BURNS BAILEY & LOVE 28 TH EDITION Copyright © 2023 Sushruta - LGS - All Rights Reserved. INTRODUCTION Copyright © 2023 Sushruta - LGS - All Rights Reserved. • Mechanism of burn injury varies according to age. • Children: • Majority of burns in children are scalds • Caused by • Accidents with kettles • Pans, hot drinks, and bath water. • Screening for NAI • Important in this age group Copyright © 2023 Sushruta - LGS - All Rights Reserved. • Adolescents: • Burns are usually caused by experimentation with • Matches and flammable liquids. • Adults: • Flame burns are more frequent. • Scald burns and contact burns • Fall against a radiator • Inability to extract • Often a burn injury in the elderly is the trigger point at which increasing frailty and inability to self-care are recognized. Copyright © 2023 Sushruta - LGS - All Rights Reserved. • Adults: • Burn injury in the elderly • Trigger point at which increasing frailty and inability to self-care are recognized. • Screening for non-accidental injuries should be done in this vulnerable age group. Copyright © 2023 Sushruta - LGS - All Rights Reserved. • Electrical and chemical injuries: • Occur in adults and are frequently associated with occupation. • Cold and radiation injuries: • Rarer thermal injuries. • Associated conditions in adults: • Mental disease (attempted suicide or assault) • Epilepsy, and alcohol or drug abuse • Underlying factors in as many as 80% of patients with burns admitted to the hospital in some populations. Copyright © 2023 Sushruta - LGS - All Rights Reserved. PATHOPHYSIOLOGY OF BURN INJURY TO THE SKIN Copyright © 2023 Sushruta - LGS - All Rights Reserved. Copyright © 2023 Sushruta - LGS - All Rights Reserved. INJURY TO THE AIRWAY AND LUNG Copyright © 2023 Sushruta - LGS - All Rights Reserved. • I. Burns pose risks beyond immediate tissue damage • Can also damage the airway and lungs • This may lead to life-threatening consequences • II. Inhalation injury from hot, smoke-filled air has three components: • Upper airway injury • Lower airway injury (true smoke inhalation) • Metabolic poisoning Copyright © 2023 Sushruta - LGS - All Rights Reserved. • III. Causes of Airway Injuries • Occur when the face and neck are burned • The significance of being trapped in an enclosed space (burning room or car) is critical Copyright © 2023 Sushruta - LGS - All Rights Reserved. Copyright © 2023 Sushruta - LGS - All Rights Reserved. Copyright © 2023 Sushruta - LGS - All Rights Reserved. • I. Metabolic Poisoning • A. Incomplete combustion may produce harmful substances • 1. Carbon monoxide, produced by carbonaceous materials • 2. Hydrogen cyanide, released from burning nitrogen-containing polymers Copyright © 2023 Sushruta - LGS - All Rights Reserved. • B. Carbon Monoxide Poisoning • 1. It's the most common immediate cause of death from fire • 2. Characteristics • - Odourless, colourless gas • - Binds with erythrocyte haemoglobin approximately 250 times more avidly than oxygen Copyright © 2023 Sushruta - LGS - All Rights Reserved. • B. Carbon Monoxide Poisoning • 3. Effects • - Carboxyhaemoglobin is inactive in oxygen transport • - Impairs oxygen delivery at the tissue level • - Competes with and inhibits oxygen binding to cytochrome oxidase • - Disrupts aerobic metabolism and decreases the capacity for cellular respiration • 4. Treatment • - Early recognition and therapy with high-flow, high-concentration oxygen Copyright © 2023 Sushruta - LGS - All Rights Reserved. • C. Cyanide Poisoning • 1. Cyanide combines with trivalent iron in the mitochondrial cytochrome A3 complex • 2. Inhibits electron transport and cellular respiration Copyright © 2023 Sushruta - LGS - All Rights Reserved. • II. Mechanical Block on Rib Movement • A. Effects of Full-thickness Burns • 1. Skin loses its elasticity, becomes stiff and leathery in appearance • 2. Combined with subcutaneous oedema, it can physically stop rib expansion • 3. When the burn extends across the chest, it compromises respiratory function Copyright © 2023 Sushruta - LGS - All Rights Reserved. INFLAMMATION AND CIRCULATORY CHANGES Copyright © 2023 Sushruta - LGS - All Rights Reserved. • A. Overview of Circulatory Changes • 1. The changes are complex and multifactorial • 2. Originate from both the actual injury of burned skin (eschar) and the inflammatory cascade • 3. These changes are governed by a complex series of events Copyright © 2023 Sushruta - LGS - All Rights Reserved. • B. Initiating Factors • 1. Release of neuropeptides and the activation of complement • initiated by the • stimulation of pain fibres • alteration of proteins by heat • 2. The activation of Hageman factor initiates a number of protease-driven cascades Copyright © 2023 Sushruta - LGS - All Rights Reserved. • C. Alterations in Biochemical Pathways • 1. Arachidonic acid pathway • 2. Thrombin pathway • 3. Kallikrein pathway • D. Physical Manifestations • 1. Fluid is lost from capillaries • 2. Oedema formation occurs Copyright © 2023 Sushruta - LGS - All Rights Reserved. Copyright © 2023 Sushruta - LGS - All Rights Reserved. OTHER LIFE-THREATENING EVENTS WITH MAJOR BURNS Copyright © 2023 Sushruta - LGS - All Rights Reserved. • IV. The Immune System and Infection • A. Impact of Inflammatory Changes • 1. The inflammatory changes caused by the burn affect the patient's immune system • 2. Cell-mediated immunity is significantly reduced in large burns Copyright © 2023 Sushruta - LGS - All Rights Reserved. • B. Increased Susceptibility to Infections • 1. Patients become more susceptible to bacterial and fungal infections • 2. Infection sources include: • - Burn wounds • - Lung injuries • - Central venous lines • - Tracheostomies • - Urinary catheters Copyright © 2023 Sushruta - LGS - All Rights Reserved. • V. Changes to the Intestine • A. Inflammatory Stimulus and Shock Impact • 1. Can cause microvascular damage and ischaemia to the gut mucosa • 2. Reduces gut motility and can prevent the absorption of food Copyright © 2023 Sushruta - LGS - All Rights Reserved. • V. Changes to the Intestine • B. Consequences • 1. Failure of enteral feeding in a patient with a large burn is a life-threatening complication • 2. The process increases the translocation of gut bacteria, a potential infection source Copyright © 2023 Sushruta - LGS - All Rights Reserved. • V. Changes to the Intestine • C. Additional Effects • 1. Gut mucosal swelling, gastric stasis and peritoneal oedema • Abdominal compartment syndrome • Splints the diaphragm and increases the airway pressures needed for respiration Copyright © 2023 Sushruta - LGS - All Rights Reserved. • VI. Danger to Peripheral Circulation • A. Full-Thickness Burns and Collagen Fibers • 1. In full-thickness burns, the collagen fibers are coagulated • 2. The normal elasticity of the skin is lost • B. Circumferential Full-Thickness Burns • 1. A circumferential full-thickness burn to a limb acts as a tourniquet as the limb swells • 2. If untreated, this can progress to limb-threatening ischaemia Copyright © 2023 Sushruta - LGS - All Rights Reserved. IMMEDIATE CARE OF THE BURN PATIENT Copyright © 2023 Sushruta - LGS - All Rights Reserved. • VII. Prehospital Care • A. Importance • 1. Good prehospital care is essential in ensuring rapid assessment and transfer Copyright © 2023 Sushruta - LGS - All Rights Reserved. • B. Key Principles • 1. Ensure rescuer safety • - Particularly important in electrical and chemical injuries, and building fires • 2. Stop the burning process • - "Stop, drop and roll" is a good method of extinguishing fire on a person Copyright © 2023 Sushruta - LGS - All Rights Reserved. • B. Key Principles • 3. Check for other injuries • - ABC (airway, breathing, circulation) check followed by a rapid secondary survey • - Patients burned in explosions or escaping from fires • Coexisting fractures or blast pattern injuries Copyright © 2023 Sushruta - LGS - All Rights Reserved. • B. Key Principles • 4. Cool the burn wound • - Provides analgesia and slows delayed microvascular damage • - Cooling should occur for a minimum of 20 minutes, effective up to 1 hour after the injury • - Important first aid step in partial-thickness burns, especially scalds • - In temperate climates, cooling should be at about 15°C, avoiding hypothermia Copyright © 2023 Sushruta - LGS - All Rights Reserved. • B. Key Principles • 5. Give oxygen • -Fire in an enclosed space should receive oxygen, especially with altered consciousness level • 6. Elevate • - Sitting a patient up or elevating burned limbs can be life-saving and reduce discomfort • 7. Analgesia • - Administration of analgesia prior to or during transfer will alleviate pain Copyright © 2023 Sushruta - LGS - All Rights Reserved. • VIII. Hospital Care • A. Principles • 1. Managing an acute burn injury follows the advanced trauma life support (ATLS) principles: • - A, Airway control • - B, Breathing and ventilation • - C, Circulation • - D, Disability – neurological status • - E, Exposure with environmental control • - F, Fluid resuscitation Copyright © 2023 Sushruta - LGS - All Rights Reserved. • B. Severity Determinants • 1. Percentage of total body surface area (TBSA) that is burned • 2. Presence of an inhalation injury • 3. Depth of the burn • 4. Age/comorbidities of the patient • C. Admission to a Burns Unit • 1. Not all burned patients need to be admitted to a burns unit Copyright © 2023 Sushruta - LGS - All Rights Reserved. Copyright © 2023 Sushruta - LGS - All Rights Reserved. AIRWAY Copyright © 2023 Sushruta - LGS - All Rights Reserved. • A. Challenges • 1. The burned airway can create problems for the patient by swelling • 2. If not managed proactively, it can completely occlude the upper airway • B. Treatment • 1. Secure the airway with an endotracheal tube • Until the swelling has subsided (usually after about 48 hours) Copyright © 2023 Sushruta - LGS - All Rights Reserved. • C. Laryngeal Oedema Indications • 1. Changes in voice • 2. Stridor • 3. Anxiety • 4. Respiratory difficulty • - Note: • Very late symptoms. • Intubation at this point is often difficult or impossible due to swelling Copyright © 2023 Sushruta - LGS - All Rights Reserved. • D. Management Procedure • 1. Acute cricothyroidotomy equipment must be at hand • 2. Early intubation of suspected airway burn is the treatment of choice • 3. Time frame from burn to airway occlusion is usually between 4 and 24 hours Copyright © 2023 Sushruta - LGS - All Rights Reserved. • E. Smoke Inhalation Treatment • 1. Though antidotes exist for specific components of smoke (carbon monoxide and cyanide) • 2. Treatment usually involves • Endotracheal intubation and ventilatory support (sometimes for several weeks) Copyright © 2023 Sushruta - LGS - All Rights Reserved. BREATHING Copyright © 2023 Sushruta - LGS - All Rights Reserved. • A. Inhalational Injury • 1. Factors to Consider • - Time : Trapped in a fire - >> • Few minutes must be observed for signs of smoke inhalation • - Signs include • Presence of soot in the nose and the oropharynx • Chest radiograph showing patchy consolidation Copyright © 2023 Sushruta - LGS - All Rights Reserved. • A. Inhalational Injury • 2. Clinical Features • - Progressive increase in respiratory effort and rate • - Rising pulse • - Anxiety and confusion • - Decreasing oxygen saturation • - Can take 24 hours to 5 days to develop Copyright © 2023 Sushruta - LGS - All Rights Reserved. • A. Inhalational Injury • 2. Clinical Features • - Progressive increase in respiratory effort and rate • - Rising pulse • - Anxiety and confusion • - Decreasing oxygen saturation • - Can take 24 hours to 5 days to develop Copyright © 2023 Sushruta - LGS - All Rights Reserved. • 3. Treatment • a. Initiate treatment once injury is suspected and the airway is secure • b. Techniques to consider: • Physiotherapy • Nebulisers • Warm humidified oxygen Copyright © 2023 Sushruta - LGS - All Rights Reserved. • 3. Treatment • c. Monitor progress using respiratory rate and blood gas measurements • d. Severe cases: • May require positive pressure (continuous or intermittent) • Intubation, and ICU management • e. Medication options: • Nebulised heparin • N-acetylcysteine • Bronchodilators (e.g., albuterol) Copyright © 2023 Sushruta - LGS - All Rights Reserved.
