1. Burn and Management of different types of Burns
Dr Muath Mustafa
Dept of Surgery, BMC
HOD. Dr. Ashraf Balbaa

2. Overview Burn Pathophysiology Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics

3. Skin Anatomy
Epidermis
Dermis
Hypodermis

4. Function of Normal Skin
Protection from infection & injury
Prevention of loss of body fluid
Regulation of body temperature
Sensory contact with environment

5. What is a Burn? Exposure to flames or hot liquids
An injury to tissue from:
Exposure to flames or hot liquids
Contact with hot objects
Exposure to caustic chemicals or radiation
Contact with an electrical current

6. Pathophysiology of Burn Injury
Zone of Coagulation:
Irreversible damage
Zone of Stasis:
Impairment of blood flow
Recovery variable
Zone of Hyperemia:
Prominent vasodilation
Usually recovers

7. Overview Burn Pathophysiology Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics

8. Severity of a Burn Depends on: Depth of burn Extent of burn
Location of injury
Patient’s age
Presence of associated injury or diseases

9. Depth of a Burn First Degree Superficial Second Deep Second
Third Degree

10. Depth of a Burn First Degree Epidermis only Erythematous
Hypersensitive
Classic sunburn
Heals without scar

11. Depth of a Burn Second Degree Superficial Deep
Epidermis + part of dermis
Superficial
Deep
Blisters
Edematous and red
Very painful
Scaring variable

12. Depth of a Burn Third Degree Full thickness burn
Can involve underlying muscle, tendon, bone
Waxy white, leathery brown or charred black
Painless
Heals with scar

13. Extent of a Burn “Rule of Nines”
Most universal guide for initial estimate
Deviates in children due to larger head surface area

14. “Robyn’s Rule of 4s”

15. ABA Burn Referral Criteria
2nd & 3rd degree burns of greater than 10% BSA in patients under 10 or over 50 yrs old
2nd & 3rd degree burns of greater than 20% BSA in other age groups
2nd & 3rd degree burns with functional or cosmetic implications
3rd degree burn of greater then 5% BSA

16. ABA Burn Referral Criteria
Significant electrical burn
Chemical injury with functional or cosmetic impairment
Inhalation injury
Circumferential burn of chest or extremity
Burn injury with pre-existing medical disorder
Any burn with concomitant trauma

17. Primary Survey A – Airway B – Breathing
C – Circulation / C-spine / Cardiac status
D – Disability / Neurologic Deficit
E – Exposure and Examination
F – Fluid Resuscitation

18. Secondary Survey Complete head-to-toe examination
Obtain as much information as possible regarding injury:
A – Allergies
M –Medications
P – Past medical history
L – Last meal or drink
E – Events preceding injury

19. Management Principles
Stop the Burning Process
Universal Precautions
Airway Management
Circulatory Management
Insertion of a Nasogastric Tube
Insertion of a Foley Catheter
Universal precautions: off the electricity, remove the offending chemical substance, evacuate the pt

20. Management Principles
Relieve Pain
Assess Extremity Pulses Regularly
Assess for Ventilatory Limitation
Provide Emotional Support
Suicide Management

21. Overview Burn Pathophysiology Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics

22. Inhalation Injury Important determinant of morbidity & mortality
Manifests within the first 5 days after injury
Present in 20-50% of pts admitted to burn centers
Present in 60-70% of pts who die in burn centers

23. Indicators of Inhalation Injury
Burned in closed space
Facial or intra-oral burns
Singed nasal hairs
Soot in mouth, nostrils, larynx
Hoarseness or stridor
Respiratory distress
Signs of hypoxemia

24. History of Event Is there a history of unconsciousness?
Were there noxious chemicals involved?
Did injury occur in closed space?

25. Types of Inhalation Injury
Carbon Monoxide Poisoning
Inhalation Injury Above the Glottis
Inhalation Below the Glottis

26. Carbon Monoxide Poisoning
Colorless, odorless gas
Binds to hemoglobin 200 times more than oxygen
Most immediate threat to life in survivors with severe inhalation injury
Toxicity related directly to percentage of hemoglobin it saturates

27. Carbon Monoxide Poisoning
Signs & Symptoms of Carbon Monoxide Toxicity
Carboxyhemoglobin (%) Signs/Symptoms
None
Headache
Headache, nausea, dizziness, tachycardia
CNS dysfunction, coma
Death

28. Normal or pale skin with lip coloration
Signs of CO Poisoning
Cherry red coloration
Normal or pale skin with lip coloration
Hypoxic with no apparent cyanosis
PaO2 is unaffected
Essential to determine carboxyhemoglobin levels !

29. CO Poisoning: Treatment
100% oxygen until carboxyhemoglobin levels less than 15
Increases rate of CO diffusion from 4 hours to 45 minutes
Hyperbaric oxygen is of unproven value
May be useful in isolated CO intoxication but complicates wound care

30. Inhalation Injury Above the Glottis
Most common inhalation injury
Results from heat dissipation into tissues
Commonly leads to obstruction
Edema lasts for 2-4 days
Dx by visualization of upper airways

31. Inhalation Injury Above the Glottis: Treatment
Intubate!!!

32. Inhalation Injury Below the Glottis
Chemical pneumonitis caused by toxic products of combustion
Ammonia, chlorine, hydrogen chloride, phosgene, aldehydes, sulfur & nitrogen oxides
Related to amount and type of volatile substances inhaled
Onset of symptoms is unpredictable
Close monitoring for first 24 hours

33. Inhalation Injury Below the Glottis: Treatment
Prior to transfer to burn center
Intubation
to clear secretions
relieve dyspnea
deliver PEEP
Improve oxygenation
Steroids not indicated
Prophylactic antibiotics unjustified
Circumferential chest burns: escharotomies

34. Inhalation Injury in the Pediatric Patient
Small airways: rapid onset of obstruction
Well secured, appropriately sized, uncuffed tube
Rib cage is not ossified
More pliable
Pt exhausts rapidly due to decrease in compliance with circumferential chest burns
Escharotomies performed with first evidence of ventilatory impairment

35. Overview Burn Pathophysiology Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics

36. Shock & Fluid Resuscitation
Goal:
To maintain vital organ function while avoiding the complications of inadequate or excessive therapy

37. Systemic Effects of Burn Injury
Magnitude & duration of response proportional to extent of surface burned
Hypovolemia
Decreased perfusion & oxygen delivery
Initial increase in PVR & decrease in CO
Neurogenic & humoral effects
Corrected with adequate fluid resuscitation
Prevent shock & organ failure

38. Cellular Response to Burn Injury
Severity dependant on temperature exposed and duration of exposure
“Zone of Stasis”: recovery of injured cells dependant on prompt resuscitation

39. Resuscitation Fluid Needs
Related to:
extent of burn (rule of nines)
body size (pre-injury weight estimate)
Delivered through large bore peripheral IV
Attempt to avoid overlying burned skin
Can use venous cut down or central line

40. Resuscitation Fluid Needs: First 24 Hours
Parkland Formula:
Adults: ml RL x Kg body weight x % burn
Children: 3-4 ml RL x Kg body weight x % burn
First half of volume over first 8 hours, second half over following 16 hours
Hypovolemia, decreased CO
Increased capillary permeability
Crystalloid fluid is keystone, colloid not useful

41. Resuscitation Fluid Needs: Second 24 Hours
Capillary permeability gradually returns to normal
Colloid fluids started to minimize volume
Only necessary in patients with large burns
(greater than 30% TBSA)
0.5 ml of 5% albumin x Kg body weight x % burn

42. Monitoring of Resuscitation
Actual volume infused will vary from calculates according to physiologic monitoring
Optimal regimen:
minimizes volume & salt loading
prevents acute renal failure
low incidence of pulmonary & cerebral edema

43. Monitoring of Resuscitation
Urinary output is a reliable guide to end organ perfusion
Adults: ml per hour
Children (less than 30 Kg): 1 ml/Kg per hour
Infusion rate should be increased or decreased by 1/3 if u/o falls or exceeds limits by more than 1/3 for 2-3 hours

44. Management of Myoglobinuria & Hemoglobinuria
High voltage electrical injury and mechanical trauma
Maintain urine output of ml per hour
Add 12.5 gm of Mannitol to each liter of fluid
Urine output not sustained
Urine pigment does not clear
Sodium bicarbonate 1 amp (50 meq) per liter of fluid
Heme pigments more soluble in alkaline urine

45. Monitoring Resuscitation
Blood pressure:
Can be misleading due to progressive edema & vasoconstriction
Heart Rate:
Tachycardia commonly observed
Hemaglobin & hematocrit:
Not a reliable guide
Transfusion not to be used for resuscitation
Baseline serum chemistries & arterial blood gases
Baseline to be obtained in burns of >30% BSA

46. Monitoring Resuscitation
CXR: daily for first 5-7 days
Normal study in first 24 hours does not r/o inhalation injury
ECG:
All electrical injuries
Pre-existing cardiovascular disease

47. Fluid Resuscitation in the Pediatric Patient
Require greater amounts of fluid
Greater surface area per unit body mass
More sensitive to fluid overload
Lesser intravascular volume per unit surface area burned

48. Overview Burn Pathophysiology Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics

49. Depth of Burn Partial Thickness Full Thickness First degree
Superficial second degree
Deep second degree
Full Thickness
Third degree
Ack 361

50. Please Pass the Mayo! Tar Burns Contact burns Bitumen is non-toxic
Immediate cooling of molten with cold H20
Removal of tar not an emergency
Cover with petroleum based product & dressed to emulsify tar
Please Pass the Mayo!

51. Overview Burn Pathophysiology Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics

52. Electrical Injury
Occurs when electricity is converted to heat as it travels through tissue
Divided into:
High voltage – greater than 1000 V
Low voltage – less than 1000
Hands & wrists are common entrance wounds
Feet are common exit wounds

53. Electrical Injury Extremely difficult to evaluate clinically
Greatest tissue damage occurs under and adjacent to contact points
Superficial tissues cool more rapidly than the deeper tissue
Accounts for non-viable tissue beneath viable, more superficial muscle

54. Types of Tissue Injury Cutaneous Burn with no underlying tissue damage
No passage of current through patient
Cutaneous Burn plus deep tissue damage
Involving fat, fascia, muscle and/or bone
Muscle damage associated with myoglobin release
Urine may be light red to “port wine” color
Risk of kidney damage

55. Lightning Injury
Direct current of > volts and up to amps
Injury results from:
Direct strike
Side flash
Flow of current between person & nearby object
Often travels on surface of body
Burns typically superficial
“splashed on” spidery pattern

56. Management of Electrical Injury
ABC’s
Assess Injury
History
LOC, cardiac arrythmia, other trauma
Physical Exam
neuro exam, long bone #, dislocations, cervical spine
Maintain Patency of Airway
Cardiac Monitoring:
Standard 12 lead ECG on admission
Continuous cardiac monitoring for first 24 hours

57. Management of Electrical Injury: Fluid Resuscitation
Administer Ringer’s Lactate in amounts estimated with Parkland Formula
Will underestimate required volume due to underlying tissue damage
Increase fluids as per urine output
Examine urine for pigment
Maintain urine output ml/hr until clear
Add 1 amp (50 meq) per liter of RL to alkalize urine
Mannitol 12.5 mg/liter to maintain urine output

58. Management of Electrical Injury: Peripheral Circulation
Hourly monitoring of skin color, sensation, capillary refill and peripheral pulses
Remove all rings, watches, jewelry
Surgical correction of vascular compromise
Decompression by escharotomy or fasciotomy
Upper limb-volar & dorsal incisions with protection of ulnar nerve
Lower limb-medial & lateral incisions

59. Electrical Burns in the Pediatric Patient
Low voltage accidents most common
Generally household (faulty insulation, frayed cords, insertion of metal object into wall socket)
Cutaneous injury, no muscle damage
Oral commisure injury
Look worse than they are
No initial debridement

60. Overview Burn Pathophysiology Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics

61. Chemical Burns: Classification
Alkalis
Hydroxides, carbonates and caustic sodas of sodium, ammonium, lithium, barium & calcium
Oven & drain cleaners, fertilizers, industrial cleaners
Acids
HCl, oxalic, muriatic & sulfuric acids
Common in household & swimming pool cleaners
Organic Compounds
Phenols, creosote, petroleum products
Contact chemical burns & systemic effects

62. Chemical Burns Factors That Determine Severity: Agent Concentration
Volume
Duration of contact (delay in treatment)

63. Treatment of Chemical Burns
Wear gloves and protective clothing
Remove saturated clothing
Brush skin if agent is a powder
Irrigate, irrigate, irrigate!
Copious amounts of water
Continued until pain or burning has decreased
Neutralization of agent contraindicated
Generation of heat may lead to further injury

64. Overview Burn Pathophysiology Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics

65. Pediatric Burns Scald burns most common burn in < 3 years
Flame burns most common in children > 3 years
Always consider child abuse

66. Pediatric Burns: Pathophysiology
Greater surface area per pound of body weight
Greater fluid needs
Greater evaporative water loss
Greater heat loss
Disproportionately thin skin
Burns may be deeper than initially assessed
Requires less exposure time to result in burn

67. Pediatric Burns: Airway
Intubation performed by someone experienced
Larynx more cephalad
More acute angulation of the glottis
Incuffed tube always used
Cricothyroidotomy is never indicated
Large bore needle placed through cricothyroid membrane may be used in emergency cases

68. Pediatric Burns: Circulatory Status
Burn > 10% BSA should be hospitalized
IV Ringer’s Lactate is administered as per formula
Must also add maintenance fluid (4-2-1 rule)
NG tube
Urinary catheter to monitor urine output:
<30 Kg: 1ml/Kg per hour
>30 Kg: ml per hour
If hypoglycemic, add 5% glucose to RL solution

69. Pediatric Patient: Wound Care
Stop burning process
Remove all clothing
Topical antibiotics not indicated before transfer
Conserve heat with thermal blankets
Escharotomy
Chest: ventilatory impairment
Limb: vascular compromise
Discuss the role of Antibiotics in adults also= No need for A/B in full thickness burns bc the bacteria also burned with the skin, so only sterile dressing, but if the patient showed s/s of sepsis then start A/B accordingly

70. Overview Burn Pathophysiology Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics

71. Radiation Injury
Effects reproductive mechanism of certain tissue cells
Mature cells suffer less damage
Stem cells are more vulnerable to injury
Large doses of radiation (> 2000 RAD) may lead to acute mortality

72. Outcomes Associated with Ranges of Whole Body Radiation
Whole Body Dose(RAD) Response
Change in # of leukocytes
Severe reduction in leuks, N/V, hair loss, death due to infection
Destruction of mone marrow, diarrhea, 50% mortality within 1 month
GI ulceration, death within 2 weeks
Death within hours due to severe damage to CNS

73. Types of Ionizing Radiation
Alpha particles
Large, highly charged particles
Associated with decay of natural radioactive elements
Penetrate only a few microns of tissue
Beta particles
Positive electrons or negatively charged particles
Penetrate approximately 1 cm of tissue

74. Types of Ionizing Radiation
Gamma and X-rays
Radioactive decay or x-ray machines
Penetrate deeply
Once removed from source, no further radiation injury occurs
Poses no threat to attendants
Protons, Deuterons, Neutrons, Mesons and Heavy Nuclei
Produced by equipment for medical and industrial use

75. Radiation Burns Identical in appearance to thermal burns
Treat as you would a non-contaminated burn
Differ from thermal burns from time between exposure and clinical manifestation
SKIN RESPONSE TO RADIATION
(RADS) Epilation
300 Erythema
Transdermal Injury
Radionecrosis

76. Cold Injuries: Frostbite
Formation of ice crystals in the tissue fluids
Occurs in areas that lose heat rapidly
Three degrees of frostbite:
First degree: painful white or yellow firm plaque
Second degree: painful superficial clear or milky blisters
Third degree: deep red or purple blisters or skin color that is markedly changed
Severity influenced by both patient & environment factors

77. Cold Injuries: Treatment of Frostbite
Rapid re-warming in 4O degree water bath
Avoid mechanical trauma - No massaging!
Tetanus prophylaxis
Escharotomy if vascularity compromised
Tissue injury is often underestimated

78. Cold Injuries: Hypothermia
Defined as a core temperature < 34 degrees C
Signs are vague & non-specific
May mimic other disease states
Treatment:
Limit stimulation of patient –V.Fib easily induced
Rapid re-warming in warm water bath
Intubation to administer warm air
Central administration of warm Ringer’s solution
V. Fib= Ventricular Fibrillation

79. Cold Injuries: Hypothermia
Monitor for systemic acidosis with serial ABGs
Treat with sodium bicarbonate
Cardiopulmonary bypass
Cardiac monitoring
Ventricular dysrhythmia
Patients not to be declared dead until rewarmed
Continue CPR until core temperature> 36 degrees C.
Secondary assessment for contributing diseases

80. Hyperthermia: Clinical Syndromes
Heat Cramps
Result from excessive loss of salt by evaporation
Experiences severe pain & cramping in muscles
Tx: oral replacement of salt & water

81. Hyperthermia: Clinical Syndromes
Heat Exhaustion
Consequence of inappropriate cardiovascular response to stress of heat
Diversion of blood to skin is not accompanied by vasoconstriction to other areas or by volume expansion
Present with postural hypotension, profuse sweating, pallor, nausea, light-headedness
Tx: oral replacement or IV normal saline if severe

82. Hyperthermia: Clinical Syndromes
Heat Stroke
Failure of body cooling mechanism
severe hyperpyrexia
Setting of physical exercise w/o acclimatization
Present with temperature>103, no sweating, decreased LOC
Tx: rapid cooling until temperature <102 deg
If shivering develops, slowly give IV Thorazine
DIC frequently reported

83. The End!