1) The document discusses the pathophysiology and management of burns in the first 24 hours, including fluid resuscitation using formulas like Parkland. 2) It describes the classification of burns by depth and recommends criteria for hospital admission. 3) Pain management involves oral or IV morphine and immobilization to keep pain at acceptable levels.

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