BURN INJURIES
Margaret Tandoh,MD
Assistant Professor of Surgery
University of Vermont
OBJECTIVES
•
•
•
•
TYPES OF BURNS
HOW DEEP IS IT
HOW MUCH IS BURNED
HOW DO YOU CARE FOR THE BURN
SCOPE OF THE PROBLEM
• Burn injuries receiving medical treatment:
~450,000
• Hospitalizations: 45,000 (10%)-- ~25,000 at
burn centers
• Fire/Burn deaths/year: 3,500– 3,000
residential, 500 other(MVC, aircraft, etc)
• 75% of deaths at scene or initial transport
SCOPE OF THE PROBLEM
• GENDER: 70% males, 30% females
• ETHNICITY: 60% Caucasian, 19% African-American, 15%
Hispanic, 6% Other
CAUSES:
–
–
–
–
–
–
Flame 44%
Scald 33%
Contact 9%
Electrical 4%
Chemical 3%
Other 7%
SCOPE OF THE PROBLEM
• In severe burns:
– 37% flame
– 24% scalds
– Structural fires: 50% of death due to CO, not burns
ANATOMY
• Largest organ
• Protective barrier
• Regulates temperature
ANATOMY
TYPES/CLASSES OF BURNS
– THERMAL
•
•
•
•
FLAME
SCALD
FLASH
CONTACT
TYPES/CLASSES OF BURNS
– NON-THERMAL
•
•
•
•
CHEMICAL
ELECTRICAL
RADIATION
COLD
PAHOPHYSIOLOGY OF THE BURN
WOUND
• Burn injury-coagulation necrosisincreased capillary permeability-fluid
moves from intravascular space toward burn
• Ebb phase
– Initial decrease in CO, metabolic rate
• Flow phase(after resuscitation)
– Increase CO, resting energy expenditure
PATHOPHYSIOLOGY cont’d
• 3 zones of tissue injury:
– Coagulation: dead or dying cells, most intimate
contact with heat source
– Stasis: vasoconstriction and ischemia, may convert
to coagulation
– Hyperemia: vasodilation, viable cells
SCALDS
• Most common cause of burns
• Water at 140F causes full-thickness burns in
3secs, at 156F in 1sec.
• Cup of coffee, 180F
• Grease clings to skin
• Thicker soups and sauces remain in contact
longer
FLAME
•
•
•
•
•
Most common in severe burns
67% in Caucasian population
66% involve a flammable liquid
63%, gasoline is liquid of choice
26% association with EtOH
CONTACT
•
•
•
•
Can be 4th degree
Unconscious patients resting on hot surface
Toddlers falling on to wood stoves
Industrial accidents: contact and crush
ELECTRICAL INJURIES
~ 20, 000 ED visits/yr
~ 500-1000 deaths/yr
> 50% of deaths occur at workplace
• 2-3% of burns in children
ELECTRICAL BURNS
• 3-5% of all admitted burns
• Visible burned areas represent only a small portion of
destroyed tissue
• Electrical currentheat tissue with lowest
resistance(nerves, vessels muscles)
• Low-voltage: similar to thermal burns, only local damage, 110220 V
• High-voltage:1000 V or more, CPR, full trauma evaluation, EKG
monitoring
• Multiple complications: cataracts(up to 30%), neurologic
CHEMICAL BURNS
•
•
•
•
•
•
Most are from household cleaners
Industrial exposures
Injury caused by protein destruction
Speed is essential in management
Copious lavage with water
Alkalis: lime, KOH, bleach, cement(calcium oxide),
NaOHusually deep
• Acids:protein breakdown by hydrolysishard escharnot as
deep as alkalis
ASSESSMENT OF THE BURN WOUND
• Outcome dependent on depth and extent of
injury
• Extent of injury
– Rule of nines
– Lund Browder chart
– Palm size(of patient) including digits
DEPTH OF BURN
• 1st degree
– Epidermis only, painful, dry, heals in ~ 7days, no
scars
• 2nd degree
– Superficial: various portions of superficial dermis,
painful, moist(dermal vessels present), blisters,
minimal scarring, heals in ~ 14 days
DEPTH OF BURN
• 2nd degree
– Deep: usually insensate, no blisters, treat like 3rd
degree
• 3rd degree
– Full-thickness necrosis, painless, dry, can be any
color, will scar, needs excision
• 4th degree
– Underlying structures(muscle, bone) involved
FOURTH DEGREE
• Extends into muscle, bone, etc
SIZE OF THE BURN WOUND
INITIAL MANAGEMENT
•
•
•
•
•
Airway
Breathing
Circulation
Disability
Exposure/environment
INITIAL MANAGEMENT
•
•
•
•
•
•
Cover with clean dry sheet
Irrigate copiously chemical burns)
No antibiotics
No ice
Leave blisters
Tetanus prophylaxis
INITIAL TREATMENT
• Stop burning process
• Primary and secondary survey
• Resuscitation: Parkland(4ml/kg/% TBSA) and
Brooke(1.5ml/kg/%TBSA + 0.5/kg/%TBSA)
• Escharotomies: edema impedes venous outflow and
then arterial inflow. Look for numbness and tingling
in limbs, increased pain in digits
• Tetanus
WOUND CARE
• Early excision and grafting deep 2nd and 3rd
degree wounds
• Full-thickness skin grafts:decreased contracture,
but limited and can only be used once. Not
commonly used in burn wounds.
• Split-thickness skin grafts: commonly used
FROSTBITE
• 1805: first modern report published
• 1814: Dominique Larrey(Surgeon General of
Napoleon’s forces) described frostbite in the
forces during the campaign in1812-1813
• His treatment held for over 150 years!
• Friction massage with snow or ice, rather than
thawing rapidly
PATHOPHYSIOLOGY
• Direct cellular damage and death
– Caused by extracellular ice crystals
– Rapid coolingintracellular ice crystals, more
severe cell damage
Progressive tissue ischemia
Wet/moist skin more susceptible
Alcohol use very common
CLASSIFICATION
• Based on acute physical findings and imaging after
rewarming:
• Frostnip: no ice crystals, no tissue loss, not frostbite,
but may precede it
• 1st degree: numbness, erythema, mild edema
• 2nd degree: clear or milky blister, erythema, edema
• 3rd degree: hemorrhagic blisters
• 4th degree: extends into muscle or bone
SIGNS AND SYMPTOMS
• 90% is acral
• Ears, nose, cheek, penis also involved
• Numbness prior to rewarming, then severe
pain, usually throbbing
• Tingling can occur
• Initial appearance can be deceptive
TREATMENT
• Rapid rewarming
• Temperature should be 40-42C for 15 – 30
mins or until complete
• Tetanus
• Drain clear blisters, leave bloody blisters
• NSAIDS
REMINDERS/PRACTICALS
•
•
•
•
•
•
Smoke alarms save lives
Set water temperature to 125F
Avoid ice to burns
Dry socks in the winter
Take oxygen off when smoking
Smother oil fire, no water
REFERENCES
• Some pictures from Google Images
• Total Burn Care, 3rd edition
• McIntosh, S et al. Wilderness Medical Society
Practice Guidelines for the Prevention and
Treatment of Frostbite, Wilderness &
Environmental Medicine. 22, 156-166(2011)
• ABA Fact Sheet 2011