updated 2017 - clinical approach and overview clinical manifestation diagnosis treatment complications. Dr.mahajna muhammad plastic surgery department Tel_Aviv-Uni Initial evaluation and management of small and moderate burns is a routine part of general plastic surgery practice. An ability to accurately evaluate and provide proper initial care for these injuries is essential. Outcomes for patients with burns have improved dramatically over the past 20 years, but burns still cause substantial morbidity and mortality. [1] Proper evaluation and management, coupled with appropriate early specialty referral, greatly help in minimizing suffering and optimizing results

1. Mahajna Mohammad
Sackler’s faculty of medicine , Tel-Aviv Uni; 2017
Thermal injur

2. INTRODUCTION
“ Concentrate all your thoughts upon the work at hand.
The sun's rays do not burn until brought to a focus”

3. 500K >50% 4K66%
33% 44% 26% 17%
Burns. 2006 Aug;32(5):529-37. Epub 2006 Jun 14.
American Burn Association White Paper. Surgical management of the burn wound and use of skin

4.  Scalded :contact with
hot liquids
 Flame: superheated,
oxidized air

5.  Thermal
 Chemical
 Electrical
 Inhalation
 Radiation
 Cold exposure (frostbite)
Dependson:

7. Jackson's thermal wound theory-1947

9. ABC of burns
Shehan Hettiaratchy, Initial management of a major burn: II—assessment and resuscitation; BMJ. 2004 Jul 10;
329(7457): 101–10; doi: 10.1136/bmj.329.7457.101

10.  Lund-Browder — is the most accurate for adults and children (larger heads and smaller lower extremities)
 It takes into account the relative percentage of BSA affected by growth
 Rule of Nines — For adult assessment, the most expeditious method :
 Each leg =18 % TBSA
 Each arm =9 %TBSA
 The anterior and posterior trunk each =18 % TBSA
 The head =9 %TBSA
 Palm method — used for irregular ,small or patchy burns
 The palm, excluding the fingers, =0.5 % TBSA
 the entire palmar surface including fingers is 1 % TBSA in children and adults
 Superficial burns are not included in the
TBSA burn assessment.

11. Determination of burn size estimates the extent of injury.
Burn size
is generally assessed by the “rule of nines”

13. Burn assessment

14. “Understanding is the first step to acceptance, and only with acceptance can there be recovery.”
J.K. Rowling, Harry Potter and the Goblet of Fire

15. Stage 1 : Emergent phase
Stage 2 : Fluid shift-<24hr , peak at 8hr
Stage 3 : Hypermetabolic phase :days-weeks
Stage 4: Resolution phase : healing / scar formation

19. Initial assessment / treatment
basic
Pre-hospital / initial treatment hospitalization
Specific injury
e.g. inhalation

21. Airway and breathing support
 Administer humidified oxygen at a rate of 10-12 L/min if signs of inhalation injury are present
 A patient who is not breathing should be intubated and ventilated with 100% oxygen
Cooling : ↓ lactate production +acidosis,promoting catecholamine function and cardiovascular homeostasis
 Remove clothing
 Immerse wound in cold (1-5°C) water for 30m
 Do not use ice water / ice directly to the burn wound
 Local cooling of burns of < 9% of TBSA can for > 30 min relieve pain

22. Fluid resuscitation –burns >15% of TBSA may produce shock as a result of hypovolemia
 Maintain IV access
 In children <6 years : intraosseous access in the proximal tibia until IV access is accomplished
 Begin immediately with warmed fluid if possible
 Cannulate burned skin if unburned skin is unavailable
 In adults: solution can be without glucose.
 In children <2 yr  should receive 5%dextrose in lactated Ringer solution

25.  Insertion of nasogastric tube (e.g Levin ,salem-sump,Andersen, Dobhof) is crucial :
• Reduce intestinal ileus
• Prevent patient from air swallowing
• Alleviates distention
 Dobhof tube should be placed into the fist part of the duodenum to maintain caloric
intake

26.  Recommendations for tetanus prophylaxis :
 All patients >10% TBSA should receive 0.5 mL of tetanus toxoid.
 250 units of tetanus immune globulin are also given If:
1. prior immunization is absent or unclear
2. the last booster dose was more than 10 years ago
Karyoute SM1, Badran IZ Tetanus following a burn injury.
Burns Incl Therm Inj. 1988 Jun;14(3):241-3.

27. Admission to burn unit 
Assets the need for intensive
care unit
Wound care
Excision Escharotomies
Coverage
dressing
Basic support
Nutritional
support
Resuscitation

29.  Consider location :e.g.
 Fingers and toes should be wrapped individually
separating the digits in order to prevent maceration
and adherence
 Wash + debride any open blisters
 Steroids have no role in treating burn wounds.
 The World Health Organization (WHO) recommends
debridement of all bullae and excision of all
adherent necrotic tissue

31. Decompressive escharotomy :
Extremities at risk are identified either on clinical examination or on
measurement of tissue pressures > 40 mm Hg.
With deep dermal and full thickness burns, the dermis can become stiff
and unyielding, and this tissue is referred to as an eschar.
escharotomy

32. Fluid selection
• Resuscitation
• Maintenance
• Over-resuscitation
Desired fluid amount
Monitoring fluid status
Over-resuscitation

33. Fluid selection
Hypertonic salineColloids (e.g, albumin solution, dextran)Crystalloids or volume expanders
 ↓ net fluid intake
 ↓ edema,
 ↑ lymph flow
• significantly more expensive
• should not be used in the fist 24 hours until
capillary permeability returned closer to
normal
• Ringer lactate is typically used
• lactate may reduce the incidence of
hyperchloremic acidosis
 Hypernatremia !!!
 Na <160 mEq/dL
 ↑ renal failure
 ↑ acute tubular necrosis
 ↑ hyper-chloremic metabolic
acidosis
• Albumin use is controversial
• The Cochrane group showed in a meta-
analysis of 31 trials that the risk of death was
higher in burned patients receiving albumin
compared with those receiving crystalloid.
RR=2.40 : (cl 95% ,1.11 - 5.19).
 5% Dextrose =D5W
 0.45% NaCl = half formal saline
 0.9% NaCl = normal saline
 Ringer lactate
 Hartmann’s
 5% dextrose, normal saline = D5NS

35. Authors’ conclusions:
Whether Hypovolemic or hypoalbuminemic
there is no evidence that albumin reduces mortality when compared with cheaper alternatives such as
saline.
Human albumin solution for resuscitation and volume expansion in critically ill patients.Albumin Reviewers (Alderson P,
Bunn F, Li Wan Po A, Li L, Blackhall K, Roberts I, Schierhout G)1. Cochrane Database Syst Rev. 2011 Oct 5;(10):CD001208. doi:
10.1002/14651858.CD001208.pub3.

36. Recommended amount
Another alternative method is the Rule of Tens depending on patient size:
 Estimate (TBSA) to the nearest 10 percent.
 Multiply the percent TBSA x 10 = initial fluid rate in mL/hour for adults 40 to 80 kg.
 > 80 kg, increase the rate by 100 mL/hour for every additional 10 kg of body weight.
Simple derivation of the initial fluid rate for the resuscitation of severely burned adult combat casualties: in silico validation of the rule of 10.
Chung KK1, Salinas J, Renz EM, Alvarado RA, King BT, Barillo DJ, Cancio LC, Wolf SE, Blackbourne LH.
Burn resuscitation.Alvarado R, Chung KK, Cancio LC, Wolf SE ;Burns. 2009 Feb; 35(1):4-1

38. Burn severity
Associated injury
comorbidities
age
Burn depth
TBSA
Location

39. Calculate amount
needed
Start initial
resuscitation
50% of the calculated
fluid requirement is
administered in the
first 8 hours
50% is given over the
remaining 16 hours
Evaluate response
adequate resuscitation
achieved  stabilized
Change crystalloid to 5 % dextrose in (ie, 0.45%Nacl) +20 mEq of KCl per liter

40. Monitoring fluid status - Non-invasive methods
 0.5 mL/kg / hr in adults
 1.0 mL/ kg/ hr in children
If urine output drops below 0.5 mL/kg/hr 
 a bolus of IV crystalloid (500 -1000 mL)
 ↑infusion rate by approximately 20 to 30 percent
Clinical signs of volume status: monitored every hour for the first 24 hours:
 heart rate
 blood pressure
 pulse pressure
 distal pulses
 capillary refill
 color and turgor of uninjured skin are
 edema

41. Monitoring fluid status
invasive methods (CVP/ Swan-ganz / Arterial BP / SVV)
Evaluate response stabilized
Change crystalloid to 5 % dextrose
in (ie, 0.45%Nacl) +20 mEq of KCl per
liter
unresponsive to resuscitation
1) > 6 mL/kg X (X%) TBSA per 24 hours
2) impending cardiac failure are present
Evaluate response
Invasive / non-invasive
Swan-Ganz
Measure Co
If adeq Vol. but ↓ urine output
dopamine (5 µg/kg/min) may be used to
increase renal perfusion.

42. Resuscitation related complication

43. CONCLUSIONS:
Restrictive resuscitation is associated with increased AKI, without changes in infectious complications.

44.  13 trials have indicated that as much as 50% of the edema observed in non-burned tissues.
 In burns > 25% TBSA , capillary permeability is increased also in non-burned areas

45. Symptoms :
 Unproportioned Pain (early ,common finding)
 burning pain
 Paresthesia (30m-2 hr;)
Examination findings
 Pain
 Tense compartment with a firm "wood-like" feeling
 Pallor (uncommon)
 Diminished sensation
 Muscle weakness (onset 2-4hr)
 Paralysis (late finding)

46.  ACS ∆ pressure = diastolic BP‒ measured compartment pressure
 ACS ∆ pressure <20 to 30 mmHg indicates need for fasciotomy
(we use <30 mmHg)
J Bone Joint Surg Am. 1994 Sep;76(9):1285-92.
Compartment pressure in association with closed tibial fractures. The relationship between tissue pressure, compartment, and the
distance from the site of the fracture.
Heckman MM1, Whitesides TE Jr, Grewe SR, Rooks MD

47. References
Burns. 2006 Aug;32(5):529-37. Epub 2006 Jun 14.
American Burn Association White Paper. Surgical management of the burn wound and use of skin
ABC of burns
Shehan Hettiaratchy, Initial management of a major burn: II—assessment and resuscitation; BMJ. 2004 Jul 10; 329(7457): 101–10; doi: 10.1136/bmj.329.7457.101
Karyoute SM1, Badran IZ Tetanus following a burn injury.
Burns Incl Therm Inj. 1988 Jun;14(3):241-3.
Human albumin solution for resuscitation and volume expansion in critically ill patients. Albumin Reviewers (Alderson P, Bunn F, Li Wan Po A, Li L, Blackhall K, Roberts I, Schierhout G)1.
Cochrane Database Syst Rev. 2011 Oct 5;(10):CD001208. doi: 10.1002/14651858.CD001208.pub3.
Simple derivation of the initial fluid rate for the resuscitation of severely burned adult combat casualties: in silico validation of the rule of 10.
Chung KK1, Salinas J, Renz EM, Alvarado RA, King BT, Barillo DJ, Cancio LC, Wolf SE, Blackbourne LH.
J Bone Joint Surg Am. 1994 Sep;76(9):1285-92.
Compartment pressure in association with closed tibial fractures. The relationship between tissue pressure, compartment, and the distance from the
site of the fracture.
Heckman MM1, Whitesides TE Jr, Grewe SR, Rooks MD
Overview of the management of the severely burned patient
Authors:
Gerd G Gauglitz, MMS, MD
Felicia N Williams, MD
Section Editor:
Marc G Jeschke, MD, PhD
Deputy Editor:
Kathryn A Collins, MD, PhD, FACS
Sabiston textbook of surgery 19th;chapter19 : burns; David C Sabiston; Courtney M Townsend, Jr.; Philadelphia, PA : Elsevier Saunders, ©2012.
Burn resuscitation.Alvarado R, Chung KK, Cancio LC, Wolf SE; Burns. 2009 Feb; 35(1):4-1