3. INTRODUCTION
History of modern burn resuscitation – Patients with large burns survived the
event but died from shock in the observation period.
Ability to treat burns has improved due to:
- Better understanding of burn shock
-Advances in fluid therapy
-Improved ability to excise dead tissue
-Use of biologic dressings
4. ANATOMY $ PHYSIOLOGY OF THE SKIN
Components of the skin
-Epidermis
-Dermis
-Subcutaneous tissue
Functions of the skin
- Protection
-Prevent fluid & protein loss
-Temperature regulation
-Sensation via nerve endings
5. Based on the above functions, victims may have:
- Difficulty with thermoregulation
- Inability to sweat
- Impaired vasoconstriction and vasodilatation
- Inability to grow hair
-Little or no sensation
6. Pathophysiologic effects of burns
Pathologic progression (Jackson)
- Zone of coagulation
- Zone of stasis
- Zone of hyperemia
Vascular injury
- Increased capillary permeability
- Damage of rbcs
General metabolic response
- Hypermetabolism
-negative nitrogen balance
-Exaggerated stress response
-Increased cortisol and catecholamine release
7. DEFINITION
Body injury resulting from cellular damage to hyperthermia or
hypothermia
Cellular damage occurs when the energetic portion of electromagnetic
fields acts on cells
8. CLASSIFICATION
According to cause
According to depth
According to size
According to the America Burn Association
10. Chemical
-Caustics
-Severity depends on type of
caustic(pH), the concentration, the
amount, the physical form, period of
time contact (Direct toxic effects on
metabolic processes)
-Usually superficial and are treated
by flushing the area copiously then
treating it as a thermal burn
Electrical
-Electrical energy+poorly conducting
body tissues= Thermal energy
-Severity depends on amount of
voltage, tissue resistance, current
pathways, S.A in contact with the
current & length of time the current
flow was sustained
-Misleading appearance. After 24h of
conservative mngmt, determine the
limits of destruction then debride the
tissue
Thermal
-Flame(Adults), flash, scald(Children),
direct contact with hot objects (80%)
-Severity depends on the
temperature and duration of
exposure to flame – 44 degrees
-Vigorous fluid resuscitation needed
11. INHALATIONAL BURNS
Produces injury through several
mechanisms
- Thermal injury to the upper airway
- Irritation or chemical injury to the airway
from soot
- Asphyxiation
- CO toxicity
Supraglottic, subglottic or global
Hx of having been injured in an enclosed
space for more than 10 mins
Presentation
- Facial burns
- Blistering or edema of the oropharynx
- Hoarseness of voice
- Carbonaceous sputum
- Signs of respiratory distress
Management (Intubation, oxygen,
bronchodilators, investigations)
12. ACCORDING TO DEPTH
Current designation of burn depths are:
- First degree - Superficial or epidermal
- Second degree- Superficial & deep
- Third degree- Full thickness burns
The term fourth degree is still used to describe the most severe burns that extend
to the muscle, bone and joints
13. 1st degree / Epidermal
Epidermis only involved
Caused by UV light or very short flash or flame exposure
Skin is red, dry and hypersensitive thus painful
No treatmentrequired except analgesia
Leaves no scar on healing by day 6
Over the next two to three days the pain & erythema subside
& by about day 4 the injured epithelium peels away from the
newly healed epidermis
14.
15. 2nd Degree
SUPERFICIAL SECOND DEGREE
- Epidermis plus the upper 1/3 of the dermis
- Commonly caused by scalds (Spill or a splash)
- Red, moist, weeping cob blisters that blanch with pressure
- Burns that initially appear to be only epidermal in depth may be
determined to be partial thickness 12-24 hrs later
- Painful due to nerve exposure and heals between 10 and 14 days
- Leaves no scarring on healing but there are potential pigment changes
16.
17. DEEP SECOND DEGREE
- Epidermis and upper 2/3 of dermis
- Damage hair follicles & glandular tissue
- Caused by scald, flame, chemicals, oil & grease
-Don’t blanch with pressure; Cheesy white, wet or waxy dry; Painful to
pressure only
-Healing takes 14-21 days
-Invariably result in hypertrophic scarring and risk of contractures
18.
19. 3rd Degree/Full thickness burns
Extend through & destroy all layers of the dermis, sometimes reaching the
underlying subcutaneous tissue
Burn eschar, the dead & denatured dermis, is usually intact & can compromise
viability of a limb if circumferential
Anaesthetic or hypoesthetic
Skin appearance varies from waxy white to leathery gray to charred and black.
Skin is dry and inelastic and doesn’t blanch with pressure. Hair can easily be
pulled out from the follicles & vesicles and blisters don’t develop.
Eschar eventually separates from the underlying tissue to reaveal a bed of
unhealed granulation tissue – w/out surgery wound heals by wound contracture
with epithelialization around the wound edges
22. 5th Degree
Bone involvement – especially common in epileptics who convulse while burning
23. ACCORDING TO SIZE
Essential in guiding therapy & determining when to transfer a patient to ICU/Burn
center
Expressed as the TBSA (%age)
Superficial burns aren’t included in this assessment.
3 methods
- Rule of palms
- Wallace rule of nine
-Lund Browder chart
24. Rule of palms/Palmar method
Used to approximate small or patchy burns using the surface area of the patient’s
palm
The palm of the patient’s hand, excluding the fingers is 0.5% of TBSA and the
entire palmar suface including the fingers is 1% in both children and adults
25.
26. Wallace rule of nines
For adult assessment, this is the most expeditious method
- Each leg represents 18% of TBSA
- Each arm represents 9% of TBSA
- Ant. & pos. trunks each represent 18% TBSA
- Head represents 9% TBSA
-Perineum 1%
27.
28. Lund-Browder Chart
Most accurate
Takes into account the relative percentage of BSA affected by growth
Children have proportionally larger heads and smaller lower extremeties, so the
percentage BSA is more accurately estimated using the following chart
29.
30. CRITERIA FOR ADMISSION
Cause
- Electrical burns
- Inhalational burns
- Chemical burns with serious threat of fxn or cosmetic impairement
Severity
- Moderate & severe burns
-15% superficial in adults
-10% superficial in children
- Non healing after 14-21 days
31. Anatomical location
- Head, neck, hands, soles & perineum
- Circumferential
- Inhalational
Patient factors
- Poor social factors
- Extremes of age (<4yrs & >50yrs)
- obese patient with burns on both limbs
-Pregnancy
-Concomitant trauma
-Pre-existing medical conditions
32. PRINCIPLES OF MANAGEMENT
Initial evaluation & Resuscitation (ATLS)
Pain control
Wound cleaning & dressing
Rehabilitation
33. Initial evaluation & Resuscitation
First 48 hours
PRIMARY SURVEY
-Airway with C spine control (Look out for & manage inhalational injury)
-Breathing (Chest rising & warm air on the cheek)
-Circulation & hemorrhage control
-Disability
-Exposure
34. Lines & tubes
- IV access with large bore
-CVP
-Urethral catheterization
-NGT
-Endotracheal tube
36. IV FLUIDS
Modified Parkland’s formula
4/3 * TBSA(%age) * Weight in Kgs
Crystalloids: Ringer’s lactate or Hartmann’s solution or N/S
Give half within the first 8 hours (From time since burn occurred NOT admission to
hospital) and the rest in the next 16 hours
Give 50% more in electrical burns and inhalational injury
37. Monitoring fluid therapy
Vitals
URINE OUTPUT
-Adults (0.5mls/kg/hour)
-Children & electrical burns (1ml/kg/hr)
-Haemoglobinuria suggests deep burns hence flush kidney with increased
fluids & mannitol
-Decrease in BP and urine output suggests a need for colloids
-Decrease in urine output but normal BP suggests a continuous need for
crystalloids
38. State of the patient – should be calm
Frequent chest auscultation to detect pulmonary oedema
CVP line is the best to avoid over infusion
Evaluate tx every 3-4 hours
39. Causes of inadequate fluid resuscitation
Inaccurate estimation of the burn size
Undiagnosed inhalational injury
Concomitant traumatic inury
Cardiac dysfunction
Refractory shock
Mathematic miscalculation
40. OTHER FLUID FORMULAS
Evan’s formula
-First formula based on BSA damaged and body weight.
-First 24h: Crystalloids 1ml/Kg/% burn plus colloids at 1ml/kg/%burn plus 2000ml
D5W
- Next 24h: Crystalloids at 0.5ml/kg/% burn, colloids at 0.5ml/kg/% burn and the
same amount of D5W as above
Thus total fluid is given in the ratio 1:1
41. Brooke formula/ Modified Brook formula
Original
- Initial 24h: RL soln 1.5ml/kg/%burns plus colloids 0.5ml/Kg/%burns plus 2000mL
D5
-Next 24h: RL 0.5ml/kg/% burn, colloids 0.25ml/kg/% burn plus 2000mL D5
Modified Brooke
- Initial 24h: No colloids. RL solution 2mL/kg/% burn in adults and 3ml/kg/% burn in
children
- Next 24h: Colloids at 0.3-0.5ml/kg/% burn and No crystalloids are given. D5 added
in required amounts to maintain good urinary output
42. Monafo formula
Recommends using a solution containing 250mEq Na, 150 mEq lactate and
100mEq Cl.
Amount adjusted according to urine output
In the following 24h ,the solution is titrated with 1/3 normal saline according to
urinary output
44. Wound care & Dressing
A) WOUND CARE
Remove all necrotic tissue and debris
Wash with warm normal saline
Apply topical antibiotic
- SSD (Thrombocytopenia, leucopenia, hypersensitivity rash)
-Silver Nitrate- Stains tissues, hypochloraemic alkalosis and hyponatremia: Good for
grafts
- Mafenide 10% - Can penetrate tissue and Eschar. Good for infected wounds and
eschars, very painful on application; Carbonic anhydrase inhibition causes metabolic
acidosis
45. DRESSING
- Open dressing
-Exposure dressing – Apply soothant e.g Vaseline
-Occlusive dressing- For small superficial previously debrided wounds
- Apply non adherent material e.g bactigras
- Change after 3 days and then apply daily upto day 21
- If there’s no healing consider grafting
46. Indications for occlusive dressing
If burn is oozing too much
Risk of infxn
Children
Comorbidities
Joints
Patient’s comfort
48. Nurtitional support
Curreri formula
-25KCal/kg + (40kCal * TBSA%)
-Induce a hypermetabolic state hence dramatic increase in resting energy expenditure
-Always give oral feeds
