This document discusses the assessment and management of burn injuries. It begins with an introduction to common causes of burns in children and adults. It then covers risk factors, types of burns, effects of burns, and classifications of burns based on depth and percentage of total body surface area affected. The pathophysiology of burns is explained. Assessment involves determining burn size, depth, and severity. Management involves initial first aid at the scene, and then hospital care which focuses on cooling burns, giving oxygen, and elevating injured areas. Causes of death from severe burns are also outlined.

1. BURN
1

2. 2
INTRODUCTION
Majorty of burns in childrenare SCALDScaused
by accidents with kettles,pans,hot drinks and
bath water
In young males burn causedbyexperimenting
With mathes and inflamable liquides
Electrical and chemical injuries occur in adultswith
Associated conditions suchasmental disease,
EpilepsyAlcohal and drug abuse

3. Risk Factors
 Fire/Combustion
 Firefighter
 IndustrialWorker
 Occupant of burning structures
 Chemical Exposure
 IndustrialWorker
 Electrical Exposure
 Electrician
 Electrical Power DistributionWorker

4. Types of Burn Injuries
 Thermal burn
 Skin injury
 Inhalation injury
 Chemical burn
 Skin injury
 Inhalation injury
 Mucous membrane injury
 Electrical burn
 Lightning
 Radiation burn

6. Effects
 Burn injury causes destruction of tissue, usually the skin,
from exposure to thermal extremes (either hot or cold),
electricity, chemicals, and/or radiation
 The mucosa of the upper GI system (mouth, esophagus,
stomach) can be burned with ingestion of chemicals
 The respiratory system can be damaged if hot gases, smoke, or
toxic chemical fumes are inhaled
 Fat, muscle, bone, and peripheral nerves can be affected in
electrical injuries or prolonged thermal or chemical exposure
 Skin damage can result in altered ability to sense pain, touch, and
temperature

7. Skin
 Largest body organ. Much more than a
passive organ.
 Protects underlying tissues from injury
 Temperature regulation
 Acts as water tight seal, keeping body fluids in
 Sensory organ

8. Skin
 Injuries to skin which result in loss, have
problems with:
 Infection
 Inability to maintain normal water balance
 Inability to maintain body temperature

9. Skin
 Two layers
 Epidermis
 Dermis
 Epidermis
 Outer cells are dead
 Act as protection and
form water tight seal

10. Skin
 Epidermis
 Deeper layers divide to produce the stratum
corneum and also contain pigment to protect
against UV radiation
 Dermis
 Consists of tough, elastic connective tissue which
contains specialized structures

11. Skin
 Dermis - Specialized Structures
 Nerve endings
 Blood vessels
 Sweat glands
 Oil glands - keep skin waterproof,usually
discharges around hair shafts
 Hair follicles - produce hair from hair root or
papilla
 Each follicle has a small muscle (arrectus pillorum)
which can pull the hair upright and cause goose flesh

12. CLASSIFICATION OF
BURNS

13. Burn Classification - Depth
 New terminology
 Superficial: only
the epidermis
 Superficial partial
thickness: epidermis
and dermis, excluding
all the dermal
appendages
 Deep partial
thickness: epidermis
and most ofthe
dermis
 Full thickness: epidermis
and all of the dermis
 Old terminology
 1st degree: only the
epidermis
 2nd degree: epidermis and
dermis, excluding all the
dermal appendages
 3rd degree: epidermis and all
of the dermis
 4th degree: epidermis,
dermis, and subcutaneous
tissues (fat, muscle, bone,
and peripheral nerves)


14. Very painful, dry, red burns which blanch with pressure.
They usually take 3 to 7 days to heal without scarring.
Also known as first-degree burns.
The most common type of first-degree burn is sunburn.

15. Very painful burns sensitive to temperature change and air exposure.
More commonly referred to as second-degree burns.
Typically, they blister and are moist, red, weeping burns which blanch with pressure.
They heal in 7 to 21 days.

16. Blistering or easily unroofed burns which are wet or waxy dry, and are
painful to pressure.
Their color may range from patchy, cheesy white to red, and they do not
blanch with pressure.

17. Burns which cause the skin to be waxy white to a charred black and
tend to be painless.
Healing is very slow, if at all, and may require skin grafting.

19. Burn Classifications
 1st degree (Superficial burn)
 Involves the epidermis
 Characterized by reddening
 Tenderness and Pain
 Increased warmth
 Edema may occur, but no blistering
 Burn blanches under pressure
 Example - sunburn
 Usually heal in ~ 7 days

20. Burn Classifications
 First Degree Burn
(Superficial Burn)

21. Burn Classifications
 2nd degree
 Damage extends through the epidermis and
involves the dermis.
 Not enough to interfere with regeneration of the
epithelium
 Moist, shiny appearance
 Salmon pink to red color
 Painful
 Does not have to blister everytime
 Usually heal in ~7-21 days

22. Burn Classifications
 2nd Degree Burn
(Partial Thickness
Burn)

23. Classification(cont
…..)
b.2nd degreeburns
affected area isred,mottled,painfull
Blister formation
Healsin 14-21
daysby epithelialization With scaring
2
3

24. CLASSIFICATION(CONT……)
al
3rddegree burns
Affected area is painless and insensetive with
Thrombosis of superfici
vessels
It requiresgrafting
10

25. Burn Classifications
 3rd degree
 Both epidermis and dermis are destroyed with burning
into SQ fat
 Thick, dry appearance
 Pearly gray or charred black color
 Painless - nerve endings are destroyed
 Pain is due to intermixing of 2nd degree
 May be minor bleeding
 Cannot heal and require grafting

26. Burn Classifications
 3rd Degree Burn
(FullThicknessburn)

29. CLASSIFICATION(CONT……)
4th degreeburns
It involvesunderlying
Tissues Muscles
bones
10

30. Degrees of burns.
Partial thickness and full thickness discussin asessmentofburn
30

31. 3
1
CLASSIFICATION OF BURNS
Depending on the percentage of burns
MILD
o Partial thickness burns <15%in adults and <10%
In children
or
o Full thickness <2%
o Canbe treated on outpatient department

32. 3
2
Classification
(cont…….
MODERA
TE
oSeconddegree burn of 15-25%burns
oThird degree burn between 2-10%burns
oBurns which are not involvingeyes,ears
Face,hand,feet and perineum

33. 3
3
CLASSIFICATION (CONT……)
SEVERE
oSeconddegree burns more then 25%in adults
and More then 20%in children
oAll third degree burns more then10%
oAll electrical burns and inhalation burns
oBurns with fracture
oBurns involving eyes,ears,feet,handsand
perineum

34. Pathophysiology of burn injury
34
Most common organ affected is the skin
Burn canalso damage airways and lungs with life
Threatening consequenses
Respiratory system injuries occure if person trapped
In a burning vehicle,house,car and is forced to inhale
Thehot and poisonous gases
Hot gasesburn the lining of airway above thelarynx
And lining start to swell later on block the airway
Steam causesdamage to the lowerairways,respiratory
Epithelium swells and detach from bronchialtree

35. Pathophysiology(cont……)
Metabolic poisoning
Carbon monoxide is a product of incomplete combustion
That is often produced by fires in a closed space is one of
Many poisonous gases
Cobinds to hb with an affinity of 240> O2soblock
Transport Of O2
Level of carboxyhaemoglobin in blood canbemeasure
Conc>10%dangerous and need treatment with pure
Oxygenfor more then 24hours
Hydrogen cynide causesmetabolic acidosis by interefering
with
1 mitochondrial respiration 13

36. Pathophysiology(cont……)
Inhalational injury
causedby minute particles within thick smokebecause
Of their small sizeand are not filtered by the upper
Airwayand are carried down to
lung parenchyma
Stick to moist liningcauses
intense reaction in alveoli
Causeschemical pneumonitis
followed by oedema within
Alveolar sacand dec gaseous
exchange
1

0/2
B
2/2
a
01
c
6
terial pneumonia occures
14

37. Pathophysiology(cont……)
10/22/2016 37
Inflamtion and circulatory changes
Burn skin release of neuropeptides activation of
Complement are intiated by stimulation of pain fibersand
Alteration of proteins byheat
Activation of hageman factor alter archidonicacid
Thrombin and kallikrein pathways

38. Pathophysiology(cont……)
10/22/2016 38
At cellular level
Complement causesdegranulation of mast cells
Attracts neutrophils which also degranulate and releases
Largeamount of free radicals andproteases
Mast cells also releases TNF@which act aschemotactic
Agent to inflamatory cells
Theseinflamatory factors alter permeability of bldvessels
Largeprotein molecules canalso escapewith ease
Damaged collagen and extravasated proteins oncotic
Pressurefurther increase flow of water fromintravascular
T
oextravascularspace

39. Pathophysiology
Heat causes coagulation necrosis of
skin and
subcutaneous tissue.
10/22/2016 39
↓
Releaseof vasoactivepeptides
↓
Altered capillary permeability
↓
Lossof fluid →Severe hypovolaemia
↓
Decreasedcardiac →Decreasedmyocardial
output function
↓
Decreasedrenal blood →Oliguria
flow (Renalfailure)
↓
Altered pulmonary resistance causing pulmonary
Oedema infection
SystemicInflammatory ResponseSyndrome (SIRS)
↓
Multi OrganDysfunction Syndrome(MODS).

40. BURN ASSESSMENT

41. ASSESSMENT OF BURNS
ASSESSING SIZE
Burn sizeshould be assessedin acontrolled environment
T
o avoid hypothermia
In smaller burns just cut apiece aclean paper the sizeof
patient ,swhole hand (digit and palm)which present 1%TBSA
And match this to thearea
Another accurate way of measuring the size of burns is to draw
Theburn on a Ruleof9or LUND AND BROWDER CHART
10/22/2 18

42. ASSESSMENT(CONT…..)
10/22/2016 42
RULEOF9 (wallace,s rule of9
Eachupper limb is 9%TBSA
Eachlower limb is 18%TBSA
Torso18%each side
Head and neck 9%
Perineum 1%
In children head and neck is 18%and
Lower limb is 13.5%each=13.5*2=27%

43. Body Surface Area
Estimation

45. ASSESSMENT(CONT…..)
10/22/2016 45
2.Assessing depth from the history
Burning of human skin is temperature and timedependent
It takes 6 hours for skin maintained at 44c* for irreversible changes
Asurface teperature of 70c* for 1 second produceepidermal
destruction
example of exposure of hot water at 65 degree C temperature
45 second exposure produce full thicknessburn
15 second exposure produce deep partial thicknessburn
7 second exposure produce superficial partial thiknessburn

46. BURN ASSESSMENT

47. ASSESSMENT(CONT…..)
10/22/2016 47
a) Superficial partial thickness burns
 No deeper then papillary dermis
 Blister formation
 Lossof epidermis
 Capillary return visible
When blanched
 Dermis is pink and moist
 Pin prick sensation normal
 Heal without scarring
In 2 weeks
 Treatment is non surgical

48. Superficial partial thickness
burns
10/22/2016 48
After 24hours afterburn After 2weeks

49. Superficial partial thickness burn after 3months
Pigment returning
10/22/2016 49

50. ASSESSMENT(CONT…..)
10/22/2016 50
b)Deep partial thickness burn
Damageto deeper parts ofdermis
Epidermis is usually lost
Fixedcapillary staining
Colour does not blanch with pressure
Sensation is reduced
Pt is unable todistinguish sharp from blunt pressure
T
akes3 or more weeks to heal without surgery
Leadsto hypertrophic scarring

51. ASSESSMENT(CONT…..)
10/22/2016 51
c)Full thicknessburns
Whole of the dermisdestroyed
Hard and leathery feel
No capillary return
Often thrombosed vesselscanbe seenunder
The skin
Theseare completely anesthetised
No pain and no bleeding

52. Burn Patient Severity
 Factors to Consider
 Depth or Classification
 Body Surface area burned
 Age: Adult vs Pediatric
 Preexisting medical conditions
 AssociatedTrauma
 blast injury
 fall injury
 airway compromise
 child abuse

53. Burn Criteria

54. Critical Burn Criteria
 30 > 10% BSA
 20 > 30% BSA
 >20% pediatric
 Burns with respiratory injury
 Hands, face, feet, or genitalia
 Burns complicated by other trauma
 Underlying health problems
 Electrical and deep chemical burns

55. Moderate Burn Criteria
 30 2-10% BSA
 20 15-30% BSA
 10-20% pediatric
 Excluding hands, face, feet, or genitalia
 Without complicating factors

56. Minor Burn Criteria
 30 < 2% BSA
 20 < 15% BSA
 <10% pediatric
 10 < 20% BSA

57. Causes of death inburns
10/22/2016 57
a. Hypovolaemia and shock
b. Renalfailure
c. Pulmonary oedema andARDS
d. Septicaemia
e. Multiorgan failure

58. Full thicknessburn
Wraped in clingfilm
10/22/2016 58

59. Deep partial thicknessburn
tangential shavingto removedead dermis
Dermis remove layer by layer untill bleeding
10/22/2016 59

60. Hypertrophicscarring following a deep dermal burn.
After 3 or moreweeks
10/22/2016 60

61. Assessment &
Management

62. Management of burns
10/22/2016 62
Management of burns is consist of
prehospital care
&
hospital care

63. Management of burns
Prehospital care
Stop the burning process
Stop,drop and roll is agood method of extinguishing
Fire
Cool the burn wound
Thisprovide analgesia and slow the delayed micro-
-vascular damage which occure after aburn injury
Cooling should be for minimum 10 mintues and up to
Onehour to avoidhypothermia
Give oxygen
Giveoxygen especialy if there is altered conciousness_
level 32

64. Management of burns
64
Elevate
Sitting apatient up with aburned airway may provelife
Saving
Elevation of burned limbs reduce swelling anddiscomfort
Check for other injuries
AstandardABCcheck followed by asecondarysurvey
Patients burned in explosions may have head and spineinjuries
And other life threateningproblems

65. Management of burns
65
Indications for admission in burns
Susectedairway or inhalational injury
Any burn require fluide resusciation
Any burn in extreme of ages
All electrical and chemicalburns
Any burn which require surgery
Burn of any significance to hands,face,feet orperineum
Suspiciousof non accidentalinjury

66. HYPOVOLAEMIC SHOCK
 Hypotension
 Oliguria
 Tachy cardia
 Sweating
 Pallor
 Hyper ventilation
 Clouding of consciousness

67. SEPTIC SHOCK
 IncreasedT*
 Hypotension < 90 mmhg
 Oliguria < 30 ml
 Dry &pink exremities
 Altered pulmonary functions

68. SKIN ASSESSMENT
 Inspection
 Appearance
 Temperature
 Moisture
 Dryness
 Texture
 Color
 Size
 Palpate lymph nodes
 Cyanosis
 Pulses
 Area
 Duration
 Itching/burning

69. Management of burns
69
Hospital care
Admit the patient
Airway control
Breathing and ventilation
Circulation
Disability
Exposure with environmentcontrol
Fluid resuscitation
Assessthe %age,degreeand type of burn
Keepthe patient in cleanenvironment
Sedation and proper analgesia

70. Management of burns
10/22/2016 70
A.AIRWAY CONTROL
Burned airway creates problems by swelling and cancompletely
Occlude the airway
Secureairway with an endotracheal tubeuntil
swelling subsided which is Usually 48hours
Delayed diagnosis of airway burn make difficult to intubate the
Patient in presence of lyrangeal oedema socricothyroidectomy
Should be done
Early intubation of suspected airway burn is the treatment of
Choice in suchpatients

71. Management of burns
10/22/2016 71
B.BREATHING
Aprogressive increase in respiratory rate and effort,anxiety
Risingpulse and confusion with decreasing o2saturation
Thesesymptoms take 24 hours to 5 daysto appear
Treatment starts assoon aspossible including
Physiotherapy
Nebulisers
Warm humidified oxygen

72. Management of burns
10/22/2016 72
Fluide resuscitation
Iv volume must be maintained following aburn in order to
provide sufficient circulation to perfuse not only the organs but
also the peripheral tissues,especially damagedskin
Iv resuscitation is appropriate for any child withaburn greater
Then 10%and 15%for TBSAfor adults
If oral resuscitation is to be commenced then water is given
Should not be saltfree
It is appropriate to give oral rehydration with asolution such as
DIORALYTE*
Most common fluid used is ringer lactate

73. Management of burns
Fluid volume is relatively constant in proportion to the area
Of body burned therefore there are formulate that calculate
The approximate volume of fluid needed for the pt of agiven
Body weight with agiven %ageof the bodyburned
Formulas to calculate the fluid replacement
1.parkland regime (commonly used)
4ML/%burn/kg body weight/24 hours
4*50*60=12000ml in 24hours
Half this volume is given in the frist 8 hours
Secondhalf is given in the subsequent 16hours
Others
1. Evan,s formula
2. Muir and barclay
10/223/2.016Modified brook formula 39

75. Management (cont…)
10/22/2016 75
Fluids used
Crystalloid resuscitation
Ringer lactate is the most commonly usedcrystalloid
Theseare aseffective ascolloids for maintaining intra-
-vascular volume
Lessexpensive
In children
Dextrose saline given for maintanaince
100ml/kg for 24 hours for frist10kg
50ml/kg for 24 hours fornext 10kg
20ml/kg for 24 hours for each kgabove 20kg bodyweight

76. Management (cont…)
10/22/2016 76
hypertonic saline
 it produces hyperosmolarity andhypernatremia
Reducesshift of intracellular water to extracellular space
Advantages
Include less tissue oedema and aresultant decrease in
Escharotomies and intubations

77. Management (cont…)
10/22/2016 77
Colloid resuscitation
Plasmaproteins are responsible for the inward oncotic
Pressure that counteracts the outward capillaryhydrostatic
Pressure.
Without proteins there willbe oedema
Proteins should be given after frist 12 hours of burn before
This time proteins will leak out of cells
Given through muir and barclay formula
0.5*%agebsa burn*weight=one portion
Periods of 4/4/4, 6/6,12 hours respectively
Oneportion to b given ineach period

78. Management (cont…)
10/22/2016 78
Monitoring of resuscitation
Thekey to monitoring of resuscitation is urinaryoutput
Output should be between 0.5ml and1.0ml/kg/hour
If urine output is below this infusion rate should increase
By50%
If still output is inadequate then abolus of 10ml/kggiven
2ml/kg/hr urinary output signals decrease in the rate of
Perfusion
Haematocrit measurement is ausefull tool in confirming
Suspected under or overhydration

79. Management (cont…)
10/22/2016
44
Asan absorbent
Treating the burn wound
Dressings
Paraffine guaze
Hydrocolloids (duoderm)
Biological dressings
synthetic (biobrane)
natural (amniotic membrane)
Full-thickness and deep dermal burns needantibacterial
dressings to delay colonisation prior tosurgery
Open method
Silver sulfadiazine application without dressingscommonly
Usedin burns of face,head andneck.
Closed method
Dressing done to soothen and to protect the wound
T
oreduce thepain

80. Management (cont…)
10/22/2016
Treating the burn wound (cont……
Tangential excision
Canbe done within 48 hours with skin grafting in patients with less
Then 25% burn
Usually done in deep
dermal burns
Deaddermis is removed
layer by layer Untill fresh
bleeding occurs
Later skin grafting done
45

81. Treating the burn wound
(cont……
Treating the burn wound (cont……
escharotomy
Circumferential full-thickness burns tothe limbs require emergency
Surgery
Thetourniquet effect of thisinjury
is easily treated by incising the whole length of full-thickness
burns.
Thisshould be done in the mid-axial line,avoiding major
Nerves
Theburn needs to be cleaned and the sizeand depth need tobe
Full thickness burns and deep partial-thickness burns thatwill
requireoperative treatment will need to be dressed with an
antibacterialdressing to delay the onset of colonisation of the
wo1
0
u/
2
2
n/
2
d0
1
6 46

83. Afull-thickness burn to the upper limb with a mid-axial
escharotomy.
Thesoot and debris have been washedoff.
10/22/2016 83

84. 10/22/2016 84
Topicalagent advantages problems
Silver sulfadiazine 1 -Antiseptic (G+ve -Neutropenia,
% and G–ve pseudoeschar
-Soothening, good -- Causeswound
penetration maceration
- Hydration and
softening of eschar
occurs
Sulfamylon – 5%- Antipseudomonal, Very irritant,painful
(Mafenide acetate) anticlostridial Causesacidosis
- Penetrates very
well in to tissues
Silver nitrate –0.5% -Antiseptic Stainsburn area
Povidone iodine Irritant
(5%) - Usedon Painfull
granulation tissue - Not used in partial
after eschar burns
separation
Silver sulphadiazine - Boostscell
and cerium nitrate mediated immunity
and forms sterile
eschar

85. Additional aspects of treating
burn patient
10/22/2016 85
Analgesia
Oral form of paracetamol and nsaids insuperficial burns
Iv opiates for largeburns
Im should not be given in over 10%of TBSAasabsorption is
Unpredictable
Short acting analgesia given beforedressing
Energy balance
Feeding should start within 6 hrs of injury to reduce gut mucosal damag
Burns patients need extra feeding
Anasogastric tube should be used in all patients withburns over 15%
of TBSAand 10%in caseofchildren
 Burn injuries are catabolic in theacute episode.
Removing the burn and achieving healing stops thecatabolic drive

86. Additional aspects of treating
burn patient
control of infection
Patients with major burns areimmunocompromised,
pathogenic and opportunistic bacteria and fungi enter via theburn
wound,cathetars and iv lines
Theyhave compromised local defences in the lungs and gut dueto
oedema
Sterile precautions must berigorous
 Swabsshould be taken regularly
Arise in white blood cell count, thrombocytosisand
increased catabolism are warnings of infection
Nursing care
Physiotherapy
Psy
10c
/2h
2/2o
016
logical support 50

87. SURGERY FORTHEACUTEBURN
10/22/2016 87
Any deep partial-thickness and full-thickness burnsexcept
those that are less than about 4 cm2, needsurgery
Atopical solution of 1:500 000 adrenaline also helps toreduce
bleeding,
deep dermal burns, the top layer of dead dermisis shaved
off untilpunctate bleeding is observed and the dermis can be
seento be free of any small thrombosedvessels
Full-thickness burns require full-thickness excision ofthe
Skin
Postoperative management of these patientsobviously
requires careful evaluation of fluid balance and levels ofhaemoglobin.

88. Delayed reconstruction and scar
management
10/22/2016 88
is common for large Full thicknessburns
Eyelids must be treated before exposure keratitisarises
Transposition flaps and Z-plasties with or withouttissue
expansion are useful
Full-thickness grafts and free flaps may be needed forlarge
or difficult areas
Hypertrophy is treated with pressure garments tobe worn
for 6-18months
Smaller areas of hypertrophy, silicone patches will speed
scar maturation,as will intralesional injection of steroid.
 Pharmacological treatment of itchis important

89. Pediatric Burns
 Thin skin
 increases severity of burning relative to adults
 Large surface/volume ratio
 rapid fluid loss
 increased heat loss  hypothermia
 Delicate balance between dehydration and
over hydration
 Immature immunological response  sepsis
 Always consider possibility of child abuse

90. Geriatric Burns
 Decreased myocardial reserve
 fluid resuscitation difficulty
 Peripheral vascular disease, diabetes
 slow healing
 COPD
 increases complications of airway injury
 Poor immunological response - Sepsis
 % mortality ~= age + % BSA burned

91. Complication of burn
10/22/2016 91
Shockdue to hypovolaemia
Renalfailure(toxins from burn&myoglobin)
Pulmonary oedema,resp infections,ARDS,resp failure
Infection by staph aureus,pseudomonas,klebsella leadsto
Septicemia
Fungaland viral infections of dangerous type canoccure
GIT
:Hypovolaemia, ischaemia of mucosa,erosive
gastritis—Curling’s ulcer (seen in burns >35%).
 Fluid and electrolyte imbalance.
immunosuppression predisposes to severe opportunistic infection.
Escharformation and its problems likedefective
circulation, ischaemia when it is circumferential.
Electrical injuries often causefractures,major
internal organ injury, convulsions.

92. Complications (cont…..)
10/22/2016
. 92
Inhalation burn causespulmonary oedema,
respiratory arrest,ARDS.
Chemical injury causessevere GITdisturbances like
erosions, perforation, stricture oesophagus (alkali),
pyloric stenosis (acid), mediastinalinjury.
Other problems
DVT,pulmonaryembolism
bed-sores,
severe malnutrition with catabolicstatus,
 Toxic shock syndrome:
It is a life-threatening exotoxin mediated disease causedby
Staphylococcusaureus. It is common in children, presentswith
rashes, myalgia, diarrhoea, vomiting, andmultiorgan
failure with highmortality

93. Complications (cont…..)
10/22/2016 93
Development of contracture is alate problem.It
leads to ectropion, microstomia, disability of
different joints, defective hand functions, growth
retardation causingshortening
COMPLICATIONS OFBURNSCONTRACTURE
Ectropion of eyelid causing keratitis andcorneal
ulcer.
Disfigurement in face.
Narrowing of mouthmicrostomia.
Contracture in the neck causing restricted neckmovements.
Disability and nonfunctioning of joints due to contracture
Hypertrophic scarand keloid formation.

94. COMPLICATIONS OFBURNS CONTRACTURE
Marjolin’s ulcer
It is avery well-differentiated squamous cell carcinoma
occurring in ascarulcer due to repeated breakdown(unstable
scar of longduration).
•It is locallymalignant.
•Asthere are no lymphatics in the scar,sothere
is no spread to lymphnodes.
• Asthere are no nerves in the scar itis painless.
•It hasraised and everted edge with induration.
•Biopsy confirms the diagnosis.
Treatment
Radiotherapy is not given forMarjolin’sulcer
.
Treatment is either wide excision or amputation. It is curable.
Once it spreads out of the scar tissue it behaves like
any other squamous cell carcinoma and socanspreadto
10/22/20r1e6gional lymphnodes 56

95. Marjolin’s ulcer developed over burnscontracture
10/22/2016 95

96. Contracture at different
parts of body
chest and neck
10/22/2016 96

97. Contracture at different
parts of body
10/22/2016 97
Severe contracture at knee joint
causing deformity Contractureatface

98. Complication of
contracture
10/22/2016 98
Hypertrophicscar Keloid formation

99. Treatment of burn
contracture
10/22/2016 99
• Releaseof contracture surgically and useof skingraft
or “Z” plasty or differentflaps.
• Proper physiotherapy and rehabilitation is essential.
• Pressuregarments to prevent hypertrophicscars.
• Management of itching in the scarusing aloevera,
antihistamines and moisturizing creams.

100. Prevention of developmentof
contracture
10/22/2016 100
•Joint exercise in full range during recovery periodof
burns
• Pressuregarments for along period
•Topical silicon sheeting
•Saline expanders for scars

101. NON THERMALINJURIES
10/22/2016 101
Electrical burns
Chemical burn
Cold injuries
Ionising radiation

102. Non thermal(cont……)
10/22/2016 102
Electrical burns 1000v
Low tension injuries
Low tension injuries do not have enough energy to cause
Significant destruction
Entry and exit points normally in the fingers suffers small
Deepburns may damage underlying nerves and vessels
Accreates atetany within musclessopatient unable to
Releasethe device untill the power wasturnedoff
May interfere with normal cardiac pacing and cancause
Cardiac arrest

103. Electrical
burns(cont…..)
high tension injuries
3 sources of damage
1) The flash
2) The flame
3) The current
When ahigh tension line is earthed itcanarc over the pt
And causesaflash burn
Extremely rapid heating of the aircausesan explosion
That propel the victimbackward
It is always amajor burn
There is awound of entry and wound ofexit
Major internal organ injuriesoccures
Convulsions candevelope
10/22/2016 65

104. Electrical
burns(cont…..)
Management
Depending on injury it is managedaccordingly
Patient should always be admitted and should be assessedby
i. ECG
ii. u/s abdomen
iii. Chestx-ray
iv. Ctscanhead sometimes
v. Cardiac enzyme analysis
Acidosis is common sobicarbonate infusion needed
Fractures and dislocations common somanaged accordingly
Releaseof myoglobin cancauserenal tubular damage andrenal
Failure somanitol is used to prevent myoglobin inducedrenal
failure (compartment syndrome)
10/22/2016 66

105. Wound of entry in anelectricburn.
Electric burn
10/22/2016 105

106. Electrical
burns(cont…..)
10/22/2016 106
An exit wound of ahigh-tension
injury,
Amputation and coverwith the
lateral portion of the secondtoe.

107. Chemical
burns
10/22/2016 107
There are 70000 different chemicals in regular usewithinindustry
Occasionally these causeburns
There are two aspects to achemicalinjury
1. Physicaldestruction to theskin
2. Systemicabsorption
Theinitial management of any chemical injury is copious lavage
With water but some need tobe remove physically eg.phosphorus
Acomponent of millitary devices
Themore common injuries are causedbyeither
1. Alkalis
2. acids

108. Chemical burns(cont…)
10/22/2016 108
Alkalis
alkalis are more destructive and especially when come incontact
With eyes
Commonly used alkalis are sodium hydroxide,lime,bleach
Theycausefat sponification,fluide loss,release of alkali proteinase
Alkali burns occur in oral cavity andoesophagus
which leads to multiple oesophagealstrictures.
After copious lavage, the next step in themanagement of any
chemical injury is toidentify the chemical
and its concentration and to elucidate whether there is any
underlying threat to the patient’s life if absorbed systemically

109. Acidaemia should be corrected by IVsodiumbicarbonate.
10/22/2016
Chemical burns(cont…)
109
Acids
Acid burn occurs in skin, soft tissues and GIT
.In GIT
,
Burns affecting the fingers and causedby dilute acid arerelatively
common.
Theinitial management is with calcium gluconate geltopically
severe burns or burns to large areas of the hand canbe
subsequently treated with Bier’s blocks containing calcium
gluconate 10 per centgel
it is common in stomach either due to nitric acid or sulphuric acid
which may lead tosevere gastritis or pyloric stenosis.
Other acids are formic acid, hydrofluoricacid.
Theycausemetabolic acidosis, renal failure, ARDS,haemolysis.

110. Cold injuries
inflammatory reactionisnot asmarked.
Thetissueismoreresistanttocoldinjurythantoheatinjury
Theassessmentof depth of injuryismoredifficult,
 Frostbite
injuries affectthe peripheriesincoldclimates
coldinjury producesdelayedmicrovasculardamagesimilarto
 that of cardiacreperfusioninjury.
Theinitial treatmentiswith rapidrewarminginabathat42°C.
Thelevelof damageisdifficult toassess
surgery
usuallydoesnot playarole in itsmanagement
Cold injuries are principally divided into twotypes
1. Acute cold injuries fromindustries
2. Frost bite
72

111. Ionising
radiation
111
Theseinjuries canbe divided into
1. Localised
2. Whole body exposure
Themanagement of localised radiation damage is usually
Conservative until the true extent of the tissue injury is apparent.
If damage have causedan ulcer, then excision and coveragewith
vascularised tissue is required.
Apatient who hassuffered whole-body irradiation and issuffering
From acute desquamation of the skin hasreceived alethal dose of
Radiation which cancauseaparticularly slow and unpleasantdeath
Dosemay be lethal and may not belethal
Giving iodine tablets, the management of these injuries is supportive

112. THANKS
10/22/2016 112