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Burns

ANATOMY AND
PHYSIOLOGY OF THE
SKIN
INTEGUMENTARY SYSTEM
LAYERS OF THE SKIN
• Epidermis
o Ectodermal origin
o Keratinized stratified squamous epithelium

• Dermis
o Mesodermal origin
o Dense connective tissue

• Hypodermis
Functions of the skin
• Protection of the body from the environment effects ;
o physical abrasion, dehydration and uv radiation
• Heat regulation
• Sensation
o Touch
o Vibration
o Pain
o temperature
• Synthesis and storage of vitamin D
DERMIS
LANGER’S LINE

Direction of the skin which


corresponds to the natural
orientation of the collagen
fibers in the dermis.
HYPODERMIS

• Attaches the reticular layer


to the underlying organs
• Loose connective tissue and
adipose tissue
• Known as superficial fascia,
subcutaneous tissue
• Major blood vessels- rete
cutaneum
SKIN APPENDAGES
• Hair follicles and hair
• Nails
• Glands
Salivary glands and
pancreatic glands

Sebaceous gland

Mammary gland
BLOOD SUPPLY
Arterial plexuses

-Subpapillary plexus (upper dermis,


capillary loops in dermal papillae)
-Deep dermal plexus (hypodermis,
deeper aspect of dermis)

Venous plexuses

-Subpapillary, reticular dermal, deep


dermal plexuses
NERVE SUPPLY
• Free nerve endings in epidermis and papillary dermis (pain
and temperature)
• Encapsulated receptors
-Meissner’s corpuscles: delicate touch
-Pacinian corpuscles: vibration & deep pressure
-Ruffini’s corpuscles: mechanical stress
How to clerk patient with burns
• A patient's history must be obtained on admission, as this may be the only time that a first
hand history is obtainable.
• Swelling may develop around the airway in the hours after injury and require intubation,
making it impossible for the patient to give a verbal history.
• A brief medical history should be taken, outlining previous medical problems, medications,
allergies, and vaccinations.
A - Allergies
M - Medication
P - Past medical history
L - Last meal
E - Events/environment related to injury eg. Duration of exposure to heat, nature of the
burning agent, first-aid measures applied and type of clothing worn
Key questions in taking the
history of a burns patient
• When did the accident take place? What is the time delay between the accident and being seen? Long
delays without treatment can be very hazardous.
• What treatment has already taken place?
• Have the appropriate measures been taken to monitor progress?
• Has resuscitation been adequate?
• How did the accident happen?
• Was flame involved?
• Explosion?
• Smoke?
• Confined space?
• Any evidence of criminal intent?
• Alcohol?
• Clothing worn at the time?
Exact mechanism
• Type of burn agent (scald, flame, electrical, chemical)
• How did it come into contact with patient?
• What first aid was performed?
• What treatment has been started?
• Is there risk of concomitant injuries (such as fall from height, road traffic crash,
explosion)?
• Is there risk of inhalational injuries (did burn occur in an enclosed space)?

Exact timing
•When did the injury occur?
•How long was cooling applied?
•How long was patient exposed to energy source?
•When was fluid resuscitation started?
Exact injury

Scalds
•What was the liquid? Was it boiling or recently boiled?
•If tea or coffee, was milk in it?
•Was a solute in the liquid? (Raises boiling temperature and causes worse
injury, such as boiling rice)

Electrocution injuries
•What was the voltage (domestic or industrial)?
•Was there a flash or arcing?
•Contact time

Chemical injuries
•What was the chemical?
MANAGEMENT OF
BURN WOUND

CPG BURN PATIENT MANAGEMENT 2011, These guidelines were developed with the collaboration of the members of the
Multidisciplinary Team of the ACI Statewide Burn Injury Service (from Royal North Shore Hospital, Concord Repatriation General
Hospital and The Children’s Hospital at Westmead).
On Arrival to Hospital
• Place patient on clean dry sheet
• Cover the burn with plastic cling wrap and clean sheet
• Elevate the burnt limbs
• Continuous running water to burn wound help to reduce pain and
stop burning process
• Chemical burn – shower the patient or irrigate it
• Burnt eyes – need stream eye saline over open eyes until the pH is neutral
• Acute management and pain management
• Assessment
• Surface area assessment
• Burn wound depth assessment
Acute Management
• Primary survey
• Airway maintenance with cervical spine control
• Chin lift, jaw thrust. Remove foreign body. Consider oropharyngeal insertion.
• Breathing
• Administer 100% O2. Expose chest and check for chest movement. Rule out rib
fracture and auscultate the lungs.
• Monitor spO2 and respiratory rate.
• Circulation
• Inspect obvious bleeding and stop it with direct pressure
• Palpate for peripheral pulses (rate,volume,rhythm)
• Capillary refill time
• Disability
• A – Alert, V - Response to Vocal stimuli, P - Responds to Painful stimuli, U -
Unresponsive
• Exposure
• Remove clothing and jewellery and keep patient warm.
• Log roll and examine posterior surface for burn or injuries
• Fluids
Fluid Resuscitation
• Indication : burn >10%(children), >15%(adult)
• Insert 2 large bore branula and peripheral IV line
• Take blood – FBC,RP,LFT,Coagulation profile, GSH,CO level.
• Weigh patient and inser indwelling catheter device for strict I/O
charting
• Commence IV Hartman’s (adult and children) resuscitation fluid using
Modified Parkland Formula and adjust according to urine output and
D5% or Normal Saline for children’s maintenance.
Modified Parkland
Formula
• 3-4 ml x kg x % TBSA burnt = IV fluid ml to be given in
24hrs following the injury
• Give ½ of this fluid in the first 8hrs from the time of injury
• Give a ½ of this fluid in the following 16hrs
• The infusion rate is guided by the urine output, not by
formula.
• The urine output should be maintained at a rate
• Adult 0.5 / kg / hr
• Children 1 ml / kg / hr
• If urine output is less increase IV fluids by 1/3 of current IV
fluid amount.
• If urine output is excessive decrease IV fluids by 1/3 of
current IV fluid amount
Surface Area Assessment
(Rule of Nine)
Palmar
Method
• Extra fluid is needed if:
• When haemochromogenuria (dark red, black urine) from
muscle injury is evident.
• Inhalation Injury
• Electrical injury
• Delayed resuscitation
• Fluid loss prior to burn (patient on diuretics, etc)
• Insert nasogastric/ nasojejunal tube for larger burns
(>20% TBSA in adults; >15%TBSA in children) or if
associated injuries.
• Pain management
• stat dose of IV morphine is 2.5 - 10mg for adults and 0.1 -
0.2 mg/kg of body weight for children.
• dose should be titrated according to the patient’s response,
including the respiratory rate.
• Secondary survey
• Take further history
• A - Allergies
• M - Medications
• P - Past Illnesses
• L - Last Meal
• E - Events/Environment related to injury
• History on incident and mechanism of injury
• Re-evaluate ABCDEF
• Give tetanus prophylaxis if required
Burn Depth Assessment
NSW Statewide Burn Injury
Service
Medical retrieval Criteria
Referral Minor burns
Meets Medical Retrieval Needs referral but not Minor burns are treated in
• Intubated patients medical consultation with the
• Head and neck burns retrieval referring
• Burns>10% in children or • Burns >5% children or >10% doctor as an outpatient;
>20% adults either
in adults • Burns to hands, feet, face, locally (at original place of
• Burns with associated genitalia, perineum and care)
inhalation major or on referral to an
• Burns with significant joints ambulatory
comorbidities • Burns with a pre-existing burns clinic for assessment
e.g. trauma medical
• Electrical/chemical injury condition eg diabetes
• Significant pre-existing • Children with suspected
medical nonaccidental
disorder injury & adults with
• Circumferential to limbs or assault, self inflicted injury
chest • Pregnancy
compromising circulation or • Spinal cord injury
respiration • Extremes of ages
Burn Wound Management
• Healing principles
• Cleansing and debridement
• Dressing and pressure
Principle of Wound Healing
• To promote wound healing and ease patient discomfort
• Ensure adequate perfusion
• Minimize bacterial contamination
• Minimize negative effects of inflammation
• Provide optimal wound environment
• Promote adequate nutrition and fluid management
• Provide adequate pain management
• Promoting re-epithelialization
• Provide pressure management
How to promote wound healing?
• Cleansing – wound surface should be free of slough, exudate,
haematoma and creams
• Debridement – removal of loose, devitalised tissue and non-
surgical removal of eschar
• Dressing
• choose appropriate primary dressing to maintain optimal moisture level
and promote wound healing
• Exudate management – choose appropriate absorbency level of
dressing
• Reduce pain and trauma on dressing removal or consider long-term
dressing
• Pressure – to manage oedema and minimise the effects of
scarring
• There will be high exudate from the wound in the first 72hrs post injury
OUTPATIENT
MANAGEMENT
Objectives of out patient burn care are:

• Rapid healing
• Pain control
• Return of full function to the injured area
Criteria to determine eligibility for out patient care should include:

• Less than 10% BSA partial thickness burns in children and elderly and less than 15% BSA
partial thickness burns in adults.
• Reasonable state of good health with minimal underlying medical problems.
• Adequate airway.
• Ability to drink adequate amounts of fluids.
• No circumferential burns.
• No additional trauma.
• No chemical burns.
• Minimal involvement of face, hands, genitalia and joints.
• No evidence of abuse or neglect.
• Patient and family demonstrate ability to carry out plan of care.
Emergency Care
1. Burns are considered trauma – do primary survey and later secondary survey
( evaluation of burn area and consideration of abuse)

2. Stop the burning process. Remove all clothing or coverings that may retain heat and
cause a deeper injury

3. Rinse the affected area with cool water for at least 15 minutes – decrease oedema
of wound

4. Pain control – morphine or NSAIDs

5. Clean wound area – sterile water to remove debris

6. Tetanus prophylaxis is indicated only when immunizations not up to date (in the
case of children) or for adults if last tetanus immunization was more than 10 years ago
Non-Emergency Care
1. Clean wound with water.

2. Leave blisters intact; only debride devitalized tissue after blister has burst. Debridement should
only
be done by the health care professional in the clinic and not left to the patient or family to do at
home.

3. Topical agent – to prevent infection ; 1% silver sulfadiazine (antiseptic) , antibiotics over small burn
area ( neomyocin,bacitracin, polymyxin)

4. Elevate injured area – to eliminate edema

5. Provide pain relief for dressing changes with acetaminophen. Make sure patient/ family know to
take medicine approximately ½ hour before dressing change and before return clinic appointment.
7. Teach family or significant other “clean” technique. Instruct to change
dressing once to twice daily, depending on your assessment of the
wound and the families’ ability (technically and economically) to do it.
Be sure to instruct them to wash wound and remove all residual cream
before applying new cream.

8. No evidence on systemic antibiotics prophylaxis in small burn wounds

9. Pruritis – manifestation of healing and healed burn wounds


Antihistamine (diphenhydramine hydrochloride) and skin moisturizing
cream

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