing distal circulatory and
respiratory impairment respectively
Only the burnt tissue is divided, not any
underlying fascia, differentiating this
procedure from a fasciotomy
Incisions are made along the midlateral
or medial aspects of the limbs, avoiding
any underlying structures

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Escharotomy in a leg with a circumferential deep dermal burn

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For the chest, longitudinal incisions are
made down each mid-axillary line to the
subcostal region
The lines are joined up by a chevron
incision running parallel to the
subcostal margin
This creates a mobile breastplate that
moves with ventilation
Escharotomies are best done with
electrocautery, as they tend to bleed

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Diagram of escharotomies for the chest

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Although they are an urgent procedure,
escharotomies are best done in an
operating theatre by experienced staff

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b. Skin grafting
Skin grafting is done for deep 2nd degree
and other full-thickness burns
Can be:-
– Permanent
– Temporary

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i. Permanent Skin Grafts
Two types:
– Autografts
– Cultured Epithelial Autografts (CEA)

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ii. Temporary Skin Grafts
 Why temporary ??
– Clients with large amounts of TBSA burned do not
have enough donor sites.
– Available donor sites are used first, but in large
burns not enough to cover all burn wounds.
– While waiting for donor site to heal so it can be
reused a temporary covering is needed.
 Types of temporary Skin Grafts
– Biosynthetic
– Artificial Skins
– Synthetic

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a. Autograft
Harvested from client
Non-antigenic
Less expensive
Decreased risk of infection
Can utilize meshing to cover large area
Negatives: lack of sites and painful

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b. Cultured Epithelial Autografts
(CEA)
 A small piece of client’s skin is harvested and
grown in a culture medium
Takes 3 weeks to grow enough for the
first graft
 Very fragile; immobile for 10 days post
grafting
 Great for limited donor sites
 Negatives: very expensive; poor long term
cosmetic results and skin remains fragile for
years

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1. Biosynthetic Temporary Skin
Grafts
Homograft
Heterograft

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a. Homograft
AKA Allograft
Live or cadaver human donors
Fairly expensive
Best infection control of all biologic
coverings
Negatives:
– Risk of disease transmission (i.e. HBV &
HIV)
– Antigenic: body rejects in 2 weeks
– Not always available
– Storage problems

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b. Heterograft
AKA Xenograft
Graft between 2 different species
– i.e. Porcine (pig) most common
Fresh, frozen or freeze-dried (longer
shelf life)
Amendable to meshing & antimicrobial
impregnation
Antigenic: body rejects 3-4 days
Fairly inexpensive
Negatives: Higher risk of infection

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2. Artificial Skins
Transcyte
– A collagen based dressing impregnated
with newborn fibroblasts
Integra
– A collagen based product that helps form a
“neodermis” on which to skin graft

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3. Synthetic
Any non-biologic dressing that will help
prevent fluid & heat loss
– Biobrane, Xeroform or Beta Glucan
collagen matrix

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Donor Site: Wound Considerations
The donor site is often the most painful
aspect for the post-operative client
– We have created a brand new wound !!
– Variety of products are used for donor sites.
• Most are left place for 24 hours and then left
open to air
– Donor sites usually heal in 7-10 days

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Complications
Ca be classified as:-
– Early Complications
– Late Complications

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a. Early Complications
 Fluid / Electrolyte imbalance
 Hypovolaemic shock
 Thermoregulation dysfunction
 Acute renal failure
 Inhalation injury
 Burn wound sepsis/Systemic infection
 Anemia
 Stress ulcers /Curling ulcers
 Acute gastric/colonic dilatation
 Cardiopulmonary failure
 Myocardial infarction

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b. Late Complications
Contractures
Keloids
Hypertrophic scars
Marjolin’s ulcer
Acalculous Cholecystitis

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Prognosis
The prognostic factors for burns are
classified as follows:-
– Patient characteristics
– Circumstances of the injury
– Characteristics of burn wound
– Treatment parameters

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Patient characteristics
Age
Sex
Pre-existing illness
HIV status

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Circumstances of the injury
Nature of the injury
Type of burn
Timing in seeking medical care
Associated injuries
Associated burning of clothes
Inhalation injury
First-aid measures taken at the site of
accident

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Clinical characteristics of burn
wound
Body regions burned
% total surface area burnt (%TSAB)
Burn depth
Severity of burn
Burn wound sepsis

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Treatment parameters
Resuscitative measures
Definitive treatment

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Prevention
1st – risk factors
2nd – early treatment
3rd – rehabilitation

Burn Injury and introduction & physiology

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