BURNS

Dr. Dinesh Kumar S Asst. Prof. Dept. of Plastic Surgery JIPMER

What is a Burn?

Soft tissue injury due to heat, chemicals, radiation or electricity It is one of the most catastrophic and devastating injuries It occurs in all age groups It occurs in developing and developed nations It affects not only the body but also leaves a psychological scar

How often does it occur?

In India, during 2001, 32,509 people died of burns Amounts to 15% of unnatural deaths (excluding suicidal deaths) In the same period, no. of burns were 6030 Preliminary surveys show mortality and incidence of 10/100000 and 995/100000 population Higher in slums (4100) and villages (2300)

Who is affected?

Most common in 15-45 yr age group (~60%) In all age groups, women are more affected (~1.6:1) Children account for nearly 20% incidence Children <5yrs mostly suffer scalds Older children suffer mostly thermal burns Children and elderly have significantly

What happens in Burns?

Can be divide into local and systemic responses Local Response

Zone of coagulation Zone of stasis Zone of hyperemia Jackson's zones 3 dimensional

What happens in Burns?

Systemic responses

Cardiovascular

increase in vascular permeability fluid loss into 3rd space lasts from 18-24 hrs Peripheral and splanchnic vasoconstriction Decreased myocardial contractility Systemic hypotension and end-organ hypo-perfusion

Respiratory > bronchoconstriction >> ARDS Metabolic BMR ~ 3X

How does it happen?

Thermal Wet/Dry Electrical Low-Tension/High-Tension Chemical Acid/Alkali Radiation

Classification

1st degree (superficial) burns

e.g. Sunburns Erythematous, painful Heals spontaneously within a week Superficial red and painful with blisters upto 10 days to heal minimal scarring Deep white and less painful (>50% dermal injury) 2-3 wks to heal with scarring/contractures

2 degree (partial thickness) burns

nd

Classification

3rd degree (Full thickness) burns

White leathery skin No pain Cannot heal on its own eschar formation wound contracture Underlying tissues are injured tendons, muscles, bone

4th degree burns

Management

Initial Assessment ABC's Look for signs of inhalational injury Get IV access Remove Burnt Clothing Cover patient with clean sheet Check for CO poisoning Check for circumferential burns Send for appropriate lab tests

Assessment (Burns Score)

Modified Lund & Browder Chart

Shriners Hospital for Children

Management

Criteria for admission to burn unit (American Burn Association)

1.Partial-thickness burns of greater than 10% of the total body surface area 2.Burns that involve the face, hands, feet, genitalia, perineum, or major joints 3.Third-degree burns in any age group 4.Electrical burns, including lightning injury, chemical burns 5.Inhalation injury

5.Burn injury in patients with preexisting medical disorders that could complicate management 6.Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality 7.Burned children in hospitals without qualified personnel or equipment for the care of children 8.Burn injury in patients who will require special social, emotional, or rehabilitative intervention

Fluid Management

Modified Parkland Formula

3-4ml/kg body weight/ %TBSA First 8 hrs give 1/2 the calculated fluids Remaining fluids to be administered over 16 hours Add maintenance fluids in children

4ml/kg for first 10kgs bbody weight 2ml/kg for next 10kgs 1ml/kg for remaining weight

Goal to maintain urine output ~ 1ml/min

Dextrose solution can be added for children <20 kgs to avoid hypoglycemia Colloids can be added after first 24 hrs (0.5ml/kg/%TBSA) Fluid administration should be rd decreased as fluids lost into 3 space start returning into circulation (1.5ml/kg/ %TBSA) Check PCV, electrolytes regularly

Nutrition

Start as early as possible High protein requirement due to increase BMR and tissue damage If oral feeds not possible consider nasogastric feeds Else consider parenteral nutrition

When should you consider surgery?

Surgery

Timing of surgery early vs delayed

It may be prudent to wait upto 10 days All wounds to be covered before 3 wks to avoid contractures if possible!!

Type of surgery tangential excision vs excision upto fascia Extent of excision?

After-Care

Significant burns not only causes physical deformities but also psychologic scars Compression garments and splints used to prevent development and/or progression of contractures Counselling/special camps for rehabilitation