Plastic surgery Classes: Burn Management

1. BURN AND ITS MANAGEMENT

2. What is a burn?
• Cutaneous injury caused by heat, electricity,
chemicals, friction, or radiation.

3. Superficial burn (1st degree)
• Only the epidermis
• Red and tender
• Mild discomfort some good over the counter
(OTC) topical creams used. Aloe vera,
Lidocaine

4. First Degree Burn
Only involves the EPI-dermis

5. Superficial partial-thickness burn
(Superficial 2nd degree burn)
• Epidermis and part of the dermis
• Blistered, red, blanches with pressure
• Often seen with scalding injuries
• Sensitive to light touch or pinprick
• Treated on outpatient basis, heal time 1-3
weeks

6. Second Degree Burn

7. Deep partial-thickness
(Deep 2nd degree)
• Epidermis and most of the dermis
• Appears white or poor vascularized; may not
blister
• Less sensitive to light touch than superficial
form
• Extensive time to heal (3-4 weeks)
• Often require excision of the wound and skin
grafting

8. Deep partial– White is deeper than pink

9. Full-thickness (3rd degree)
• Epidermis, dermis and into subcutaneous
tissue
• Dry, leathery and insensate. Typically no
blistering
• Commonly seen when clothes are caught on
fire or skin is directly exposed to flame
• Extensive healing time and need for skin
grafting

10. Third Degree Burn

11. Fourth degree
• Full-thickness extends to muscle or bone
• Commonly seen with high voltage electric
injury or severe thermal burns
• Hospital admission, maybe surgical
amputation of the affected extremity

12. Fourth Degree
Electrical burns go deep

13. Types of burns

14. Circumstances of injury

15. Where do burns occur

16. Classification
• More then 20% TBSA – Major burn
• More then 40% TBSA – Severe Burns

17. Pathophysiology
• The main factor responsible for mortality in
thermally injured patients
• Carbon monoxide the most common toxin
– 200 times greater affinity
– Competitive inhibition with cytochrome P-450

19. Carbon Monoxide Poisoning
• 10% COHb – asymptomatic, seen most often
in smokers, truck drivers, traffic police
• 20% COHb - headache, nausea, vomiting, loss
of dexterity
• 30% COHb - confusion & lethargy, possible
ECG changes
• 40-60% COHb - coma
• 60% + - usually fatal

20. Burns begin at 44 degrees C
• 6 hours for burns to occur at
111 degrees F (44 C)
• 1 second of burns to occur at
140 degrees F (60 C)

21. Time For Full Thickness
Burns To Occur In Scalds
• 5 seconds in water @ 140 F (60 C)
• 30 seconds in water @ 130 F (55 C)
• 5 minutes in water @ 120 F (49 C)

22. Physiological Changes
• 10 to 50 fold increase in catecholamines – lasts upto
9 months
• Metabolic rate – 120% 6 months post burn
• Increase in cardia workload
• Lipolysis
• Liver dysfunction – 200% increase
• Severe muscle catabolism
• Insulin resistance
• Increased cytokines
• Decreased sex hormones and growth hormones

23. MANAGEMENT

24. FIRST AID
• First Goal is to STOP THE BURNING PROCESS!
I. Stop, drop and roll. Smother with blanket or douse with
water. DO NOT RUN!
II. Disconnect the person from the source of electricity
III. Remove clothing and jewelry. Take off blanket used to
smother fire
IV. Cool burns or scalds by immediate immersion of water for
at least 20 min.
V. Irrigation of chemical burns should be for 1 hour.
VI. Do NOT use ice for cooling
VII. Avoid hypothermia, keep the person as warm as possible.

25. How do we get to where we are going?
STRATEGY
I. Assessment
1. Primary and secondary assessment/resuscitation
2. Focused assessment
a) Subjective data collection
b) Objective data collection
3. Psychological/social/environmental factors
a) Occupational risk factors
b) Alterations in ability to perceive environmental threats
c) Social risk factors
d) Environmental risk factors
4. Diagnostic procedures
a) Laboratory studies
b) Imaging studies
c) Other

26. STRATEGY: Assessment
• Primary:
– Airway / C-spine
– Breathing
– Circulation
– Disability
– Expose / Environmental controls

27. Airway
• Open airway?
• Singed facial or nose hairs?
• Soot in back of throat?
• Throat swollen or burned?

28. Airway considerations
• Maintain low threshold for
intubation and high index of
suspicion for airway injury
• Swelling is rapid and progressive
first 24 hours
• Consider RSI to facilitate
intubation – cautious use of
succinylcholine hours after burn
due to K+ increase
• Prior to intubation attempt:
have smaller sizes of ETT
available
• Prepare for cricothyrotomy
for tracheostomy
• Utilize ETCO2 monitoring –
pulse oximetry may be
inaccurate or difficult to apply
to patient.

29. Airway considerations
• Upper airway injury (above the glottis): Area
buffers the heat of smoke – thermal injury is usually
confined to the larynx and upper trachea.
• Lower airway/alveolar injury (below the glottis):
- Caused by the inhalation of steam or chemical
smoke.
- Presents as ARDS often after 24-72 hours

30. Criteria for intubation
• Changes in voice
• Wheezing / labored
respirations
• Excessive, continuous
coughing
• Altered mental status
• Carbonaceous sputum
• Singed facial or nasal hairs
• Facial burns
• Oro-pharyngeal edema /
stridor
• Assume inhalation injury in
any patient confined in a
fire environment
• Extensive burns of the face
/ neck
• Eyes swollen shut
• Burns of 50% TBSA or
greater

31. Pediatric intubation
• Normally have smaller airways than adults
• Small margin for error
• If intubation is required, an uncuffed ETT should be
placed
• Intubation should be performed by experienced
individual – failed attempts can create edema and
further obstruct the airway
AGE + 4 = ETT size
4

32. Ventilatory therapies
• Rapid Sequence Intubation
• Pain Management, Sedation and Paralysis
• PEEP
• High concentration oxygen
• Avoid barotrauma
• Hyperbaric oxygen

33. Ventilatory therapies
• Burn patients with ARDS requiring
PEEP > 14 cm for adequate ventilation should
receive prophylactic tube thoracostomy.

34. Management of Carbon Monoxide Intoxication
• Remove patient from source of exposure.
• Administer 100% high flow oxygen
Half life of Carboxyhemoglobin in patients:
• Breathing room air 120-200 minutes
• Breathing 100% O2 30 minutes

35. C-spine
• Any trauma (fall or RTI)- concerning c-spine
injury?
• IMMOBILIZE EARLY
• Remember ACLS! Jaw thrust/chin lift or Head
tilt appropriate?

36. Breathing
• Chest rise and fall
• Retractions, Rate
• Circumferential cyanosis
• Breath sounds

37. Circulation
• Shock and tissue perfusion
• Color of skin
• Blistering
• Depth of burn (degree)
• Capillary refill

38. Circulation considerations
• Formation of edema is the greatest initial volume
loss
• Burns 30% or <
Edema is limited to the burned region
• Burns >30%
Edema develops in all body tissues, including non-
burned areas.

39. Circulation considerations
• Capillary permeability increased
• Protein molecules are now able to cross the
membrane
• Reduced intravascular volume
• Loss of Na+ into burn tissue increases osmotic
pressure this continues to draw the fluid from
the vasculature leading to further edema formation

40. Circulation considerations
• Loss of plasma volume is greatest during the
first 4 – 6 hours, decreasing substantially in 8 –
24 hours if adequate perfusion is maintained.

41. Impaired peripheral perfusion
• May be caused by mechanical compression,
vasospasm or destruction of vessels
• Escharotomy indicated when muscle compartment
pressures > 30 mmHg
• Compartment pressures best obtained via ultrasound
to avoid potential risk of microbial seeding by using
slit or wick catheter

42. Fluid resuscitation
• Goal: Maintain perfusion to vital organs
• Based on the TBSA, body weight and whether
patient is adult/child
• Fluid overload should be avoided – difficult to
retrieve settled fluid in tissues and may
facilitate organ hypoperfusion

43. Fluid resuscitation
• Lactated Ringers - preferred solution
• Contains Na+ - restoration of Na+ loss is
essential
• Free of glucose – high levels of circulating
stress hormones may cause glucose
intolerance

44. Fluid resuscitation
• Burned patients have large insensible fluid
losses
• Fluid volumes may increase in patients with
co-existing trauma
• Vascular access: Two large bore peripheral
lines (if possible) or central line.

45. Fluid resuscitation
• Fluid requirement calculations for infusion
rates are based on the time from injury, not
from the time fluid resuscitation is initiated.

46. Assessing adequacy of resuscitation
• Peripheral blood pressure: may
be difficult to obtain – often
misleading
• Urine Output: Best indicator
unless ARF occurs
• A-line: May be inaccurate due to
vasospasm
• CVP: Better indicator of fluid
status
• Heart rate: Valuable in early
post burn period – should be
around 120/min.
• > HR indicates need for > fluids
or pain control
• Invasive cardiac monitoring:
Indicated in a minority of
patients (elderly or pre-existing
cardiac disease)

47. Parkland Formula
• 4 cc R/L x % burn x body wt.
In kg.
• ½ of calculated fluid is
administered in the first 8
hours
• Balance is given over the
remaining 16 hours.
• Maintain urine output at 0.5
cc/kg/hr.
• ARF may result from
myoglobinuria
• Increased fluid volume,
mannitol bolus and NaHCO3
into each liter of LR to
alkalinize the urine may be
indicated

48. Galveston Formula
• Used for pediatric patients
• Based on body surface area
rather than weight
• More time consuming
• L/R is used at 5000cc/m2 x
% BSA burn plus
2000cc/M2/24 hours
maintenance.
• ½ of total fluid is given in
the first 8 hrs and balance
over 16 hrs.
• Urine output in pediatric
patients should be
maintained at 1 cc/kg/hr.

49. Disability / Neurological
• LOC?
• AVPU
– Alert
– Verbal
– Pain
– Unresponsive
• PERRLA
– Pupils
– Equal
– Round
– Reactive
– Light
– Accommodation
• GCS?
– Glasgow
– Coma
– Scale
– 0-15

50. Expose / Environmental controls
• Stop the burning process
• Expose the patient
• Keep warm

51. Secondary assessment
• Full set of vitals, Focused adjuncts, Facilitate
family presence
• Give comfort measures
• History and Head-to-Toe Assessment
• Inspect posterior surfaces

52. Focused assessment
1. Subjective data :
– HPI / Chief complaint
• Mechanism
• Pain
• Length of time exposed to burn source
• Time of occurrence
• Body area and type
– Environment
– Electrical / Lightening
– Chemical

53. • LOC
• Related injuries
• CPR at scene
• Efforts to relieve symptoms
– Home remedies
– Alternative therapies
– Medications
» prescribed
» OTC

54. – Past medical history
• Current preexisting disease or illness
• Surgical procedures
• Smoking history
• Substance / alcohol abuse
• LNMP
• Suicidal behavior
• Medications
– Prescriptions
– OTC/Herbal
– Allergies
– Immunization status

55. 2. Objective data collection
– General appearance
• LOC, behavior, affect
• Vital signs
• Odors
• Gait
• Hygiene
• Level of distress or discomfort

56. What needs to be done?
• Diagnostic procedures
– Labs: CBC, Chemistries, HbCO, Type and
crossmatch, Coags, UA, U preg, ABG, Serum and
urine toxicology
– Imaging: Chest x-ray, c-spine, CT, FAST,
– Other: PL, ECG

57. STRATEGY : PLANNING
IMPLEMENTATION/INTERVENTIONS
• Determine the priorities in care
• FLUID MANAGEMENT
• PREVENTION OF HYPOTHERMIA
• WOUND MANAGEMENT
• PAIN MANAGEMENT
• TETANUS

58. BSA estimation: “Rule of 9s”

59. Lund and Browder
Area Age 0 1 5 10 15 Adult
A= ½ of head 9 ½ 8 ½ 6 ½ 5 ½ 4 ½ 3 ½
B= ½ of one
thigh
2 ¾ 3 ¼ 4 4 ½ 4 ½ 4 ¾
C= ½ of one
leg
2 ½ 2 ½ 2 ¾ 3 3 ¼ 3 ½
Source Unknown

60. Lund and Browder
Artz CP, JA Moncrief: The Treatment of Burns, ed. 2. Accessed at: http://www.merckmanuals.com/professional/injuries_poisoning/burns/burns.html

61. Fluid management
• Remember that a formula is only an estimate and adjustments need to be made based on patient’s
status.
• Fluid Resuscitation Protocol
• Establish and maintain adequate circulation
↓
• Burns >20% TBS require initial fluid resuscitation
↓
• Use at least one large bore intravenous catheter. Begin Ringer’s Lactate. Estimate initial rate
according to the estimated percent of total body skin surface burned (%TBS). Estimated body
weight (4cc/kg/%TBS burn in 24 hours giving half of the estimate in 1-8 hours.)
↓
• Maintain: Blood Pressure>90 systolic, Urine output 0.5-1.0ml/kg/hr, Pulse <130Temperature
>37°C
↓
• Modify protocol in the presence of massive burns, inhalation injury, shock, and in elderly patients:-
Fluid requirements are greater to prevent burn shock- Include colloid: either Hespan or Albumin in
the patients from the beginning
↓
• Transfer to Burn Center if a Major Burn is Present or a Moderate Burn depending on Local
Resources

62. Prevention of hypothermia
• Cover patients with a dry
sheet – keep head covered
• Pre-warm trauma room
• Administer warmed IV
solutions
• Avoid application of saline-
soaked dressings
• Avoid prolonged irrigation
• Remove wet / bloody
clothing and sheets
• Paralytics – unable to shiver
and generate heat
• Avoid application of
antimicrobial creams
• Continual monitoring of
core temperature via foley
or SCG temperature probe

63. Pain management
Adequate analgesia imperative!
DOC: Morphine Sulfate
Dose: Adults: 0.1 – 0.2 mg/kg IVP
Children: 0.1 – 0.2 mg/kg/dose IVP / IO
Other pain medications commonly used:
• Demerol
• Vicodin ES
• NSAIDs

64. Burn Injury: Pain Management
• Treatment, dosing titrated to achieve effect
• IV morphine remains the gold standard
– tolerance may occur if therapy is prolonged
– discontinuation of opiates should be anticipated
and tapered as wound healing occurs
• Use opiates cautiously in infants who are not
mechanically ventilated
• Consider role of anxiolytics

65. Burn Injury: Pain Management
• PCA may be an option in older patients
• Ketamine may be useful during procedures
– profound analgesia, respiratory reflexes intact
– HTN, emergence delirium, hallucinations
• midazolam 0.1 mg/kg to reduce ketamine “edge”
• Propofol, other modalities
• Do not overlook analgesia/sedative needs of
patients receiving neuromuscular blockade

66. Assessment of burns
• Superficial burn (1st degree)
• Superficial partial-thickness (2nd degree)
• Deep partial-thickness (2nd degree)
• Full-thickness (3rd degree)

67. Burn Injury: Wound Management
• Escharotomy/fasciotomy may be necessary
within hours
– neurovascular compression; chest wall motion
• Surgery for wound closure is necessary for full
thickness injury, or areas of deep partial
thickness that would heal with delay or scar
• In life threatening burns, urgency to graft
before substantial colonization occurs

68. Burn Injury: Wound Management
• Integra
– inert material mimicking the structure of dermis
– collagen strands provide ordered matrix for
fibroblast infiltration/native collagen deposition
– allows harvesting of thin epidermal layer for graft,
with more rapid healing at donor sites
• Appropriate tetanus prophylaxis mandatory
• Consider relative risk of DVT, prophylaxis

69. Burn Injury: Topical Antibiosis
• Colonization via airborne &/or endogenous
gram+ flora within the 1st week is the rule;
subsequent colonization tends to be gram-
• Complications of topical agents
– hyponatremia, hyperosmolarity, metabolic
acidosis, methemoglobinemia
• Silvadene resistance universal for E. clocae
– S. aureus common, Pseudomonas occasional

70. Burn Injury: Infection
• Types of infections in burn patients
– burn wound invasion/sepsis, cellulitis, pneumonia,
supparative thrombophlebitis, miscellaneous
nosocomial infections
• Organisms causing burn wound invasion
– pseudomonas-45%, mycotic 19%
– other gram negatives-16%, mixed bacterial-8%
– mixed bacterial/mycotic-10%, Staph-1-3%

71. Burn Injury: Wound Sepsis
• Characterized by gray or dark appearance,
purulent discharge, systemic signs of sepsis
• If true burn wound sepsis, wound culture
should yield >105 organisms/gram of tissue
• Gram negative bacteremia/sepsis
– think wound, lungs
• Gram positive bacteremia/sepsis
– think indwelling lines, wound

72. Other considerations
• Check tetanus status – administer Td as
appropriate
• Debride and treat open blisters or blisters
located in areas that are likely to rupture
• Debridement of intact blisters is controversial

73. Calories
• Energy expenditure increases about 72 hours
postburn, peaks 5 to 7 days and can remain
elevated upto 2 years.
• Factors affecting energy expenditure post burn
– Wound Closure
– Surgical Procedures
– Nutritional support
– Physical therapy
– Sepsis
– Ambient temperature.

74. Measurement of calories
• Indirect
Calorimetry
– Gold standard
– Measures Carbon
Dioxide and
oxygen exchange
– WEIR equation
• Metabolic rate (kcal per
day) = 1.44 (3.94 VO2 +
1.11 VCO2
• Pitfalls
– Cumbersome
– Time frame dependant

75. • Mathematical equations
• Pitfalls
– Fallacious
– One equation does not fit
all

76. Protein
• 1.5 to 2 g per Kg body weight in adult burn
patients
• >2.2 g/kg does not result in higher protein
synthesis : Level of evidence 2
• Usage of Ideal body weight

77. Carbohydrate
• 55 to 60 % total energy requirement
• Maximum IV carbohydrate infusion rate is 5 to
7 mg/kg/day

78. Lipid
• Nonburned individuals require a maximum of
30% of energy from lipid.
• No evidence to support increasing lipid
consumption postburn injury

79. Nutrition therapy
Routes
Enteral Nutrition
Parenteral
Nutrition
Oral

80. Oral route
• Oral route with high protein foods and small,
frequent feedings is always preferred, if the
patient is able to consume adequate intake.
• Consider EN or PN when inadequate intake –
i.e less than 60 % of estimated energy
requiements.

81. Enteral route
• Early EN is the recommended feeding route in patients
with major burns.
• Infusion initiation as early as 4 to 6 hours postburn helps
to
– achieve a positive nitrogen balance,
– increases insulin levels to support healing,
– Reduces catecholamine levels,
– lowers levels of tumor necrosis factor and serum
endotoxins
– decrease in bacterial translocation
– reduction in mortality
• Current recommendation : the initiation of EN within 48
hours in critically ill patients, with titration to goal as
tolerated by day 7 of hospitalization.

82. • Small bowel feeding tube placement suggested for burn
patients.
– Lower pneumonia
– Lower sepsis
– Improves gastric stasis
• Reach goal EN prescription by day 5.
• Start at 40 ml/hour and increase by 20 mL every 2 hours.
• Continuous feeds better than bolus
• If oral feeding also exists – shift to nocturnal feeding
pattern
• Stop once patient is able to meet 60 % energy needs

83. • Monitoring for EN
intolerance
– Nausea/Vomiting
– Abdominal pain
– Distention
– GRV (Gastric residual
volume) : Once a standard
of care is no longer
considered to be a valid
marker.
• Should only be monitored if
other signs of intolerance
are present.
– Stop EN in
• Patients with MAP < 50 mm
Hg
– If requirement of EN is
longer than 4 week
• Long term access – e.g PEG

84. Parenteral Nutrition
• Indications
– Unable to begin EN
• Bowel perforation
• High dose vasopressor support
– Unable to reach EN goal rate by day 8
– Malnourished at admission

85. Micronutrient supplementation
• Depletion of antioxidant mechanism = Higher
requirement of vitamins and trace elements
• Many compositions used, but evidence lacking for use
except.
– Vitamin C
– Vitamin A
– Copper
– Selenium
– Zinc
– Thiamine (h/o alcohol use)
• Intravenous supplementation necessary with EN and PN
– presence of antagonistic mechanisms except
– Glutamine : Level 1

87. Other Pharmacological measures
• Propanolol
– Reduces REE and insulin resistance
– Start as early as 24 hours post burn.
• Oxandrolone
– Improves muscle protein synthesis = increases lean
mass, bone mineral content and muscle strength.
• Blood glucose
– Earlier levels 80 to 110 mg% recommended
– New guidelines : 140 to 180 mg%

92. Chemical burns
• Acids: Drain cleaners
• Alkali: Rust removers, swimming pool cleaners
• Organic compounds: Phenols and petroleum
cleaners
Source Unknown

93. Chemical burn
http://www.burnsurgery.com/Betaweb/Modules/initial/bsinitialsec8.htm

94. Chemical burns
• Denature protein within the the tissues or a
desiccation of cells.
• Alkali products cause more tissue damage than acids.
• Dry substances should be wiped off first.
• Wet substances should be irrigated with copious
amounts of water.
• All fluids used to flush should be collected and
contained not placed into the general drainage system.
• Decontaminate patient: flush with warm water
medially to laterally
• Protect yourself

95. Alkali burns go deep
http://www.burnsurgery.com/Betaweb/Modules/initial/bsinitialsec8.htm

96. Chemical burns
• The depth can be deceiving until the tissue
begins to slough off days later.
• Because of this chemical burns should always
be considered deep partial-thickness or full-
thickness burns.

97. Tar burn
http://www.burnsurgery.com/Modules/initial_mgmt/sec_6.htm

98. Chemicals burns
• Is the pain our of proportion to the skin involvement?
Consider hydrofluoric burns
– Hydrofluoric acid burns are unique in several ways
• Hydrofluoric (HF) acid, one of the strongest inorganic acids, is used
mainly for industrial purposes (eg, glass etching, metal cleaning,
electronics manufacturing). Hydrofluoric acid also may be found in
home rust removers.
• Dilute solutions deeply penetrate before dissociating, thus causing
delayed injury and symptoms. Burns to the fingers and nail beds
may leave the overlying nails intact, and pain may be severe with
little surface abnormality.
• The vast majority of cases involve only small areas of exposure,
usually on the digits.
• A unique feature of HF exposure is its ability to cause significant
systemic toxicity due to fluoride poisoning.

99. Treatment of HF burns
• Immerse burn area for 2 hours in 0.2% iced aqueous
tetracaine benzethonium chloride (Hyamine 1622) or
iced aqueous benzalkonium chloride (Zephiran).
• Apply towels soaked with Zephiran and change every 2-
4 minutes.
• Ice packs to relieve pain
• Obtain serum chemistries: hypocalcemia, hyperkalemia
• Insitiute cardiac monitoring: HF acid exposure can:
– prolong QT interval
– peak T waves
– ventricular dysrhythmias

100. HF treatment
• Calcium gluconate:
– Apply 2.5% calcium gluconate gel to burn area
– Subcutaneous infiltration: 0.5mL of 10% calcium
gluconate/cm2 of burn, extending 0.5 cm beyond
margin of involved tissue.
– IV regional: Dilute 10-15 mL of 10% calcium
gluconate in 5000 units heparin, then dilute in 40
mL dextrose 5% in water (D5W)

101. Electrical
• AC- Alternating current- household current (more
likely to induce fibrillation)
• DC- Direct current- car battery
• Path of least resistance:
– electrical current will find the easiest way to travel
through the body. Nerves tissue, muscle and blood
vessels are easier to travel through than bone or fat.
– nervous system is particularly sensitive. damage seen
in the brain, spinal cord and myelin-producing cells.

102. Electrical burns
Source Unknown

103. Airway compromise?
Respiratory distress?
Circulatory compromise?
Intubation, 100% O2
IV access, fluids
Multiple
trauma?
Yes No
Evaluate &
treat injuries
Burns >15%, or
complicated
burns?
Yes No
Burn care, tetanus prophylaxis, analgesia
IV access; fluid
replacement
Circumferential full
thickness burns?
Escharotomy
Yes
Yes
No
No