Management of burn

1. Dr Manharsinh Rajput
(PGT-Surgery)

2.  The estimated annual burn incidence in India
is approximately 6-7 million per year.
 The high incidence is attributed to illiteracy,
poverty and low level safety consciousness in
the population.
 The situation becomes further grim due to
the absence of organized burn care at
primary and secondary health care level.

3.  Causes:
Flame-damage from superheated oxidized air,
Scald- contact with hot liquid,
Chemical
contact-damage from the contact with hot or cold solid material
Electric burn
 Depths:
• First degree-localised to the epidermis
• Superficial Second degree-upto superficial dermis.
• Deep Second degree- deep into the dermis.
• Third degree- through the epidermis and dermis
into the subcutaneous fat
• Fourth degree- through subcutaneous fat into
underlying muscle or bone.

4. Superficial Partial Thickness Burn Deep Partial Thickness Burn

5. Full Thickness Burn Deep Full Thickness Burn

6.  Zone of Coagulation
devitalized, necrotic, white, no circulation
 Zone of Stasis ‘circulation sluggish’
TXA2-vasoconstriction,vaascular damage and
leakage, inflam mediators rx-antioxidant ,brady
antagonist , monoclo ab in animal model
may covert to full thickness, mottled red
Rx- antioxident ,bradyk anta, anti cd18, monoclonal ab
 Zone of Hyperemia
outer rim, good blood flow, red

7.  Rule of Nine- in child take 4% from each
thigh and 1% from genitalia to head , infant
21% head
 Lund and Browder Chart - age
 Berkow Formula
 Palm Method- small burns , mixed
distribution

8.  Total burns>10% TBSA in children and > 15% TBSA in
Adults or >2% full thickness
 Any burn likely to require surgery
 Patients with burns over hands, face feet or perineum
 Patients whose psychiatric or social background makes
it inadvisable to send them to home
 Any suspicion of non-accidental injury
 Any burn in a patient at extremes of age
 High tension electric burn and chemical burn

9. Basic Treatment:
Prehospital Management
Initial Assessment
Initial Wound Care
Transport
Resuscitation
Escharotomies
Specific Treatment:
Inhalation Injury
Wound care
Antimicrobials
Burn wound excision
Burn wound coverage
Multiorgan failure

10.  Remove from the source of injury
 Oxygen inhalation
 Remove tight ornaments- torniquet effect
 Pour room temperature water

11.  Primary survey(ABCDE) f/b secondary survey
 D-In case of explosion or deceleration accident- spinal
cord injury- spine sabilization
 Urine output

12.  Wound should be covered
 Pain- slow IV opiods
 Rapid transport is not a priority

13. Formula Crystalloid Colloid Free Water
Parkland 4ml/kg/% TBSA
Burn(wt*bsa*4)
None None
Brooke 1.5 ml/kg/% TBSA
Burn
0.5 ml/kg/% TBSA
Burn
2.0 litres
Galveston
(Paediatric)
5000ml/m2
burned area+
1500 ml/ m2 total
area
None None
Capillary perm returns to normal after 24 hours where others say 6 hours- so that time
colloids should be used.
RL is the fluid of choice, child < 2 years- add dextrose
Hypertonic saline solution-serum sodium concentration should not exceed 160 mEq/dl
It reduce edema,n net fluid intake , inc lymph flow ,some stud- renal failure
Modified solution- 1 ampule of sodium bicarbonate (50mEq) in 1 L of RL solution

14. • Parkland underestimates need- called as fluid creep
• Monitor abd comp pressure-foley , u.o-.5 to 1,if less
bolus 10ml/kg , acid base , hematocrit
• Role of albumin- not recommended
• Nasogastric tube- to prevent regurgitation with an
intestinal ileus
• Tetanus Toxoid
• Tetanus immunoglobulin(if not known/ >10 years)
• Escharotomy- Deep 2/ 3rd degree- doppler, capillary refill ,
medial and lateral side of extremity , compli-release of
anearobic metabolites, blood loss– hypotension
• Chest escharotomy

15.  Inhalation injury:
 25-50% mortality, examination, bronchoscopy ,xenon carboxyhb
 Diagnosis- history , bronchoscopy
 Rx-100% o2, intubation if required(high freq, low tidal volume),
pressure control ventilation wid permissive hypercarbia
Inhalation Treatment for smoke inhalation injury
Brochodilator - 4 times a day
Nebulized Heparin - 5000 to 10,000U
with 3 ml normal
saline 4 hrly
Nebulized acetylcystein - 20% 3ml 4 hrly
Hypertonic Saline - induce effective coughing
Racemic epinephrine - Reduce mucosal edema

16. Clinical Indication for intubation:
Criteria Value
Pao2(mm Hg) <60
PaCO2 (mm Hg) >50
PaO2/FiO2 ratio <200
Respiratory Impending
Upper airway edema severe

17.  The main purpose of wound dressing is to provide the ideal
environment for wound healing
Ideal dressing- not a clinical reality.
Desired Characteristics of wound dressing
Promote wound healing (maintain moist environment)
Comfortability
Pain control
Odour control
Nonallergenic and non-irritating
Permeability to gas
Safety
Non-traumatic removal
Cost-effectiveness
Convenience

18. Topical antibiotics-
salves – to be applied on skin
 1% Silver sulfadiazine-transient leucopenia
 11%Mafenide acetate –effective agaist pseudo n enterococci
,penetrates eschar,painful, met acidosis
 Petroleum based- pm b , neo , bacitracin,mupirocin -fascial ,
patial thickness, graft site
Soak-poured into dressing
 .5%Silver nitrate- adv- pless , good coverage dis-staining, elect
imblnce, methhb,
 dakin solution(.025 na hocl)
 .25%Acetic acid solutions,5% mefenide

19.  Immediate
-Escharotomy
-Tracheostomy
 Early
Early excision and grafting
 Intermediate
It is done when burn depth is difficult to
determine at the time of injury.
little sign of healing after 1 week.
 Late
3 weeks after burn and is seldom indicated.

20.  Partial thickness- attempt is made to preserve viable
dermis
 Full-thickness- all necrotic and infected tissue are
removed leaving behind a viable wound bed of fascia,
fat, or muscle.
 The following techniques are generally used-
Tangential Excision- deep dermal burn-shaving eith
dermatome(.005-.010inch)
Full-Thickness Excision-(.015-.030)
Fascial Excision-3/4th degree-full upto fat with
goulian knife, dis- blood loss,defect, lymph edema

21.  Autograft- from the uninjured skin
but it is difficult when the burns exceed
40% of the TBSA
 Allograft- cadaver skin frequently serve as skin
substitute for severely burned patients
 Xenografts
 Skin Substitute:
Integra(arteficial dermal matrix)
Alloderm- acellular human dermal allograft.
Apligraf( Cultured epithelial autograft)

22.  Skin Banking is a process in which skin is removed from
a donor body, tested for suitability as a graft material,
packaged, stored, and finally reused as a graft.
 Graft are stored at ultra-low temperatures (below-
60̊℃). Frozen grafts can have a shelf life of up to five
years.

23.  The excess graft which are harvested can be stored by
replacing over donor site for 5 days.
 If need to be stored for more than 5 days can be placed
in a saline solution at 4℃ and with added antibiotics. It
can be stored for 21 days.
 A solution containing a combination of growth factors,
steroids, insulin and adenine called Ready Mix
currently achieves 60% keratinocytes viability at
30days of incubation.

24.  Bilayered membrane system for skin
replacement
 First layered-porous matrix of cross linked
bovine tendon collagen and GAG( chondroitin
6 Sulphate)
 Second layer-synthetic polysiloxane polymer
(Silicone) and function to control moisture
loss from the wound
 Once vascularization of dermal layer is
complete, a thin autograft can be applied
after removal of silicon layer.

25.  Used in acute burn
 It is an acellular dermal matrix derived from
donated human skin tissue.
 It provide matrix for revascularization and
incorporation into host tissue.
 But it does not provide matrix to support skin
graft as that of integra.

26.  It is bilayered biological dressing.
 Initially neonatal derived dermal fibroblasts
are cultured in a collagen matrix for 6 days.
 Human keratinocytes are then cultured on
the top of this neodermis.

27. Non-Pharmacological Modalities
 Nutritional support
 Goal-improve organ fun , prevent pro caloric mal
Curreri formula:
25kcal/kg/day+40kcal/%TBSA burned/day
Sutherland formula:
Children->60kcal/kg+35kcal/%TBSA
Adults ->20kcal/kg+70kcal/%TBSA
Davies formula:
Children-> 3%/kg+1g/%TBSA
Adults ->1g/kg+3g/%TBSA
Protien needs:
Greatest nitrogen losses between days 5 and 10
20% of calories should be provided by protien

28. Environmental Support:
• Burned patients can lose as much as 4000ml/m2 burned/day of
Body water through evaporative loss from extensive burn wound.
• The hyper metabolic response try to offset heat losses associated
with it which raises the core temperature 2℃ higher than the normal.
• Rasing the ambient temparature from 25℃ to 33℃ can diminish the
magnitute of this response from 2.0 to 1.4 resting energy expenditure
In patients with burns exceeding 40% of the TBSA

29. Exercise and Adjunctive Measures:
• Resistant exercise- augments incorporation of amino acids into the
Muscle proteins, and increase muscle strength and the ability to Walk
distances by approx. 50%
• Narcotic support, appropriate sedation and supportive psychotherapy.

30.  RhGH-.2 mg/kg/day
 IGF-I
 Oxandrolone-10mg BD
 Propanolol- 4 mg/kg/day
Attenuation of Postburn Hyperglycaemia
 Insulin
 Metformin

31.  Apart from standard infection control measures, early
excision and skin grafting is now accepted practice.
 Selective decontamination of the digestive tract (SDD) in
burns is generally supported by a small number of studies
 Large burns are associated with fungal colonization and
infection so additional investigation and antifungals may be
required
 Hydrocortisone should be used in patients with septic
shock only if they are poorly responsive to both fluid
resuscitation and inotropic support because there is a lack
of evidence showing any significant reduction in mortality.

32.  Decreasing urine output, fluid overload, electrolyte
abnormalities, including metabolic acidosis and
hyperkalemia, azotemia and increased serum
creatinine levels.
 Dialysis may be necessary.

33.  Decrease in saturation to less than 92% is
indicative of failure.
 When ventilation begins to fail, denoted by
increasing respiratory rate and hypercapnia,
then intubation is needed.

34.  Challenging without many solution.
 After severe burn liver increases in size to
more than 200% of normal.
 Coagulopathies- factors II, VII, IX and X
 Albumin.

35.  It starts immediately after injury.
 Hands are a primary concern, especially deep burns of
the dorsal surface.
 It begins with range of motion, splinting, edema
control and scar modulation.
 Pressure garments, thermoplastic splints, serial
casting, silicone inserts and plastics facemasks are use
to decrease hypertrophic scars and joint contractures.

36.  There have been significant improvements in outcome following burn
injuries in the latter half of the 20th century, reflecting advances in critical
care – in particular, following the introduction of fluid resuscitation
protocols, early burn excision and closure, antimicrobials and infection
control, nutritional support and modulation of the metabolic response.
 Full thickness injuries have no regenerative elements left. Unless they are
very small they will take weeks to heal and undergo severe contraction.
They should be referred for surgery as early as possible.
 Any burn not healed within two weeks should be referred for assessment.
 With numerous studies underway that will hopefully provide further
guidance for the management of these critically ill patients

37. THANK YOU