BURNS

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• 1 - Epidermis
• 2- dermis : recticular ( lower) and papillary layer
◦ a - papillary layer
◦ b - recticular layer
• 3 - Subcutaneous tissue
• 4 - Muscle

Functions of the skin

• thermal regulation
• Sensory reception
• Hermetic barrier against infections

Jacksonian/ Jackson burn wound model

• Describes the pathophysiology of a burn to an area of the skin
• Includes an area of necrosis ( coagulative necrosis) , zone of stasis and zone of
inflammation
Zone of inflammation
Zone of stasis
o
• Zone of necrosis
• Zone of stasis-
• zone of inflammation - blood accumulates

Definition
Refers to the necrosis of the skin (either coagulative or liquefactive) caused by
several agents such as heat, chemicals( acid or alkaline), electricity, radiation

Classification of burns
The extent of damage of a burn depends on
• contact duration
• Surface temperature

There are three main ways of classifying burns

• traditional : 1st, 2nd, 3rd and 4th Preferred
• Contemporary : partial and full thickness
• Radical : deep and superficial
Traditional classification Contemporary classification Radical classification

1st degree ( epidermis)

Partial thickness Superficial
2nd degree
Papillary layer

Recticular layer Deep burns

3rd degree
( subcutaneous tissue) Full thickness

4th degree( bone and

muscle )
Traditional classification of burns
• classified into 1st, 2nd, 3rd and 4th degree burn

1st degree
limited to the epidermis
Presents with erythema
Heals spontaneously without scars
Pain

2nd degree burn

• affects the dermis layer
• Divided into
‣ superficial 2nd degree burns
‣ Deep 2nd degree burn

Superficial 2nd degree burns

• affects the papillary layer
• Presents with blisters and blanching
• Heals within 3 weeks without scars

Deep 2nd degree burn

affects the reticular layer of dermis
Causes mottling
Heals with unfavorable scars
Heals within 3 weeks

3rd degree burn

• it is a full thickness burn ( epidermis + dermis + subcutaneous tissue)
• Affects the subcutaneous tissue and gives a leathery appearance
• It is insensitive to pain

4th degree burns

• extends to the underlying structures( muscles and bones)
• Gives a charred/ blackened appearance
• Insensitive to pain
Contemporary method/ classification
• Divided into partial thickness and full thickness burn

Partial thickness burns

• Has two main subclassification : superficial partial thickness and deep partial
thickness
• Includes the 1st and 2nd degree burns
• Superficial partial thickness - affects the papillary layer upwards
• Deep partial thickness - affects the recticular layer upwards

Full thickness burns

• includes the 3rd degree and 4th degree

Radical method/classification
• Divided into superficial and deep burns

Superficial burns
• from the epidermis to the recticular layer
• Managed conservatively

Deep burns
• from the recticular layer to the underlying structures ( bone and muscle)
• Only surgical management is helpful

Pathophysiology/Changes to the body during burns

CNS
irritability, confusion, disorientation, loss of consciousness( LOC), drownsiness,
agitation

Cardiovascular system
hypotension, hypovolemia, bowditch phenomenon (tachycardia), thrombosis

Bowditch phenomena
• a compensatory mechanism by the body in response to burns
• When there is a burn there is a decrease in blood volume, triggering a
compensatory mechanism to stabilize the blood pressure by causing an increase
in cardiac output and an increase in TPR ( BP = CO x TPR)
• When this happens, diastole is reduced, and systole is increased
• This prevents/ reduces calcium efflux during diastole
• The extended presence of calcium in the cell causes the heart to contract more
resulting in tachycardia

Sludge phenomenon
• Due to the burn, there is hypovolemia, ischemia and hypoxia
• This Leads to erythropoiesis as a compensatory mechanism
• This erythropoiesis results in the RBCs aggregating together and making the blood
viscous
• This increased viscosity, results in thrombotic events
• There is an increase in viscosity of the blood due to hypovolemia

Respiratory system
• laryngeal edema
• Trachiobronchitis
• Pulmonary parenchyma injury
• Pulmonary edema

Gastrointestinal system
• Curling’s ulcer
◦ due to the hypovolemia
◦ There is reduced perfusion to the GI tract
◦ This results in a decreased availability of prostaglandins which protect the
gastric mucosa
◦ However, HCL production is not influenced but rather increased resulting in
production of hcl in the absence of protective mucosa, resulting in an ulcer
• infection
• Paralytic ileus
◦ Due to low perfusion to the gut resulting in slow gut motility

• Increase in inflammatory markers ie. CRP and ESP

Kidneys
• Acute kidney injury( prerenal injury)
◦ Oliguria
• Acute tubular necrosis
• Kidney stones

Endocrine system
• When there is a burn there is release of catecholamines and ACTH
Catecholamine : any amine with a catechol ring
• they are naturally occurring amines that act as
neurotransmitters and hormones sighing thr body
• Stimulate sympathetic action

• Catecholamines causes vasoconstriction

• ACTH results in an increased production of the stress hormone, cortisol
• Cortisol ( a counter regulatory hormone) , results in an increase in glucose in the
blood, hyperglycemia
• Due to hypovolemia there is an increase in aldosterone to conserve water and
sodium, resulting in hypernatremia and hypokalemia

Immune system
• Decrease in the immunoglobulins (GAMED)
◦ There is a reduced production of immunoglobulins/ opsonization resulting in a
reduced activation/ response to infections

Haematological
• pancytopenia
• Anemia

Management of a burns patients

• In managing a burns patient, there are 4 main principles, ie
Resuscitation
the 4 Rs.
◦ Revive
◦ Restore
◦ Repair
◦ Rehabilitations

Steps
• admit
• Perform primary survey,ie assess airway, breathing, circ
ulation, exposure and correct deficits
• Take a quick detailed history
◦ Type of burn
◦ Time of burn
◦ Location of burn
◦ Intentional or accidental
◦ Tetanus immunization
◦ Any medical history of note
◦ Drug history Wallace rule of nine
◦ Allergies
• Perform a quick physical exam of the patient ( IPPA)
◦ Determine depth of the burn
◦ Determine the percentage of the burns using either:
‣ the Wallace rule of
nine(mostly adults) side of head and neck = 4.5%, since it
‣ Lund and browder involves the half
chart( mostly for
pediatrics)
‣ Patients Palmer surface

• establish IV access with two wide bore canullae

• Take blood for relevant investigations ( FBC, bue creatinine, LFT, clotting profile,
 CS, GCM, creatinine kinase levels, myoglobulin levels)
• Give IV fluids, using the parkland formula
• Insert urinary catheter and insert NG tube if needed
• Making sure to drain at least 1ml/ kg/ hr in adults ( or averagely 30-50ml/hr) or
1.2 ml/kg/hr in children
◦ If output is less than 30ml/hr , increase IV fluid
◦ If output more than 50ml/hr, reduce IV fluid
• Monitor vitals ( urine output, blood pressure, respiratory rate, heart rate,
temperature)
• Give appropriate analgesia ( morphine, pethidine,
• Give antibiotics cover
• Give PPIs to prevent curling ulcer , consider heparin ( because of sludge )
• Give anti tetanus serum
• Nutritional support: high in calories, proteins, vitamins, irons
• Debridement / Removal of dead tissue and slough
• Wound dressing
◦ Open - antibiotic powder, silver sulphadiazine
◦ Closed - Vaseline gauze, honey, silver sulphadiazine, iodine povidine , silver
nitrate
• Consider skin grafting
• Physiotherapy and/or psychotherapy

Example
A patient presents with a burn on his face, abdomen and his own right hand,
calculate the percentage

Answer : 4.5( face) + 9 ( abdomen) + 9( right hand) = 22.5 percent

A 20 ear odo gentleman presents with burns in his whole right leg, chest and
genitals
18 + 9+ 1 = 28 percent

IV fluid resuscitation in burns

The average weight of an
• Fluid of choice for burns is ringers lactate adult African male is 70kg
◦ Reduces the lactic acidosis( cortisol ->
 hyperglycemia/ hypovolemia -> hypoxia -> cells undergo anaerobic
respiration-> lactic acidosis)

Calculating the amount of IV fluid in a burns patient

There are various methods:
• parklands formula/ Baxter formula
• Brooks formula( 2mlx weight x TBSA)
• Galveston formula

Parkland formulae
• a formulae used to calculate the total fluid requirement of a burns patient in 24
hours from the time of burns
• States that in
◦ adults = 4mls x weight of patient(kg) x TBSA( % )
◦ Children = 3ml x weight of patient ( kg) x TBSA ( % )

Day 1 - parkland formula

Day 2 - daily fluid requirement + 1/2 parkland formula
Day 3 - daily fluid requirement only

• Fluid is divided into 2 halves

• The first half - first 8 hours from the time of burn
• Second half - remaining 16 hours

Holliday segar method / rule

• used to calculate the maintenance fluid/ daily fluid requirement (DFR)

• 100 : 50 : 20 ratio is used to calculate the daily requirement and 4:2:1 ratio to
calculate the hourly requirement
◦ First 10kg - 100ml/kg/day
◦ Second 10kg - 50ml/kg/day
◦ Remaining kg - 20ml/kg/ day

Examples
Calculate the maintenance fluid for a 60kg man
Ans
(100x 10) + (50x10) + (20 x 40) = 2300ml/day

Calculate the maintefluid for a 57 kg man

Ans
( 100 x 10) + (50x 10) + ( 37 x 20)= 2240ml/day

Calculate the maintenance fluid for a 17 kg boy

Ans
( 100 x 10) +( 50x 7) = 1350ml/day

Calculate the DFR of a man weighing 44kg

(100x10) + (50x 10) +( 24x20) = 1980 ml/day

Calculate the DFR of a man who weight 87kg

(100x 10) + (50x10) +( 67x 20) = 2840 ml/day

So in calculating the total fluid requirement in the first 24 hours :

Example
A 50 year old man who weighs 50lg presents with burns on his head, arm and chest
Calculate his total fluid requirement for day 1
Ans
Day 1= DFR + parkland formulae

DFR = (100x 10) + ( 10x 50) + (30 x20) = 2100ml

TBSA (%) = 9+ 9 + 4.5 = 22.5%

Parkland = 4 x 22.5 x 50 = 4500ml

Total fluid = 2100 + 4500 = 6600ml

A 60 year old man who weighs 55kg has burns on the left leg, left arm and genitals.
Calculate the total fluid requirement on the first day

TBSA = 9 + 4.5 + 1 =14.5 %

Day 1 = DFR + parkland formulae

DFR = (100x10) + (50x10) +(35x20) =2200ml
Parkland formulae = 4x 55x 14.5 = 3190ml
Day 1=3190 + 2200 = 5390ml Chronic complications
• keloids
• Hypertrophic scars
• Contractures
Complications of burns • Deformity
• has acute and chronic complications • Psychological
effect(Depression)
Acute complications • Malignant skin change
• infections( commonest) • Bone deformity
• Hypovolemic shock
• Dvt
• Acute kidney injury
• Pulmonary embolism
• Curling ulcer
• Paralytic ileus
• Acute gastric dilatation
• Hyperkalemia

Commonest Complications resulting in death

• Hypovolemic shock
• Septecemia
• Acute kidney Injury
• respiratory distress

Criteria for admission of a burns patient

• greater than 15 percent TBSA in adults ( major burn )
• Greater than 10 percent in children( major burn)
• Partial or full thickness burn in critical areas such as the face, arms, feet, genitals,
perineum
• Full thickness burn greater than 5 percent of TBSA
• partial thickness burn greater than 10peecent of TBSA
• Any form of inhalation injury
• Significant thermal burn, chemical injury, electrical burn, lightning with co-
existing/ pre existing condition
• Burn in an elderly, Total fluids = colloid + cyrstalloid + pregnant
woman or very young child

Brooks formulae
Has to do with separating the fluids into crystalloids and colloids

Colloids
0.5 x weight x TBSA
Crystalloids
1.5 x weight x TBSA
Daily fluid requirement
3 ( 1L r/l + 2L 5% ns)

Signs of Inhalation injury

• singed nasal haired
• Burns to face or orophargnx
• Blistered palate
• Sooty sputum
• Drowsiness or confusiojndue to carbon monoxide poisoning
• Increased respiratory effort
• Breathlessness
• stridor/ hoarseness ( signs of impeding airway obstruction )

Lichtenburg figures