Explain burn in surgical subject

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Burns in Surgical Practice

A burn is a traumatic injury to skin and underlying tissues caused by thermal, chemical, electrical, or radiation agents. Burns remain a major cause of morbidity and mortality globally. Surgical care has evolved dramatically since the introduction of early burn excision and structured fluid resuscitation protocols.

1. Aetiology / Classification by Cause

Type	Examples
Thermal	Scalds (hot liquids/steam), flame, contact with hot objects, flash burns
Chemical	Acid, alkali (alkali penetrates deeper due to liquefactive necrosis)
Electrical	Low-voltage, high-voltage, lightning; causes "entry and exit" wounds with internal damage disproportionate to surface appearance
Radiation	UV exposure (corneal burns/keratitis), nuclear, X-ray
Friction	Road rash, machinery injuries

Diathermy burns (surgical context): Monopolar diathermy can cause unintended burns when:

The indifferent (return) electrode has inadequate contact area
The patient is earthed via contact with metal (Mayo table, stirrups)
Faulty insulation of leads
Accidental activation or contact of the active electrode with retractors/towel clips
Channelling - when current is applied to a narrow tissue stalk (e.g., risk of penile/spermatic cord coagulation during circumcision), bipolar diathermy must be used instead

Alcohol-based skin preparation agents can ignite from diathermy sparks under theatre lights, making these fires difficult to detect early. - Bailey and Love's Short Practice of Surgery 28th Ed, p.133

2. Burn Depth Classification

This is the single most important determinant of surgical decision-making.

Superficial (First-Degree)

Involves epidermis only
Erythematous, painful, no blistering
Not included in TBSA% calculations
Heals in days with supportive care

Superficial Partial-Thickness (Second-Degree)

Involves papillary dermis
Pink, moist, blistering, brisk capillary return (blanches)
Normal pinprick sensation
Heals in 2 weeks without surgery, no significant scarring

Deep Partial-Thickness (Deep Dermal)

Involves reticular dermis
Dermis less moist, less erythematous; fixed capillary staining; does not blanch
Reduced sensation (cannot distinguish sharp from blunt)
Takes >3 weeks to heal and invariably leads to hypertrophic scarring without surgery

Full-Thickness (Third-Degree)

Destroys entire dermis; leathery, insensate, white/brown/black
No spontaneous healing - requires surgical grafting
Fourth-degree: Involves underlying fascia, muscle, or bone

Burn wound comparison between superficial dermal and deep dermal

Superficial (S/D) vs. deep (D) dermal burn, <24 hours post injury (Bailey & Love, p.691)

3. Assessment of Burn Size - TBSA

The Rule of Nines (Wallace Rule of Nines) for adults:

Head and neck = 9%
Each arm = 9%
Anterior trunk = 18%
Posterior trunk = 18%
Each leg = 18%
Perineum = 1%

The Lund and Browder chart is more accurate, especially in children, because it accounts for age-related changes in body proportions (head is larger relative to body in infants). The patient's palm (wrist crease to fingertips) = approximately 1% TBSA - useful for irregular burns.

Superficial (first-degree) burns are excluded from TBSA calculations for resuscitation purposes.

4. Admission Criteria (Burns Unit)

Burns meeting any of these criteria require admission to a burns unit (Bailey & Love's, p.688):

Suspected airway or inhalational injury
Any burn likely to require fluid resuscitation
Any burn likely to require surgery
Burns of significance to hands, face, feet, or perineum
Suspicion of non-accidental injury
Extremes of age
High-tension electrical burns or concentrated hydrofluoric acid burns
Social/psychiatric factors precluding home management

5. Major Determinants of Outcome

Percentage TBSA involved
Depth of burn
Presence of inhalational injury
Age and comorbidities

6. Initial Management - ATLS Approach

Management follows ABCDEF:

A - Airway control (early intubation if airway burn suspected)
B - Breathing/ventilation
C - Circulation
D - Disability (neurological status)
E - Exposure with environmental control
F - Fluid resuscitation

Airway Burns

Signs suggesting airway involvement:

History of entrapment in smoke/hot gases
Burns on palate or nasal mucosa; singed nasal hairs
Deep burns around mouth/neck
Hoarseness, stridor - these are late signs; intubation may already be impossible

The airway swells rapidly (4-24 hours post-burn). Early elective intubation is the treatment of choice. Cricotyroidotomy equipment must be available if delayed. Upper airway burns are managed by bypassing the obstruction with an ETT; lower airway/inhalational injury may progress to ARDS, usually after 48 hours - this determines the "anaesthetic window" for early surgery.

Burns to face and neck with inhalation injury requiring intubation

Inhalational Injury

Inhaled agents include CO (toxic/hypoxic), HCN (from burning synthetics), and direct thermal injury. Carboxyhaemoglobin >10% requires 100% O2 for 24 hours. Cyanide poisoning is treated with IV hydroxycobalamin (vitamin B12) - forms water-soluble cyanocobalamin. Nebulised heparin + N-acetylcysteine reduces fibrin cast formation in the lower airway. Bailey & Love's, p.689

Escharotomy

Full-thickness chest wall burns can cause a mechanical block to breathing (restricted chest expansion, CO2 retention, high ventilatory pressures). Treatment: escharotomy - scoring cuts through burned skin to allow chest expansion.

Escharotomy placement (Bailey & Love's, p.690):

Site	Placement
Upper limb	Midaxial; anterior to elbow medially (avoid ulnar nerve)
Hand	Midline in digits; release muscle compartments if tight - best done in theatre
Lower limb	Midaxial; posterior to ankle medially (avoid long saphenous vein); anterior to head of fibula (avoid common peroneal nerve)
Chest	Lateral to nipples vertically; horizontal below clavicle and at xiphisternum level
General	Extend beyond the deep burn; diathermy bleeding vessels; apply haemostatic dressing and elevate limb

7. Fluid Resuscitation

Fluid shifts occur due to the inflammatory capillary leak driven by the burn. Resuscitation is mandatory for:

Children with burns >10% TBSA
Adults with burns >15% TBSA

Parkland / Baxter Formula (crystalloid-based):

3-4 mL × kg body weight × %TBSA of Lactated Ringer's

Half given in first 8 hours from time of burn
Half given over subsequent 16 hours

The most recent ABA consensus formula recommends 2 mL/kg per %TBSA due to the tendency toward over-resuscitation with traditional formulas. (Schwartz's Principles of Surgery, p.282)

Muir and Barclay Formula (colloid-based, used in UK):

%TBSA × weight (kg) × 0.5 = one portion

6 portions given over 36 hours (4-hourly × 3 for first 12h; 6-hourly × 2 for next 12h; one portion over final 12h)

Monitoring of Resuscitation:

Urine output is the primary endpoint: 0.5-1.0 mL/kg/h in adults
Bolus 10 mL/kg if urine output drops with signs of hypoperfusion (tachycardia, cool peripheries, elevated lactate)
Urine output >2 mL/kg/h should prompt reduction in infusion rate (avoid over-resuscitation)
Complications of over-resuscitation: abdominal compartment syndrome, extremity compartment syndrome, intraocular compartment syndrome, pleural effusions

Patients with inhalational injury require significantly more fluid (average 5.76 mL/kg per %TBSA vs 3.98 without inhalation injury). (Schwartz's, p.282)

8. Burn Wound Treatment

Partial-Thickness Burns

Two key management goals:

Prevent factors that cause the burn to "change group" (deepen) - infection is the primary culprit
Control pain during dressing changes

Dressing options:

Simple exposure (face only - painful, intensive nursing)
Vaseline-impregnated gauze (± chlorhexidine), Mepitel (fenestrated silicone)
Acticoat (silver nanocrystals) - antimicrobial, left for up to 7 days
Hydrocolloids (Duoderm) - change every 3-5 days; high protease levels debride deeper areas; good evidence in burns
Biosynthetic (Biobrane) / amniotic membranes - ideal for superficial burns, not for mixed-depth as they detach if applied to deep wounds

If the wound is heavily contaminated, formal wound cleaning under general anaesthetic is advised. Silver sulphadiazine cream is used for 2-3 days for contaminated wounds.

Full-Thickness Burns - Surgical Excision

The principle of early excision has transformed burn mortality. Two approaches:

1. Early Total Burn Excision:

Excision of the entire burn as soon as possible after stabilisation
Exploits three critical time windows:
- Anaesthetic window: Before inhalational injury progresses to ARDS (usually after 48h) - surgery must happen before this
- Haemodynamic window: Before progressive inflammatory vasodilation and coagulopathy reduce effectiveness of vasoconstrictors; removes the eschar that drives fluid shifts
- Bacterial window: Necrotic eschar is a bacterial culture medium; early removal reduces infection risk

2. Staged/Serial Debridement:

Multiple operating sessions in the first week
Shorter individual operating times, lower blood transfusion requirement
Chosen when resources/facilities do not allow early total excision

Advantages of early excision (Bailey & Love's Summary Box 46.15, p.691):

Reduces bacterial load
Majority of surgery performed before substantial lung injury
Allows effective use of vasoconstrictive tumescence fluids
Enables earlier wound closure and rehabilitation

9. Wound Coverage

After excision, the wound requires coverage:

Method	Indication
Split-thickness skin graft (STSG)	Most common; harvested from donor sites; meshed grafts allow coverage of larger areas
Full-thickness skin graft	Small areas, especially face/hands
Biological dressings (allograft, xenograft)	Temporary coverage while awaiting definitive grafting
Synthetic dressings (Integra, Biobrane)	Dermal substitutes for large burns
Cultured epithelial autografts (CEA)	Severe burns with limited donor sites; 3-week culture time required
Flap reconstruction	Areas over joints, specialised areas requiring bulk

10. Nutrition

Hypermetabolism is one of the most profound responses to burn injury. Resting metabolic rate may rise by up to 200%, driving protein catabolism and loss of lean body mass. (Schwartz's, p.285)

Early enteral feeding (within hours of admission) is safe for burns >20% TBSA; reduces hypermetabolism, preserves lean body mass, reduces ICU stay and wound infection rates
Caloric need: Harris-Benedict × 2 or Curreri formula (25 kcal/kg/d + 40 kcal × %TBSA/d)
Supplements: glutamine (immune modulation), antioxidant vitamins (C, E), trace minerals (selenium, zinc, copper)
Oxandrolone (anabolic steroid): proven in paediatric burns to improve lean body mass, bone density, liver protein synthesis, and reduce length of stay
Beta-blockers (especially propranolol in children): reduce heart rate, resting energy expenditure, and protein catabolism

11. Complications

Complication	Notes
Infection / Sepsis	Most common cause of death in burns; surface wound colonisation vs. invasive infection
Inhalational ARDS	Develops 48h post-burn; drives ventilator management
Abdominal compartment syndrome	From over-resuscitation
Extremity compartment syndrome	From oedema or circumferential burns; requires escharotomy/fasciotomy
Acute renal failure	From myoglobinuria (electrical burns), hypovolaemia
Hypertrophic scarring	Deep dermal burns that heal spontaneously; treated with pressure garments, silicone, or surgical revision
Contractures	Especially over joints; require splinting and eventually surgical release
Curling's ulcer	Stress ulcer; prophylaxis with H2 blockers/PPIs
Heterotopic ossification	Rare; around joints in major burns

12. Special Considerations

Chemical Burns

Alkali burns penetrate deeply and cause ischaemic necrosis (more dangerous than acid)
Immediate copious irrigation until pH is neutral; remove all particles from fornices
Hydrofluoric acid: systemic fluoride toxicity; treat with topical/intralesional/IV calcium gluconate

Electrical Burns

Entry and exit wounds with internal damage disproportionate to surface area
Risk of deep muscle necrosis, rhabdomyolysis, renal failure
Cardiac monitoring mandatory (arrhythmias, arrest)
High-tension burns require burns unit admission

Burns in Children

Thinner skin - deeper burns from the same exposure
Larger surface area to body mass ratio - greater fluid losses; larger fluid volumes needed per kg
Immature kidneys: urine output goal 1 mL/kg/h (vs. 0.5 in adults)
Scald injuries most common in <2 years; flame burns more common in teenagers
Carbon monoxide falsely elevates pulse oximetry - arterial blood gas mandatory

13. Prognosis

Mortality in burns correlates with:

Increasing age
Increasing %TBSA
Presence of inhalational injury

The Baux score (age + %TBSA) is a simple prognostic tool; a score >140 historically carried near-certain mortality, though with modern burn centre care, even this has improved.

Sources:

Bailey and Love's Short Practice of Surgery, 28th Edition - Ch. 46 Burns
Schwartz's Principles of Surgery, 11th Edition - Ch. 8 Burns
Sabiston Textbook of Surgery - Paediatric Burns

Explain me with the textbook of concise textbook of surgery

Finding Sources

The library's full list of general surgery textbooks is confirmed. "A Concise Textbook of Surgery" by S. Das is not in the library. Here is my honest answer to the user:

The "Concise Textbook of Surgery" (by S. Das) is not available in the medical textbook library I have access to. The library contains the following general surgery textbooks:

Book	Author/Edition
Bailey and Love's Short Practice of Surgery	28th Edition
Schwartz's Principles of Surgery	11th Edition
Sabiston Textbook of Surgery	Latest Edition
S Das - A Manual on Clinical Surgery	13th Edition
Current Surgical Therapy	14th Edition
Fischer's Mastery of Surgery	8th Edition
Mulholland and Greenfield's Surgery	7th Edition
Pye's Surgical Handicraft	22nd Edition

The S Das - A Manual on Clinical Surgery (13th Ed.) is available, but it does not contain a dedicated chapter on burns - only scattered references to burn contractures and keloids.

What I can offer instead:

Bailey and Love's Short Practice of Surgery (28th Ed.) - Has a comprehensive Burns chapter (Ch. 46) that is very similar in depth and style to S. Das's Concise Textbook. Bailey & Love is the gold standard reference for surgical exams in South Asia and the UK.
Schwartz's Principles of Surgery (11th Ed.) - Excellent American surgical text with a detailed burns chapter.

Would you like me to use Bailey and Love's to give you a detailed, exam-oriented explanation of burns? It covers all the same topics you would find in S. Das - classification, TBSA assessment, fluid resuscitation, wound management, surgical excision, and complications - and I already have the full chapter loaded. Just say yes and I will format it in the structured, point-wise style typical of concise surgery textbooks.

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