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Published on : Mar 14, 2014
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Slide 1 - Burn Injuries Dr. Eranda Epaarachchi
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Slide 9 - The layers of the skin
Slide 10 - Anatomy of the skin
Slide 11 - Classification of burns – By depth
Slide 12 - What is shown here?
Slide 13 - What is the diagnosis?
Slide 14 - First degree burns
Slide 15 - Characteristics Epidermis is involved Appearance : Redness (Erythema) Dry & painful Heals within 1 week Complications : Risk of developing skin cancer in later life
Slide 16 - What are these lesions?
Slide 17 - Superficial – partial thickness burn (20)
Slide 18 - Second degree – Partial thickness
Slide 19 - Characteristics Extends into superficial dermis Red with clear blister & Blanches with pressure Moist & painful Heals within 2-3 weeks Complications : Local infection, Cellulitis
Slide 20 - What are these lesions?
Slide 21 - What are these lesions?
Slide 22 - Deep partial thickness burn
Slide 23 - Characteristics Extends into deep dermis Red-and-white with bloody blisters & Less blanching Moist & painful May heal in weeks or progress into a third degree burn Complications : Scarring, contractures (May need skin grafts)
Slide 24 - What are these lesions?
Slide 25 - Third degree burns (Full thickness)
Slide 26 - Characteristics Extends through entire dermis Stiff and white/brown Dry, leathery to touch Painless Requires excision Complications : Scarring, contractures, amputation
Slide 27 - What are these lesions?
Slide 28 - It’s a fourth degree burn
Slide 29 - Characteristics Extends through skin, subcutaneous tissue and into underlying muscle and bone Black (charred) Dry Painless Requires excision Complications : Amputation, significant functional impairment, possible gangrene, and in some cases death
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Slide 31 - Classification of burns by causes
Slide 32 - Chemical Most chemicals that cause burns are strong acids & bases Acids : H2SO4, HNO3, HCl Bases : NaOH Acid burns : Most of the injury occurs at the point of impact Alkali burns : Capable of deep penetration and can cause severe pain
Slide 33 - NaOH burn after 44 hours from exposure
Slide 34 - Electrical burns – Causes Workplace injuries Taser wounds Being defibrillated without a conductive gel Lightning
Slide 35 - Electrical burns Human body is very vulnerable to application of supra-physiologic electric fields Some electrocutions produce no external burns at all, as very little current is required to cause fibrillation of the heart muscle The internal injuries sustained may be disproportionate to the size of the burns seen (if any), and the extent of the damage is not always obvious Such injuries may lead to Cardiac arrhythmias Cardiac arrest Unexpected falls with resultant fractures or dislocations
Slide 36 - Electrical burns – Low voltage injuries Low-voltage (<500 AC volts) injuries usually doesn’t have skin burns This is sufficient to cause cardiac arrest and ventricular fibrillation
Slide 37 - VF (Can lead to aystole in minutes) – Defibrillation to save the life
Slide 38 - Electrical burns – High voltage (> 1000V) injuries Common cause of third and fourth degree burns Explosions caused by electrical faults produce high intensity Ultraviolet radiation which can also cause radiation burns
Slide 39 - Radiation burn – causes Radiation burns are caused by prolonged exposure to UV light (Sun exposure – the commonest) : Severity UVB > UVA Tanning booths Radiation therapy Radioactive fallout X-rays More severe cases of sun burn result in what is known as "heatstroke“ Microwave burns are caused by the thermal effects of microwave radiation
Slide 40 - Heatstroke
Slide 41 - Microwave burn
Slide 42 - Scalding Caused by hot liquids (water or oil) or gases (steam) Immersion scald is created when an extremity is held under the surface of hot water (Common form of burn seen in child abuse) Scald burns are more common in children Generally scald burns are first or second degree burns, but third degree burns can result, especially with prolonged contact (Diabetic neuropathy)
Slide 43 - Scald
Slide 44 - Immersion scald
Slide 45 - Child abuse?
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Slide 47 - SSSS
Slide 48 - Inhalation injury Steam, smoke and high temperatures can cause inhalational injury to the airway and lungs
Slide 49 - Inhalation injury
Slide 50 - Pathophysiology of burns injuries Burn injury results in a local or systemic inflammatory response (Depends on the size of the burn) The lungs may be doubly compromised by smoke inhalation Following a major burn injury, heart rate and peripheral vascular resistance increase This is due to the release of catecholamines from injured tissues and the relative hypovolemia that occurs from fluid volume shifts
Slide 51 - Pathophysiology of burns injuries Initially cardiac output decreases At approximately 24 hours after burn injuries, cardiac output returns to normal if adequate fluid resuscitation has been given Following this, cardiac output increases to meet the hyper-metabolic needs of the body
Slide 52 - Pathophysiology of burns injuries The effects of high temperature on tissue include speeding chemical reactions & denaturing proteins
Slide 53 - Pathophysiology of burns injuries Due to the inflammatory response, permeability of blood vessels is increased in the burn area This causes exudation of proteins and fluid into the adjacent interstitial tissue Red cells are not extravasated This results in increase in the oncotic pressure in the interstitium
Slide 54 - Pathophysiology of burns injuries The volume of fluid loss is directly proportional to the burn area If burn area is 10% to 15% of the total body surface area (TBSA), then the consequent fluid loss may cause circulatory shock If it is more than 25% of TBSA, then inflammation occurs even in the blood vessels remote to the burn, causing greater fluid loss
Slide 55 - Diagnosis – By severity By American Burn Association
Slide 56 - Major burns – Treat in specialized burn units Age 10-50yrs : Partial thickness burns >25% of total body surface area Age <10 or >50 : Partial thickness burns >20% of total body surface area Full thickness burns >10% Burns involving the hands, face, feet or perineum Burns that cross major joints Circumferential burns to any extremity Any burn associated with inhalational injury Electrical burns Burns associated with fractures or other trauma Burns in infants and the elderly Burns in persons at high-risk of developing complications
Slide 57 - Moderate burns – Treat in hospitals Age 10-50yrs : Partial thickness burns involving 15-25% of total body surface area Age <10 or >50 : Partial thickness burns involving 10-20% of total body surface area Full thickness burns involving 2-10% of total body surface area
Slide 58 - Minor burns – Doesn’t require hospitalization Age 10-50yrs : Partial thickness burns <15% of total body surface area Age <10 or >50 : Partial thickness burns involving <10% of total body surface area Full thickness burns <2% of total body surface area, without associated injuries
Slide 59 - Estimating surface area burnt – Rule of 9
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Slide 61 - Lund & Browder charts (More accurate) The size of a person's hand print (palm and fingers) is approximately 0.8% of their TBSA, but for quick estimates, medical personnel round this to 1%, slightly overestimating the size of the affected area Burns of >/= 10% in children or >/=15% in adults are potentially life threatening injuries (because of the risk of hypovolemic shock) and should have formal fluid resuscitation and monitoring in a burns unit
Slide 62 - Lund & Browder charts
Slide 63 - Lund & Browder charts
Slide 64 - Management Once the injured person is stabilized, attention is turned to the care of the burn wound itself Until then, it is advisable to cover the burn wound with a clean and dry sheet or dressing Early cooling reduces burn depth and pain, but care must be taken as uncontrolled cooling can result in hypothermia
Slide 65 - IV fluids Children with >10% TBSA burns, and adults with >15% TBSA burns need formal fluid resuscitation and monitoring (blood pressure, pulse rate, temperature and urine output) Once the burning process has been stopped, the injured person should be volume resuscitated according to the Parkland formula This formula calculates the amount of Ringer's lactate required to be administered over the first 24 hours post-burn.
Slide 66 - Parkaland formula
Slide 67 - Composition of Ringer’s lactate Hartman’s solution (Very similar, but ionic concentrations are different) Na+ = 131 K+ = 5 Ca2+ = 4 Cl– = 111 Lactate = 29
Slide 68 - IV fluids Parkland formula = 4ml x (percentage of total body-surface-area sustaining non-superficial burns) x (person's weight in kg) Half of this total volume should be administered over the first 8 hours, with the remainder given over the following 16 hours This time frame is calculated from the time at which the burn is sustained, and not the time at which fluid resuscitation is begun
Slide 69 - IV fluids Children also require the addition of maintenance fluid volume The formula is a guide only and infusions must be tailored to the urine output and central venous pressure Inadequate fluid resuscitation may cause renal failure and death, but over-resuscitation also causes morbidity Crystalloid fluids appear just as good as colloid fluids and as colloids are more expensive they are not recommended
Slide 70 - Other aspects of the management Wound care : Biosynthetic dressings may speed healing Antibiotics Analgesics Surgery : Skin grafts (As early as possible for better results) Alternative therapy : Bee honey
Slide 71 - Biosynthetic dressing
Slide 72 - Complications – Infections Risk factors for infections Burn > 30% TBSA Full-thickness burn Extremes in age (very young, very old) Preexisting disease e.g. diabetes Virulence and antibiotic resistance of colonizing organism Failed skin graft Improper initial burn wound care Prolonged open burn wound
Slide 73 - Complications Burn wounds are prone to tetanus (A tetanus booster shot is required if individual has not been immunized within the last 5 years) Circumferential burns of extremities may compromise circulation. Elevation of limb may help to prevent dependent edema Acute Tubular Necrosis of the kidneys can be caused by myoglobin and hemoglobin released from damaged muscles and red blood cells
Slide 74 - Prognosis The modified Baux score determines the futility point for major burn injury The Baux score is determined by adding the size of the burn (% TBSA) to the age of the patient In most burn units a score of 140 or greater is a non-survivable injury, and comfort care should be offered In children all burn injuries less than 100% TBSA should be considered a survivable injury. A major concern of a survivor of any traumatic injury is post-traumatic stress disorder (PTSD) Another significant concern for children is coping with a disturbance in body image
Slide 75 - Thank you!