Burns

BURNS

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CLASSIFICATION OF BURNS  Erythema – red, dry skin that easily blanches then rapidly refills  Superficial – red moist wound that blanches and rapidly refills  Superficial dermal – pale, dry, blanching wound that regains colour slowly  Deep dermal – mottled cherry red and does not blanch. The blood is thrombosed and fixed in damaged capillaries in the deep dermal plexus  Full thickness – dry, leathery or waxy, hard wound that does not blanch. In extensive burns, full thickness burns can be mistaken for unburnt skin

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3 ZONES OF MAJOR BURNS

Sepsis is likely if burns become infected, leading to organ failure and death Organisms – Strep pyogenes, Pseudomonas aeruginosa

ELECTROCUTION BURNS  Voltage - determinant of the severity  Musle damage – rhabdomyolysis and renal failure  Extent of burning is proportional to electrical resistance through which current is transmitted  Bone offer highest resistance; current passes through, bone become heated adjoining muscle damage.  Fasciotomy – to decompress muscle compartment CHEMICAL BURNS  Depends on agent, concentration, quantity and duration of contact  Tend to be deep because corrosive continue to act until fully removed  Alkalis tend to penetrate more deeply than acid ASSESSMENT OF BURNED PATIENT

1. Central zone of coagulation in the area of maximum damage where skin cells are irreversibly damage 2. Surrounded by zone of stasis characterized by decreased tissue perfusion. Injured cell can survive or die according to effectiveness of the treatment. 3. The outer zone of erythema is superficial. Cells here minimally injured and will recover in 7 days. Is not included in clalculation of burnt area. SYSTEMIC CHANGES  Systemic and 3rd space fluid losses lead to hypovolaemia  Systemic inflammatory response occurs once burns affect 30% of body surface area  Myocardial contractility becomes depressed  In smoke inhalation, bronchocontriction and ARDS occur  Basal metabolic rate increases up to 3 fold  General capillary permeability is increased  Peripheral and splanchnic vasoconstriction occurs  Red cells are destroyed by burns

HISTORY  Source of burn  Temperature  Duration of contact  Inhalation of noxious gas CALCULATING THE BURNED AREA

ASSESSING DEPTH OF BURN

2. Full thickness burns Insensate and do not bleed on needling.

PRINCIPLE OF MANAGEMENT OF BURNS

1. Partial burns 1. Superficial Affect the dermis 2. Superficial dermal Destroy epidermis and upper layer of dermis; blistering usually occurs. Burn may be covered with soot or dirt (need removing) and blister (deroofed to check base). Capillary refill can be tested by pressure from sterile cotton bud. A 21 g needle to test sensation and bleeding; pain normally felt in superficial dermal and bleeding is brisk. 3. Deep dermal Destroy all of the epidermis and most of the dermis, leaving only the skin adnexae, sweat glands and some hair follicles. On needle testing, bleeding is delayed and only nonpainful sensation is experienced.

First aid Stop the burning process. Remove heat source. Active cooling – immersing burned area in tepid water for 15 – 20 minutes Analgesia Cooling and covering burns Larger burns – opioids later NSAIDs Dressings PVC film – sterils and forms a pliable, non adherent, impermeable barrier which is transparent to allow inspection. MANAGEMENT OF BURNS OF SPECIFIC DEPTH 1. Superficial burns Supportive therapy with regular analgesia and dressing moist area 2. Superficial dermal burns Exposed superficial nerves make these burns particularly painful. Healing expected within 2 weeks from keratinocytes within sweat glands and hair follicle. Treatment needs at least weekly changing. If burns are still unhealed after 2

weeks, depth assessment was incorrect, should refer to burns unit. 3. Deep dermal burns Density of skin adnexae is less at this depth and healing is slower and subject to contracture. Some of these burns heal spontaneously if kept warm, moist and free fro infection. If deep dermal burns are extensive/ fuctionally/ cosmetically sensitive area, they are better treated in burns unit by excision to a viable depth and skin grafting within 5 days. 4. Full thickness burns All regenerative elements in burned area have been destroyed; without grafting, contraction and distortion would be substantial. Ideally need excision and grafting.

RESUSCITATION AND FLUID MANAGEMENT  Effective resuscitation maintain tissue perfusion in the zone of stasis  Greates fluid is lost in the first 8-12 hours  Substantial fluid losses continue for at least another 36 hours  Rapid boluses should not be given early on as raised intravascular hydrostatic pressure drives it rapidly out of the circulation

MANAGEMENT OF THE BURNS  Partial thickness – re-epithelise spontaneously  Full thickness – require excision and skin grafting  Grafting should be done within 5 days  Wound to be graft should be free from infection  Deep circumferential burns of the limbs and thorax begin to contract early – restrict blood flow and respiratory movement  If excision not done early and these signs develop – escharotomy is performed.