Burns Injury

8/14/2019 Burns Injury

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BURNS INJURYBURNS INJURY

ByByDr. S. M. AshrafDr. S. M. Ashraf

Assistant ProfessorAssistant Professor

Department of SurgeryDepartment of Surgery

Computed By: Mr. M. Hassan Saleem


2/23

Management of The Burn InjuryManagement of The Burn Injury

Victim:Victim:

Burns injury can be one of the most serious andBurns injury can be one of the most serious anddevastating form of trauma.devastating form of trauma.

Destruction of the skin by heat results in severe localDestruction of the skin by heat results in severe local

and systemic physiological alterations. Managementand systemic physiological alterations. Managementof the burns victim requires understanding of theof the burns victim requires understanding of the

pathophysiology, diagnosis and treatment not only ofpathophysiology, diagnosis and treatment not only of

the local skin injury, but also of the derangements thatthe local skin injury, but also of the derangements that

occur in the haemodynamic, metabolic, nutritional,occur in the haemodynamic, metabolic, nutritional,

immunological and psychological haemostaticimmunological and psychological haemostatic

mechanism.mechanism.


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Evaluation of Burn Victims:Evaluation of Burn Victims:

First essential step in treating a burns victim is to treatFirst essential step in treating a burns victim is to treat

immediate life-threatening problems including airwayimmediate life-threatening problems including airway

management and shock.management and shock.

Next Determine the severity of the injury. Next Determine the severity of the injury.

Level of expertise necessary to care for the patient.Level of expertise necessary to care for the patient.

Guidelines:Guidelines:(1)(1) Age:Age: Extremes of age carry greater morbidity andExtremes of age carry greater morbidity and

mortality 60 years.mortality 60 years.The age dictates the amount of stress that the victim canThe age dictates the amount of stress that the victim can

with standwith stand


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(2) Extent of Burn:(2) Extent of Burn:

It can be determined by careful observation and should beIt can be determined by careful observation and should be

recorded graphically, in terms of percentage of bodyrecorded graphically, in terms of percentage of bodysurface involved, only areas of partial thickness and fullsurface involved, only areas of partial thickness and full

thickness are included in this assessment.thickness are included in this assessment.

Rough estimate rules of nine.Rough estimate rules of nine.

(3) Depth of Burn:(3) Depth of Burn:

Since the volume of tissue destroyed is ultimately important,Since the volume of tissue destroyed is ultimately important,

both the depth and the extent of injury must be evaluated.both the depth and the extent of injury must be evaluated.

Depth of burn may be difficult to assess accurately depth ofDepth of burn may be difficult to assess accurately depth of

burn may be non uniform through the burns extent.burn may be non uniform through the burns extent.


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Superficial Burns:Superficial Burns: (Partial Thickness)(Partial Thickness)

Erythema of the wound, blanching of the tissuesErythema of the wound, blanching of the tissues

thin watery blisters, with severe pain.thin watery blisters, with severe pain.

Deeper Burns: (Full thickness)Deeper Burns: (Full thickness)

Thick-walled blisters pale, poorly or non-Thick-walled blisters pale, poorly or non-blanching wound bed, a dry leathery eschar.blanching wound bed, a dry leathery eschar.

Sensation may be unreliable.Sensation may be unreliable.

Full thickness burns have pressure sensation.Full thickness burns have pressure sensation. Pin prick is absent in deep burns.Pin prick is absent in deep burns.


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Emergency Department TreatmentEmergency Department Treatment

a)a) Minor Burns:Minor Burns:

Can be treated in an ambulatory settingCan be treated in an ambulatory setting..Active immunization 3000I/UActive immunization 3000I/U

Tetanus prophylaxisTetanus prophylaxis

Passive Toxoid boosterPassive Toxoid booster

Patient who had immunization tetanus toxoid booster.Patient who had immunization tetanus toxoid booster. Analgesia:Analgesia:

In minor burn wound, true burn wound sepsis is rare.In minor burn wound, true burn wound sepsis is rare.

(Careful studies have shown that prophylactic treatment with penicillin or(Careful studies have shown that prophylactic treatment with penicillin orother antibiotics does not alter the clinical course in major & minor burns).other antibiotics does not alter the clinical course in major & minor burns).

Topical antibacterial are unnecessary for burns of limited size.Topical antibacterial are unnecessary for burns of limited size. Just clean the wound with a bland soap and carefully dressed.Just clean the wound with a bland soap and carefully dressed. Dressing:Dressing:

Non adherent gauze (sofratulle) next to the wound followed by a bulkyNon adherent gauze (sofratulle) next to the wound followed by a bulkyabsorptive dressing.absorptive dressing.

Immobilize part in a safe functional position and injured extremity elevated ifImmobilize part in a safe functional position and injured extremity elevated ifpossible.possible.

Inspect the wound at 24 hr and periodically until healing occurs.Inspect the wound at 24 hr and periodically until healing occurs.


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(b) Moderate to major burn:(b) Moderate to major burn:

Requires hospitalizationRequires hospitalization

Immediate treatment of impending vascular collapseImmediate treatment of impending vascular collapseis begun by introducing a plastic catheter into ais begun by introducing a plastic catheter into a

peripheral or central vein, preferably throughperipheral or central vein, preferably through

unburned skin.unburned skin.

Blood is drawn for cross match, blood countBlood is drawn for cross match, blood count

electrolytes, glucose, urea / creatinin.electrolytes, glucose, urea / creatinin.

ABGs and pH are obtained if there is any suspicionABGs and pH are obtained if there is any suspicionof inhalation injury or respiratory dysfunction.of inhalation injury or respiratory dysfunction.


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An infusion of electrolyte solution is begun at a rateAn infusion of electrolyte solution is begun at a ratedependant on the size of the burns.dependant on the size of the burns.

Initial monitoring of the resuscitation is performed byInitial monitoring of the resuscitation is performed by

inserting an indwelling urinary catheter attached to a closedinserting an indwelling urinary catheter attached to a closeddraining system.draining system. Following air way stabilization and the initiation ofFollowing air way stabilization and the initiation of

resuscitation, the adequacy of respiration is evaluated byresuscitation, the adequacy of respiration is evaluated by

chest movement, respiratory rate, cyanosis and ABGS.chest movement, respiratory rate, cyanosis and ABGS. If respiratory distress early cause could be a deep burn withIf respiratory distress early cause could be a deep burn with

an unyielding eschar about the anterior & lateral chest wall.an unyielding eschar about the anterior & lateral chest wall. Early chest eseherectomy to release the restriction of ribEarly chest eseherectomy to release the restriction of rib

movements (motion) and increase thoracic excursion, thusmovements (motion) and increase thoracic excursion, thusimproving ventilatory function.improving ventilatory function.

Inhalation of steam & noxious gases can cause epiglottal orInhalation of steam & noxious gases can cause epiglottal orpharyngeal edema, resulting in upper airway obstructionpharyngeal edema, resulting in upper airway obstruction

requiring intubation or tracheostomy.requiring intubation or tracheostomy.


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Tracheostomy is best avoided in emergencyTracheostomy is best avoided in emergency

situation, unless mandated by associated injuriessituation, unless mandated by associated injuries

such as severe fascial fractures.such as severe fascial fractures.

Relieving pain and anxiety should be consideredRelieving pain and anxiety should be considered

once the state of shock and the respiration statusonce the state of shock and the respiration status

have been evaluated cold saline or water for 15-20have been evaluated cold saline or water for 15-20

min is helpful in decreasing pain and edema.min is helpful in decreasing pain and edema.

Blisters are best debrided since they are hard toBlisters are best debrided since they are hard to

maintain intact in the larger burn wounds. If themaintain intact in the larger burn wounds. If the

blisters are broken, serum and desquamated cellsblisters are broken, serum and desquamated cellsform a crust that is susceptible to bacterial invasion.form a crust that is susceptible to bacterial invasion.

Following debridement, the wound is dressed with aFollowing debridement, the wound is dressed with a

topical antibacterial agent.topical antibacterial agent.


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(2) Definitive Treatment:(2) Definitive Treatment:a) Resuscitative fluid management:a) Resuscitative fluid management:

To determine the resuscitative fluid replacement, it isTo determine the resuscitative fluid replacement, it isimportant to realize that greatest loss of fluid occurs duringimportant to realize that greatest loss of fluid occurs duringthe first 8-12 hr post burn and then continues more slowlythe first 8-12 hr post burn and then continues more slowlyover the next 12-16 hrs. Because of the increase capillaryover the next 12-16 hrs. Because of the increase capillary

permeability, colloid replacement seems to be of no benefitspermeability, colloid replacement seems to be of no benefitsin the immediate post burn period. Osmotic pressure cannotin the immediate post burn period. Osmotic pressure cannotbe built up over a freely permeable membrane, therefore,be built up over a freely permeable membrane, therefore,since sodium ( seems to be the ion that is lost to thesince sodium ( seems to be the ion that is lost to thecirculation in disproportionate amounts), sodium ions andcirculation in disproportionate amounts), sodium ions andnot colloid) appear to be the key to resuscitation. Allnot colloid) appear to be the key to resuscitation. Allformulae given approximately 0.5 mmol of Na/kg b w/%formulae given approximately 0.5 mmol of Na/kg b w/%

body burn. In order to compensate for the obligatory lossbody burn. In order to compensate for the obligatory lossfrom the vascularfrom the vascular


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compartment, this must be given at a rate exceedingcompartment, this must be given at a rate exceeding

4.4ml/kg/hr. when Na ion is replaced in this amount and at4.4ml/kg/hr. when Na ion is replaced in this amount and at

this rate, cardiac output returns to normal by 24 hr postthis rate, cardiac output returns to normal by 24 hr post

burn.burn.Following return of the cardiac output at 24hrs, there remainsFollowing return of the cardiac output at 24hrs, there remains

a plasma gap. This amounts to approximately 0.35-0.5a plasma gap. This amounts to approximately 0.35-0.5

ml/kg/% body burn. By 24 hr capillary integrity returns andml/kg/% body burn. By 24 hr capillary integrity returns and

starlings hypothesis appears to be restored. Therefore,starlings hypothesis appears to be restored. Therefore,

colloid can be used to replace the plasma volume.colloid can be used to replace the plasma volume.

By 30hrs, both cardiac output and plasma volume should beBy 30hrs, both cardiac output and plasma volume should be

returned to normal and effective resuscitation completed.returned to normal and effective resuscitation completed.Acute resuscitation is begun with a buffered balanced saltAcute resuscitation is begun with a buffered balanced salt

solution given at a rate of calculated at 2-4 ml/kg/% bodysolution given at a rate of calculated at 2-4 ml/kg/% body

burn.burn.


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Approximately of this volume will be required in the first 8Approximately of this volume will be required in the first 8

hr following injury, and the remaining volume in thehr following injury, and the remaining volume in thesucceeding 16 hrs.succeeding 16 hrs.

The administered volume is titrated hrly depending primarilyThe administered volume is titrated hrly depending primarily

on the urinary output, pulse, blood pressure, haematocriton the urinary output, pulse, blood pressure, haematocrit

and base deficit.and base deficit.

Resuscitation is continued for 24 hrs and at that time dextroseResuscitation is continued for 24 hrs and at that time dextrose

and water replace the salt solution. Collide is added toand water replace the salt solution. Collide is added to

replace the remaining plasma volume deficiency.replace the remaining plasma volume deficiency.A urine output of 30-50 ml /hr in the adult or1 1/ml/kg/h inA urine output of 30-50 ml /hr in the adult or1 1/ml/kg/h in

the child is the best monitoring parameter.the child is the best monitoring parameter.


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Respiratory Management:Respiratory Management:Major burns victims should receive supplemental oxygenMajor burns victims should receive supplemental oxygen

during the burn shock period.during the burn shock period.100% of O100% of O2,2, if there is evidence of CO intoxication. High Oif there is evidence of CO intoxication. High O22

should be continued until the carboxyhaemoglobin (CO Hb)should be continued until the carboxyhaemoglobin (CO Hb)level falls to less than 5%.level falls to less than 5%.

All patients with major burn ABGs should be done during theAll patients with major burn ABGs should be done during thefirst 18-24hrs. Upper airway edema of the pharynx,first 18-24hrs. Upper airway edema of the pharynx,epiglottis and vocal cords is evaluated by, indirectepiglottis and vocal cords is evaluated by, indirectlaryngoscopy or fibreoptic bronchoscopy. In mild edema,laryngoscopy or fibreoptic bronchoscopy. In mild edema,

intermittent positive pressure ventilation (breathing) with aintermittent positive pressure ventilation (breathing) with abronchodilator is sufficient. Inbronchodilator is sufficient. In

significant edema, endotrachial intubation should be carriedsignificant edema, endotrachial intubation should be carriedout to maintain ventilatory function.out to maintain ventilatory function.


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The Burn Wound:The Burn Wound:

Attention to the burn wound must not take precedence over theAttention to the burn wound must not take precedence over the

life-saving support of other systems in the burn woundlife-saving support of other systems in the burn woundvictim.victim.

Proper treatment of the wound begins with causing no harm toProper treatment of the wound begins with causing no harm to

the injured cells, so that any tissue still viable after thethe injured cells, so that any tissue still viable after the

initial thermal event can survive, the necrotic cells notinitial thermal event can survive, the necrotic cells not

capable of recovery must be removed and replaced.capable of recovery must be removed and replaced.

Closure of the wound with viable tissue or cells toClosure of the wound with viable tissue or cells to

provide a functional and aesthetically satisfactory coverageprovide a functional and aesthetically satisfactory coverageas rapidly as possible is the goal of burn wound treatment.as rapidly as possible is the goal of burn wound treatment.

Determination of wound viability and predicting healing isDetermination of wound viability and predicting healing is

one of the most difficult problems facing the burn surgeons.one of the most difficult problems facing the burn surgeons.


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Excision of burn wounds and grafting are nowExcision of burn wounds and grafting are now

performed reasonable early after injury. Excision areperformed reasonable early after injury. Excision are

associated with significant and in some casesassociated with significant and in some cases

extensive blood losses. When excision areextensive blood losses. When excision are

performed relatively early, bleeding is generally lessperformed relatively early, bleeding is generally less

than when excision is delayed for a weak or longer.than when excision is delayed for a weak or longer.Early burn is still in ischemic phase and burnEarly burn is still in ischemic phase and burn

Haemorrhage is limited. Early burn excision andHaemorrhage is limited. Early burn excision and

wound closure have essentially eliminated burnwound closure have essentially eliminated burnwound sepsis as a clinical problem.wound sepsis as a clinical problem.

d h i f h i jB d th t i f th i j


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Advantages:Advantages: Removal of only necrotic tissue.Removal of only necrotic tissue.

Salvage of injured tissue that would otherwise haveSalvage of injured tissue that would otherwise have

progressed to necrosis.progressed to necrosis. Preservation of the biological properties of the dermis.Preservation of the biological properties of the dermis.

Preventions of contractures by immediate skin grafting andPreventions of contractures by immediate skin grafting and

custom made tight garments.custom made tight garments. The choices for burn treatment include excision with skinThe choices for burn treatment include excision with skin

dressings.dressings.

To be effective, the dressing must be carefully constructed andTo be effective, the dressing must be carefully constructed and

applied using applied meticulous aseptic technique.applied using applied meticulous aseptic technique.

Based on the concentric zones of the injuryBased on the concentric zones of the injuryelucidatedelucidated

by Jackson, an intradermal or a tangentialby Jackson, an intradermal or a tangential

excisionexcisionhas evolved.has evolved.

C f i & iC f l l i & d b id


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Careful cleaning & debridement.Careful cleaning & debridement.

Inner layer of fine mesh or impregnated gauze (to allow drainage)Inner layer of fine mesh or impregnated gauze (to allow drainage)

Bulky absorptive materialBulky absorptive material

Non-distensible inelastic wrap (for careful immobilization)Non-distensible inelastic wrap (for careful immobilization)

Only change dressing if wound exudates, soak through it or badOnly change dressing if wound exudates, soak through it or bad

odour, pain and fever.odour, pain and fever.

Most commonly used chemotherapeutic agents used are silverMost commonly used chemotherapeutic agents used are silver

sulfadiazine, silver nitrate solution and mafenide acetate.sulfadiazine, silver nitrate solution and mafenide acetate.

Regardless of the agent used efficiency should be monitored byRegardless of the agent used efficiency should be monitored byconstant surveillance of the bacterial flora of the burn wound .constant surveillance of the bacterial flora of the burn wound .

Daily debridement following removal of the topical agent can beDaily debridement following removal of the topical agent can be

carried out in hydrotherapy, in a dedicated treatment room.carried out in hydrotherapy, in a dedicated treatment room.

O ti ti h b d ith i f d t 10 14 dOnce necrotic tissue has been removed with in few days or up to 10 14 days


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Once necrotic tissue has been removed with in few days or up to 10-14 daysOnce necrotic tissue has been removed with in few days or up to 10-14 dayswound closure can be carried out by.wound closure can be carried out by.

Deep partial thicknessDeep partial thickness

+full thickness+full thickness AutographtsAutographts

Meshed graftsMeshed grafts If donor sites are notIf donor sites are notsufficientsufficient

Decreased fluid andDecreased fluid and Temporary closure with protein loss,Temporary closure with protein loss,biological dressing .e.g. Decreased painbiological dressing .e.g. Decreased pain

allograft, xenograftsallograft, xenograftsAmniotic membraneAmniotic membrane

material most widelymaterial most widelyaccepted for extensiveaccepted for extensivewounds is cadaver allograftwounds is cadaver allograftavailable in fresh frozen oravailable in fresh frozen orpreserved forms from localpreserved forms from localor distant banks.or distant banks.

Applied to burn wound following removal of eschar and remain in place from 48Applied to burn wound following removal of eschar and remain in place from 48to 96 hr.to 96 hr.


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Common complications of burn injury.Common complications of burn injury.

1.1.

Renal failure. Acute profound prolonged shock due toRenal failure. Acute profound prolonged shock due topoor resuscitation of volume and haemoglobinuria.poor resuscitation of volume and haemoglobinuria.

2.2. Inhalation injury.Inhalation injury.

Asphyxia because the combustion consumes the OAsphyxia because the combustion consumes the O22

available with in moments of injury.available with in moments of injury.

Laryngeal edema, spasm may cause immediate death ifLaryngeal edema, spasm may cause immediate death if

sulpher dioxide are present.sulpher dioxide are present.

3. Gastrointestinal stress unless GI ulcers 80% of patients with3. Gastrointestinal stress unless GI ulcers 80% of patients withmajor burns develop bleeding which is difficult to controlmajor burns develop bleeding which is difficult to control

4. Infectious complication. Bacterial, viral, fungal infection4. Infectious complication. Bacterial, viral, fungal infection

and burn wound sepsis.and burn wound sepsis.


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Non Thermal Burn Injury:Non Thermal Burn Injury:

Usually divided into low and high voltage injuries.Usually divided into low and high voltage injuries. Low voltage injuries cause small, localized, deep burn.Low voltage injuries cause small, localized, deep burn.

They can cause cardiac arrest through pacing interruptionThey can cause cardiac arrest through pacing interruption

without significant direct myocardial damage.without significant direct myocardial damage. High-voltage injuries damage by flash (external burn) andHigh-voltage injuries damage by flash (external burn) and

conduction (internal burn)conduction (internal burn)

Myocardium may be directly damaged without pacingMyocardium may be directly damaged without pacing

interruption.interruption.

Limbs may need fasciotomies or amputation.Limbs may need fasciotomies or amputation.

Look for and treat acidosis and myoglobinuria.Look for and treat acidosis and myoglobinuria.

A) Electrical Injuries:


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B) Chemical Injuries:B) Chemical Injuries:

The more common injuries are caused by either acidsThe more common injuries are caused by either acids

and alkalies. Alkalies are usually the moreand alkalies. Alkalies are usually the moredestructive and are especially dangerous if theydestructive and are especially dangerous if they

have come in contact with the eyes.have come in contact with the eyes.

The initial management of any chemical injury isThe initial management of any chemical injury iscopious lavage with water. Common cause of acidcopious lavage with water. Common cause of acid

burn is hydrofluoric acid. The initial management isburn is hydrofluoric acid. The initial management is

with calcium gluconate gel topically.with calcium gluconate gel topically.

C) Ionizing Radiation Injury:C) Ionizing Radiation Injury:


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C) Ionizing Radiation Injury:C) Ionizing Radiation Injury: These injuries can be divided into two groupsThese injuries can be divided into two groups

depending on whether radiation exposure was to the wholedepending on whether radiation exposure was to the wholebody or localized. The management of local injury isbody or localized. The management of local injury isusually conservate until the true extent of the tissue injury isusually conservate until the true extent of the tissue injury isapparent. Local burns causing ulceration need excision andapparent. Local burns causing ulceration need excision andvascularized flapvascularized flap

cover-usually with free flaps.cover-usually with free flaps.

Systemic over dose needs supportive treatment.Systemic over dose needs supportive treatment.

D) Cold Injuries:D) Cold Injuries:Principally divided into two types acute cold injuriesPrincipally divided into two types acute cold injuries

from industrial accidents( liquid nitrogen) and frostbite. Thefrom industrial accidents( liquid nitrogen) and frostbite. The

damage is more difficult to define and slower to developdamage is more difficult to define and slower to developthan burns.than burns.

Acute frostbite needs rapid rewarning than observation.Acute frostbite needs rapid rewarning than observation.

Delay surgery until demarcation is clear.Delay surgery until demarcation is clear.


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Thank YouThank You

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Burns Injury