BURNS

INITIAL ASSESSMENT
Initial evaluation of the burned patient involves four
crucial assessments:
Airway Management
Evaluation of other Injury
Burn size Estimation
CO & Cyanide Poisoning

AIRWAY MANAGEMENT
Signs of impending respiratory compromise may include:

a hoarse voice
wheezing, or
stridor;
subjective dyspnea is a particularly concerning symptom
and should trigger prompt elective endotracheal
intubation.

In patients with combined multiple trauma, especially

oral trauma, nasotracheal intubation may be useful but
should be avoided if oral intubation is safe and easy

 A primary survey should be conducted in accordance

with ATLS guidelines.
Concurrently with the primary survey, large-bore
peripheral intravenous (IV) catheters should be
placed and fluid resuscitation should be initiated; for
a burn larger than 40% total body surface area
(TBSA), two largebore IVs are ideal

 Rarely, IV resuscitation is indicated in patients with

burns smaller than 15% who can usually hydrate
orally.
Pediatric patients with burns larger than 15% may
require intraosseous access in emergent situations if
venous access cannot be attained.
An early and comprehensive secondary survey must
be performed on all burn patients, but especially
those with a history of associated trauma such as
with a motor vehicle collision.

 Urgent radiology studies, such as a chest x-ray,

should be performed in the emergency department,
but nonurgent skeletal evaluation (i.e., extremity xrays) can be done in the intensive care unit (ICU) to
avoid hypothermia and delays in burn resuscitation.
Hypothermia is a common prehospital complication
that contributes to resuscitation failure. Patients
should be wrapped with clean blankets in transport.
Cooling blankets should be avoided in patients with
moderate or large (>20% TBSA) burns.

 Patients with acute burn injuries should never receive

prophylactic antibiotics.
A tetanus booster should be administered in the
emergency room.
Also consider treatment of long-term anxiety :
anxiolytic such as a benzodiazepine with the initial
narcotics.
Most burn resuscitation formulas estimate fluid
requirements using the burn size as a percentage of
TBSA (%TBSA).
The rule of nines is a crude but quick and effective
method of estimating burn size.

 In adults :

the anterior and posterior trunk each account for 18%

each lower extremity is 18%
each upper extremity is 9%, and
the head is 9%.

GUIDELINES FOR REFERRAL TO A

BURN CENTER

Partial-thickness burns greater than 10% TBSA

Burns involving the face, hands, feet, genitalia, perineum, or
major joints
Third-degree burns in any age group
Electrical burns, including lightning injury
Chemical burns
Inhalation injury
Burn injury in patients with complicated pre-existing
medical disorders
Patients with burns and concomitant trauma in which
the burn is the greatest risk. If the trauma is the greater
immediate risk, the patient may be stabilized in a trauma
center before transfer to a burn center.
Burned children in hospitals without qualified personnel for
the care of children
Burn injury in patients who will require special social,
emotional, or rehabilitative intervention
TBSA = total body surface area.

 An important contributor to early mortality in burn

patients is carbon monoxide (CO) poisoning resulting
from smoke inhalation.
Unexpected neurologic symptoms should raise the
level of suspicion, and an arterial carboxyhemoglobin
level must be obtained because pulse oximetry can be
falsely elevated.
Administration of 100% oxygen is the gold standard for
treatment of CO poisoning and reduces the half-life of
CO from 250 minutes in room air to 40 to 60 minutes
on 100% oxygen.

 Patients who sustain a cardiac arrest as a result of their

CO poisoning have an extremely poor prognosis
regardless of the success of initial resuscitation
attempts.
Hydrogen cyanide toxicity may also be a component of
smoke inhalation injury.
Afflicted patients may have a persistent lactic acidosis
or ST elevation on electrocardiogram (ECG)
Cyanide inhibits cytochrome oxidase, which is required
for oxidative phosphorylation

 Treatment consists of
Sodium thiosulfate, hydroxocobalamin, and 100%
oxygen. Sodium thiosulfate works by transforming
cyanide into a nontoxic thiocyanate derivative, but it
works slowly and is not effective for acute therapy.
Hydroxocobalamin quickly complexes with cyanide, is
excreted by the kidney, and is recommended for
immediate therapy.

In the majority of patients, the lactic acidosis will

resolve with ventilation, and sodium thiosulfate
treatment becomes unnecessary.

CLASSIFICATION OF
BURNS
Burns are commonly classified as
Thermal
electrical, or chemical burns, with thermal burns
consisting of flame
contact, or
scald burns.

 Electrical burns make up only 4% of U.S. hospital

admissions but have special concerns including the
potential for cardiac arrhythmias and compartment
syndromes with concurrent rhabdomyolysis.
A baseline ECG is recommended in all patientswith an
electrical injury, and a normal ECG in a low-voltage
injury may preclude hospital admission.
Because compartment syndrome and rhabdomyolysis
are common in high-voltage electrical injuries,
vigilance must be maintained for neurologic or vascular
compromise, and fasciotomies should be performed
even in cases of moderate clinical suspicion.

 Long-term neurologic and visual symptoms are not

uncommon with high-voltage electrical injuries, and
ophthalmologic and neurologic consultation should
be obtained to better define a patients baseline
function.

 Chemical burns are less common but potentially severe

burns.
The most important components of initial therapy are
careful removal of the toxic substance from the patient
and irrigation of the affected area with water for a
minimum of 30 minutes, except in cases of concrete
powder or powdered forms of lye, which should be
swept from the patient to avoid activating the
aluminum hydroxide with water.

 The offending agents in chemical burns can be

systemically absorbed and may cause specific
metabolic derangements.
Formic acid has been known to cause hemolysis and
hemoglobinuria, and hydrofluoric acid causes
hypocalcemia.
Hydrofluoric acid is a particularly common offender due
to its widespread industrial uses Calcium-based
therapies are the mainstay of treating hydrofluoric acid
burns, with topical application of calcium gluconate onto
wounds and IV administration of calcium gluconate for
systemic symptoms
19

 Patients undergoing intra-arterial therapy need

continuous cardiac monitoring. Persistent refractory
hypocalcemia with electrocardiac abnormalities may
signal the need for emergent excision of the burned
areas.

BURN CLASSIFICATION

BURN DEPTH
BY:DUPUYTREN
Superficial First Degree Burn
Pain without blister

Partial Thickness Second Degree Burn

Pain with Blister and weeping

Full Thickness Third Degree Burn

leathery, painless, nonblanching, narcotic

Underlying Soft Tissue Fourth Degree Burn

stasis, vasoconstriction and ischemia

RESCUCITATION
3 to 4 mL/kg/% burn of lactated Ringers
half is given during the first 8 hours after burn and the
remaining half is given over the subsequent 16 hours.
A classic study by Navar et al showed that burned
patients with inhalation injury required an average of
5.76 mL/kg/% burn. 3.98 mL/kg/% burn for patients
without inhalation injury

TRANSFUSION
A large multicenter study of blood transfusions in
burn patients found that increased numbers of
transfusions were associated with increased
infections and higher mortality in burn patients, even
when correcting for burn severity.

INHALATION INJURY AND

VENTILATOR
MANAGEMENT
Smoke inhalation causes injury in two ways:
Direct injury to the upper airway causes airway
swelling that leads edema.
Aggressive pulmonary toilet and routine use of
nebulized bronchodilators such as albuterol are
recommended. Nebulized N-acetylcysteine is an
antioxidant free radical scavenger designed to
decrease the toxicity of high oxygen concentrations.

Aerosolized heparin aims to prevent formation of

fibrin plugs and decrease the formation of airway
casts

TREATMENT OF THE
BURN WOUND
Silver sulfadiazine has a wide range of antimicrobial
activity, primarily as prophylaxis against burn wound
infections rather than treatment of existing
infections.
Mafenide acetate, is an effective topical
antimicrobial. It is effective even in the presence of
eschar and can be used in both treating and
preventing wound infections; the solution formulation
is an excellent antimicrobialfor fresh skin grafts

 Silver nitrate has broad-spectrum antimicrobial

activity as a topical solution. The solution used must
be dilute (0.5%), and prolonged topical application
leads to electrolyte extravasation with resulting
hyponatremia. A rare complication is
methemoglobinemia.
For smaller burns or larger burns that are nearly
healed,topical ointments such as bacitracin,
neomycin, and polymyxin B can be used.

NUTRITION
Nutritional support may be more important in
patients with large burns than in any other patient
population.
This formula estimates caloric needs to be 25
kcal/kg/d plus 40 kcal/%TBSA/d.

COMPLICATION IN BURN
CARE
Ventilator-associated pneumonia -> Oral Hygene,
Pulmonary Toilet
Abdominal Compartment Syndorme
Deep Vein Thrombosis
Catheter related Stream Infection

SURGERY
Full-thickness burns with a rigid eschar can form a
tourniquet effect as the edema progresses, leading to
compromised venous outflow and eventually arterial inflow.
The resulting compartment syndrome is most common in
circumferential extremity burns.
Abdominal compartment syndrome should be suspected
with decreased urine output, increased ventilator airway
pressures, and hypotension. Hypoventilation, increased
airway pressures, and hypotension may also characterize
thoracic compartment syndrome

SURGERY
The strategy of early excision and grafting in burned
patients revolutionized survival outcomes in burn care.
Not only did it improve mortality, but early excision
also decreased reconstruction surgery, hospital length
of stay, and costs of care. Once the initial resuscitation
is complete and the patient is hemodynamically stable,
attention should be turned to excising the burn wound.
Burn excision and wound coverage should ideally start
within the first several days, and in larger burns, serial
excisions can be performed as patient condition allows.

SURGERY
When indicated, they are usually performed at the
bedside, preferably with electrocautery to minimize
blood loss. Extremity incisions are made on the lateral
and medial aspects of the limbs in an anatomic
position and may extend onto thenar and hypothenar
eminences of the hand.

SURGERY
Excision is performed with repeated tangential slices using a
Watson or Goulian blade until viable, diffusely bleeding tissue
remains. It is appropriate to leave healthy dermis, which will
appear white with punctate areas of bleeding.
Excision to fat or fascia may be necessary in deeper burns.
The downside of tangential excision is a high blood loss, though
this may be ameliorated using techniques such as instillation of
an epinephrine tumescence solution underneath the burn.
Pneumatic tourniquets are helpful in extremity burns, and
compresses soaked in a dilute epinephrine solution are
necessary adjuncts after excision.

SURGERY
A fibrinogen and thrombin spray sealant (Tisseel
Fibrin Sealant; Baxter, Deerfield, IL) also has beneficial
effects on both hemostasis and graft adherence to the
wound bed, these techniques has markedly decreased
the number of blood transfusions given during burn
surgery.
For patients with clearly deep burns and concern for
excessive blood loss, fascial excision may be
employed. In this technique, electrocautery is used to
excise the burned tissue and the underlying
subcutaneous tissue down to muscle fascia.

REHABILITATION
Unable to actively should have passive range of motion done at
least twice a day. This includes patients with burns over joints, such
as with hand burns. Patients should be taught exercises they can do
themselves to maintain full range of motion. Patients with foot and
extremity burns should be instructed to walk independently without
crutches or other assistive devices to prevent extremity swelling,
desensitize the burned areas, and prevent disuse atrophy; when
patients are not ambulating, they must elevate the affected
extremity to minimize swelling. the graft should be evaluated early
and at frequent intervals so that active exercise can be resumed at
the earliest possible occasion
Tight-fitting pressure garments provide vascular support in burns
that are further along in the healing process. Whether they prevent
hypertrophic scar formation has been long debated. However, they
do provide vascular support that many patients find more
comfortable.

REHABILITATION
In patients with healed burns or donor sites, hypertrophic
scar-related morbidity includes pruritus, erythema, pain,
thickened tight skin, and even contractures. Within these
scars, there is believed to be an increased inflammatory
response that has increased neovascularization, abundant
collagen production, and abnormal extracellular matrix
structure. Treatment for these scars has included
nonsurgical therapies such as compression garments,
silicone gel sheeting, massage, physical therapy, and
corticosteroid. Surgical excision and scar revision represent
more invasive scar management approaches that are often
necessary for functional and aesthetic recovery.
Laser-based therapies provide addition treatment options
for symptomatic hypertrophic scars.

PSYCHOLOGICAL
REHABILITATION
Psychological rehabilitation is equally important in
the burn patient. Depression, posttraumatic stress
disorder, concerns about image, and anxiety about
returning to society constitute predictable barriers to
progress in both the inpatient and outpatient setting.

WOUND COVERAGE (COSMETIC

CAUSE FULL THICKNESS BURN)
Split-thickness sheet autografts
Perfect permanent synthetic skin substitute remains elusive.
Integra (Integra LifeSciences Corporation, Plainsboro, NJ) is a
bilayer product with a porous collagenchondroitin 6-sulphate
inner layer that is attached to an outer silastic sheet, which
helps prevent fluid loss and infection as the inner layer becomes
vascularized, creating an artificial neodermis
Epidermal skin substitutes such as cultured epithelial autografts

Drainage of blood and serous fluid to prevent accumulation

under the skin graft with subsequent graft loss.
Areas of cosmetic importance such as the face, neck, and
hands should be grafted with nonmeshed sheet grafts to
ensure optimal appearance and function.

PREVENTION
Despite many areas of progress in prevention,
burns continue to be a common source of injury. Some
successful initiatives have included community-based
interventions targeting simple home safety measures.
Smoke alarms are known to decrease mortality from
structural fires, but not all homes are equipped with
proper smoke alarms, particularly in low-income
households.

RADIATION BURNS
The explosion results in a direct pressure wave and
an indirect wind drag. The direct pressure can destroy
windows and buildings, rupture eardrums, and cause
pulmonary contusions, pneumothoraces, and
hemothoraces.
The combination of radiation exposure and burn
wounds has the potential to increase mortality
compared with traditional burns

PREVENTION
Home safety measures.
Smoke alarms are known to decrease mortality from
structural fires, but not all homes are equipped with
proper smoke alarms, particularly in low-income
households.

RADIATION BURNS
The mechanism
20-kiloton nuclear device generates 180 mph winds
0.8 miles from the epicenter. The explosion results in
a direct pressure wave and an indirect wind drag. The
direct pressure can destroy windows and buildings,
rupture eardrums, and cause pulmonary contusions,
pneumothoraces, and hemothoraces.

RADIATION BURNS
Syndromes include hematologic (18 Svexposure)
Gastrointestinal (830 Sv exposure), and
cardiovascular/
Neurologic syndromes (>30 Sv exposure)
The latter two being nonsurvivable
4 hours of exposure are unlikely to have severe
clinical effects. Emesis within 2 hours suggests a
dose of at least 3 Sv, and emesis within 1 hour
suggests at least 4 Sv

RADIATION BURNS
Decontamination and triage are vital to maximize the
number of survivors. Initial decontamination requires
removal of clothing and washing wounds with water.
Irrigation fluid should be collected to prevent
radiation spread into the water supply.

TERIMA KASIH