Burn Management

Mohamed Ahmed Sayed

Assistant Lecturer of Plastic and Reconstructive Surgery
Ain Shams University – Faculty of Medicine

dr_mohamed_a@yahoo.com
http://www.geocities.com/dr_mohamed_a
• Burn wounds occur when there is contact
between tissue and an energy source, such
as heat, chemicals, electrical current, or
radiation.

• The effects of the burn are influenced by the:

intensity of the energy
duration of exposure
type of tissue injured
Where do most burns occur?
• 0 - 4 years, from kitchen, bathroom.
• 5-74 years, outdoors, kitchen.
• Teenagers, suicide (females).
• > 75 years, kitchen, outdoors.

When do most burns occur?

• Winter more than summer
Major cause of fires in the home
• Carelessness with cigarettes!!
• Hot water from water heaters set at high
levels above 60° C
• Cooking accidents
• Space heaters
• Gasoline, lighter fluids, etc.
• Chemicals
Types of Burn Injury
• Thermal burns: flame, flash, contact with hot objects.

• Scald burns: hot fluids.

• Chemical burns: necrotizing substances (acids, alkali).

• Electrical burns: intense heat from an electrical current

• Smoke & inhalation injury: inhaling hot air or noxious

chemicals
• Cold thermal injury: frostbite.
Thermal Burns
Scald Burns
Chemical Burn
examples: cleaning agents...
Remember….
• Tissue destruction may continue for up to 72 hours.
• It is important to remove the person from the burning
agent or vice versa.
• The latter is accomplished by lavaging the affected area
with copious amounts of water.
Smoke and Inhalation Injury
• Can damage the tissues of the
respiratory tract

• Although damage to the respiratory

mucosa can occur, it seldom
happens because the vocal cords
and glottis closes as a protective
mechanisms.
Electrical Burns
Electrical Burns
• Injury from electrical burns results from coagulation
necrosis that is caused by intense heat generated
from an electric current.

• The severity depends on:

amount of voltage
tissue resistance
current pathways
surface area in contact with the current
length of time the current flow.
Electrical injury can cause:
• Fractures of long bones and vertebra
• Cardiac arrest or arrhythmias--can be
delayed 24-48 hours after injury
• Severe metabolic acidosis--can develop in
minutes
• Myoglobinuria--acute renal tubular
necrosis.
Treatment of electrical burns…
• Fluids--Ringers lactate or other fluids-flushes
out kidneys--you want 75-100 cc/hr until
urine sample clear
• an osmotic diuretic (Mannitol) may be given
to maintain urine output
Cold Thermal Injury (Frostbite)
Classification of Burn Injury
Severity is determined by:
– depth of burn
– extend of burn calculated in percent of total body
surface (TBSA)
– location of burn
– patient risk factors
Depth of Burns
Medicolegal classification clinical classification

1st
Erythema

Super.

2nd Dermal

Deep
Dermal

Full
3rd
Thickness
 Extend of Burns
Lund-Browder Chart Rule of Nines

Age in years 0 1 5 10 15 Adult

A-head (back or front) 9½ 8½ 6½ 5½ 4½ 3½
B-1 thigh (back or front) 2¾ 3¼ 4 4¼ 4½ 4¾
C-1 leg (back or front) 2½ 2½ 2¾ 3 3¼ 3½
Location of Burns
• Vital organs of burn:
• Face, neck
• Chest
• Perineum
• Hand
• Joint regions
• Other areas
Patient risk factors
• Associated trauma
• Inhalation injuries
• Circumferential burns
• Electricity
• Age (young or old)
• Pre-existing disease
• Abuse
3 Phases of Burn Management

–emergent (resuscitative)
–acute
–rehabilitative
Pre-hospital Care
• Remove from area! Stop the burn!
• If thermal burn is large--FOCUS on
the ABC’s
A=airway-check for patency, soot
around nares, or signed nasal hair
B=breathing- check for adequacy of
ventilation
C=circulation-check for presence and
regularity of pulses
Other precautions...
• Burn too large--don’t immerse in water due to
extensive heat loss
• Never pack in ice
• Pt. should be wrapped in dry clean material
to decrease contamination of wound and
increase warmth
Emergent Phase (Resuscitative Phase)
• Lasts from onset to 5 or more days but
usually lasts 24-48 hours
• begins with fluid loss and edema formation
and continues until fluid motorization and
diuresis begins
• Greatest initial threat is hypovolemic
shock to a major burn patient!
 Management in the emergent phase is...

• Airway management-early nasotracheal or endotracheal

intubation before airway is actually compromised (usually 1-2
hours after burn)
• ventilator? ABGs? Escharotomies?
• 6-12 hours later: Bronchoscopy to assess lower respiratory
tact
• chest physiotherapy, suction
Complications during emergent phase
of burn injury are 3 major organ
systems...

–Cardiovascular
–Respiratory
–Renal systems
 Fluid Therapy
• 1 or 2 large bore IV lines
• Fluid replacement based on:
– size/depth of burn
– age of pt.
– individualized considerations.

• options- RL, D5NS, dextam, albumin, etc.

• there are formula’s for replacement:
– Parkland formula
– Brooke formula
Assessment of adequacy of fluid replacement
• Urine output is most commonly used
parameter
• Urine osmolarity is the most accurate
parameter

• UOP= 30-50 ml/hr in an adult

Wound care
• Escharotomy / Fasciotomy
• Escharectomy + homograft
• Dressing / hydrotherapy
• Debridement
• Application of autograft
• Splinting

• PB contractures management
Wound Care continued...
• Staff should wear disposable hats, gowns,
gloves, masks when wounds are exposed
• appropriate use of sterile vs. nonsterile
techniques
• keep room warm
• careful handwashing
• any bathing areas disinfected before and
after bathing
Other care measures include
• Face
– eye
– ear

• Hands & arms

• Perineum

• Physiotherapy
Drug Therapy
• Analgesics and Sedatives
• Tetanus immunization
• Antimicrobial agents: Silver sulfadiazine

Nutritional Therapy
• Burn patients need more calories & failure
to provide will lead to delayed wound
healing and malnutrition.
Clinical Manifestations
• Burn wound either heals by
primary intention or by grafting.
• Scars may form & contractures.
• Mature healing is reached in 6
months to 2 years
• Avoid direct sunlight for 1 year on
burn
• new skin sensitive to trauma
 Care of BURNS
B - breathing
U - urine output
R - rule of nines
resuscitation of fluid
N - nutrition
S - shock
silvadene
Referral Criteria
• 2nd or 3rd Degree Burns
• >10% TBSA
• Burns to vital organs of burn
• circumfrential burns
• Electrical Burns
• Chemical Burns
• Inhalation Injury
Referral Criteria
• Concomitant trauma (If Major Trauma, The
Trauma Center , Not the Burn Center should
be the initial stabilizing unit)
• When in doubt , consult with a burn center
Questions?