1. Joseph Hardwicke SpR Burns & Plastic Surgery West Midlands Deanery
BURN INJURY
Joseph Hardwicke
SpR Burns & Plastic Surgery
West Midlands Deanery

2. TIMELINE OF BURN CARE THEN GREAT WAR WWII FALKLANDS NUTRITIONAL
SUPPORT
ANTI-SEPSIS
FLUID
RESUSCITION
BURN
EXCISION
"BURN
TOXINS"
SKIN
GRAFTS
MESHED
GRAFTS
MULTI-DISCIPLINARY
APPROACH

3. ? TIMELINE OF BURN CARE NOW REHABILITATION ORGAN SUPPORT SKIN CELL
CULTURE
SKIN
SUBSTITUTES
SCAR
MANAGEMENT
PSYCHOLOGICAL
SUPPORT

4. FIRE DISASTER

6. AIMS Causes of burns and the demographics of UK burn injury
The anatomy of the skin, depth of burn and the Jackson burn wound model
Estimation of burn % total body surface area (%TBSA) and fluid resuscitation
Inhalation injury

7. CAUSES OF BURNS AND THE DEMOGRAPHICS OF UK BURN INJURY

8. CAUSES OF BURNS THERMAL HOT  COLD
Hot or cold
HOT  COLD
Liquid - scald - Freezing - frostbite / nip
Solid - contact - Non-freezing - trench foot
Gas - flame
Direct cellular destruction  Freeze-thaw
 Embolic/thrombotic

9. CAUSES OF BURNS ELECTRICAL Conduction through tissues
Low voltage < 1,000V
High voltage > 1,000V
Superhigh voltage > 10,000V
Conduction through tissues

10. CAUSES OF BURNS Deep tissue destruction Myoglobinuria
Compartment syndrome
Cardiac dysrhythmias

11. CAUSES OF BURNS CHEMICAL ACID  ALKALI IRRIGATION Acid Alkali
Coagulative necrosis - Liquifactive necrosis
Painful - Non-painful tissue destruction
IRRIGATION
Copious water to correct pH

12. CAUSES OF BURNS
RADIATION
UVB
Ionising radiation

13. UK BURN DEMOGRAPHICS 250,000 burns/year 175,000 A&E attendances
13,000 hospital admissions
1,000 resuscitation burns
50% < 16 yrs
300 deaths/year
Majority > 60 yrs

14. CAUSES OF BURNS BURNS FIRST AID THERMAL ELECTRICAL CHEMICAL RADIATION
Stop the burning process
Cool the burn
Cool running water
10-30 minutes
Cover the burn
A&E if area of SKIN LOSS
bigger than palm of hand
KEY POINT
THERMAL
ELECTRICAL
CHEMICAL
RADIATION
Extremes of age
Non-accidental injury
Psychiatric co-morbidity
Industrial / workplace

15. THE ANATOMY OF THE SKIN, DEPTH OF BURN AND THE JACKSON BURN WOUND MODEL

16. SENSORY BARRIER METABOLIC
ANATOMY OF THE BURN
Functions of the skin
SENSORY
BARRIER
METABOLIC
THERMO-
REGULATION
PSYCHO-
SOCIAL

17. DEPTH OF BURN SUPERFICIAL ERYTHEMA PARTIAL THICKNESS FULL THICKNESS
No skin loss
Not included in burn %TBSA
PARTIAL THICKNESS
Superficial
Deep
FULL THICKNESS

18. BURN ZONE OF STASIS
Adequate fluid resuscitation may preserve zone of stasis
Infection may cause burn extension
Early burn excision reduces necrotic load
Prognosis determined by the size of the burn
unburnt skin
zone of
coagulation
zone of
hyperaemia

19. INITIAL BURNS MANAGEMENT
KEY POINT
A : AIRWAY + C-SPINE CONTROL
OXYGEN
B : BREATHING + VENTILATION
C : CIRCULATION
IV ACCESS, STOP BLEEDING
D : DISABILITY
GCS
E : EXPOSURE
TEMPERATURE CONTROL
%TBSA
F : FLUID CALCULATION

20. ESTIMATION OF BURN % TOTAL BODY SURFACE AREA (%TBSA) AND FLUID RESUSCITATION

21. ESTIMATION OF %TBSA BURN
Average adult TBSA 1.7m2
Distribution changes with age

22. BODY WEIGHT Important to calculate fluid requirements
Measure or estimate
MEASURE
ESTIMATE
Under 10 yrs
(age + 4) x 2 = kg
Over 10 yrs
age x 3 = kg

23. FLUID RESUSCITATION Hartman's solution / Ringer's lactate
Then titration of fluids depending upon urine output etc.
KEY POINT
Higher value for:
Inhalation injury
Electrical burns
Paediatric burns
2 - 4 mls/kg/%TBSA
From time of burn
Half given in first 8h
Half given in next 16h

24. INHALATION INJURY

25. INHALATION INJURY Mortality increased by 40% Early airway management
KEY POINT
POINTERS TO INHALATION INJURY
Enclosed space
Delayed extraction
Facial burns
Singed facial hair
Carbonaceous sputum
Hoarse voice / stridor

26. SITE OF INJURY Supraglottic Infraglottic Bronchoalveolar lavage
Thermal injury from inhaled gases
Airway spasm
Infraglottic
Chemical burns from products of combustion
Bronchoalveolar lavage

27. Oxygen-dissociation curve
TOXINS
Products of combustion
CARBON MONOXIDE
Preferential binding to Hb (200x)
Arterial blood gas
<10% normal >60% fatal
HYDROGEN CYANIDE
Synthetic rubber, polyurethane
Inhibits cytochrome C oxidase
Antidote and oxygenate
Oxygen-dissociation curve
shifts to the left

28. OVERVIEW Causes of burns and the demographics of UK burn injury
The anatomy of the skin, depth of burn and the Jackson burn wound model
Estimation of burn % total body surface area (%TBSA) and fluid resuscitation
Inhalation injury

29. WOUND HEALING

30. BASICS OF WOUND HEALING
Sequential process
Driven by cellular and matrix components

31. BURN WOUNDS
Superficial partial thickness wounds heal by re-epithelialisation
Keratinocyte reserve in "epidermal derivatives"
Hair follicles
Sweat glands
Should heal by 2 weeks
Minimal scarring

33. DEEPER BURNS Loss of keratinocyte reserve
Loss of epidermal derivatives
Hair follicles
Oil / sweat glands
May heal by contraction from wound edge
Myofibroblasts
New matrix formed
Fibroblasts
SCAR FORMATION

34. SCARS End stage of normal wound healing NORMAL PATHOLOGICAL
contracture
hypertrophic
keloid

35. IMPAIRED WOUND HEALING
PATIENT FACTORS
Medications
Nutrition
Mobility
Systemic disease
Continence
Smoking
LOCAL FACTORS
Infection
Skin loss
Pressure necrosis
Wound tension
Tissue maceration

36. WOUND DRESSINGS …don't need to be confusing
Adequate cleaning or surgical debridement
Aim for:
Controlled wound environment
Moist wound healing
Infection control
Analgesia

37. THREE COMPONENTS
When putting a dressing on, consider who will be taking it off (and when)….
All (nearly!) are made of 3 things:
A NON-ADHERENT LAYER ± antimicrobials
AN ABSORBANT LAYER depending on exudate
AN ADHESIVE LAYER depending on anatomy
Tailor-made for each patient

38. BURN DRESSINGS After initial assessment and stabilisation
If the burn is suitable for treatment in primary care
Clean wound, deroof large blisters
Definitive dressing
Review at 48h
If transfer is needed to burns centre
Temporary wound cover
Minimal interference
Reduce need for analgesia

39. SKIN GRAFTS The ideal wound dressing?
Supplies cellular and matrix components and is incorporated into the wound
Speeds up wound healing
Reduces pathological scarring in large burn wounds
BUT…
Limited resource
Donor site

40. SPLIT THICKNESS SKIN GRAFT

41. QUESTIONS?

42. FURTHER READING