Demographics

• Approximately 130,000 people with burn injuries visit emergency departments in England and Wales each year

• Around 500 patients are admitted with severe burn injuries which require fluid resuscitation

• Around half of these are children under 16 years of age

• Approximately 300 deaths in hospital after burn injuries each year

• A severe burn may cost in the order of £500,000 for acute hospital treatment, rehabilitation, time off work, and loss of earnings

Local and general response to burn injury

• Local response (based on Jackson model 1950)

  • Zone of coagulation​

    • Nearest to the heat source​

    • Heat energy cannot be conducted rapidly enough to prevent immediate coagulation of cellular proteins, causing rapid cell death

  • Zone of stasis

    • Circulation in this area compromised due to damage to the microcirculation​

    • Will progress to necrosis if untreated due to inflammatory reaction influenced by mediators by the tissue's response to injury

    • Clinically seen as progression of the depth of burning

  • Zone of hyperaemia

    • Production of inflammatory mediators cause widespread dilatation of blood vessels​

    • Tissues return to normal following resolution of hyperdynamic vascular response

    • If burn >25% TBSA, the zone of hyperaemia may involve the whole body

  • Clinical significance - inappropriate early treatment of burn may convert zone of stasis to zone of coagulation​

• General response​​

  • Abnormal capillary exchange​

    • Caused by inflammatory mediators released by damaged endothelial cells, platelets and leucocytes​

    • Vasodilatation causes:

      • Increase in capillary hydrostatic pressure​

      • Opening up of all capillaries

      • Stretching of capillary wall and opening of spaces between endothelial cells

      • Pooling of blood in small veins

    • Increase in permeability of the capillary membrane​

      • Increased transport of substances especially large molecule transport​

      • Mass albumin movement across the capillary membrane causing interstitial oedema

    • Breakdown of intercellular ground substance​

      • Rapid increase in colloid osmotic pressure of the interstitial space​

  • Effects on the whole body​​

    • Caused by release of inflammatory mediators and neural stimulation​

    • Hypovolaemia

      • Loss of protein and fluid into the interstitial space​

      • If burn >25% TBSA, the whole body is affected

      • Correction of hypovolaemia is a life saving task in the first hours after major thermal injury

    • Hypermetabolic state​

      • Caused by secretion of stress hormones - cortisol, catecholamines and glucagon​

      • Suppression of and resistance to anabolic hormones - growth hormone, insulin and anabolic steroids

      • Profound cabolism resulting in muscle protein breakdown

      • Tachycardia, hyperthermia and protein wasting

    • Immunosuppression​

      • Depression of cellular and humoral immune system​

    • Barrier function of gut impaired leading to bacterial translocation​​​​

      • RIsk reduced by early enteral feeding​

    • Respiratory inflammatory response leads to ARDS even in absence of inhalation injury​

    • Widespread whole body changes in growth can persist for months or years after healing of the burn wound

      • Central deposition of fat, decreased muscle growth, decreased bone mineralisation and decreased longitudinal growth of the body​

      • Catch up does not occur

Specialised burn service levels

• Burn facilities

  • Inpatient care equivalent of a standard plastic surgical ward for the care of non-complex burn injuries​

• Burn units​

  • Inpatient care for the moderate level of injury complexity and offers a separately staffed, discrete ward​

• Burn centres

  • Inpatient burn care for the highest level of injury complexity and offers a separately staffed, geographically discrete ward​

  • Skilled to the highest level of critical care and has immediate operating theatre access​​

Support and reassure patients, relatives and staff

• Burn injuries are associated with significant emotional overlay

• Feelings of grief, loss, guilt, self reproach, fear, depression and anger are common

• Requires sympathetic handling and counselling before death

• Frequent method of self harm or suicide

• May require psychiatric assessment may urgently be needed

• Abnormal personalities or influence of intoxicating substances may cause patients to be violent