management of acute and old burns

1. Burn Management
Mohamed Ahmed Sayed
Assistant Lecturer of Plastic and Reconstructive Surgery
Ain Shams University – Faculty of Medicine
dr_mohamed_a@yahoo.com
http://www.geocities.com/dr_mohamed_a

2. • Burn wounds occur when there is contact
between tissue and an energy source, such
as heat, chemicals, electrical current, or
radiation.
• The effects of the burn are influenced by the:
intensity of the energy
duration of exposure
type of tissue injured

3. Where do most burns occur?
• 0 - 4 years, from kitchen, bathroom.
• 5-74 years, outdoors, kitchen.
• Teenagers, suicide (females).
• > 75 years, kitchen, outdoors.
When do most burns occur?
• Winter more than summer

4. Major cause of fires in the home
• Carelessness with cigarettes!!
• Hot water from water heaters set at high
levels above 60° C
• Cooking accidents
• Space heaters
• Gasoline, lighter fluids, etc.
• Chemicals

5. Types of Burn Injury
• Thermal burns: flame, flash, contact with hot objects.
• Scald burns: hot fluids.
• Chemical burns: necrotizing substances (acids, alkali).
• Electrical burns: intense heat from an electrical current
• Smoke & inhalation injury: inhaling hot air or noxious
chemicals
• Cold thermal injury: frostbite.

6. Thermal Burns

7. Scald Burns

8. Chemical Burn
examples: cleaning agents...
Remember….
• Tissue destruction may continue for up to 72 hours.
• It is important to remove the person from the burning
agent or vice versa.
• The latter is accomplished by lavaging the affected area
with copious amounts of water.

9. Smoke and Inhalation Injury
• Can damage the tissues of the
respiratory tract
• Although damage to the respiratory
mucosa can occur, it seldom
happens because the vocal cords
and glottis closes as a protective
mechanisms.

10. Electrical Burns

11. Electrical Burns
• Injury from electrical burns results from coagulation
necrosis that is caused by intense heat generated
from an electric current.
• The severity depends on:
amount of voltage
tissue resistance
current pathways
surface area in contact with the current
length of time the current flow.

12. Electrical injury can cause:
• Fractures of long bones and vertebra
• Cardiac arrest or arrhythmias--can be
delayed 24-48 hours after injury
• Severe metabolic acidosis--can develop in
minutes
• Myoglobinuria--acute renal tubular
necrosis.

13. Treatment of electrical burns…
• Fluids--Ringers lactate or other fluids-flushes
out kidneys--you want 75-100 cc/hr until urine
sample clear
• an osmotic diuretic (Mannitol) may be given
to maintain urine output

14. Cold Thermal Injury (Frostbite)

15. Classification of Burn Injury
Severity is determined by:
– depth of burn
– extend of burn calculated in percent of total body
surface (TBSA)
– location of burn
– patient risk factors

16. Depth of Burns
Medicolegal classification clinical classification
Erythema
Super.
Dermal
Deep
Dermal
Full
Thickness
1st
2nd
3rd

17. Extend of Burns
Lund-Browder Chart Rule of Nines
Adult1510510Age in years
3½4½5½6½8½9½A-head (back or front)
4¾4½4¼43¼2¾B-1 thigh (back or front)
3½3¼32¾2½2½C-1 leg (back or front)

18. Location of Burns
• Vital organs of burn:
• Face, neck
• Chest
• Perineum
• Hand
• Joint regions
• Other areas

19. Patient risk factors
• Associated trauma
• Inhalation injuries
• Circumferential burns
• Electricity
• Age (young or old)
• Pre-existing disease
• Abuse

20. 3 Phases of Burn Management
–emergent (resuscitative)
–acute
–rehabilitative

21. Pre-hospital Care
• Remove from area! Stop the burn!
• If thermal burn is large--FOCUS on
the ABC’s
A=airway-check for patency, soot
around nares, or signed nasal hair
B=breathing- check for adequacy of
ventilation
C=circulation-check for presence and
regularity of pulses

22. Other precautions...
• Burn too large--don’t immerse in water due to
extensive heat loss
• Never pack in ice
• Pt. should be wrapped in dry clean material
to decrease contamination of wound and
increase warmth

23. Emergent Phase (Resuscitative Phase)
• Lasts from onset to 5 or more days but
usually lasts 24-48 hours
• begins with fluid loss and edema formation
and continues until fluid motorization and
diuresis begins
• Greatest initial threat is hypovolemic
shock to a major burn patient!

24. Management in the emergent phase is...
• Airway management-early nasotracheal or endotracheal
intubation before airway is actually compromised (usually 1-2
hours after burn)
• ventilator? ABGs? Escharotomies?
• 6-12 hours later: Bronchoscopy to assess lower respiratory
tact
• chest physiotherapy, suction

25. Complications during emergent phase
of burn injury are 3 major organ
systems...
–Cardiovascular
–Respiratory
–Renal systems

26. Fluid Therapy
• 1 or 2 large bore IV lines
• Fluid replacement based on:
– size/depth of burn
– age of pt.
– individualized considerations.
• options- RL, D5NS, dextam, albumin, etc.
• there are formula’s for replacement:
– Parkland formula
– Brooke formula

27. Assessment of adequacy of fluid replacement
• Urine output is most commonly used
parameter
• Urine osmolarity is the most accurate
parameter
• UOP= 30-50 ml/hr in an adult

28. Wound care
• Escharotomy / Fasciotomy
• Escharectomy + homograft
• Dressing / hydrotherapy
• Debridement
• Application of autograft
• Splinting
• PB contractures management

29. Wound Care continued...
• Staff should wear disposable hats, gowns,
gloves, masks when wounds are exposed
• appropriate use of sterile vs. nonsterile
techniques
• keep room warm
• careful handwashing
• any bathing areas disinfected before and
after bathing

31. Other care measures include
• Face
– eye
– ear
• Hands & arms
• Perineum
• Physiotherapy

32. Drug Therapy
• Analgesics and Sedatives
• Tetanus immunization
• Antimicrobial agents: Silver sulfadiazine
Nutritional Therapy
• Burn patients need more calories & failure
to provide will lead to delayed wound
healing and malnutrition.

33. Clinical Manifestations
• Burn wound either heals by primary
intention or by grafting.
• Scars may form & contractures.
• Mature healing is reached in 6
months to 2 years
• Avoid direct sunlight for 1 year on
burn
• new skin sensitive to trauma

34. Care of B U R N S
B - breathing
U - urine output
R - rule of nines
resuscitation of fluid
N - nutrition
S - shock
silvadene

35. Referral Criteria
• 2nd or 3rd Degree Burns
• >10% TBSA
• Burns to vital organs of burn
• circumfrential burns
• Electrical Burns
• Chemical Burns
• Inhalation Injury

36. Referral Criteria
• Concomitant trauma (If Major Trauma, The
Trauma Center , Not the Burn Center should
be the initial stabilizing unit)
• When in doubt , consult with a burn center

37. Questions?