Burn

BURN INJURY

Outlines

• Introduction
• Epidemiology
• Causes
• Classification
• Management

General intervention

Introduction

Burn injury can be defined as bodily injury resulting from exposure to heat, cold, chemical, electricity or radiation.

• Human skin can tolerate temperature up to 42-44 centigrade

Burn causes coagulation necrosis of the skin and underlying tissues Patients with extensive burns frequently die, and for those with less severe injuries, physical recovery is slow and painful Patients also may suffer emotional and psychological problem

EPIDEMIOLOGY

Affecting approximately 1% of the world population each year In the United States, approximately 2.4 million burn injuries are reported every year, 700,000 visits per year and 45,000 require hospitalization.

In East African countries such as Uganda and Tanzania, studies have found that the age range mostly affected was 1-10 years (53% were female, 47% were male and scalding burns formed 65% of all burn injuries) Risks can be reduced by improving social circumstances, housing and industrial safety.

CAUSES

• Thermal energies
• Scald – (injury with hot liquids, or steam)

Flame

Contact -direct contact to extremely hot objects or the contact was abnormally long, commonly seen in people with epilepsy or those who misuse alcohol or drugs

CAUSES Cont…

• Chemical (acids like hydrochloric acid)
• Electrical energy
• Radiations
• Cold injuries

Child abuse

Adult carelessness, child’s exploring and curious nature, failure to supervise the child adequately all contribute to higher incidence of burn injuries in children

Pathophysiology of burn

• Burns are caused by transfer of energy from the heat source to the body

through conduction or radiation

Heat energy → tissue destruction due to coagulation, protein denaturation or ionization of cellular contents The skin and the mucosa of the upper airways are the sites of tissue destruction.

Pathophysiology of burn cont…

The depth of the injury depends on the temperature of the burning agent and duration of contact with agent Disruption of the skin can lead to

• increased fluid loss
• infection
• hypothermia

scarring

Classification of burns

Classification of burns cont…

• Burns are classified according to the depth of tissue destruction
• 1st degree burn (superficial-thickness)
• 2nd degree burn(partial-thickness burn)
• 3rd degree burns(deep partial-thickness burn)

4th degree burns(Full thickness burn)

Superficial-thickness burn/1st DEGREE BURN

The epidermis is destroyed or injured, but there is no destruction of tissue or nerve endings.

• The wound is painful, may appear red and dry, with blister
• The wound usually takes 3 to 7 days to heal without scarring

There is prompt regeneration

Superficial burn cont…

Partial-thickness burn/2nd Degree burn (superficial & deep)

• Superficial 2nd degree burn
• Injury involves destruction of epidermis and upper half of dermis

The wound is painful, sensitive to temperature change and air exposure Wound Appearance: Red to pink, Wet and weeping wounds, Thin-walled, fluid-filled blisters, Mild to moderate edema, Extremely painful Wound Healing: In 2 weeks (spontaneous) Minimal scarring; minor pigment discoloration may occur Regeneration of the skin usually occur from the remaining viable epithelial cells in the dermis

Partial-thickness burn cont…

Deep partial-thickness burn/ 3rd Degree burn

Injury involves destruction of entire epidermis and dermis, and in some cases underlying tissue as well The color of the wound varies from white to red, brown or black Pain less severe than in superficial partial thickness burn

Full-thickness burn/4th Degree burn

Burns which cause the skin to be waxy white to a charred black and tend to be painless.

Includes destruction of epidermis and the entire dermis as well as possible damage to the SQ tissues, muscle and bone Healing is very slow if at all, and may require skin grafting.

Calculating % of burn

injuries

The extent of burned body surface area can be estimated or determined by the following ways;

• Rule of nine
• Palm method

Lund and browder method

The rule of nines

• Rule of nines is a quick way of calculating the extent of burns
• The system assigns percentages in multiples of nine to the body surfaces
• 9% for whole head
• 9% for left arm

9% for right arm

Rule of nines cont…

• 9% for abdomen
• 9% for anterior thorax (chest)
• 9% for posterior thorax (upper back)
• 9% for posterior abdomen (lower back)
• 9% for anterior right leg
• 9% for anterior left leg
• 9% for posterior right leg
• 9% for posterior left leg

1% for genital area

Rule of palm

In patients with scattered burns, the useful method to estimate percentage of burn is the palm method This method assumes that the size of the patient’s palm is approximately 1% of the body surface area(BSA)

Rule of palm cont…

• Rule of palm

Patient’s palm equals 1% of his body surface area

Lund and browder method

Is the more precise method of estimating the extent of burn This method recognizes that the percentages of body surface area of various anatomic parts varies with growth The total BSA burned can be estimated by dividing the body into very small areas and assign percentage for each part.

Lund and browder: for adults

Severity of burn injuries

• Severity of burn injury based on the following;
• Depth
• Extent
• Location
• Cause

Patient age

Severity of burn cont…

• Burns severity is determined primarily by % of burn injury and its depth
• This combined information, expressed as percentage and depth, include;
• Mild burn injury
• Moderate burn injury
• Severe burn injury

Major burn injury

Severity of burn cont…

• Mild burn injury
• Involves 1st Degree burn and
• 2nd degree burn with < 10% TBSA
• Moderate burn injury
• 2nd degree burn with 10-30% TBSA

or 3rd degree burn with < 10% TBSA

Severity of burn cont…

• Severe burn injury
• burn with total area of 30-50%
• or 3rd degree burn with 10-20%
• or burn with shock, airway burn, and combined injury
• Major burn injury
• burn with total area >50%
• or 3rd degree burn with >20%

or burn with severe complications

Body response to burn injuries

• Burn injuries can lead to;-
• local responses
• systemic responses
• Burns that do not exceed 25% TBSA produce primarily local response.

Burns that exceed 25% TBSA may produce both a local and a systemic response Systemic response is due to the release of cytokines and other mediators into the systemic circulation

Local response

Divided into three zones of a burn which were described by Jackson in 1947 →Jackson’s zones of burn wound These zones include:-

• Zone of coagulation – point of maximum damage
• Zone of stasis/ischaemia – is characterized by decreased tissue perfusion

Zone of hyperemia – outermost zone tissue perfusion is increased

Systemic responses

The initial systemic response after a major burn injury is hemodynamic instability, resulting from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces.

Systemic responses cont…

• Cardiovascular response

Due to hypovolemia

Greatest volume deficit occurs in the first 24 to 36 hours after the burn, peaking by 6 to 8 hours Hypovolemia is the immediate consequence of fluid loss → ↓ oxygen delivery and perfusion

Systemic responses cont…

As fluid loss continues and vascular volume decreases → ↓ in CO and ↓ in BP The sympathetic nervous system releases catecholamines, resulting in ↑ in peripheral resistance (vasoconstriction) and an increase in pulse rate Myocardial contractility may be suppressed by the release of inflammatory cytokine necrosis factor

Systemic responses cont…

• Pulmonary response

Inhalation injury is the leading cause of death in fire victims Bronchoconstriction caused by release of histamine, serotonin, and thromboxane, a powerful vasoconstrictor due to full-thickness chest burns can lead to pulmonary problems

Systemic responses cont…

• There is
• Upper airway edema and obstruction from inhaling heated gases
• Lower airway obstruction and pneumonia from inhalation of smoke
• Carbon monoxide poisoning and hypoxia from end product of combustion

Atelectasis and respiratory failure

Systemic responses cont…

Renal response

Reduced blood flow to the kidney leads to decreased urine output which put patient in a risk for acute renal failure ↑ blood urea nitrogen (BUN)

Systemic responses cont…

• GIT response

↓ perfusion of GIT and liver due to ↓ blood flow ↓ gastric acid production for 48─72 hrs followed by ↑ acid production and risk of stress ulcer

Phases of management

As in all trauma patients the mgt of burn injury is divided into 5 phases according to ATLS (Advanced Trauma Life Support) Phase I: Primary survey phase

• Phase II: Resuscitation phase
• Phase III :Secondary survey phase
• Phase IV: Supportive care phase

Phase V: Definitive treatment phase

Phase I: Primary survey phase

• Aim: to identify life threatening conditions
• The life threatening conditions include:

A=Airway

B=Breathing

C=Circulation

• D=Disability- neurological status

E=Exposure

This should go hand in hand with the phase II

Phase II: Resuscitation phase

• Aim: to treat the immediately life threatening condition
• Airway –secure airway & Immobilize the cervical spine
• Breathing – optimize ventilation
• Circulation- establish i.v. access
• Disability- assess neurological deficit
• Expose the patient to avoid missed injury

Fluid therapy

Fluid replacement + Fluid maintenance

• Fluid replacement
• should be administered through a wide bore canula
• The volume of fluid to be given is calculated as follows:-
• = 4ml x %TBSA x kg of body weight

The type of fluid to be given in the 1st 24 hrs is Crystalloid 50% of the calculated fluid is given in the 1st 8 hrs, and the remaining half is distributed over remaining 16th hrs Calculation fluid commences at time of injury not at admission Fluid maintenance

At the end of 24 hours, colloid infusion may be given at a rate of 0.5 ml x (total burn surface area (%))x(body weight (kg)), and maintenance crystalloid (usually dextrose-saline) is continued at a rate of 1.5 ml x (burn area) x (body weight) The end point to aim for is a urine output of 0.5-1.0 ml/kg/hour in adults and 1.0-1.5 ml/kg/hour in children.

Phase III :Secondary survey phase

• This include:-
• History
• Physical examination

Investigations

Phase IV: Supportive care phase

• Analgesics – iv narcotics
• Systemic antibiotics against ß- hemolytic streptococcus – (broad spectrum)
• Tetanus toxoid
• Nasogastric tube for patients with > 25%TBSA
• Monitor
• vital signs
• Fluid Input and output
• Urethral catheterization

Nutrition support

Phase V: Definitive treatment phase (Wound care)

• Depends on the characteristics and size of the wound
• Conservative treatment
• Indicated for superficial 1st and 2nd degree burn
• Involves:-
• Wound dressing
• Topical antimicrobial agents +/- systemic antibiotics
• Surgical treatment
• Escharotomy

Skin grafting

General interventions

• Supporting cardiac output

Administration of I.V. fluids

major burns are followed by a reduction in blood volume due to outflow of plasma into the tissues.

• Maintain and record intake and output
• record time and amount of all fluids given.

patient should be catheterized

General interventions cont…

• maintain urine output of (30-50mL/hour or 1mL/kg/hour
• monitor vital signs
• pulse
• BP
• temp

capillary refill

General interventions cont…

• Preventing infection
• Provide skin care to prevent infection and promote healing.
• Observe burn wounds with each dressing change
• assess drainage for color and odor

Administer tetanus prophylaxis

General interventions cont…

• Ensuring adequate nutrition for healing process

Be aware of ↑ nutritional intake because of the extreme hyper metabolism related to large burn injuries Give high-protein intake to replace protein lost by exudation

General interventions cont…

Vitamin and mineral supplement needed, particularly vitamins B and C, iron, and zinc

General interventions cont…

• Preserving mobility
• Make sure that physical and occupational therapy are begun early to facilitate mobility
• Encourage range-of-motion exercises, ambulation, joint and skin
• Not only help to promote mobility

also may help to prevent complications like contractures

General interventions cont…

General interventions cont…

• Controlling pain

Assess for signs of pain, such as irritability, crying, increased BP, tachycardia, decreased mobility, and inability to sleep.

Administer analgesics or sedatives to relieve pain in severe burns, analgesia should be given I.V. because of lack of absorption of I.M. injections during the emergency phase.

General interventions cont…

• Provide diversional activities appropriate for age to distract from focus on pain

Recognize that fear may exacerbate discomfort; provide reassurance and empathy

General interventions cont…

• Preventing negative body image
• Encourage the patient to talk about the way he/she feels and looks.
• They may be fearful of the appearance of bandages or scars

offer reassurance.

General interventions cont…

• Reducing fear and anxiety

Explain procedures, surgeries, and treatments to the patient Ensure the care giver that the child may have normal life if reconstructive surgeries will be done To have normal appearance is possible

Early complications

• Fluid / Electrolyte imbalance
• Hypovolemic shock
• Thermoregulation dysfunction
• Acute renal failure
• Inhalation injury
• Burn wound sepsis/Systemic infection
• Anemia
• Stress ulcers /Curling ulcers
• Acute gastric/colonic dilatation
• Cardiopulmonary failure

Myocardial infarction

Late complications

• Contractures
• Keloids
• Hypertrophic scars
• Stress ulcers

Acalculous Cholecystitis