Burn Notes
Burn Notes
Burn Notes
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"
"
• 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
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
• 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