Burns

Burn  Burn is a dry heat injury caused by the application of flame or heated solid substances to the body resulting coagulation necrosis of the tissues.

Scalds  Scald is a moist heat injury caused by the application of a liquid, at or near its boiling point or in its gaseous form (such as steam), to the body.

Causes of burn 1. Dry heat burn – Partial & full thickness a. Burn b. Flame 2. Moist heat burn – Partial thickness a. Scald 3. Chemical burn – Partial & full thickness a. Acid b. Alkali 4. Cold injury – Partial thickness a. Frost bite b. Acute cold burn or Freezing 5. Friction burn – Partial thickness 6. Irradiation – Partial thickness 7. Electric burn – Partial & full thickness

Classification of burns

A) Modern 1. Superficial burn  Epidermis fully affected, sometimes up to part of dermis. 2. Deep burn  all layers are affected. B) Wilson’s Classification 1. First degree burn 2. Second degree burn 3. Third degree burn C) Traditional 1. Superficial partial thickness burn 2. Deep partial thickness burn 3. Full thickness burn

Classification of burn and characteristics:

Depth of burn Characteristics Cause First degree (Superficial) Erythema Pain Absence of blisters Sunburn

Second degree (Deep partial thickness) Superficial or Deep Involve epidermis & dermis Blister Intact pain Red or mottled Flash burns Heals with scars Contact with hot liquids Fire

Third degree (Full Thickness) Involve all skin layers Painless Dark and leathery Dry Fire Electricity or lightning Prolonged exposure to hot liquids/ objects

Management of Burn

A) Immediate Pre-hospital Emergency Care • Ensure rescuer safety first  If the rescuer is able to secure himself then he can save the victim • Stop the burning process  STOP-DROP-ROLL is a good method of extinguishing fire burning on a person • Removal of the victim from the source of burn • Removal of clothing to reduce contact burn and further burning • Ensure ABC – airway, breathing, circulation • First Aid  COOL-COVER-CALL Immediate care of a burn injury should always include: • Cooling all burns with tepid to cool water, regardless of degree. Continue flushing the area for up to 10 minutes. Do not apply ice, ointments, butter or other “home remedies”. • Cover affected areas with a thin clean dry cotton cloth but no contact with the raw skin. • Call for medical attention and hospitalize if burn is larger than the victim’s hand size, if the victim is a child or elderly person.

B) Burn assessment in hospital • Brief history • Ensure ABCDE (Airway, Breathing, Circulation, Disability limitation, Environmental exposure control) • Ensure immediate opening of intravenous channels in different sites • Assessment of extend of burn by – • Rules of 9’s (Adult, children >10 yrs) • Rules of 9’s – modified (Children <10 yrs) • Rules of palm (Small burn & Infant) – Palm represents 1% • The Lund and Browder chart – mostly in specialised burn care centre like DMCH burn unit or City Hospital • Assessment of the depth of burn (Superficial partial to deep)

C) General Management • Send blood for grouping and Rh typing • Relief of pain by IV morphine or pethidine or alternatives; avoid IM injections • Fluid balance; ideally by plasma but in our country we usually use • Ringer’s lactate solution • Hartmann’s solution • 5% DNS or other fluid if above are unavailable. Formula  Parkland Formula: 4 X body weight in Kg X % of burn = volume in ml (additional to normal daily needs) Regimen • 1st day – ½ of the measured fluid in first 8 hrs

                                                 ½ of the measured fluid in next 16 hrs

• 2nd day – ½ of the measured fluid in next 24 hrs • 3rd day onward – Maintenance fluid + daily requirement on output. Fluid is given when – adult burn >15%, children >10%, infant >5% • Blood transfusion when – adult burn >30% and children >25% • Monitoring of urinary output, better to catheterize. It should be 0.5-1 ml per Kg body weight per hour. • Prevention of infection by • Inj TT • Inj Penicillin 10 lac IU 6 hrly (after skin test) or • Other suitable antibiotics • High protein diet

D) Local Management • Open method (Superficial burn) • Clean room with good ventilation • Low humidity • No dressing • Local antiseptic cream (Nebanol) • Closed Method (Deep burn) Dressing in three layers • Innermost : antiseptic cream • Middle : Gauze (lubricated) • Outer : Absorbent wool • In body surface of adult we use 1% Silver Sulphadiazine Cream (Silcream/Burnsil/Dermazin) • In the face and in children we use neomycin+bacitracin+polymyxin B combination ointment (Nebanol plus ointment) • Skin Grafting – in full thickness burn

E) Prevention of Contracture • Keeping the affected part in the functional position • Regular passive movement

Additional aspect 1. Varieties in burn dressing a. Around the world varieties of substances were used in burn like – honey, potato peel, egg etc. b. Recent advances in medical science invent hydrocolloid dressing, permeable dressing, silicon sheet, duoderm, biological synthetic membranes or most effective amniotic membrane. 2. Analgesia a. Strong analgesics initially needed in severe burn in IV routes but do not use IM. b. Subsequently oral analgesics can be given afterwards. 3. Gastro protection a. Gastro protective should be given to prevent stress ulceration in GI tract b. We use H2 blockers (Neoceptin R/Neotack) or proton pump inhibitors (Losectil/Proceptin) 4. Nutrition a. Burn is a catabolic state so it needs extra protein rich diet like egg, milk, meat, fish, pulses etc. b. In addition vitamin supplementation needed like B-complex, zinc and most importantly vitamin C c. Fresh lemon are the best source of Vit. C which helps in rapid healing. d. Calorie requirement 50-60 Kcal/kg/day 5. Control of infection a. Restrict the visitor as the victim is immuno-compromised (very difficult here in Bangladesh, patients attendances are not cooperative) b. Cleanliness of the care taker of the patient is very important. 6. Physiotherapy a. It should be started on day 1 b. It prevents the limbs from future bending or rigidity following post burn contracture.

Complications

1. Immediate • Compartment syndrome from circumferential burns (limb burns → limb ischaemia, thoracic burns → hypoxia from restrictive respiratory failure) • prevent by urgent escharotomy

2. Early • Hyperkalaemia  (from cytolysis in large burns). Treat with insulin and dextrose. • Acute renal failure  (combination of hypovolaemia, sepsis, tissue toxins). Prevent by aggressive early resuscitation, ensuring high GFR with fluid loading and diuretics, treat sepsis. • Infection  (beware of Streptococcus). Treat established infection with systemic antibiotics. • Stress ulceration  (Curling’s ulcer). Prevent with antacid, H2-blocker or proton pump inhibitor prophylaxis.

3. Late • Contractures.

Figure: Hypertrophic Scar and Electric burn wound

• Medicine