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burns

7 min read

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Burns

M K Zaky

Professor of surgery

ILOs

  • Mechanisms
  • Local & systemic effects
  • Assessment - Degree & Surface area of burn, SPECIAL SITES
  • Management- accident site & hospital
    • Fluid requirements , ANALGESIA
    • Wound management
  • Prognosis & COMPLICATIONS

Introduction

  • Trivial → OPD management
  • Major → may need a long hospital stay +

Death & disability (disfigurement/ impaired function)

Introduction

Risk groups.

  • Toddler
  • Children
  • Elderly
  • Infirm & alcoholics
  • Smokers
  • WORKERS

Survival.

  • Depends on the degree of the burn and the services provided

Epidemiology

  • 66% - at home
  • Death: predominantly in the extremes of age

Bimodal 1. Immediately after injury (in severe burn)

  1. Later from sepsis

Mechanisms of burn injury

  • Sunburn
  • Flame burn
  • Scalds (children <5 years)
  • Hot solids
  • Friction
  • Electricity
  • Chemicals
  • Irradiation

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Burn compromises skin functions:

  • Barrier to infection
  • Temperature regulation
  • Regulator of fluid loss

Local effects of burn injury

Destruction of tissues:

  • Superficial (1st degree) burn- epidermal remnants → healing with no effects.

  • Deep burn- epidermal loss → healing by scar formation (disfigurement, incomplete healing)

  • Inflammation of surrounding tissues → inflammatory cascade

  • Thrombosis of vessels

  • Fluid loss from the surface

Damaged capillaries permeable to protein- exudate

Exudation highest in first 12 hors

  • Loss of barrier to infection- sepsis

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Systemic effects of burn injury

  • Depends upon surface area & depth

Moderate - Large burn:

  • Generalized capillary leak-max- 24 hrs. → Hypovolemia → AKI
  • Increased metabolic rate- catabolism
  • Hypothermia
  • Systemic inflammatory response syndrome (SIRS)
  • Immune suppression
  • Lryngeal & Pulmonary oedema: inhalation burn
  • Electrolyte disturbance

Burn Depth

  • First-Degree (Superficial): Affects only the epidermis (outer layer). Symptoms include redness, pain, and no blisters (e.g., mild sunburn). Heals in 3–5 days.
  • Second-Degree (Partial Thickness): Damages the epidermis and part of the dermis layer. Appears red, blistered, swollen, and is very painful. Superficial second-degree takes ~2 weeks to heal; deep second-degree may take longer and require surgery.
  • Third-Degree (Full Thickness): Destroys all skin layers (epidermis and dermis). The area may appear white, leathery, or charred and is often numb due to nerve destruction.
  • Fourth-Degree (Deep Full Thickness): Extends through the skin into fat, muscle, and sometimes bone

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Depth of burn

Depth - depends upon degree of temperature & duration of contact

☐ 1st degree: (superficial layer of the epidermis)

  • Limited to epidermis
  • Skin red, painful, no blisters
  • Heal spontaneously- 3-4 days

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Depth of burn

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2nd degree: A) Superficial partial thickness burn

  • Epidermis & superficial dermis Hot surface, hot liquids, chemical
  • Blister, erythema, very painful, & swelling
  • Fluid loss (depends on the area involved). Healing- from appendages (sweat glands, hair follicles, sebaceous glands) (\sim) 2-3 weeks Full function & good cosmetic result (pigmentation may occur)
  • Infection can change a (2^{\text{nd}}) degree burn to a (3^{\text{rd}}) degree

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Depth of burn

2nd degree: B) Deep-dermal burn

  • Involve epidermis & much of dermis
  • Nerve endings are damaged
  • Blisters, pale white, absent pain sensation, swelling
  • Marked fluid loss
  • Healing takes longer, from few remaining epithelium
  • Often heal with an ugly hypertrophic scar
  • Infection- may convert it to full thickness injury & delay healing.

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Depth of burn

3rd degree: Full thickness burn

  • Epidermis, whole dermis (with subcutaneous tissue) & all appendages destroyed.
  • Coagulative necrosis & eschar formation.
  • Eschar separates after 2-3 weeks.
  • Healing: unless grafted, healing by wound contraction & fibrosis.
  • Ugly contracture formation.

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Depth of burn

4 degree; (charring)

Deep fascia, muscle & bone

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How to determine burn depth?

  • No perfect method
  • Accurate assessment- may take days

How to determine burn depth?

1.Mechanism of burn

  • Scald- partial thickness.
  • Flame- may be partial / more commonly full thickness
  • Electricity- almost always full thickness

How to determine burn depth?

2. Appearance

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  • Partial thickness: Erythema, blanching on pressure, blisters
  • Deep dermal: Dead white appearance- burn
  • Full thickness: Dry leathery with thrombosed veins.

How to determine burn depth?

3. Sensation

  • Intact sensation- Superficial. Nerve endings intact. Very painful
  • Loss of sensation- Deep burns

Pain decreases as burn depth increases (nerve destruction)

Rule of ‘9’ - % body surface areas (BSA) of a burn

Small area: patient’s hand- palm+ extended fingers = 1%

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Minor: < 10 BSA, partial

Moderate: 10-20% BSA, partial

Severe: > 20% BSA, face, hand, airway,

Management- First aid

  • Stop burning process-

  • Cooling the burn area using running tap water for 20 minutes (avoid hypothermia)

  • Chemical burn - copious irrigation with running water.

  • Electrical - switch off or push patient with wooden object.

  • Ensure airway:

  • Move patient away from smoke.

  • Secure the airway/ventilation- if respiratory arrest.

  • Avoid contamination:

  • Cover with clean sheet

  • Quick transfer to hospital:

  • IV infusion & analgesic - on way to hospital.

Signs of inhalation injury

  • Facial burn
  • Singing of eyebrows
  • Carbon deposits in oropharynx/ sputum
  • Burns to head & trunk
  • Confinement to burning environment
  • All these patient will need respiratory support (intubation)

Hospital management

Severe burns → hospital admission, preferably to a specialized unit

Indications:

  • Second degree burn > 20% BSA (adult), > 5% (children < 2y), > 10% (3-10 y), > 15% (10-15y), > 10% (> 65y)
  • All full thickness burns (3rd degree)
  • Burn involving face, hands, feet, genitals, joints
  • Inhalation burn
  • Circumferential burn
  • Chemical and electric burn
  • Comorbidities

Use trauma approach (ATLS): ABCDE

Initial management

  • A: Airway secured, humidified O₂ (100%), pulse oximetry, early intubation for inhalation burn
  • B: assisted ventilation may be needed for inhalation or aspiration
  • C: IV fluids (2ⁿᵈ-4ᵗʰ degree burn)- calculated from injury time, CBC, U/E, ABG, lactate, carboxyhaemoglobin, X-match, urinary catheter (monitor output)
  • D: assess GCS
  • E: remove clothes, jewellery, prevent hypothermia
  • Analgesia- IV (morphine, pethidine), anti Tetanus prophylaxis (if needed)
  • Assess the type, depth, BSA of burn and associated injuries

Fluid resuscitation

  • Needed for burn > 10% in children, > 20% in adults. LR solution is given according to Parkland’s formula (first 24 h)

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  • Colloid solutions - may be added after 24 hours.
  • Oral fluids- restrict for 48 hours (acute gastric dilatation and/or paralytic ileus (>25%)), then encouraged, consider PPI (Curling ulcer)
  • Watch for:

Hyponatremia (effect of ADH which is secreted as a result of trauma) Hyperkalaemia (tissue destruction)

Resuscitation- monitor for organ failures

  • Respiratory- CXR, ABG

  • Renal failure- adequate fluid

  • Nutritional support (calorie & protein demand is high)

  • Monitor for sepsis: Routine antibiotics not recommended in the first 48 h

    o Regular blood culture & swabs. o Organisms- Staph (most common), pseudomonas, hemolytic strep.

  • Gastric erosions & duodenal ulcer (Curling’s): Early feeding , H2 blockers. PPI

Local management of burn wound

  • Shocked patients: Cover with sterile towel until stabilized.
  • GA / IV analgesia- opiate (after stabilizing the patient)
  • Wound- cleaned with mild detergent in saline
  • Grossly devitalized tissue removed
  • Better to keep blisters intact (evacuated with a sterile needle and left intact)
  • Face, neck, perineum - left exposed, MEBO ointment may be used
  • Other areas- covered with non-adherent dressing. Silver sulfadiazine cream, MEBO ont
  • Dressing can be changed every 2-3 days

Local management of burns

  • Escharotomy- full-thickness incision through insensate burn eschar for circumferential deep burn (neck, chest, limbs)

  • Full thickness burn- early (72 hrs.) excision & grafting

  • Extensive burn- delayed skin grafting once slough has separated

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Local management of burns

  • Skin cover by split skin graft within 2- 3 days for deep burn after excising eschar – small burn
  • Large burn- staged skin grafting in < 3 months
  • Wound clean & granulating before grafting
  • Skin grafts & donor sites- moisturizing crème to keep it supple
  • Splints – to prevent contracture
  • Physiotherapy- mobilize joints
  • Late reconstructive procedures
  • Long term support & counselling

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Prognosis

  • Age: Extremes of age fare less well.
  • Extent of burn: Hypovolemic shock, >15% in adults or >10 % in children
  • Depth of burn: Superficial burn- heal rapidly , good cosmetic result.
  • Deep burn- heal with scarring, risk of infection. Sepsis - life threatening.
  • Site: Face, neck, hands, feet & perineum- threaten appearance & function.
  • Respiratory injury: Inhalation of smoke from burning plastics- can be fatal
  • Infection- higher morbidity & mortality

Complications

Local :

  • Scarring
  • Contracture
  • Hypertrophic scar / keloid

General:

  • Respiratory: smoke injury
  • Renal failure: hypovolemia, haemoglobinuria, myoglobinuria
  • Upper GI bleeding: Curling ulcer, gastric erosions
  • DVT
  • Sepsis
  • Psychological problems

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Graph View

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