MANAGEMENT OF BURNS
MEDICAL & SURGICAL
PHT 331 – 1435 -1436H – 1st SEMESTER
Lecture Outline
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This lecture deals about the medical & surgical
aspects of the burn.
PHT 331 – 1435 -1436H – 1st SEMESTER
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Lecture Objective
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At the end of this lecture, the student will able to;
Explain the management of first aid, Emergency
care, Modern burn care, Burn wound healing,
Medical & surgical management.
PHT 331 – 1435 -1436H – 1st SEMESTER
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FIRST AID
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A friend, relative or stranger may rescue the victim
of a serious burn accident.
The decisions made and the treatment given at the
scene of the accident – especially the quality of the
first aid - has often had a profound effect on
mortality and morbidity (British Burns Association
2001, p. 17).
Flame burns must be smothered.
Cold water applied continuously over the burnt
area relieves pain and limits the depth of the burn
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CHEMICAL BURNS
contaminated clothing must be removed and copious quantities of
running water applied to the area. Neutralizing agents need to be
identified and applied accordingly.
SCALDS
cold water can limit the extent of the damage and reduce the pain.
ELECTRICAL BURNS,
the patient may require CPR before attention can be paid to the
injury. Unlike heat burns, these injuries do not spread and it is
sufficient to cover the area with a clean cloth that has been soaked
in clean cold water
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MINOR BURNS
These are defined as less than 10% surface area in a child
or less than 15% in an adult. If the injury is noncomplex
these injuries are cleaned with chlorhexidine and covered
with a bactericidal non-stick dressing.
The patient can rest at home and, depending on local
circumstances,the dressings are changed every 2-3 days.
MAJOR BURNS
These are injuries that involve 10% or more of the body
surface area in children and 15% or more in an adult.
If the injury is complex the patient will be admitted to the
burns unit or intensive care unit
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First aid and Emergency treatment of burned
patients
The main aims of this stage are :
 removal
of victim from fire or agent
 check airway
 evaluation of associated injuries
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Initiation of resuscitation
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 Remove
the victim from the fire
 Wrapping
patient in a clean sheet or blanket
 Rolling the in on the ground or immersion into lake or river
are not recommended because of possibility of massive
contamination.
 Remove the victim from contact with electricity either by
disconnecting the source or by using a non conductor to move
the victim from the point of contact.
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Irrigating the affecting area with water( cold water
for a period 15-20 min). in case of chemical burn
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N.B. The use of cold water to
 Decrease
pain
 Decrease inflammatory response
 Decrease exudation
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Check the airway
Insertion of oropharangeal airway, if the patient is 
unconscious and the tongue appears to be obstructing
airway.
 Insertion of an endotracheal airway in upper airway
obstruction cases.
 Evaluation of associated injuries:
 Rapid check of patient's thorax, upper and lower limbs
and abdomen.
 Observe fractures and dislocations.
 Lock for head injuries.
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Initiation of resuscitation and transportation
Resuscitation
<20%
oral fluid
20-50 %
I.V. lines in un
burned area
50-60 % or more
two I.V. lines in
burned and non burned
Transportation
The patient should be transported to the nearest
medical facility
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Management in emergency room and triage
Check airway and vital signs
Re-evaluate the presence or absence of associated
injuries.
Evaluate total burn size
Triage.
Triage:
Decision making with regard to admission or
discharge
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Indications of some cases that need admission to
hospital
Burn larger than 15% of total body surface in adult
or 10 % in children
All burns which have a third degree.
Burns of face, hands and perineum.
All electrical and chemical burn.
PHT 331 – 1435 -1436H – 1st SEMESTER
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Modern burn care
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Modern burn care may be divided into the following 4
general phases:
The first phase, initial evaluation and resuscitation,
occurs on days 1-3 and requires an accurate fluid
resuscitation and thorough evaluation for other injuries
and comorbid conditions.
The second phase, initial wound excision and biologic
closure, includes the maneuver that changes the natural
history of the disease. This is accomplished typically by
a series of staged operations that are completed
during the first few days after injury.
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The third phase, definitive wound closure, involves
replacement of temporary wound covers with a
definitive cover; there is also closure and acute
reconstruction of areas with small surface area but
high complexity, such as the face and hands.
The final stage of care is rehabilitation,
reconstruction, and reintegration. Although this
begins during the resuscitation period, it becomes
time-consuming and involved toward the end of the
acute hospital stay.
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BURN WOUND HEALING
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EPIDERMAL HEALING:
Occur on the surface of the wound
The intact epithelium attempts to cover an exposed
wound through ameboid movement of cell from basal
layer of surrounding epidermis into wound.
The epithelial cells stops migration when they are
completely in contact with other epithelial cells.
After this contact inhibition - cells can begin to divide
and multiply through mitosis.
Dryness is common
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DERMAL HEALING
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Scar formation occurs
Divided in to 3
phases:Inflammatory,Proliferative,Maturation
INFLAMMATORYPHASE:
begins at time of injury ends in 3-5days.Characterized
by inflammatory reactions
redness,warmth,edema,pain,decreased ROM.
Initially there is decreased blood flow,platelets
aggregate and Fibrin is deposited.
Later Vasodilation occcurs, leukocytes infilterate
,presences of macrophages,attracts Fibroblast.
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PROLIFERATIVE PHASE:
Re-epithelialization occurs at the surface
In deep wound Fibroblast migrates ,which synthesis
Scar tissue.
During this period of Fibroplasia, the tensile
strength of the wound increases at a rate proptional
to the rate of collagen synthesis.
Wound contraction occurs
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MATURATION PHASE
Reduction in the number of Fibroblast
Remodeling of collagen
Collagen becomes more parallel in arrangements and
forms stronger bonds
If rate of collagen production exceeds breakdown then
hypertrophic scar may result.
Keloid is large firm scar that overflows the boundaries
of original wound. It may lead to Functional and
cosmetic deformities
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PHASES OF WOUND HEALING
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HEALING OF WOUND
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MEDICAL MANAGEMENT
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EARLY HOSPITAL MANAGEMENT (INCLUDING THE SHOCK
PHASE).
Maintenance of a clear airway
pain relief
Assessment of TBSA
Maintenance of fluid balance
Removal of adherent clothing
covering of the Burns with sterile cotton dressings
Reassurance and explanation to the patient
Transfer to a burns unit or admission to an intensive care unit.
(Whether the person is sent to the operating theatre for shaving of
burns and grafting depends on the depth of the burns, the age of
the patient and whether the patient is fit for surgery.)
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Resuscitation
Fluid replacement is administered over a 36-hour
period (from the occurrence of the burn, not the time of
arrival at hospital).
The volume of plasma required by the burns patient is
related to the TBSA and the size of the patient (Evans
et al. 1952; cited by Settle 1986, p. 14).
To calculate the volume of fluid required for
resuscitation, the following formula is used (Muir and
Barclay 1962):
mL of plasma = TBSA x age of patient.
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Management of wound areas varies according to the
experience of the staff and facilities available.
The two main themes are 'open' or 'closed'.
OPEN METHOD
This method leaves the wound exposed. If exudate is
cleaned away regularly, the area dries out. Bacterial
growth is inhibited and this method is used for areas
that are difficult to dress, such as the face. Healing of
the epithelium tends to be slower than with the closed
method.
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CLOSED METHOD
The primary layer of dressing is non-adherent, for example
petroleum jelly gauze. This is then covered with layers of absorbent
cotton gauze ,held in place by crepe bandages or net. With
bandages securing the dressings the patient may be able to begin
to mobilise about the ward with the aid of the physiotherapist. Silver
sulfadiazine is commonly used.
When a hand is affected, a polythene bag containing chlorhexadine
may be placed over the hand and bandaged to the forearm. The
patient is able to regularly exercise the hand freely through full
range of motion.The bag is changed daily or more frequently if
indicated by large amounts of exudate collecting in the bag.The
bag is changed to dry dressings at the nurse's discretion.
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CLOSED METHOD
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SURGICAL MANAGEMENT
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ESCHARECTOMY
It is surgical removal of the dead, burnt skin by a
method of excision or shaving.
SKIN GRAFTING
involves covering the open tissues with a layer of split
skin.
Z- PLASTY
Surgical correction of Scar contracture. It serves to
lengthen a scar by interposing normal tissue in the line
of the scar.
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ESCHARECTOMY
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Z-PLASTY
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SKIN GRAFTING
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Grafting is the closure of a burn wounds with skin tissue. The
closure may be temporary or permanent depending on the
tissue chosen.
involves covering the open tissues with a layer of split skin.
Skin graft: It is nonvascular skin transfers may be divided
into two groups.
A) Split-thickness skin graft.
B) Full-thickness skin graft
Grafts are kept in position with petroleum jelly gauze and
bandages, and splints can be applied to immobilise the
joints adjacent to the grafts
Skin is usually removed with a dermatome
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Indications for Skin Grafts:
1) To achieve temporary cover
A) Close an open wound
B) Prevent infection
C) Hasten initial healing
D) Prevent exposure of underlying structures
2) For definitive cover:
A) Provide permanent skin replacement which is supple
sensate and durable.
B) to resurface areas of scarring or contracture.
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Types of skin graft
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1. Auto graft: It is skin transferred from one - area of the body to
another. This should provide permanent cover.
2. Allograft (homograft):
It is skin from another human (possibly a cadaver) is used. This
provides
only temporary cover until an autograft is available.
3. Xenograft (heterograft): This uses animal (e.g.) pig skin or
porcine and is also only a temporary cover (donor- site).
N.B.
- The most common way to close a deep burn wound after removal
of eschar is with the use of non vascular skin transfers
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A) A split - thickness skin graft (STSG):
Include the epidermis and any portion of the dermis.
- The Donor sites of the split thickness skin graft are
generally obtained from the thigh, buttock, or abdomen.
B) Full thickness skin graft (FTSG):
Includes the epidermis and entire dermis.
All subcutaneous fat is removed from the dermis to improve
the survival of the graft.
- The Common donor site includes the groin and the medial
aspect of the arm because the residual scar is hidden.
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SPLIT THICKNESS GRAFT
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FULL THICKNESS GRAFT
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SHEET GRAFT{ Skin is applied without alteration
following harvesting from donor site usually in
face,neck,hand}
MESH GRAFT – When limited skin is available ,meshing
of a graft consist of processing sheet graft that makes
tiny parallel incision in a linear arrangement.This
process permits Skin graft to be expanded before
applying. Allow coverage of large area.Skin graft is
held by sutures,staples, steri-strips.
Pressure dressing facilitates
DONOR SITE site where skin is
taken{Thigh,Buttocks,back
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MESH GRAFT
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SHEET GRAFT
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Advantages of non vascular graft:
1 - Include a large supply of donor areas.
2- Ease of harvesting.
3-Reusable donor sites.
4- Decreased primary (early) contracture.
5- And the ability to cover large surface areas
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Disadvantages of non vascular graft:
1- Bad cosmetic appearance .
2-Decrease durability.
3- Hyper pigmentation.
4- Increase secondary (or late) contracture.
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(1) The split thickness graft undergoes secondary (Late) contracture
when it contracts as it heals, pulling the wound margins inward.
(2) Both Types of grafts can be held in place with sutures, staples, or
tape.
(3) Meshing the graft is helpful in improving survival where
moderate serous drainage is expected.
(4) Where grafts may be exposed to shear forces, "tie - voer"
dressing are useful.
(5) Donor Site: Skin harvesting from the scalp in children can be
recommended as first choice. The Advantages, especially the rapid
epithelialisation and the lack of visible scars, over come the
problems and the risks .
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PHT 331 – 1435 -1436H – 1st SEMESTER
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Healing of skin Grafts:
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The healing skin grafts can be divided into three
phases.
1. The first phase: the phase of serum imbibition
begins immediately ,after placing the graft on the
wound bed. Because there are no vascular connections,
nutrients fluid supplied by diffusion of serum from the
bed. The graft is held in place only by weak fibrin and
fibronection bonds.
2. Second phase: at 24-48 hours new capillaries start
invading the skin graft making the phase of
revascularization.
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3. Third phase: the phase of organization starts
at 4-5 days when collagen linkages are made
between the wound bed and the graft to create
firm attachments.
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Factors Affecting Wound Healing:
1. Age: affects wound repair. The rate of healing
appears to slow with increasing age.
2. Infection: infection lead to healing failures.
3. Nutritional factors; nutrition is of extreme
important factor for wound healing.
4. Vitamins: vitamins are important for normal
tissue repair as vitamin C, A, E, B, (Thiamine) and B2
(pantothenic acid).
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Trace elements are metals: that are needed for enzyme function.
As iron zinc, copper, manganese calcium, and magnesium.
Shortages in trace elements may contribute to impair healing.
6. Oxygen:
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Adequate blood supply is essential for healing. Oxygen is required to
supply the energy for high metabolic needs healing wound.
Poor vascularity essentially translates into hypoxia.
7. Diseases causing impaired wound healing:
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Diabetes altered healing.
Chronic renal failure and liver failure lead to impaired healing
Malignancy lead to healing abnormalities
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8. Other causes of impaired healing:
 Steroids
drugs altered healing.
 Chemotherapy agents lead to impair healing.
 Radiations
 Drug that alter immune system
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Complications of skin grafts:
 Wound
problems due to grafting on an inadequately
prepared
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or unsuitable bed.
A
vascularity.
 Infection.
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Graft problems:
Early:
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Inadequate fixation (shearing)
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Haematoma
Failure of take/graft lysis due to infection
Late:
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Failure of take due to inadequate contact between graft bed.
Avoidable scarring/contracture
Excessively expanded mesh graft
Graft insensate
Graft too thin for permanent cover
Donor Site Problems:
Failure to heal Infection
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SURVIVAL OF SKIN GRAFT
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CIRCULATION: Provides a nutritive supply to graft
INOSCULATION: Process by which direct connection is
established between a graft and host vessels( within72
hours)
PENETRATION of the host vessel into graft site
Initially , structural connections are Fibrous, Collagen is
then laid down to secure the attachment of the graft.
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