Burns Trauma.

ASSIGMENT Presented to: Dr. Manzar Hassan Topic: An introduction to Burns Trauma By: Farah Iqbal Lodhi From: 2nd yr, CC. DOW UNIVERSITY OF HEALTH & SCIENCES. KARACHI.

SKIN:INTRODUCTION: The integument is composed of skin and its associated tissues, sweat glands, sebaceous glands, hair, and nails.  Largest organ of the body; ~16% of the body weight  Covers the entire body  Continuous with the digestive system (lips and anus), respiratory system (nose), and urogenital system (urethra).

STRUCTURE:The skin often mirrors the health of the whole body. The skin is the largest organ of the body and is as indispensable as the body's other major organs. A radiant clear complexion begins with proper nutrition, efficient digestion and assimilation of nutrients by the body and regular elimination.

The skin consists of: 1) Epidermis: The epidermis is the outermost layer and is a microscopic 0.2 mm (8/1000 inch) thick on the face. The surface consists of dead cells which are in the process of flaking away and new ones which are growing to take their place. Between the epidermis and dermis lies the basal layer, where new epidermal cells are formed and progress to the surface. It takes approximately twenty-eight days for a new cell to reach the top.

2) Dermis:The dermis also varies in thickness depending on the location of the skin. It is .3 mm on the eyelid and 3.0 mm on the back. The dermis is composed of three types of tissue that are present throughout - not in layers. The types of tissue are:  collagen  elastic tissue  reticular fibers

Layers of the Dermis The two layers of the dermis are the papillary and reticular layers.  The upper, papillary layer contains a thin arrangement of collagen fibers.  The lower, reticular layer is thicker and made of thick collagen fibers that are arranged parallel to the surface of the skin.

3) THE HYPODERMIS: The hypodermis is composed of loose connective tissue with large numbers of adipose cells. 

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The hypodermis provides insulation, shock absorption, energy storage, and the ability of skin to slide over joints. It also contains the major blood vessels of the skin. Many epidermal appendages extend into the hypodermis. These provide a source of keratinocytes when the epidermis is destroyed by abrasion or burns.

Epidermal appendages: The epidermal appendages include hair follicles, various glands, and nails.  Hair is composed of dead epidermal cells that have undergone a modified epidermal keratinization including the expression of specific keratin proteins that are highly cross linked by disulfide bonds. It is derived from hair follicles, which are epidermal invaginations that project into the dermis or hypodermis.

Sebaceous glands are appendages of hair follicles and are embedded in the dermis and hypodermis throughout the body except on the hands and soles. They are prominent in the face, neck and upper body.

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They consist of several acini that join in a short duct that empties into hair follicles. They secrete by holocrine secretion in which the entire cell contents becomes the secretion due to autolysis. The dead cells are replenished by mitosis at the periphery of the gland. The secretion is sebum, a wax-like mixture of triglycerides and cholesterol. It likely functions as a protective agent and to maintain skin texture and hair flexibility.

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Eccrine sweat glands are simple coiled tubular glands located in the deep dermis or underlying hypodermis and are present throughout the body. Their primary function is evaporative cooling. 

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They develop as invaginations of the epithelium of the epidermal ridge and grow into the dermis. The deep aspect becomes the glandular portion of the sweat gland. Eccrine sweat glands have two regions: a secretory region and a duct region. The secretory portion is comprised of simple coils of cuboidal epithelium containing two kinds of cells. Adults produce between 0.5-10 liters/day.

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Apocrine sweat glands are simple tubular glands that empty into hair follicles in axillary and anogenital regions. The secretion is a mixture of proteins, carbohydrates, and ferric ions that is odorless when secreted, but is acted on by commensal bacteria. They begin to function at puberty; but their function is unknown.

The Function of skin are as follows:  

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Physical barrier against friction and shearing forces. Protection against infection, chemicals, ultraviolet irradiation, particles Prevention of excessive water loss or absorption Ultraviolet-induced synthesis of vitamin D - Sensible exposure to sunlight synthesizes the production of vitamin D through interaction with ergosterol, a naturally occurring fat found in the skin. Vitamin D absorption helps metabolize calcium and phosphorous, which is important to bone and tooth health. Temperature regulation - It is also very involved in maintaining the proper temperature for the body to function well. Sensation (pain, touch and temperature) Antigen presentation/immunological reactions/wound healing.

BURN INJURY: Any injury to the tissue resulting due to exposure and absorption of heat comes under the heading of burn injury.

TYPES OF BURNS ACCORDING TO CAUSES: Fire burn  Electricity burn  Chemical burns  Sunburns  Burns due to contact of skin with extreme hot materials, like frying pan, oven's grill, etc  Radiation  Scalds burn (steam, hot bath water, tippedover coffee cups, cooking fluids, and so on).

DIFFERENT BURN WOUNDS

TYPES OF BURNS ACCORDING TO SEVERITY:Burns are generally put into three categories. These classes are first, second and third degree burns. The burn category indicates the severity of the burn along with the amount of body area covered by the burn injury.  First Degree Burn  Second Degree Burn  Third Degree Burn

1) First-Degree Burns:First-degree burns, the mildest of the three, are limited to the top layer of skin: These burns produce redness, pain, and minor swelling. The skin is dry without blisters. Healing time is about 3 to 6 days; the superficial skin layer over the burn may peel off in 1 or 2 days.

2) Second-degree burns:- are subdivided into superficial and deep partial-thickness burns. a) Superficial partial-thickness burn injury:involves the papillary dermis, containing painsensitive nerve endings. Burn management, burns, burn Blisters or bullae may be present, and the burns usually appear pink and moist. This burn management, burns, burn injuries heal with little or no scarring.

b) Deep partial-thickness burn injury:- damages both the papillary and reticular dermis. These injuries may not be burn management, burns, burn painful and often appear white or mottled pink. Deep partial-thickness burns can produce burn management, burns, burn significant scarring.

3) Third-degree burns or Full-thickness:involve all layers of the epidermis and dermis and may destroy subcutaneous structures. They appear white or charred. These burns are usually insensate because of destruction of nerve endings, but the surrounding areas are extremely painful. Third-degree burns are best treated with skin grafting to limit scarring.

INHALATION INJURY:Damage to the pulmonary parenchyma caused by inhalation of substances such as very hot air, toxic gas, asbestos, and chemical products of plastic manufacture.

HOW TO CALCULATE % OF BURN:Various methods can be used to determine the percent of the body burned: • palm method • rule of nine

* The palm method provides a rough estimate in the field. The surface area of an adults palm is equal to 1% of her BSA. By holding a palm over burns and adding up the areas, you can estimate total bum size.

(Palm of Pt = 1%)

* The rule of nine is another method used by many rescue teams and EDs. In this system, the body is divided into groups equal to about 9% of BSA (for example, the head and neck count as 9% of BSA), and the size of the bum is estimated as a percentage. Because BSA changes with age, a pediatric version of the rule of nines must be used for children.

You can estimate the body surface area on an adult that has been burned by using multiples of 9. An adult who has been burned, the percent of the body involved can be calculated as follows:  Head = 9%  Chest (front) = 9%  Abdomen (front) = 9%  Upper/mid/low back and buttocks = 18%  Each arm = 9%  Each palm = 1%  Groin = 1%  Each leg = 18% total (front = 9%, back = 9%)

BURN TRAUMA SCORE (BTS):The main determinants of mortality after burn injury that can be measured on admission include age, total burn size (% burn), and inhalation injury (INHAL). Other variables, measured during resuscitation, may provide additional information about injury severity. BTS = (Age of Pt. + TBSA + Co-morbid factor)

COMPLICATIONS OF BURN: When skin is burned, it loses its ability to protect, which increases the risk of infection. So it is important that the damaged area be thoroughly cleansed within the first six hours, and that the area is kept clean while it is healing.  If, after a few days, there are signs of an infection - ie the skin is becoming increasingly red, hot, and swollen, and the victim experiences a throbbing pain - contact a doctor or your practice nurse.  Severe burns can cause scarring.  In cases of extensive severe burns, the body may lose large quantities of fluid. This can disturb the blood circulation and cause problems with the body's salt balance. Such injuries should be assessed at your local Accident and Emergency department.

First Aid for Minor Burns:

• Cool the burn with running water or a cold damp cloth. Do not use ice--this may result in more damage to the skin. • Do not use butter, grease, oils, or ointments on the burn. • Cover the burn with sterile gauze or a clean cloth. • Do not use a fluffy cloth such as a towel or blanket. • Take an over-the-counter pain reliever, like acetaminophen (Tylenol)/ Panaram (Paracetamol). • Do not break or pop any blisters. This may result in an infection • If you see signs of infection, get medical attention. Signs of infection include: o Increased pain o Redness o Fever o Swelling o Oozing of pus Once a minor burn is completely cooled you can consider using a fragrance free lotion or moisturizer to prevent drying and make the area more comfortable. Special Cases:

First Aid for Chemical Burns:

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If the chemical causing the burn is a powder, brush the powder away from the skin first. • Check the package insert for emergency information. For certain dry or powdered chemicals it may not be appropriate to flush the skin with water. • If indicated, flush the skin with cool running water for 20 minutes or more. • Remove any contaminated clothing or jewelry while flushing the skin. • If the eyes are affected, flush eyes with cold water until medical help arrives. • Cover burn with sterile gauze or a clean cloth. Do not use a fluffy cloth such as a towel or blanket. • Do not break or pop any blisters. • Keep the person from becoming chilled or overheated. Take the person to the nearest hospital if there are any signs of shock, difficulty in breathing, or if the chemical burn occurred on the eye, hands, feet, groin, face, buttocks, or over a major joint. Emergency medical assistance is also indicated if the chemical caused a partial-thickness burn greater than 2-3 inches in diameter, or if you are unsure if a substance is toxic.

First Aid for Electrical Burns: • Stop the electrical current by unplugging the appliance from the electrical outlet. Do not touch the person until the current has been stopped. • If you cannot turn off the source of the electricity, move the source away from you and the person by using a no conducting object, such as cardboard, plastic, or wood. • Once you and the person are clear of the source of electricity, check the person for airway, breathing, and circulation. Start CPR if necessary and call 911. • Cover burn with sterile gauze or a clean cloth. Do not use a fluffy cloth such as a towel or blanket. • Do not break or pop any blisters. • Keep the person from becoming chilled or overheated. All patients with electrical burns or jolts need to go to a hospital immediately. Electrical burns can cause serious internal damage, without much evidence on the skin. In such cases, people need to be evaluated for heart rhythm disturbances as well as burns.

Entrance wound

Exit wound

INITIAL ASSESTMENT OF MAJOR BURN:A →

Airway

B →

Breathing

C →

Circulation

D →

Deformity or Disability

E →

Exposure with environmental control

F →

Fluid Resuscitation

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Assess burn size and depth. Establish good intravenous access and give fluids. Give analgesia. Catheterize patient or establish fluid balance monitoring. Take baseline blood samples for investigation. Dress wound. Perform secondary survey, reassess, and exclude or treat associated injuries. Arrange safe transfer to specialist burns facility.

INITIAL FLUID RESUSCITATION; PARKLAND FORMULA:

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Initiation of fluid resuscitation should precede initial wound care. In adults, IV fluid resuscitation is usually necessary in second- or third-degree burns involving greater than 20% TBSA. In pediatric patients, fluid resuscitation should be initiated in all infants with burns of 10% or greater TBSA and in older children with burns greater than 15% or greater TBSA. Two large-bore IV lines should be placed. Lactated Ringer's solution is the most commonly used fluid for burn resuscitation.

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The Parkland formula is used to guide initial fluid resuscitation during the first 24 hours. The formula calls for 4 cc*kg*TBSA burn (second and third degree) of lactated Ringer's solution over the fast 24 hours. Half of the fluid should be administered over the first eight hours post burn, and the remaining half should be administered over the next 16 hours. The volume of fluid given is based on the time elapsed since the burn. The Parkland formula is used to guide initial fluid resuscitation during the first 24 hours. The formula calls for 4 cc*kg*TBSA burn (second and third degree) of lactated Ringer's solution over the fast 24 hours. Half of the fluid should be administered over the first eight hours post burn, and the remaining half should be administered over the next 16 hours. The volume of fluid given is based on the time elapsed since the burn. Urine output should be used as a measure of renal perfusion and to assess fluid balance. In adults, a urine output of 0.5-1.0 mL/kg/h should be maintained. Patients with significant burns should have a Foley catheter inserted in order to monitor urine output.