What is burns?
Coagulative necrosis of skin epithelium
What are types of burns?
- Thermal
- Electrical
- Chemical
- Radiation
Local effects of burn
- Tissue damage/ disctruction
- Fluid loss due to increase vessel permeability
- Infection
- Red cell destruction
- Venous thrombosis
Regional effects of burns
- Compartment syndrome
- Contracture/ hypertrophic scar
- Circulation compromise
Systemic effect of burns
- Fluid and electrolyte imbalance
- Protein loss/ Catabolism /Hypermetabolism
- Impaired humeral and cellular immune response → sepsis/ SIRS/ multi-organ failure
SUPERFICIAL (1st) BURNS
What is the depth?
What are the features?
How long does it take to heal?
Depth: Epidermis only
Features: erythema, no blister
Healing duration: few days, no scarring
PARTIAL BURNS (SUPERFICIAL + DEEP)
Depth: superficial (epidermis + upper layer of dermis), deep (extends to deeper layer of dermis)
Features: erythema, blanch on pressure, blister, painful with intact pinprick sensation, deep: (no blanching on pressure, reduced pain sensation)
Duration:
superficial: 2-3 weeks, no scar, hyperpigmentation
deep: longer than 3 weeks, hypertrophic scar
FULL THICKNESS (3rd degree) BURNS
Depth: full thickness
Features: no pain, non-blanchable, deadly white
Healing: fibrosis, contracture
What is classified as a major burn?
Adult 15-20% TBSA
Children 10% TBSA
Describe the rule of 9
Modified Brooke formula
2ml/kg x % TBSA = amount of lactated Ringer solution over first 24 hours, with 50% over first 8 hours
Parkland formula
4ml/kg x weight x % TBSA = total fluids in 24 hours with half in first 8 hours
What is standard ATLS guidelines for fluid management in burns
2ml lactated Ringer’s x BW x % TBSA, half in first 8 hours, half in remainin in subsequent 16 hours
Subsequent fluids adjusted to target urine output 0.5ml/kg/hr (30-50ml/hr) for adults and 1ml/kg/hr for children
Management framework for burns
- Immediate:
- Arrest burning process
- ATLS protocol
- Early
- Resuscitation
- Fluid mx
- Pain control
- Sepsis control
- Sedation
- PPI prophlyaxis
- Nutrition
- Tetanus
- Resuscitation
- Local wound management
Signs for inhalation injury
- Singed nostril/facial hair
- Soot on face
- Facial neck burns
- Erythema/swelling within mouth
- Carbon deposites in oropharynx
- Stridor, hoarsness of voice, CO>10%
What are the pathophysiological zones of injury in burns?
- Zone of coagulation: coagulative necrosis with permanent cell death
- Zone of stasis: tissue not permanently damaged but may progress if poorly managed
- Zone of hyperaemia: inflammation, no permanent tissue damage
At what temperature does permanent cell death occur?
45C
At what temperature does protein denaturation occur?
42C
What are potential systemic effects of burns?
- Cardiovasular:
- hypovolemic shock due to fluid shift
- Peripheral/splanchnic vasoconstriction
- Decrease cardiac output (decrdase myocardial contractility
- Respiratory
- Bronchoconstriction -inflammatory mediators
- ARDS: due to direct lung injury or inflammatory mediators
- Metabolic: increase BMR, catabolism
- Immune: downregulation
Criteria for complex burn injuries that may require transfer to burn unit?
- Burn factors
- Location/size: large
- Site: face/ hands/feet/genitalia/circumferential
- Causative agent: chemical, electrical
- Patient factors: extreme age, vulnerable
- Concerning features: unwell, child, NAI, non-healing burns for 2 weeks
What is initial management for circumferential burns?
- Remove any jewelry/watches from patient’s extremities
- Assessment of neurovascular status to
- Relieve any circulatory compromise by escharotomy
How to perform escharotomy on the upper limb?
Two parallel incision on the radial and ulnar borders of forearm and arm through burnt skin until subcutaneous tissue.
Care near elbow and wrist not to injure neurovasculature.
Signs and symptoms of compartment syndrome
- Pain out of proportion to stimulus or injury
- Pain on passive stretching of affected muscle
- Tense swelling
- Paresthesia or altered sensation in distal to affected compartment
How do you perform escharotomy for circumferential chest/abdominal burns?
Longitudinal incisions along anterior axillary lines with cross-incision at clavicular line and junction of thorax/ abdomen
