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THE BURN MANUAL

Diagnosis and Management of Acute Burns


Initial/Resuscitative Period! Definitive Management Period
(first 48 hours) (after 48 hours)

•  Assessment of burn injury" •  Excision and grafting"


•  Classification of burn injury" •  Control of infection"
•  Criteria for admission" •  Nutrition"
•  Initial ER management" •  Rehabilitation"
•  Fluid resuscitation" •  Complication"
•  Monitoring"
Initial Rescucitation
Assessment of a burn injury
1.  Complete history"
Eg: burn injury in an enclosed space – risk for inhalational
injury"
2.  Classify as to type of burn"
•  Scald burn: caused by hot liquids ( hot water, soups,
sauces) which are thicker in consistency, remain in
contact with the skin for a longer period of time"
•  Flame burn: house fires, improper use of flammable
liquids, kerosene lamps, careless smoking, vehicular
accidents, clothing ignited from stove"
•  Flash burn (under flame burn): explosions of
natural gas propane, gasoline and other
flammable liquids causing intense heat for a very
brief period of time."
•  Contact burn: results from hot metals, plastic,
glass or hot coals; usually limited in extent but
very deep"
"
"
•  Chemical burn: caused by strong alkali or acids; these
cause progressive damage until chemical is deactivated
with reaction with tissue or reaction with water"
–  Acid burns: more self limiting than alkali burns; acid tend
to tan the skin creating an impermeable barrier limiting
further penetration of the acid"
–  Alkali burns: combine with cutaneous lipids to create soap
and thereby continue to dissolve the skin until they are
neutralized"
•  Electrical burns: injury from electrical current classified as
high voltage or low voltage (high voltage 1000 V)"
3. Estimate the Burn Size
•  Expressed as %BSA; count only areas with partial (2nd
degree) or full thickness ( 3rd degree) burns"
•  Accurately done using the Lund and Browder charts"
•  Rule of Nines obtains a rough estimate of the areas
involved but not accurate in children due to the large
surface are of the child’s head and the relatively smaller
are of lower extremities."
•  In electrical injuries, the %BSA does not correspond to
the extent of injuries of the underlying soft tissues."
•  - may have normal looking skin over it
4. Assess the Burn Depth
Important in estimating burn size and fluid requirement in
determining the need for surgery and in evaluating the
progress of the patient"
First Degree Burns – will heal in 7-10 d"
•  Ex: sunburn
"
"
Partial Thickness Burns
•  Second degree burns"
•  Extends to the dermis but not through full thickness of the skin"
•  Heals from epithelialization from surviving epidermal elements"
•  (+) blanching when pressed"
"
Superficial partial thickness burns: with blisters;underlying
skin is moist, pinkish, painful; will heal in 2-3 weeks"
"
Deep partial thickness burn: white to pale pink; moist to
dry to waxy, slightly anesthetic, will heal in 3-5 weeks
resulting in hypertrophic scarring and potential
contracture"
"
Both types of partial thickness burns can convert to full
thickness burns, signifying worsening of the patient’s
condition"
Full Thickness Burns
▫  Burns extending through full depth of the skin"
▫  May appear white, brown or gray with a waxy,
leathery feel, skin is anesthetic"
▫  Presence of visible thrombosed veins
[pathognomonic]"
▫  Heals by granulation and will require future skin
coverage for wound coverage"
"
5. Check for other injuries/medical problems

•  These problems play a role in the origin of burn and will


have to be integrated in the management of burn"
•  Eg: seizure disorders, diabetesdisorders, fractures, blunt abdominal
injuries"
Classification of Burn Injury
MINOR! MODERATE! MAJOR!
CHILDREN!
partial thickness burn" <10% BSA" 10-20% BSA" >20%BSA"
Full thickness burn! <2% BSA! 2-10%BSA! >10%BSA!
ADULTS"
partial thickness burn! <15%BSA! 15-25%BSA! >25%BSA!
Full thickness burn" <2%BSA" 2-10%BSA" >10%BSA"
AGE! Patients <2yrs with Patients <10yrs
minor injury! with major injury!
INVOLVEMENT OF HANDS, FACE, (-)" (-)" Moderate injury
FEET, PERINEUM" involvement"
ELECTRICAL INJURY! (-)! (-)! (+)!
CHEMICAL INJURY" (-)" (-)" (+)"
Inhalational Injury! Not suspected! Not suspected! (+)!
Major Associated medical Illness" (-)" (-)" (+)"
Associated fractures, multiple (-)! (-)! (+)!
trauma!
Criteria for Admission to the Burn Unit
•  Acute burn patients with moderate and major injuries"
•  Acute burn patients <2y/o regardless of % TBSA"
•  Acute burn patients with injuries to the hands, face, feet and
perineum"
•  Acute electrical burn patients"
•  Acute chemical burn patients"
•  Acute burn patients with smoke inhalation injury, other
associated medical illness, or multiple trauma"
Criteria for Admission to the Burn Unit
•  Patients with massive exfoliative disease, such as:"
▫  Toxic Epidermal Necrosis (TENS)"
▫  Steven Johnson Syndrome (SJS)"
▫  Staphylococcal Scalded Skin Syndrome (SSSS) "
Initial Labs
•  CBC"
•  Blood typing"
•  RBS, BUN, Crea, Na, K, Cl, Albumin"
•  ABG (if inhalational injury is suspected)"
"
Other labs:"
•  Chest X-ray"
•  ECG (for electrical burns)"
•  Urinalysis (for electrical burns, urine myoglobin & pH also
included)"
"
1.  Cool wound with tap water"
2.  Administer tetanus prophylaxis"
▫  TT booster if not received for the past 5 years"
▫  0.5cc TeAna and 3000 u ATS (adults)"
3.  Clean wound with soap and water/betadine scrub"
4.  Debride dead tissue"
▫  Big blisterà unroof"
▫  Small blisterà aspirate"
Initial ER Management: 

MINOR Burns
5.  Apply bland ointment (i.e., Bacitracin, Trimycin,
Vaseline) and non-stick porous gauze and wrap with
gauze"
6.  NO systemic prophylactic antibiotics are given"
7.  Oral/IM analgesics during wound cleaning"
8.  Send patients home with oral analgesics and
instructions to clean the wound OD to BID and apply
ointment and gauze.
Initial Management: 

MAJOR & CRITICAL Burns
1.  Wear sterile gloves"
2.  Remove all burnt clothing"
3.  Check & secure airway. Suspect inhalational injury if with:"
▫  Burn to face"
▫  Sooty phlegm"
▫  Singed nostril hairs"
▫  Hoarseness or stridor"
▫  History of burn in enclosed space "
"or unconscious at scene"
▫  Circumferential chest burn
Initial Management: 

MAJOR & CRITICAL Burns
v Intubate if with: "
•  Burns 50% BSA"
•  Suspected inhalational injury"
•  Smoke inhalation"
4.  Do complete PE, check for other injuries"
5.  Insert IV line for fluid resuscitation"
6.  Insert foley catheter (to monitor UO)."
7.  Insert NGT (to decompress stomach). Start IV PPI (to
avoid Curling’s ulcer).
Initial Management: 

MAJOR & CRITICAL Burns
8.  Weigh patient and record. If not possible, estimate:"
▫  For children: Wt (kg) = [2 x (age in years)] + 5"
▫  For adults: Wt (kg) = 0.9 x [ht in cms – 100]"
9.  Administer ATS and TeAna"
10. Check pulses, assess adequacy of chest expansion "
▫  Absent pulses or limited chest excursion is a
surgical emergency and an indication for
escharotomy
Initial Management: 

MAJOR & CRITICAL Burns
Escharotomy"
•  Extremities"
▫  Prep with betadine soap"
▫  Cut through entire depth of
skin along medial and lateral
aspects of involved extremity.
Avoid injuring the ulnar nerve
and the peroneal nerve;
facilitate separation of the
skin by blunt dissection. "
•  Chest"
▫  Cut along both anterior
axillary lines and along the
costal margin producing a W-
shaped incision
Initial Management: 

MAJOR & CRITICAL Burns

11.  Refer all pediatric patients to Pedia for co-


management. Patients with other medical
problems should also be referred accordingly."
12.  No prophylactic antibiotics are given, unless there
are concomitant medical conditions that indicate
its’ early use.
Fluid Resuscitation
Fluid Resuscitation
•  Most common cause of mortality in the first 48
hours is inadequate fluid resuscitation"
•  (Minor: inc OFI, Moderate to Major: IV route)"

•  Start ASAP in the ER and even before other


diagnostic exams
Fluid Resuscitation: PARKLAND FORMULA
Day 1"
• Adults: "
Plain LR 4mL/kg BW per % BSA burned to be given:"
•  ½ during the first 8 hours"
•  ½ during the next 16 hours"
• Children:"
D5 LR 3mL/kg BW per % BSA burned to be given:"
•  ½ during the first 8 hours"
•  ½ during the next 16 hours"
•  + maintenance"

• Cardiac, elderly patients: 2mL/kg BW per % BSA"


•  Inhalational, electrical injury: 6mL/kg BW per % BSA"
Fluid Resuscitation: PARKLAND FORMULA

Day 2"
• Adults / children:"
•  D5NR(adults), half normal saline (children) and colloid
sufficient to maintain good urine output"
Fluid Resuscitation
•  Colloid may be given in the form of plasma albumin or
cryoprecipitate"
•  Most protocols start colloid infusion after the first 24 hrs
(capillary permeability thought to be restored by then)"
•  For massive burns, colloid infusion can be started as
early as 12 hours post-burn (to decrease total fluid
requirements and lessen edema)
Fluid Resuscitation
•  Regulate fluids to maintain adequate urine output"
•  Adults: 0.5 mL/kg BW/hr"
•  Children: 1.0 mL/kg BW/hr up to 30 kg BW"
Age influences relationship of body fluids to size: children have larger
BSA per body volume"
•  Fluid calculations – not absolute and should not be
given by rate"
•  Excessive urine volumes à overcorrection and run the
risk of fluid overload; "
•  Smaller volumes à inadequate resuscitation"
•  UO monitoring should be done strictly Q1
Fluid Resuscitation
•  For electrical injuries:"
•  Adjust fluid volume to maintain UO of 75-100 mL/hr
(target UO: 1-2 cc/kg BW)"
•  Mannitol 12.5-25g may be infused to promote diuresis"
•  If UO and pigment clearing do not respond to fluid
resuscitation, 12.5g osmotic diuretic mannitol may be
added to each liter of resuscitation fluid"
•  NaHCO3 can be added to maintain a slightly alkaline
urine (pH>5.5) to promote solubility of heme pigments"
Wound Dressing
Wound Dressing
Debridement/Initial Dressing:"
•  Sterile technique"
•  Cut hair or items that may reach any burned or
dressing area"
•  Full body bath with soap and water"
•  Debride burned areas; visualize all affected areas.
Reassess depth and %BSA of burn wounds"
•  Wash with betadine soap, rinse with sterile water"
•  Dress



Silver Sulfadiazine 

(Flammazine, Silvadene, Silversurf)
•  For full thickness burns, applied as sandwich dressing"
•  May cause transient leucopenia"
•  MOA: silver ion binds with the DNA of the organism and release
sulphonamide which interferes with the metabolic pathway of the
microbe"
•  Effective against: Pseudomonas aerugenosa, Enterics,
S. aureus, Klebsiella sp!
•  Maximum of 2 weeks bec it retards wound healing"
•  Leaves a yellow green pseudo-eschar which must be
scraped off during dressing"
Silver Sulfadiazine + Cerium nitrate
(Flammacerium)
•  Topical antimicrobial"
•  Applied in cases wherein early excision-grafting cannot be
done (mass burn, extensive burns)"
•  Reduces mortality by neutralizing toxin present in burned
skin"
•  Mechanism of action:"
•  Cerium induces calcification of the dermal collagen remaining in the
wound which produces the typical tanned, leathery crust"
Silver Nitrate (not used anymore)
• Used as 0.5% solution"
• Gauze dressing must be wet, solution loses effectivity
when dry"
• Creates a brownish black discoloration with anything it
comes in contact with (will peel off with the burned skin)"
• Bacteriostatic for S. aureus, E. Coli, P. aeruginosa!
• Does not injure regenerating epithelium in the wound"
• Caution with children as it tends to leach out electrolytes
(Na, Cl)"
"
Dakin’s Solution
•  Sodium hypochlorite 0.025% solution:"
15 mL Sodium hypochlorite (Zonrox) + 985 mL NSS"
•  Must be used within hours after it is prepared"
•  Used in preparing granulation tissue for grafting"
•  Bactericidal to S. aureus, P. aerugenosa, and other
G(-) and G(+) bacteria"
Monitoring
•  Burn injury is a dynamic process. The initial
exposure to the wounding agent starts a train of
physiologic events that present to the physician
a patient with complex and precarious
physiologic state, which has to be optimized to
maximize chances of a positive outcome.
Monitoring
At the ER:"
• Check VS, UO, consciousness, pulmonary status
Q1"
• Hgb, typing, Na, Cl, BUN, Crea, RBS"
• CXR and ABG (for inhalational injury)"
• ECG, urine myoglobin (for electrical burns)"
Monitoring
During fluid resuscitation:!
•  Check signs of adequate hydration"
•  Weigh patient daily"
•  Vital signs hourly"
•  Monitor peripheral perfusion hourly (pulses,
capillary refill)"
•  Presence of Hgb and myoglobin in urine of
electrical burn patient suggest delayed or
inadequate fluid resuscitation"
Monitoring
During fluid resuscitation:!
•  Pulmonary status every 4-5 hours"
•  Daily determination of Hgb, Hct, WBC, Na, K,
BUN, crea"
•  Status of wound daily during dressing change"
Monitoring
Post resuscitative period:"
•  Vital signs every 4 hours"
•  Daily determination of weight, BUN, crea, Na, K"
•  Assess burn status daily"
•  Burn biopsies (not swabs) twice a week"
•  Blood CS once a week if wound is infected or
patient is septic"
•  Weigh patient daily"
Definitive Management
Priority in the 1st 48 hours—maintain intravascular
volume!
Once addressed, definitive management ensues"
"
Classical Method:"
Allow eschar to spontaneously separate (3 weeks),
wait until bed is ready for grafting, then place skin
graft
Definitive Management
Present trend:"
Early excision (within 7d post burn) of burn wound,
followed by skin grafting"
- improve survival and shorten hospital stay"
- adopted strategy by the PGH Burn Unit
Excision and Grafting
Excision and Grafting
•  To remove full thickness and deep partial burns until
clean viable bleed is encountered and a skin graft is
placed immediately to cover the wound"

•  Early excision – done within 7 days"


•  wound is not yet colonized by microorganisms, reducing
the chances of infection and promoting good graft take"
Preparation for OR prerequisites

•  Stable vital signs"


•  Not in septic shock"
•  Afebrile"
•  Blood available for OR use (200-400mL/%BSA)"
•  Normal albumin"
•  No contraindications for surgery
Conduct for OR

"
•  OR table covered by sterile linen"
•  Keep OR warm"
•  Prep patient using betadine soap and paint for the
donor site and betadine soap for the wound"
•  Prep the donor site"
•  Drape donor site separate from the burn wound
Tangential Excision
•  Principle: to excise the wound in thin layers
using a blade held at very acute angle with
the skin surface"
•  Goal: to remove non viable tissue leaving
as much dermis as possible (excellent
surface for grafting)"
Fascial Excision
•  Best used when excising large flat areas"
•  When excision of the burn wounds has to be done with
minimum blood loss"
•  Less bloody than tangential excision, but with cosmetic
effect defect"
•  Limited use in extremities due to problems of edema
distal to the area of excision, presence of avascular
fascia and presence of superficial nerves
Skin Graft Harvesting
•  Preferred areas are thighs, buttocks, and abdomen"
•  The only area in which color match between donor and
recipient site is of significant concern is the face and
neck.  Upper chest and upper back are a good color
match for face and neck.
Stages of skin graft revascularization/’take’
Stage
Imbibition First 24-48 hours

A fibrin network forms between the graft and wound bed and binds
both layers initially

Survival of graft is dependent on diffusion of nutrients through


plasma exudates from the wound bed

Possible barriers between graft and wound bed: hematoma,


seroma, pus, non-viable tissue from inadequate excision

Inosculation 48-72 hours

Old capillaries from the wound graft link with vessels on the graft,
causing revascularization
Stages of skin graft revascularization/’take’
Stage
Neovascularizatio Direct ingrowth of host vessels into the skin graft
n
Under ideal conditions, full circulation achieved within
4-7 days
Maturation Months to 1-2 years

New collagen bridges form between the wound bed and


the graft

Reinnervation of graft occurs within 2 months to years


Applying Skin Graft
•  Best to place grafts on the wound at the time of excision  "
•  Since the graft itself controls hemostasis and protects the
wound, it makes little sense to wait 24-48hrs until bleeding
has stopped"
•  This approach requires an additional procedure and there is
a significant risk of the wound bed becoming desiccated or
reinfected"
•  Better to have a slight overlap of skin on the wound rather
than to leave excised wound uncovered.  Hypertrophic
scarring will result and most evident at the edges of the
graft, especially if a ridge of open wound is left to heal
primarily.
Care of the Skin Graft
•  First graft opening: 3-5th day post op. Open
early if suspecting infection
•  Remove bulky dressing slowly, not disturbing
any graft using copious amounts of sterile water
•  Graft uptake: Pinkish color of graft with
adherence to skin bed
•  Wash area gently with betadine soap and rinse
with water. Dress graft with bulky wet dressing
•  Staples can be removed at first dressing change
•  Can be dressed everyday if not infected
•  If with good take, skin graft can be left open on
the 7th post op day. "
Nutrition
•  Patients with Burns have a hypermetabolic response,
which persist until burns are covered"
•  Curreri’s Formula"
• Adult "(25 x kg) + (40 x %BSA Burn)"
• Children "(60 x kg) +(35 x %BSA Burn)"
"
•  Rough Guide: 2,500 cal/d in adults, proteins= 2g/kgBW"
" "At Burn Unit, 6 egg whites/day"
•  Carbs = 60%, fats = rest "
•  Give Vit C and Zinc Supplements
Complications
•  Sepsis"
▫  Most common cause of death in burns"
▫  Suspect in the presence of: fever, hypotension, conversion from
PT to FT burns, ecthyma gangrenosum"
▫  Start antibiotics"

•  ARDS"
▫  Setting of electrical/Inhalational/pulmonary injury"
▫  Progressive hypoxemia unresponsive to inc FiO2"
▫  Xrays may be normal in early phase"
▫  Manage with intubation: 100% FiO2"

•  Contractures"
▫  Prevented with proper posture and splinting, coordinate with
Rehab
Pain Control
• Meperidine 50mg IV q6"
• Nalbuphine q4"
• Narcotics are not given IM since absorption
is erratic
Criteria for Discharge
•  No existing complications of thermal injury such as
inhalational injury"
•  Fluid resuscitation completed"
•  Adequate pain tolerance"
•  Adequate nutritional intake"
•  No anticipated septic complications
Thank You! J

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