Burns

Dr. Esraa Alghaban

reference Davidsons
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•
.Burns are one of the most common household injuries, especially among children
• They characterized by severe skin damage that causes the affected skin cells to die.
• Burns can be minor medical problems or life-threatening emergencies.The
• treatment of burns depends on the location and severity of the damage. Most
• people can recover from burns without serious health consequences,depending
• on the cause and degree of injury. More serious burns require immediate medical
• care to prevent complications and death. It is important to estimate the depth of
• .the burn to assess its severity and to plan future wound care

•
Burn levels

• There are three primary types of burns: first-, second-, and third-degree.Each degree .is based on
the severity of damage to the skin. There are also fourth-degree burns
• The type of burn is not based on the cause of it. Scalding, for example, can cause all three burns,
depending on how hot the liquid is and how long it stays in contact .with the skin
• Chemical and electrical burns warrant immediate medical attention because they .can affect the
inside of the body, even if skin damage is minor
• .
 Burns can be divided as shown below

PAIN LEVEL, CAUSE SURFACE APPEARANCE BURN DEGREE

1-Painful Flash flame ultraviolet Erythematous, dry,no blisters no or minimal edema) first(superficial)
• (sunburn)
2-Very painful Contact with hot liquids ,Mottled white to pink cherry red Moist blebs, blisters second(partial thickness)
or solids, flash flame
, to clothing direct flame.
chemical ultraviolet
3-little or no contact with hot liquid mixed white,waxy,pearly,dark,khaki,mahogany, charred third(full thickness)
Pain, hair pulls or solids, flame dry with leathery eschar, charred vessels visible under
Out easily chemical,electrical skin
4-same as third prolong contact with flame same as third possible with exposed bone or fourth( involves underlying structures)
electrical muscle

•
First-degree burns

•
• cause minimal skin damage. They are also called "superficial burns" because they affect the outermost
layer of skin(epidermis). The signs and symptoms disappear once the skin cells shed. It usually heal
within 7 to 10 days without scarring
• First-degree burns are usually treated with home care. Treatments for a first-degree :burn include
• soaking the wound in cool water for five minutes or longer, taking acetaminophen or
• ibuprofen for pain relief, applying lidocaine or using an antibiotic cream on skin
• and loose gauze to protect and sooth the affected area
• Make sure you don't use ice, as this may make the damage worse. Never apply cotton balls to a burn
because the small fibers can stick to the injury and increase the risk of infection. Also, avoid home
remedies like butter and eggs as these are .not proven to be effective

•
 Second-degree burn

are more serious because the damage extends beyond the top layer of skin. This type burn causes the skin to blister and
become extremely .red and sore
• Some blisters open, giving the burn a wet appearance. Due to the delicate nature of these wounds, keeping the area clean
and bandaging it properly is required to .prevent infection. This also helps the burn heal quicker
• Some second-degree burns take longer than three weeks to heal (deep second), but
• most heal within two to three weeks without scarring, but often with pigment
• .changes to the skin
• The worse the blisters are, the longer the burn will take to heal. In some severe
• cases, skin grafting is required to fix the damage. Skin grafting takes healthy skin
• .from another area of the body and moves it to the site of the burned skin
• :Treatments for a mild second-degree burn generally include
• running the skin under cool water for 15 minutes or longer , taking pain medication .(acetaminophen or ibuprofen) ,
applying antibiotic cream to blisters
• However,seek emergency medical treatment if the burn affects a widespread area, :or special areas such as any of the
following
• .Face,hands, buttocks, groin, feet

•
 Third-degree burn

• Excluding fourth-degree burns,third-degree burns are the most sever type. They cause the most damage, extending
through every layer of .skin(epidermis and dermis)
• With this type of burn the damage is so extensive that there may not
• be any pain because of nerve damage, but there is a risk of ischemia
• and impair blood supply particularly of the limb if the burn is
• .circumfrancial
• :The symptoms of third-degree burns include
• waxy and white color, char, dark brown color, raised and leathery texture , blisters do not develop
• Without surgery, these wounds heal with severe scarring and .contracture
• Never attempt to self-treat a third-degree burn. Don't get undressed, .but make sure no clothing is stuck to the burn

•
Etiology
•
• Burn injuries can result from a variety of causes
• Scald burns are the most common cause of burn injury in the civilian population. The -
• depth of scald burn is determined by the temperature of the liquid, the duration of
• exposure to the liquid, and the viscosity of the liquid. Scald burns with hot liquids
• will typically heal without the need for skin grafting. Grease burns, however, tend to
• .result in deeper dermal burns and will occasionally require surgical management
• Flame burns, the next most common cause of bum injury, typically result from house -
• fires, campfires, and the burning of leaves or trash. If the patient's clothing catches
• .fire. burns will usually be full thickness
• Flash burns are quite common as well and typically result from ignition of propane-or gasoline.
Flash burns will typically injure exposed skin (most commonly face and .extremities) and usually
result in partial thickness burns
• Contact bums occur from contact with woodstoves, hot metals, plastics, or coals.-.Contact bums
are usually deep but limited in extent of body surface area injured .In addition burn injury can
result from electrical and chemical agents as well- -
•
PATHOPHYSIOLOGY OF BURN
• Inflammation and Circulatory Changes
:

• Burns cause damage in a number of different ways, but by far the most common .organ affected is the skin
• The changes occur because burned skin activates a web of inflammatory cascades.
• The release of neuropeptides and the activation of complement are initiated by
• the stimulation of pain fibers and the alteration of proteins by heat. At a cellular
• level, complement causes the degranulation of mast cells. This attracts
• neutrophils, which also degranulate. Mast cells also release primary cytokines .
• This cause the subsequent release of many secondary cytokines. These alter the
• permeability of blood vessels so that intravascular fluid escapes and large protein
• molecules can also escape with ease. These extravasated proteins increase the
• oncotic pressure within the burned tissue. The overall effect of these changes is to
• produce a net flow of water, solutes and proteins from the intravascular to the
• extravascular space. In a small burn, this reaction is small and localized but, as the
• burn size approaches 10-15% of total body surface area (TBSA), the loss of
• intravascular fluid can cause a level of circulatory shock. Furthermore, once the
• area increases to 25% of TBSA, the inflammatory reaction causes fluid loss in
• .vessels remote from the burn injury

•
INJURY TO THE AIRWAY AND LUNGS
• The hot gases can physically burn the nose, mouth, tongue,
• palate and larynx. Once burned, the linings of these
• structures will start to swell. After a few hours, they may start
• to interfere with the larynx and may completely block the
• airway if action is not taken to secure an airway. Burns can
• also damage the airway and lungs, with life-threatening
• .consequences
• Warning signs of burns to the respiratory system
• 1-Burns around the face and neck··
• 2-A history of being trapped in a burning room··
• 3-Change in voice··
• 4-Strider··
Dangers of smoke, hot gas or steam inhalation

•
• Inhaled hot gases can cause supraglottic airway burns and laryngeal edema··
• Inhaled steam can cause subglottic burns and loss of respiratory epithelium··
• Inhaled smoke particles can cause chemical alveolitis and respiratory failure ··
• Inhaled poisons, such as carbon monoxide, can cause metabolic poisoning··
• Full-thickness burns to the chest can cause mechanical blockage to rib movement·

•
NON-THERMAL BURN INJURY
• Electrical burns
• Low-voltage injuries cause small, localized, deep burns. They can cause cardiac··
• arrest through pacing interruption without significant direct myocardial damage
• High-voltage injuries damage by flash (external burn) and conduction (internal burn).··
• Myocardium may be directly damaged without pacing interruption. Limbs may need
• amputation. Look for and treat acidosis and myoglobinuria
• Radiation burns
• .Local burns causing ulceration need excision and vascularised flap covere· Systemic overdose needs supportive
treatment··
• Cold injuries : divided into two types, acute cold injuries from industrial accidents and
• frostbite . The tissue is more resistant to cold injury than to heat injury, and the
• inflammatory reaction is not as marked

•
• Chemical burn damage is from corrosion and poisoning, it may cause a reaction on skin or
• .within the body. This burn can affect internal organs if chemicals are swallowed
• Acids and bases cause most chemical burns. Some of the most common products that
• :cause chemical burns are
• car battery acid ,ammonia, bleach
• denture cleaners,teeth whitening products
• pool chlorination products
• Copious lavage with water helps in most cases··Then identify the chemical and··
• assess the risks of absorption

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Complications

• 1-Infection,which may lead to a blood stream infection (sepsis) all burns carry the risk of infections
because bacteria can enter broken skin.Also infection from.lungs,gut,lines and catheters
2-Fluid loss, including low blood volume (hypovolemia) shock, which is often could lead to death
3-.Malabsorption from the gut ,and stress ulcer
• 4-Breathing problems from the intake of hot alr or smoke
• 5-Scars or keloids
• 6-Bone and joint problems, such as when scar tissue causes the shortening,
• 7-tightening of skin, muscles or tendons (contractors)
• 8-Tetanus is possible with burns of all levels. It is a bacterial infection affects the
• .nervous system.Every member should receive updated tetanus shots every 10 years
• 9-Severe burns also carry the risk of hypothermia
• 10-Circumferential burns may compromise circulation to a limb

•
 When admit patient to hospital
1-Patients requiring close airway monitoring , difficulty breathing or burns to the airway ( suspected inhalation injury)
2-Second-and third-degree burns >10% body surface area (BSA) in patients <10or>50 years old
.3-Second-and third-degree burns >20% BSA in other groups
4-Second and third-degree burns with serious threat of functional or cosmetic impairment that involve the face, hands,
feet, genitalia, perineum, and major joints
5-.Third-degree burns >5% BSA in any age group
6-Electrical burns, including lightening injury
.7-Chemical burns with serious threat of functional or cosmetic impairment
8- any child with suspicion of abuse
.
.
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 IMMEDIATE CARE OF THE BURN PATIENT (Pre hospital care)

The principles of pre hospital care are:·Ensure rescuer safety. This is particularly important in house
fires and in the case of electrical andchemical injuries. · Stop the burning process. Stop, drop and roll is
a good method of extinguishing fire burning on a person. ·Check for otherinjuries. A standard ABC
(airway, breathing, circulation) check followed by a rapid secondary survey will ensure that no other
significant injuries are missed. Patients burned in explosions or even escaping from fires may
have head or spine injuries and other life-threatening problems.·Cool the burn wound. This provides
analgesia and slows the delayed microvascular damage that can occur after a burn injury. Cooling
should occur for aminimum of 10 minutes and is effective up to 1 hour after the burn injury.
In temperate climates, cooling should be at about 15°C, and hypothermia
must be avoided.·Give oxygen. Anyone involved in a fire in an enclosed
space should receive oxygen, especially if there is an altered consciousness
level. ·Elevate. Sitting a patient up with a burned airway may prove life-
saving in the event of a delay in transfer to hospital care. Elevation of
.burned limbs will reduce swelling and discomfort
 Treatment
Most minor burns can be treated at home. They usually heal within a couple of .weeks
For serious burns, after appropriate first aid and wound assessment, treatment may involve
medications, wound dressings, and surgery. The goals of treatment are to control pain, remove
dead tissue, prevent infection, reduce scarring risk and
.regain function
No individual is capable of meeting the acute and long-term needs of the burn patient.
Therefore, burn care is best delivered in a specialized burn center where experienced
physicians, nurses, physical and occupational therapists, nutritionists, psychologists, and social
workers can all participate in the care of the individual. With the exception of small burns,
patients with burn injuries should be referred to a burn center. They may need skin grafts to
cover large wounds. And they may .need emotional support and months of follow-up care
 Medical treatment
1-Water-based treatments. care team may use techniques such as ultrasound mist
.therapy to clean and stimulate the wound tissue
2-Fluids to prevent dehydration.
3-Pain and anxiety medications. PATIENT may need morphine and anti-anxiety medications
-particularly for dressing changes
4-Burn creams and ointments. If not being transferred to aburn center care team may
select from a variety of topical products for wound healing, such as bacitracin and silver
sulfadiazine (Silvarene). These help prevent infection and prepare the wound to close
5-Dressings.
6- Drugs that fight infection. If infection.need IV antibiotics
7-Tetanus shot.
ABCDE MANAGEMENT OFThe burns patient

1- Assess Airway
2-Breathing:beware of inhalation and rapid airway compromise
3-Circulation:fluid replacement
4-Disability: compartment syndrome
.5-Exposure:percentage area of burn
Essential management points: Stop the burning then ABCDE
Determine the percentage area of burn (Rule of 9's)
Physical and occupational therapy
If the burned area is large, especially if it covers any joints, physical
therapy exercises may need. These can help stretch the skin so that the
joints can remain flexible. Other types of exercises can improve muscle
strength and coordination and occupational therapy may help if have
difficulty doing .normal daily activities
Surgical and other procedures

:May need one or more of the following procedures

1-Breathing assistance. If have been burned on the face or neck, throat may swell . If that appears likely,
doctor may insert a tube down windpipe (trachea) to keep oxygen .supplied to lungs
2-Feeding tube. People with extensive burns or who are undernourished may need nutritional support.
Doctor may .thread a feeding tube through your to stomach
3-Easing blood flow around the wound. If a burn scab (eschar) goe completely around a limb, it can tighten
and cut off the blood circulation. An eschar that goes completely around the chest can make it difficult to
breathe. Doctor may cut the eschar to .relieve this pressure
4-Skin grafts. A skin graft is a surgical procedure in which sections of healthy skin are used to replace the
scar tissue caused by deep burns
Plastic surgery. Plastic surgery (reconstruction) can improve the appearance of burn scars and increase the
flexibility of joints .affected by scarring, release contractures
 Major determinants of the outcome of a burn

1-Percentage surface area involved·

2-·Depth of burns·
3-·Presence of an·· inhalational injury

The burned airway creates problems for the patient by swelling and, if not managed proactively, can completely occlude the
upper airway. The treatment is to secure the airway with an endotracheal tube until the swelling has subsided, which is usually
after about 48 hours. The symptoms
of laryngeal edema, such as change in voice, stridor, anxiety and respiratory difficulty, are very late symptoms. Intubation at this
point is often difficult or
impossible owing to swelling, so acute cricothyroidotomy equipment must be at hand when intubating patients with a delayed
diagnosis of airway burn.
Because of this, early intubation of suspected airway burn is the treatment of choice in such patients. The time-frame from burn
to airway occlusion is
usually between 4 and 24 hours, so there is time to make a sensible decision with senior staff and allow an experienced
anesthetist to intubate the patient
Evaluation of the Burn Patient
Advanced Trauma Life Support (ATLS) protocol. Airway, breathing, and circulation must be assessed
immediately. In addition , the presence of additional injuries- particularly life threatening injuries requires
exclusion. A thorough history of the burn injury is critical as it may provide some important information
that will ultimately affect management. Details related to the location of the injury (indoors vs. outdoors),
type of liquid involved in a scald, duration of extraction from fire, as well as details of the patient's other
medical problems are important.
Adults with burn injuries greater than 15% to 20% are admitted to an intensive
.care unit for adequate monitoring and infectious control
:-The severity of the burn is determined by
Burned surface area
Depth of burn
.Other considerations
Morbidity and mortality rises with increasing burned surface area. It also rises with .increasing age so that
even small burns may be fatal in elderly people
Determination of Burn Extent

The extent and depth of burn wounds are established shortly following admission. The
total body surface area (TBSA) burned is calculated using one of several techniques.
When calculating TBSA, one includes those areas of partial and full thickness burns.
Superficial burns are not included in the calculation. The rule of
nines is perhaps the best known method of estimating burn extent. However, it is
important to note that the proportions of infants and children are different than those
of adults. The head of children tends to be proportionately greater than 9% TBSA, and
the lower extremities are less than 18%. A second technique of estimating TBSA is
using the patient's hand. The patient's hand represents about 1% TBSA and the total
burn size can be estimated by determining how much of the patient's (not the
examiner's) hand areas are burned. Lund and Browder charts are
a more accurate method of assessing burn extent. They provide
an age-based diagram to assist in more precisely calculating the
.burn size
The scope of plastic surgery
The tools of reconstruction are used for a wide range of conditions:·trauma:·soft-tissue loss
(skin, tendons, nerves, muscle);
·hand and lower limb injury;·faciomaxillary;·burns;·cancer:
·skin, head and neck, breast, soft tissue sarcoma;·congenital:
·clefts and craniofacial malformations;·skin, vascular
malformations;·urogenital;·hand and limb malformations;
·miscellaneous:· Bell's (facial) palsy;·pressure sores;·aesthetic
.surgery;·chest wall reconstruction
Plastic surgery principles.Optimise wound by adequate debridement
or resection .Wound or flap must have a good blood supply to
heal Place scars carefully - 'lines of election'aReplace defect with
similar tissue -