This document provides information on the management of burn injuries. It discusses initial first aid including stopping the burning process and cooling the burned area. It then covers indications for admission, initial treatment including cleaning and dressing, fluid resuscitation protocols, wound management including dressing, grafting and escharotomy, and prevention and treatment of contractures. The document is a comprehensive overview of burn management from initial emergency response through long-term wound healing and rehabilitation.

1. MANAGEMENT OF
BURN
INJURIES By- ANNU KOHLI
Roll NO. - 16

2. FIRST AID
• STOP THE BURNING PROCESS AND KEEP THE PATIENT AWAY FROM THE BURNING
AREA.
• COOL THE AREA WITH TAP WATER BY CONTINUOUS IRRIGATION FOR 20 MINUTES
INDICATIONS FOR ADMISSION IN BURNS
• ANY MODERATE AND SEVERE BURNS
• AIRWAY BURNS OF ANY TYPE
• BURNS IN EXTREMES OF AGE
• ALL ELECTRICAL/DEEP CHEMICAL BURNS

3. • CLOTHING SHOULD BE REMOVED
• COOLING OF THE PART BY RUNNING WATER FOR 20 MINUTES
• CLEANING THE PART TO REMOVE DUST, MUD, ETC
• CHEMOPROPHYLAXIS—TETANUS TOXOID; ANTIBIOTICS; LOCAL ANTISEPTICS
• COVERING WITH DRESSINGS BY DIFFERENT METHODS
• COMFORTING WITH SEDATION AND PAIN KILLER
INITIAL TREATMENT

4. DEFINITIVE TREATMENT
• ADMIT THE PATIENT.
• MAINTAIN AIRWAY, BREATHING, CIRCULATION.
• ASSESS THE PERCENTAGE, DEGREE, AND TYPE OF BURN.
• KEEP THE PATIENT IN A CLEAN ENVIRONMENT.
• SEDATION AND PROPER ANALGESIA.
• PATIENT SHOULD BE IN BURNS UNIT (IDEALLY AIR-CONDITIONED) WITH
BARRIER NURSING, STERILE CLOTHES, BED SHEETS WITH ALL ASEPTIC
METHODS.

5. FLUIDS USED:
• NORMAL SALINE,
• RINGER LACTATE,
• HARTMANN FLUID,
• PLASMA.
RINGER LACTATE IS THE FLUID OF CHOICE. BLOOD IS TRANSFUSED
IN LATER PERIOD (AFTER 48 HOURS).
Fluid Resuscitation

6. A. PARKLAND REGIME: COMMONLY USED:
• 4 ML/% BURN/KG BODY WEIGHT/24 HOURS.
• MAXIMUM PERCENTAGE CONSIDERED IS 50%.
• HALF THE VOLUME IS GIVEN IN FIRST 8 HOURS, REST
GIVEN IN 16 HOURS.

7. B. MUIR AND BURCLAY REGIME:
• % BURNS × BODY WEIGHT IN KG= 1 RATION
2
• 3 RATIONS GIVEN IN FIRST 12 HOURS.
• 2 RATIONS IN SECOND 12 HOURS.
• 1 RATION IN THIRD 12 HOURS.
C. GALVESTON REGIME (PAEDIATRIC):
• 5000 ML/M2BURNED + 1500 ML/M2 TOTAL

8. D. MODIFIED BROOKE FORMULA:
FIRST 24 HOURS:
• RL: 4 ML/KG/% BURNS IN 24 HOURS (FIRST HALF IN FIRST 8 HOURS)
• COLLOID—NONE.
SECOND 24 HOURS:
• CRYSTALLOIDS—TO MAINTAIN URINE OUTPUT
• COLLOIDS—0.3 ML TO 0.5 ML/KG/BURNS IN 24 HOURS.

9. E. EVAN’S FORMULA:
IN FIRST 24 HOURS:
• NORMAL SALINE 1 ML/KG/% BURNS
• COLLOIDS 1ML/KG/% BURNS
• 5 % DEXTROSE IN WATER, 2000 ML IN ADULT.
IN SECOND 24 HOURS:
• HALF OF THE VOLUME USED IN FIRST 24 HOURS.

10. FIRST 24 HOURS ONLY
• CRYSTALLOIDS SHOULD BE GIVEN (CRYSTALLOIDS ARE ONE WHICH CAN PASS
THROUGH CAPILLARY WALL LIKE SALINE EITHER HYPO, ISO OR HYPERTONIC,
DEXTROSE SALINE, RINGER LACTATE).
• SODIUM IS ASSESSED BY FORMULA: 0.52 MMOL × KG BODY WEIGHT × % BODY
BURNS
• GIVEN AT A RATE OF 4.0 TO 4.4 ML/KG/HOUR.

11. AFTER 24 HOURS
• UP TO 30-48 HOURS, COLLOIDS SHOULD BE GIVEN TO COMPENSATE PLASMA
LOSS (COLLOIDS ARE ONE WHICH ARE RETAINED IN INTRAVASCULAR
COMPARTMENT).
• PLASMA, HAEMACCEL (GELATIN), DEXTRANS, HETASTARCH ARE USED.
USUALLY AT A RATE OF 0.35-0.5 ML/ KG/% BURNS IS USED IN 24 HOURS.

12. • URINARY CATHETERIZATION TO MONITOR OUTPUT; 30-50
ML/HOUR SHOULD BE THE URINE OUTPUT.
• TETANUS TOXOID.
• MONITORING THE PATIENT: HOURLY PULSE, BP, PO2, PCO2,
ELECTROLYTE ANALYSIS, BLOOD UREA, NASAL OXYGEN, OFTEN
INTUBATION IS REQUIRED.
• IV RANITIDINE 50 MG 8TH HOURLY.

13. • RYLE’S TUBE INSERTION: INITIALLY FOR ASPIRATION PURPOSE LATER FOR
FEEDING (ENTERAL FEEDING).
• ANTIBIOTICS: PENICILLINS, AMINOGLYCOSIDES, CEPHALOS PORINS,
METRONIDAZOLE.
• CULTURE OF THE DISCHARGE; TOTAL WHITE CELL COUNT AND PLATELET
COUNT AT REGULAR INTERVALS ARE ESSENTIAL TO IDENTIFY THE SEPSIS
ALONG WITH FEVER, TACHYCARDIA AND TACHYPNOEA.
• IN BURNS OF ORAL CAVITY TRACHEOSTOMY MAY BE REQUIRED TO MAINTAIN
THE AIRWAY.

14. • TOTAL PARENTERAL NUTRITION (TPN) IS REQUIRED FOR FASTER
RECOVERY, USING CARBOHYDRATES, LIPIDS, VITAMINS
• TRACHEOSTOMY/INTUBATION TUBE MAY BE REQUIRED IN IMPENDING
RESPIRATORY FAILURE OR UPPER AIRWAY BLOCK.
• INTENSIVE NURSING CARE.

15. LOCAL MANAGEMENT
• DRESSING AT REGULAR INTERVALS UNDER GENERAL ANAESTHESIA USING
PARAFFIN GAUZE, HYDROCOLLOIDS, PLASTIC FILMS, VASELINE IMPREGNATED
GAUZE OR FENESTRATED SILICONE SHEET
• BIOLOGICAL DRESSINGS LIKE AMNIOTIC MEMBRANE OR SYNTHETIC
BIOBRANE.

16. • OPEN METHOD WITH APPLICATION OF SILVER
SULFADIAZINE WITHOUT ANY DRESSINGS, USED
COMMONLY IN BURNS OF FACE, HEAD AND NECK.
• CLOSED METHOD IS WITH DRESSINGS DONE TO
SOOTHE AND TO PROTECT THE WOUND, TO REDUCE
THE PAIN, AS AN ABSORBENT.

17. • TANGENTIAL EXCISION OF BURN WOUND WITH SKIN GRAFTING CAN BE
DONE WITHIN 48 HOURS IN PATIENTS WITH LESS THAN 25% BURNS.
• IT IS USUALLY DONE IN DEEP DERMAL BURN WHEREIN DEAD DERMIS IS
REMOVED LAYER BY LAYER UNTIL FRESH BLEEDING OCCURS. LATER SKIN
GRAFTING IS DONE.
• ADVANTAGES OF TANGENTIAL EXCISION:
• IT REDUCES—THE CHANCE OF SECONDARY INFECTION, THE HOSPITAL STAY,
AND FORMATION OF HYPERTROPHIC SCAR OR CONTRACTURE & THE COST.
• IN BURNS OF HEAD AND NECK REGION, EXPOSURE TREATMENT IS ADVISED.
• SLOUGH EXCISION IS DONE REGULARLY.

18. • AFTER CLEANING WITH POVIDONE IODINE SOLUTION SILVER SULFADIAZINE
OINTMENT IS USED. IT IS AN ANTISEPTIC AND SMOOTHENING AGENT. IT
CAUSES NEUTROPENIA.
• OTHER AGENTS USED ARE SULFAMYLON (MAFENIDE ACETATE) AND SILVER
NITRATE.
• SULFAMYLON IS ANTIPSEUDOMONAL AND ANTICLOSTRIDIAL AGENT. IT
PENETRATES WELL INTO THE TISSUES BUT IT IS VERY IRRITANT. IT CAUSES
ACIDOSIS.

19. • SILVER NITRATE CAUSES STAINING OF BURNT AREA.
• 0.025% SODIUM HYPOCHLORITE (DAKIN’S SOLUTION) IS EFFECTIVE AGAINST
GRAM +VE ORGANISMS;
• 0.25% ACETIC ACID IS EFFECTIVE AGAINST GRAM – VE ORGANISMS, BUT BOTH
MILDLY INHIBIT EPITHELIALISATION.
• REGULAR CULTURE AND SENSITIVITY FOR BACTERIA IS REQUIRED, TO SEE
FOR STREPTOCOCCAL GROWTH WHICH SHOULD BE LESS THAN 1,00,000 PER
GRAM OF TISSUES.

20. WOUND COVERAGE
• ONCE THE AREA GRANULATES WELL, IN 3 WEEKS USUALLY, SPLIT SKIN
GRAFTING IS DONE (SSG, THIERSCH GRAFT).
• FOR WIDER AREA MESH SPLIT SKIN GRAFT IS USED.
• IF THERE IS ESCHAR, ESCHAROTOMY IS REQUIRED TO PREVENT
COMPRESSION OF VESSELS.
• IN CERTAIN AREAS LIKE FACE AND EAR, FULL THICKNESS GRAFT (WOLFE
GRAFT) OR FL AP IS REQUIRED.

21. • CULTURED SKIN: FULL THICKNESS SKIN BIOPSY OF PATIENT’S SKIN IS DONE
IMMEDIATELY AFTER ADMISSION.
• BY SPECIALIZED CULTURE TECHNOLOGY SHEETS OF SKIN CAN BE MANUFACTURED IN
3 WEEKS AS CULTURED EPITHELIAL GRAFTS.
• IT CAN COVER SKIN OF ALMOST ENTIRE BODY. IT IS USUALLY USEFUL IN BURNS OF
>80%.
• TAKE UP OF CULTURED GRAFT IS 60-75%.
LIMITATIONS ARE—
• TIME TAKEN TO DEVELOP CULTURED GRAFT;
• MORE VULNERABILITY FOR MECHANICAL
• TRAUMA;
• COSTLY;
• TIME TAKEN TO MANUFACTURE;
• SCARRING.

22. SYNTHETIC DRESSINGS IN BURN WOUND
• VASELINE IMPREGNATED GAUZE DRESSING PREVENTS STIFFNESS OF
ESCHAR.
• HYDROCOLLOID DRESSING (DUODERM) HELPS MOIST ENVIRONMENT,
PROPER EPITHELIALISATION.
• IT IS USEFUL IN MIXED DEEP BURNS.
• IT IS CHANGED ONCE IN 3 DAYS.

23. • OPSITE IS LESS EXPENSIVE, WITH LESS PAIN, CREATES MOIST BARRIER.
• BUT IT DOES NOT HAVE ANTIMICROBIAL EFFECT AND IT CAUSES
ACCUMULATION OF EXUDATES.
• BIOBRANE IS COLLAGEN COATED SILICONE SHEET WHICH GETS
ADHERENT TO WOUND ACTING AS BARRIER WITHOUT ANY PAIN.
• BUT IT DOES NOT HAVE ANTIMICROBIAL EFFECT AND IT CAUSES
ACCUMULATION OF EXUDATES.
• IT IS USED FOR 2ND DEGREE BURNS.

24. • TRANSCYTE
• HAS SIMILAR FEATURES OF BIOBRANE.
• IT CONTAINS GROWTH FACTOR DERIVED FROM CULTURED FIBROBLASTS
WHICH PROMOTES WOUND HEALING.
• INTEGRA
• CONTAINS DEEPER COLLAGEN MATRIX AS DERMAL SUBSTITUTE;
• OUTER SILICONE SHEET AS EPIDERMAL SUBSTITUTE.
• INNER COLLAGEN MATRIX ACTS AS DERMIS WHEREAS OUTER SILICONE SHEET
IS REMOVED 2 WEEKS AFTER DRESSING AND ADDITIONAL AUTOGRAFT
SHOULD BE PLACED.
• IT PROVIDES COMPLETE WOUND COVER. SCARRING AFTER HEALING IS
REDUCED SIGNIFI CANTLY.

25. BIOLOGIC DRESSINGS FOR BURN WOUND
• IT IS USED TO COVER THE WOUND TEMPORARILY AS A BARRIER AND ALSO TO
HAVE SOME IMMUNOLOGIC FUNCTION.
• EVENTUALLY GRAFT WILL SLOUGH. LATER WOUND IS COVERED WITH AUTO-
SKIN GRAFT .
• IT IS USED FOR MASSIVE BURN INJURIES MORE THAN 50%.
• POSSIBLE PROBLEM IS TRANSMISSION OF VIRAL DISEASES.
• XENOGRAFT IS OF PIG SKIN.
• ALLOGRAFT IS OF CADAVER SKIN (HOMOGRAFT)—IT GIVES ALL EXISTING
NORMAL SKIN FUNCTION FOR TEMPORARY PERIOD. IT MAY LEAVE A DERMAL
EQUIVALENT IN THE WOUND LATER.

26. ESCHAR
• IT IS CHARRED, DENATURED, FULL THICKNESS, DEEP BURNS WITH
CONTRACTED DERMIS.
• IT IS INSENSITIVE, WITH THROMBOSED SUPERFICIAL VEINS.
• CIRCUMFERENTIAL ESCHAR IN THE UPPER LIMB, LOWER LIMB, NECK, THORAX
CAN CAUSE MORE OEDEMA WHICH INITIALLY CAUSES VENOUS COMPRESSION
AND LATER ARTERIAL COMPRESSION CAUSING ISCHAEMIA, GANGRENE OF
THE DISTAL PART.
• SO DISTAL AREA SHOULD BE MONITORED FOR CIRCULATION.

27. • IF REQUIRED DEEP LONGITUDINAL FULL THICKNESS INCISIONS ARE MADE IN
DIFFERENT AREAS SO AS TO PREVENT COLLECTION OF OEDEMA FLUID AND
ALSO TO PREVENT COMPRESSION OVER THE VESSELS.
• THIS IS CALLED AS ESCHAROTOMY.
• ESCHAROTOMY CAUSES LARGE QUANTITY OF BLOOD LOSS AND SO BLOOD
TRANSFUSION IS NEEDED WHILE DOING ESCHAROTOMY.
• INCISION SHOULD BE OF ADEQUATE LENGTH AND DEPTH DURING
ESCHAROTOMY.
• IT SHOULD BE PLACED IN SUCH A WAY SO AS TO AVOID INJURY TO MAJOR
NEUROVASCULAR SYSTEM.
• RELEASE OF MUSCLE COMPARTMENT IS NEEDED OFTEN IN THESE PATIENTS.

28. • MULTIPLE INCISIONS OR INCISIONS OVER THE JOINTS MAY BE
NEEDED.
• EARLY RAPID SEPARATION OF ESCHAR INDICATES SEVERE
SEPSIS UNDERNEATH.
• EVENTUALLY ESCHAR SHOULD BE EXCISED AND THE AREA IS
ALLOWED TO GRANULATE AND SKIN GRAFTING SHOULD BE
DONE.
• PSEUDOESCHAR IS THICKENED BURNT SKIN DUE TO REPEATED
SILVER SULPHADIAZINE APPLICATION.

29. CONTRACTURE IN BURN WOUND
• CONTRACTURE IN BURNS CAN OCCUR ANYWHERE.
• IT IS MORE COMMON WHEREIN FLEXIBILITY AND MOBILITY IS PRESENT LIKE
ALONG THE JOINT, EYELIDS, CHEEKS, LIPS, NECK, ELBOW, KNEE, ETC.
• CONTRACTURE CAN BE INTRINSIC BY LOSS OF TISSUE OR EXTRINSIC BY PULL
DURING HEALING PHASE CONTRACTION.
• CONTRACTURE PROCEEDS TOWARDS POSITION OF COMFORT UNTIL IT MEETS
OR CLOSELY REACHES OPPOSITE SURFACE.
• THERE IS CLEARLY WOUND SHORTENING.

30. • DISORGANISED OVER FORMATION OF COMPACT COLLAGEN (3 TIMES NORMAL)
CAUSES HYPERTROPHIC SCAR LEADING FURTHER CONTRACTURE.
DEFICIT OF NECK EXTENSION IS GRADED,
• NORMAL > 110°; E1 95-110°;
• E2 IS 85-95°;
• E3 IS < 85° WITH MENTOSTERNAL SYNECHIA.

32. CLASSIFICATION OF BURNS CONTRACTURE IN
THE NECK (BM ACHAUER)
• MILD (LESS THAN 1/3RD)—INABILITY TO SEE CEILING.
• MODERATE (1/3RD TO 2/3RD)—FLEXION IS POSSIBLE BUT NOT EXTENSION.
• SEVERE (MORE THAN 2/3RD)—FULLY CONTRACTED IN FLEXED POSITION WITH
PULL ON LOWER LIP.
• EXTENSIVE—CONTRACTION IS EXTENSIVE WITH MENTOSTERNAL ADHESIONS.

33. IFEANYICHUKWU HAS CLASSIFI ED NECK CONTRACTURE INTO:
• TYPE 1— MILD ANTERIOR WITH NARROW CONTRACTING BAND LESS THAN
FINGERBREADTH (1A) OR BROAD BAND (1B);
• TYPE 2—MODERATE ANTERIOR WITH NARROW BAND (2A) OR BROAD BAND
(2B);
• TYPE 3—SEVERE ANTERIOR MENTOSTERNAL ADHESION WITH SUPPLE NECK
SKIN (3A) OR WITHOUT SUPPLE SKIN (3B);
• TYPE 4—POSTERIOR WITH NARROW BAND (4A) OR MULTIPLE OR BROAD
BAND (4B).
RECONSTRUCTION TERRITORIES IN NECK IN BURN CONTRACTURE BASED ON
FUNCTIONAL BENEFITS ARE—
• CENTRAL ABOVE;
• CENTRAL BELOW;
• CENTRAL ABOVE AND BELOW;
• LATERAL.

34. COMPLICATIONS OF BURNS CONTRACTURE
• ECTROPION OF EYELID CAUSING KERATITIS AND CORNEAL ULCER.
• DISFIGUREMENT IN FACE.
• NARROWING OF MOUTH MICROSTOMIA.
• CONTRACTURE IN THE NECK CAUSING RESTRICTED NECK MOVEMENTS.
• DISABILITY AND NON-FUNCTIONING OF JOINTS DUE TO CONTRACTURE.
• HYPERTROPHIC SCAR AND KELOID FORMATION.
• REPEATED BREAKING OF SCAR AND INFECTION, ULCER, CELLULITIS.
• PAIN AND TENDERNESS IN THE SCAR CONTRACTURE.

36. • MARJOLIN’S ULCER: IT IS A VERY WELL-DIFFERENTIATED SQUAMOUS
CELL CARCINOMA OCCURRING IN A SCAR ULCER DUE TO REPEATED
BREAKDOWN (UNSTABLE SCAR OF LONG DURATION).
• IT IS LOCALLY MALIGNANT.
• AS THERE ARE NO LYMPHATICS IN THE SCAR, SO THERE IS NO SPREAD TO
LYMPH NODES.
• AS THERE ARE NO NERVES IN THE SCAR IT IS PAINLESS.
• IT HAS RAISED AND EVERTED EDGE WITH INDURATION.
• BIOPSY CONFIRMS THE DIAGNOSIS.

38. • TREATMENT: RADIOTHERAPY IS NOT GIVEN FOR MARJOLIN’S
ULCER.
• TREATMENT IS EITHER WIDE EXCISION OR AMPUTATION. IT IS
CURABLE.
• ONCE IT SPREADS OUT OF THE SCAR TISSUE IT BEHAVES LIKE
ANY OTHER SQUAMOUS CELL CARCINOMA AND SO CAN SPREAD
TO REGIONAL LYMPH NODES.

39. TREATMENT FOR CONTRACTURE
• RELEASE OF CONTRACTURE SURGICALLY AND USE OF SKIN GRAFT OR “Z”
PLASTY OR DIFFERENT FLAPS.
DIFFERENT FLAPS USED ARE—
• TRANSPOSITION FLAPS,
• VERTICAL OR TRANSVERSE;
• LATERALLY BASED FLAP;
• BILOBED FLAP;
• BIPEDICLED FLAP;
• ADVANCEMENT FLAP;

40. • REGIONAL FLAP;
• RANDOM CUTANEOUS FL AP (EPAULETTE FL AP, CHARRETERA FLAP);
• FASCIOCUTANEOUS/ MYOCUTANEOUS FLAP;
• TUBE FLAP;
• EXPANDED SKIN FLAP;
• COMBINED SKIN GRAFT AND FLAP;
• MICROVASCULAR FREE FLAP.

41. • PROPER PHYSIOTHERAPY AND REHABILITATION IS ESSENTIAL.
• PRESSURE GARMENTS TO PREVENT HYPERTROPHIC SCARS.
• MANAGEMENT OF ITCHING IN THE SCAR USING ALOEVERA,
ANTIHISTAMINES AND MOISTURIZING CREAMS.

42. PROBLEMS IN MANAGING BURN
CONTRACTURE
• GIVING PROPER ANAESTHESIA IS CHALLENGING
• NEED FOR REPEATED SURGERIES AS STAGED ONE.
• MAINTAINING THE POSITION WITH SKELETAL TRACTION, FIXATION, B COLLAR,
POP CAST, ETC.
• PSYCHOLOGICAL PROBLEMS AND NEEDS COUNSELLING.
• PROLONGED HOSPITAL STAY, COST FACTORS.

43. PREVENTION OF DEVELOPMENT OF CONTRACTURE
• JOINT EXERCISE IN FULL RANGE DURING RECOVERY PERIOD OF BURNS
• PRESSURE GARMENTS FOR A LONG PERIOD
• TOPICAL SILICON SHEETING
• SALINE EXPANDERS FOR SCARS