Burns
Burns
Burns
Contents
Definition
Burns are a result of the effects of thermal
injury on the skin and other tissues
Human skin can tolerate temperatures up to
42-440 C (107-1110 F) but above these, the
higher the temperature the more severe the
tissue destruction
Below 450 C (1130 F), resulting changes are
reversible but >450 C, protein damage
exceeds the capacity of the cell to repair
Depth of Burns
Superfacial (First-degree) burns
Depth of Burns
Partial-thickness
Superfacial(Seconddegree) burns
*Involve epidermis and
some portion of dermis
*Can be either
superficial or deep
Partial thickness
Deep Second degree burns
Epidermis & deeper degrees of dermis
destroyed
Are pink to cherry red, wet, shiny with
serous exudate
Very painful when touched or exposed to air
Heal in 14- 28 days with scarring
May need early excision and grafting
Partial thickness
Deep Second degree burns
Depth of Burns
Fullthickness(Thirddegree) burns
Extend through
all layers of skin
Need better
phtls
Full-thickness(Third-degree)
burns
Will appear as thick, dry, leathery, waxy
white to dark brown regardless of race or
skin color
May have a charred appearance with visible
thrombosis of blood vessels
Will have little to no sensation because
nerve endings have been destroyed except
in surrounding tissues with partial thickness
burns
Full-thickness(Third-degree)
burns
Depth of Burns
Fourth-degree burns
Extend through all
layers of skin as well
as extending to
underlying fat,
muscle, bone or
internal organs
Burn Photos
2nd degree Burn 1 day
Mild Burn
2nd degree Burn 2 days
Rule of Nines
In the adult, most areas of the body can be
divided roughly into portions of 9% or
multiples of 9.
In the child, similar portions are assigned
This division is useful in estimating the
percentage of body surface damage an
individual has sustained in burn.
Rule of Nines
Lund-Browder Chart
Palmer Method
The palmer surface
of the patients hand
from crease at
wrist to tip of
extended fingersequals ~ 1% of the
patients total body
surface area
Extent of Burns
Surface
area
Head
18%
Anterior Torso
18%
Posterior Torso
18%
Each Leg
14%
Each Arm
9%
Perineum
1%
Kinds of Burns
Flame Burn: due
to gasoline,
kerosene, liquified
petroleum gas
(LPG) or burning
houses
Kinds of Burns
Scald Burn: most
frequent in home
injuries; hot
water, liquids and
foods are most
common causes;
above 65o C, cell
death
Kinds of Burns
Chemical Burns
2 types of chemical burns
acids-can be neutralized
Chemical Burns
With chemical burns, tissue destruction may
continue for up to 72 hours afterwards.
It is important to remove the person from
the burning agent or vice versa.
Chemicals, heat, and light rays can burn the
eye.
Kinds of Burns
Radiation Burns
from X-ray,
radioactive
radiation and
nuclear bomb
explosions
Kinds of Burns
Electrical Burns
worse than the other types; with entrance
and exit wounds; may stop the heart and
depress the respiratory center; may cause
thrombosis and cataracts
Electrical Burns
Burn Photos
Electrical Burns
Exit Wounds
Severe swelling
peaks 24-72 hrs after
Electrical Burns
Entrance Wounds
Inhalation injury
Airway edema & Carbon deposits
1. Carbon monoxide poisoning (CO poisoning and asphyxiation count for majority of
deaths)
Treatment- 100% humidified oxygen-draw carboxyhemoglobin level- can occur without any
burn injury to the skin
Emergent Phase
(Resuscitative Phase)
Lasts from onset to 5 or more days but
usually lasts 24-48 hours
Begins with fluid loss and edema formation
and continues until fluid motorization and
diuresis begins
Greatest initial threat is hypovolemic shock
to a major burn patient
Emergent Phase
Initial Management/Care
MAKE SURE YOU ARE SAFE !!!
Remove patient from area! Stop the burn!
Airway-check for patency, soot around nares,
or signed nasal hair. 100% O2 via NRM @
15L. Watch for early upper airway edema
>intubate is in doubt.
Breathing- check for adequacy of ventilation,
consider need for early intubation or early
escharotomy if ventilation is impaired
Cardiovascular
Respiratory
Renal
Cardiovascular System
Arrhythmias, hypovolemic shock which may
lead to irreversible shock
Circulation to limbs can be impaired by
circumferential burns and then the edema
formation
Causes: occluded blood supply thus causing
ischemia, necrosis, and eventually gangrene
Escharotomies (incisions through eschar)
done to restore circulation to compromised
extremities
Respiratory System
Vulnerable to 2 types of injury
1. Upper airway burns that cause edema formation &
obstruction of the airway
2. Inhalation injury can show up 24 hrs later-watch for
respiratory distress such as increased agitation or change
in rate or character of respirations
preexisting problem (ex. COPD) more prone to get
respiratory infection
Pneumonia is common complication of major burns
Is possible to overload with fluids--leading to pulmonary
edema
Renal System
Most common renal complication of burns
in the emergent phase is Acute Tubular
Necrosis (ATN) (muscle destruction >
myoglobulin release > protein leak clogs
kidney cells >ischemia) Because of
hypovolemic state, blood flow decreases,
causing renal ischemia. If it continues,
acute renal failure may develop.
U.S. Statistics
About 2.4 million people suffer
burns annually
Account for an estimated
700,000 ER visits per year and
45,000 require hospitalizations
Between 8,000-12,000 burn
patients die, and approximately
one million will sustain
substantial or permanent
disabilities
Fires kill about 500 children
<14 years annually and injure
40,000 others
Fire ranks 5th among accidental
injuries, after motor accidents,
poisoning, falls and drowning
Lab studies
Severe burns:
CBC
Chemistry profile
ABG with
carboxyhemoglobin
Coagulation profile
U/A
CPK and urine
myoglobin (with
electrical injuries)
12 Lead EKG
Imaging studies
CXR
Plain Films / CT scan: Dependent upon
history and physical findings
Physiological Response
Pathologic Features
Pathophysiology
Pathophysiology
Usual indices (BP, CVP) of volume status unreliable in burn patients; urine output best
surrogate marker of volume resuscitation
Pathophysiology
Pathophysiology
Pathophysiology
Anemia is common
Pathophysiology
Complications of Burns
Burn Shock
Pulmonary complications due to inhalation
injury
Acute Renal Failure
Infections and Sepsis
Curlings ulcer in large burns over 30%
usually after 9th day
Extensive and disabling scarring
Psychological trauma
Cancer called Marjolins ulcer, may take 21
years to develop
5.
Airway
Breathing
Circulation
Depth of Burn
Extent of Injury(s)
Breathing Assessment/Support
Ensure adequate oxygenation
ABG with carboxyhemoglobin level preferred
humidified 100% FiO2 emperically
Breathing Assessment/Support
NG tube placement
thoracic decompression; reduce aspiration risk
Initial Management:
Circulatory
Fourth degree
third degree with extension into bone/joint/muscle
Hypoglycemia
stress response; smaller glycogen stores
Vaccination
adequate tetanus prophylaxis mandatory
Hospital Management
1. General assessment and cardiopulmonary
stabilization
2. Resuscitation
3. Establishment of IV lines and blood studies
4. Wound care and infection control
5. Pain relief and psychological support
6. Nutritional support
7. Physical Therapy/Occupational Therapy
Airway compromise?
Respiratory distress?
Circulatory compromise?
Yes
Intubation, 100% O2
IV access, fluids
No
Multiple trauma?
Yes
No
Burns >15% or
complicated burns?
No
Yes
IV access;
fluid replacement
Circumferential full
thickness burns?
Yes
Escharotomy
No
Burn care, tetanus prophylaxis,
analgesia
Initial Procedures
Fluid infusion must be started immediately
NGT insertion to prevent gastric dilatation, vomiting
and aspiration
Urinary catheter to measure urine output
Weight important and has to be taken daily
Local treatment delayed till respiratory distress and
shock controlled
Hematocrit and bacterial cultures necessary
Fluid Resuscitation
For most, Parkland formula a suitable starting
guide (4 ml Ringers Lactate/kg body weight/%
BSA burned), to be given over 1st 8 hr from
time of onset while remaining over the next 16 hr
During 2nd 24 hr, of 1st day fluid requirement to
be infused as D5LR
Oral supplementation may start 48 hr after as
homogenized milk or soy-based products given
by bolus or constant infusion via NGT
Albumin 5% may be used to maintain serum
albumin levels at 2 g/dl
Packed RBC recommended if hematocrit falls
below 24% (Hgb <8 g/dl)
Sodium supplementation may be needed if burns
greater than 20% BSA
Inhalation Injury
Three syndromes:
1. Early CO poisoning, airway obstruction & pulmonary
edema major concerns
2. ARDS usually at 24-48 hrs or much later
3. Pneumonia and pulmonary emboli as late
complications (days to weeks)
Assessment:
1. Observation (swelling or carbonaceous material in
nasal passages
2. Laboratory determination of carboxyhemoglobin and
ABGs
Treatment:
1. Maintain patent airway by early ET intubation,
adequate ventilation and oxygenation
2. Aggressive pulmonary toilet and chest physiotherapy
Infection Control
Tetanus prophylaxis: 250-500 IU TIG or 3000 units equine
ATS ANST IM; Toxoid also
Antibiotic of choice is one that will include Pseudomonas in its
spectrum; most frequent pathogens in burns are
Staphylococcus aureus, Pseudomonas aeruginosa and the
Klebsiella-Enterobacter species
Topical therapy:
0.5% Silver nitrate dressing
Mafenide acetate or Sulfacetamide acetate cream
Silver sulfadiazine cream
Povidone-iodine ointment
Gentamicin cream or ointment
Nutritional Support
Shriners Burn Institute at Galveston,
Texas Guidelines for Caloric Intake
1000 kcal/m2 BSA burned +
Infants
2100 kcal/m2 total BSA
2-15 years
Adolescents
B.U.R.N.S.
B - Breathing
Body image
U - Urine output
R - Rule of nines
Resuscitation of fluid
N - Nutrition
S - Shock
Silvadene
Support
B.U.R.N.S.
B.U.R.N.S.
B.U.R.N.S.
R- RESUSCITATION OF FLUID
Salt & electrolyte solutions are essential over the
1st 24 hrs -First 24 hour calculation starts at the
time of injury
- RULE OF NINES-
B.U.R.N.S.
N -NUTRITIONProtein & Calories are components of the
diet
Supplemental gastric tube feedings or
hyperalimentation may be used in pts with
large burned areas.
Daily weights will assist in evaluating the
nutritional needs
B.U.R.N.S.
Thank You!