Burns - Principles

Burns

Lecture- Medical Lincenciate

Dr Robert Zulu

Introduction

• Burn injury may be defined as damaged to an epithelial surface caused by heat.

• Scald refers to burns caused by hot water.

• Morbidity and mortality depends on the Body surface area involved, depth of the injury and age of the patient

Pathophysiology

Local effects• Thermal injury causes coagulative necrosis

to the epidermis and the underlying tissues.• These constitute local effects. The zone of

coagulation is surrounded by a zone of stasis which is surrounded by a zone of hyperaemia.

•

Pathophysiology

Burn depth• the specific material involved in the burn

injury will determine the severity of the burn injury

• May be classified as first degree, second degree, third degree, and fourth degree

• May also be classified as superficial and deep burns

Pathophysiology

• First degree burns are localised to the epidermis• Second degree burns involve the superficial

dermis, and may go as far as deep into the dermis• Third degree burns also called full thickness burns

involve the epidermis, dermis and into the subcutaneous fat

• Fourth degree burns may extend into the underlying muscle

PathophysiologyPathophysiology

Burns size

Determination of the burn size estimates the extent of injury

Rule of nines

Rule of sevens

Rule of the palm

Pathophysiology

Systemic Effects

Significant burns associated with release of massive inflammatory mediators

These produce vasoconstriction and vaso dilatation, increased capillary permeability and oedema locally and distant organs

Pathophysiology

Systemic effects

• Hypermetabolic state

• Vascular permeability and oedema

• Immunosuppression

• Increased GUT mucosal permeability

• Decreased renal blood flow

• Alter haemodynamics

Aetiology

• Flame:- superheated, oxidised air

• Scald:- Hot liquids

• Friction:-

• Chemical:-

• Electrical:-

Management

Resuscitation

• A-Inhalation burns

• B-Breathing

• C-Fluid management

• D-specific type of burns

Management

Pre-hospital

Remove patient from hazard

Inhalation burns- 100% oxygen

Caregiver should wear protective clothing

Burning clothes should be removed, cover victim with dry blanket

Remove all rings, belts, watches and jewelry

Management

• Wound care outside the hospital involves applying clean dry dressing on the wounds

• Do not apply any creams or lotions or herbs

• Cover the patient in a warm dry blanket

• Morphine may be given after initial assessment

Manaement

Wound care• Daily cleaning, +/- silver sulphadiazin• Wet soaks• Pus swabs• Antibiotics• Blood transfusion• Sloughectomy• Escharotomy

Management

Fluid management

Muir and Barclay

-% Burns X Weight X 0.5= x mls

-1st 24hrs= x(4hrs) x(4hrs) x(4hrs), x(6hrs) x(6hrs)

-2nd 24hrs= x(12hrs), x(12)

-Remember to add maintenance fluid

Management

Monitoring

a. Fluid replacement:-

.Urine output, Pulse, Mental status, oedema

b. Wound healing

. Colour, pus, slough, features of the wound

c. Nutritional status

.Weight, skin fold thickness, oedema

Complications

Early complications

Airway obstruction,

Hypothermia

Fluid and electrolyte inbalance

Anaemia

Myoglobinuria

Hyponatraemia

Hypernatraemia

Complications

Late complications

Wound infection

SIRS

MODS

Skin Contractures

Curling’s ulcer

Skin Grafting

• Autograft ( own skin)• Xeno graft (pig skin)Provides wound cover and some

immunological benefit. Must be removed completely or allowed to slough.

• Allograft ( Homograft, Cadaver skin)Provides all the normal skin functions.

Epithelium can be allowed to slough.

Skin grafting

• Deep burns do not heal in timely fashion.• Superficial burns heal by re-epitheliasing

within 10-14days as long as the wounds the conditions for healing are present

• Excision and grafting of deep burns on the 3rd or 4th post burn day.

• Or assess after two weeks and skin graft unhealed areas

Skin Grafting

• Early excision and grafting is the current practice

• Some wounds may need serial excision of slough

• Leaving these dead tissues only serves as a niddus of infection

Skin grafting

• Split thickness skin graft

• Full thickness skin graft

• Flaps( rotational, advancement)

Skin Grafting

Avoid

Infected wound

Anaemic patients

Wound with slough

Absence of granulation tissue

Malnourished patients

Exercise

• One year child with burns of both lower limbs. Is seen at the hospital 6 hours latter.

• The child weigh 10kg.

• Describe your management plan the next 24hrsfrom the time you see the patient