BurnBurn

Dr. Jalal Ali HassanDr. Jalal Ali Hassan

Plastic SurgeonPlastic Surgeon

Lecture No. 1Lecture No. 1

SKIN :SKIN :

The skin is the largest organ in the The skin is the largest organ in the body,body,

Thermal injury to the skin disrupts Thermal injury to the skin disrupts several several

vital protective and homeostatic vital protective and homeostatic functions functions

as in the table belowas in the table below

Functions of Skin : Functions of Skin :

1-Protective Barrier1-Protective Barrier Immunological Immunological Fluid evaporationFluid evaporation Thermal (insulation, sweat production,vasomotor Thermal (insulation, sweat production,vasomotor

thermoregulation)thermoregulation) 2-Sensory 2-Sensory 3-Metabolic (vitamin D synthesis and excretory function)3-Metabolic (vitamin D synthesis and excretory function) 4-Social( self-image, social image)4-Social( self-image, social image)

BurnBurnDefinitionDefinition: Burn is a wound in : Burn is a wound in which there is coagulative which there is coagulative necrosis of the tissue, by direct necrosis of the tissue, by direct flame, scalds, chemical agents, flame, scalds, chemical agents, electricity, sun exposure, flash electricity, sun exposure, flash flame, friction and irradiation.flame, friction and irradiation.

Assessment of Burn areaAssessment of Burn area

Rule of NinesRule of Nines: This acts as a : This acts as a rough guide to body surface arearough guide to body surface area

Lund and Browder chartLund and Browder chart : According : According to the age there is change in the size to the age there is change in the size

of head , thighs and legs.of head , thighs and legs.

Hand size 1% ( hand and fingers ) Hand size 1% ( hand and fingers ) fingers closed.fingers closed.

Wound assessment and caresWound assessment and cares

I_ Superficial Burn (1st degree)I_ Superficial Burn (1st degree)e.g.: Sun Burn, Flash flame, involve only e.g.: Sun Burn, Flash flame, involve only the Epidermis.the Epidermis. No topical Antibiotics needed. No topical Antibiotics needed. No blisters (only edema). Erythematous. No blisters (only edema). Erythematous.Dry.Dry. Painful and tender due to P.G. Painful and tender due to P.G. production.production. Healing occurs within 5-7 days. Healing occurs within 5-7 days. No scar formation. No scar formation.

II_ Partial -thickness burn(2II_ Partial -thickness burn(2ndnd degree) degree) Superficial dermal. Superficial dermal. Deep dermal. Deep dermal. There is destruction of all of Epidermis and There is destruction of all of Epidermis and variable thickness of dermis and it is divided variable thickness of dermis and it is divided into :into :

Superficial dermalSuperficial dermal:Heat injury to upper 1\3 of :Heat injury to upper 1\3 of dermis.dermis.- Light pink.- Light pink.- Wet.- Wet.-Very painful with blister formation.-Very painful with blister formation.-Healing will occur within 7-14 days by epithelial -Healing will occur within 7-14 days by epithelial cell formation from skin appendages cell formation from skin appendages

-Minimal scar formation -Minimal scar formation

Deep dermal:Deep dermal:--Few viable cells remain.Few viable cells remain.- Slow epithelialization which - Slow epithelialization which needs months with scar needs months with scar formation .formation .- Red mottled with white areas.- Red mottled with white areas.-Less moist.-Less moist.-Painful.-Painful.-Positive pin prick test.-Positive pin prick test.-Blisters are not characteristic -Blisters are not characteristic because thick and adherence of because thick and adherence of dead tissue layer to underlying dead tissue layer to underlying viable dermis.viable dermis.

III- Full thickness burn (3rd III- Full thickness burn (3rd degree)degree)Destruction of entire epidermis and Destruction of entire epidermis and dermis.dermis. Will not heal. Will not heal. Color is waxy white , or leathery Color is waxy white , or leathery brown to black .brown to black . Eschar with visible coagulate veins. Eschar with visible coagulate veins. Dry.Dry. No blisters. No blisters. No pain ( no sensation). No pain ( no sensation). Hair pull out easily. Hair pull out easily.

IV- Fourth degree burnIV- Fourth degree burn

Involves underlying Involves underlying structures , same finding as structures , same finding as 3rd degree burn with 3rd degree burn with involved bone, muscle and involved bone, muscle and tendon.tendon.

Zone of Coagulation :Zone of Coagulation : Dead tissue.Dead tissue.Zone of Ischemia (Stasis) :Zone of Ischemia (Stasis) : Marginally viable tissue but still viable, Marginally viable tissue but still viable, the vessels in this area are injured or prone the vessels in this area are injured or prone to injury (damaged endothelial cells) lead to to injury (damaged endothelial cells) lead to mediator release or infection and further mediator release or infection and further decrease in blood flow and converting this decrease in blood flow and converting this zone to non viable tissue ( i.e. the burn zone to non viable tissue ( i.e. the burn

changes from 2nd degree to 3rd degree).changes from 2nd degree to 3rd degree). Zone of hyperemia :Zone of hyperemia :Viable tissue responding to injury by Viable tissue responding to injury by inflammation.inflammation.

Severity of burn depend onSeverity of burn depend on ::

1-Size.1-Size.2-Site.2-Site.3-Depth .3-Depth .4-Age Increased mortality in less than two 4-Age Increased mortality in less than two years of age because of years of age because of A-increase the surface area.A-increase the surface area.B-immature immune system.B-immature immune system.C-immature kidneys.C-immature kidneys.Also increased mortality in patients over 50 Also increased mortality in patients over 50 years of age because of associated diseases.years of age because of associated diseases.5-Associated injury e.g. fractures, inhalation 5-Associated injury e.g. fractures, inhalation injury, head injury, internal bleedinginjury, head injury, internal bleeding

Severity of burn can be classified Severity of burn can be classified intointo1-Major1-MajorPTB ( 2nd degree ) > 25%PTB ( 2nd degree ) > 25%FTB ( 3rd degree ) > 10% FTB ( 3rd degree ) > 10% Or burn of critical areas like face, hand , foot , Or burn of critical areas like face, hand , foot , perineum or complex injuries , inhalation injury or perineum or complex injuries , inhalation injury or other trauma.other trauma.Treatment is in burn center.Treatment is in burn center.2-Moderate2-Moderate Burn of TBSA of 15-25% of 2nd degree or 3-10% of Burn of TBSA of 15-25% of 2nd degree or 3-10% of 3rd degree burn.3rd degree burn.Usually treated in community hospital.Usually treated in community hospital.3-Minor3-MinorTotal burn <15% of TBSA 2nd degree or less than Total burn <15% of TBSA 2nd degree or less than 3% 3rd degree burn.3% 3rd degree burn.Usually treated in ambulatory clinic.Usually treated in ambulatory clinic.

Indication for admissionIndication for admission 1-PTB > 15% in adult.1-PTB > 15% in adult.2-PTB > 10% in child.2-PTB > 10% in child.3-FT B> 10% any age.3-FT B> 10% any age.4-Burn in face , hand, foot , perineum4-Burn in face , hand, foot , perineum( except minor cases).( except minor cases).5-Inhalation injury.5-Inhalation injury.6-Electrical burn.6-Electrical burn.7-Associated major medical illness e.g. 7-Associated major medical illness e.g. DM.DM.8-Other considerations age, home 8-Other considerations age, home situation and level of cooperation.situation and level of cooperation.

Electrical burnElectrical burnLow tension .Low tension .High tension.High tension. Severity of electrical burn depends on : Severity of electrical burn depends on :

Voltage.Voltage. Current. Current. Type of current. Type of current. Site. Site. Duration. Duration. Moisture. Moisture.

Electrical burn damage by Electrical burn damage by ::

Electrical flash out ( actual contact).Electrical flash out ( actual contact).Hotness of wires.Hotness of wires.Passage of electrical current (true Passage of electrical current (true electrical burn).electrical burn).

Burned skin after Burned skin after healinghealing

Hypo or hyper pigmentation.Hypo or hyper pigmentation.Scar.Scar.Susceptible for sun burn.Susceptible for sun burn.Dry.Dry.Itching.Itching.

BurnBurn

Dr. Jalal Ali HassanDr. Jalal Ali Hassan

Plastic SurgeonPlastic Surgeon

Lecture No.2Lecture No.2

Effects of burn injuryEffects of burn injury

Local effects.Local effects.

Regional effects ( circulatory problems).Regional effects ( circulatory problems).

Systemic effects from burning.Systemic effects from burning.

Local effects : Local effects : 11- - Tissue damageTissue damage 2- Inflammation 2- Inflammation 3- Infection 3- Infection

1-1-Tissue damage:Tissue damage:Heating of tissue leads to direct cell rupture or cell Heating of tissue leads to direct cell rupture or cell necrosis.necrosis. At the periphery the cells may be viable but At the periphery the cells may be viable but injured.injured.Collagen is denaturized, and damage to the Collagen is denaturized, and damage to the peripheral microcirculation occurs.peripheral microcirculation occurs. Capillaries thrombosed or increased permeability Capillaries thrombosed or increased permeability (edematous tissue).(edematous tissue). External leakage of serous fluid. External leakage of serous fluid. The difference between PTB and FTB is the depth The difference between PTB and FTB is the depth injury.injury.

2- Inflammation:2- Inflammation:

Marked and immediate inflammatory Marked and immediate inflammatory response occur in the areas less damaged response occur in the areas less damaged by burning.by burning. Manifest as erythema. Manifest as erythema.Mild areas of erythema resolve with in few Mild areas of erythema resolve with in few hours.hours.More severely damaged tissue may develop More severely damaged tissue may develop a more prolonged inflammatory response.a more prolonged inflammatory response.Macrophages produce inflammatory Macrophages produce inflammatory mediators or cytokines e.g. transforming mediators or cytokines e.g. transforming growth factor-B and neutrophils and later growth factor-B and neutrophils and later lymphocytes provide protection against lymphocytes provide protection against infection.infection. Damaged tissue separates by an active Damaged tissue separates by an active cellular process described as desloughing cellular process described as desloughing generally completes by 3 weeks.generally completes by 3 weeks.

3- Infection :3- Infection :

The damaged tissue presents a nidus The damaged tissue presents a nidus for infection.for infection.Burn wounds will almost inevitably be Burn wounds will almost inevitably be colonized by microorganisms within colonized by microorganisms within 24-48 hours, and this may remain as a 24-48 hours, and this may remain as a local wound or regional infection.local wound or regional infection.Bacterimia.Bacterimia.Septicemia.Septicemia.Metastatic infections.Metastatic infections.

Regional effects Regional effects (problems) in burn:(problems) in burn:Circulation :limb circulation may Circulation :limb circulation may be compromised, direct damage be compromised, direct damage to a main vessel is unlikely except to a main vessel is unlikely except in high tension electrical burn.in high tension electrical burn. Gross edema in a limb following Gross edema in a limb following burn , the swelling and tissue burn , the swelling and tissue tension may lead to venous tension may lead to venous obstruction specially in obstruction specially in circumferential burned tissue circumferential burned tissue (Eschar).(Eschar).

Systemic effects:Systemic effects:

1- fluid loss :1- fluid loss :

From damage capillaries either by visible external From damage capillaries either by visible external loss or internally into the tissue from edema in the loss or internally into the tissue from edema in the region of the burn or even of the entire body.region of the burn or even of the entire body.

2- multiple organ failure:2- multiple organ failure:

There may be progressive failure of renal or hepatic There may be progressive failure of renal or hepatic function or heart failure. function or heart failure. The precise cause of the complications is uncertain The precise cause of the complications is uncertain and may be due to fluid loss, toxemia from infection and may be due to fluid loss, toxemia from infection or uncontrolled over reaction of the inflammatory or uncontrolled over reaction of the inflammatory response to sepsis , MOF may however occur response to sepsis , MOF may however occur without obvious systemic infection.without obvious systemic infection.

3- inhalation injury:3- inhalation injury:Occur in those trapped in closed spaces, particularly Occur in those trapped in closed spaces, particularly common in association with burns of head and common in association with burns of head and neck. Various parts of the respiratory tract may be neck. Various parts of the respiratory tract may be injured, inhalation of hot gases lead to thermal burn injured, inhalation of hot gases lead to thermal burn to upper airway, manifest early by strider, to upper airway, manifest early by strider, hoarseness , cough , and respiratory obstruction.hoarseness , cough , and respiratory obstruction.Inhalation of the products of combustion cause a Inhalation of the products of combustion cause a chemical burn to the bronchial tree and lungs, chemical burn to the bronchial tree and lungs, manifested by hypoxia, acute respiratory distress manifested by hypoxia, acute respiratory distress syndrome and respiratory failure, it may be a syndrome and respiratory failure, it may be a delayed onset.delayed onset.Systemic absorption of carbon mono oxide (CO) and Systemic absorption of carbon mono oxide (CO) and hydrogen cyanide from burning plastic causes hydrogen cyanide from burning plastic causes poisoning. CO displaces oxygen from hemoglobin to poisoning. CO displaces oxygen from hemoglobin to form carboxyhemoglobin reducing the oxygen form carboxyhemoglobin reducing the oxygen carrying capacity of the blood and it also has carrying capacity of the blood and it also has intracellular effects, the patient may arrive intracellular effects, the patient may arrive confused or unconscious.confused or unconscious.

4-Systemic complications:4-Systemic complications:

well documented systemic complications in well documented systemic complications in association with burns include: association with burns include: Curling ulcer( gastric or duodenal ) leading to acute Curling ulcer( gastric or duodenal ) leading to acute hematamesis.hematamesis.

Immune suppression which increase the rate of Immune suppression which increase the rate of septic complications.septic complications.

Weight loss due to catabolism (response to trauma )Weight loss due to catabolism (response to trauma )

55- nonspecific complications:- nonspecific complications:

include UTI from catheterization .include UTI from catheterization . DVT and pulmonary embolism. DVT and pulmonary embolism.

Clinical Picture of Burn InjuriesClinical Picture of Burn Injuries1-1- PainPain : Is immediate, acute and intense with superficial burns, : Is immediate, acute and intense with superficial burns, persist until strong analgesic is administered.persist until strong analgesic is administered.

2- 2- Acute AnxietyAcute Anxiety: the patient is severely distressed at the time of : the patient is severely distressed at the time of injury. It is frequently to patient to run or in an attempt to escape and injury. It is frequently to patient to run or in an attempt to escape and secondary injury may result.secondary injury may result.

3- 3- Fluid loss and dehydrationFluid loss and dehydration: if replacement is delayed or : if replacement is delayed or inadequate the patient may be clinically dehydrated.inadequate the patient may be clinically dehydrated.

4- 4- Local tissue edemaLocal tissue edema: : Superficial burn: blisterSuperficial burn: blisterDeep burn: edema formation in the subcutaneous spaces then may Deep burn: edema formation in the subcutaneous spaces then may be marked in head and neck, with sever swelling which may obstruct be marked in head and neck, with sever swelling which may obstruct the airway.the airway.Limb edema may compromise the circulation.Limb edema may compromise the circulation.

5- 5- Special sitesSpecial sites: Burn of the eyes are uncommon in house fires, the : Burn of the eyes are uncommon in house fires, the eyes may be involved in explosion injuries or chemical burns.eyes may be involved in explosion injuries or chemical burns.Burn in the nose, airway, mouth, and upper airway may occur in Burn in the nose, airway, mouth, and upper airway may occur in inhalation injuries.inhalation injuries.

6- 6- ComaComa: burning furniture is particularly toxic and patient may : burning furniture is particularly toxic and patient may

suffer from carbon monoxide or cyanide poisoning.suffer from carbon monoxide or cyanide poisoning.

Management of BurnManagement of Burn

1-The first priority is the maintenance of the 1-The first priority is the maintenance of the patient airway.patient airway.

2-Effective ventilation2-Effective ventilationIf there is apnea, inhalation injury or CO If there is apnea, inhalation injury or CO poisoning do Endo-tracheal intubation which poisoning do Endo-tracheal intubation which will be impossible later when the edema is will be impossible later when the edema is increased, mechanical ventilator is needed, increased, mechanical ventilator is needed, otherwise tracheotomy or oro-tracheal or otherwise tracheotomy or oro-tracheal or

naso-tracheal intubation is indicated.naso-tracheal intubation is indicated.

3-Support of systemic circulation3-Support of systemic circulation Put IV line and start I.V fluid e.g. Ringer Put IV line and start I.V fluid e.g. Ringer Lactate if burn is more than 15% (adult), and Lactate if burn is more than 15% (adult), and more than 10% (children) after doing the more than 10% (children) after doing the rest of the life saving measures take the rest of the life saving measures take the patient weight and estimate the % of total patient weight and estimate the % of total and calculate the fluid requirement by and calculate the fluid requirement by Parkland formulaParkland formula..Parkland formula = body wt. x % of TBSA x Parkland formula = body wt. x % of TBSA x 4.4.Fluid (type , volume , rate).Fluid (type , volume , rate).

Ringer Lactate can be given.Ringer Lactate can be given.

4-Look for and manage other complicating life 4-Look for and manage other complicating life threatening injuries e.g. head injury , threatening injuries e.g. head injury , pneumothorax, intra abdominal injury and pneumothorax, intra abdominal injury and increased blood loss, these may lead to death more increased blood loss, these may lead to death more rapidly than the burn itself.rapidly than the burn itself.5-Cold water application5-Cold water applicationIf done early it leads to : If done early it leads to : a-decreased tissue damage. a-decreased tissue damage. b-Decreased pain. b-Decreased pain. C-Stabilizes mast cells (decreases edema). C-Stabilizes mast cells (decreases edema).

DisadvantagesDisadvantages of it , it increases heat loss leads of it , it increases heat loss leads to shivering , increased O2 + caloric demand, leads to shivering , increased O2 + caloric demand, leads to depletion of glycogen store lead to hypothermia to depletion of glycogen store lead to hypothermia and potentiation of shock.and potentiation of shock.Indications:Indications:for heat neutralization ( initially for minutes).for heat neutralization ( initially for minutes).Pain relief in second degree (not third degree) burn Pain relief in second degree (not third degree) burn which is less than 15%TBS.which is less than 15%TBS.

6-Evaluate the burn wound and look for the most 6-Evaluate the burn wound and look for the most two important conditions:two important conditions:

a- emergent management of inhalation injury is a- emergent management of inhalation injury is difficult, diagnosis by (history, blood gases, blood difficult, diagnosis by (history, blood gases, blood carboxy hemoglobin levels) fibroptic endoscopy is carboxy hemoglobin levels) fibroptic endoscopy is very important.very important.Do early endotracheal intubation.Do early endotracheal intubation.If carboxy Hb is increased ( more than 10%) give If carboxy Hb is increased ( more than 10%) give 100% O2 administration.100% O2 administration.

b- release of constricting eschar which lead to b- release of constricting eschar which lead to decrease chest wall movement (respiratory decrease chest wall movement (respiratory embarrassment) embarrassment) Extremity constriction (compartment syndrome Extremity constriction (compartment syndrome or distal ischemia and necrosis). or distal ischemia and necrosis).

EscharatomyEscharatomyShould be done through out the length and depth of the Should be done through out the length and depth of the eschar, release of the underlying tissue indicate adequate eschar, release of the underlying tissue indicate adequate incision.incision.

Chest EscharatomyChest EscharatomyOnly for full thickness burn extend to subcutaneous tissue, Only for full thickness burn extend to subcutaneous tissue, by bilateral incision on anterior axillary line in full length by bilateral incision on anterior axillary line in full length and depth of the eschar, if still inadequate chest and depth of the eschar, if still inadequate chest movement do Chevron incision over the costal margin and movement do Chevron incision over the costal margin and join it to the first incision.join it to the first incision.

Extremity EscharatomyExtremity Escharatomy Eschar First increase pressure which impedes venous Eschar First increase pressure which impedes venous return which lead to further increase pressure lead to return which lead to further increase pressure lead to decrease arterial flow.decrease arterial flow.Tissue pressure more than 25mm Hg is more than capillary Tissue pressure more than 25mm Hg is more than capillary hyper static pressure leads to decreased arterial flow.hyper static pressure leads to decreased arterial flow.Escharatomy is indicated when intracompartment pressure Escharatomy is indicated when intracompartment pressure is more than 40 mm Hg.is more than 40 mm Hg.Do it in the midline , avoid ulnar nerve posterior to Do it in the midline , avoid ulnar nerve posterior to epicondyle and common peroneal nerve at fibular head.epicondyle and common peroneal nerve at fibular head.In digits do it in mid lateral line in ulnar aspect of 2In digits do it in mid lateral line in ulnar aspect of 2ndnd,3,3rdrd and fourth fingers, radial aspect of the thumb and 5and fourth fingers, radial aspect of the thumb and 5thth finger.finger.Escharatomy is painless for full thickness and painful for Escharatomy is painless for full thickness and painful for partial thickness.partial thickness.

7- Folleys Urinary Catheter7- Folleys Urinary Catheter

done in burn more than 25% TBSA.done in burn more than 25% TBSA.UOP should be not less than 30-50 ml/hr(adult) and 0.5-1ml/kg UOP should be not less than 30-50 ml/hr(adult) and 0.5-1ml/kg body wt/hr in children.body wt/hr in children.

8- 8- NGTNGT

done in burn more than 25% TBSA. With suction for gastric done in burn more than 25% TBSA. With suction for gastric decompression, because there is chance of paralytic ileus.decompression, because there is chance of paralytic ileus.

9- 9- Analgesic and SedationAnalgesic and Sedation

in major burn only IV not IM or SC morphine 0.2 mg/kg or into in major burn only IV not IM or SC morphine 0.2 mg/kg or into the drip.the drip.

10- 10- Anti Ulcer TreatmentAnti Ulcer Treatment

gastric or duodenal lesion occur within 48 hrs after burn, give gastric or duodenal lesion occur within 48 hrs after burn, give prophylactic ranitidine (H2 receptor antagonist) or give prophylactic ranitidine (H2 receptor antagonist) or give antiacids by NGT.antiacids by NGT.

11-Tetanus Immunization11-Tetanus Immunizationall burn injuries considered as contaminated, all burn injuries considered as contaminated, tetanus prophylaxis is mandatory except in actively tetanus prophylaxis is mandatory except in actively immunized patient within one year(0.5 mg tetanus immunized patient within one year(0.5 mg tetanus toxoid IM)toxoid IM)

12- 12-blood Transfusionblood Transfusionnot always indicated in the resuscitation phase, not always indicated in the resuscitation phase, blood is given in the first 24 hrs if there is either pre blood is given in the first 24 hrs if there is either pre existing anemia or associated injuries.existing anemia or associated injuries.

13- 13-Inotropic SupportInotropic Supportif adequate perfusion can not be maintained given if adequate perfusion can not be maintained given in case of poor ventricular function( elderly or in case of poor ventricular function( elderly or inhalation injury)inhalation injury)low dose dopamine leads to increase renal blood low dose dopamine leads to increase renal blood flow( 2 microgram/kg/min).flow( 2 microgram/kg/min). moderate dose of dopamine or dobutamine lead to moderate dose of dopamine or dobutamine lead to increase contractility and increase COP (2-5 increase contractility and increase COP (2-5 microgram/kg/min). microgram/kg/min).

14- Oxygen Therapy14- Oxygen Therapyit is important in respiratory injury.it is important in respiratory injury.

15- 15- Careful monitoring which includesCareful monitoring which includesa-monitoring of the general condition or vital signs.a-monitoring of the general condition or vital signs.

b-monitoring of the fluid resuscitation for adequate perfusion.b-monitoring of the fluid resuscitation for adequate perfusion.

c- investigations for renal,metabolic and hematological c- investigations for renal,metabolic and hematological condition.condition.

16- 16-Antibiotics (controversy)Antibiotics (controversy)sometime penicillin prophylaxis given in more than 10% burn sometime penicillin prophylaxis given in more than 10% burn to prevent hemolytic streptococcal infection.to prevent hemolytic streptococcal infection.

17- 17- Physiotherapy and prevent bed sorePhysiotherapy and prevent bed sore..