BURNS Burn patient mortality:

 CO poisoning- Tx: 100% O2 inhalation

INITIAL EVALUATION  Cyanide poisoning
4 crucial assessment: -Tx: Sodium Thiosulfate
 Airway management Hydroxocobalamin (immediate therapy)
 Evaluation of other injuries 100% O2 inhalation
 Estimation of burn size
 Diagnosis of CO and cyanide poisoning CLASSIFICATION OF BURNS
Flame Burns
*Direct thermal injury to the upper airway or smoke - most common
inhalation --> rapid and severe airway edema - higher mortality
Tx: intubation and establishing an early airway - inhalation injury and/or CO poisoning
Electrical Burns
*Signs of impending respiratory compromise -Cardiac arrhythmias
-hoarse voice Compartment syndromes
-wheezing / stridor Concurrent rhabdomyolysis
- dyspnea -ECG
Tx: elective endotracheal intubation -low-voltage injury with normal ECG pt may not be
admitted
Primary survey -high-voltage injury- for admission due to
-Burned patients should be first considered as trauma compartment syndrome and rhabdomyolysis
patients -long term neurologic and visual symptoms
-Large-bore peripheral IV catheters should be placed and Chemical Burns
fluid resuscitation should be initiated -less common but pontentially severe burns
-2 large-bore IV are ideal for burn >40% TBSA -initial therapy:
-Central venous access provide useful info as to volume -careful removal of the toxic substance
status -irrigation of the affected area with water
-IV resuscitation is rarely indicated in patients with burns (30 mins) except for powder/ powder
<15% who can usually hydrate orally forms of lye to avoid activating
-Pediatric: burns >15% may require intraosseous access aluminium hydroxide with water
Secondary survey -FORMIC ACID
-Performed on all burn patients; evaluation of other - causes hemolysis and hemoglobinuria
injuries -HYDROFLOURIC ACID
-Urgent radiology studies -hypocalcemia
HYPOTHERMIA- common prehospitall complication that -tx: Calcium-based therapy:
contributes to resuscitation failure Topical Calcium Gluconate
Tx: wrapped with clean blankets; cooling blankets is - wounds
contraindicated with patients with moderate or large IV Calcium Gluconate
burns (>20% TBSA) - systemic symptoms
-effective tx for progressive tissue
Acute burn injury injury and intense pain
-should never receive prophylactic antibiotics -needs continuous cardiac monito
-Tetanus booster should be administered in the ER -persistent refractory hypocalcemia with
-pain management and anxiolytics (Benzodiazepines) electrocardiac abnormalities
tx: emergent excision of burned area
RULE OF NINES
-quick and effective estimate of burn size as a percentage
of TBSA in order to estimate fluid requirement
Anterior trunk – 18%
Posterior trunk – 18%
Lower ext – 18% each
Upper ext – 9% each
Head – 9%
Pubis – 1%
BURN DEPTH CLASSIFICATION
-by Dupuytren (1832)
First-degree (superficial)
-painful and do not blister
Second -degree (Partial-thickness)
-Superficial (depth of involved dermis)
-Deep
-dermal involvement
-weeping and blisters, extremely painful
Third-degree (Full-thickness)
-leathery, painless, non-blanching
Fourth-degree (affect underlying soft tissue)
3 Zones of Tissue Injury
 Zone of Coagulation
-most severely burned portion
-center of the wound
-coagulated, necrotic, 3rd – 4th degree burn
-need excision and grafting
 Zone of Stasis
-peripheral
-vasoconstrictionischemia
- 2nd-degree burn
Superficial – heal with expectant mgt
Deep – require excision and grafting
 Zone of Hyperemia
- Heal with minimal or no scarring and is most
like a superficial or first-degree burn
Note:
*Burn wound evolve over 48-72 hours after injury
*Full-thickness biopsy
- effective ways to determine burn depth
-limitation: painful, potentially scarring
*Laser Doppler
-measure skin perfusion to predict burn depth
with a positive predictive value of upto 80%
*Non-contact Ultrasound
-painless modality to predict non-healing wound
PROGNOSIS
BAUX SCORE
Formula: Mortality risk = Age + %TBSA
RESUSCITATION
PARKLAND OR BAXTER FORMULA
- 3-4 mL / kg / % burn of Lactated Ringer’s
solution
-half is given during first 8 hours after burn
- other half is given over the subsequent
16 hours
*Children <20 kg
- weight-based maintenance IV fluid with glucose
supplementation + resuscitation fluid with LR
*BP and urine output – gauge burn resuscitation
MAP 60mmHg- ensues end –organ perfusion
Urine output goal – 30 mL/hour (adults)
1-1.5 mL/kg/hour (pedia)
*Serum Lactate
-better predictor of mortality in severe burns
Base Deficit
-predicts organ dysfunction and mortality
*Hypertonic Solutions
-transiently decrease initial resuscitation volumes
-downside: causing hyperchloremic acidosis
*High-dose ascorbic acid (Vit. C)
- decrease fluid vol requirements and ameliorate
respiratory embarrassment during resuscitation
*Plasmapheresis
-decrease fluid requirements in patients who
require higher volumes than predicted to maintain
adequate urine output and MAP
-filter out inflammatory mediators decreases
vasodilation and capillary leak
*Ultrasound
– make rapid, non-invasive assessments during
acute changes in clinical condition
TRANSFUSION
*Blood transfusions are considered to be
immunosuppressive decrease infection and shorter time
to recurrence after oncologic surgery
*Increases number of transfusions were assoc. with
increased infections and higher mortality in burn patients
INHALATION INJURY
-commonly seen in tandem with burn injury increase
mortality
- decreases lung compliance and increase airway
resistance work of breathing, increase metabolic demands
Decreases PaO2 : FiO2 ratio (<200)
- inhalation injury, increased fluid needs
-Burn + Inhalation Injury + Pneumonia = 60% mortality
-Burn + Inhalation Injury + ARDS = 66% mortality
- >60% TBSA + Inhalation Injury + ARDS = 100% mortality
-Smoke inhalation causes injury in 2 ways:
 Direct heat injury to upper airways swelling 
maximal edema in first 24-48 hours
Tx: short course endotracheal intubation
 Inhalation of combustion products into the lower
airwayscause mucosal sloughing, edema,
reactive bronchoconstriction, and finally
obstruction of the lower airways
-treatment:
 Aggressive Pulmonary Toilet
 Routine use of nebulized bronchodilators
(Albuterol)
 Nebulized N-acetylcysteine
-antioxidant free radical scavenger
decrease s the toxicity of high O2 conc.
 Aerosolized Heparin
-prevent formation of fibrin plugs and
decrease formation of airway casts
 Intrabronchial surfactant
-salvage therapy in patients with severe
burns and inhalation injury
 Inhaled Nitric Oxide
-useful as last effort in burn pts with
severe lung injury who are failing other
means of vent. support
TREATMENT OF BURN WOUNDS
SILVER SULFADIAZINE
-one of the most widely used in clinical practice
-wide range of antimicrobial activity
-prophylaxis against burn wound infections rather
treatment of existing infections
-inexpensive, easily applied, soothing qualities
-destroys skin grafts
-contraindicated on burns or donor sites in
proximity to newly grafted areas
-retard epithelial margination in healing partial-
thickness wounds
-SE: Neutropenia
MAFENIDE ACETATE
-cream or solution, effective topical antimicrobial
-effective even in the presence of eschar and can
be used in both trating and preventing wound
infections
-solution: antimicrobial for fresh skin grafts
- absorbed systematically
-SE: pain to partial-thickness burns, metabolic
acidosis from carbonic anyhydrase inhibition
SILVER NITRATE
-broad spectrum antimicrobial activity as a topical
solution
-solution must be diluted (0.5%) and prolonged
topical application leads to electrolyte
extravasation with resulting hyponatremia
-rare complication: Methemoglobinemia
-inexpensive, causes black stains
DAKIN’S SOLUTION (0.5% sodium hypochlorite sol.)
-used as inexpensive topical antimicrobial
BACITRACIN, NEOMYCIN, POLYMIXIN B
-topical ointments for smaller burns or larger
burns that are nearly healed
-useful for superficial partial-thickness facial burns
as they can be applied and left open to air without
dressing coverage
-used with greasy gauze to meshed skin grafts
-AE: Nephrotoxic
MUPIROCIN
-for methicillin-resistant Staphylococcus aureus
(MRSA)
ACTICOAT, AQUACEL Ag, MEPILEX Ag
-silver-impregnated dressings
-increasingly being used for donor sites, skin
grafts, partial-thickness burns
-more comfortable,reduce number of dressing
changes and shorten hosp. length of stay
BIOBRANE
-biologic membrane
-provide a prolonged barrier under which wounds
may heal
-typically used only on fresh superficial partial-
thickness burns that are clearly not contaminated
due to its occlusive nature
NUTRITION
 Hypermetabolic response in burn injury may raise
baseline metabolic rate as much as 200%, w/c leads
to catabolism of muscle proteins and decreased lean
body mass that delay recovery.
 Early enteral feeding for patients with burns larger
than 20% TBSA is not only safe , but may help prevent
loss lean body mass
 If enteral feeds are started w/in few hours after
admission, gastric ileus can often be avoided
 Metoclopramide can promote GI motility, advancing
the tube into small bowel with nasojejunal feeding
can be attempted.
 Immune modulating supplements such as glutamine
may decrease infectious complications and mortality
in burn px via prevent’n of T-cell suppression
 Formula for calculating caloric needs:
Harris-Benedict equation
Curreri formula
 Harris-benedict= calculate caloric needs using factors
such as geder, age, height and weight.
It uses activity factor for specific injuries
and for burns basal energy expenditure is
multiplied by 2
Inacurate in burns of less than 40%
 Curreri formula- this formula estimates caloric
needs =25kcal/kg per day+40kcal/% TBSA per day
 Titrating caloric needs closely is important because
overfeeding patients will lead to storage of fat instead
of muscle anabolism
 Beta blocker use in pediatric patients decreases HR
and resting energy expenditure and abrogates CHON
metabolism
 Anabolic steroid oxandrolone has demonstrated
improvements in lean body mass and bone density in
severely burnd patients
 Insulin itself may have a metabolic benefit with
improvements of lean body mass
 Oral hypoglycemic agents such as metformin also help
to avoid hyperglycemia and may contribute to
prevention of muscle catabolism
COMPLICATIONS IN BURN CARE
 Ventilator-associated pneumonia, as with all critically
ill patients, is a significant problem in burn patients
 Simple measures such as elevating the head of the
bed and maintaining excellent oral hygeine and
pulmonary toilet are recommended to help decrease
the risk of pneumonia
 Deep vein Thrombosis has been commonly believed
to be a rare phenomenon in burn px.
 Heparin is given for prophylaxis in this population
 Unfortunately the use of both prophylaxis and
therapeutic heparin may be associated with heparin
induced thrombocytopenia
 Thrombotic complications onclude DVT, pulmonary
embolus, and even arterial thrombosis requiring limb
amputation
 Burn px often req. Central venous access for fluid
resuscitation and hemodynamic monitoring.
SURGERY
 Full thickness burns with a rigis eschar can form a
tourniquet effect as the edema progresses, leading to
compromised venous outflowand and arterial inflow.
 Compartment syndrome- common in circumferential
extremity burns
 Abdominal and thoracic compartment syndrome may
also occur
 Warning signs of compartment syndrome include:
Paresthesias
Pain
Decreased capillary refill
Loss of distal pulses
 Abdominal compartment syndrome should be
suspectedwith decrease urine output, increased
ventilator airway pressures and hypotension
 Thoracic compartment syndrome- hypoventilation,
increased airway pressure amd hypotension
 Escharotomies are rarely needed within the first 8hrs
following injury and should not be performed unless
indicated bec. Of terrible aesthetic sequelae
 Extremity incisions are made on the lateral and medial
aspects of the limns and extend onto the thenar an
hypothenar eminences of the hand.
 Early excision and grafting in burned patient did not
only improve mortality but also decreased
reconstruction surgery, improved hospital length stay
and reduce cost of care
 Excision is performed with repeated tangential slice
using a Watson or Goulian blade until only nonburned
tissue remains
 Excision to fat or fascia may be necessary in deeper
burns
 The disadvan. of tangential excision is a high blood
loss, though this may be ameliorated with
epinephrine clysis soln. Underneath the burn
 Fibrinogen and thrombin spray sealant also has
beneficial effects on both hemostasis and raft
adherence to wound bed.
 Electrocautery is used to excise the burned tissue and
underlying SC tissue down to muscle fascia
 For excision of burns of burns in difficult anatomic
areas such as the face, eyelids or hands, a pressurized
water dissector may offer more precision but is time
consuming
  Tight fitting pressure garments provide vascular
supportin burns
WOUND COVERAGE  Psychological rehabilitation is equally important in the
 Split thickness sheet autografts harvested with a burn px.
power dermatome make the most durable wound
coverings. PREVENTION
 In larger wounds, meshing of autografted skin  Installation of smoke alarms
provides a larger area of wound coverage.  Regulation of hot water heater temperature
 Areas of cosmetic importance such as the face, neck  Community based programs emphasizing education
and hands should be grafted with nonmeshed sheet and home inspection
grafts to ensure optimal appearance
 Integra- a bilayer product with porous collagen-
chondroitin 6-sulphate inner layer that is
attached to an outer sheet of silastic By:
-The silastic barrier helps prevent fluid loss and Dahren Gloria
infectionthe inner layer becomes vascularized, Monica Claudine Reas
creating artificial neodermis
-approximately 2wks the silastic layer is removed
and a thin autograft placed over the neodermis.
-Fatser healing of the donor site, less
hypertrophic scarring and improved joint fxn.
 Epidermal skin substitute such as cultured epithelial
autografts are an option in patients with massive
burns and very limited donor site
 Thighs make convenient anatomic donor sites, w/c
are easily harvested and hidden from aesthetic
standpoint
 Thicker skin of the back is useful in older px, who have
thinner skin elsewhere
 Buttocks are excellent donor site in infants and
toddlers
 Scalp is an excellent donor site since it is thick and
consist of many hair follicles thus heals quickly
 Epinephrine clysis is necessary for harvesting the
scalp, for both hemostasis of this hypervascular area
and also to create a smooth surface area

REHABILITATION
 Rehabilitation of burn px is integral part of clinical care
 Physical and occupational therapy is mandatory to
prevent loss of physical fxn.
 Px w/ mechanical ventilation should have passive
range of motion done at least twice a day
 Px should be taught exercise they can do themselves
to maintain full range of motion
 Px with foot and extremity bur shoud be instructed to
walk independently w/o the help of crutches to
prevent extremity swelling, desensitize burned areas
and prevent disuse atrophy.
 If postoperative immobilization is used for graft
protection, the graft should be evaluated early and at
frequent intervals so that the active exercise can be
resumed at the earliest possible occasion