Burns

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Burns

A burn is a type of injury to the flesh or skin caused by heat, electricity, chemicals, friction, or radiation.

Burn disease


Burns that affect only the superficial skin are known as superficial or first degree burns. When damage penetrates one of the underlying layers, then we say that we have a – deep – partial thickness burn or second degree burn. In a -total -burn or third-degree burn, the injury extends to all layers of the skin. A fourth-degree burn additionally involves injury to deeper tissues, such as muscles or bones.

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The treatment required depends on the severity of the burn. Superficial burns can only be treated with simple pain analgesics, while severe burns may require prolonged treatment at specialized burn rehabilitation centers. Cooling the burn with a little tap water may relieve pain and reduce damage, however prolonged exposure can lead to hypothermia.

For deep-partial burns, it may be necessary to clean with soap and water and bandage the wound. Total fat burns usually require surgery, such as a skin graft. Extended burns usually require large doses of intravenous fluids because the subsequent inflammatory reaction will result in significant capillary fluid leakage and swelling.

The most common complications of burns are related to infection. Although extensive burns can be fatal, modern therapies developed since 1960 have significantly improved outcomes, especially in children and adolescents. An estimated 11 million people worldwide seek medical treatment, and 300,000 people die from burns each year. In the United States, about 4% of burn victims who go to a burn rehabilitation center die from their injuries. The long-term effect is primarily related to the size of the burn and the age of the burn.


Causes


Burns are caused by a variety of external sources that are distinguished into thermal, chemical, electrical and radiation. In the United States, the most common causes of burns are: fire or flame (44%), scalding from hot liquid (33%), hot objects (9%), electricity (4%), and chemicals (3%). Most burn injuries (69%) occur at home or at work (9%), while most are caused by an accident, with 2% resulting from an attack by someone else and 1-2% resulting from a suicide attempt. These causes can cause inhalation injury to the airways and / or lungs, occurring in up to 6%.

Most burn injuries are more common in the poor. Smoking is a risk factor, while alcohol use is not a risk factor. Fire-related burns are usually more common in colder climates. In the developing world, specific risk factors include cooking over an open fire or on the floor, as well as developmental problems in children and chronic diseases in adults.


Thermal burns


In the United States, fire and hot liquids are the most common causes of burns. Of the house fires that cause death, smoking causes 25% and radiators cause 22%. Almost half of the injuries are due to attempts to extinguish a fire. Scalding is caused by hot liquids or gases and is most often caused by exposure to hot liquids, high tap water in the bath or shower, hot cooking oil, or steam.

Scalding injuries are more common in children under the age of five, while in the United States and Australia, this population accounts for 2/3 of all burns. Contact with hot objects causes about 20-30% of burns in children. Usually scalding burns are first or second degree, however third degree burns can also occur especially if there is extensive contact. Fireworks are a common cause of burns during the holidays in many countries. This is a specific risk for adolescent boys.



Chemical burns


Chemicals cause 2 to 11% of all burns and contribute up to 30% of burn-related deaths. . Chemical burns can be caused by more than 25,000 substances, most of which are either a strong base (55%) or a strong acid (26%). Most deaths from chemical burns come second after ingestion.

Common agents are: sulfuric acid as found in toilet cleaners, sodium hypochlorite as found in bleach, and halogenated hydrocarbons as found in bleach, among others. Hydrofluoric acid can cause very deep burns which may not occur immediately but at some point after exposure to them. Formic acid can damage a significant number of red blood cells.


Electrical burns


Burns or injuries caused by electricity are classified as high voltage (greater than or equal to 1000 volts), low voltage (less than 1000 volts), or radiation burns secondary to a voltage arc. The most common causes of electrical burns in children are electrical wires (60%) and electrical outlets (14%). Lightning can also cause electrical burns. Risk factors that can cause lightning strike include outdoor activities such as mountaineering, golf, sports played on the field / track and outdoor activities. The mortality rate from lightning strike is about 10%.

Although electrical injuries mainly result in burns, they can also cause fractures or dislocations as secondary to blunt trauma or muscle contraction. In high voltage electrical injuries, most of the damage can be done internally and so the extent of the injury cannot be estimated from a single skin examination. Contact with low or high voltage electricity can cause heart arrhythmias or heart attack.


Radiation


Radiation burns can be caused by prolonged exposure to ultraviolet rays (such as those from the sun, in tanning chambers or electric arc welding) or by ionizing radiation (such as radiation therapy, radiographs or radioactive dust). Sun exposure is the most common cause of radiation burns as well as the most common cause of superficial burns in general. There is a significant variation in how easily people get sunburn depending on their skin type.

The effects on the skin of ionizing radiation depend on how much it has been exposed to the area, then 3 Gy hair falls out, followed by 10 Gy redness, 20 Gy skin peeling, and then necrosis. 30 Gy. Redness, if it occurs, may appear sometime after exposure. Radiation burns are treated like any other burn. . Microwave burns occur through heat heat generated by microwave ovens. Although small exposures such as two seconds can cause injury, this is not often the case.


Non-accidental


In those hospitalized for either scalding or fire burns, 10% are attacked. Reasons include: child abuse, personal disputes, marital abuse, elder abuse, and business disputes An injury or burn from immersion in hot liquid may indicate child abuse. It is caused when one limb or lower body (rear or perineum) is held below the surface of hot water. It usually forms a sharp upper edge and is often symmetrical.

Other high-risk signs of possible abuse include: peripheral burns, lack of splash marks, a burn of even depth, and any association with other signs of neglect or abuse. Burning the bride, a form of domestic violence, takes place in some cultures such as India, where the woman is burned because her husband or family considers the dowry to be insufficient.

In Pakistan, acid burns account for 13% of international burns and are often associated with domestic violence. Self-immolation (setting oneself on fire as a form of protest) is also very common among Indian women.


Pathophysiology


At temperatures above 44 ° C (111 ° F), proteins begin to lose their three-dimensional shape and break down. This leads to the destruction of cells and tissues. Many of the immediate effects of a burn are secondary to disruption of normal skin function. These include impaired skin sensation, the ability to prevent water loss through evaporation, and the ability to control body temperature. Disruption of cell membranes causes cells to lose potassium outside the cell and receive water and sodium.

In large burns (over 30% of the total body surface area) there is a significant inflammatory response. This leads to increased leakage of fluid from the capillaries, and consequent swelling of the tissues. It causes a total loss of blood volume, with the rest of the blood experiencing significant plasma loss, making the blood more concentrated. Poor blood flow to organs such as the kidneys and gastrointestinal tract can lead to kidney failure and stomach ulcers.

Elevated levels of catecholamines and cortisol can lead to a state of hypermetabolism, which can last for years. This is associated with increased heart rate, metabolism, rapid heart rate and poor immune function.


Mode


Burns can be classified according to the depth, the mechanism of the injury, the extent and the related injuries.

Dept.
The most commonly used classification is based on the depth of the injury. The depth of a burn is usually determined by examination, although a biopsy may also be used. It can be difficult to pinpoint the depth of a burn in a single examination, and repeated exams may be needed over a period of a few days. Those who have a headache or dizziness and have fire burns should be tested for carbon monoxide poisoning. Cyanide poisoning should also be considere.

Size
The size of a burn is measured as a percentage of total body surface area (TBSA) affected by partial or full thickness burns. First-degree burns that are merely red and have no blisters are not included in this estimate. Most burns (70%) extend to less than 10% of TBSA.
There are a number of methods for determining TBSA, including the “rule of 9”, Lund and Browder tables, and calculations based on a person’s palm size. It is easy to remember the rule of 9, but it is only accurate for people over 16 years old. More accurate calculations can be made using Lund and Browder tables, which take into account the different proportions of body parts in adults and children. The size of a person’s handprint (including the palm and fingers) is about 1% of his TBSA.


Seriousness


American Burn Association severity classification

Small Medium Large

Adults <10%>
Adults 10-20% TBSA

Adults> 20% TBSA

Young or old <5% = "">

Young or old 5-10% TBSA

Young or old> 10% TBSA

<2% burn = "" complete = "">
2-5% full thickness burn

> 5% full thickness burn

High voltage injury

High voltage burn

Possible injury from aspiration

Known aspiration injury

Perimeter burn

Significant burn on face, joints, arms or legs

 

Other health problems

Related injuries

 

To determine the need for referral to a specialist burn unit, the American Burn Association devised a classification system. According to this system, burns can be classified as large, medium and small. Size is assessed based on a number of factors, including the total body surface area affected, the involvement of specific anatomical zones, the age of the individual, and related injuries. Minor burns can typically be treated at home, moderate burns are often treated in the hospital and large burns are treated at a burn center.


Prevention


Historically, it is estimated that about half of all burns could have been prevented. Burn prevention programs have significantly reduced the rates of severe burns. Precautions include: limiting hot water temperatures, smoke detectors, sprinkler systems, proper building construction and fireproof clothing. Experts recommend setting the water heater temperature below 48.8 C. Other measures to prevent burns include the use of a thermometer to measure bath water temperatures and splash guards in ovens. Although the effect of fireworks regulations is unclear, there are some indications of benefit with the recommendations including restricting the sale of fireworks to children.


Treatment


Resuscitation begins with the evaluation and stabilization of the individual’s airway, respiration and circulation. If aspiration injury is suspected, early intubation may be required. This is followed by the care of the burn wound itself. People with extensive burns may be wrapped in clean sheets until they reach the hospital. Because burns are prone to infections, an anti-tetanus booster vaccine should be given if the person has not been vaccinated in the last five years.

In the United States, 95% of burns presented to the emergency department are treated and discharged, while only 5% require hospitalization. In the case of large burns, early feeding is important. In addition to traditional therapies, hyperbaric oxygenation can be used.



Intravenous fluid administration


Concentrated doses of isotonic crystalline solution should be given to patients with poor tissue perfusion. In children with burns above 10-20% TBSA and in adults with burns above 15% TBSA, formal fluid recovery and follow-up should follow. This should be started before hospitalization if possible in those with burns greater than 25% TBSA. Parkland formula can help determine the volume of intravenous fluids needed during the first 24 hours. The formula is based on TBSA and the weight of the affected person.

Half of the fluid should be given within the first 8 hours and the rest given within the next 16 hours. The time frame is calculated from the moment the burn occurred and not from the moment the fluid recovery began. Children need extra maintenance fluid, which includes glucose. In addition, those with aspiration injuries need more fluids. While insufficient fluid recovery can cause problems, excessive recovery can also be harmful.

The formulas are just a guide, with infusions ideally suited to urine output> 30 mL / h for adults or> 1mL / kg for children and an average blood pressure higher than 60 mmHg. Although Ringer’s Lactic Solution is often used, there is no evidence that it is superior to saline. Crystalline liquids appear to be just as good as colloidal liquids and because colloids are more expensive, they are not recommended.

Blood transfusions are rarely required. They are typically only recommended when the hemoglobin level falls below 60-80 g / L (6-8 g / dL) due to the associated risk of complications. Intravenous catheters can be inserted through the burned skin if necessary or intraosseous infusion can be used.


Trauma care


Early cooling (within 30 minutes of the burn) reduces the depth and pain of the burn, but measures must be taken as excessive cooling can lead to hypothermia. It should be done with cold water 10–25 C and not with ice, as the latter can cause further injury. Chemical burns may require extensive irrigation. Cleaning with soap and water, removing dead tissue and applying bandages are important elements of wound care.

Second degree burns should be re-evaluated after two days. There is little qualitative evidence to determine the type of dressings to be used when treating first and second degree burns. It makes sense to treat first-degree burns without bandages. While topical antibiotics are often recommended, there is little evidence to support their use. Sulfadiazine silver is not recommended as it may prolong the healing time. There is insufficient evidence to support the use of silver-containing dressings or for the treatment of negative pressure wounds.


Medicines


Burns can be very painful and there are a number of options that can be used to treat the pain. These include simple analgesics (such as ibuprofen and acetaminophen) and opioids such as morphine. Benzodiazepines can be used in combination with analgesics to help with anxiety. During the healing process, antihistamines, massage, or percutaneous nerve stimulation can be used to help with the itching. Antihistamines, however, are effective for this purpose in only 20% of people. There is evidence to support the use of gamapentin and its use may make sense to those who do not improve without antihistamines. Intravenous antibiotics are recommended before surgery for those with extensive burns (> 60% of TBSA).

Standard: The guidelines do not recommend their general use due to concerns about antibiotic resistance and an increased risk of fungal infections Indicative evidence, however, suggests that they may improve survival rates in those with severe burns. Erythropoietin has not been found to be effective in preventing or treating anemia in people with burns. In hydrofluoric acid burns, calcium gluconate is a specific antidote and can be used intravenously and / or topically.


Surgery


Injuries that require surgical closure with skin grafts (typically anything larger than a small full-thickness burn) should be treated as soon as possible. Perimeter burns of the limbs or chest may require urgent surgical release of the skin, known as a scarotomy. This is done to treat or prevent problems with the peripheral circulation or ventilation. It is uncertain whether it is useful for burns on the neck or fingers. Electric burns may require incisions of the fascia.

In low-income countries, burns are treated up to a third of the time with traditional medicine, which may involve applying eggs, mud, leaves or cow dung. Surgery is limited to a few classes due to insufficient financial resources and availability. There are a number of other methods that can be used in conjunction with medications to reduce surgery pain and stress, including: virtual reality therapy, hypnosis, and behavioral approaches, such as distraction techniques.


TBSA forecast


Mortality

<10%>

10-20% 2,9%

20-30% 8,6%

30-40% 16%

40-50% 25%

50-60% 37%

60-70% 43%

70-80% 57%

80-90% 73%

>90% 85%

Suction 23%

The prognosis is worse for those who have more burns, those who are older, and women. The presence of a smoke aspiration injury, other significant injuries such as large bone fractures and serious comorbidities (eg heart disease, diabetes, psychiatric illness and suicidal ideation) also affect the prognosis. On average, 4% of people admitted to burn centers in the United States die, with the result for individuals depending on the degree of burn injury. For example, those with burn areas below 10% of TBSA had a mortality rate of less than 1%, while those with more than 90% of TBSA had a mortality rate of 85%. In Afghanistan, people with burns over 60% of TBSA rarely survive. The Baux score has historically been used to determine the prognosis of major burns; however, with improved care, it is no longer very accurate. The score is determined by adding the size of the burn (% TBSA) to the age of the person, who used to be more or less equal to the risk of death.


Complications


There can be a number of complications, with infection being the most common. In order of frequency, possible complications include: pneumonia, cellulite, urinary tract infections and respiratory failure. Risk factors for infections include: burns greater than 30% of TBSA, full-thickness burns, extreme ages (young or old) or burns to the legs or perineum. Pneumonia occurs especially often in those who have aspiration injuries. Anemia is secondary to full-blown burns that are greater than 10% of TBSA.

Electric burns can lead to compartment syndrome or rhabdomyolysis due to muscle damage. It is estimated that 6 to 25% of people have blood clots in the veins of the legs. Hyper-metabolic conditions, which can persist for years after a major burn, can lead to a decrease in bone density and loss of muscle mass.

Keloids can develop after a burn, especially in those who are young and have dark skin. After a burn, children may have severe psychological trauma and experience post-traumatic stress disorder. Scars can also lead to body image disorder. In the developing world, major burns can lead to social exclusion, extreme poverty and child abandonment.


Epidemiology


In USA since 2004, 11 million burns have required medical care worldwide and have resulted in 300,000 deaths. This makes them the 4th leading cause of injuries after motor vehicle collisions, falls and violence. About 90% of burns occur in the developing world. This has been attributed in part to overcrowding and unsafe cooking conditions. Overall, almost 60% of fatal burns occur in Southeast Asia at 11.6 per 100,000.

In the developed world, adult men have twice the mortality rate of women due to burns. This is probably due to higher risk occupations and more risky activities. In many countries in the developing world, however, women are twice as likely as men. This is often related to kitchen accidents or domestic violence.

In children, burn deaths occur more than ten times more often in the developing world than in the developed world. Overall, it is one of the top 15 causes of death in children. From the 1980s to 2004, many countries saw a decline in both fatal burns and burns in general.


Developing countries


In India, about 700,000 to 800,000 people suffer significant burns each year, although few are cared for in special burn units. The highest rates occur in women aged 16-35. Part of this high percentage is related to the unsafe kitchens and loose clothing that are common in India. It is estimated that one third of all burns in India are caused by clothes that catch fire. Intentional burns are also a common cause and occur in higher rates in young women, secondary to domestic violence and self-injury.


History


Guillaume Dupuytren (1777-1835) who created the classification of burn grades. Cave paintings dating back more than 3,500 years before documenting burns and their treatment. Smith’s Egyptian papyrus, dating from 1500 BC, describes treatments using honey and resin ointments. Over the years many other remedies have been used, including Chinese tea leaves, documented in 600 BC, hog fat, and Hippocrates’ vinegar, documented in 400 BC. and wine and myrrh from Celsus, documented in 100 AD. The French barber-surgeon Ambroise Paré was the first to describe the different degrees of burns in the 1500s. [69] Guillaume Dupuytren extended these degrees to six different degrees in 1832.

The first burn hospital opened in 1843 in London, England, and the development of modern burn care began in the late 1800s and early 1900s. During World War II, Henry D. Dakin and Alexis Carrel developed standards for defining and disinfection of burns and wounds with the use of sodium hypochlorite solutions, which significantly reduced mortality. During the 1940s, the importance of early skin resection and transplantation was recognized, and around the same time, fluid repair and formulas were developed to guide them. In the 1970s, researchers demonstrated the importance of the hyper-metabolic state that accompanies major burns.


Types of burns


Burn is the tissue destruction of the skin due to the effect on it of a harmful cause. Depending on the type of cause, burns are divided into thermal, chemical, electrical, radial. Due to its important role in the body’s defense, preventing the passage of germs in the body, its role in thermoregulation, protecting the body from extreme incompatible with life temperatures, its extensive loss is incompatible with life.

Types of burns

Chemical burn with sodium hydroxide 1. Heat burns: They are caused by the effect of heat directly on the skin such as fire, flammable clothes, hot objects, hot water (scalding), friction temperature. 2. Chemical burns: Contact of chemicals on the skin (alkalis such as KOH, acids such as HNO3, lime, phosphorus, hydrogen fluoride, etc.). 3. Electric burns: are caused by the effect of electricity on the skin. The electric burn should not be confused with a thermal burn caused by an electrical appliance, eg contact with a hot electric iron. 4. Radial burns: They come from the effect of radiation (sun, nuclear)

Burn Separation Many attempts have been made to categorize burns. • In the classic categorization, burns are divided into 3 degrees (a ‘, b’, c ‘) 1. First degree: It concerns the damage only to the skin 2. Second degree: It concerns the damage beyond the skin and the skin 3. Third degree : Concerns the skin, the skin, as well as the glands (sweat-producing, sebaceous), hair •

Another way to separate the burns is to divide them into epidermal (corresponding to those of grade A and B) and subcutaneously (grade C) • We can separate them into deep (all the thickness of the skin) and superficial (part of the thickness of the The American Burn Society classification is as follows: Second-degree child burns Second-degree adult burns Third-degree burns Mild <10% area = "" skin = ""> <15% area = "" skin = " "> <2% area =" "skin =" "waist =" "gravity =" "10% -20% =" "area =" "skin =" "15% -25% =" "area =" "skin = ""> <10% area = "" skin = "" heavy = ""> 20% skin area> 25% skin area> 10% skin area

Mild burns can be treated at an outpatient level, moderate burns require hospital care, and severe burns need a specialized burn center. First aid given to the burn Removal of clothing, placement of a venous catheter for the administration of fluids, collection of arterial blood for the determination of blood gases, administration of analgesics intravenously, culture (from the wound) to detect infection and localization , administration of an anti-tetanus vaccine. Scar cuts may also be performed to prevent compression of the soft tissues and cavities by the swelling of the tissues.

Shock
The life-threatening condition of the burn victim is shock, due to loss of plasma either in the form of bubbles or in the intercellular space (edema) due to vasodilation. So the body has losses of albumin and water and consequently we have an increase in hematocrit, because in less blood volume we have the same red blood cells. Due to the increase in the hematocrit, it is more difficult for the red blood cells to pass through the vessels and it is difficult for the tissues to oxygenate.

The rate of plasma extravasation depends on the extent and not the depth of the burn. Shock is treated with colloidal solutions such as plasma (which is scarce) and dextrans (liver complications have been reported). Because of these difficulties, isotonic electrolyte solution (Ringer’s lactate) and human albumin are used.

Dosage schedule The administration of the substances depends on the extent of the burn and the weight of the body. x (cubic cm) = Burn area% * Body weight (kg) / 2 The phase of shock which lasts 36-48 is divided into (3) four hours, (2) six hours and 1 to 2 twelve hours (depending on condition and needs of the burn victim). We administer in each phase one x, accompanied by 4G every four hours, 2G every six hours, and 1G every twelve hours, where G is 100 cc of 5% glucose.

Respiratory It is very important to detect carbon monoxide (CO) poisoning, as CO has 210 times higher affinity for hemoglobin than oxygen. Inhalation burns may also be caused, especially if there are burns on the face. A third risk is the occurrence of laryngospasm due to the entry of hot air and toxic substances.


Treatment


Treatment of burns can be conservative and surgical Conservative Treatment

Open method: Exposure of burn surfaces to air rather than gauze coverage. The advantages of the method are: dryness and light prevent the multiplication of germs, the wounds can be monitored immediately and easily, the mobility of the limbs is allowed and the kinesiotherapy starts immediately. A necessary condition for the choice of this method is the existence of isolated wards for hospitalization as well as specialized medical and nursing staff to avoid infections. The open method is suitable for burns of the face, perineum, while for burns of limbs and trunk the closed one is preferred.

Closed method:

Cover the burn areas with Vaseline gauze coarse weave. The advantages of the method are the protection of the wound from infection, the absorption of exudates and keeping the wound dry, as well as the reduction of pain. The use of substances to control germs is essential in both methods.

Surgical treatment

To reduce the time of hospitalization and the best functional and aesthetic restoration of the burn area and to avoid complications, surgical treatment is performed. Each center, depending on its experience in each method, the needs of the case, chooses which method to follow.
• Transplantation on carnivorous surfaces after apoptosis of scars (created by scars). Late (8-15 post-burn days) grill resection and transplantation with cuttings from a healthy area.
• Immediate (3 post-burn days) resection of grate and transplantation with transplants from a healthy area. It is indicated for facial burns, on the hands and in the breast area of ​​little girls so that the gland is not damaged.


Surgery
Burn

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Dr. Karantonis Professionalism. Perfection. Experience.






Professionalism. Perfection. Experience.




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