THE BURN MANUAL

Montarde, MaybelleOmana, JamesPantig, Francesca MaePastoral, Avigail Martha

Diagnosis and Management of Acute BurnsINITIAL/RESUSCITATIVE PERIOD Assessment of burn

injury Classification of burn

injury Criteria for admission Initial ER

management Fluid resuscitation Monitoring

DEFINITIVE MANAGEMENT PERIOD Excision and grafting Control of infection Nutrition Rehabilitation Complication

Initial Resuscitative Period

Assessment of a burn injury

1. Complete history2. Classify as to type of burn▪ Scald burn: caused by hot liquids ( hot water,

soups, sauces)which are thicker in consistency, remain in contact with the skin for a loner period of time▪ Flame burn: house fires, improper use of

flammable liquids, kerosene lamps, careless smoking, vehicular accidents, clothing ignited from stove

▪ Flash burn: explosions of natural gas propane, gasoline and other flammable liquids causing intense heat for a very brief period of time.▪ Contact burn: results from hot meals, plastic, glass or

hot coals; usually limited in extent but very deep• Chemical burn: caused by strong alkali or acids; these

cause progressive damage until chemical is deactivated with reaction with tissue or reaction with water– Acid burns: more self limiting than alkali burns; acid tend to tan

the skin creating an impermeable barrier which limits further penetration of the acid

– Alkali burns: combine with cutaneous lipids to create soap and thereby continue to dissolve the skin until they are neutralized

• Electrical burns: injury from electrical current classified as high voltage or low voltage

3. Estimate the burn size• Expressed as %BSA• Count only areas with partial (2nd degree) or full

thickness ( 3rd degree) burns• Accurately done using the Lund and Browder charts• The Rule of Nines obtains a rough estimate of the

areas involved but not accurate in children due to the large surface are of the child’s head and the relatively smaller are of lower extremities.

• In electrical injuries, the %BSA does not correspond to the extent of injuries of the underlying soft tissues.

4. Assess the burn depth▪ Important in estimating burn size and fluid

requirement in determining the need for surgery and in evaluating the progress of the patient▪ First Degree Burns▪ are red and painful with no blisters▪ Ex: sunburn

▪ Partial Thickness Burns– Second degree burns– Extends to the dermis but not through the full thickness of the

skin–Heals from epithelialization from the epidermal elements

surviving– (+) blanching when pressed

i. Superficial partial thickness burns: with blisters; underlying skin is moist, pinkish, painful; will heal in 2-3 weeks

ii. Deep partial thickness burn: white to pale pink; moist to dry to waxy, slightly anesthetic, will heal in 3-5 weeks resulting in hypertrophic scarring and potential contracture

iii. Both types of partial thickness burns can convert to full thickness burns, signifying worsening of the patient’s condition

▪ Full Thickness Burns▪ Defined as burns extending through the full depth of

the skin▪ May appear white, brown or gray with a waxy,

leathery feel, skin is anesthetic▪ Presence of visible thrombosed veins is

pathognomonic▪ Heals by granulation and will requires future skin

coverage for wound coverage

5. Check for other injuries/medical problems▪ Play a role in the origin of burn and will have

to be integrated in the management of burn

Classification of Burn InjuryMINOR MODERATE MAJOR

CHILDREN partial thickness burn <10% BSA 10-20% BSA >20%BSAFull thickness burn <2% BSA 2-10%BSA >10%BSAADULTS partial thickness burn <15%BSA 15-25%BSA >25%BSAFull thickness burn <2%BSA 2-10%BSA >10%BSAAGE Patients

<2years with minor injury

Patients <10years with major injury

INVOLVEMENT OF HANDS, FACE, FEET and PERINEUM

(-) (-) Moderate injury involvement

ELECTRICAL INJURY (-) (-) (+)CHEMICAL INJURY (-) (-) (+)Inhalational Injury Not suspected Not suspected (+)Major Associated medical Illness (-) (-) (+)Associated fractures, multiple trauma (-) (-) (+)

Criteria for Admission to the Burn Unit Acute burn patients with moderate & major injuries Acute burn patients < 2 years old regardless of %

TBSA Acute burn patients with injuries to the hands, face,

feet and perineum Acute electrical burn patients Acute chemical burn patients Acute burn patients with smoke inhalation injury,

other associated medical illness, or multiple trauma Patients with massive exfoliative disease, such as:

Toxic Epidermal Necrosis (TENS) Steven Johnson Syndrome (SJS) Staphylococcal Scalded Skin Syndrome (SSSS)

Initial Labs CBC Blood typing RBS, BUN, Crea, Na, K, Cl ABG (if inhalational injury is suspected)

Other labs: Chest X-ray ECG (for electrical burns) Urinalysis (for electrical burns, urine Hgb &

pH also included)

Initial ER Management: MINOR Burns Cool wound with tap water Administer tetanus prophylaxis Clean wound with soap & water, or with

betadine scrub Debride dead tissue

Small blister -> leave for 2-3 days Big blister -> aspirate

Initial ER Management: MINOR Burns Apply bland ointment (i.e., Bacitracin,

Trimycin, Vaselin) & non-stick porous gauze & wrap with gauze

No systemic prophylactic antibiotics are given

Oral/IM analgesics during wound cleaning Send patients home with oral analgesics

and instructions to clean the wound OD to BID

Initial Management: MAJOR & CRITICAL Burns Wear sterile gloves Remove all burnt clothing Check & secure airway. Suspect inhalational

injury if with: Burn to face Sooty phlegm Singed nostril hairs Hoarseness or stridor History of burn in enclosed space or unconscious

at scene Circumferential chest burn

Initial Management: MAJOR & CRITICAL Burns Intubate if:

With burns 50% BSA With suspected inhalational injury With smoke inhalation

Do complete PE, check for other injuries Insert IV line for fluid resuscitation Insert foley catheter Insert NGT. Start IV H2-blockers.

Initial Management: MAJOR & CRITICAL Burns Weigh patient and record. If not possible,

estimate: For children: Wt (kg) = [2 x (age in years)] + 5 For adults: Wt (kg) = 0.9 x [ht in cms – 100]

Administer ATS, TeAna Check pulses, assess adequacy of chest

expansion Absent pulses or limited chest excursion is a

surgical emergency & an indication for escharotomy

Initial Management: MAJOR & CRITICAL BurnsEscharotomy Extremities

Prep with betadine soap Cut through the entire depth of skin along the

medial & lateral aspects of involved extremity. Avoid injuring the ulnar nerve and the perineal nerve. Facilitate separation of skin by inserting your finger and bluntly dissecting through the cut skin.

Chest Cut along both anterior axillary lines and along

the coastal margin producing a W-shaped incision

Initial Management: MAJOR & CRITICAL Burns Refer all pediatric patients to Pedia for co-

management. Patients with other medical problems should also be referred accordingly.

No prophylactic antibiotics are given, unless there are concomitant medical conditions.

Fluid Resuscitation

Most common cause of mortality in the first 48 hours is inadequate fluid resuscitation

Start as early as possible in the ER and even before other diagnostic exams

Fluid Resuscitation:PARKLAND FORMULADay 1 Adults:

Plain LR 4mL/kg BW per % BSA burned to be given:▪ ½ during the first 8 hours▪ ½ during the next 16 hours

Children:D5 LR 3mL/kg BW per % BSA burned to be given:▪ ½ during the 1st 8 hours▪ ½ during the next 16 hours▪ + maintenance

In the presence of increased capillary permeability, colloid content of resuscitation fluid exerts little influence on intravascular retention during the initial hours postburn

Hence, crystalloid fluids are given

Fluid Resuscitation:PARKLAND FORMULA

Day 2 Adults / children:

D5W (adults), half normal saline (children) and colloid sufficient to maintain good urine output

Fluid Resuscitation

Colloid may be given in the form of plasma albumin or cryoprecipitate Most protocols start colloid infusion after

the first 24 hours (capillary permeability thought to be restored by then)

For massive burns, colloid infusion can be started as early as 12 hours post-burn (to decrease total fluid requirements and lessen edema)

Fluid Resuscitation

Regulate fluids to maintain adequate urine output Adults: 0.5 mL/kg BW/hr Children: 1.0 mL.kg BW/hr

Excessive urine volumes signify overcorrection and run the risk of fluid overload; smaller volumes signify inadequate resuscitation

Urine output monitoring should be done strictly every hour

Fluid Resuscitation

For electrical injuries: Adjust fluid volume to maintain UO of

75-100 mL/hr Mannitol 12.5-25g may be infused to

promote diuresis

Fluid Resuscitation

If UO and pigment clearing do not respond to fluid resuscitation, 12.5g cosmetic diuretic mannitol may be added to each liter of resuscitation fluid

NaHCO3 can be added to maintain a slightly alkaline urine

Wound DressingDebridement/Initial Dressing: Sterile technique Cut hair or items that may reach any

burned or dressing area Full body bath with soap and water Debride burned areas, making sure to

visualize all affected areas. Reassess depth and %BSA of burn wounds

Wash with betadine soap, rinse with sterile water

Dress

Wound DressingSilver Sulfadiazine (Flammazine, Silvadene,

Silversurf)

For full thickness burns, applied as sandwich dressing

Changed once or twice a day By itself retards wound healing May cause transient leucopenia

Wound DressingSilver Sulfadiazine (Flammazine, Silvadene,

Silversurf)

Mech of action: silver ion bings with the DNA of the organism and release sulphonamide which interferes with the metabolic pathway of the microbe

Effective against: Pseudomonas aerugenosa, enterics, Staph aureus, Klebsiella sp

Wound DressingSilver Sulfadiazine + Cerium nitrate

(Flammacerium)

Topical antimicrobial Applied in cases wherein early excision-

grafting cannot be done (mass burn, extensive burns)

When combined with burned skin, forms a pliable leathery layer acting as a protective barrier against contamination

Reduces mortality by neutralizing a toxin present in burned skin

Wound DressingSilver Sulfadiazinen+ Cerium nitrate

(Flammacerium)

Mechanism of action:Cerium induces calcification of the dermal collagen remaining in the wound which produces the typical tanned, leathery crust

Wound DressingSilver Nitrate

Used as 0.5% solution Gauze dressing must be wet, solution loses

effectivity when dry Creates a brownish black discoloration

with anything it comes in contact with (will peel off with the burned skin)

Wound DressingSilver Nitrate

Bacteriostatic for S. aureus, E. Coli, P. aerugenosa

Does not injure regenerating epithelium in the wound

Caution with children as it tends to leach out electrolytes (Na, Cl)

Wound Dressing

Daikin’s Solution

Sodium hypochlorite 0.025% solution:15 mL sodium hypochlorite (Zonrox) + 935 mL NSS

Must be used within hours after it is prepared

Used in preparing granulation tissue for grafting

Bactericidal to S. aureus, P. aerugenosa, and other G(-) and G(+) bacteria

Monitoring At the ER:

Check vital signs, urine output, consciousness, pulmonary status hourly

Hgb, typing, Na, Cl, BUN, Crea, RBS CXR and ABG for those suspicious for

inhalational injury ECG, urine Hgb and myoglobin for

electrical burns

Monitoring

During fluid resuscitation:

Check signs of adequate hydration Weigh patient daily Vital signs hourly Monitor peripheral perfusion hourly

(pulses, capillary refill) Presence of Hgb and myoglobin in urine of

electrical burn patient suggest delayed or inadequate fluid resuscitation

Monitoring

During fluid resuscitation:

pulmonary status every 4-5 hours Daily determination of Hgb, Hct, WBC, Na,

K, BUN, crea Status of wound daily during dressing

change

Monitoring Post resuscitative period:

vital signs every 4 hours Daily determination of weight, BUN, crea,

Na, K Assess burn status daily Burn biopsies (not swabs) twice a week Blood CS once a week if wound is infected

or patient is septic

Definitive ManagementPriority in the 1st 48 hours- maintain

intravascular volumeOnce addressed, definitive management

ensues

Classical Method:Allow eschar to spontaneously separate (3

weeks), wait until bed is ready for grafting, then place skin graft

Definitive ManagementPresent trend:Early excision (within 7 days post burn) of

burn wound, followed by skin grafting

- shown to improve survival and shorten hospital stay

- adopted strategy by the PGH Burn Unit

Excision and Grafting

To remove full thickness and deep partial burns until clean viable bleed is encountered and a skin graft is placed immediately to cover the wound

Early excision – done within 7 days When the wound is not yet colonized by

microorganisms, reducing the chances of infection and promoting good graft take

Preparation for OR prerequisitesStable vital signsNot in septic shockAfebrileBlood available for OR use (200-

400ml/%BSA)Normal albuminNo contraindications for surgery

Conduct for OROR table covered by sterile linenKeep OR warmPrep patient using betadine soap and

paint for the donor site and betadine soap for the wound

Prep the donor siteDrape donor site separate from the

burn wound

Tangential Excision

- The principle is to excise the wound in thin layers using a blade held at very acute angle with the skin surface

- The goal is to remove non viable tissue leaving as much dermis as possible which is an excellent surface for grafting

Fascial Excision

Best used when excising large flat areas When excision of the burn wounds has to

be done with minimum blood loss Less bloody than tangential excision, but

with cosmetic effect defect Limited use in extremities due to

problems of edema in the area distal to the excision, the presence of avascular fascia and presence of nerves of superficial locations

Skin Graft Harvesting

Preferred areas are thighs, buttocks, and abdomen

The only area in which color match between donor and recipient site is of significant concern is the face and neck.  Upper chest and upper back are a good color match for face and neck.

Applying Skin Graft It is best to place grafts on the wound at the time of

excision  Since the graft itself controls hemostasis and

protects the wound, it makes little sense to wait 24 to 48 hours until bleeding has stopped

This approach requires an additional procedure and there is a significant risk of the wound bed becoming desiccated or reinfected

It is better to have a slight overlap of skin on the wound rather than to leave excised wound uncovered.  Hypertrophic scarring will result and most evident at the edges of the graft, especially if a ridge of open wound is left to heal primarily.

Care of Skin Graft First opening could be as early as 3rd post op

day or as late as 5th post op day. Open early if the skin graft is suspected to be infected as when it as foul-smelling odor

Remove the bulky dressing slowly. Take care not to disturb the skin graft. Use copious amounts of water. Skin graft take is indicated by pinkish color of graft and adherence to graft bed. Gently wash the area with betadine soap and rinse with water. Dress graft with bulky wet dressing

Care of Skin Graft

Staples can be removed at the 1st dressing change

Skin grafts can be dressed every day if not infected. If with good take, the skin graft can be left open on the 7th post op day. Small areas of graft loss could be cleansed by mercurochrome

Nutrition

Patients with Burns have a hypermetabolic response

Curreri’s Formula Adult (25 x kg) + (40 x %BSA Burn) Children (60 x kg) +(35 x %BSA Burn)

Rough Guide: 2,500 cal/day in adults, proteins at 2g/kgBW

At Burn Unit, 6 eggs/day Give Vit C and Zinc Supplements

Complications

Sepsis Most common cause of death in burns

ARDS Electrical/Inhalational/pulmonary injury

Contractures Prevented with proper posture and

splinting

Pain Control

Meperidine 50mg IV q6 Nalbuphine q4

Narcotics are not given IM since absorption is erratic

Criteria for Discharge

No existing complications of thermal injury such as inhalational injury

Fluid resuscitation completed Adequate pain tolerance Adequate nutritional intake No anticipated septic complications

END.