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Acute Burn Acute Burn

Diagnosis and Management of Acute Burn Injuries

Although burn injuries are frequent in our society, many surgeons feel uncomfortable in managing patients with major thermal trauma.burn
Only motor vehicle accidents cause more accidental deaths than burns. Mortalities are highest among the very young and very old. Two-thirds of all burn accidents occur at home and most commonly involve young adult males and children. Young adults are most commonly burned by flammable liquids, while toddlers are most often scalded by hot liquids while in the kitchen. Inhalation injury, that caused by inhaling of smokes in closed places, has the biggest impact on both early and late mortality.

What is BURN injury?

The skin is the largest organ is the body, comprising 15% of body weight and covering approximately 1.7 m² in the average adult. The function of the skin is complex: it warms, it senses, and it protects. Of its 2 layers, only the epidermis is capable of true regeneration. When the skin is seriously damaged, this external barrier is violated and the internal milieu is exposed and altered.

Burn Injury
A burn injury implies damage or destruction of skin and/or its contents by thermal, chemical, electrical or radiation energies or combinations thereof. Thermal injuries are by far the most common and frequently present with concomitant inhalation injuries.

A thermal injury involves the heating of tissues above the critical level at which damage occurs via protein denaturation.
Tissue injury is a function of the heat content of the burning agent, length of exposure and thermal conductivity of the involved tissue. The hydrophilic human skin possesses a high specific heat and a low thermal conductivity. Therefore, skin becomes overheated quite slowly, but also cools slowly. As a result, thermal damage continues after the burning agent is extinguished or removed.


How to Estimate the Severity of Burn injury?
role of 9
Severity is determined by:
- Depth of burn or degree of burn
- Extend of burn calculated in percent of total body surface (TBSA)
- Site of burn.
- Patient factors as age, previous diseases..etc.

The effects of the burn are influenced by the:
- intensity of the effectors.
- duration of exposure.
- type of tissue injured.

Major cause of fires in the home:
- Carelessness with cigarettes!!
- Hot water from water heaters set at high levels above 60° C
- Cooking accidents
- Space heaters
- Gasoline, lighter fluids, etc.
- Chemicals

What are the Types of Burn Injury?

- Thermal burns: flame, flash, contact with hot objects.
- Scald burns: hot fluids.
- Chemical burns: necrotizing substances (acids, alkali).
- Electrical burns: intense heat from an electrical current.
- Smoke & inhalation injury: inhaling hot air or noxious chemicals.
- Cold thermal injury: frostbite.

How to Determine degree and extend of the burn?

DEGREE

DEPTH

HISTORY

ETIOLOGY

SENSATION

APPEARANCE

HEALING

1st degree

superficial

momentary exposure

sunburn

sharp, uniform pain

blanches red, pink, edematous, soft, flaking, peeling

+ 7 days

2nd degree

partial thickness

exposure of limited duration to lower temperature (40-55°C)

scalds, flash burn without contact, weak chemical

dull or hyperactive pain, sensitive to air/temp changes

mottled red, blanches red/pink, BLISTERS, edema, serous exudate, moist

14-21 days

3rd degree

full thickness

long duration of exposure to high temperature

immersion, flame, electrical, chemical

painless to touch and pinprick, may hurt at deep pressure

no blanching, pale white, tan charred, hard, dry, leathery, hair absent

granulates, requires grafting

4th degree

underlying structures

prolonged duration of exposure to extreme heat

electrical, flame, chemical

usually painless

charred, 'skeletonized'

amputation
fasciectomy



burn degrees

 
The Extend of Burn can be calculated by rule of nine or roughly by hand area of the patient as it equal to 1%.

But more accurately it could be estimated by Lund and Browder Chart.

Lund and Browder Chart


Most Dangerous area or Vital organs of Burn are:
Face, neck >> Chest >> Perineum >> Hand >> Joint regions >> Other areas.

Criteria of Referral to Hospital or Burn center:

- 2nd or 3rd Degree Burns.
- More than 10% TBSA.
- Burns to vital organs of burn.
- Circumferential burns.
- Electrical Burns.
- Chemical Burns.
- Inhalation Injury.
- Concomitant trauma (If Major Trauma, The Trauma Center , Not the Burn Center should be the initial stabilizing unit).
- When in doubt , consult with a burn center.

First aids for Burns:

Pre-hospital Care
- Remove from area! Stop the burn!
- Washing burned areas with water many many times.

first aids of burn


- If thermal burn is large--FOCUS on the ABC’s
A=airway-check for patency, soot around nares, or signed nasal hair
B=breathing- check for adequacy of ventilation
C=circulation-check for presence and regularity of pulses
- Burn too large--don’t immerse in water due to extensive heat loss Never pack in ice. Patient should be wrapped in dry clean material to decrease contamination of wound and increase warmth.

If Simple Burn, What is after?

- Burn patients need more calories & failure to provide will lead to delayed wound healing and malnutrition.
- Drug Therapy: Analgesics and Sedatives, Tetanus immunization and Local Antimicrobial agents: Silver sulfadiazine, MEBO ointments.
- Burn wound either heals by primary intention or by grafting. Scars may form & contractures.
- Mature healing is reached in 6 months to 2 years Avoid direct sunlight for 1 year on burn
- New skin is sensitive to trauma

Are There Any Risks to burns?

Superficial burns usually heal without leaving any scars.

However deeper burns usually cause many problems that could be permanent such as:

A- Early Complications of Burn:
1. Fluid and Electrolyte Imbalance The burn wound becomes rapidly edematous due to microvascular changes induced by direct thermal injury and by release of chemical mediators of inflammation. This results in systemic intravascular losses of water, sodium, albumin and red blood cells. Unless intravascular volume is rapidly restored, shock develops.
2. Metabolic Disturbances This is evidenced by an increased resting oxygen consumption (hypermetabolism), an excessive nitrogen loss (catabolism), and a pronounced weight loss (malnutrition).
3. Bacterial Contamination of Tissues The damaged integument creates a vast area for surface infection and invasion of microorganisms. Burned patients with a major thermal injury are unable to mount an adequate immunologic defense, increasing the risks for septic shock.
4. Complications from Vital Organs All major organ systems are affected by the burn injury. Renal insufficiency can result from hypoperfusion or from nephron obstruction with myoglobulin and hemoglobin. Pulmonary dysfunction may be caused from initial respiratory tract damage of from progressive respiratory insufficiency due to pulmonary edema, adult respiratory distress syndrome or bronchopneumonia. Gastrointestinal complications include paralytic ileus and gastrointestinal ulcerations. Small bowel ischemia and stasis promote bacterial translocation as a mechanism for endogenous infection. Multi-system organ failure is a common final pathway leading to late burn mortality.

B- Late Sequels or late complications:
1- Scars
2- Contractures and Contractions.