2012.10.20

Epidemiology

Pathophysiology

Mechanisms

First aids

Minor burns

Major burns

Assessment

Fluid resiscitation

Burn wounds

One of the most devastating conditions

Assault on all aspects of the patient

physical

psychological

Affects all ages

babies to elderly people

Up to 4 years - 20% of all burn injuries.

Most injuries (70%) are scalds

10% of burns happen to children between the

ages of 5 and 14

accelerants such as petrol,

electrocution

Most burns ( > 60%) ages15-64 yrs

mainly flame burns

a third due to work related incidents

10% of burns occur in aged > 65 scalds

contact burns

flame burns compromised by some other factor

acoholism

epilepsy

chronic psychiatric or medical illness

Rescue

Resuscitate

Retrieve - specialist burns unit

Resurface - simple dressings to aggressive

surgical debridement and skin grafting.

Rehabilitate

Reconstruct-scarring

Review

Local response -3 zones

Zone of coagulation

at the point of maximum damage.

irreversible tissue loss due to coagulation

proteins.

Zone of stasis

decreased tissue perfusion

potentially salvageable tissue

aim of resuscitation is to increase tissue perfusion

here and prevent any damage becoming irreversible

Zone of hyperaemia

outermost zone

tissue perfusion is increased

tissue here will invariably recover unless

severe sepsis

prolonged hypoperfusion

Three dimensional

Loss of tissue in the zone of stasis

wound deepening

widening.

Systemic response

Cytokines, other inflammatory mediators at

the site of injury has a systemic effect

once the burn reaches 30% of total body surface

area

Cardiovascular changes

Capillary permeability increased

loss of intravascular proteins and fluids into the

interstitial compartment

Peripheral and splanchnic vasoconstriction

Myocardial contractility decreases

?tumour necrosis factor

These + fluid loss = systemic hypotension +

end organ hypoperfusion.

Respiratory changes

Bronchoconstriction

in severe burns - ARDS

Metabolic changes

BMR increases up to three times

This + splanchnic hypoperfusion

necessitates early and aggressive enteral feeding

decrease catabolism

maintain gut integrity

Immunological changes

Non-specific down regulation of the immune

response

celll mediated

humoral

Thermal injuries

Scalds—About 70% of burns in children

Flame—50% of adult burns

Inhalational injury

Concomitant trauma.

Contact—In older

Electrical injuries

3-4%

Amount of heat and hence the level of tissue

damage

0.24×(voltage)2×resistance

Voltage = main determinant of the degree of

tissue damage

Domestic electricity - Low voltages Small deep contact burns

Exit and entry sites

Alternating nature can cause arrhythmias

High tension injuries =>1000 V

True high tension

Current passes through

Large amount of soft and bony tissue necrosis.

Muscle damage - rhabdomyolysis

>70 000 V is invariably fatal

Flash injury

heat from an arc cause superficial flash burns to

exposed body parts typically the face and hands.

Electric burns

Need cardiac monitoring

Normal ECG on admission + no LOC monitoring is

not required

If ECG abnormalities+ or LOC+ need 24 hours of

monitoring

Chemical injuries

Tend to be deep,

Alkalis tend to penetrate deeper, cause

worse burns than acids.

Specific chemical burns and treatments

Chromic acid,Dichromate salts—Rinse with dilute

sodium hyposulphite

Hydrofluoric acid—10% calcium gluconate L.A as a

gel or injected in to affected tissues

Initial management is the same irrespective

of the agent.

all contaminated clothing must be removed

area thoroughly irrigated.

best achieved by showering the patient. Shown to

limit the depth of the burn

Litmus test - removal of alkali or acid.

Eye injuries should be irrigated copiously and

referred to an ophthalmologist.

Stop the burning process

Cool with water

Stops burning process

Minimises oedema

Reduces pain

Cleanses wound

Cooling the burn Effective within 20 minutes of the injury.

Immersion or irrigation with running tepid water (15°C)

Iced water should not be used as intense vasoconstriction

can cause burn progression

Analgesia Opioids

NSAIDS

Covering the burn PVCfilm

Cotton sheet (preferably sterile)

Hand burns - clear plastic bag

Topical creams should be avoided at this stage

- interfere with assessment of the burn

Cleaning the burn

New burn - essentially sterile

Clean with soap and water or mild

antibacterial - dilute chlorohexidine

Blisters

Large – de-roofed, dead skin removed

Smaller blisters - left intact.

Dressings

simple gauze impregnated with paraffin

Dressing changes for burns

Use aseptic technique

First change after 48 hours, and every 3-5 days

thereafter

Criteria for early dressing change:

Excessive “strike through” of fluid from wound

Smelly wound

Contaminated or soiled dressings

Slipped dressings

Signs of infection (such as fever)

Management of facial burns

Clean the face b.d. dilute chlorohexidine solution

Cover with cream liquid paraffin on hourly basis

Men should shave daily

Sleep propped up on two pillows minimise oedema

Follow up Physiotherapy

Support and reassurance

Major burn

burn covering 25% or more of total body

surface area

any injury over more than 10% should be

treated similarly

Initial assessment of a major burn

Perform an ABCDEF primary survey

A—Airway with cervical spine control

B—Breathing

C—Circulation

D—Neurological disability

E—Exposure with environmental control

F—Fluid resuscitation

Assess burn size and depth

Establish good IV access and give fluids

Catheterise If >20% BSA

Give analgesia

Take baseline blood samples for investigation

Dress wound

Perform secondary survey, reassess, and exclude or treat

associated injuries

Arrange safe transfer to specialist burns facility

Analgesia

Superficial burns - extremely painful

Patients with large burns should receive IV

morphine

dose appropriate to body weight

titrated against pain and respiratory depression.

Investigations for major burns

General Full blood count

Packed cell volume

Urea

Electrolyte concentration

Clotting screen

Blood group + save or crossmatch serum

Electrical injuries 12 lead electrocardiography

Cardiac enzymes (for high tension injuries)

CK MB

Inhalational injuries

Chest x ray

Arterial blood gas analysis

Can be useful in any burn

base excess is predictive of the amount of fluid

resuscitation required

helpful for determining success of fluid resuscitation

essential with inhalational injuries or exposure to

carbon monoxide

Secondary survey

After primary survey and the start of

emergency management

Head to toe examination looking for any

concomitant injuries

Dressing the wound

BSA and depth have been estimated

burn wound washed,loose skin removed

Blisters should be deroofed except palmar blisters (painful), unless these are large

enough to restrict movement.

BSA

Palmar surface

The surface area of a patient’s palm

(includingfingers) is roughly 0.8%

Can be used to estimate

small burns ( < 15% of total surface area)

very large burns ( > 85%, when unburnt skin iscounted)

For medium sized burns, it is inaccurate.

Wallace rule of nines

Lund and Browder

chart

Fluid losses from the injury must be replaced

to maintain homoeostasis

No ideal resuscitation regimen

Main aim is to maintain tissue perfusion to

the zone of stasis - prevent the burn

deepening.

too little - cause hypoperfusion

too much - oedema causing tissue hypoxia

Greatest amount of fluid loss - first 24 hours

after injury

First eight to 12 hours- of fluid from the

intravascular to interstitial fluid

compartments

Colloids have no advantage over crystalloids

in maintaining circulatory volume

Fast fluid boluses have little benefit

rapid rise in intravascular hydrostatic pressure

will drive more fluid out of the circulation

much protein is lost through the burn wound,

need to replace this oncotic loss

Some regimens introduce colloid after the

first eight hours

BSA/TSA

>15% of in adults

>10% in children

Needs formal resuscitation

Pure crystalloid formula.

Fluid requirement in the first 24 hours

Children require maintenance fluid in

addition to this

Starting point for resuscitation is the time of

injury, not the time of admission

Any fluid already given should be deducted

from the calculated requirement

4 ml×(BSA (%))×(body weight(kg)) 50% given in first 8 hours

50% given in next 16 hours

Children receive maintenance fluid in addition at

hourly rate of 4 ml/kg for first 10 kg of body weight plus

2 ml/kg for second 10 kg of body weight plus

1 ml/kg for > 20 kg of body weight

End point

Urine output

0.5-1.0 ml/kg/hour in adults

1.0-1.5 ml/kg/hour in children

After 1st 24 hours

colloid infusion is begun

0.5 ml×(BSA (%))×(body weight (kg))

maintenance crystalloid (usually dextrose-

saline) is continued

1.5 ml×(BSA)×(body weight)

High tension electrical injuries require

substantially more fluid

9 ml×(BSA)×(body weight) in the first

24hours

higher urine output 1.5-2 ml/kg/hour

Inhalational injuries require more fluid.

Hartman’s solution most appropriate

Colloid of choice FFP for children

Albumin or synthetic high molecular weight starches for adults

Continuously adjusted according to UOP

Physiological parameters pulse, blood pressure, and respiratory rate

Investigations 4 – 6 H for monitoring PCV

SE

Base excess

Lactate.

The infusion rate is guided by the UOP

not by formula.

The urine output should be maintained at a rate Adult 0.5 / kg / hr

Children 1 ml / kg / hr

UOP <0.5mls/kg/hr increase IV fluids by 1/3 of current IV fluid amount

UOP >1ml/hr for adults or >2ml/kg/hr for children decrease IV fluids by 1/3 of current IV fluid amount Last hrs urine = 20mls, received 1200mls/hr, increase IV to

1600mls/hr

Last hrs urine = 100mls, received 1600mls/hr, decrease IV to 1065mls

Indications

Circumferential deep dermal or full thickness

burn

Circumferential chest burns

Only the burnt tissue is divided, not any underlying

fascia, differentiating this procedure from a

fasciotomy.

Best done with electrocautery, as they tend

to bleed.

Packed with Kaltostat alginate dressing and

dressed with the burn.

Partial thickness -do not extend through all

skin layers

Superficial

Superficial dermal

Deep dermal

Full thickness burns -extend through all skin

layers in to the subcutaneous tissues

Superficial = epidermal burn

affects the epidermis

not the dermis (eg: sunburn)

Superficial dermal

extends through the epidermis into the upper

layers of the dermis

associated with blistering

Deep dermal

burn extends through the epidermis into the

deeper layers of the dermis

not through the entire dermis.

History - clues to the expected depth:

Bleeding- test with 21 gauge needle

Brisk bleeding on superficial pricking -

superficial or superficial dermal

Delayed bleeding on a deeper prick - a deep

dermal burn

No bleeding - full thickness burn

Sensation— with a needle

Pain - a superficial or superficial dermal burn

non-painful - deep dermal injury,

insensate - full thickness

Appearance and blanching

often difficult

burns may be covered with soot or dirt

Blisters should be de-roofed to assess the base

Capillary refill - assessed by pressing with a sterile

cotton bud

red, moist wound that obviously blanches and rapidly refills

superficial

pale, dry but blanching wound that regains its colour slowly

superficial dermal

mottled cherry red colour that does not blanch (fixed capillary staining)

Deep dermal

dry, leathery or waxy, hard wound that does not blanch

full thickness

Most burns are a mixture of different depths

Epidermal burns

supportive therapy

regular analgesia

intravenous fluids for extensive injuries.

Superficial partial thickness burns

antimicrobial creams

occlusive dressings

Deep partial thickness

Excised to a viable depth

skin graft

Some will heal if the wound environment is

optimised

keeping it warm, moist, and free of infection.

newer tissue engineered dressings are designed

to encourage this by supplying exogenous

cytokines

Full thickness injuries

healing occurs from the edges

considerable contraction

excised and grafted unless they are < 1 cm in

diameter

wounds should have epithelial cover within

three weeks to minimise scarring

eschar is shaved tangentially or excised to

deep fascia

large areas of deep burn must be excised

before the burnt tissue triggers multiple

organ failure or becomes infected

ideal covering is split skin autograft

graft is perforated with a mesher to allow

expansion

Bacteria

Β haemolytic streptococci—Such as Streptococcus

pyogenes.

Staphylococci—MRSA

Gram negative bacteria—Pseudomonas aeruginosa,

Acinetobacter baumanii, Proteus species

Fungi

Candida—Most common

Filamentous fungi—Aspergillus, Fusarium, and

phycomycetes.

Viruses

Herpes simplex

Topical

Silver sulfadiazine

Cerium nitrate-silver sulfadiazine

Silver nitrate

Mafenide

systemic

depends on the predominant flora

Prophylactic use of systemic antibiotics is

controversial

Critical Cre

Nutrition

Reconstruction

Rehabilitation

Psychological support