Acute Management of burns

1. Mx Of Burns in the 1st 24 hrs
Dr. V. Singh Chauhan
Mmed Ortho Y2Dr. V Singh Chauhan

2. Discussion
• Pathophysiology of Burns
• Classification of Burns
• Mx
– Primary Survey
– Medical Management
• Fluid Resuscitation
• Pain Management
• Others
– Nutrition
– Wound Care
Dr. V Singh Chauhan

3. Some incidents in the past
Nakumatt
Downtown
- 2009
Sachang’wan
2009
Dr. V Singh Chauhan

4. Introduction
• Burns
– Tissue injury caused by thermal, radiation,
chemical or electrical contact
– Results in :
• Protein denaturation
• Loss of intravascular volume
– Increased vascular permeability
– Edema
Dr. V Singh Chauhan

5. Pathophysiology
• 3 stages
– Local
– Systemic
– Burn Shock
Dr. V Singh Chauhan

6. Pathophysiology
• Local
– Injury = release of inflammatory mediators
(Histamine, PGs, NO, Tx2). These increase capillary
permeability = localised burn wound edema.
– Followed by (in min – hrs) production of highly
reactive O2 species (ROS) during reperfusion of
ischemic tissues
– ROS cause local cell memb dysfxn & propagate
immune response
Dr. V Singh Chauhan

7. Pathophysiology
• Systemic Inflammatory response (SIR)
– Release of circulatory mediators (TNF alpha, IL 1,2,5,8
& Interferon gamma) = SIR
– Impairement of tissue O2 delivery due to increased
microvasc permeability, vasodilation, vasc. Stasis and
decreased cardiac output
– Increased microvasc permeability = Massive leak of
proteins and fluid from intravasc cmpt
– Loss of proteins into intestitial space decreases
intravascular colloid osmotic pressure = reversed
osmotic gradient Dr. V Singh Chauhan

8. Pathophysiology
• Edema is enhanced by a massive vasodilatory response
(in resp to decreased CO) and lymph vessel obstruction
by platelets, erythrocytes leucocytes that impair fluid
drainage to venous circulation
• Edema max = 24hrs. Resolution in 1-2 days
• Peak of 3rd spacing occurs at around 6-12 hrs as
capillary barrier begins to retain its integrity
– Reduction in fluid req. as observed in resuscitation
formulae at this point.
– Colloid therapy may also play a part here
Dr. V Singh Chauhan

9. Pathophysiology
• Burn Shock
– Combo of distributive, hypovolemic & cardiogenic
shock where there’s loss of intravasc vol to
intestitium.
– Plasma vol inadeq to sustain adeq preload hence CO
drops and tissue hypoperfusion occurs
– Lack of adeq resuscitation
• Sig. organ injury from SIRS (Syst Inflammatory Response
Synd) or MODS (Multiorgan dysfxn synd)
Dr. V Singh Chauhan

10. Pathophysiology
Dr. V Singh Chauhan

11. • Zone 1 – Zone of coagulation
– Non viable
• Zone 2 – Zone of ischemia / Stasis
– Not devitalized initially but due to microvasc. Insult
can progress irreversibly to necrosis over several days
if not resuscitated properly
• Zone 3 – Zone of hyperemia
– Tissues here undergo vasodilatory changes due to
neighbouring inflammatory mediator release
– Are not injured thermally & remain viable
Dr. V Singh Chauhan

12. Classification of Burns
• According to Cause
– Thermal, Chemical, Elec, Frostbite, Radiation
• According to Depth of injury
– 1st Degree
– 2nd Degree
• Superficial
• Deep
– 3rd Degree
– 4th Degree
– 5th Degree
Dr. V Singh Chauhan

13. According to Depth
Dr. V Singh Chauhan

14. 1st Degree
• Epidermis only
• Commonly caused by UV light or very short
flash or flame exposure
• Skin is red, dry & hypersensitive
• No treatment except analgesia
• Leaves no scarring on healing
Dr. V Singh Chauhan

15. 2nd Degree
• Superficial
• Epidermis + Upper ⅓ of Dermis
• Commonly caused by scald (spill
or splash)
• Red, moist, weeping, cob blisters
that Blanche with pressure
• Painful - due to nerve exposure, &
heals from 7-14days
• Leaves no scarring on healing but
there is potential pigmentary
changes
Dr. V Singh Chauhan

16. 2nd Degree
• Deep
• Epidermis + Upper ⅔ of Dermis
• Commonly caused by scald, flame,
chemicals, oil & grease
• Cheesy white, wet or waxy dry;
Do not Blanche with pressure
• Healing takes >21days
• Severe scarring & risk of
contractures
Dr. V Singh Chauhan

17. 3rd Degree
• Full Epidermis + Dermis are destroyed leaving no
cells to heal
• Commonly caused by scald, steam, flame,
chemicals, oil, grease & high voltage electricity
• Grey to charred & black, insensate, contracted,
pale, leathery tissue
• Severe scarring & high risk of contractures
Dr. V Singh Chauhan

18. 4th & 5th Degree
• 4th Degree Burns
– Muscle involvement
• 5th Degree Burns
– Bone involvement - Especially in epileptics who
convulse during burning
Dr. V Singh Chauhan

19. Dr. V Singh Chauhan

20. Mx of Burns – Primary Survey
• Airway
– Stabilize neck for suspected cervical spine injury
(Epileptics)
– Maintain a patent airway.
Dr. V Singh Chauhan

21. Mx of Burns – Primary Survey
• Breathing
– Admin 100% O2
– Expose chest & ensure adeq. Chest expansion
– Palpate for rib # & crepitus
– Auscultate for breath sounds
– Ventilate via bag & mask or intubate if necessary
– Monitor Resp rate & beware of R/R <10 or >20
– Consider CO poisoning
• Non burnt skin looks cherry pink in non breathing pt
Dr. V Singh Chauhan

22. Mx of Burns – Primary Survey
• Circulation
– Inspect for obvious bleeding
• Stop any with direct pressure
– Monitor & record peripheral pulse for rate,
strength & rhythm
– Check cap refil
• >2s = poor perfusion due to hypotension, hypovolemia
or need for escharotomy
Dr. V Singh Chauhan

23. Mx of Burns – Primary Survey
• Disability & Neuro Status
– Establish level of consciousness (AVPU, GCS)
– Examine pupils for response to light + size
– Be alert for restlessness & decrease in level of
consciousness
• Hypoxaemia, CO intoxication, Shock, Alcohol, drug etc
Dr. V Singh Chauhan

24. Mx of Burns – Primary Survey
• Exposure with environ control
– Remove clothing
– Keep warm
Dr. V Singh Chauhan

25. Fluid Resuscitation
• Who requires Fluid therapy?
– Patients sustaining 1st & 2nd degree burns >10%
for children and >15% in adults
– Electrical burns
– 3rd degree burns
Dr. V Singh Chauhan

26. Fluid Therapy
• Estimation of Burn Area
– Wallace Rule of Nines
• Adults
• Palmer surface + fingers of
pt’s hand = 1% TBSA
Dr. V Singh Chauhan

27. • Lund Browder
Chart
– Children
Dr. V Singh Chauhan

28. Criteria for Admission
• Cause
– Electrical Burns
– Chemical burns
• Severity
– 3rd & 4th degree regardless of TBSA
– Moderate & severe burns
• Moderate – 10-15% in children, 15-25% in adults, 2-5% in 3rd
degree burns
• Major - >15% children, >25% in adults, >5% in 3rd degree
– Non healing burns (>14-21 days)
Dr. V Singh Chauhan

29. Criteria for Admission
• Burns with concormitant trauma where injury poses
greatest risk of morbidity and mortality.
• Patient factors
– Extremes of age (<4 & >50)
– Pregnancy
– Burns with preexisting medical disorders e.g. DM, epilepsy,
Infxns (complicates Mx & prolongs recovery)
• Anatomical location
– Head, neck, hands, soles and perineum
– Circumferential limb burns
– Burns to the back
– All inhalational burns
Dr. V Singh Chauhan

30. Fluid resuscitation
• No single recommendation agreed upon hence depends
from centers to centers
• Parkland’s Formula
– 4ml x Wt (Kgs) x %TBSA
– Give ½ of the amount in the 1st 8hrs and the other half in the
next 16 hours.
– Fluid = Ringers Lactate
– Give ~50% more for inhalational and electric burns
– Adjust according to urine output
• Adults = 30-50ml/hr
• Children = 0.5 – 1ml/kg/hr
– Rule of 1/3
• If urine output <0.5ml/kg/hr, increase IV fluids by 1/3 and vice versa
Dr. V Singh Chauhan

31. Fluid Resuscitation
• Defense of Ringers Lactate
– Is an isotonic crystalloid
– Has low Na+ concentration than normal saline
(130meq/l vs 154meq/l)
– Has higher pH (6.5 vs 5.0) hence nearer to physiologic
pH
– Also has buffering effect of the metabolized lactate on
the associated metabolic acidosis
– Hence is the preferred solution at least in the first 24-
48hrs
Dr. V Singh Chauhan

32. Colloids
• Role of colloids is controversial
• Colloids remain longer in the intravascular space than
crystalloids, expand plasma vol to a greater extend.
• Studies have shown little benefit with colloids when
given in the 1st 24hrs post burn and may have
detrimental effect on pulmonary function.
• Cochrane reviews conclude no survival benefit with use
of colloids for resuscitation
Dr. V Singh Chauhan

33. Colloids
• However, Vlachau et al (2006) showed that endothelial
dysfunction & capillary leaks are present within 24hrs of
burn injury and last for a median of 5 hrs (much shorter
than thought)
• Du et al (1991) had reported successful resuscitation with
colloids in early post burn period.
• O’Mara et al (2005) showed decreased fluid requirement as
compared to crystalloid resuscitation by the use of plasma
in 1st 48hrs following large TBSA (>50%)
• Most centers still advocate for crystalloid therapy (including
KNH)
Dr. V Singh Chauhan

34. So when do we consider colloids in the
1st 24hrs
• When there is loss of capillary integrity during
early burn shock
• Strategy for testing whether capillary leak has
began to resolve is by substituting equal vol of
albumin for RL solution
– Increased urine output suggests at least some of
the leak has resolved and hence further
introduction of colloid can help reduce fluid load
Dr. V Singh Chauhan

35. Albumin
• Contributes to intravascular oncotic pressures
• When administered IV as 5% solution, ½ of the volume
remains intravascular as opposed to 20-30% of crystalloid
solution
• Some centres use FFP as it replaces the whole range of
plasma prot lost rather than albumin alone.
• Problem
– Expensive
– Anaphylaxis – rare
– Doesn’t restore intestitial space
• Guideline
– 0.5 – 1ml/kg per % burn during the 1st 24hrs beginning 8-10hrs
post burn as an adjunct to RL solution resuscitation
Dr. V Singh Chauhan

36. Vitamin C
• Acts as an antioxidant to minimize oxidant mediated
contributions tot the inflammatory cascade.
• Benefits of vitamin C
– Decrease fluid requirement hence less tissue edema and
body wt gain.
– Hence less respiratory impairement and reduced
requirement for mechanical ventilation.
• Fear
– May increase risk of Renal Failure
Dr. V Singh Chauhan

37. Vitamin C
• Tanaka Et al (Arch Surg 2000) showed a sig.
reduction in fluid vol requirement, wt gain &
wound edema + improvement in pulmonary fxn
• Kahn SA, Beer RJ. Resuscitation after severe burn
injury using high dose ascorbic acid: A
retrospective review : J Burn Care Res. 2011 Jan-
Feb; 32(1): 110-7
– Showed that vitamin C can be safely used without
increased risk of renal failure
Dr. V Singh Chauhan

38. Vitamin C
• Where does vitamin C come in?
– Following burn injury, up reg of Xanthine oxidase triggered
by Histamine hence formation of Oxygen free radicals
leading to sig. cell injury
– Enhanced by impairement of native anti-oxidant
mechanisms and additional free radical production by
neutrophils.
• Recommendation
– 66ml/kg/hr for initial 24hrs of burn resuscitation
– Cover with black bag to prevent light induced auto-
oxidation
– Comes with diuretic effect hence adjust to maintain urine
output to 50-100ml/hr during resuscitation
Dr. V Singh Chauhan

39. Remember
• More IV fluids required in:
– Inhalation injuries
– Escharotomy & Fasciotomy
• Increased fluid loss from the wound
– Haemochrogenuria (dark red, brown urine)
• Thermal damage to muscle esp in electrical injuries
– Electrical injuries
• Due to large and underappreciated tissue insult
– Delayed Resuscitation
• Increase upto 30%
• Due to occurrence of an increased inflammatory cascade
Dr. V Singh Chauhan

40. Other Formulae
• Muir & Barclay (Colloid)
– Wt (kgs) x BSA x 2 per period
– Provide vol required in colloid to be given in 1st 4hrs
– Volume should be repeated
• Every 4hrs for 1st 12hrs
• Every 6hrs between 12-24hrs
• Every 12 hrs between 24 – 36hrs
• Evans (Colloid + Crystalloid)
– 2ml x Wt (kgs) x %TBSA………………….in 24hrs
– Crystalloid (NS/5% dext) : Colloids (Blood, dextran)
1:1
– Add 2000ml 5% dextrose for insensible losses
– Give ½ in 1st 8hrs. In the 2nd 24hrs give ½ of initial calculated +
insensible losses
Dr. V Singh Chauhan

41. Paeds issues
1. IV fluid resuscitation required for patients with
smaller burn area (10-20%) as compared to adults
2. Venous access is difficult in children hence saphenous
cut down + central line permitted
3. Children have a larger BSA than adults hence the use
of Lund – Browder Table
4. Hepatic glycogen reserves can be exhausted quickly
leading to fatal hypoglycemia
Dr. V Singh Chauhan

42. Paeds issues
• Hence
– Recommended endpoints higher in children (urine
output 0.5 – 1ml/kg/hr
– Use of dextrose 5% in RL to px hypoglycemia
– Use of BSA based resuscitation + infusion of
maintenance requirements
• Most common maintenance calculation
Dr. V Singh Chauhan

43. Pain Management
• Assessment
– How much pain does the patient have (Scale –
Visual Analogue Scale (VAS))
– How much analgesia has been given prior to
arrival
– Use of alcohol and illicit drugs
Dr. V Singh Chauhan

44. Pain Management
• Acute Mx
– Oral Morphine / pcm for minor burns
– IV morphine (2.5 – 10mg in adults and 0.1mg/kg
in titrated boluses in children)
– IM morphine (0.2mg/kg in children)
– Antiemetics with narcotics
– Antihistamines if excess itch
– Immobilization with sling and splinting
– KEEP PAIN TO ACCEPTABLE LEVELS
Dr. V Singh Chauhan

45. Nutritional Support
• Burn injury increases body’s metabolic
demands….increases nutritional req
• Adeq. Nutrition lowers incidence of metabolic
abnormalities hence improving survival and
decreasing hospital stay
• Formula
– Curreri formula
• 25kcal/kg + (40kcal x % TBSA)
Dr. V Singh Chauhan

46. Nutritional support
• Qn of early vs late enteral feed exists
• Wesiak J et al (2006) showed uncertainty over
early vs late feeding though they suggested
early feed may blunt hypermetabolic response
to thermal injury
Dr. V Singh Chauhan

47. Other drugs
• Tetanus toxoid
• PPI to prevent curling ulcers
• Haematinics
• DVT prophylaxis esp in lower limb burns
• Zinc
– Needed by >300 enzymes responsible for wound healing,
prot synthesis, immunity, free radical protection, DNA
replication
– At cellular level its critical for cell survival (affects protein
synthesis)
– Zn essential for growth immune fxn, antioxidant defense &
wound healing
– Zn levels usually decrease post burn (>urinary excretion)
Dr. V Singh Chauhan

48. Acute Wound Management
• Concepts
– Cleaning – surface should be free of slough, exudate, haematoma etc.
– Debridement – removal of all necrotic debris
– Cover wound
• Open dressing – No dressing applied
• Exposure dressing – Apply soothant e.g. vaseline
• Occlusive dressing – e.g. for small superficial previously debrided wounds
– Apply topical antibiotic e.g.
• * Silver sulphadiazine (S/E - thrombocytopenia, leucopoenia, rash)
• * 0.5% Silver Nitrate - Stains tissues & can cause hypochloraemic alkalosis
• * Mafenide - can penetrate tissue & eschar. Good for infected wounds &
eschars. Painful on application.
• * Neosporin or Bacitracin - Good for facial burns as they are not toxic to the
eyes
– Apply non-stick material e.g. Bactigras
– Apply 3-5 layers of dry material e.g. gauze
– Cover with crepe bandage
– Change after 3days & then daily up to day 21. If there is no healing,
consider skin grafting. Dr. V Singh Chauhan

49. Dr. V Singh Chauhan

50. Dr. V Singh Chauhan

51. Inhalational Burns Additional Points
• Has 3 components
– Upper Airway obstruction (Laryngospasm, Edema or sloughing
of mucosa = infxn & blockage = Pneumonia
– Acute Respiratory failure
– CO poisoning.
• S/s
– History of having been injured in an enclosed space e.g. house,
motor vehicle
– Physical stigmata i.e. Facial burns, singed nasal hairs & soot in
nasopharynx
– Coughing up carbonaceous sputum/soot
– Stridor or new onset hoarseness of voice (will indicate vocal
cord swelling)
– Tachypnoea - ≥25 breaths/min
Dr. V Singh Chauhan

52. • Mx
– Admit
– Give 100% O2 by Mask or Endotracheal tube in
serious inhalational injury
– ABGs
– Bronchoscopy + Lavage
– CXR
– Escharotomy if restrictions to movement of chest
– Remember to adjust fluid requirements as discussed
earlier
Dr. V Singh Chauhan

53. Electrical Burns Additional Points
• Resistance of body tissue
– Nerves and blood vessels are good conductors
– Bone & skin are resistant to passage of current.
• Extent of injury depends on
– Type of current (AC vs DC)
– Pathway of flow – Shortest distance between wounds
– Local tissue resistance
– Duration of contact
Dr. V Singh Chauhan

54. • Low voltage current
– Alter cardiac cycle
– Usually involve hands and oral cavity
• High voltage current
– Cause concomitant tissue damage
– Entry wound charred, centrally depressed & leatherly
– Exit wound more likely to explode as charge exits
– Current chooses shortest path btwin contact points & involves
vital structures in its path.
– Bone has high resistance thus readily transforms current to heat
production = periosteal necrosis
– Wounds signal local destruction of deeper tissues with
unpredictable magnitude
Dr. V Singh Chauhan

55. • Mx
– Admit
– Airway / Breathing
• Always Examine For Airway Patency
• Think Of Pneumothorax
– Not Uncommon With High-Tension Injuries
– Circulation
• ? History Of Cardiac Arrest
• ECG and Electrocardiographic Monitoring
• Assess Peripheral Circulation
– ? Need For Escharotomy / Fasciotomy
– May Measure Muscle Compartment Pressures
– Disability
• Neurological Status
• Assess For Focal Motor and Sensory Deficits
Dr. V Singh Chauhan

56. • Mx
– Qty of fluids to be given cannot be estimated using TBSA
therefore titrate qty of fluid to maintain adeq. Urinary
output
– End point of resuscitation can be predicted by pt’s
haematocrit & plasma levels that will return to normal.
– Continued cardiac monitoring and treatment of
dysarrythmias
– In presence of haemochromogens in urine, rate of infusion
should be sufficient to maintain urine output of 100ml/hr
• Continue until urine is free of pigment
• Alkalization of urine by sodium bicarb increases solubility and
clearance rate of myoglobulin in urine
• Beware of Renal failure due to myonecrosisDr. V Singh Chauhan

57. • Mx
– Fasciotomy is important as intestitial pressures of
the cmpt exceed capillary pressure hence muscle
ischemia that’s irreversible after 6-8hrs.
– Transfusions unnecessary during 1st 24hrs unless
multiple escharotomies lead to significant blood
loss
Dr. V Singh Chauhan

58. References
• Bailey and Love, A short Textbook of surgery 26th edition
• Agency for Clinical Innovation : Clinical practical guidelines: Burn Patient
Management, August 2011
• Al-Kaisy A.A., Salih Sahib A. Effect of Zinc supplementation in prognosis of burn
patients in Iraq. Annals of Burns and Fire Disasters. 2006;19:115-122.
• Emedicine.medscape.com/article/1277360
• Tricklebank S. Modern trends in fluid therapy for burns. Burns. 2009;35: 757-767
• Cochrane library – Burns
• Standard treatment guidelines. Gertrudes Children Hospital. Edition 2, June 2010
• http://www.surgicalcriticalcare.net/Guidelines/fluid_resuscitation_2009.pdf
• BS Atiyeh, S.A Dibo, A Ibrahim. Acute burn resuscitation & fluid creep: its time for
colloid rehab. Annals of Burns and Fire Disasters. 2012;25(2):59-65.
• http://www.surgicalcriticalcare.net/Guidelines/ascorbic%20acid.pdf
• Kahn SA, Beers RJ. Resuscitation after severe burn injury using high dose ascorbic
acid. A retrospective review. J Burn Care Res. 2011;32(1) 110-7
• Stander M, Wallis L. The Emergency Management and treatment of burns.
Emergency Medicine International. 2011
Dr. V Singh Chauhan

59. Dr. V Singh Chauhan