Doc, could you please explain the cellular and chemical
processes that occur when the tissues are burnt?
Rony v, Goa
A number of inflammatory processes both local (at the site of
the burn) as well as systemic (in the rest of the body) take place when burns
occur which eventually lead to the shifting of fluid from the vascular
compartment to the interstitial spaces. Subsequent to the burn a number of
cells like Neutrophils,
macrophages, and lymphocytes cross over into the burned tissues and start releasing
chemical mediators like histamine, serotonin, prostaglandins, kinins, platelet
products and complement components. These chemical substances damage the normal
blood capillary barrier which leads to an increase in the permeability of the
vessels. Intravascular fluids therefore start to leak from the walls of the
vessels and this ultimately leads to a decrease of the circulating
intravascular blood volume. A fact that is not commonly recognized is that
these processes that occur in the burn tissues also take place in the tissues
that have not suffered any burns and therefore one can see edema in areas of
the body that have not suffered burns. Thermal injury also ends up damaging the
cell wall and collagen fibers which in turn lead to inadequacy of the cell wall
transport mechanisms and buildup of sodium and water and eventual death of the
cell if the fluid imbalances are not immediately corrected. In minor burns such
as 10 percent in children and about 15 percent in adults these fluid balances
are well adjusted and tolerated and therefore additional fluid replacements are
not needed. However in patients with TBSA higher than the one’s mentioned above
intravenous fluid resuscitation is needed.
The capillaries begin to
regain their functional integrity and the leak eventually gets controlled, but
this often takes more than 8 hours post burn. Crystalloids are usually given in
the first 8 hours and one’s the integrity of the capillary wall is regained
after 8 hours, colloid fluids are started since they will not leak out. Adding
colloids also help to reduce the fluid overload that may result of excess of
crystalloid infusions. Burn wounds are composed of three zones- a central zone
of coagulation or severe tissue damage, a peripheral zone of hyperemia or
vasodilatation, and an intervening zone
of stasis or low blood flow (ischaemia). If the fluid imbalances that occur
from the fluid shifts as noted above are not corrected on time then these zones
can extend and more tissue damage can result explaining the fact that some
superficial burns on admission can end up as deep over period of time. This can
also happen when burn wounds get infected.
(an original initiative in burn care education from asktheburnsurgeon)
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