emergency management of burns

1. EARLY MANAGEMENT OF
THERMAL BURNS
DR MAKANGA

2. Pathophysiology
• Coagulative necrosis of skin (duration,
temperature)
• Zones of injury
• Fluid loss and burn shock
– 3rd spacing, evaporative losses, myocardial
depression
• Systemic response to burn injury
– Neuroendocrine response
– Cytokine response

3. Zones of injury after a burn

4. Multi-systemic effects

5. Evaluation
• ATLS protocol – associated injuries
• Inhalation injury
• Extent
– Wallace rule of 9s
– Lund and Browder charts
– Berkow’s formula
• Depth - 1º,2º,3º,4º
– Significance of assessing depth
– Challenges
• Wound evolution
• Mixed burns
• Alteration of depth by factors (resuscitation, infection, noxious
agents)

6. Berkow estimation

7. Criteria for admission
• High tension electrical burn, chemical burns
• Significant associated injuries e.g. fractures & other
major trauma
• Inhalational Injury present
• Comorbidities e.g. DM, HTN, epilepsy
• Suspected child abuse, alcoholism

8. Resuscitation
• Fluid therapy
– Parkland formula
– Modified Brooke’s
– Galvenston’s for kids – also 5%D, add maintenance
• 5L/TBSA in m2 + 2L/TSA in m2
• Merits and demerits of formula based regimens
• Endpoints of resuscitation
– Urine output* (bolus 500ml and increase fluid by 20-
30% if below target)
– MAP, pulse rate, CVP
– Lactate and base deficit
Current advances in the initial management of major thermal burns. Gueugniaud PY; Intensive Care Med 2000 Jul;26(7):848-56

9. Caveats
• Over resuscitation
– Pulmonary oedema – fluid overload
– compartment syndrome (abdominal, orbital,
intrafascial)
– Hypothermia, coagulopathy (cold fluids)
• ?Role of colloid therapy

10. Ancillary measures
• Tetanus toxoid >10% burns
• Escharotomy
• IV analgesia – morphine +
benzodiazepines
• No role for empirical systemic antibiotics –
predisposes to resistant bug selection
• NG tube decompression >20% burns
• Ulcer prophylaxis

11. Escharotomy

12. Nutrition
• Feeding started ASAP, within 24 hrs
• Enteral route preferable unless ileus is present
(trial of promotility agent), continous and 
osmolarity
• Curreri formula - 25 kcal/kg/day + 40 kcal per
percent TBSA
• Harris-Benedict
• Protein – 2g/kg/day
• Danger of overfeeding
– Hepatic steatosis
– Hyperglycemia

13. Nutrition
• Carbohydrate calories preferable over lipids
• Weekly assessment of anabolism
– Body weight
– Anthropometric measurements
– Indirect calorimetry
• Novel therapy
– growth hormone, insulin-like growth factor,
insulin, oxandrolone, testosterone and
propranolol

14. Early wound care
• Clean wound with saline
• ?blister mx
• Topical antibiotic dressing
– Ag sulfadiazine – poor eschar penetration
– Mafenide acetate – pain, acidosis in wide appl
– Mupirocin – expensive, doesn’t inhibit
epithelialization
– Ag nitrate – staining of skin
– Moist exposed burn ointment (MEBO)

15. Early excision and coverage/grafting
• Prevents sub-eschal infection
• Reduces cytokine mediated systemic
response
• Reduces metabolic demand

16. Early excision and grafting
• Within the first 3-5 days*
• If extensive, staged procedures, spaced in
2-3 days
• 2 types of excision
– Fascial
– tangential

17. Fascial

18. Tangential

19. Grafting / coverage
• Autograft
• Cadaveric allograft
• Synthetic
– Biobrane
– Transcyte
– Collagen

20. References
• Surgery - Basic Science and Clinical Evidence 2nd Ed
• Sabiston T.Surgery.18th Ed
• Grabb and Smith Text Book of plastic surgery
• Saffle, JR. Practice guidelines for burn care. J Burn Care 2001;
22(Suppl
• Martinez, S. Ambulatory management of burns in children. J Pediatr
Health Care 1992; 6:32.
• Bjerknes, R, Vindenes, H, Laerum, OD. Altered neutrophil functions
in patients with large burns. Blood Cells 1990; 16:127.
• Schwacha, MG, Ayala, A, Chaudry, IH. Insights into the role of
gammadelta T lymphocytes in the immunopathogenic response to
thermal injury. J Leukoc Biol 2000; 67:644.
• Peter, FW, Schuschke, DA, Barker, JH, et al. The effect of severe
burn injury on proinflammatory cytokines and leukocyte behavior:
Its modulation with granulocyte colony-stimulating factor. Burns
1999; 25:477.
• Current advances in the initial management of major thermal burns.
Gueugniaud PY; Intensive Care Med 2000 Jul;26(7):848-56