Burns

Definition
A burn occurs when there is injury to the tissues of the body caused by heat, chemicals, electrical current or radiation.

Health Promotion
Majority of burn is preventable and accidental. It can occur anywhere. Education on burn first aid is important. Advocate for fire risk reduction strategies in the home eg smoke alarm, fire blankets, and fire extinguishers. Sun protection in the summer is also important.

Types of Burn
Thermal burns: caused by flame, flash, scald, sunburn or contact with hot objects are the most common types Chemical burns: caused from acids, alkalis and organic compounds. Alkali burns can be more difficult to manage than acid burns because alkaline substances are not neutralized by tissue fluids as readily as acid substances. Alkalis adhere to tissue, causing protein hydrolysis and liquefaction. This damage continues even continues after neutralization. Smoke and inhalation: of hot air and noxious chemical can cause damage to the respiratory tract. Redness, airway edema may result. Three types: 1. Systemic intoxication injury: this follows absorption of CO, hydrogen cyanide, hydrofluoric acid, phosgene and ammonia. Carbon Monoxide produced by incomplete combustion. When inhaled, it displaces the oxygen from hemoglobin. Skin colour: cherry red. Cyanide poisoning can occur as a result of production of hydrogen cyanide from burning plastics. It is absorbed through the lungs and impairs the oxidative apparatus in mitochondria and decreases cellular utilization of oxygen. 2. Inhalation injury above the glottis: inhalation of hot air, steam or smoke. Mucosal burns of the oropharynx and larynx are manifested by redness, blistering and oedema. Mechanical obstruction can occur, true medical emergency. Clue: facial burns, sighed nasal hair, hoarseness, painful swallowing, and darkened oral and nasal membranes, carbonaceous sputum, and clothing burns around the chest and neck. 3. Inhalation injury below the glottis: Tissue injury to the lower respiratory tract is related to the length of exposure to smoke or toxic fumes. Pulmonary oedema may not appear until 12-24 hours after burn. Electric Burn: result from coagulation necrosis that is caused by intense heat generate from the electrical current. It can also result from direct damage to nerves or vessels causing tissue hypoxia. Electric burn in head, vital organs may cause more damage than other areas, as bones and fat tissues offers more resistance where blood vessels and nerves dont. Electrical burn can cause muscle contraction that can fracture ribs. It can cardiac arrest, or arrhythmia, severe arrhythmia, severe metabolic acidosis and myoglobinuris which can lead to acute renal tubular necrosis. Delayed cardiac arrest can also occur. Extensive tissue destruction and cell rupture can cause metabolic acidosis. ABG should be evaluated. Myoglobin is released from muscle

tissue and hemoglobin from damaged RBC into the circulation whenever massive muscle and blood vessel damage occurs. Transported to the kidney and cause blockage. -> ATN.

Classification of Burn Injury

Depth of Burn
Destruction of integumentary system. Skin is divided into 3 layers: epidermis, dermis and subcutaneous tissue.

Classifications Superficial partial thickness

Clinical Appearance Erythema, blanching on pressure, pain and mild swelling, no vesicle or blisters Fluid-filled vesicles that are red, shiny, wet (if ruptured); severe pain caused by never injury, mild to moderate oedema

Cause Superficial sunburn Quick heat flash

Deep partial thickness

Flame Flash Scald Contact burn Chemical tar

Full-Thickness

Dry, waxy white, leathery or hard skin. Visible thrombosed vessels, insensitivity to pain and pressure because of nerve destruction; possible involvement of muscle tendon and bones.

Flame Scald Chemical Tar Electric current

Structure Only superficial devitalisation with hyperaemia is present. Tactile and pain sensation intact. Epidermis and dermis involved to vartying depth. Some skin elements, from which epithelial regeneration can occur, remain viable. Surgical intervention required for healing. All skin elements and nerve endings destroyed. Coagulation necrosis present. Surgical intervention required for healing

Extent of Burn
Total body surface area Rule of nines Lund-Browder chart

Location of Burn
Burns to face and neck and circumferential burns of the chest/back may inhibit mechanical ventilation and respiratory function due to the mechanical obstruction secondary to oedema or eschar formation. These injuries may also indicate the possibility of inhalation injury and respiratory damage. Burns of hands, feet, joints and eyes are concern due to self-care difficulties. Those ears and nose are susceptible to infection due to poor blood supply to cartilage. Circumferential burns of the extremities can cause circulatory compromise distal to the burn, which subsequent neurological impairment of the affected extremities.

Hands and feet are difficult to manage medically because of the superficial vascular and nerve supply system.

Local Response to Burn Injury

Zone of coagulative necrosis: central zone of tissue death. Zone of stasis: surrounds the zone of coagulative. Skin and subcutaneous tissue is compromised and blood flow is sluggish and may progress towards necrosis in three days. Zone of hyperaemia: vasculature is compromised snd dilation of vessels of hyperdynamic vascular response to the burn injury.