Lecture 3: Basics Of Burn Injury PDF

LECTURE 3 BASICS OF BURN INJURY DR. LAMIAA SAID ◦A burn is defined the phenomenon that skin cells are destructed or necrotized by heat sources. ◦In addition to the burns caused by heat sources, hot water, friction by hot objects, high-voltage electricity, various chemicals, the toxic gases,...

LECTURE 3 BASICS OF BURN INJURY DR. LAMIAA SAID ◦A burn is defined the phenomenon that skin cells are destructed or necrotized by heat sources. ◦In addition to the burns caused by heat sources, hot water, friction by hot objects, high-voltage electricity, various chemicals, the toxic gases, carbon monoxide, and even the damage of the airway caused by exhaust fumes fall into the category of burns in a broad sense. ◦Burns are acute wounds and progress rapidly through an orderly series of healing steps. Types of burn  Thermal 1-Hot fluid ◦The depth of the burn injury is related to contact temperature, duration of contact of the external heat source, and the thickness of the skin. ◦Hot fluid burn is caused by hot liquids (water, oil, etc.) or hot steam. ◦Hot fluid burns are mainly second-degree burns and often occur in young children or elder people.  2-Flame Burn ◦Flame burn is caused by fire or gas explosion. ◦It mainly breaks out in confined areas in industrial sites or at home. ◦The burn victims are mostly damaged by the flame, and the depth of the damage is severe. ◦ In flame burns, serious damage to the respiratory system is caused by inhalation of the gas accompanying the flame  Cold Exposure ◦Damage occurs to the skin and underlying tissues when ice crystals puncture the cells or when they create a hypertonic tissue environment. ◦ Blood flow can be interrupted, causing hemo concentration and intravascular thrombosis with tissue hypoxia.  Contact Burn ◦Contact burn is caused by the direct contact with a hot grill, cooking utensils, electric iron, or play equipment exposed to the sunlight for a long time. ◦The damaged area is topical but most of the contact burns lead to the second-degree deep burn.  Chemical Burns ◦Chemical burn is caused by the contact with acid, alkali, and other toxins. ◦The severity of damage varies depending on the nature of the chemical, concentration, and the duration of the contact.  Electrical Current ◦Electrical burn is caused by exposure to high voltage electricity. ◦It is mostly caused by electrical shock in the industrial sites, and electrical burn induces serious damage to internal organs.  Inhalation ◦Inhalation burn is caused by breathing in high temperature heat directly or inhaling carbon monoxide or harmful substances directly. ◦When inhaling toxic gases produced from harmful combustion substances, airway resistance increases due to bronchoconstriction. ◦As a function of the cilia in the airway mucosa is degraded, and alveoli are necrotized, the series of respiratory failure symptom that air ventilation is declined, namely, the pulmonary edema, is induced. ◦Also, the mortality rate of inhalation burn is very high due to respiratory failure and high risk of secondary infection  Radiation Burn ◦Radio frequency energy or ionizing radiation can cause damage to skin and tissues. ◦The most common type of radiation burn is the sunburn. ◦Depending on the photon energy, radiation can cause very deep internal burns. ◦ Radiation burns are often associated with cancer due to the ability of ionizing radiation to interact with and damage DNA. ◦The clinical results of ionizing radiation depend on the dose, time of exposure, and type of particle that determines the depth of exposure.  Classification Of Burn ◦According To Depth Of Burn: Superficial or epidermal (first-degree). partial-thickness (second degree). Full thickness (third degree). Burns extending beneath the subcutaneous tissues and involving fascia, muscle and/or bone are considered )fourth degree(  First-Degree Burn ◦First-degree burn or superficial burn refers to the burn that only the epidermis is damaged, and it is commonly caused by sunburn. ◦ First-degree burn does not involve blisters but the skin is inflamed, and it is accompanied with pain after the skin damage. ◦It is then accompanied with a slight headache, but it will be healed in 3–10 days without leaving a scar unless there’s inflammation  Second-Degree Burn ◦Second-degree burn or partial-thickness burn is classified into second-degree superficial burn (or partial‐thickness superficial burn) and second‐degree deep burn (or partial ‐ thickness deep burn) depending on whether the entire epidermis and dermis are damaged or some part of the epidermis and dermis are damaged. ◦Second-degree superficial burn refers to the burn that the epidermis and the papillary layer of the dermis are damaged, and it involves blisters, erythema, edema, and pain, and it takes about 1–3 weeks to be healed, ◦ whereas second‐degree deep burn refers to the burn which the entire epidermis and dermis are damaged, in other words, even the reticular layer is damaged as well as the papillary layer. ◦ In the case of second‐degree deep burn, formed blisters are destroyed and the burnt area is red or white. ◦Hypoesthesia and pain may be accompanied and it takes about 3–5 weeks to be healed  Third-Degree Burn ◦Third-degree burn or full-thickness burn refers to the burn that the damage reaches to full thickness of the skin, i.e., epidermis, dermis, and subcutaneous tissue. ◦The burnt area is white or brown due to the blood clot and becomes hard and dry like dried leather. As nerves are damaged, the patient cannot feel any pain and the skin becomes insensible. ◦In addition, eschar is formed due to necrotic skin tissues, and necrotic skin tissues are naturally eliminated after 2–3 weeks. ◦If the treatment is appropriate, skin tissues will be regenerated; thereby, the wound can be healed. However, since skin regeneration function has been destroyed, skin graft is required for extensive wound treatment. ◦For third-degree burn patients, shock is the most important issue because of large amount of water loss  Fourth-Degree Burn ◦Fourth-degree burn or subcutaneous burn refers to the burn in which adipose tissues, muscles, tendons, and even osseous tissues are completely destroyed as well as the epidermis, dermis, and subcutaneous tissue. ◦ Fourth-degree burn is caused by electrical burn, hot fluid burn, or flame burn for a long time, and the skin becomes barren and dry as it gets burnt black like a mummy. ◦The damage affects the osseous, so sometimes the bones are exposed and amputation is needed. To treat fourth-degree burns, extensive skin graft is required ◦A precise classification of the burn wound may be difficult and may require up to three weeks for a final determination. ◦Children under the age of five and adults over the age of 55 are also more susceptible to deeper burns because of thinner skin.  According To Extent Of Burn ◦A through and accurate estimation of burn size is essential to guide therapy and to determine when to transfer a patient to a burn center. ◦The extent of burns is expressed as the total percentage of body surface area (TBSA). ◦ Superficial burns are not included in the TBSA burn assessment.  Pathophysiological Symptoms During Different Recovery Stages ◦Shock Phase ◦ Burn shock is a term used to describe certain signs such as: Hypovolemia, Increased blood viscosity due to increased ratio of red blood cells to plasma, Reduced cardiac output, Increased heart rate ◦This incident leads to the release of inflammatory substances such as histamines and prostaglandins into the circulation resulting in large movements of fluid from the capillary space. ◦Burn shock mostly occurs within the first 24 hours after sustaining burn injuries with its peak levels at 6 to 8 hours after the injury. It may extend up to 2 to 3 days and last longer in the elderly population ◦Management of Burn Shock ◦Burn shock is better prevented or minimized than treated. ◦The administration of fluid resuscitation promptly, within the first 24 hours of the occurrence of burn injuries is crucial, especially when burns are extensive and above 20% of the total burn surface area in both adults and children. ◦Fluid resuscitation is primarily aimed at the maintenance of vital organ function while also avoiding the complications that may stem from over and under resuscitation. ◦The Parkland formula is mostly used to determine the amount of fluid to infuse. It is given as: ◦Four ml lactated ringers solution × percentage total body surface area (%TBSA) burned × patient's weight in kilograms = total amount of fluid given in the first 24 hours. ◦It is advised that one-half of the quantity of the fluid obtained from the formula be administered over the first 8 hours post thermal injury while the second half should be given over the next 16 hours. ◦The formula only serves to determine the initial fluid rate which is there after adjusted to achieve an hourly urine output between 30 and 50 mL in a 70-kg adult with urine output being an important factor that guides fluid management. ◦It is important to achieve optimal fluid resuscitation as an under- resuscitation can lead to acute kidney injury, reduced perfusion and death, while an over-resuscitation may result in: massive edema formation, compartment syndrome, acute respiratory distress syndrome and multiple organ dysfunction ◦ Contraindications to Fluid Resuscitation ◦ Hemodynamically stable patients may not benefit from fluid resuscitation as this may lead to edema ◦ Complications of Burn Shock May include: ◦ Acute renal failure ◦ Decreased perfusion ◦ Pulmonary edema ◦ Liver failure ◦ Cardiac failure ◦ Occlusion of arteries ◦ Permanent brain damage ◦ Death  ◦Eschar Detachment Phase ◦ The skin of the burn is replaced with eschar and it begins to be detached after 3–4 weeks. ◦ In case of first-degree burn or second-degree superficial burn, the burn begins to be healed from the bottom layers of the skin naturally, but second- degree deep burn or third- to fourth-degree burn requires surgical treatment such as skin graft.  ◦Healing Phase ◦First-degree burn or second-degree superficial burn is healed to normal without any burnt mark, but scar tissues can be formed in some cases. ◦However, second-degree deep burn or third- to fourth-degree burn requires skin graft or surgical treatment which might take over several weeks or several years. complications after burn  ◦1- Cardiovascular response: Acute phase: It is characterized by decreased blood flow to tissues and organs and is thought to be caused by hypovolemia following injury. The acute phase lasts about 48 hours and is followed by: Hyper metabolic phase: Characterized by increased blood flow to the tissues and organs and increased internal core temperature. During the hyper metabolic phase rapid edema formation occurs and this has been attributed to hypo proteinemia, which favors the outward movement of water from the capillary to the interstitium which contributes to edema. ◦Patients with acute burn injuries develop a hyper metabolic state with associated catecholamine production. ◦Increased adrenergic stimulation is one of the triggers of myocardial infarction and cardiac arrhythmias.  ◦2- Pulmonary response: ◦- Respiratory failure is one of the major causes of death after burn injury. ◦- Thermal injury itself, without smoke inhalation, has been shown to produce significant lung changes in numerous animals and in humans Respiratory complications due to local burn include: a- Lung inflammation. These processes occur in the first several hours after a local burn injury and persist for at least 5 days after the burn. b- Lung antioxidant defenses may also be decreased post burn. Respiratory complications due to smoke inhalation: ◦These are the primary cause of mortality for burn victims ◦Typically, the pathophysiological sequence 24-72 hours after burn trauma with inhalation injury. ◦Respiratory complications include: ◦a- pulmonary arterial hypertension. ◦b- bronchial obstruction. ◦c- increased airway resistance. ◦d- reduced pulmonary compliance. ◦e- atelectasis.  ◦3- Renal response: ◦ Diminished blood volume and cardiac output cause a post burn decrease in renal blood flow and glomerular filtration rate. If untreated, the resulting may progress to acute renal failure. ◦The pathophysiologic mechanism may be related to filtration failure or tubular dysfunction.  ◦4- Gastrointestinal Response: ◦The burn patient has been found to have a high incidence of ulcers. ◦Erosion of the stomach lining and duodenum has been demonstrated in 86% of major burn patients within 72 hours of injury, with more than 40% of patients having gastrointestinal bleeding.  ◦5- Immune Response: ◦Severe thermal injury induces an immunosuppressed state that predisposes patients to subsequent sepsis and multiple organ failure, which are the major causes of morbidity and mortality in burn patients.  ◦6-Ocular complications ◦Corneal scarring ( due to thermal coagulation of corneal epithelium or drying of cornea). ◦Cataract formation (specially with high voltage electrical injury).  ◦7-Bone and joint problems Deep burns can limit movement of the bones and joints. Scar tissue can form and cause contractures, when skin, muscles or tendons shorten and tighten, permanently pulling joints out of position. - Osteomyelitis & Heterotopic ossification are a form of skeletal complications that may be accompanied with thermal injury. ◦Osteomyelitis is infection of bone caused by bacteria or other germs (Bacteria can reach bone by traveling through bloodstream or by bacterial invasion of compound fracture from associated trauma). ◦Heterotopic ossification is a process by which bone tissue forms outside of the skeleton (associated with large deep burns).  ◦8-Musculoskeletal complications of burn injury ◦ The metabolic responses of patients following burn are marked by increased urinary losses of nitrogen, potassium, phosphorus and other intracellular constituents indicating an accelerated catabolism or breakdown of muscle in the body. ◦These requirements are met by glycogenolysis, proteolysis (from muscles), lipolysis (to produce energy). This hyper-dynamic response leads to increased:  ◦9-Neurological Complications after Burn ◦ Causes: - ◦Tight Dressings cause compression. ◦Intramuscular injections cause direct injury to the nerve. ◦Scar formation cause direct compression on nerve. ◦Immobilization after skin graft may cause compression on superficial nerves. ◦Edema cause direct compression on nerve or compression on blood vessels that cause decrease blood supply to peripheral nerves and ischemia. ◦Patient positioning and splinting may cause compression on superficial nerves (brachial plexus injury in shoulder burns, ulnar nerve injury in elbow burns, and peroneal nerve injury in knee burns).  10-Hypertrophic scar formation - Hypertrophic scar is overgrowth of dermal constituents within the boundaries of the wound. - Keloid is overgrowth of dermal constituents beyond the boundaries of the wound.  11-Amputation ◦Amputation is often implemented to the burn patients who get severe burn such as third- degree burn or high-voltage electrical burn because nerves, blood vessels, and even osseous tissues including the skin are damaged and the recovery is impossible. ◦Amputation to the burn patients often incurs the problems if the patients are with prosthetics because skin condition of the patients is not good.  Photosensitivity ◦Second-degree deep burn patients have an abnormal skin reaction to sunlight. ◦Melanogenesis continues over 6 months after the burn, and melanization lasts up to 2–3 years after the burn. ◦At this time, the burn can be discolored due to the exposure to sunlight; thus, it is important to block the sunlight so that the burn is not exposed through wearing long sleeves or a hat  Pruritus ◦Pruritus is the complication that appears to most burn patients; it lasts about 6 month to 2 years after the burn. ◦The burn site becomes dry due to destroyed sebaceous glands, and it causes pruritus. ◦ But the more serious problem is that the patients scratch the wound severely because of itchiness, and it badly deteriorates the wound and prolongs the recovery period. ◦In order to minimize the complications, applying oil regularly to prevent skin from drying and constant skin care such as taking antihistamine agents or implementing desensitization treatments are needed. Intervention Approach  Medical Treatment ◦ Emergency Care ◦ ① Remove the cause of the burn and isolate the patient from the cause. If the burn area is wide or if the patient has the burn on the face, hand, and foot or around the anus, ask for help from a medical team. ◦ ② Cut out the clothes on the burn; however, if the clothes are stuck on the burn, do not remove the clothes by force. Especially when removing the metallic stuffs such as wristwatch or ring, one should care not to cause secondary damages. ◦ ③ Cover the burn with sterile gauze or a clean cloth. ◦ ④ Do not apply unascertained medicine (creams, ointments, or any other similar medicines). This may cause the secondary infection and can make the recovery process difficult. ◦ ⑤ In case of chemical burns, dilute the chemical by applying running water sufficiently. At this time, be careful that the chemical is not transferred to other parts of the body. ◦ ⑥ While being prepared to carry the patient to the hospital where manages the burn patients professionally, observe carefully whether the symptoms such as shock, respiratory disorder, or trauma occur to the patient or not.  Fluid Therapy ◦Fluid therapy is absolutely necessary to prevent the shock because water loss is sharply increased in the early days of the burn. ◦Fluid therapy must be started if damaged area is over 20 % of TBSA.  Wound Treatment ◦The purpose of wound treatment caused by the burn is to prevent infections and to have less secondary damages so that the treatment duration can be shortened by helping the healing of the wound and also dysfunction and deformity can be lessen as much as possible. ◦In case of first- degree burns and second-degree burns, clean and dress the wounded areas to prevent infection. ◦And in case of third-degree burns and fourth- degree burns, the early excision of necrotized tissues and skin graft are needed to cover the wounds.  Nutrition Supply ◦For burn patients, nutrition supply is very important. ◦Nutritional imbalance may arise due to an excessive amount of nitric acid loss and declined nitrogen intakes. ◦Resistance to infection of malnourished patients becomes weak, and their crust separation and wound healing period are prolonged. ◦In case of severe burn patients who cannot swallow the food, feed them protein and high-calorie food mainly using the Levin tube.  Surgical Treatment ◦Burn Plastic Surgery Primarily, burn plastic surgery prevents hypertrophic scars caused by the burn which is formed as a burn injury becomes larger in order to make the scars smaller as much as possible. ◦Secondarily, it is performed to recover the appearance and to eliminate the dysfunction by eliminating contracture scars caused by hypertrophic scars  Necrotized Tissue Debridement ◦ The treatment that can effectively heal the burn by removing the necrotized tissue on the wound caused by a burn is the necrotized tissue debridement. ◦ There are three ways in necrotized tissue debridement. ◦ The first way is the surgical way that removes adhesive tissue directly using surgical knives or scissors. ◦ The second way is mechanical method that removes necrotized tissue through water therapy and stimulation of electrical therapy. ◦ The third method is autolysis that efficiently removes the wound of a small area using an enzyme. ◦ In order to remove the necrotic tissue more effectively to improve the skin condition of the patient, a nutritional support such as albumin or protein helps in healing of the wound.  Skin Graft ◦is implemented to cure the area where burns, torn wounds, ulceration, and pressure sore occur. ◦ It is the only medical treatment method that can close the open wounds. ◦For major burn patients who are suffering from third- or forth degree burns, it is better to implement skin graft as early as the eschar is separated, and it is essential for full-thickness burn patients. ◦However, the skin graft is needed in some cases if the wound is on the face, neck, armpit, knees, hands, or feet even though the damaged area is small. Physical therapy treatment  Assessment Of Burn ◦Patient History ◦ 1. Cause of burn injury: What was the source of the burning agent (e.g., Flame, electricity, chemical)? What were the circumstances of the injury? Did it occur in an enclosed space? ◦ 2. The patient’s chief complaint ◦ 3. Time of injury ◦ 4. First Aid Measures ◦ 5. Other trauma Is there related trauma? ◦ 6. Past Medical History Any previous disease, trauma, surgery and burn. Vision and hearing acuity. Balance and co-ordination. Neuromuscular or skeletal deficits. ◦ 7. Medications / allergies / vaccination history What medication does the patient take (including recent ingestion of illegal drugs or alcohol)? ◦ 8. Initial management ◦ 9. Communication  Examination ◦Obtain a complete set of vital signs ◦ Blood pressure should be obtained in an unburned extremity, if possible ◦ Patients with severe burns or preexisting cardiac or medical illness should be monitored by electrocardiogram (ECG) ◦ Other lab. and radiological investigation such as: CBC, blood grouping and cross matching, serum creatinine, urea, random blood sugar, serum electrolytes, serum albumins and chest X-ray  Edema Assessment ◦The techniques of tissue edema evaluation are: ◦ Tape measure form The selected tape measure circumferences can be used as an objective means to record changes in edema formation. ◦ Water displacement method This method is used to assess formation of edema in patients with an acute burn injury especially hand or foot burns This measurement technique requires the patient to place the limb (hand or / foot) in a dependent position.  Sensory Assessment ◦It is the testing of cutaneous sensation by using pin-pricking technique. ◦ Second degree burns Pin pricking can be used to assess cutaneous sensation ◦ Third degree burns: Pin pricking can be used to help the depth of burns. ◦The spinal cord injury may be due to an auto-accident or fall while escaping the fire. These cases require an extensive sensory evaluation (complete sensory assessment).  ROM ASSESSMENT ◦The main standard indicator to assess and measure joint range of motion with burn cases is goniometer. With burn cases, the main causes of the limitation of range of motion are pain, edema, and inelastic eschar  Muscle Strength Assessment ◦There are two types of manual muscle testing: ◦ (1) Gross m. testing, ◦(2) individual (specific) m. testing. ◦ If a burn patient functioned at a normal level before the injury, the gross muscle testing may be required. ◦On the other hand, the specific muscle testing should be considered in cases of severe edema. ◦ The main causes of non physiologic decrease in muscle strength are: (1) Pain. (2) Edema formation. (3) Anxiety.  Endurance Assessment ◦A patient's aerobic capacity is directly affected by consequences of burn injury such as prolonged bed rest and immobilization, rather than as a direct result of burn injury unless an inhalation injury is present  Ambulation Assessment ◦Permission for a patient's ambulation after burn injury is a medical decision. Lower extremity burns are major obstacles that may interfere with ambulation, also the location of the burns may inhibit ambulation especially when the planter aspect of the foot, Achilles tendon area or popliteal space is involved. Deviations in gait patterns are related primarily to pain.  Functional Assessment ◦Technical protocols or / step to achieve functional assessment are: ◦ Hand dominance should be recorded for functional and patient self assistive assessment. ◦ Therapist should know the patient's previous daily living routine to play an important role in planning appropriate treatment and hospitalization progresses. Work, leisure times activities, school level and personal interests should be involved in the treatment program. ◦ The accomplishment of basic task such as feeding, grooming and personal hygiene adds to patient's feeling of progress and self-worth. ◦ Assistive devices may be required to complete these functional activities.  Assessment Of Extend Of Burn ◦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 ◦For adult assessment, the most expeditious method to estimate TBSA in adults is the "Rule of Nines": ◦ Each leg represents 18 percent TBSA ◦ Each arm represents 9 percent TBSA ◦ The anterior and posterior trunk each represent 18 percent TBSA ◦ The head represents 9 percent TBSA 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 TBSA ◦https://youtu.be/j4v7PFw5wA0 ◦https://youtu.be/iZ3P5BuLr8w