2. Chapter Statement
The most significant difference between
burn and other injuries is that the
consequences of burn injury are directly
linked to the extent of the inflammatory
response to the injury.
3. Objectives
• Explain the pathophysiology of burn injury.
• Identify the unique problems that can be encountered in the initial
assessment.
• Describe how to manage the unique problems.
4. Primary Survey & Resuscitation of Victim with
Burn
• Stop burning process
• Completely remove victim clothing
• Establish airway control
• Ensure adequate ventilation
• Manage circulation with burn shock
resuscitation
5. Primary Survey & Resuscitation of Victim with
Burn
Airway
• Risk of obstruction?
• Signs?
• Early intubation (American Burn Life Support – ABLS)
• What are the indications?
Airway obstruction with burn injury may not
be present immediately
6. Primary Survey & Resuscitation of Victim with
Burn
Breathing
• Direct thermal injury to the lower airway is very rare.
• Exposure to superheated steam or ignition of inhaled flammable
gases.
• What are the breathing concern?
• Hypoxia
• Carbon monoxide poisoning
• Smoke inhalation injury
7. Primary Survey & Resuscitation of Victim with
Burn
Hypoxia
• Causes?
• Management:
• Supplemental O2 with or
without intubation
8. Primary Survey & Resuscitation of Victim with
Burn
CO poisoning:
• High suspicion in victim with burned in enclosed areas
• Direct measurement of carboxyhemoglobin (HbCO)
• Pitfall:
• Spo2 monitor not reliable in CO poisoning
• Cherry red skin / Stridor may be late presentation
• Management
• Consider for intubation if needed
9. Primary Survey & Resuscitation of Victim with
Burn
Smoke inhalation injury
• Risks:
• Enclosed area
• Prolonged exposure
• Diagnosis: (According to American Burn Association)
• Exposure to the combustible agent
• Exposure of smoke to lower airway below vocal cords (seen in
bronchoscopy)
10. Primary Survey & Resuscitation of Victim with
Burn
Circulation
• Fluid deficit secondary to ongoing losses from capillary leak due to
inflammation.
• Management:
• Secure the IV line in burn
• Consider central venous access or intraosseous infusion in
difficult IV line
Tachycardia is a poor marker for resuscitation in burn
patient.
11. Primary Survey & Resuscitation of Victim with
Burn
Fluid management in burn
• Goal: To maintain perfusion of the tissue and avoid over-fluid
resuscitation
Which fluid?
How much fluid?
Its less or over or enough?
14. Assessment
Caveats
• Do not include superficial burns in size estimation.
• For irregular or oddly sized burns, use patient’s palm and fingers to
represent 1% BSA.
• Log roll patient to assess their posterior aspect
16. Wound Care
• Gently cover the wound
• Do not break blister or apply antiseptic agent
• Do not apply cold water to a patient with extensive burn (i.e,>10%
TBSA)
• A fresh burn is a clean area that must be protected from
contamination
• Early diagnosis of compartment and immediate fasciotomy
• Consider for adequate pain relief, antibiotic and tetanus prophylaxis
17. Chemical Burn
• Dry Powder :
• Brush it away
• Flush with large
amount warm water
(20-30- min)
21. Management
Do :
• Remove damp clothing
• Cover with warm blanket
• Drink hot fluids
• Place injured part at 40oC
circulating water
• Give adequate analgesics
Don’t :
• Attempt rewarming if
there is risk of refreezing
• Rub and massage
Warming of large area can result in
reperfusion syndrome, with acidosis,
hyperkalemia, and local swelling.
Therefore, monitor the cardiac status
and peripheral perfusion during
rewarming.
22. Criteria for Transfer to Burn Center
• Partial thickness burns or greater than 10% TBSA
• Third degree burn
• Electrical burns / Lightening injury
• Chemical burns
• Inhalation injury
• Burn injury with preexisting medical disorder
• Any burns and concomitant trauma
23. Case Scenario
23 years old sustained second
degree almost 80% of burn while
working in the factory.
What will you do first?
24. Summary
• Burn injuries are unique; inflammation and edema may not be
immediately evident.
• Immediate lifesaving measures includes
• stopping burn process
• recognizing inhalation injury and assuring an adequate airway,
oxygenation and ventilation
• rapidly instituting IV fluid therapy
• Fluid resuscitation is needed to maintain perfusion and management
of fluid should be judicious.
Picture: Airway can be compromised due to odematous larynx resulting from inhalation injury
Risks:
Direct injury (eg inhalation injury)
Facial edema
Burn in mouth
Signs: Stridor, hoarseness, accessory muscle use
Indications of intubation?
Sign of airway obstruction
Extend of the burn (TBSA burn >40%-50%)
Extensive and deep facial burns
Burn inside he mouth
Significant edema or risk for edema
Difficulty swallowing
Signs of respiratory compromise
Decrease GCS with airway protective reflexes are impaired
Causes of hypoxia:
Inhalation injury
Poor compliance due to circumferential chest burns
Thoracic trauma unrelated to the thermal injury
Emphasize that fluid deficit is not due to ongoing blood loss
Which fluid? All adult or children > 30kg- warmed isotonic lactated ringer’s solution, Children <30 KG- D5LR
How much fluid? First half - 8 hours (time of burn) and another half in subsequent 16 hours
Emphasize that fluid management will be titrated to urine output. This is just a guide for initial fluid resuscitation.
Emphasize that traditional parkland (4ml/kg) – avoid due to concern of over-resuscitation and associated mortality.
Depth of burn
Superficial
Superficial partial thickness
Deep partial thickness
Full thickness
Picture A: Superficial partial
Picture B: Deep partial
Picture C & D: Deep
Urine output:
Adults: 100mL/hr
Children <30kg: 1-1.5mL/kg
Emphasize that we will only talk about frostbite in our presentation
1st : hyperemia, edema
2nd : Vesicle formation, hyperemia, edema, partial thickness necrosis
3rd : full thickness and subcutaneos tissue necrosis, hemorhagic vesicle
4th : full thickness skin necrosis (include muscle and bones
Managemnt:
Airway
Breathing
Circulation- fluid
Exposure and wound care
