1

BURNS –
PATHOPHYSIOLOGY,
EVALUATION &
MANAGEMENT
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Clinical Significance

 Important to identify respiratory insult & Early Intubation in case required.

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EVALUATION
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Wallace’s Rule of “9”

 Head & Neck - 09

 Upper limbs - 09 x 2

 Trunk - 18 x 2

 Lower limbs - 18 x 2

 Perineum - 01
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4.5
4.5

18 18
9 9
4.5 4.5 4.5
1
18 18
9 9 9 9 1

7 7 7
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Lund and Browder Charts
7
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Palm Method

 Size of Patient’s palm  1% of TBSA

 Irregular wounds with scattered distribution.

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OVERVIEW

 Part I  Part II
 Historical perspective  Pre-hospital Care
 Statistics  Resuscitation & Nutritional support
 Classification of Burns  Burn wound care
 Pathophysiology  Complications

 Evaluation  Rehabilitation
MANAGEMENT OF
BURNS
 PHASES OF TPT

 Phase 1: Treatment at the scene and tpt to initial care facility

 Phase 2: Assessment and stabilization at initial care facility and tpt to

burn ICU.
 PRE HOSPITAL MANAGEMENT

 Rescuer to avoid injuring himself

 Remove patient from source of injury

 Stop burn process

 Burning clothing; jewelry, watches, belts to be removed

 Pour ample water on burnt area (not ice/ ice packs – skin injury &
hypothermia)
 PRE HOSPITAL MANAGEMENT

 Chemical burns:
 Remove saturated clothing
 Brush skin if agent is powder
 Irrigation with copious amount water to be started and continued in
hospital

 Electrical burns:
 Turn off the current
 Use non-conductor item to separate from source
PRE HOSPITAL MANAGEMENT

PRIMARY ASSESSMENT

 A – B – C – Cervical spine immobilization

 Respiratory tract:
 Edema of upper airway sets in very fast
 Upper airway obstruction
 100% humidified O2 if no obvious resp distress
 PRE HOSPITAL MANAGEMENT

PRIMARY ASSESSMENT
 ET intubation + assisted ventilation with 100% O2 if:
 Overt signs and symptoms of airway obstruction (Progressive hoarseness)
 Suspected inhalational injury (smoke/ carbon monoxide intoxication)
 Unconscious patient/ rapidly deteriorating patient
 Acute respiratory distress
 Burns of face & neck
 Extensive Burns (> 40% TBSA)
PRE HOSPITAL MANAGEMENT

PRIMARY ASSESSMENT

 Pulse rate better monitor than BP

 Spinal immobilization:
 Explosion/ deceleration injury
 Cervical collar (Philadelphia collar)
 PRE HOSPITAL MANAGEMENT

 Ice/ice cold water causes numbness, intense vasoconstriction, hypothermia

causing further damage.
 Do not break blisters.
 Do not apply lotions, powders, grease, ghee, gentian violet, calamine lotion,
toothpastes, butter and other sticky agents over the burn wound.
 Prevent contamination: Wrap burn part in clean dry sheet /cloth.
 Assess for life threatening injuries.
PRE HOSPITAL MANAGEMENT

 NO I/M or S/C inj (Capillary leakage results in unpredictable absorption)

 I/V morphine to allay anxiety

 Pain relief and reassurance

 Withhold oral intake

PRE HOSPITAL MANAGEMENT

 Co-morbid conditions/ pre-existing illness

 Initiate rapid transfer to hospital

 Secure and protect the airway

 Cervical spine immobilization; if necessary

 PRE HOSPITAL MANAGEMENT

SECONDARY ASSESSMENT

 Performed only if no immediate life threatening injury/ hazard present

 Thorough head to toe evaluation

 Medical history, medication, allergies, mechanism of injury

 Start IV line (not reqd in hospital <60 min away)

 PRE HOSPITAL MANAGEMENT

SECONDARY ASSESSMENT
 RL infusion:
≥ 14 yrs – 500mL/hr
 6-14 yrs – 250mL/hr
≤ 5yrs – 125mL/hr
 Apply clean dressing/ sheet to protect area and minimize heat loss
 IV Tramadol to relieve pain
 No topical antimicrobial
 HOSPITAL MANAGEMENT
INITIAL CARE FACILITY

 C–A–B

 Establish adequate airway

 ET intubation – impending airway edema (post initiation of IV therapy)

 Maintain cervical spine immobilization

 INITIAL CARE FACILITY

 History
 Mechanism of injury
 Time of injury
 Surroundings (closed space/ chemicals)
 Physical examination
 Head to toe assessment
 Careful neurological examination (cerebral anoxia)
 Corneal fluorescent examination in facial burns
 Labs: CBC, electrolytes, BUN
 Pulmonary assessment: ABG, CXR, carboxyhemoglobin
 INITIAL CARE FACILITY

 Pulse in extremities: manual/ doppler

 Loss of distal circulation
Pallor/coolness/absent pulse/loss capillary refill/decreased oxygen
saturation
 Pain on passive extension
 Deep pain at rest
 Absent pulse: emergency escharotomy to release constrictive, unyielding
eschar
 ESCHAROTOMY

 Deep 2nd & 3rd degree circumferential burns

 Chest: To allow respiratory movement
 Limb: To restore circulation in limb with excess swelling under rigid eschar

 Bedside, IV sedation, cautery

 Midaxial incision into eschar, Across joints
 Caution at elbow, wrist, fibular head, medial ankle, neck
 Not in SC tissue  Exposes SC fat
ESCHAROTOMY

 Elevate limbs above level of heart

 Monitor pulses for 48 hrs

 Chemical escharotomy if pulses +nt but feeble.

 Useful in hand burns.

 Enzyme – collagenase

 Complications : bleeding, infection

 Antimicrobial prophylaxis must to prevent sepsis

INDICATIONS FOR ADMISSION

 >15% burns in adults

 10% burns in children
 Airway and inhalation injury.
 Significant burn involving face, hands, feet and perineum.
 Extremes of age.
 Suspected non-accidental burns.
 Burns that require early surgery (deep partial thickness / full thickness)
 Patients deficient of nursing care by attendants at home
 Severe electric and acid burns that is likely to have serious sequelae
 RECEPTION

• Resuscitation –ensure ABC

• Large gauge I.V catheter
• Central line Insertion
• Venesection
• Foleys catheter and NG tube placement
• Quick assessment of extent
• Tetanus prophylaxis (the only IM administered inj)
• Weigh the patient
Respiratory Care

 Assess airway, respiration & breath sounds

 Removal of pulmonary secretions

 O2 Humidification
 Chest physiotherapy, deep breathing & coughing
 Frequent position changes and suction

 Pharmacologic Considerations:
 Bronchodilators and mucolytics

 Circumferential chest burns can impair ventilation


 Cardiovascular Care

 Increase capillary permeability

 “Capillary Leakage Syndrome”
 Fluid shift  intravascular to interstitial space  blistering and massive
edema

 Excessive insensible loss via burn wound 3-5 lit/d !!

 Finally  hypovolemia  untreated BURNS’ SHOCK

Severity of Burn Injuries

 Treatment of burns as per severity of injury

 Severity is determined by:

 Depth of burns
 TBSA involved
 Site - face, hands, feet, face or perineum
 Age
 Associated injuries

N Engl J Med 1996;335:1581 J Trauma 1994;36;59

 OUTCOME

PROGNOSIS (Baux Score)

Sum of Age in years
+
Area of burn in % TBSA

< 80 good
80-100 life threatening
>100 bad
Resuscitation Phase

 First 24-48 hours after initial burn injury or until spontaneous diuresis occurs.
 Resuscitation phase characterized by:
 Life-threatening airway problems
 Cardiopulmonary instability
 Hypovolemia

 Goal:
 Maintain vital organ function and perfusion
PARENTERAL FLUIDS
Parkland Formula

 Fluid of Choice
 Lactated Ringer’s (RL)
 NS can produce hyperchloremic acidosis
 4 ml x % of burn x weight (Kg) in 24 hours
 First ½ of total volume given in the first 8 hours
 Remaining ½ of total volume given over following 16 hours

 NEXT 24 HRS
 Total volume ½ of first day
 Colloids ( 0.5 ml / kg / % )
 5 % glucose to make up the rest
Parkland Formula

 Maximum applicable TBSA – 50%

 Fully dilated capillaries

 Maximum capillary permeability

 No further mounting of inflammatory response

 Adult Fluid Resuscitation

 Evan’s formula:

 Requirement for first 24 hrs

 Colloids : 1ml/kg/% burn
 Saline : 1ml/kg/% burn
 D5 : 2000ml

 Requirement for second 24 hrs

 ½ of first 24 hrs
 Adult Fluid Resuscitation

 Brooke formula

 Requirement for first 24 hrs

 Colloids : 0.5ml / kg /% burn
 RL : 1.5ml / kg / %burn
 D5 : 2000ml in adults

 Requirement for second 24 hrs

 ½ of first 24hrs
 Pediatric age group

Carvajal Formula

 5000cc x m2 x % BSA initial + 2000cc x m2 maint /d

 Change to 5%D+RL with albumin after 6 hrs

 Urine output 1-2 cc/ kg/h
 Assessment of Adequacy of
Fluid Resuscitation
 Monitor
 Urinary Output
Adult: > 1 ml/ kg/ hr
 Daily Weight
 Vital Signs
Heart rate and blood pressure
CVP

Level of Consciousness
 Laboratory values
RESUSCITATION FAILURE

 Delayed resuscitation
 Electric burns
 Inhalation injury
 Escharotomy
 Carbon monoxide poisoning
 Elderly patients
 Nutritional Support

 Burn wounds consume large amounts of energy:

 Requires massive amounts of nutrition to promote wound healing

 Monitoring Nutritional Status

 Weekly albumin levels
 Daily weight
 EMR (Estimated metabolic requirement) (Curreri formula)
=25kcal x body weight (kg) + 40 kcal x % BSA
 Routes of Nutritional Support

 High-protein & high-calorie diet

 Often requiring various supplements
 Routes:
ORAL (BEST)
Enteral
 Gut is the preferred alternative route
 G-tube or J-tube (Head injury/ surgery/ unconscious)
Parenteral
 TPN and PPN
 Associated with an increased risk of infections
Nutritional Support

Formulas to Predict Caloric Needs in Severely Burned Children

Age group Maintenance needs Burn wound needs

Infants (0-12 mo) 2100 KCal/ %TBSA/ 24hr 1000 KCal/ %TBSA/ 24hr

Children (1-12 yr) 1800 KCal/ %TBSA/ 24hr 1300 KCal/ %TBSA/24 hr

Adolescents (12-18 yr) 1500 KCal/ %TBSA/ 24hr 1500 KCal/ %TBSA/ 24hr
BURN WOUND CARE
 Burn Wounds

Risk for Infection

 Skin  first line of defense

 Necrotic tissue  bacterial growth

 Management

Burn wounds are frequently monitored for bacterial colonization

Wound swab cultures and invasive biopsies
 Role of burn wound cultures

 Early cultures positive/ high counts  early contamination of the burn wound

 Routine cultures  aid in empiric antimicrobial coverage if the patient subsequently

becomes ill

 Increasing colony counts  change topical antimicrobial agents.

 Colonization by virulent or resistant organisms  predictor of impending invasive burn

wound infection.

 Wound colony counts >106  high risk of infectious & graft failure.
Burn Wound Care

Hydrotherapy

Shower, bed baths or clear water spray

Maintain appropriate water and room temperature
Limit duration to 20-30 minutes
Trim hair around wound; except eyebrows
Dry with towel; pat dry, don’t rub!
Clean unburned skin and hair
 Burn Wound Care

Antimicrobial Agent
 Silvadene (silver sulfadiazine)
 Broad spectrum; the most common agent used
 Painless & easy to use
 Doesn’t penetrate eschar
 Leaves black tattoos from silver ion

 Sulfamylon (mafenide acetate)

 Penetrates eschar
 Painful for approximately 20 minutes after application
 Metabolic acidosis
 Burn Wound Care

Antimicrobial agent
 Bacitracin/ Neomycin/ Polymyxin B
- not broad spectrum, painless, easy to apply
 Nystatin(Mycostatin)
- antifungal
 Mupirocin(Bactroban)
- anti staphylococcal
 Burn Wound Care

 Betadine

 Drying effect makes debridement of the eschar easier

 Acticoat (antimicrobial occlusive dressing)

 A silver impregnated gauze that can be left in place for 5 days

 Moist with sterile water only; remoisten every 3-4 hours
 Soak silver dressings and gauze
in WATER (not saline).

Apply the
silver dressing.

Wrap with moist gauze.

Secure with mesh, gauze or tape.
 Burn Wound Care

Antimicrobial (SOAKS)
 0.5% Silver nitrate
 Effective against all micro-organism
 Stains contacted area, leaches sodium from wound
 Methemoglobinemia
 5% Mafenide acetate
 Painful
 metabolic acidosis
 0.025 Sodium hypochlorite - Gram Positive organism

 0.25% Acetic acid - Gram Negative organism

Closed Dressing

 Advantages • Disadvantages
• Less wound desiccation • Time consuming
• Expensive
• Decreased heat loss
• Increase chances of
• Decreased cross
infection if not changed
contamination
frequently
• Debriding effect
• More comfortable
 Burn Wound Care

Cover with a Sterile Dressing

 Most wounds covered with several layers of sterile gauze dressings.

 Special Considerations:
 Joint area lightly wrapped to allow mobility
 Facial wounds may be left open to air
 Circumferential burns: wrap distal to proximal
 All fingers and toes should be wrapped separately
 Splints over dressings
Burn Wound Care

Debridement of the wound

 May be completed at the bedside or as a surgical procedure.
 Types of Debridement:
Natural
 Body & bacterial enzymes dissolve eschar; takes a long time
Mechanical
 Sharp (scissors), Wet-to-Dry Dressings or Enzymatic Agents
Surgical
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Why excise the burn?

 Burn wound is a focus for sepsis  Non full-thickness burns may heal
spontaneously
 Burn stimulates inflammatory mediators but
 Superficial burns heal with acceptable
scars
 Deep burns cannot heal without grafts

 Excised burn wound must be closed

 Possible effect on future scar quality

 Major burn surgery is hazardous

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Timing of surgery

 “Ultraconservative”
 Conservative
 Early
 Acute
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Urgent surgery

High-tension electrical injury

Deep encircling burns - escharotomy

 limbs
 trunk
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For small burns

Excision and grafting as soon as possible

clearly non-healing
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Early excision of burns

 Tangential excision to
viable tissue on day 2-3

 Janzekovic (1970)
Jackson & Stone (1972)

 Current concept – within hours

 Hardly any bleed
 Upto 60% burns
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TANGENTIAL BURN EXCISION
& EARLY SPLIT SKIN GRAFTING