Review Class Burns Burns are injuries to tissues caused by heat, friction, electricity, radiation, or chemicals

Burns are characterized by degree, based on the severity of the tissue damage Depth of Burn First Degree Superficial Second Degree Superficial partial thickness Deep partial thickness Third Degree Full thickness Subdermal Wound color Red Surface appearance No blisters, Capillary Refill Brisk 1-2s Edema Minimal Healing Within 7 days

Bright pink or red Blotchy Red/ White Blotchy Red/ White Charred

Intact blisters,

Brisk 1-2s

Moderate

Within 14 days

Broken blisters

Sluggish >2s Sluggish >2s or absent absent

Marked

2-3weeks Grafting required Grafting required

Parchment like Subcutaneous tissue evident

Area depressed

Tissue Defects

The severity of the burn is also judged by the amount of body surface area (BSA) involved. Lund Browder Chart Rule of Nines Rule of the Palm The severity of the burn will determine not only the type of treatment, but also where the burn patient should receive treatment. Minor burns may be treated at home or in a doctor's office. These are defined as first- or second-degree burns covering less than 15% of an adult's body or less than 10% of a child's body, or a third-degree burn on less than 2% BSA. Moderate burns should be treated at a hospital. These are defined as first- or seconddegree burns covering 15%-25% of an adult's body or 10%-20% of a child's body, or a thirddegree burn on 2%-10% BSA. Critical, or major, burns are the most serious and should be treated in a specialized burn unit of a hospital. These are defined as first- or second-degree burns covering more than 25% of an adult's body or more than 20% of a child's body, or a third-degree burn on more than 10% BSA.

In addition, burns involving the hands, feet, face, eyes, ears, or genitals are considered critical. Other factors influence the level of treatment needed, including associated injuries such as bone fractures and smoke inhalation, presence of a chronic disease, or a history of being abused. Also, children and the elderly are more vulnerable to complications from burn injuries and require more intensive care.

Types of Burns: Chemical burns Chemical burns are tissue damage caused by exposure to a strong acid or alkali Electrical burns An electrical injury occurs when an electrical current from an external source runs through the body as heat. The points of entrance and exit on the skin are burned, along with the muscle and subcutaneous tissues through which the current passes. It is possible that fatal cardiac arrhythmia may result. In this situation contact your local burn center or emergency room immediately. Thermal burns Thermal burns are the most common types of burns. These often occur from residential fires, automobile accidents, playing with matches, improperly stored gasoline, space heaters, electrical malfunctions, or arson. Epidemiology MC cause of burns = Thermal Burns Scald injuries are the predominant cause in children under the age of 5. Pathophysiology Local Response Zone of coagulationThis occurs at the point of maximum damage. In this zone there is irreversible tissue loss due to coagulation of the constituent proteins. Zone of stasisThe surrounding zone of stasis is characterized by decreased tissue perfusion. The tissue in this zone is potentially reversible. Zone of hyperaemiaIn this outermost zone tissue perfusion is increased. The tissue here will invariably recover unless there is severe sepsis or prolonged hypoperfusion. These three zones of a burn are three dimensional, and loss of tissue in the zone of stasis will lead to the wound deepening as well as widening. Systemic response The release of cytokines and other inflammatory mediators at the site of injury has a systemic effect once the burn reaches 30% of total body surface area. Cardiovascular changesCapillary permeability is increased, leading to loss of intravascular proteins and fluids into the interstitial compartment. Peripheral and splanchnic vasoconstriction occurs. Myocardial contractility is decreased, possibly due to release of tumour necrosis factor . These changes, coupled with fluid loss from the burn wound, result in systemic hypotension and end organ hypoperfusion. Respiratory changesInflammatory mediators cause bronchoconstriction, and in severe burns adult respiratory distress syndrome can occur.

Metabolic changesThe basal metabolic rate increases up to three times its original rate. This, coupled with splanchnic hypoperfusion, necessitates early and aggressive enteral feeding to decrease catabolism and maintain gut integrity. Immunological changesNon-specific down regulation of the immune response occurs, affecting both cell mediated and humoral pathways.pathways.

Clinical Manifestations Respiratory Cardiovascular Hypovolemic shock and cardiac output Impaired circulation/tissue perfusion Potential for ECG changes Direct airway injury Carbon monoxide poisoning Thermal injury Smoke poisoning Pulmonary fluid overload External factors Renal/urinary Changes R/T renal perfusion and debris Fluid shift GFR and urine output Fluid remobilization-- GFR and diuresis Tubular blockage from myoglobin and uric acid Fluid resuscitation should maintain output at 30-50 mL/hour

Integumentary Size of injury is important to diagnosis and prognosis Specific treatments dependent upon depth of injury

* Infection is a major complication in burns Phases of treatment: A. Emergent/Shock Phase a. Fluid Resuscitation b. IVF Resuscitation i. Brookes Formula ii. Parkland Formula B. Acute (healing) phase a. Wound Care b. Wound Debridement c. Wound Coverage Surgical Management 1. Debridement 2. Skin Grafting

Compiled by: Edison A. Bono, PTRP