Clinical Atlas of
Burn Management
(Trang không có chữ)
Clinical Atlas of
Burn Management
JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD
New Delhi • Panama City • London
®
Sujata Sarabahi MS MCh DNB MNAMS
Associate Professor and Senior Plastic Surgeon
Department of Burn, Plastic,
Maxillofacial and Microvascular Surgery
Vardhaman Mahavir Medical College and
Associated Safdarjung Hospital
New Delhi, India
VK Tiwari MS MCh
Professor and Consultant Plastic Surgeon
Department of Burns, Plastic,
Maxillofacial and Microvascular Surgery
Vardhaman Mahavir Medical College and
Associated Safdarjung Hospital
New Delhi, India
Published by
Jaypee Brothers Medical Publishers (P) Ltd
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Clinical Atlas of Burn Management
© 2011, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by
any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors and
the publisher.
This book has been published in good faith that the material provided by authors is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and authors will not be held responsible for any inadvertent error(s). In case of
any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition : 2011
ISBN 9978-93-5025-276-5
Typeset at JPBMP typesetting unit
Printed at
Dedicated to
The fond memories of my Father-in-Law
(Late) Padmashree Dr LC Gupta
Without whose inspiration and guidance,
I would not have been able to complete this book
— Sujata Sarabahi
(Trang không có chữ)
As a sequel to our textbook Principle and Practice of Burn Care, and to keep ourselves updated with the latest in
the clinical and surgical principles of Burn Care, we have prepared and brought out an Atlas.
This Clinical Atlas of Burn Management depicts different types of burn cases, well illustrated with colorful
photographs. In this effort, we have been guided by our seniors and other experts in this field also. This atlas
is, therefore, an outcome of our enormous experience from our day-to-day dealings with such varied types of
burn patients. It is meant to help both students and treating surgeons to identify and determine the exact
nature of the damage caused by severe burns and resultant wounds.
We are sure that the readers will find it different from what we have on our bookshelves so far and it will
prove to be handy for a quick reference on matters related to diagnosis and proper treatment after accurate
assessment.
Hoping that this atlas will fulfil the long recognized need of having a short, yet comprehensive book in
every surgeon’s clinic.
Wishing our readers Best of Luck …
Sujata Sarabahi
VK Tiwari
Preface
(Trang không có chữ)
1. Causes and Classification of Burns................................................................................................................... 1
2. Pathophysiology of Burn Shock and Burn Wound ...................................................................................... 31
3. Initial Management of Burns ........................................................................................................................... 41
4. Burn Wound Management ................................................................................................................................ 65
5. Burn Wound Infection ..................................................................................................................................... 101
6. Electric Burns ..................................................................................................................................................... 129
7. Chemical Burns ................................................................................................................................................. 165
8. Burns of Special Areas..................................................................................................................................... 177
9. Postburn Sequelae ............................................................................................................................................ 193
10. Radiation Burns ................................................................................................................................................ 239
Index .................................................................................................................................................................... 245
Contents
Causes and Classification of Burns 1
Clinical Atlas of Burn Management
2
DEFINITION OF BURNS
Burns is a syndrome of local and systemic manifestations following any injury to the body by an energy
source which could be heat, electricity, radiation, friction or by chemicals. They can be classified according
to etiology, depth and percentage body area burnt.
CLASSIFICATION ACCORDING TO ETIOLOGY
a. Physical agents—heat, electricity, friction, radiation, laser, etc.
b. Chemical agents—acids, alkalis, etc.
Thermal Burns
Causes and Classification of Burns
3
Fig. 1.1: Adult sustaining flame burns due to clothes catching
fire. Superficial burns involving 25 percent body surface area
(BSA). Flames are the most common agent of burn injuries
in developing and underdeveloped countries
Fig. 1.2: Four weeks old post-burn raw area in lower leg due
to contact with hot object—silencer of motor bike.These burns
are always localized to the area of contact and are usually
deep and require grafting either after primary excision or
after the wound granulates
Fig. 1.3: Another child with silencer burns to foot which
are deep dermal and took 4 weeks to heal completely
Fig. 1.4A: Accidental burn due to contact with hot iron in
a 3-year-old child. The central area of burn wound is deep
dermal and peripheral area is superficial dermal
Clinical Atlas of Burn Management
4
Fig. 1.4B: Same patient treated with collagen dressing. The
peripheral superficial burns healed in 5 days and the central
deeper wound healed in 3 weeks. The child required silicone
gel sheet and pressure garment to prevent hypertrophy in the
central area
Fig. 1.5A: Blast injury right hand due to fire cracker (Anar
or flowerpetal or fountain) exploding prematurely in the hand
causing extensive damage to the soft tissues and bones. The
fractured bones of fingers were fixed with K-wires and since
the vascularity was initially doubtful the skin closure was
delayed and done after a second assessment for viability on
5th day
Fig. 1.5B: Dorsal aspect of the same hand—nail bed of
little and ring finger showing discoloration and doubtful
viability
Fig. 1.6A: View of blast site at Sarojini Nagar market, New
Delhi in November 2005. Terrorist planted a bomb near a
LPG cylinder in an eatery corner. The combined effect of
blast and fire caused extensive damage to both human life
and property
Causes and Classification of Burns
5
Fig. 1.6B: Same blast site next day
Fig. 1.7: The number of casualties during such blasts is
enormous and majority are extensively burnt beyond
recognition
Fig. 1.8: Superficial scalds on chest in a child due to hot
water spillage. Scalds are the commonest cause of burns in
developed nations and second commonest cause in
developing and underdeveloped nations. The depth of damage
depends upon the temperature of liquid and duration of
contact. Scalds in adults are usually superficial though in
infants and toddlers they may be actually deeper because
their skin is comparatively thinner
Fig. 1.9: Deep burns of face caused by improper use of
steam for inhalation in an infant for treatment of upper
respiratory tract infection. These burns are deep because of
the release of latent heat from steam. It can even cause
upper airway edema on inhalation
Clinical Atlas of Burn Management
6
Electric Burns
Fig. 1.10: Electric contact burn involving right hand in a
construction worker. Wound of entry is seen in the fingers.
Wrist and elbow show evidence of arcing phenomenon. The
hand appears to be viable as seen in the nail bed, but there
is a high chance of progressive damage and compartment
syndrome which can hinder the circulation to the hand.
Procedures to prevent damage secondary to compartment
syndrome, like a fasciotomy will be required early
Fig. 1.11: Electric flash burn in lower leg following sparking
from electric transformer. The burns are due to the high
temperature electric sparks coming in contact with the skin
for varying duration of time causing deep dermal burns at
some places and superficial burns at other places leading to
a cobble stone appearance
Causes and Classification of Burns
7
Radiation Burns
a. Ionizing radiation—γ-rays, X-rays
b. Nonionizing radiation—radiowaves, microwaves
Fig. 1.12: Evolution of cutaneous radiation syndrome following accidental exposure to an industrial radiographic device
showing fixed erythema and blistering 4 weeks postexposure. Erythema is best appreciated in fair skinned individuals. The
transient erythema cannot be appreciated in the dark skinned. In the dark skinned, fixed erythema appears darkly pigmented.
(Courtesy: Dr BC Shankar, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India)
Fig. 1.13: Frictional burns on thigh due to truck tyre running over the limb. The friction between skin and tyre produces
kinetic energy which is converted to thermal energy or heat leading to superficial to deep dermal burns
Friction Burns
Friction burns are associated with mechanical injury in majority of the cases.
Clinical Atlas of Burn Management
8
Figs 1.14A and B: (A) Frictional burns on one side of face of a young boy who fell from a bike and was dragged along on
the road for some distance. The soft tissue of the face rubbing against the hard irregular surface of the road produces a
large amount of heat energy which causes burns. Though the wounds apparently appear to be deep, they usually heal well
in the face because of the good blood supply, without leaving any scars. (B) 3 months post-trauma picture of the same
patient with hardly visible scars
Fig. 1.15: Friction burns over dorsal aspect of fingers due to fingers coming under a pressing machine. In this case,
the burns were deep over the area of the proximal interphalangeal joints which require skin grafting
A
B
Causes and Classification of Burns
9
Laser Burns
Laser burns: Laser energy producing heat leads to burns if not used properly.
Fig. 1.16: Laser burns in axilla following laser treatment for hair removal. The damage to the skin will depend upon the
energy released by the laser. The lesions are typically deep and punctate which heal by contraction and leave behind
hypertrophic scars. In case of hair removal, cold air blast is to be given along with the laser beam to nullify the effects of
heat
Chemical Burns
Clinical Atlas of Burn Management
10
Fig. 1.17: Homicidal deep acid burns of face in a woman destroying both the eyes
CLASSIFICATION ACCORDING TO PLACE AND MODE OF INJURY
Causes and Classification of Burns
11
Fig. 1.18: Kerosene pump stove is the commonest cause of
accidental flame burns in developing countries when these
appliances malfunction due to defective manufacturing. This
works on the principle of aerosolized kerosene oil. It is a
pressure stove in which continuous pumping aerosolizes the
kerosene. If the burner nozzle is choked and vigorous pumping
of the stove tank is continued, pressure builds up inside this
molded tin tank and it very frequently bursts. This is usually
used for commercial purposes by street vendors
Fig. 1.19: This kerosene stove is used for domestic purposes
and also works on the same principle of aerosolized kerosene
oil. However, the tank which forms the base of the stove is
made of brass which is a stronger metal and the capacity of
this tank is less. The chance of the base bursting are also
less. In case of excessive pressure formed due to blockage of
nozzle of the burner an attempt is made to open it up by a
stove pin, it causes sudden release of large volume of kerosene
aerosol which ignites into a fireball when the stove burner is
lit. This is wrongly labeled as ‘Stove burst’
Fig. 1.20: Liquid petroleum gas (LPG) stoves are among
the second commonest cause of accidental flame burns,
though they are safer than kerosene pump stove. LPG
mishaps involve a larger number of casualties than the latter
where only the operator is involved
Fig. 1.21: Unauthorized construction near the high tension
wires is a very common cause of accidental high voltage
contact burn both in adults and children
Clinical Atlas of Burn Management
12
Fig. 1.22: Electrical burns while flying kite is very common
in India especially in young children due to thread getting
entangled in high tension cables, especially during rainy
season
Fig. 1.23: Typical case of almost 100% homicidal burns
showing intact skin as a white band on the face with
surrounding burned skin indicating that the patient was gagged
before setting her on fire
Fig. 1.24: Extensive accidental burns (75% TBSA) due to
clothes catching fire following LPG cylinder gas leak which
burst into flames when patient lit a matchstick
Fig. 1.25: Deep chemical burns of face in
a homicidal attempt
Causes and Classification of Burns
13
Fig. 1.26A: Anatomy of skin
Fig. 1.26B: Histopathological picture of normal skin
Fig. 1.27: Different degrees of burn as per the depth of involvement of skin—superficial partial thickness burns involving
epidermis and upper papillary dermis; deep partial thickness burns involving epidermis, papillary and reticular dermis; full
thickness burns involving the entire thickness of epidermis and dermis till subcutaneous fat
CLASSIFICATION ACCORDING TO BURN DEPTH
Clinical Atlas of Burn Management
14
ANATOMICAL CLASSIFICATION OF BURNS INTO FOUR DEGREES
Burns
Involvement
Features
Depth
First degree
(Sun Burn)
Epidermis
Erythema (Hyperemia) only.
Partial thickness
Very painful
Heals in 3-5 days with no scars at all
Second degree
Epidermis and
Extremely painful Blister/vesicle formation
Partial thickness
a. Superficial dermal
papillary dermis
—when deroofed it exposes a wet,
or superficial
glistening pink dermis which blanches
partial thickness
on pressure indicating a rich capillary
arborization in superficial dermis
Hair not pulled out easily
Heals in 10-15 days with minimal scarring,
more of pigmentary changes
b. Deep dermal or deep Epidermis, papillary
Less painful, Waxy
Partial thickness
partial thickness
dermis and part of
White appearance which does not blanch
reticular dermis
on pressure. No bullae or blisters.
Can give a fallacious erythematous look or
pinkish white look because of fixation of
erythrocytes which leak out of damaged
capillaries. So blanching test is important
to differentiate superficial and deep dermal
burns if red looking areas.
Hair follicles are easily pluckable signifying
devitalization. Heals in 3-5 weeks with
severe hypertrophic scarring and tendency
for contracture formation
Third degree
Entire thickness of
Painless
Full thickness
skin
Inelastic, translucent, parchment like
eschar with visible thrombosed vessels
shining through the dead skin
Never heal on their own and require skin
grafting. High risk of contracture if not grafted
Fourth degree
Skin, subcutaneous
Thick eschar to gangrene
Full thickness
tissue, muscle,
carbonization of limb
or gangrene
Classification According to Severity
Grade
Criteria
Critical burns
Partial thickness burns >25% TBSA (total body surface area) in adults or >15% in
children and >5% in infants
Full thickness burns >10% in adults and >3% in children
Burns of special sites like hands, face and perineum
Burns with associated injury to head, abdomen or thorax or any pre-existing illness
and old age
Electrical burns
Chemical burns
Burns complicated by respiratory tract involvement
Contd.
Causes and Classification of Burns
15
Fig. 1.28: First degree burn or epidermal burn on thigh—skin
is erythematous but intact without any blistering. Typically
seen in a sunburn and characterized by hypersensibility and
discomfort. Pain and warmth may persist for 2 to 3 days.
Within 7 to 10 days, the epithelium may peel off leaving
intact epidermis below. There is no residual scarring. Treatment
is with moisturizers and analgesics only
Fig. 1.29: First degree burn on lower leg. No dressing is
required for such burns
Fig. 1.31: Second degree burn or superficial dermal burns
involving dorsum of hand showing blistering which is more
common in dorsum of hand than palmar surface because of
the thin skin. Elevation of limb, splinting in position of function
and early mobilization are essential for proper treatment of
hand burns
Fig. 1.30: Superficial dermal burns. Photomicrograph
showing involvement of epidermis and superficial papillary
dermis (100 × H & E). Separation at dermo—epidermal
junction is also seen as indicative of blister formation.
(Courtesy: Dr Geetika Khanna, Safdarjung Hospital, New
Delhi, India)
Moderate burns
Partial thickness burns 15-25% TBSA in adults and 10-15% in children
Full thickness burns 3-10% TBSA in adults and 1-3% in children
Minor burns
Partial thickness burns <15% TBSA in adults and <10% in children. Full thickness
burns <3% TBSA in adults and <1% in children
Contd.
Clinical Atlas of Burn Management
16
Fig. 1.32: Superficial partial thickness or superficial dermal
burns over the chest and trunk. The burnt epidermis has
been debrided because it was loose, to reveal a typically
pink, moist and very painful wound. Treatment is conservative
with some form of dressing and it heals within 7 to 10 days
with minimal scarring
Fig. 1.33A: Second degree burn following scalds with hot
oil involving dorsum of hand. Blistering is usually seen after
a few hours because of collection of plasma exudates at the
dermo—epidermal junction which lifts up the dead burnt
epidermis. Healing takes place by the epithelialization from
the epidermal appendages within 7 to 10 days
Fig. 1.33B: Same patient’s healed hand after 1 month
showing hypopigmentation and the pigmentation returning
gradually with a tendency to eventually show
hyperpigmentation because of stimulation of residual
melanocytes
Fig. 1.34A: Scalds with hot water over chest producing
typically moist pink wound surface which blanches on
pressure. Treated with collagen dressing
Causes and Classification of Burns
17
Fig. 1.34B: Same patient’s healed area after 3 months
with hardly visible scars
Fig. 1.35: Superficial dermal burns over arm as seen after
first dressing showing the area starting to epithelialize
Fig. 1.36: Second degree burn showing majority of the hair
are intact. The fast re-epithelialization takes place from the
cells lining these hair follicles as well as the sweat and
sebaceous glands
Figs 1.37A and B: (A) Superficial dermal burns over lower
leg—medial aspect showing intense hyperemia (Courtesy:
Dr N Jithendran, Global Hospital, Hyderabad, Andhra
Pradesh, India). (B) Dorsal aspect of foot of same patient
A
B
Clinical Atlas of Burn Management
18
Figs 1.37C and D: Healed foot and leg of same patient after 15 days of conservative management
Fig. 1.38: Deep dermal burns—photomicrograph showing
involvement of epidermis, superficial papillary and deep reticular
dermis both (100 × H & E). There is total loss of epidermal layers.
(Courtesy: Dr Geetika Khanna, Safdarjung Hospital, New Delhi,
India)
C
D
Causes and Classification of Burns
19
Fig. 1.40: Epithelial buds seen growing over a deep
dermal burn
Fig. 1.41: Deep dermal scald of hand in an infant. Scalds
may be deeper in children because of the thinner skin.
Superficial dermal burns are seen in the upper forearm. There
is a zone of intense hyperemia peripherally (a) followed by
zone of stasis (b) and innermost zone of necrosis (c)
Fig. 1.42A: Appearance of deep dermal burns in lower leg
after 2 weeks of conservative management with 1% silver
sulphadiazine. Eschar has separated to reveal epithelialization
in the bed
Fig. 1.39: Typical deep dermal burns in hand with a pinkish-
white appearance. Blistering is not normally seen. These areas
are usually much less painful compared to superficial dermal
burns because of blunting of nerve endings. The ideal
treatment would be tangential excision and skin grafting
Clinical Atlas of Burn Management
20
Fig. 1.42B: Appearance at three weeks over the knee
Fig. 1.42C: Appearance of same patient’s leg at three
weeks—wounds have almost healed except in the middle,
with return of pigmentation as dark spots in the healed area
Fig. 1.43: Mixed superficial (A), deep dermal (B) and
deep burns (C) of an arm
Fig. 1.44: Deep dermal burns on dorsum of hand in patches
giving a hyperemic appearance which blanches on pressure
but capillary refill is sluggish. Fingers show superficial dermal
burns with epithelium peeled off
B
C
A
Causes and Classification of Burns
21
Fig. 1.45: Deep burns following electric injury in lower leg.
Note the thrombosed vessels under the burnt skin. The reddish
purple mottled look of the area is due to stasis of blood and
staining of skin
Fig. 1.46: Salt and pepper look in a deep burn
Fig. 1.47: Mixed burns with the red area indicating superficial
dermal burn, white area—deep dermal burn and parchment
like patch on the extreme right indicating full thickness burns
Fig. 1.48: Full thickness burns—photomicrograph showing
complete destruction of epidermis and dermis with complete
loss of dermal appendages (100 × H & E) (Courtesy:
Dr Geetika Khanna, Safdarjung Hospital, New Delhi, India)
Clinical Atlas of Burn Management
22
Fig. 1.50A: Extensive electric flash burns involving 65%
TBSA. The exposed area of the body, i.e. the arms show the
typical cobblestone appearance due to high temperature
sparks falling directly on skin. The chest and abdomen which
are covered by clothes shows the effect of flame burns due
to the clothes catching fire
Fig. 1.50B: Same patient’s thigh also showing deeper burns
at places where the sparks came in contact with the skin
and surrounding skin shows superficial dermal burns due to
the effect of the dispersed heat
Fig. 1.51: Full thickness or third degree burns with the dry,
transluscent and leathery eschar and thrombosed superficial
veins shining through the eschar. These burns are not painful
as all terminal nerve endings are destroyed
Fig. 1.49: Full thickness burns in upper limb with dry
transluscent parchment like eschar with thrombosed vessels
shining through it
Causes and Classification of Burns
23
Fig. 1.52: Third degree burns over distal forearm with a
cherry red nonblanching color due to hemosiderin deposition
from lysed red cells within the skin. They are insensate to
touch. The distal hand is black and charred again indicating
full thickness burns
Fig. 1.53: Fourth degree burns—in this type of injury there
is extensive damage not only to skin and subcutaneous tissue
but also to the underlying deep structures like muscle which
is totally necrosed and even till the bone. This injury is due
to contact with high tension wire
Fig. 1.54: Contact burn involving scalp and outer and inner
table of skull with a very high morbidity and mortality
Fig. 1.55A: Big blister on palmar surface of hand in a
toddler due to scalds following accidental immersion of hand
in a bucket full of hot water
Clinical Atlas of Burn Management
24
Fig. 1.55B: Same hand after 10 days following removal of
loose and dried skin of the blister showing a completely healed
area beneath it
Fig. 1.55C: Same hand after 3 weeks with minimal evidence
of burn because of lack of scarring on palmar surface of
hand
Fig. 1.56: Superficial partial thickness burns over a free
flap done in a traumatic leg wound due to contact with
motorbike silencer. The sensations over the flap are decreased
thereby allowing greater duration of contact with hot objects
leading to deeper burns
Fig. 1.57A: Second degree scalds over abdomen and lower
chest after removal of blisters showing shiny pink surface.
Managed with collagen dressing
Causes and Classification of Burns
25
Fig. 1.57B: Same wounds completely healed
after 10 days
Fig. 1.58: Case of re-burn, i.e. burns in a post-burn scar
area. These are usually deep as the dermis is thin because of
the previously healed scar
Fig. 1.59: Case of flame burns of the face which are
superficial, yet causing a lot of edema of the facial tissues
Fig. 1.60: Blistering over dorsal aspect of thumb due to
droplets of hot oil spilling on hand while cooking. If
accidentally water droplets fall into hot oil while cooking,
the water settles down and oil comes to the surface being
lighter and when this water evaporates due to heat it forces
the oil above it to burst into a spray of droplets. Though the
temperature of hot oil is higher than that of water which
normally should be causing deeper burns but in this case the
oil is mixed with water bringing down its temperature causing
superficial burns only
Clinical Atlas of Burn Management
26
Fig. 1.61: Superficial dermal burns on palmar aspect of
hand after removal of blister showing shiny pink surface.
Skin of palm has got an extra layer of stratum lucidum and
a thicker stratum corneum because of which burns on palmar
aspect of hand are usually not deep and heal faster
Fig. 1.62A: Superficial scalds over chest involving the areola
and nipple (Courtesy: Dr N Jithendran, Global Hospital,
Hyderabad, Andhra Pradesh, India)
Fig. 1.62B: Healed areas after 15 days with loss of the
normal texture of the areola
Causes and Classification of Burns
27
Fig. 1.64A: Second degree scalds in a 5-year-old child.
The burnt epidermis has peeled off to reveal glistening pink
dermis below. Managed by dry collagen dressing
Fig. 1.64B: All wounds dry and healed uneventfully after
three dressings on the 10th day
Fig. 1.63B: All wounds healed in 10 days with conservative
treatment, i.e. dressing with 1% silver sulphadiazine
Fig. 1.63A: 10% second degree scalds in an adult
Clinical Atlas of Burn Management
28
Figs 1.65A and B: Deep dermal burns to both feet sustained due to accidental fall in container of hot jaggery while it was
being processed from sugar cane juice. In sole however, the healing is very quick because of the thick skin (i.e. thicker
stratum corneum layer and extra layer of stratum lucidum) and usually does not require skin grafting
Figs 1.66A and B: Case of Kawasaki’s syndrome presenting with picture like superficial dermal burns involving the entire
body. Blistering and peeling of the superficial layers of skin can be seen. These usually heal within 7 to 10 days if there is
no infection in the involved skin and therefore need to be managed only with application of topical antibiotic cream
A
A
B
B
Causes and Classification of Burns
29
Fig. 1.67: Immersion scalds in an infants hand and forearm. The red discoloration of the palm is not due to hyperemia of
superficial burns, but because of staining by blood due to leakage from damaged capillaries. This is usually seen in the
deep burns
Pathophysiology of Burn Shock and Burn Wound 2
Clinical Atlas of Burn Management
32
Flow Chart Showing Pathophysiological Changes Following Burns
Pathophysiology of Burn Shock and Burn Wound
33
Body Response According to Severity of Burn
Clinical Atlas of Burn Management
34
Fig. 2.1A: Patient with 50% flame burns involving face at
10 hours postburn showing the start of facial edema leading
to closure of eyes
Fig. 2.1B: Patient after 24 hours showing increasing soft
tissue edema. The burn edema is maximal between 24-48 hr
post-injury because of increased capillary permeability due
to heat damage
Fig. 2.1C: Same patient after 72 hours with edema receding
as the capillary permeability is restored and the interstitial
fluid is reabsorbed back slowly
Fig. 2.1D: Five days post-burn showing healing burn
wound with edema having subsided completely
Pathophysiology of Burn Shock and Burn Wound
35
Fig. 2.1E: Six weeks post-burn with completely healed
areas showing scarring
Fig. 2.2A: Forty-five percent TBSA burn with involvement
of only lower half of face on one side mainly, seen 6 hours
after burns
Fig. 2.2B: Same patient 48 hours after burns with edema
of the entire face, even in the normal skin indicating the
response of the rest of the body to the trauma of burns.
Severe burns presents with increased capillary permeability
all over the body leading to edema in burned and unburned
tissues both
Fig. 2.2C: Seven days post-burn showing edema
completely settled
Clinical Atlas of Burn Management
36
Fig. 2.3A: Diagrammatic representation of three zones as described by Dr Douglas Jackson. Zone of coagulation is the
central zone with complete coagulative necrosis of the tissue cells which become completely nonviable and obviously
cannot recover with any treatment. Zone of stasis is on the periphery of zone of coagulation where a significant reduction
in microcirculation occurs following damage to the tissues and its arterioles, venules and capillaries. The circulation is
sluggish. Zone of hyperemia is the outermost zone, peripheral to the zone of stasis, due to intense vasodilatation
Fig. 2.3B: Changes in the burn wound which can occur due to various pathological conditions and as a result of response
to adequate treatment. The zone of hyperemia eventually recovers following adequate resuscitation, with passage of time.
The zone of stasis can also recover after adequate resuscitation and proper wound care eventually resulting in healing of the
burn wound. With inadequate resuscitation initially and due to invasive sepsis later, this zone can get converted into a zone
of coagulative necrosis converting the area to full thickness burn
Pathophysiology of Burn Shock and Burn Wound
37
Fig. 2.4A: Jackson’s three zones seen in a patient. Zone of
hyperemia is seen as a intensely reddish area (A) Zone of
stasis is seen as a light pinkish area (B) and zone of necrosis
is seen as white ischemic area (C)
Fig. 2.4B: Seven days post-burn showing healing in
peripheral zone of hyperemia (A) and stasis (B) central
necrotic zone (C) will require debridement and grafting
Fig. 2.5: Infection of the burned area converting zone of
stasis into area of necrosis
Fig. 2.6A: Young boy involved in a furnace blast with 45%
TBSA burns at 24 hours showing edema of facial soft tissue
especially the lips indicating some element of inhalational
injury
Clinical Atlas of Burn Management
38
Fig. 2.6B: Seventy-two hours post-burn showing soft tissue
edema resolving gradually. The lid edema still preventing the
left eye from opening The swelling of the lips has subsided
substantially
Fig. 2.7A: Patient with 25% TBSA burns with involvement
of face and neck also with gross edema after 24 hours
following injury. Lid edema causing closure of both eyes.
Patient’s head end needs to be in elevated position to decrease
the swelling and eye care in the form of some antibiotic
drops/ointment is essential
Fig. 2.7B: Same patient at 72 hours—face edema
starting to reduce
Fig. 2.7C: Same patient at 5 days
Pathophysiology of Burn Shock and Burn Wound
39
Fig. 2.7D: Same patient at 10 days. Edema has
completely resolved and wounds are in healing phase
Fig. 2.8: Patient with edema in the lax tissue of the unburnt
lower lid skin even though the burn is in the lower half of
face on the same side
Fig. 2.9A: Histopathology of mature scar with atrophy of
overlying epidermis and bundles of fibrocollagen in the dermis.
(Courtesy: Dr Geetika Khanna, Safdarjung Hospital, New
Delhi, India)
Fig. 2.9B: Mature well settled post-burn scar in the neck
Clinical Atlas of Burn Management
40
Fig. 2.10A: Histopathology of hypertrophic scar (H & E,
100×) showing increased keratin, epidermal hyperplasia with
marked increase in collagen in the upper dermis. (Courtesy:
Dr Geetika Khanna, Safdarjung Hospital, New Delhi, India)
Fig. 2.10B: Higher magnification of a hypertrophic scar (H
& E, 200×) showing marked epidermal hyperplasia with
collagenization of the upper dermis (Courtesy: Dr Geetika
Khanna, Safdarjung Hospital, New Delhi, India)
Fig. 2.10C: Grossly hypertrophic scar on face following
burns, not extending into the normal skin
Fig. 2.11: Post-burn keloids on face and ear
Initial Management of Burns 3
Clinical Atlas of Burn Management
42
FIRST AID IN BURNS
Do’s
•
Stop the burning process—victim to drop on ground and roll on surface
•
Use water or sand to douse fire
•
ABC of resuscitation—check for airway, breathing, circulation
•
Cool burnt area especially if extremity under running tap water or in a bucket full of tap water till
burning sensation disappears
•
If patient is unconscious think of smoke inhalation or associated head injury and maintain patent
airway
•
Cover the part with a clean cloth or sterile polyethylene drape
•
If patient is conscious give salt—sugar solution to patient orally
•
Shift patient to appropriate burn care facility
•
In case of electric burn switch off the source of electricity and move the source of electricity away
from the injured person by using nonconducting object like wood or plastic
•
In case of chemical burns—flush chemicals from skin surface with running tap water for 15 min or
more
•
In case the burning chemical is a powder, brush it off the skin before flushing with water. Clothes
and jewellery soaked in chemicals should be removed
Dont’s
•
Do not immerse severe large burns or whole body in cold water
•
Do not use ice as it can cause cold injury and damage skin further
•
Do not forcefully remove clothes adherent to burnt skin
•
Do not apply any local agents like gentian violet, mercurochrome, toothpaste to the wound as it
interferes with evaluation of burn depth and extent
•
Do not break blisters
•
Do not cover burnt area with cotton wool
•
In electric burn do not pour water over the patient to douse fire and do not touch the injured
person