This document provides an overview of burn management, including the pathophysiology and systemic effects of major burns involving over 20% of total body surface area. Major burns can cause fluid shifts, hemodynamic changes, increased metabolic demands, renal issues, pulmonary impacts, hematological changes, immunological effects, and gastrointestinal problems. The severity of burns is determined by depth, extent of total body surface area affected, age, location on the body, medical history, and presence of inhalation injury. Patients with over 10% TBSA burns, young children, and those with full thickness or circumferential burns often require hospitalization.

1. BURNS MANAGEMENT

2. Introduction
• Burns are a form of traumatic injury caused by
thermal, electrical, chemical, or radioactive agents.
• 50% to 60% of fire deaths are secondary to
inhalation injury.
• Most accidents occur at home.
• Flame injury is the leading cause of accidents for
adults.
• Scalding is the leading cause of accidents for
children.
• The very young and the elderly are at greatest risk
for burn injuries.

3. • Burn injury is a result of heat transfer from one site
to another.
• The skin and the mucosa of the upper airways are
sites of tissue destruction.
• Tissue destruction results from coagulation, protein
denaturation, or ionization of cellular contents.
• Burns that do not exceed 20% TBSA produce a
primarily local response.
• Burns that exceed 20% TBSA may produce both a
local and a systemic response and are considered
major burn injuries.

4. Pathophysiology of Burn Injury
• The extent of a burn injury is determined by the
degree of heat and duration of exposure of the
tissue to the source.
• The mechanism of injury can provide a useful guide
to the possible severity; e.g., fat scalds produce a
deeper injury than water scalds due to the density.
• Coagulation, stasis, and hyperemia are the 3
recognized zones of burn injury.
• Zone of coagulation – here, irreversible
coagulation of tissue protein has occurred and this
area is therefore unsalvageable.

5. • Zone of stasis – this is characterized by
decreased tissue perfusion. Thus the aim of
initial burns management is to improve blood
flow to this area to prevent extension of the
injury.
• Zone of hyperemia – this has increased
perfusion and therefore is not at risk unless
there are added factors such as infection.

7. • Physiologic reaction to a burn is similar to the
inflammatory process:
o Adjacent intact vessels dilate, causing redness and
blanching with pressure.
o Platelets and leukocytes begin to adhere to the
vascular endothelium
o Increased capillary permeability produces wound
edema.
o An influx of polymorphonuclear leukocytes and
monocytes occurs at the injury site.

8. Systemic Changes in Major Burns
• Major burns involving more than 25% of total body
surface area (TBSA):
(1) Fluid Shifts –
o There are alterations and disruptions in the
vascular and other systems of the body.
o Capillary permeability increases, permitting fluid
and protein to move from vascular to interstitial
spaces (edema results) for the first 24 to 36 hrs,
peaking at 12 hrs postburn.
o There is loss of protein-rich fluid in burned tissues
and by weeping of 2nd-degree wounds and
surface of full-thickness wounds.

9. • With reduced vascular volume, the patient will go
into shock if untreated.
• Capillary permeability starts to change in about 48
hrs, but protein lost in interstitial spaces may remain
there for 5 days to 2 wks before returning to the
vascular system.
o When fluid mobilizes (moves from interstitial
spaces back to vascular compartment), patients
with good cardiac and renal function will diurese.
o Patients with impaired cardiac or renal function
are in danger of fluid overload and pulmonary
edema at this time.

10. • Red blood cell (RBC) mass is also diminished bcoz of
thrombosis, sludging, and RBC death from thermal
injury.
• As fluid escapes from the capillary walls, blood
concentrates and the hematocrit rises, causing
sluggish flow.
• Capillary stasis may cause ischemia and necrosis.
• The body attempts to compensate for losses of
plasma volume.
– Constriction of vessels.
– Withdrawal of fluid from undamaged extracellular
space.
– The patient is thirsty. (Oral fluids are not given
until bowel sounds are heard or until patient is no
longer intubated).

11. (2) Hemodynamic Changes –
o Lessened circulating blood volume results in
decreased cardiac output (CO) and increased PR.
o There is a decreased stroke volume and a marked rise
in peripheral resistance (due to constriction of
arterioles and increased hemoviscosity).
o This results in inadequate tissue perfusion, which may
in turn cause acidosis, renal failure, and irreversible
burn shock.
o Electrolyte imbalance may also occur.
• Hyponatremia usually occurs during the 3rd to
10th day due to fluid shift.
• The burn injury also causes hyperkalemia initially
due to cell destruction, followed by hypokalemia as
fluid shifts occur and potassium is not replaced.

12. (3) Metabolic Demands –
o Catecholamine release mediates the
hypermetabolic response to burn injury.
o “Burn fever” (first wk), is common and is
dependent on depth of burn and percentage of
TBSA involved.
o Healing a large surface area requires much energy;
and glucose is the primary metabolic fuel.
o Because total body glucose stores are limited and
stored liver and muscle glycogen is exhausted
within the first few days postburn, hepatic glucose
synthesis (gluconeogenesis) increases.

13. • Insulin levels decrease early postburn, and patients
develop hyperglycemia.
• They continue to be hyperglycemic when insulin
levels increase, probably due to increased
gluconeogenesis.
• Skeletal and visceral protein are mobilized to meet
increased nutritional demands.

15. (4) Renal Needs –
o Glomerular filtration may be decreased in
extensive injury.
o Without resuscitation or with delay, decreased
renal blood flow may lead to high output or
oliguric renal failure and decreased creatinine
clearance.
o Hemoglobin and myoglobin, present in the urine
of patients with deep muscle damage commonly
associated with electrical injury, may cause acute
tubular necrosis and call for a greater amount of
initial fluid therapy and osmotic diuresis.

16. (5) Pulmonary Changes –
o Hyperventilation and increased oxygen
consumption are associated with major burns.
o The majority of deaths from fire are due to smoke
inhalation.
o Overzealous fluid resuscitation and the effects of
burn shock on cell membrane potential may cause
pulmonary edema, contributing to decreased
alveolar exchange.

17. (6) Hematologic Changes –
o Hematological changes in postburn period –
 Thrombocytopenia
 Abnormal platelet function
 Depressed fibrinogen levels
 Inhibition of fibrinolysis
 Deficit in several plasma clotting factors
o Anemia results from the direct effect of –
 Destruction of RBCs due to burn injury
 Reduced life span of surviving RBCs
 Overt or occult blood loss from duodenal or gastric
ulcers
 Blood loss during diagnostic and therapeutic
procedures

18. (7) Immunologic Activity –
o The loss of the skin barrier and presence of eschar
favor bacterial growth.
o Abnormal inflammatory response after burn injury
causes a decreased delivery of antibiotics, WBCs
and oxygen to the injured area.
o Hypoxia, acidosis, and thrombosis of vessels in the
wound area impair host resistance to pathogenic
bacteria.
o Several major immunoglobulins, complement, and
serum albumin are decreased soon after the burn
occurs.

19. (8) GI Impact –
o As a result of sympathetic nervous system
response to trauma, peristalsis decreases and
gastric distention, nausea, vomiting, and paralytic
ileus may occur.
o Ischemia of the gastric mucosa and other etiologic
factors put the burn patient at risk for duodenal
and gastric ulcers, manifested by occult bleeding
and, in some cases, life-threatening hemorrhage.

20. Burn Depths
• The 3 main categories of burn depth are –
o Superficial (1st degree)
o Partial thickness (2nd degree)
o Full thickness (3rd degree)
• Partial thickness injuries are further subdivided
into superficial and deep.
• In day-to-day clinical practice, the burn depth is
assessed based on clinical evaluation using a
combination of characteristics; e.g., pain,
appearance, color, blisters (presence or absence),
sensation, and capillary refill.

21. Superficial Burns –
o Red and painful.
o Only involve the epidermis.
o Usually heal within 7 days.
o In the very superficial burn with no epidermal loss, no
dressing will be required.
o These burns are very painful and a topical analgesic
cream may be useful.
Superficial partial thickness burns –
o Produce blistering,
o Once debrided, appear pink and wet with brisk
capillary refill.
o They are painful and will usually heal within 14 days.

22. Deep partial thickness burns –
o Less painful.
o Have a dry and fixed blotchy red appearance, and
do not blanch under pressure.
o May take longer to heal (about 21 days or more).
Full thickness burns –
o Appear dry but with a white or brown leathery
appearance.
o They are not painful and generally require excision
and skin grafting to allow healing.

25. Severity of Burns
• Severity of burns is determined by:
1) Depth: 1st , 2nd (partial-thickness), 3rd degree
(full thickness).
2) Extent: Percentage of TBSA.
3) Age: The very young and very old have a poor
prognosis.
4) Area of the body burned: Face, hands, feet,
perineum, and circumferential burns require
special care.
5) Medical history and concomitant injuries and
illness.
6) Inhalation injury.

26. Burns requiring hospitalization
o Greater than 10% TBSA in children
o Any burn in the very young
o Full thickness burns
o Burns to the face, hands, feet or perineum
o Circumferential burns
o Inhalation injuries

27. Assessment for Inhalation Injury
• If victim was burned in a closed area, there should be
a high index of suspicion that smoke inhalation has
occurred.
• Evaluate all pts in closed-space fires for symptoms of
CO poisoning—headache, visual changes, confusion,
irritability, decreased judgment, nausea, ataxia, and
collapse.
• Ask about types of things that burned in this room—
type of carpet, vinyl articles, and synthetics – reason
- with the increasing use of synthetics, toxicity from
aldehydes, cyanide, and other substances is
increasing and must be considered.

28. • Listen for hoarseness and crackles. Increasing
hoarseness, stridor, and drooling are indicators of
increasing need for intubation.
• Extent of Body Surface Burned –
o Anatomic location—burns affecting hands, feet,
face, and perineum require specialized care.
o Circumferential burns also require special
attention, possibly escharotomy.
o Determination is based on the use of tables for
this purpose, such as the “rule of nines” or the
rule of the palm.
o The patient's palm (including the fingers) is
approximately 1% of the TBSA burned.

30. Treatment of Burn Injury
• INITIAL ASSESSMENT
Primary Survey
• A – Airway
 Secure the airway first.
 Get history as much as reasonably possible before
intubation
 Soot or singed nasal hairs?
• B – Breathing
 High flow Oxygen for all.
 Escharotomy? - Monitor chest wall excursion in
presence of FT torso burns
 Listen: verify breath sounds
 Assess rate & depth

31. • C – Circulation
 Monitor BP
 pulse rate
 skin color
 Establish IV access
 Warm IV fluids
 Monitor peripheral pulses in circumferential burns
• D - Disability
 Associated Injuries?
 CO poisoning?
 Substance abuse?
 Hypoxia?
 Pre-existing medical condition

32. • E – Exposure
 Remove all clothing and jewelry
 Ensure warm environment
 Clean DRY blankets
 It is OK to use water to stop the burning process
and clean but not at the expense of reducing body
core temperature.
• Secondary survey
o Repeat Primary
o Complete head to toe evaluation
o Start after resuscitation fully established

33. • Complete the HPI
 What type of burn (flame, chemical, scald)
 Duration of exposure
 What time did burn occur?
 What treatment already provided.(chemical brushed
off, water to cool, etc)
 Did burn occur in house fire/enclosed space (think
inhalation injury)
• Order labs and x rays
 CBC, BUN, Cr, electroytes
 Carboxyhemoglobin
 CXR
 Blood gas
 Insert Foley catheter
 EKG (especially in electrical injury)

34. Special considerations;
 Abuse patterns
 Children, elderly
 Concomitant trauma
 C-spine precautions
 Trauma protocols if trauma is majority of injuries
• Determine TBSA
 Use Lund Browder chart.
 Can start with patients palm = 1% of patients BSA

35. Management of the Acute Burn Injury
• Hemodynamic stabilization
• Metabolic support
• Wound debridement
• Use of topical antibacterial therapy
• Biologic dressings
• Wound closure
• Prevention and treatment of complications
• Rehabilitation

36. Hemodynamic Stabilization
• Immediate I.V. fluid resuscitation is indicated for:
– Adults with burns involving more than 18% to 20%
of TBSA.
– Children with burns involving more than 12% to
15% of TBSA.
– Patients with electrical injury, elderly patients, or
those with cardiac or pulmonary disease and
compromised response to burn injury.
• The goal is to give sufficient fluid to allow
perfusion of vital organs without over-
hydrating the patient and risking later
complications and circulatory overload.

37. • Generally, a crystalloid (Ringer's lactate)
solution is used initially.
• Colloid is used during the second day (5%
albumin, Plasmanate, or hetastarch).

38. Fluid resuscitation –
• Fluid is key for:
o Restoring adequate intravascular volume to
prevent hypotension and shock.
o Correcting electrolyte abnormalities.
o Minimize renal insufficiency.
• If burns >15%:
o Massive fluid shifts will likely occur due to
systemic inflammatory response syndrome (SIRS)
o Fluid needs will be greater than anticipated based
on appearance of burn alone

39. Initial fluid resuscitation for burns >15% -
• Parkland formula:
o 3-4 ml x kg x % total burn surface area (TBSA)
½ in first 8 hours
Remaining in next 16 hours
• Galveston Shriner’s formula
o 5000 mL/m2 TBSA burn + 2000 mL/m2 body
surface area (BSA)
• Fluid: Lactate Ringer
- plus 12.5 g 25% albumin per L
- plus D5W as needed for hypoglycemia

40. • NB: Remember to monitor glucose levels
SINCE glycogen stores of children < 5 year old
run out quickly.
• Goal of fluid resuscitation - adequate urine
output (>1ml/kg/hr).

41. • Enzymatic agents applied to the burn wound may be
used for more rapid debridement of eschar.
• Fluids may be titrated to achieve a urine output of 30
to 50 mL/hour (0.5 mL to 1.0 mL/kg/hour in an adult,
and approximately 1 mL/kg/hour in a child).
• An indwelling urinary catheter is needed to monitor
response to fluid therapy.
• Weigh the patient on admission and then daily.
• Elevate extremities.
• Monitor peripheral pulses.
• Administer humidified oxygen through a nasal
cannula, mask, or ventilator support.

42. Metabolic Support
• Initially, institute nothing-by-mouth (NPO) status
until bowel sounds return (1 to 2 days).
• Small amounts of erythromycin may be used to
encourage GI motility.
• Reduce metabolic stress by allaying pain, fear, and
anxiety and maintaining a warm environment.
• Nutritional management must be aggressive to
combat acute nutritional deficiency and weight loss;
a positive nitrogen balance should be the goal
throughout the postburn care.
• When bowel sounds return, administer oral fluids
and advance diet as tolerated.

43. Wound Cleansing and Debridement
• Treatment of the burn wound includes daily or twice-
daily wound cleansing with debridement or
hydrotherapy (tubbing/showering) and dressing
changes.
• Nonviable tissue (eschar) may be removed through
natural, enzymatic, mechanical, and/or surgical
debridement.
• Burn eschar will begin to separate from the
underlying viable tissue by a natural process of
bacterial growth, which causes a lysis of protein at
the viable-nonviable tissue interface.

44. Hydrotherapy
• Hydrotherapy is bathing of the burn patient in
a tub of water or with a water shower to
facilitate cleansing and debridement of the
burned area.

45. Topical Antimicrobials
• Topical medications are used to cover burn areas and
to reduce the number of organisms.
• They are applied directly to the burn area as
ointments, creams, or solutions that do not stick to
the wound but permit drainage.
Immediate post-burn wound care
o Tetanus prophylaxis
o Debride all bullae and necrotic tissue
o Cleanse with mild water-based antiseptic
o Apply thin layer antibiotic cream
o Dress with petroleum gauze and dry gauze