DEGREES OF BURN AND MANAGEMENT

• BURNS  &  SCALDS
• ELECTRICAL BURNS
• CHEMICAL BURNS
• RADIATION
• LIGHTENING

PRE-HOSPITAL CARE

• Remove patient from source
• Extinguish burning clothes
• Careful with electric source
• CPR
• If hospital is 30- 45 min away try to start IV
• Cold soaks ↓ pain but ↓ heat, so avoid hypothermia
• Cover the areas with clean sheets
• 100% O2  if suspected CO poisoning
• Check for respiratory burns

IN EMERGENCY

• ABC
• Assess the percentage and degree of burn
• Start IV line and infuse Ringer’s Lactate and calculate the fluid requirement
• Take patient’s weight                         
• Catheterize
• Oxygen if required
• TT  injection
• Morphine 
• Wound care- clean with saline and apply 1%silver sulphadiazene
• No role  of prophylactic antibiotic

ASSESSMENT OF BURNS

Wallace’s Rule of Nine-in adults each upper extremity, and the head and neck are 9% TBSA, lower extremities, anterior and posterior trunk each are 18% while genitalia and perineum forms 1% of TBSA

Infant head is 18 % and lower limb is 14%, for each year after one year 1% to be taken off the head and neck area and added to the lower limbcs

Patient’s palm as 1 %

FLUID RESUSCITATION

• Modified Parkland’s formula
• 4ml X   Body weight X % Burns ( 50 % ) 
• Ringer’s lactate to be given. 50% in first eight hours from the time of burns
• 50% in next 16 hours
• Response- 1ml/Kg/hr urine output. 50-70ml in adults

DEGREES OF BURN

FIRST  DEGREE

• Sunlight exposure or burn by hot tea cup
• Injury confined to epidermis
• Red and dry
• Very painful
• Heals in 3-6 days without scarring
• Not included while calculating fluid requirement for burns

SECOND DEGREE SUPERFICIAL

• Hot liquid or flash flame
• Pink or mottled red in appearance
• Blisters or bulla, soft and moist
• Painful
• 7-10 days to heal and may have hypo or hyper pigmented areas

SECOND DEGREE DEEP

• Chalky white
• Soft and moist 
• Sensation is obtunded
• More than 21 days to heal
• Heals with lot of scarring and contractures

THIRD DEGREE BURN

• Prolonged exposure or electric burn
• Dry and parchment like
• Translucent, can see fat and thrombosed veins
• No sensation
• Needs debridement of eschar and skin grafting

MAJOR BURNS

Partial thickness greater than 25%

Partial or full thickness burns of face, hands, genitalia and feet

Third degree burn greater than 10% area

Burns complicated by

Respiratory tract injury

Major soft tissue injury

Fractures

Electrical burns

MODERATE

Second degree burns 15-25%

Third degree less than 10% except hands, face and feet

MINOR

Second degree less than 15 %

Third degree less than 2 %

PATHOPHYSIOLOGY

Jackson’s three zones

• Zone of coagulation
• Zone of stasis
• Zone of hyperaemia

CVS- shift of fluid, ↓cardiac output, greater than 25 % burn even non burned tissue also swell

LUNGS- hyperventilation, ↓ protein, poor lung function

GIT- ileus, mucosal ischaemia, curling’s ulcers, translocation of bacteria

RENAL- renin- angiotensin- aldosterone system activated, ↓ urine output, ATN

IMMUNE SYSTEM- destruction of barrier, depression of cellular immunity

BODY TEMP. – loss of protective mechanism, heat loss & hypothermia, ↑ spike after dressing due to pyrogens such as interleukin-1

WOUND CARE

Clean with surgical detergent or clean water shower or water tank and twice daily dressing with 1% SSD

BIOLOGICAL  DRESSINGS

Allograft, skin substitutes- collagen amino acid films

Amnion, porcine skin, integra, homograft, Burn mesh

Local care

Dressings

Open- neck, hand, 

occlusive,

Biological

Early surgical excision and grafting

Tangential excision

ANTIBACTERIALS

Sulfonamide

Thick application

Twice daily

Good penetration

Silver Nitrate

Bacteriostatic

Black discoloration

Thick pads required

Leaching of Na, K, Cl, Mg and Ca

Poor penetration

Silve sulphadizene

1968 Charles Fox

Silver nitrate and acid sulphadizene

Bacteriostatic

Good penetration

Gentamicin

2.2% Cerium nitrate and SSD

NUTRITION

Metabolic needs ↑ by two to three fold

CURARIE  FORMULA

25KCal  x  Body weight + 40KCal x  % Burns

Supplement Vit C, zinc and B complex 

INFECTION ( Clinical)

Conversion of 2o - 3o

Focal dark brown or black discoloration

Degeneration of wound with neoeschar

Rapid separation of eschar

Hemorrhagic discoloration of subeschar fat

Erythematous wound margin

Metastatic septic lesion in unburned tissue

INFECTION ( Histological)

Organism in unburned tissue

Hemorrhage in unburned tissue

↑ inflammatory reaction in adjacent tissue

Small vessel thrombosis or ischaemic necrosis of unburned tissue

Perineural and intralymphatic migration of organism

Vasculitis and perivascular cuffing of organisms

Other septic complications

• Pneumonia
• Sup. Thrombophlebitis
• Endocarditis
• Sepsis

Verduria

FASCIOTOMY, ESCHAROTOMY, ESCHARECTOMY, SKIN GRAFTING

Eschar is the burnt dead skin

Fascia is the deeper tissue covering the muscles

Burn wound excision

↓ hospital stay

↓ sepsis ( greater than 30% increased chance of sepsis)

Better cover, early healing, ↓ scar

Rapid restoration of function

ESCHAROTOMY

• If vascular or respiratory compromise due to thick constricting eschar
• Escharotomy done at the neutral lines. 
• If no improvement do fasciotomy( mostly in electric burns) 

ESCHARECTOMY

Surgical removal of eschar 

Early- done in 7- 12 days

Late- separates after two weeks.

Prepares bed for early grafting

Tangential excision and grafting

In second degree deep burns

Done on 2nd to 5th day

After 7 days it softens

Not more than 20% in one sitting

SEQUENTIAL EXCISION

• Done in deep second degree and third degree burns
• Blood loss  5% area one unit blood required
• Eschar sequentially removed with a guarded knife and grafted

SKIN GRAFTING

Pinch, mesh, stamp, sheet

Thin, Intermediate, Thick ( Split thickness graft)

Full thickness graft

Priority areas

face, hands, axilla, cubital and popliteal fossa

Autograft, homograft, heterograft

ELECTRIC BURNS

• Low voltage ( greater than 1000 volts )
• High voltage ( less than 1000 volts )
• Conversion of electrical energy to heat is governed by Ohm’s law
• C= V/R current in amperes
• Joule’s Law- J= C2RT relation between current and heat production

• Bone offers the most resistance
• Current takes the shortest path
• Body acts as volume conductor
• Arc injury is very deep
• “no release” phenomenon
• Skeletal injury due to fall.

• Cardiac- arrest, VT, AF, SVT, RBBB
• Renal- ARF, Myoglobinuria
• CNS- convulsions, coma, paraplegia
• Abdomen- Splenic injury

MANAGEMENT

General

Deep burns- maintain urine output of 2ml/kg/hr

Mannitol 12.5 gm/hour

50ml 7.5% NaHCO3 ( 45 mEq)

Cardiac monitoring ( CPK-MB)