the thermal injury

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Done BY :

Dr.Sara Al-Ghanem | Medical intern from KFU

THE THERMAL INJURY

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OBJECTIVES :

I-definition & incidence

II- types ( etiology )

III- classifications According

4-management of burn

5-complicatios

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I- DEFINITION

A burn is defined as a traumatic injury to the skin or other organic tissue primarily caused by thermal or other acute exposures. Burns occur when some or all of the cells in the skin or other tissues are destroyed by heat, cold, electricity, radiation, or caustic chemicals.

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INCIDENCE :

Burns are the fourth most common type of trauma worldwide,following traffic accidents, falls, and interpersonal violence.Approximately 90 percent of burns occur in low to middle income countries.Most burn injuries occur in a domestic setting, with cooking asthe most common activity.Pediatric burns occur more commonly in the home (84% ) and while children are unsupervised (80%) .Adults are equally likely to sustain a burn in the home, outdoorsor at work. Burns to adult females occur mostly at home, while burns to adult males occur mostly in outdoor or work locations.The elderly are most likely to sustain a burn in the bathroom, followed by the kitchen .

Thermal

Cold exposure (frostbite)

Chemical burns

Electrical current

Inhalation

Radiation burns

TYPES ON INJURY ( CAUSES )

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IV- classifications According to:

Burn depth & clinical presentation of each typeSize or extentSeverity grading

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Burn depth

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SUPERFICIAL

involve only the epidermal layer of skinNo blister, painful dry, red, and blanch with pressure.healed in six days without scarring. commonly seen with sunburns.

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Partial-thicknessI- superficial:

Superficial – blisters painful, red, and weeping, and blanch with pressure. heal in 7 to 21 days. scarring is unusual. pigment changes may occur.

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PARTIAL-THICKNESSI- deep:

extend into the deeper dermis damage hair follicles and glandular tissue. painful to pressure only almost always blister (easily unroofed), are wet or waxy dry, and have variable mottled colorization from patchy cheesy white to red .They do not blanch with pressure.Healing in three to nine weeks. invariably cause hypertrophic scarring. If they involve a joint, joint dysfunction is expected even with aggressive physical therapy. A deep partial-thickness burn that fails to heal in three weeks is functionally and cosmetically equivalent to a full thickness burn

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PARTIAL-THICKNESSI- deep:

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FULL-THICKNESS

extend through and destroy all layers of the dermis and often injure the underlying subcutaneous tissue. Burn eschar, the dead and denatured dermis, is usually intact..

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FULL-THICKNESS

eschar can compromise the viability of a limb or torso if circumferential. Full thickness burns are usually anesthetic or hypoesthetic. Skin appearance can vary from waxy white to leathery gray to charred and black. skin is dry and inelastic and does not blanch with pressure Hairs can easily be pulled from hair follicles. Vesicles and blisters do not develop.Without surgery, these wounds heal by wound contracture with epithelialization around the wound edges. Scarring is severe with contractures complete spontaneous healing is not possible.

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FOURTH DEGREE BURNS

extend through the skin into underlying tissues such as fascia, muscle, and/or bonepotentially life-threatening injuriesNever heal , unless surgically treated

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II- THE EXTENT OF BURNS :

• The two commonly used methods of assessing TBSA in adults are the Lund-Browder chart and "Rule of Nines,”

• whereas in children, the Lund-Browder chart is the recommended method because it takes into account the relative percentage of body surface area affected by growth.

• When the burn is irregular and/or patchy, the palm method may be useful

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Role of 9 Adult

head & neck = 9% TBSAupper limb = 9 % TBSAtrunk = 18% TBSAback = 18% TBSAgenitalia = 1% TBSAlower limb= 18 % TBSA

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Lund-Browder chart

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PALM METHOD

Small or patchy burns can be approximated by using the surface area of the patient's palm. The palm of the patient's hand, excluding the fingers, is approximately 0.5 percent of total body surface area and the entire palmar surface including fingers is 1 percent in children and adults

III-THE SEVERITY OF THE BURNS :

The major determinants of severity of any burn injury are :-Burn factors:- Type of the burn- the percentage of total body surface area- the presence of an inhalational injury,- depth & site of the burn- presence of infection - associated injuries -complications-Patient's factors : age , sex , mentality , socio-economic status, concomitant diseases

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MANAGEMENT OF BURN :

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IMMEDIATE CARE OF THE BURN PATIENT

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PRE-HOSPITAL CARE

• Ensure rescuer safety. This is particularly important in house fires and in the case of electrical and chemical injuries.

• Stop the burning process. Stop, drop and roll is a good method of extinguishing fire burning on a person.

• Check for other injuries. A standard ABC (airway, breathing, circulation) check for other significant injuries might be missed.

• Give oxygen. Anyone involved in a fire in an enclosed space should receive oxygen, especially if there is an altered consciousness level.

• Elevate. Elevation of burned limbs will reduce swelling and discomfort.

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HOSPITAL CARE

The principles of managing an acute burn injury are the same as in any acute trauma case:A Airway control. B Breathing and ventilation. C Circulation. D Disability – neurological status. E Exposure with environmental control. F Fluid resuscitation

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Initial management of the burned airway (A)

• Early elective intubation is safest • Delay can make intubation very difficult because of

swelling • Be ready to perform an emergency cricothyroidotomy

if intubation is delayed • Recognition of the potentially burned airway• A history of being trapped in the presence of smoke

or hot gases • Burns on the palate or nasal mucosa, or loss of all the

hairs in the nose • Deep burns around the mouth and neck

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Breathing : management of inhalational injury (B) :

• The clinical features are : a progressive increase in respiratory effort and rate, rising pulse, anxiety and confusion and decreasing oxygen saturation. These symptoms may not be apparent imme- diately and can take 24 hours to 5 days to develop.• Treatment starts as soon as this injury is suspected

and the airway is secure. Physiotherapy, nebulisers and warm humidified oxygen are given .

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FLUID RESUSCITATION

In children with burns over 10% TBSA and adults with burns over 15% TBSA, consider the need for intravenous fluid resuscitation

Fluids needed can be calculated from a standard formula

The key is to monitor urine output

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CRYSTALLOID FORMULA

Parkland = 4ml X kg X % TBSA

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FLUID RESUSCITATION

• 50% daily requirement in first 8 hrs• Monitoring must; Pulse, BP, UO• No blood in first 48 hr

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PRINCIPLES OF DRESSINGS FOR BURNS

Full-thickness and deep dermal burns need antibacterial dressings to delay colonization prior to surgery

Superficial burns will heal and need simple dressings

An optimal healing environment can make a difference to outcome in borderline depth burns

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OPTIONS FOR TOPICAL TREATMENT OF DEEP BURNS

• The four most common dressings for full-thickness and contaminated wounds are :

• 1% silver sulphadiazine cream • 0.5% silver nitrate solution • Mafenide acetate cream • Serum nitrate, silver sulphadiazine and cerium

nitrate

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ADDITIONAL ASPECTS OF TREATING THE BURNED PATIENT

1-Analgesia

2-Energy balance and nutrition

3-Monitoring and control of infection

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Infection control in burns patients:

• Burns patients are immunocompromised • They are susceptible to infection from many routes • Sterile precautions must be rigorous • Swabs should be taken regularly • A rise in white blood cell count, thrombocytosis and

increased catabolism are warnings of infection • If there are signs of infection, then further cultures

need to be taken and antibiotics started

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4-Nursing care

5-Physiotherapy

6-Psychological

ADDITIONAL ASPECTS OF TREATING THE BURNED PATIENT

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7-Surgical treatment

• Deep dermal burns need tangential shaving and split-skin grafting

• All full-thickness burns need surgery

• The anaesthetist needs to be ready for significant blood loss

• Topical adrenaline reduces bleeding

• All burnt tissue needs to be excised

• Stable cover, permanent or temporary, should be applied at once to reduce burn load

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Escharotomy

incising the whole length of full-thickness burns

TREATING THE BURN WOUND

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graft

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COMPLICATIONS OF BURN :

general complications of burns 1-inhalation injury & airway damage2-CO poisoning3-all types of shocks4-renal failure (acute tubular necrosis) 5-supra-renal failure6-GI ulcers ( curling ulcers ) 7-multi-organ failure

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LOCAL COMPLICATIONS OF BURN :

-Wound infections .-Wound escher( is a very tough layer in the 3rd degree burn covering the row area & necrotic tissue) >> causing deformities & movement restriction-Malignant ulcers -Loss of functions-Dupuytren contracture (wrist joint movement restriction)-Hypertrophic scar (keloid)

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SOCIAL COMPLICATIONS OF BURN :

-disfigurement-Family breaking & divorce -Low self-esteem-Long absence from the work -unemployment-pressure

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REFERENCES

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THANK YOU

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the thermal injury

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