BURNS
BAILEY & LOVE 28 TH EDITION
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INTRODUCTION
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• 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
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• 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.
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• 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.
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• 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.
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PATHOPHYSIOLOGY OF BURN INJURY
TO THE SKIN
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INJURY TO THE AIRWAY AND LUNG
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• 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
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• 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
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• 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
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• 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
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• 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
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• C. Cyanide Poisoning
• 1. Cyanide combines with trivalent iron in the mitochondrial cytochrome A3 complex
• 2. Inhibits electron transport and cellular respiration
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• 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
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INFLAMMATION AND CIRCULATORY
CHANGES
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• 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
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• 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
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• 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
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OTHER LIFE-THREATENING EVENTS
WITH MAJOR BURNS
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• 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
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• 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
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• 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
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• 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
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• 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
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• 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
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IMMEDIATE CARE OF THE BURN PATIENT
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• VII. Prehospital Care
• A. Importance
• 1. Good prehospital care is essential in ensuring rapid assessment and transfer
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• 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
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• 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
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• 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
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• 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
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• 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
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• 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
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AIRWAY
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• 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)
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• 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
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• 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
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• 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)
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BREATHING
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• 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
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• 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
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• 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
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• 3. Treatment
• a. Initiate treatment once injury is suspected and the airway is secure
• b. Techniques to consider:
• Physiotherapy
• Nebulisers
• Warm humidified oxygen
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• 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)
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