BURN INJURIES

Akbar Fauzi (08310017)

Wounds caused by exposure to:
1. excessive heat
2. Chemicals
3. fire/steam
4. radiation
5. electricity

Results in 10-20 thousand deaths annually
Survival best at ages 15-45
Survival best burns cover less than 20% of
TBA

TYPES OF BURNS
Thermal
Exposure to flame or a hot object
Chemical
Exposure to acid, alkali or organic substances
Electrical
Result from the conversion of electrical energy into heat.
Extent of injury depends on the type of current, the
pathway of flow, local tissue resistance, and duration of
contact
Radiation
Result from radiant energy being transferred to the body
resulting in production of cellular toxins

CHEMICAL BURN

ELECTRICAL BURN

BURN WOUND ASSESSMENT
Classified according to depth of injury and
extent of body surface area involved
Burn wounds differentiated depending on the
level of dermis and subcutaneous tissue
involved
1. superficial (first-degree)
2. deep (second-degree)
3. full thickness (third and fourth degree)
CLASSIFICATION OF BURN DEPTH


SUPERFICIAL BURNS
(FIRST DEGREE)
Epidermal tissue only affected
Erythema, blanching on pressure, mild
swelling
no vesicles or blister initially
Not serious unless large areas involved
sunburn


DEEP (SECOND DEGREE)
Involves the epidermis and deep layer of the
dermis
Fluid-filled vesicles red, shiny, wet, severe
pain
Hospitalization required if over 25% of body
surface involved
tar burn, flame



FULL THICKNESS (THIRD/FOURTH DEGREE)
Destruction of all skin layers
Requires immediate hospitalization
Dry, waxy white, leathery, or hard skin, no
pain
Exposure to flames, electricity or
chemicals can cause 3
rd
degree burns



CALCULATION OF BURNED BODY SURFACE
AREA

RULES OF NINES
Head & Neck = 9%
Each upper extremity (Arms) = 18%
Each lower extremity (Legs) = 36%
Anterior trunk= 18%
Posterior trunk = 18%
Genitalia (perineum) = 1%

PERCENTAGE TOTAL BODY
SURFACE AREA (TBSA)
TREATMENT
General information
All burn patients should initially be treated with
the principles of Advanced Burn and/or Trauma
Life Support
The ABC's (airway, breathing, circulation) of trauma
take precedent over caring for the burn

AIRWAY
Extensive burns may lead to massive edema
Obstruction may result from upper airway
swelling
Risk of upper airway obstruction increases
with
Massive burns
All patients with deep burns >35-40% TBSA should be
endotracheally intubated
Burns to the head
Burns inside the mouth

Intubate early if massive burn or signs of
obstruction
Intubate if patients require prolonged transport and
any concern with potential for obstruction
If any concerns about the airway, it is safer to intubate
earlier than when the patient is decompensating
Signs of airway obstruction
Hoarseness or change in voice
Use of accessory respiratory muscles
High anxiety
Tracheostomies not needed during resuscitation
period
Nb Remember: Intubation can lead to
complications, so do not intubate if not needed

BREATHING
Hypoxia
Fire consumes oxygen so people may suffer
from hypoxia as a result of flame injuries
Carbon monoxide (CO)
By product of incomplete combustion
Binds hemoglobin with 200 times the affinity of
oxygen
Leads to inadequate oxygenation

Diagnosis of CO poisoning
Nondiagnostic
PaO
2
(partial pressure of O
2
dissolved in serum)
Oximeter (difference in oxy- and deoxyhemoglobin)
Patient color ("cherry red" with poisoning)
Diagnostic
Carboxyhemoglobin levels
<10% is normal
>40% is severe intoxication
Treatment
Remove source
100% oxygen until CO levels are <10%

CIRCULATION
Obtain IV access anywhere possible
Unburned areas preferred
Burned areas acceptable
Central access more reliable if proficient
Cut-downs are last resort
Resuscitation in burn shock (first 24 hours)
Massive capillary leak occurs after major burns
Fluids shift from intravascular space to interstitial space
Fluid requirements increase with greater severity of burn
(larger % TBSA, increase depth, inhalation injury,
associate injuries - see above)

IV fluid rate dependent on physiologic response
Place Foley catheter to monitor urine output
Goal for adults: urine output of 0.5 ml/kg/hour (or ~30-
50 ml/hour)
Goal for children: urine output of 1 ml/kg/hour
If urine output below these levels, increase fluid rate
Preferred fluid: Lactated Ringer's Solution
Isotonic
Cheap
Easily stored

RESUSCITATION FORMULAS ARE JUST A
GUIDE FOR INITIATING RESUSCITATION

Resuscitation formulas:Parkland formula most
commonly used
IV fluid - Lactated Ringer's Solution
Fluid calculation
4 x weight in kg x %TBSA burn
Give 1/2 of that volume in the first 8 hours
Give other 1/2 in next 16 hours
NB : Despite the formula suggesting cutting the fluid
rate in half at 8 hours, the fluid rate should be
gradually reduced throughout the resuscitation to
maintain the targeted urine output, do not follow the
second part of the formula that says to reduce the
rate at 8 hours, adjust the rate based on the urine
output
Resuscitation endpoint: maintenance rate
When maintenance rate is reached
(approximately 24 hours), change fluids to
D50.5NS with 20 mEq KCl at maintenance level
Maintenance fluid rate = basal requirements
+ evaporative losses
Basal fluid rate
Adult basal fluid rate = 1500 x body surface area (BSA)
(for 24 hrs)
Pediatric basal fluid rate (<20kg) = 2000 x BSA (for 24
hrs)
May use
100 ml/kg for 1st 10 kg
50 ml/kg for 2nd 10 kg
20 ml/kg for remaining kg for 24 hrs

Evaporative fluid loss
Adult: (25 + % TBSA burn) x (BSA) = ml/hr
Pediatric (<20kg): (35 + % TBSA burn) x (BSA) =
ml/hr

COMPLICATIONS OF OVER-RESUSCITATION
Compartment syndromesBest dealt with
at Verified Burn Centers
If unable to obtain assistance, compartment
syndromes may require management
Limb compartments
Symptoms of severe pain (worse with movement),
numbness, cool extremity, tight feeling compartments
Distal pulses may remain palpable despite ongoing
compartment syndrome (pulse is lost when pressure >
systolic pressure)

Compartment pressure >30 mmHg may
compromise muscle/nerves
Measure compartment pressures with arterial line
monitor (place needle into compartment)
Escharotomies may save limbs (high index of
suspicion in completely circumferential burns)
Performed laterally and medially splitting eschar
along entire limb
Performed with arms supinated
Hemostasis is required
Fasciotomies may be needed if pressure does not
drop to <30 mmHg
Requires surgical expertise
Hemostasis is required


Chest Compartment Syndrome
Increased peak inspiratory pressure (PIP) due
to circumferential trunk burns
Escharotomies through mid-axillary line,
horizontally across chest/abdominal junction
Abdominal Compartment Syndrome
Pressure in peritoneal cavity > 30 mmHg
Measure through Foley catheter
Signs: increased PIP, decreased urine output
despite massive fluids, hemodynamic
instability, tight abdomen



Treatment - decompression via:
Abdominal escharotomy (only if abdominal surface
is circumferentially burned)
NG tube
Possible placement of peritoneal catheter to drain
fluid
Laparotomy as last resort
Acute Respiratory Distress Syndrome
(ARDS)
Increased risk and severity if over-
resuscitation
Treatment supportive

THANKS