Medical Dictionary Search here

DEGREES OF BURN AND MANAGEMENT

  • BURNS  &  SCALDS
  • ELECTRICAL BURNS
  • CHEMICAL BURNS
  • RADIATION
  • LIGHTENING


PRE-HOSPITAL CARE
  • Remove patient from source
  • Extinguish burning clothes
  • Careful with electric source
  • CPR
  • If hospital is 30- 45 min away try to start IV
  • Cold soaks ↓ pain but ↓ heat, so avoid hypothermia
  • Cover the areas with clean sheets
  • 100% O2  if suspected CO poisoning
  • Check for respiratory burns


IN EMERGENCY
  • ABC
  • Assess the percentage and degree of burn
  • Start IV line and infuse Ringer’s Lactate and calculate the fluid requirement
  • Take patient’s weight                         
  • Catheterize
  • Oxygen if required
  • TT  injection
  • Morphine 
  • Wound care- clean with saline and apply 1%silver sulphadiazene
  • No role  of prophylactic antibiotic


ASSESSMENT OF BURNS

Wallace’s Rule of Nine-in adults each upper extremity, and the head and neck are 9% TBSA, lower extremities, anterior and posterior trunk each are 18% while genitalia and perineum forms 1% of TBSA
Infant head is 18 % and lower limb is 14%, for each year after one year 1% to be taken off the head and neck area and added to the lower limbcs
Patient’s palm as 1 %

FLUID RESUSCITATION

  • Modified Parkland’s formula
  • 4ml X   Body weight X % Burns ( 50 % ) 
  • Ringer’s lactate to be given. 50% in first eight hours from the time of burns
  • 50% in next 16 hours
  • Response- 1ml/Kg/hr urine output. 50-70ml in adults


DEGREES OF BURN

FIRST  DEGREE
  • Sunlight exposure or burn by hot tea cup
  • Injury confined to epidermis
  • Red and dry
  • Very painful
  • Heals in 3-6 days without scarring
  • Not included while calculating fluid requirement for burns



SECOND DEGREE SUPERFICIAL
  • Hot liquid or flash flame
  • Pink or mottled red in appearance
  • Blisters or bulla, soft and moist
  • Painful
  • 7-10 days to heal and may have hypo or hyper pigmented areas



SECOND DEGREE DEEP
  • Chalky white
  • Soft and moist 
  • Sensation is obtunded
  • More than 21 days to heal
  • Heals with lot of scarring and contractures



THIRD DEGREE BURN
  • Prolonged exposure or electric burn
  • Dry and parchment like
  • Translucent, can see fat and thrombosed veins
  • No sensation
  • Needs debridement of eschar and skin grafting



MAJOR BURNS

Partial thickness greater than 25%
Partial or full thickness burns of face, hands, genitalia and feet
Third degree burn greater than 10% area
Burns complicated by
Respiratory tract injury
Major soft tissue injury
Fractures
Electrical burns

MODERATE

Second degree burns 15-25%
Third degree less than 10% except hands, face and feet

MINOR

Second degree less than 15 %
Third degree less than 2 %

PATHOPHYSIOLOGY

Jackson’s three zones
  • Zone of coagulation
  • Zone of stasis
  • Zone of hyperaemia

CVS- shift of fluid, ↓cardiac output, greater than 25 % burn even non burned tissue also swell

LUNGS- hyperventilation, ↓ protein, poor lung function
GIT- ileus, mucosal ischaemia, curling’s ulcers, translocation of bacteria
RENAL- renin- angiotensin- aldosterone system activated, ↓ urine output, ATN
IMMUNE SYSTEM- destruction of barrier, depression of cellular immunity
BODY TEMP. – loss of protective mechanism, heat loss & hypothermia, ↑ spike after dressing due to pyrogens such as interleukin-1

WOUND CARE

Clean with surgical detergent or clean water shower or water tank and twice daily dressing with 1% SSD

BIOLOGICAL  DRESSINGS

Allograft, skin substitutes- collagen amino acid films
Amnion, porcine skin, integra, homograft, Burn mesh


Local care

Dressings
Open- neck, hand, 
occlusive,
Biological
Early surgical excision and grafting
Tangential excision

ANTIBACTERIALS

Sulfonamide
Thick application
Twice daily
Good penetration

Silver Nitrate
Bacteriostatic
Black discoloration
Thick pads required
Leaching of Na, K, Cl, Mg and Ca
Poor penetration

Silve sulphadizene
1968 Charles Fox
Silver nitrate and acid sulphadizene
Bacteriostatic
Good penetration
Gentamicin
2.2% Cerium nitrate and SSD

NUTRITION

Metabolic needs ↑ by two to three fold
CURARIE  FORMULA
25KCal  x  Body weight + 40KCal x  % Burns
Supplement Vit C, zinc and B complex 

INFECTION ( Clinical)

Conversion of 2o - 3o
Focal dark brown or black discoloration
Degeneration of wound with neoeschar
Rapid separation of eschar
Hemorrhagic discoloration of subeschar fat
Erythematous wound margin
Metastatic septic lesion in unburned tissue


INFECTION ( Histological)

Organism in unburned tissue
Hemorrhage in unburned tissue
↑ inflammatory reaction in adjacent tissue
Small vessel thrombosis or ischaemic necrosis of unburned tissue
Perineural and intralymphatic migration of organism
Vasculitis and perivascular cuffing of organisms

Other septic complications
  • Pneumonia
  • Sup. Thrombophlebitis
  • Endocarditis
  • Sepsis


Verduria

FASCIOTOMY, ESCHAROTOMY, ESCHARECTOMY, SKIN GRAFTING

Eschar is the burnt dead skin
Fascia is the deeper tissue covering the muscles
Burn wound excision
↓ hospital stay
↓ sepsis ( greater than 30% increased chance of sepsis)
Better cover, early healing, ↓ scar
Rapid restoration of function

ESCHAROTOMY
  • If vascular or respiratory compromise due to thick constricting eschar
  • Escharotomy done at the neutral lines. 
  • If no improvement do fasciotomy( mostly in electric burns) 



ESCHARECTOMY

Surgical removal of eschar 
Early- done in 7- 12 days
Late- separates after two weeks.
Prepares bed for early grafting
Tangential excision and grafting
In second degree deep burns
Done on 2nd to 5th day
After 7 days it softens
Not more than 20% in one sitting


SEQUENTIAL EXCISION
  • Done in deep second degree and third degree burns
  • Blood loss  5% area one unit blood required
  • Eschar sequentially removed with a guarded knife and grafted
SKIN GRAFTING

Pinch, mesh, stamp, sheet
Thin, Intermediate, Thick ( Split thickness graft)
Full thickness graft
Priority areas
face, hands, axilla, cubital and popliteal fossa
Autograft, homograft, heterograft


    ELECTRIC BURNS
    • Low voltage ( greater than 1000 volts )
    • High voltage ( less than 1000 volts )
    • Conversion of electrical energy to heat is governed by Ohm’s law
    • C= V/R current in amperes
    • Joule’s Law- J= C2RT relation between current and heat production
    • Bone offers the most resistance
    • Current takes the shortest path
    • Body acts as volume conductor
    • Arc injury is very deep
    • “no release” phenomenon
    • Skeletal injury due to fall.
    • Cardiac- arrest, VT, AF, SVT, RBBB
    • Renal- ARF, Myoglobinuria
    • CNS- convulsions, coma, paraplegia
    • Abdomen- Splenic injury
    MANAGEMENT

    General
    Deep burns- maintain urine output of 2ml/kg/hr
    Mannitol 12.5 gm/hour
    50ml 7.5% NaHCO3 ( 45 mEq)
    Cardiac monitoring ( CPK-MB)