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.
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