Burn&scald
SKINBurn Definition: Burn is a wound in which there is coagulative necrosis of the tissue. Causes: 1- thermal direct flame scalds hot object 2- chemical agents 3- electricity 4-sun exposure 5- friction and irradiation.
Major determinants of the outcome of a burn 1- Percentage surface area involved 2- Depth of burns 3-Presence of an inhalational injury
Assessment of Burn area 1- Rule of Nines: This acts as a rough guide to body surface area 2-Lund and Browder chart : According to the age there is change in the size of head , thighs and legs. 3-Hand size 1% ( hand and fingers ) fingers closed useful in small burn.
Wound assessment(depth) and cares 1- Superficial Burn (1st degree) Sun Burn, Flash flame, involve only the Epidermis. No topical Antibiotics needed. No blisters (only edema). Erythematous. Dry. Painful and tender due to Prostaglandin production. Healing occurs within 5-7 days. No scar formation.
2- Partial -thickness burn(2nd degree) Superficial dermal. Deep dermal. There is destruction of all of Epidermis and variable thickness of dermis and it is divided into : Superficial dermal: Heat injury to upper 1\3 of dermis. - Light pink. - Wet. -Very painful with blister formation. -Healing will occur within 7-14 days by epithelial cell formation from skin appendages -Minimal scar formation
Deep dermal: -Few viable cells remain. - Slow epithelialization which needs months with scar formation . - Red mottled with white areas. -Less moist. -Painful. -Positive pin prick test. -Blisters are not characteristic.
3- Full thickness burn (3rd degree) Destruction of entire epidermis and dermis. Will not heal. Color is waxy white , or leathery brown to black . Eschar with visible coagulate veins. Dry. No blisters. No pain ( no sensation). Hair pull out easily. 4-Fourth degree burn Involves underlying structures , same finding as 3rd degree burn with involved bone, muscle and tendon.
Severity of burn depend on : 1-Size. 2-Site. 3-Depth . 4-Age Increased mortality in less than two years of age because of A-increase the surface area. B-immature immune system. C-immature kidneys. Also increased mortality in patients over 50 years of age because of associated diseases. 5-Associated injury e.g. fractures, inhalation injury, head injury, internal bleeding
Severity of burn can be classified into 1-Major PTB ( 2nd degree ) > 25% FTB ( 3rd degree ) > 10% Or burn of critical areas like face, hand , foot , perineum or complex injuries , inhalation injury or other trauma. Treatment is in burn center. 2-Moderate Burn of TBSA of 15-25% of 2nd degree or 3-10% of 3rd degree burn. Usually treated in community hospital. 3-Minor Total burn <15% of TBSA 2nd degree or less than 3% 3rd degree burn. Usually treated in ambulatory clinic.
Indication for admission 1-PTB > 15% in adult. 2-PTB > 10% in child. 3-FT B> 10% any age. 4-Burn in face , hand, foot , perineum ( except minor cases). 5-Inhalation injury. 6-Electrical burn. 7-Associated major medical illness e.g. DM. 8-Other considerations age, home situation and level of cooperation.
Burned skin after healing Hypo or hyper pigmentation. Scar. Susceptible for sun burn. Dry. Itching.
Effects of burn injury(complications) 1-Local effects: 1- Tissue damage (leakage of serous fluid) 2- Inflammation (erythema) 3- Infection 2-Regional effects :( circulatory problems: limb circulation may be compromised). 3-Systemic effects : 1-fluid loss either external or internal. 2-multiple organ failure.
4-Systemic complications: Curling ulcer( gastric or duodenal ) leading to acute hematamesis. Immune suppression which increase the rate of septic complications. Weight loss due to catabolism (response to trauma 5- nonspecific complications: - UTI from catheterization . -DVT and - pulmonary embolism
Clinical Picture of Burn Injuries 1- Pain : 2- Acute Anxiety: 3- Fluid loss and dehydration: 4- Local tissue edema: Superficial burn: blister Deep burn: edema formation in the subcutaneous spaces then may be marked in head and neck, with sever swelling which may obstruct the airway. Limb edema may compromise the circulation. 5- Special sites: Burn of the eyes are uncommon in house fires, the eyes may be involved in explosion injuries or chemical burns. Burn in the nose, airway, mouth, and upper airway may occur in inhalation injuries. 6- Coma: from carbon monoxide or cyanide poisoning.
Management of Burn MINOR BURNS/OUT-PATIENT BURNS Local burn wound care Blisters. Initial cleaning of the burn wound Washing the burn wound with chlorhexidine solution is ideal for this purpose. Topical agents , dressings with a non-adherent material such as Vaseline-impregnated gauze 1% silver sulphadiazin cream 1- A- AIRWAY The first priority is the maintenance of the patient airway. 2-B-Breathing Effective ventilation
3-C –Circulation Put IV line and start I.V fluid if burn is more than 15% (adult), and more than 10% (children) calculate the fluid requirement by Parkland formula.Parkland formula = body wt. x % of TBSA x 4.Type of fluid:1-Crystalloid resuscitation.Ringer’s lactate is the most commonly used crystalloid. Crystalloidsare said to be as effective as colloids for maintaining intravascularvolume. In children, maintenance fluid must also be given. This isnormally dextrose–saline given as follows:• 100 ml kg–1 for 24 hours for the first 10 kg;• 50 ml kg–1 for the next 10 kg;• 20 ml kg–1 for 24 hours for each kilogram over 20 kg body 2-Colloid resuscitationPlasma Proteins should be given after the first 12hours of burn because,
4-Manage other complicating life threatening injuries . 5-Cold water application a-decreased tissue damage. b-Decreased pain. C-Stabilizes mast cells (decreases edema). Pain relief in second degree (not third degree) burn which is less than 15%TBS. 6-Evaluate the burn wound and look for the most two important conditions: a- inhalation injury b- release of constricting eschar (Escharatomy) which lead to decrease chest wall movement (respiratory embarrassment) Extremity constriction (compartment syndrome or distal ischemia and necrosis).
7- Folleys Urinary Catheter done in burn more than 25% TBSA. UOP should be not less than 30-50 ml/hr(adult) and 0.5-1ml/kg body wt/hr in children. 8- NGT done in burn more than 25% TBSA. With suction for gastric decompression, because there is chance of paralytic ileus. 9- Analgesic and Sedation in major burn only IV not IM or SC morphine 0.2 mg/kg or into the drip. 10- Anti Ulcer Treatment gastric or duodenal lesion occur within 48 hrs after burn, give prophylactic ranitidine (H2 receptor antagonist) or give antiacids by NGT.
11-Tetanus Immunization 12-blood Transfusion 14- Oxygen Therapy 15- Careful monitoring which includes a-monitoring of the general condition or vital signs. b-monitoring of the fluid resuscitation for adequate perfusion. c- investigations for renal,metabolic and hematological condition. 16-Antibiotics (controversy) sometime penicillin prophylaxis given in more than 10% burn to prevent hemolytic streptococcal infection. 17- Physiotherapy and prevent bed sore.