1. BURN

2. Mechanism of burn:
a burn is a tissue injury from thermal (heat or cold) application or from the absorption of physical energy or chemical contact.

3. Causes
*Scalds as by hot water 100°C. *Fat burns has: higher temperature 180°C *Flame burns occur mostly in confined space and may be associated with inhalation injury. Generally deep burn will result. *Electrical burns *Cold injury *Friction burns : combination of heat and abrasion *Ionizing radiation *Chemical burns

4. Assessment of the burn area
An approximate clinical rule in wide use is the RULE OF NINE . which acts as a rough guide to body surface area . An adult with more than 20% of body surface area involved or a child with more than 10% will require I.V. fluid replacement . Prognosis depend on the percentage body surface area burned .

6. Indication for referral to a burn center
1. Partial thickness burns greater than 10% total body surface area. 2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints. 3. Third degree burns in any age group. 4. Electrical burns, including lightning injury. 5. Inhalation injury. 6. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.

7. 7. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality.
8. Burned children in hospitals without qualified personnel or equipment for the care of children.
9. Chemical burns.
10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention
* Committee on Trauma, American College of Surgeons

8. Assessment of burn depth
In thermal burn, it depends on: 1.Temp, of the burned injury. 2.The mode of the heat transmission . 3.The duration of the contact with burn agent. Superficial burns: in-epidermal burn , look red , painful without blisters and heal rapidly without squeal. Dermal burns are blistered and painful, they should heal by epithelialization (no scar) within 14 days.

10. Deep burns: include epidermis + dermis ( no adnexal structure intact -hair follicles , sweat and sebaceous glands ), if left it will heal by second intention with scarring . Look blotchy red appearance and no capillary return on pressure , with negative sensation on pinprick . Full thickness burns: contain totally destroyed skin look white or charred and no sensation . This charred layer consist of denatured contracted dermis called eschar.

11. Effects Of Burn Injury
1. Local: as a. Tissue damage include cells , blood vessels and permeability. b. 1nflammation as erythema c. Infection : within hours may cause bacteremia and septicemia . Most common organisms are B- hemolytic streptococci and pseudomonas. 2. Regional affect circulation causing ischemia , venous obstruction and ischemia muscle lead to claw position .

12. 3. Systemic: a. fluid loss "lead to external or internal loss into the tissue due to capillary damage . b. Multiple organ failure as renal, hepatic and heart. c. Inhalation injury. d. Systemic complications : as stress ulcer immunosuppresion , catabolic response to trauma and severe loss of weight, urinary tract infection , deep vein thrombosis and pulmonary embolism .

13. Clinical features of burn injury
* Pain. * Acute anxiety. * Fluid loss and dehydration. * Local tissue oedema . * Superficial burn will blister and deep burn cause oedema of subcutaneous tissue. * Coma due to asphyxia or head injury. * CO or cyanide poisoning (as in burning furniture).

14. MANAGEMENT OF BURNED PATIENT:
1. First aid: stop the burning process and cool the burn area.
2.Emergency examination & treatment :priority is
A (air way)
B (breathing)
C (circulation)
D (disability, neurological status)
E (exposure & environment control — keep warm)
F (fluid resuscitation)

15. 3. Fluid resuscitation : Adult (PARKLAND) formula is ( 4ml
3. Fluid resuscitation : Adult (PARKLAND) formula is ( 4ml*kgm body weight * %burn *100) in the fist 24 hours , half of it in the first 8 hours , and the next in the next 16 hours , Timing begin from the time of burn and not from time of hospital admission .Hartmann solution is preferred , but other isotonic fluid may be used . Formulae are only a guide and the adequacy of fluid resuscitation is monitored by regular clinical assessment . A urinary catheter is essential because urine output is the best guide for tissue perfusion ; in an adult one should aim for 30 – 50 ml of urine /hour.

16. 4.Further management : include ; A/ Pain relief B/ Dressing : Epidermal burn with erythema and no blisters do.not need dressing . Burn of the face are largely treatedby exposure . Superficial dermal burn with blistering are usually dressed to absorb exudate, prevent desiccation , provide pain relief , encourage epithelialization and prevent infection . Appropriate dressing are plastic films , hydrocolloid , preserved cadaver or pig skin , paraffin gauze . In deep burn.a topical antimicrobial agent such as silver sulphadiazine cream is used .

17. Any wound that remains unhealed or granulating at three weeks will not heal satisfactory without surgical intervention. C/ Control of infection , most common organism are staphylococci , B- hemolytic streptococci &pseudomonas .These organisms may be best treated by local antiseptic preparation , and when there is evidence of cellulitis systemic antibiotic should be used .Frequent wound swabs for culture & sensitivity test Blood culture is indicated when there is rise of temperature

18. d. Surgical treatment: partial thickness burns should heal without surgical intervention, but full thickness burns (deep) require surgical management. There are two alternative policies for treating deep burns , either waiting for spontaneous desloughing and apply split skin graft at three weeks, or early excision of the burn is carried out with application of skin cover, usually a skin graft or a flap
e. Early mobilization and rehabilitation.
f. Plastic repair of contracture.

19. Toxic shock syndrome: is a life-threatening , exotoxin- mediated disease caused by staphylococcus aureus leading to hypotesion and multi-organ failure ., occur mainly in children