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Burn Management

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Functions

Skin is the largest organ of the bodyEssential for:- Thermoregulation

- Prevention of fluid loss by evaporation

- Barrier against infection - Protection against environment provided

by sensory information

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Types of burn injuries

Thermal: direct contact with heat(flame scald contact! Electrical

"#$# % alternating current (residential!

$# % direct current (industrial'lightening! $hemical rostbite

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First degree burn

+nvolves only theepidermisTissue will blanch with

pressureTissue is erythematousand often painful

+nvolves minimal tissuedamageSunburn

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Second degree burn

,eferred to as partial-thickness burns+nvolve the epidermis and

portions of the dermisften involve otherstructures such as sweatglands hair follicles etc#Blisters and very painfulEdema and decreased bloodflow in tissue can convertto a full-thickness burn

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Third degree burn

,eferred to as full-thickness burns$harred skin ortranslucent white color $oagulated vessels visible"rea insensate % patientstill c'o pain from

surrounding seconddegree burn area$omplete destruction oftissue and structures

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Fourth degree burn

+nvolves

subcutaneous tissue

tendons and bone

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Burn extent

. BS" involved morbidity

Burn e)tent is calculated only on individualswith second and third degree burns

Palmar surface / 0. of the BS"

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Measurement charts

Rule of Nines:1uick estimate of percent of burn

Lund and Browder: 2ore accurate assessment tool 3seful chart for children % takes into account

the head si4e proportion#

Rule of Palms:5ood for estimating small patches of burn wound

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Imaging studies

$9,

Plain ilms ' $T scan: &ependent upon history and physical findings

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Criteria for burn center

admissionFull-thickness > 5 BS!

Partial-thickness > "# BS!

!n$ full-thickness or %artial-thickness burn involvin&critical areas 'face( hands(feet( &enitals( %erineum( skinover ma)or )oint*

+hildren with severe burns

+ircumferential burns ofthora, or e,tremities

Si&nificant chemical in)ur$(electrical burns( li&htenin&in)ur$( co-e,istin& ma)ortrauma or si&nificant %re-e,istin& medical conditions

Presence of inhalation in)ur$

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Initial patient treatment

Stop the burning process

$onsider burn patient as a multiple trauma patient untildetermined otherwise

Perform "B$&E assessment

"void hypothermia

,emove constricting clothing and *ewelry

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Details of the incident

$ause of the burnTime of in*uryPlace of the occurrence (closed space

presence of chemicals no)ious fumes!8ikelihood of associated trauma(e)plosion ;!Pre-hospital interventions

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ir!ay considerations

aintain low threshold forintubation and hi&h inde, ofsus%icion for airwa$ in)ur$

Swellin& is ra%id and%ro&ressive first ./ hours

+onsider RS0 to facilitateintubation 1 cautious use ofsuccin$lcholine hours afterburn due to 23 increase

Prior to intubation attem%t:

have smaller si4es of 66available

Pre%are for cricoth$rotom$for tracheostom$

7tili4e 6+8. monitorin& 1%ulse o,imetr$ ma$ beinaccurate or difficult to a%%l$to %atient9

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ir!ay considerations

7%%er airwa$ in)ur$ 'above the &lottis*: "rea buffers the heat of smoke % thermal in*ury isusually confined to the laryn) and upper trachea#

Lower airwa$ alveolar in)ur$ 'below the&lottis*:

- $aused by the inhalation of steam or chemicalsmoke#- Presents as ",&S often after 7

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Criteria for intubation

$hanges in voice>hee4ing ' laboredrespirations

E)cessive continuouscoughing"ltered mental status$arbonaceous sputum

Singed facial or nasal hairsacial burnsro-pharyngeal edema 'stridor

"ssume inhalation in*uryin any patient confined ina fire environmentE)tensive burns of theface ' neck Eyes swollen shutBurns of ?@. TBS" orgreater

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"ediatric intubation

Aormally have smaller airways than adultsSmall margin for error

+f intubation is re uired an uncuffed ETT should be placed+ntubation should be performed by e)periencedindividual % failed attempts can create edema andfurther obstruct the airway

"5E C < / ETT si4e isconsinformula

+n the field'pre-transfer reasonable to begin+F fluids (8,! at 7@cc'kg'hour (for 0-7 hrs!

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Burn Injury' Fluid -esuscitation

D2$ approach: modified Parkland formula % &eficit: (H cc'kg! ) (wt in kg! ) (. BS"! as 8,

Q?@. over 0st J hours ?@. over ensuing 0G hoursQSubtract documented fluids given en route or in E,

% 2aintenance: & ?#7?AS customarily calculated

veraggressive volume resuscitation mayresult in iatrogenic complication % pulmonary edema compartment syndrome

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Fluid -esuscitation -eminders'

Titrate +F fluids to achieve desired rehydra-tion uantified mainly by urine output

% mucous membranes skin turgor fontanelletears pulse rate sensorium capillary refill

6aliuresis can be profoundM +F replacementmay be re uired+ncreased "&D release (pain'an)iety! mayconfuse picture

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Burn Injury' .utritional Support

Essential for wound healing graft survivalM prevents Nat riskO partial thickness in*ury

from converting to full thickness in*uryEnteral feeds preferred over TPA % may prevent gut bacterial translocation

% early (within < hours! institution of enteralfeeds may achieve early positive A 7 balance

% may be precluded by paralytic ileus

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Burn Injury' .utritional Support

Dypermetabolic state favors breakdown'useof fat and proteinM rate of loss of lean body

mass can be slowed by appro)imating positive nitrogen balanceM high proteincontent of enteral formula therefore favoredEnteral formulas should be lactose free andless than

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Burn Injury' .utritional Support

$urreri ormula: % calories'day/(wt in kg! (7?! C (

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Burn Injury' /ound Management

Escharotomy'fasciotomy may be necessarywithin hours

% neurovascular compressionM chest wall motionSurgery for wound closure is necessary forfull thickness in*ury or areas of deep partialthickness that would heal with delay or scar +n life threatening burns urgency to graft

before substantial coloni4ation occurs

B I j ' / d

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Burn Injury' /ound Management

+ntegra % inert material mimicking the structure of dermis

% collagen strands provide ordered matri) forfibroblast infiltration'native collagen deposition

% allows harvesting of thin epidermal layer forgraft with more rapid healing at donor sites

"ppropriate tetanus prophyla)is mandatory$onsider relative risk of &FT prophyla)is

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B rn In& r : Pain

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Burn In&ury: Pain Management

P$" may be an option in older patients6etamine may be useful during procedures

% profound analgesia respiratory refle)es intact % DTA emergence delirium hallucinations

Qmida4olam @#0 mg'kg to reduce ketamine NedgeO

Propofol other modalities&o not overlook analgesia'sedative needs of patients receiving neuromuscular blockade

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Burn In&ury: (opical Anti)iosis

$oloni4ation via airborne L'or endogenousgramC flora within the 0st week is the ruleM

subse uent coloni4ation tends to be gram-$omplications of topical agents % hyponatremia hyperosmolarity metabolic

acidosis methemoglobinemia

Silvadene resistance universal for E# clocae % S# aureus common Pseudomonas occasional

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Burn In&ury: Infection

Types of infections in burn patients % burn wound invasion'sepsis cellulitis

pneumonia supparative thrombophlebitismiscellaneous nosocomial infections

rganisms causing burn wound invasion % pseudomonas-

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Burn In&ury: Woun Sepsis

$haracteri4ed by gray or dark appearance purulent discharge systemic signs of sepsis

+f true burn wound sepsis wound cultureshould yield 0@ ? organisms'gram of tissue5ram negative bacteremia'sepsis % think wound lungs

5ram positive bacteremia'sepsis % think indwelling lines wound

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Burn In&ury: Pre'ention

Pre-emptive counseling of families essential water heater temperature from ?< o$ to

< o$ (0H@07@o ! es time for full thick-ness scald from IH@ seconds to 0@ minutes$igarette misuse responsible for H@. of

house firesSmoke detector installation'maintenance

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Burn In&ury: Pre'ention

Burn prevention has far greater impact on public healththan refinements in burn careBurn risks related to age:

% infancy: bathing related scaldsM child abuse % toddlers: hot li uid spills % school age children: flame in*ury from matches % teenagers: volatile agents electricity cigarettes % introduction of flame retardant pa*amas

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Burn In&ury: Summary

2any risk factors age dependentPediatricians primary role: prevention

Digh risk of multiple organ system effects prolonged hospitali4ation+nitial care: "B$s then surgical issues

% special attention to airway hemodynamics$hronic care issues: scarring lean mass loss