management of burns

1. 2012.10.20

2.  Epidemiology
 Pathophysiology
 Mechanisms
 First aids
 Minor burns
 Major burns
 Assessment
 Fluid resiscitation
 Burn wounds

3.  One of the most devastating conditions
 Assault on all aspects of the patient
 physical
 psychological
 Affects all ages
 babies to elderly people

5.  Up to 4 years - 20% of all burn injuries.
 Most injuries (70%) are scalds
 10% of burns happen to children between the
ages of 5 and 14
 accelerants such as petrol,
 electrocution

6.  Most burns ( > 60%)
 ages15-64 yrs
 mainly flame burns
 a third due to work related incidents
 10% of burns occur in aged > 65
 scalds
 contact burns
 flame burns
 compromised by some other factor
 acoholism
 epilepsy
 chronic psychiatric or medical illness

7.  Rescue
 Resuscitate
 Retrieve - specialist burns unit
 Resurface - simple dressings to aggressive
surgical debridement and skin grafting.
 Rehabilitate
 Reconstruct-scarring
 Review

8. Local response -3 zones
 Zone of coagulation
 at the point of maximum damage.
 irreversible tissue loss due to coagulation
proteins.
 Zone of stasis
 decreased tissue perfusion
 potentially salvageable tissue
 aim of resuscitation is to increase tissue perfusion
here and prevent any damage becoming irreversible

9.  Zone of hyperaemia
 outermost zone
 tissue perfusion is increased
 tissue here will invariably recover unless
 severe sepsis
 prolonged hypoperfusion
 Three dimensional
 Loss of tissue in the zone of stasis
 wound deepening
 widening.

11. Systemic response
 Cytokines, other inflammatory mediators at
the site of injury has a systemic effect
 once the burn reaches 30% of total body surface
area

12.  Cardiovascular changes
 Capillary permeability increased
 loss of intravascular proteins and fluids into the
interstitial compartment
 Peripheral and splanchnic vasoconstriction
 Myocardial contractility decreases
 ?tumour necrosis factor
 These + fluid loss = systemic hypotension +
end organ hypoperfusion.

13.  Respiratory changes
 Bronchoconstriction
 in severe burns - ARDS
 Metabolic changes
 BMR increases up to three times
 This + splanchnic hypoperfusion
necessitates early and aggressive enteral feeding
 decrease catabolism
 maintain gut integrity

14.  Immunological changes
 Non-specific down regulation of the immune
response
 celll mediated
 humoral

15. Thermal injuries
 Scalds—About 70% of burns in children
 Flame—50% of adult burns
 Inhalational injury
 Concomitant trauma.
 Contact—In older

16. Electrical injuries
 3-4%
 Amount of heat and hence the level of tissue
damage
0.24×(voltage)2×resistance
 Voltage = main determinant of the degree of
tissue damage

17. Domestic electricity - Low voltages
 Small deep contact burns
 Exit and entry sites
 Alternating nature can cause arrhythmias
High tension injuries =>1000 V
 True high tension
 Current passes through
 Large amount of soft and bony tissue necrosis.
 Muscle damage - rhabdomyolysis
 >70 000 V is invariably fatal

18.  Flash injury
 heat from an arc cause superficial flash burns to
exposed body parts typically the face and hands.

19. Electric burns
 Need cardiac monitoring
 Normal ECG on admission + no LOC monitoring is
not required
 If ECG abnormalities+ or LOC+ need 24 hours of
monitoring

20. Chemical injuries
 Tend to be deep,
 Alkalis tend to penetrate deeper, cause
worse burns than acids.
Specific chemical burns and treatments
 Chromic acid,Dichromate salts—Rinse with dilute
sodium hyposulphite
 Hydrofluoric acid—10% calcium gluconate L.A as a
gel or injected in to affected tissues

21.  Initial management is the same irrespective
of the agent.
 all contaminated clothing must be removed
 area thoroughly irrigated.
 best achieved by showering the patient. Shown to
limit the depth of the burn
 Litmus test - removal of alkali or acid.
 Eye injuries should be irrigated copiously and
referred to an ophthalmologist.

22.  Stop the burning process
 Cool with water
 Stops burning process
 Minimises oedema
 Reduces pain
 Cleanses wound
Cooling the burn
 Effective within 20 minutes of the injury.
 Immersion or irrigation with running tepid water (15°C)
 Iced water should not be used as intense vasoconstriction
can cause burn progression

23.  Analgesia
 Opioids
 NSAIDS
 Covering the burn
 PVCfilm
 Cotton sheet (preferably sterile)
 Hand burns - clear plastic bag
Topical creams should be avoided at this stage
- interfere with assessment of the burn

24. Cleaning the burn
 New burn - essentially sterile
 Clean with soap and water or mild
antibacterial - dilute chlorohexidine
 Blisters
 Large – de-roofed, dead skin removed
 Smaller blisters - left intact.

25. Dressings
 simple gauze impregnated with paraffin
Dressing changes for burns
 Use aseptic technique
 First change after 48 hours, and every 3-5 days
thereafter
 Criteria for early dressing change:
 Excessive “strike through” of fluid from wound
 Smelly wound
 Contaminated or soiled dressings
 Slipped dressings
 Signs of infection (such as fever)

26. Management of facial burns
 Clean the face b.d.
 dilute chlorohexidine solution
 Cover with cream
 liquid paraffin on hourly basis
 Men should shave daily
 Sleep propped up on two pillows
 minimise oedema
 Follow up
 Physiotherapy
 Support and reassurance

27. Major burn
 burn covering 25% or more of total body
surface area
 any injury over more than 10% should be
treated similarly

28. Initial assessment of a major burn
 Perform an ABCDEF primary survey
 A—Airway with cervical spine control
 B—Breathing
 C—Circulation
 D—Neurological disability
 E—Exposure with environmental control
 F—Fluid resuscitation
 Assess burn size and depth
 Establish good IV access and give fluids
 Catheterise If >20% BSA
 Give analgesia
 Take baseline blood samples for investigation
 Dress wound
 Perform secondary survey, reassess, and exclude or treat
associated injuries
 Arrange safe transfer to specialist burns facility

29. Analgesia
 Superficial burns - extremely painful
 Patients with large burns should receive IV
morphine
 dose appropriate to body weight
 titrated against pain and respiratory depression.

30. Investigations for major burns
 General
 Full blood count
 Packed cell volume
 Urea
 Electrolyte concentration
 Clotting screen
 Blood group + save or crossmatch serum
 Electrical injuries
 12 lead electrocardiography
 Cardiac enzymes (for high tension injuries)
 CK MB

31.  Inhalational injuries
 Chest x ray
 Arterial blood gas analysis
 Can be useful in any burn
 base excess is predictive of the amount of fluid
resuscitation required
 helpful for determining success of fluid resuscitation
 essential with inhalational injuries or exposure to
carbon monoxide

32. Secondary survey
 After primary survey and the start of
emergency management
 Head to toe examination looking for any
concomitant injuries
Dressing the wound
 BSA and depth have been estimated
 burn wound washed,loose skin removed
 Blisters should be deroofed
 except palmar blisters (painful), unless these are large
enough to restrict movement.

33. BSA
 Palmar surface
 The surface area of a patient’s palm
(includingfingers) is roughly 0.8%
 Can be used to estimate
 small burns ( < 15% of total surface area)
 very large burns ( > 85%, when unburnt skin iscounted)
 For medium sized burns, it is inaccurate.

34.  Wallace rule of nines

35.  Lund and Browder
chart

36.  Fluid losses from the injury must be replaced
to maintain homoeostasis
 No ideal resuscitation regimen
 Main aim is to maintain tissue perfusion to
the zone of stasis - prevent the burn
deepening.
 too little - cause hypoperfusion
too much - oedema causing tissue hypoxia

37.  Greatest amount of fluid loss - first 24 hours
after injury
 First eight to 12 hours- of fluid from the
intravascular to interstitial fluid
compartments
 Colloids have no advantage over crystalloids
in maintaining circulatory volume

38.  Fast fluid boluses have little benefit
 rapid rise in intravascular hydrostatic pressure
will drive more fluid out of the circulation
 much protein is lost through the burn wound,
need to replace this oncotic loss
 Some regimens introduce colloid after the
first eight hours

39.  BSA/TSA
 >15% of in adults
 >10% in children
Needs formal resuscitation

40.  Pure crystalloid formula.
 Fluid requirement in the first 24 hours
 Children require maintenance fluid in
addition to this
 Starting point for resuscitation is the time of
injury, not the time of admission
 Any fluid already given should be deducted
from the calculated requirement

41. 4 ml×(BSA (%))×(body weight(kg))
 50% given in first 8 hours
 50% given in next 16 hours
 Children receive maintenance fluid in addition at
hourly rate of
 4 ml/kg for first 10 kg of body weight plus
 2 ml/kg for second 10 kg of body weight plus
 1 ml/kg for > 20 kg of body weight
 End point
Urine output
 0.5-1.0 ml/kg/hour in adults
 1.0-1.5 ml/kg/hour in children

42. After 1st 24 hours
 colloid infusion is begun
0.5 ml×(BSA (%))×(body weight (kg))
 maintenance crystalloid (usually dextrose-
saline) is continued
1.5 ml×(BSA)×(body weight)

43.  High tension electrical injuries require
substantially more fluid
9 ml×(BSA)×(body weight) in the first
24hours
higher urine output 1.5-2 ml/kg/hour
 Inhalational injuries require more fluid.

44.  Hartman’s solution most appropriate
 Colloid of choice
 FFP for children
 Albumin or synthetic high molecular weight starches
for adults
 Continuously adjusted according to
 UOP
 Physiological parameters
 pulse, blood pressure, and respiratory rate
 Investigations 4 – 6 H for monitoring
 PCV
 SE
 Base excess
 Lactate.

45.  The infusion rate is guided by the UOP
not by formula.
 The urine output should be maintained at a
rate
 Adult 0.5 / kg / hr
 Children 1 ml / kg / hr
 UOP <0.5mls/kg/hr increase IV fluids by 1/3 of
current IV fluid amount
 UOP >1ml/hr for adults or >2ml/kg/hr for
children decrease IV fluids by 1/3 of current IV
fluid amount
 Last hrs urine = 20mls, received 1200mls/hr, increase IV to
1600mls/hr
 Last hrs urine = 100mls, received 1600mls/hr, decrease IV to
1065mls

46. Indications
 Circumferential deep dermal or full thickness
burn
 Circumferential chest burns
Only the burnt tissue is divided, not any underlying
fascia, differentiating this procedure from a
fasciotomy.

47.  Best done with electrocautery, as they tend
to bleed.
 Packed with Kaltostat alginate dressing and
dressed with the burn.

50.  Partial thickness -do not extend through all
skin layers
 Superficial
 Superficial dermal
 Deep dermal
 Full thickness burns -extend through all skin
layers in to the subcutaneous tissues

52.  Superficial = epidermal burn
 affects the epidermis
 not the dermis (eg: sunburn)
 Superficial dermal
 extends through the epidermis into the upper
layers of the dermis
 associated with blistering
 Deep dermal
 burn extends through the epidermis into the
deeper layers of the dermis
 not through the entire dermis.

53.  History - clues to the expected depth:
 Bleeding- test with 21 gauge needle
 Brisk bleeding on superficial pricking -
superficial or superficial dermal
 Delayed bleeding on a deeper prick - a deep
dermal burn
 No bleeding - full thickness burn

54.  Sensation— with a needle
 Pain - a superficial or superficial dermal burn
 non-painful - deep dermal injury,
 insensate - full thickness
 Appearance and blanching
 often difficult
 burns may be covered with soot or dirt
 Blisters should be de-roofed to assess the base
 Capillary refill - assessed by pressing with a sterile
cotton bud

59.  red, moist wound that obviously blanches and
rapidly refills
 superficial
 pale, dry but blanching wound that regains its
colour slowly
 superficial dermal
 mottled cherry red colour that does not blanch
(fixed capillary staining)
 Deep dermal
 dry, leathery or waxy, hard wound that does not
blanch
 full thickness
 Most burns are a mixture of different depths

60.  Epidermal burns
 supportive therapy
 regular analgesia
 intravenous fluids for extensive injuries.
 Superficial partial thickness burns
 antimicrobial creams
 occlusive dressings
 Deep partial thickness
 Excised to a viable depth
 skin graft

61.  Some will heal if the wound environment is
optimised
 keeping it warm, moist, and free of infection.
 newer tissue engineered dressings are designed
to encourage this by supplying exogenous
cytokines
 Full thickness injuries
 healing occurs from the edges
 considerable contraction
 excised and grafted unless they are < 1 cm in
diameter

62.  wounds should have epithelial cover within
three weeks to minimise scarring
 eschar is shaved tangentially or excised to
deep fascia
 large areas of deep burn must be excised
before the burnt tissue triggers multiple
organ failure or becomes infected
 ideal covering is split skin autograft

63.  graft is perforated with a mesher to allow
expansion

64.  Bacteria
 Β haemolytic streptococci—Such as Streptococcus
pyogenes.
 Staphylococci—MRSA
 Gram negative bacteria—Pseudomonas aeruginosa,
Acinetobacter baumanii, Proteus species
 Fungi
 Candida—Most common
 Filamentous fungi—Aspergillus, Fusarium, and
phycomycetes.
 Viruses
 Herpes simplex

65.  Topical
 Silver sulfadiazine
 Cerium nitrate-silver sulfadiazine
 Silver nitrate
 Mafenide
 systemic
 depends on the predominant flora
 Prophylactic use of systemic antibiotics is
controversial

66.  Critical Cre
 Nutrition
 Reconstruction
 Rehabilitation
 Psychological support