This document provides an overview of burn management, including the pathophysiology of burns, classification of burn depth, criteria for transfer to a burn center, initial assessment and management, airway management, shock and fluid resuscitation, burn wound management including for electrical and chemical burns. It details the Parkland formula for fluid resuscitation and management of potential airway compromise, circumferential limb burns requiring escharotomy, wound infection prevention and timing of excision and grafting.

1. Burn Management
Burn Management
Tad Kim, M.D.
UF Surgery
tad.kim@surgery.ufl.edu
(c) 682-3793; (p) 413-3222

2. Burn Management
Overview
• Pathophysiology of Burns
• Burn Classifications
• Criteria for Transfer to Burn Center
• Initial Assessment & Management
• Airway Management
– Smoke Inhalation Injury
• Shock & Fluid Resuscitation
• Burn Wound Management
– Electrical Injury & Chemical Burns

3. Burn Management
Pathophysiology of Burns
• Burns cause coagulative necrosis
– Chemical/Electricity also cause direct injury to
cell membranes, in addition to heat transfer
• Causes:
– Flame, Scald, Contact, Chemical, Electricity
• Depth of burn depends on:
– 1. Temperature
– 2. Time exposed
– 3. Specific heat (higher for grease)

4. Burn Management
Pathophysiology of Burns
• Burns a/w release of inflamm. mediators
• Increased capillary permeability
– Leak proteins into interstitium
• Get edema in burned & non-burned skin
• Large fluid loss due to fluid shifts & also
losses from exposed burned skin
• Characteristic “Ebb and Flow” of burns
– Ebb: Low metabolism/cardiac output, ↓Temp
– Flow: hypermetabolism, high cardiac output,
hyperglycemia, increased heat produx

5. Burn Management
Classification of Burn Depth
• 1st
degree: localize to epidermis (sunburn)
• 2nd
degree: injury to both dermis/epidermis
– Superficial 2nd
: papillary dermis
• Typically red, painful, blister, “wet” appearing
• Regen in 7-14 days from hair follicles/sweat glands
– Deep 2nd
: reticular dermis
• Typically more pale/mottled, dry, ↓sensation
• 3rd
degree: full thickness epidermis/dermis
– Hard, leathery eschar, painless
• 4th
degree: involves muscle, bone, etc.

6. Burn Management
Classification of Burn Depth

7. Burn Management
Criteria for Burn Center Referral
• Partial thickness > 10%
• Inv. face, hands, feet,
genital/perineum, joints
• Any full thickness burn
• Electrical injury
• Chemical burn
• Inhalational injury
• Comorbidities (CHF)
• Concomitant trauma
• Children
• Special emotional,
social, or rehab needs

8. Burn Management
Initial Assessment
• Called to the ER for a 35yo male rescued
from housefire w face/trunk/extrem burns
• Always start with ABC
– In trauma/burns, ABCDE (disability/exposure)
• Airway can be an issue with severe burns
or inhalational injury (esp. with indoor fire)
– Direct injury from heated air/smoke -> edema
– Edema from inflammatory response to burns
– Edema from the resuscitation fluids

9. Burn Management
Initial Assessment
• Suspect airway injury if:
– Facial burns, singed nasal hairs, wheezing,
carbonaceous sputum, tachypnea
• Give pt oxygen & put on pulse oximetry
• Progressive hoarseness is a sign of
impending airway obstruction
• Pre-emptively intubate anyone with:
– Respiratory distress, inhalational injury, large
burns (due to inevitable edema from resusc)
– Bronchoscopy to help dx inhalational injury

10. Burn Management
Initial Assessment
• Breathing (Breath sounds, chest rise, ET CO2)
– Chest escharotomies if constrictive eschar
• Circulation: get vitals (HR & BP)
– 2 large bore IV (unburned before burned skin)
– Start burn resuscitation with Lactated Ringer’s
– Place patient on continuous EKG / monitor
– Palpate or doppler extremity signals with
circumferential extremity burns
• Disability (GCS less than eight -> intubate)
• Exposure: remove all clothing

11. Burn Management
Initial Assessment
• AMPLE history
– Allergies
– Medications (also ask about last tetanus)
– Past medical history (CHF – careful w fluids)
– Last meal
– Events regarding the injury (how did the fire
start, how long was the exposure, what type
of exposure – flame, grease)

12. Burn Management
Initial Assessment
• Burn Resuscitation with Lactated Ringer’s
• Figure out burn size by “rule of nines” or
entire palmar surface of pt’s hand = 1%
• Parkland formula
– 4 x Wt(kg) x %TBSA = mL to give in 1 day
– Half over 1st
8hrs (subtract what was given)
– Give other Half over next 16 hours
– In reality, titrate to UOP of 0.5mL/kg/hr in
adults and 1mL/kg/hr in children
• Do not give colloid in first 24 hrs

13. Burn Management
Burn Resuscitation
• 70kg male with 40% TBSA
– EMS administered 1.5L of fluids already
• What rate of LR should he receive?

14. Burn Management
Burn Wound Management
• Circumferential deep 2nd
or 3rd
degree
extremity burn can compromise circulation
• Assess for the 6 P’s
– Pain, pallor, pulselessness (check Doppler),
paresthesias, paralysis, poikilothermia
– Directly measure tissue pressure (30 is cutoff)
• Dx: Compartment syndrome
• Tx: Escharotomy
• (Give tetanus toxoid if not up to date)

15. Burn Management
Burn Wound Management
• Burn patients are susceptible to infection
– Due to immunologic insult of large burns
– Also because dead tissue is easily colonized
• Initially clean/debride & cover with topical
antimicrobial (no data for oral or IV abx)
• Superficial 2nd
: can use temporary pigskin
• 3rd
& (most) deep 2nd
need early excision &
grafting, except palm/soles/face/genitals
– Perform at ~3-7 days post-burn

16. Burn Management
Topical Antimicrobials
• Sulfamylon for ears
– Good at penetrating eschar & is painful
– Side effect: metabolic acidosis via carbonic
anhydrase inhibition
• Bacitracin for face
– Few side effects
• Silvadene for trunk, neck, extremities
– Does not penetrate eschar very well
– Side effects: neutropenia/thrombocytopenia

17. Burn Management
Electrical Burns
• Most significant injury is within deep tissue
• Edema can compromise circulation
• Be ready to perform eschar-/fasciotomies
• Explore & debride necrotic tissue
• May have to re-explore questionable
areas
• EKG if heart was in conduction path
• Follow serial CPK & urine myoglobin due
to possibility of rhabdomyolysis

18. Burn Management
Chemical Burns
• Speed is essential
• ABCDE – remove all clothing
• Irrigate with 15-20L of water
– Brush off any dry powder before irrigation
• Alkalis generally cause worse damage
• Do not attempt to counteract acid burns
using alkali or alkali burns using acid

19. Burn Management
Take Home Points
• Always start with ABCDE for trauma/burns
• Know what can compromise airway in
burn patients
– Chest escharotomy may be needed
• Know and apply the Parkland formula
• Recognize the need for limb escharotomy
• Know depths of burn & which req excision
• Know the types & side effects of topicals
• Basics of treating chemical/electrical burns