This document provides an overview of burns including types, degrees, physiology, assessment, fluid resuscitation, dressing, analgesia, antibiotics, and management of specific burn types. It discusses that burns can be contact, flame, chemical, electrical, scald, grease, or friction burns. Assessment involves calculating burn percentage using Lund and Browder chart or Rule of Nines. Management involves ABCDE approach, fluid resuscitation using Parkland formula, silver sulfadiazine or other dressings, and analgesia like morphine. Inhalation injuries require monitoring for consolidation. Electrical burns can cause cardiac issues. Chemical burns need irrigation. Inhalational burns risk laryngeal edema and respiratory failure.

1. BURN By : Dr. Ali
Sarhan

2. WHAT'S BURN ? TYPES ?
A burn is an injury to the skin or other organic tissue primarily caused by heat or
due to radiation, radioactivity, electricity, friction or contact with chemicals
1. Contact
2. Flame
3. Chemical
4. Electrical
5. Scald : it happens by hot water
6. Grease
7. Friction
8. Flush

3. DEGREES
1st degree : erythema , pain and itching , it affects epidermis , dead
tissue will peel off and healing will in 5 days . (its not calculated in
burn percentage )
2nd degree :
 Partial : involves part of the epidermis , appear pink or red with blisters ,
painful , and healing occur within 3 weeks.
 Full thickness : red or white in color , no pain and dry, usually needs skin graft
3rd degree : all skin layers , appear leathery , no pain and black in
color or white .
4th degree : beyond skin .

5. PHYSIOLOGY
1. Inflammatory process
it begins by platelets aggregation and releasing ADP ( adenosine
diphosphate ) leading to vaso-constriction, then after
macrophages will release histamine and prostaglandins leading to
vaso-dilation ; It needs up to 72 hours .
2. Proliferative
It’s the onset of granulation fibers and angiogenesis , with
condensation of collagen type 3 ; it needs 3 days to 3 weeks .
3. Remodeling
It takes up to 2 years ; in which collagen type 3 converted to
collagen type 1

6. CONT.
There is an immune suppression , and the patient will be more
susceptible for infections , as there is damage to the intestinal
vessels , with reduction of gut motility .
All of the this will lead to reduction in nutrient absorption , and
increase bacterial translocation  sepsis !
Inflammatory cascade  complement system activation 
neutrophils degranulation  release proteinase and cytokines 
shock !
Its catabolic condition , so good nutrition is essential .

7. UNHEALTHY GRANULATION
• Dirty
• Discharge
• Over-growth
• Easily bleed
• Bad-smell

8. ESCHAR

9. Patients
hand
PERCENTAGE
CALCULATION

10. LUND AND PROWDER CHART

11. ADMISSION IN CASE OF ?
1. 2nd degree 20% burn in adults
2. 2nd degree 10 % burn in extreme ages (Age < 3 years or > 60
years)
3. 3rd degree 5% burn
4. Inhalational , chemical , and electrical
5. Circumferential
6. Suicidal
7. Involvement areas and organs affect the function ( face and neck ,
perineum )
8. Trauma-associated
9. With comorbidities

12. PRE-HOSPITAL CARE
1. Stop burn process
2. ABCDE
3. IV access , with bolus RL ( 20ml/kg )
4. Cool the area , ( avoid hypothermia )
5. O2 ( even with normal SpO2 )
6. Limb elevation

13. Hospital
care
ABCDE
Fluid
replacement
Dressing
Analgesia

14. ABCDE
o if suspicion of airway burn took place( burn around mouth , nose,
burned hair , or even history exposure to hot gases ) , intubate the
patient with endotracheal tube , before giving chance for edema to
happen , and avoidance of difficult intubation ( within 2-4
hours ) .
o if not , do cricothyroidotomy .

15.  Its important to do chest x-ray for detection consolidation which
occurs due to fine particles inhaled and settled at the alveoli,
 Patients symptoms will be : tachypnea , reduced Spo2 , and
confusion .
 Keep in mind the latency in the presentation , as the patient might
show symptoms 1-5 days later .
 Treatment is mainly by nebulizer , moist O2 , and sometimes severe
cases might need CPAP ( continuous positive airway pressure ) , or
even intubation .

16. FLUID RESUSCITATION
If burn percentage is more than 15 % in adults and 10 % in children ,
be aware of hyponatremia ,or water toxicity.
Oral fluid and salts should be added
Urine output should be monitored and maintained between 0.5-1.5
ml/kg/hour
The best sort of fluid to be used is ringer lactate (similar effect to
colloid )

17. PARKLAND’S FORMULA
Its used for fluid replacement in burn conditions
Burn percentage x weight in KG x 4 = ml per 24 hours
You give half of the amount over 8 hours , then second half on the next
16 hours , then the fluid amount should be adjusted by urine output
Maintenance : ( for children )
 100 ml/kg/day ( for the first 10 kgs )
 50 ml /kg/day ( for the second 20 kgs )
 20 ml/kg/day ( for the weight after 20 kgs )
 For adults : its 30-40 ml / kg / day

18. FLUID RESUSCITATION
Hyper tonic saline can be used for shock and to prevent edema
To give colloid , muir and barcley formula can be used here .
Every one portion is : 0.5 x weight in Kgs x burn percentage
4 hours - 4 hours - 4 hours - 6 hours - 6 hours - 12 hours ( each
period one portion)

19. …
Fluid replacement should be stopped after 48 hours if :
1. Age less than 1 year : systolic pressure >60 mmhg , and urine output
>1ml/kg/hour.
2. Age 1-12 years : SP >70+(age x 2) mmhg , UOP > 1ml/kg/hour.
3. Adults : SP > 90 mmhg , UOP > 1ml/kg/hour.
In patients with oliguria despite adequate fluid replacement:
- dopamine IV: 5 to 15 μg/kg/min by IV pump
- epinephrine IV: 0.1 to 0.5 μg/kg/min by IV pump
Stop the infusion after 48 hours, if fluid requirements can be met by the
oral route or gavage.

20. DRESSING
1. Silver sulfadiazine : it acts against pseudomonas aeruginosa and
staphylococcus aureus . Use it once or twice daily .
2. Silver nitrate : it acts against pseudomonas aeruginosa , Apply a cotton
applicator dipped in solution/ointment on the affected area 2-3 times per
week for 2-3 weeks.
3. 5% mafenide acetate cream : Bacteriostatic activity against both gram
positive and negative organisms.
4. Silver sulphadiazine and cerium nitrate : to boost immunity and create a
sterile eschar .
In pregnant women its very critical ,although most dressing substances are
category c , still we use it in some urgent cases , Vaseline is a good choice
to cover the wound with.

21. …
Application of gauze with antibiotics ,
Vaseline , amniotic membranes ,or
antiseptics can be used to cover the burn
.
Another choices are , fenestrated silicone
or hydrocolloid sheets (its amazing !!!! ) .
Skin graft might be needed sometime .

22. SOME PROBLEMS !
oBurn at joints will cause contracture , and will affect joint movement later ,
physiotherapy and surgical interventions might be needed
oEye lid exposure will affect its closure , then causing keratitis .
oBurn blisters ?! There is a controversy about its contents to keep it or not .
Fluid there inside will reduce the chemotaxis and immunity , but on the
other hand it offers a optimal medium for skin and tissue re-generation .

23. – Insert a urinary catheter if burns involve > 15% of BSA, and in the
case of electrical burns or burns of the perineum/genitalia.
– Insert a nasogastric tube if burns involve > 20% of BSA (in the
operating room while carrying out dressing procedure).
– Intensive monitoring: level of consciousness, pulse, blood pressure,
pulse oximeter, respiratory rate (RR) hourly; temperature and urine
output every 4 hours.
– Burns alone do not alter the level of consciousness. In the case if
altered consciousness, consider head injury, intoxication, postictal
state in epileptic patients.

24. ANALGESIA IN BURN
* Morphine is the treatment of choice for moderate to severe pain
(SC/IM : 5-10 mg every 4 hours )
– Moderate pain:
paracetamol PO: 60 mg/kg/day in 4 divided doses
+ tramadol PO: 4 to 8 mg/kg/day in 4 divided doses
– Moderate to severe pain:
paracetamol PO: 60 mg/kg/day in 4 divided doses
+ slow release morphine PO: 1 to 2 mg/kg/day in 2 divided doses

25. ANALGESIA IN BURN
In patients with severe burns, oral drugs are poorly absorbed in the
digestive tract during the first 48 hours. Morphine must be
administered by SC route: 5-10mg every 4 hours.
adding ketamine IM at analgesic doses (0.5 to 1 mg/kg) reinforces
the analgesic effect of the paracetamol + tramadol combination given
before a dressing change.
anesthesia is a final choice

26. ANTIBIOTICS IN BURN
Check for temperature > 38.5°C or < 36°C, tachycardia , tachypnoea,
elevation of white blood cell count by more than 100% (or substantial
decrease in the number of white blood cells). having 2 out of 4
should raise the suspicion of infection and Antibiotics should be
initiated .
There is NO indication for prophylactic antibiotics in the early post-
burn period. Antibiotics should be reserved for the treatment of
infection.

27. ADDITIONAL INFORMATION'S
•If signs of systemic infection appeared , Bacteriological
surveillance of the wound, catheter tips , blood culture , and
sputum helps to build a picture of the patient’s flora and
source .
• must depend on culture , and in case of sepsis , empirical
therapy must be initiated immediately
• The most frequent pathogen is S aureusand P aeruginosa ,(in addition
to P aeruginosa , A baumannii, Enterobacter species, K pneumoniae, E
coli,Proteus species)
•Antimicrobial-resistant bacterial infection among burn patients is

28. …
Inadequate initial antimicrobial therapy to treat multidrug-
resistant (MDR) infections results in higher mortality rates.
If an multidrug-resistant pathogen is isolated, colistin should
be considered.
cefazolin IV
Children > 1 month: 75 mg/kg/day in 3 divided doses
Adults : 1 g three times daily
+ ciprofloxacin PO
Children > 1 month: 30 mg/kg/day in 2 divided doses
Adults: 500 mg twice daily

29. …
Tetanus Immunization should be used if the depth of the burn is
more than 1 cm ( full thickness second degree ) contaminated , delay
beyond 6 hours ; IM injection .
Tdap :Unvaccinated adults should receive the first 2 doses at least 4
weeks apart and the third dose 6–12 months after the second dose
• for vaccinated adults , single dose is enough

30. …
injury from explosions can result in internal injuries or fractures ,
always check for associated injuries .
BASELINE DETERMINATIONS FOR PATIENTS
WITH MAJOR BURNS
Obtain samples for a complete blood count (CBC), type and
crossmatch/screen, an arterial blood gas with HbCO, serum glucose,
electrolytes, and pregnancy test in all females of childbearing age. A
chest x-ray should be obtained for those patients who are intubated
or have a suspected smoke inhalation injury

31. ELECTRICAL BURN
Damage the heart
Can cause heart block
During first 24 hours : normal ECG , no loss of conscious  patient
will be ok and no need for ICU
LOW VOLTAGE : small, deep, entrance and exit , causes tetany and
cardiac arrhythmia but no myocardial damage
HIGH VOLTAGE : Flush also might cause some damage , it causes
subcutaneous damage and myocardial injury , might cause
rhabdomyolysis (dark urine and myoglobinuria) , or even
compartment syndrome , it elevates cardiac enzymes ( keep good
urine output )

32. ELECTRICAL BURN
Different rates of heat loss from superficial and deep tissues allow for
relatively normal overlying skin to coexist with deep muscle necrosis.
o As such, electrical burns frequently are more serious than they appear
on the body surface, and extremities, especially digits and may cause
local thrombosis and nerve injury with increased risk of compartment
syndrome .
- Rhabdomyolysis is a risk here, which can cause acute renal failure. Do
not wait for laboratory confirmation before instituting therapy for
myoglobinuria. If the patient’s urine is dark, assume that
hemochromogens are in the urine. Fluid administration should be
increased to ensure a urinary output of 100 mL/hr in adults or 2 mL/
kg/hr in children <30 kg. Metabolic acidosis should be corrected by
maintaining adequate perfusion.

33. CHEMICAL BURN
• Exposure to alkali and acidic materials can
cause chemical burn .
• At the presentation the burn must be
irrigated with water for few minutes(15-
30mins) , and elemental sodium or phosphor
must be removed manually .
• Alkali materials injury is more damaging (
sparks substance )
• Assess systemic effect if possible
• Exposure to acidic (H2SO4 ) or hydrofluoric
acid ( industrial uses ) should be treated with
topical Ca2+ gluconate in addition to water

34. INHALATIONAL BURN
It occurs by exposure to toxic or hot gases .
 effect :
1. Laryngeal edema
2. Epithelia damage and necrosis
3. Chemical alveolitis  respiratory failure
4. Poisoning
 After injury , cells accumulation and subglottic edema will occur.
 Carbon monoxide has 240 times affinity more than O2 to Hb ,
treated by oxygen therapy ,and severe cases might need hyperbaric
oxygen therapy .
 10 % CO is treatable , 60 % is fatal .

35. …
Patients with CO levels of less than 20% usually have no physical
symptoms. Higher CO levels can result in:
■ headache and nausea (20%–30%)
■ confusion (30%–40%)
■ coma (40%–60%)
■ death (>60%)
its half-life is 250 minutes (4 hours) when the patient is breathing room
air, compared with 40 minutes when breathing 100% oxygen.
measurements of arterial PaO2 do not reliably predict CO poisoning,
because a CO partial pressure of only 1 mm Hg results in an HbCO level
of 40% or greater, so Do direct measurement of carboxyhemoglobin
(HbCO) to diagnose the case

36. KEEP IN MIND
• The Rule of Nines is useful but it differs considerably
for children.
• Check for Associated external ,internal injuries or
fractures.
• Immediate lifesaving measures for patients with burn
injury is fundamental
• Carbon monoxide poisoning should be suspected and

37. Bailey and Love’s Short Practice of Surgery (26th Ed.)
MSF Clinical guidelines
Oxford Handbook of Clinical Surgery, 4th Edition
ATLS-9th edition
https://emedicine.medscape.com/article/213595-treatment
https://www.cdc.gov/vaccines/schedules/hcp/imz/adult-
conditions.html