BURNS INJURY

By
Dr. S. M. Ashraf
Assistant Professor
Department of Surgery

Computed By: Mr. M. Hassan Saleem

Management of The Burn Injury
Victim:
 Burns injury can be one of the most serious and

devastating form of trauma.

 Destruction of the skin by heat results in severe local

and systemic physiological alterations. Management

of the burns victim requires understanding of the
pathophysiology, diagnosis and treatment not only of
the local skin injury, but also of the derangements that
occur in the haemodynamic, metabolic, nutritional,
immunological and psychological haemostatic
mechanism.
 Evaluation of Burn Victims:
 First essential step in treating a burns victim is to treat
immediate life-threatening problems including airway
management and shock.
 Next Determine the severity of the injury.
 Level of expertise necessary to care for the patient.
Guidelines:
(1) Age: Extremes of age carry greater morbidity and
mortality <3 years > 60 years.
The age dictates the amount of stress that the victim can
with stand
 (2) Extent of Burn:
It can be determined by careful observation and should be
recorded graphically, in terms of percentage of body
surface involved, only areas of partial thickness and full
thickness are included in this assessment.
Rough estimate rules of nine.
(3) Depth of Burn:
Since the volume of tissue destroyed is ultimately important,
both the depth and the extent of injury must be evaluated.
Depth of burn may be difficult to assess accurately depth of
burn may be non uniform through the burns extent.
 Superficial Burns: (Partial Thickness)
Erythema of the wound, blanching of the tissues
thin watery blisters, with severe pain.
Deeper Burns: (Full thickness)
 Thick-walled blisters pale, poorly or non-

blanching wound bed, a dry leathery eschar.

 Sensation may be unreliable.

 Full thickness burns have pressure sensation.

 Pin prick is absent in deep burns.

Emergency Department Treatment
a) Minor Burns:
Can be treated in an ambulatory setting.
Active immunization 3000I/U
Tetanus prophylaxis
Passive Toxoid booster
Patient who had immunization tetanus toxoid booster.
 Analgesia:
In minor burn wound, true burn wound sepsis is rare.
(Careful studies have shown that prophylactic treatment with penicillin or
other antibiotics does not alter the clinical course in major & minor burns).
 Topical antibacterial are unnecessary for burns of limited size.
 Just clean the wound with a bland soap and carefully dressed. Dressing:
Non adherent gauze (sofratulle) next to the wound followed by a bulky
absorptive dressing.
Immobilize part in a safe functional position and injured extremity elevated if
possible.
Inspect the wound at 24 hr and periodically until healing occurs.
(b) Moderate to major burn:
 Requires hospitalization

 Immediate treatment of impending vascular collapse

is begun by introducing a plastic catheter into a

peripheral or central vein, preferably through
unburned skin.
 Blood is drawn for cross match, blood count

electrolytes, glucose, urea / creatinin.

 ABGs and pH are obtained if there is any suspicion

of inhalation injury or respiratory dysfunction.

 An infusion of electrolyte solution is begun at a rate
dependant on the size of the burns.
 Initial monitoring of the resuscitation is performed by
inserting an indwelling urinary catheter attached to a closed
draining system.
 Following air way stabilization and the initiation of
resuscitation, the adequacy of respiration is evaluated by
chest movement, respiratory rate, cyanosis and ABGS.
 If respiratory distress early cause could be a deep burn with
an unyielding eschar about the anterior & lateral chest wall.
 Early chest eseherectomy to release the restriction of rib
movements (motion) and increase thoracic excursion, thus
improving ventilatory function.
 Inhalation of steam & noxious gases can cause epiglottal or
pharyngeal edema, resulting in upper airway obstruction
requiring intubation or tracheostomy.
 Tracheostomy is best avoided in emergency
situation, unless mandated by associated injuries
such as severe fascial fractures.
 Relieving pain and anxiety should be considered
once the state of shock and the respiration status
have been evaluated cold saline or water for 15-20
min is helpful in decreasing pain and edema.
Blisters are best debrided since they are hard to
maintain intact in the larger burn wounds. If the
blisters are broken, serum and desquamated cells
form a crust that is susceptible to bacterial invasion.
Following debridement, the wound is dressed with a
topical antibacterial agent.
 (2) Definitive Treatment:
a) Resuscitative fluid management:
To determine the resuscitative fluid replacement, it is
important to realize that greatest loss of fluid occurs during
the first 8-12 hr post burn and then continues more slowly
over the next 12-16 hrs. Because of the increase capillary
permeability, colloid replacement seems to be of no benefits
in the immediate post burn period. Osmotic pressure cannot
be built up over a freely permeable membrane, therefore,
since sodium ( seems to be the ion that is lost to the
circulation in disproportionate amounts), sodium ions and
not colloid) appear to be the key to resuscitation. All
formulae given approximately 0.5 mmol of Na/kg b w/%
body burn. In order to compensate for the obligatory loss
from the vascular
compartment, this must be given at a rate exceeding
4.4ml/kg/hr. when Na ion is replaced in this amount and at
this rate, cardiac output returns to normal by 24 hr post
burn.
Following return of the cardiac output at 24hrs, there remains
a plasma gap. This amounts to approximately 0.35-0.5
ml/kg/% body burn. By 24 hr capillary integrity returns and
starlings hypothesis appears to be restored. Therefore,
colloid can be used to replace the plasma volume.
By 30hrs, both cardiac output and plasma volume should be
returned to normal and effective resuscitation completed.
Acute resuscitation is begun with a buffered balanced salt
solution given at a rate of calculated at 2-4 ml/kg/% body
burn.
Approximately ½ of this volume will be required in the first 8
hr following injury, and the remaining volume in the
succeeding 16 hrs.
The administered volume is titrated hrly depending primarily
on the urinary output, pulse, blood pressure, haematocrit
and base deficit.
Resuscitation is continued for 24 hrs and at that time dextrose
and water replace the salt solution. Collide is added to
replace the remaining plasma volume deficiency.
A urine output of 30-50 ml /hr in the adult or1 1/ml/kg/h in
the child is the best monitoring parameter.
 Respiratory Management:
Major burns victims should receive supplemental oxygen
during the burn shock period.
100% of O2, if there is evidence of CO intoxication. High O2
should be continued until the carboxyhaemoglobin (CO Hb)
level falls to less than 5%.
All patients with major burn ABGs should be done during the
first 18-24hrs. Upper airway edema of the pharynx,
epiglottis and vocal cords is evaluated by, indirect
laryngoscopy or fibreoptic bronchoscopy. In mild edema,
intermittent positive pressure ventilation (breathing) with a
bronchodilator is sufficient. In
significant edema, endotrachial intubation should be carried
out to maintain ventilatory function.
 The Burn Wound:
Attention to the burn wound must not take precedence over the
life-saving support of other systems in the burn wound
victim.
Proper treatment of the wound begins with causing no harm to
the injured cells, so that any tissue still viable after the
initial thermal event can survive, the necrotic cells not
capable of recovery must be removed and replaced.
Closure of the wound with viable tissue or cells to
provide a functional and aesthetically satisfactory coverage
as rapidly as possible is the goal of burn wound treatment.
Determination of wound viability and predicting healing is
one of the most difficult problems facing the burn surgeons.
Excision of burn wounds and grafting are now
performed reasonable early after injury. Excision are
associated with significant and in some cases
extensive blood losses. When excision are
performed relatively early, bleeding is generally less
than when excision is delayed for a weak or longer.
Early burn is still in ischemic phase and burn
Haemorrhage is limited. Early burn excision and
wound closure have essentially eliminated burn
wound sepsis as a clinical problem.
Based on the concentric zones of the injury
elucidated
by Jackson, an intradermal or a tangential
excision
has evolved.
Advantages:
 Removal of only necrotic tissue.

 Salvage of injured tissue that would otherwise have

progressed to necrosis.
 Preservation of the biological properties of the dermis.

 Preventions of contractures by immediate skin grafting and

custom made tight garments.

 The choices for burn treatment include excision with skin

dressings.
To be effective, the dressing must be carefully constructed and
applied using applied meticulous aseptic technique.
Careful cleaning & debridement.

Inner layer of fine mesh or impregnated gauze (to allow drainage)

Bulky absorptive material

Non-distensible inelastic wrap (for careful immobilization)

Only change dressing if wound exudates, soak through it or bad

odour, pain and fever.
Most commonly used chemotherapeutic agents used are silver
sulfadiazine, silver nitrate solution and mafenide acetate.
Regardless of the agent used efficiency should be monitored by
constant surveillance of the bacterial flora of the burn wound .
Daily debridement following removal of the topical agent can be
carried out in hydrotherapy, in a dedicated treatment room.
Once necrotic tissue has been removed with in few days or up to 10-14 days
wound closure can be carried out by.

Deep partial thickness

+full thickness Autographts

Meshed grafts If donor sites are not

sufficient

Decreased fluid and Temporary closure with protein loss,

biological dressing .e.g. Decreased pain
allograft, xenografts
Amniotic membrane

material most widely

accepted for extensive
wounds is cadaver allograft
available in fresh frozen or
preserved forms from local
or distant banks.
Applied to burn wound following removal of eschar and remain in place from 48
to 96 hr.
Common complications of burn injury.

1. Renal failure. Acute profound prolonged shock due to

poor resuscitation of volume and haemoglobinuria.
2. Inhalation injury.
Asphyxia because the combustion consumes the O2
available with in moments of injury.
Laryngeal edema, spasm may cause immediate death if
sulpher dioxide are present.
3. Gastrointestinal stress unless GI ulcers 80% of patients with
major burns develop bleeding which is difficult to control
4. Infectious complication. Bacterial, viral, fungal infection
and burn wound sepsis.
 Non Thermal Burn Injury:
A) Electrical Injuries:
Usually divided into low and high voltage injuries.
 Low voltage injuries cause small, localized, deep burn.

 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 fasciotomies or amputation.

 Look for and treat acidosis and myoglobinuria.

 B) Chemical Injuries:
The more common injuries are caused by either acids
and alkalies. Alkalies are usually the more
destructive and are especially dangerous if they
have come in contact with the eyes.
The initial management of any chemical injury is
copious lavage with water. Common cause of acid
burn is hydrofluoric acid. The initial management is
with calcium gluconate gel topically.
C) Ionizing Radiation Injury:
These injuries can be divided into two groups
depending on whether radiation exposure was to the whole
body or localized. The management of local injury is
usually conservate until the true extent of the tissue injury is
apparent. Local burns causing ulceration need excision and
vascularized flap
cover-usually with free flaps.
Systemic over dose needs supportive treatment.
D) Cold Injuries:
Principally divided into two types acute cold injuries
from industrial accidents( liquid nitrogen) and frostbite. The
damage is more difficult to define and slower to develop
than burns.
Acute frostbite needs rapid rewarning than observation.
Delay surgery until demarcation is clear.
Thank You