What types of burn can you get
Thermal = most common - Scald = paeds - Flame = adult - Contact Electrical Chemical Radiation Friction
What causes a scald and when is it common
Wet heat
Commonly paediatric
What does it result in usually but what can it
Superficial skin loss
Boiling water or fat can cause full thickness in seconds
What causes thermal burn
Dry heat from direct contact with flames or hot appliances
What does it result in
Deep burn
What does depth of electrical burn depend on
Energy transfer
- Voltage - high or low
- Contact time
- Factors that lower resistsce
What can electrical burn cause
Sparing of skin but damage to deep tissue
What does severity of chemical burns depend on
Type of chemical
Alkali = more dangerous
What model for changes that burns cause at local level and what are these
- EXAM
Jackson’s Burns Model
Zone of Coagulative Necrosis
Zone of Stasis
Zone of Hyperaemia
What is the Zone of Coagulative Necrosis
Region where direct transfer or heat
Unable to conduct heat away rapidly enough
Leads to immediate coagulation of cellular protein and death
Irrerversible
Loss of sensation
What is the Zone of Stasis
Area of tissue that surrounds necrosis
Damage to dermal microcirculation leads to ischaemia and compromised circulation
Potentially viable tissue
What can happen in Zone of stasis
Can recover under correct condition e.g fluid resus
May undergo necrosis over 3-5 days = known as progression over burn
Always get back to review
May compromise sensation dependent on depth
What is Zone of Hyperaemia
Release of inflammatory mediators from damaged tissue leads to widespread vasodilation and increase in blood flow
Red area
When would this zone involve entire body
If burn >25%
Dangerous as can affect all the body system
What is a significant burn and what requires resus fluids always
20-25% TBSA as will alter all organ system
>15% adults
>10% in children or very frail adults
What systems affected
Vascular / CVS Renal Respiratory GI Metabolic Immune Long term
What happens to vascular system / CVS
Loss from weeping area / skin dysfunction due to zone of hyperaemia = obvious loss
Large volume 3rd space loss = oedema
Vasodilation + increased permeability due to inflammatory mediators
Causes hypo-perfusion and hypovolaemia
Cell death due to ischaemia
What can be life saving and easily correctable
Hypovolaemia with fluid resus
What is an Eschar
Rigid area which doesn’t allow expansion of swelling tissue
Occurs in deep burns down to fat
If circumferential will act as tourniquet
What is required
Escharotomy
Aids respiration and prevents ischaemia
How is renal affected
Hypovolaemia = vasoconstriction of renal artery
Myoglobin from rhabdomyolysis / damaged muscle
Hb from haemolytic further damage kidney
= AKI
How is resp system affected
Widespread bronchoconstriction = ARDS
Bilateral infiltrate on GXR
How is GI affected
Gastroparesis due to SIRS
Stress ulcers
What should you do
Give PPI
How is metabolism affected
Stress hormones released - Cortisol - Glucagon - Catecholamines Suppression of anabolic - Insulin - GH
What does this lead too
Profound catabolic state
Muscle protein breakdown to provide AA to repair burnt tissue
How is immune system affected
Cortisol impacts on immune Infection = biggest mortality in burns Delayed healing Cortisol also causes hyperglycaemia Loss of gut barrier function leads to whole body sepsis
What are most problematic organisms
Psueodomona
MSRA
Fungal in later stage
What is long term consequences
Growth and development Nightmares Social problem Wound breakdown Hypertrophic scars
How do you prevent growth being affected
Correct positioning
Splinting
Early physio
What is most important determinant in severity of burn
Depth of tissue affected
% Body surface area affected
How do you measure BSA affected
Lung and Browder
Wallace Rule of 9’s
Patients palm surface
What is most accurate
Lung and Browder
Used in hospital setting
When is Rule of 9’s used
Outside hospital Divide body parts into multiples of 9 9% = UL and head 18% = LL and torso front and back Groin = 1%
What is patients palm
Palm = 1% of patient’s body
When is it not accurate
Burns >15%
When is it most appropriate
Small burns
Children
Or large burns to measure area not affected
What are types of burn depth
Epidermal Superficial derma (1) Mid-dermal (2) Deep-dermal Full thickness (3)
1st, 2nd, 3rd not used
What causes epidermal
Sunburn = most common
Hot liquid
How do they appear
Red burn
Wet burns
No blisters
SEVERE pain
CRT
Brisk due to vasodilation
How do they heal / scar
Spontaneous with 2 intention
Usually 7-14 days
Minimal scar
Where does superficial-mid dermal extend to
Papillary dermis (upper)
What causes
Sunburn
Hot liquid
How does it present
Pink skin Darker if mid-dermal Small blisters but large if mid-dermal Blanches Superficial = painful Mid = reduced pain
CRT
Slow
How does it heal
Spontaneous
May take 2-4 weeks
Heals with minimal to moderate scar
Mid dermal can go either way
Where deep dermal extend too
Involves entire epidermis and dermis
What causes
Chemical
Flames
How does it present
Dry or moist
Cherry red / blotchy
Blisters or may have none depending on how much dermis
White
Can be painful or painless due to nerve fibres dying
Painless
No sensation
CRT
Absent - no blanching or sluggish
How long to heal
3-8 weeks
What is required to heal
Skin graft
Refer early to skin surgeon
Dress with Ax prior
Will scar
Where does full thickness affect
Destroys epidermis and dermis
Invades into underlying structures
What causes
Chemical
Flames
Explosion
How does it present
Dry White eschar Can see yellow fat Charred No blisters NO PAIN NO SENSATION
CRT
ABSENT
How does it heal
Requires skin graft
Severe scars
What should you always look for with burn
Hidden injury that is masked by visible burn
How does sunburn make you feel ill
Cytokine release
Why does CRT slow
As blood supply is damaged
Do with something sterile
What should you do if on genitalia
Get catheter in quick before swelling
What do you always do
Reassess after 24-72 hours due to progression
