A complete review for all medical students and doctors working in burn unit in any hospital. #Emergency #BurnProtocol #protocol #Burns #Abhishek #MUSTKNOW #knowledge #Medical #Health

1. Burns
Prepared by
Dr Abhishek Tamrakar

2. Objectives
• Epidemiology
• Classification of burns
• Immediate care of Burn patient
• Criteria for admission to burn unit
• Assessment of burn wound and resuscitation
• Treatment of burn wound

3. Introduction
• Burns are a result of the effects of thermal injury on the skin and
other tissues
• Human skin can tolerate temperatures up to 42-44° C (107-111° F)
but above these, the higher the temperature the more severe the
tissue destruction
• Below 45° C (1130 F), resulting changes are reversible but >45° C,
protein damage exceeds the capacity of the cell to repair

4. Epidemiology
• Burn is a public health problem, accounting for an estimated 265,000
deaths annually throughout the world
• Majority of these occur in low- and middle-income countries and
almost half occur in the WHO South-East Asia Region.
• Burns are among the leading causes of disability-adjusted life-years
(DALYs) lost in low- and middle-income countries.
• In 2004, nearly 11 million people worldwide were burned severely
enough to require medical attention
(WHO Burns review : Fact sheet)

5. Epidemiology
• Most of the burn victim belong to the working age group between
15-60 yrs old
• Flame burns were found to be the most common cause of burn
injury followed by scald burn, whereas scald burn were the most
common cause of burn injury among among the pediatric population
• Home being the most common place of burn injury
• The average hospital stay among the burn victim ranged from 13 to
60 days.
• Mortality among the burn victims ranged from 4.5 to 23.5%, with
highest mortality among the flame burn patients.
• Epidemiology of burn injury in Nepal; S.tripathee and S.J. Basnet

6. Physiological Response
• Typically, biphasic response
• The initial period of hypofunction manifests as: (a) Hypotension, (b) Low cardiac
output, (c) Metabolic acidosis, (d) Ileus, (e) Hypoventilation, (f) Hyperglycemia,
(g) Low oxygen consumption and (h) Inability to thermoregulate
• This ebb phase occurs usually in the first 24 hours and responds to fluid
resuscitation
• The flow phase, resuscitation, follows and is characterized by gradual increases
in (a) Cardiac output, (b) Heart rate, (c) Oxygen consumption and (d)
Supranormal increases of temperature
• This hypermetabolic hyperdynamic response peaks in 10-14 days after the
injury after which condition slowly recedes to normal as the burn wounds heal
naturally or surgically closed by applying skin grafting

8. Pathologic Features
• Zone of coagulation (necrosis):
Superficial area of coagulation necrosis
and cell death on exposure to
temperatures >450 (primary injury)
• Zone of stasis (vascular thrombosis):
Local capillary circulation is sluggish,
depending on the adequacy of the
resuscitation, can either remain viable or
proceed to cell death (secondary injury)
• Zone of hyperemia (increased capillary
permeability)

9. Kinds of Burns
• Scald Burn: most frequent in home injuries; hot water, liquids
and foods are most common causes; above , cell death
• Flame Burn: due to gasoline, kerosene, liquified petroleum gas
(LPG) or burning houses
• Chemical Burn: common in industries and laboratories but may
also occur at home; acid is more common than alkali
• Electrical Burn: worse than the other types; with entrance and
exit wounds; may stop the heart and depress the respiratory
center; may cause thrombosis and cataracts
• Radiation Burn: from X-ray, radioactive radiation and nuclear
bomb explosions

10. Classification: depth of burn
• First degree: Injury localized to the epidermis
• Superficial second degree: Injury to the
epidermis and superficial dermis
• Deep second degree: Injury through the
epidermis and deep into the dermis
• Third degree: Full thickness injury through
the epidermis and dermis into subcutaneous
fats
• Fourth degree: Injury through the skin and
subcutaneous fat into underlying muscle or
bone

11. Immediate care of the BURN patient

12. Pre-hospital care
• Ensure rescuer safety
• Stop the burning process
• Check for other injuries
• Cool the burn wound
• Give oxygen
• Elevate

13. Hospital care
• A- Airway control
• B- Breathing and ventilation
• C- Circulation
• D- Disability (Neurological status)
• E- Exposure with environmental control
• F- Fluid resiscitation

14. Major determinants of the outcome of burn
• Percentage surface area involved
• Depth of burns
• Presence of an inhalational injury

15. Criteria for admission to burn unit
• Partial thickness burn more than 10% of TBSA
• Burns involving the face, hands, feet, genitalia, perineum
• Any full thickness burn
• Electrical burns, including lightning injury
• Chemical burns
• Inhalation injury
• Burn in pt with preexisting medical disorder that could complicate
management, prolong recovery or affect outcome
• Any pt with burns and concomitant trauma in which the burn injury poses
the greater immediate risk of morbidity and mortality.
• Burned children without personnel or equipment to care for children
• Pt requiring special social, emotional or long term rehabilitative
Sabiston textbook of surgery, 19th edition

16. Initial management of burned airway
• Early elective intubation is safest
• Delay can make intubation very difficult because of swelling
• Be ready to perform an emergency cricothyroidotomy if intubation is
delayed
The time frame from burn to airways occlusion is usually between 4 and 24 hrs

17. Assessment of burn wound
• The patient’s whole hand is 1% TBSA, and is a useful
guide in small burns
• The Lund and Browder chart is useful in large burns
• The Rule of Nine is adequate for a first approximation
only.

19. Assessing depth of burn
Superficial Partial
thickness Burns
• No deeper than
papillary dermis
• Blistering and loss of
epidermis
• Blanching present
• Heals without scar
in 2 wks
• Nonsurgical
treatment
Full thickness
burns
• Whole dermis is
destroyed
• Hard, leathery feel
• Charred black skin
• No capillary return
• Completely
anaesthetised
Deep Partial
thickness Burns
• Deeper part of
reticular dermis
• Epidermis lost
• Blanching absent
• Sensation reduced
• Heals usually
leading to
hypertrophic scar in
3 or more wks

20. Fluid resuscitation
• There are three types of fluid used
• Ringer’s lactate or Hartmann’s solution
• Human albumin solution or Fresh frozen plasma
• Hypertonic saline
• Parkland formula:
Volume(ml) = Total % of BSA x weight(kg) x 4
Half of this volume is given in the first 8 hours and second half in subsequent 16
hours

21. Crystalloid resuscitation
• Ringer’s Lactate is most commonly used
• Less expensive
• Large protein molecule leak out of capillaries following burn injury
• Maintenance fluid
• 100 ml/kg for 24 hrs for the first 10 kg
• 50 ml/kg for next 10 kg
• 20 ml/kg for 24 hrs for each kg over 20 kg body weight,

22. Hypertonic saline
• Produces hyperosmolarity and hypernatremia. This reduces the shift
of intracellular water to the extracellular space
• Advantage:
• Less tissue edema
• Decrease in escharotomies and intubations

23. Colloid resuscitation
• Proteins should be given after the first 12 hrs of burn because, before
this time, massive fluid shifts cause protein to leak out of the cells.
• Muir and Barclay formula:
• 0.5 x % of BSA butny x weight (kg) = One portion
• Peroid of 4/4/4, 6/6 and 12 hrs respectively
• One portion to be given in each peroid

24. Monitoring resuscitation
• Key monitoring of resuscitation is Urine Output
• UO is maintained between 0.5 to 1 ml/kg/hr
• If UO is below this, infusion rate should be increased by 50 %
• If the UO is inadequate and the patient is showing signs of
hypoperfusion then a bolus of 10ml/kg body weight should be given
• Decrease rate of infusion when UO is over 2 ml/kg/hr
• Other measures of tissue perfusion:
• Acid base balance
• Haematocrit
• Filling pressure by transoesophageal ultrasound or with invasive central line

25. Treating the burn wounds

26. Escharotomy
INDICATIONS:
• Circumferential deep dermal or full
thickness burns
• 5 Ps: Pain, Pallor, Paraesthesia,
Paresis, Pulselessness
• Could be difficult in severely burned
patient

27. Options for topical treatment of deep burns
• 1% silver sulphadiazine
cream
• 0.5% silver nitrate
solution
• Mafenide acetate
cream
• Silver nitrate, silver
sulphadiazine and
cerium nitrate
• Hydrocolloid dressing
PRINCIPLES OF DRESSINGS FOR BURNS
• Full thickness and deep dermal burns
need antibacterial dressing to delay
colonization prior to surgery
• Superficial burns will heal and need
simple dressing
• An optimal healing environment can
make a difference to outcome in
borderline depth burns
-Bailey and Love 26th edition

28. Additional aspects
• Analgesia
• Energy balance and nutrition
• Burn pt. needs extra feeding
• NG tube is used in burn over 15% TBSA

29. Monitoring and control of infection
• Immunocompromised
• Susceptible to infection
• Sterile precautions
• Swabs should be taken
• Rise in WBC, thrombocytosis are warning signs of infection.

30. Nursing Care
• Intensive nursing care
• Bandaged hands and joints, stiff
and painful, need careful
coaxing.
• Personal hygiene, baths and
showers
Physiotherapy
• Elevation
• Splintage
• Exercise reduces swelling
• Physiotherapy started on day 1

31. Surgical Management
• Deep dermal burns need tangential shaving and split-skin grafting
• All but the smallest full thickness burns need surgery
• Must be prepared for significant blood loss
• Topical adrenaline reduces bleeding
• All burnt tissue needs to be excised
• Stable cover, permanent or temporary should be applied at once to
reduce burn load
Any deep partial-thickness and full thickness burns, except those that are less then
about 4cm2 needs surgery. Any burn of intermediate depth should be reassessed
after 48 hours

32. Delayed reconstruction and scar management
• Eyelids must be treated before exposure keratitis arises
• Transposition flaps and Z-plasties with or without tissue expansion
are useful
• Full thickness grafts and free flaps may be needed for large or difficult
areas
• Hypertrophy is treated with pressure garments
• Pharmacological treatment of itch is important.

33. References
• Bailey and Love’s Short practice of surgery, 26th edition
• Sabiston textbook of surgery, 19th edition
• Schwartz’s Principles of surgery, 10th edition
• Tintinalli’s Emergency medicine, 7th edition

34. Thank you