BURNS

Epidemiology:Quality of Burn Care

SurvivalLong-term FunctionAppearance

Surgeon’s GoalWell-healed, durable skin with normal function and near-normal appearance

*Depth of Injury is directly proportional to:Temperature appliedDuration of contactThickness of the skin

Etiology:1. Scald Burns

- usually household from hot water- most common among civilians

injuriesespecially children

2. Flame Burns- 2nd most common mechanism- secondary to house fires, MVA

3. Flash Burns- explosion of gases & other

combustible liquids- covers larger TBSA- with thermal damage to upper

airway4. Contact Burns

- contact with hot metals, plastics, glass

- common in industrial accidents- often 4th degree

5. Electrical Burns- either occupational or household

injuries- severity based on voltage, duration

of contact & resistance of the patient6. Chemical Burns

- due to strong acids or alkalis- industrial accidents or assaults

PHASES OF BURN INJURY

•Acute PhaseFluids & ElectrolytesPain ControlBurn Wound Care & CoverageSeptic ComplicationsNutritional Management

•Chronic PhaseRehabilitationReconstructionPsychological Support

Pathophysiology of Burn Injury1. Coagulation Necrosis2. Increased Capillary Permeability3. Hemolysis

ACUTE PHASE•Immediate Care

Rescue and First Aid = on scene- remove source of heat- CPR if necessary; O2 inhalation

Assessment and Resuscitation = at the ER - ABC’s take priority- Intubation if necessary

Preparation for transfer to a burn facility- for burns more than 5 – 10%

TBSA

•Immediate first aid measuresCooling the burned area

- application of cool water NOT iced water

Removal of patient’s clothing- remove source of heat &

exposure of injuriesPrevention of hypothermia

- wrap patient in clean blanket•Admission Criteria to a Burn Facility

Partial Thickness Burns =/> 15%Full Thickness Burns =/> 5%Burns on Face, Feet, Hands &

PerineumAll Electrical & Chemical BurnsPresence of Smoke Inhalation InjuryAssociated Injuries

Admission CriteriaChild AbusePatients <10 y.o. & >50 y.o.Patients w/ Associated medical

illnessAll infected burnsDependent persons

Patient Assessment1. History

Time of InjuryPlace of InjuryMechanism of Injury

2. Physical ExamPrimary Survey = ABC’s 2ndary Survey = Other injuries

Estimation of Burn Injury SeverityBurn Size:

Rule of Nines = massive burnsPatient’s Palm = patchy burnsLund-Browder Chart = pediatrics

“Rule of Nines” for estimating TBSAAnatomic Area % body surfaceHead 9Rt. Upper extremity 9Lt. Upper extremity 9Rt. Lower extremity 18Lt. Lower extremity 18Anterior trunk 18

Posterior trunk 18 Perineum 1

Estimation of Burn Injury SeverityBurn Depth is dependent on: a. Temperature of burn source b. Thickness of the skin c. Duration of contact d. Heat dissipating capability of skin

Classification of Burn Depth1. Shallow Burns a) Epidermal Burns

(1st Degree Burns)- do not blister but erythematous- relatively painful

ex. Sunburn b) Superficial Partial-Thickness Burns

(2nd Degree Burns)

- form blisters, pink & wet- hypersensitive to pain- blanch with pressure- spontaneously heal

< 3 weeks2. Deep Burns

a) Deep Partial-Thickness Burns (2nd Degree)

- blisters, mottled pink and white - capillary refill is slow to absent - less sensitive to pain - heals in 3 to 9 weeks

b) Full Thickness Burns

(3rd Degree) - all layers of dermis

- leathery, dry white, firm & insensate- develop “ESCHAR”- heal by contracture or skin grafting

c) Fourth Degree Burns - full thickness skin, SQ fat,fascia & muscles

- electrical, contact, immersion burns in an unconscious patient

Assessment of Burn DepthMethods:1. Clinical observation – only 70% accurate2. Detection of Dead cells or denatured collagen

- biopsy, ultrasound, use of vital dyes3. Assessment of Change in Blood Flow

- fluorometry, laser Doppler, thermography4. Analysis of Wound Color

- light reflectance method5. Evaluation of Physical Changes

- magnetic resonance imaging

Physiologic Response to Burn Injury

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS)- pathologic alterations in metabolic, cardiovascular, gastrointestinal and coagulation systems- hypermetabolism, increased cellular, endothelialand epithelial permeability- extensive microthrombosis

BURN SHOCK- circulatory dysfunction- increase in vascular permeability & micro- vascular hydrostatic pressure

Mediators:1. Histamine – release mast cells which

disrupts venular endothelial junctions2. Serotonin – increase pulmonary vascular

resistance3. Eicosanoids – increase levels of vasodilator PG’s

Diagnostic Work-upComplete Blood CountUrinalysis, BUN & Serum CreatinineBaseline electrolytesArterial blood gas determinationX-rays (Chest, other areas)Electrocardiography

Fluid ResuscitationRecommended Fluids:

Plain Lactated Ringer’s Solution = 1st 24 hours

Colloids or D5Water = after 24 hours

Fluid Computation & Administrationa) 1st 24 hours

“Parkland Formula” TFR = BW x TBSA x 4 mg/kg/%burns(1/2 given in1st 8H; 1/2 next 16H)b) 2nd 24 hours

D5W replace evaporative lossesColloids maintain plasma volume

c) After 48 hoursMaintenance Fluids = 30-40

cc/kg/day

Parameters for Monitoring Fluid Therapy1. Urine Output

Adults: 0.5 cc/kg/hourPedia : 1 cc/kg/hour

2. Vital SignsBlood pressure & Heart rateCentral Venous Pressure

3. Sensorium

Reasons for Failed Resuscitation1. Delayed resuscitation2. Presence of electrical burns3. Smoke inhalation injury4. Coronary artery disease

Ancillary Management Measures1. Gastric decompression2. Pain control & sedation3. Antibiotics4. Tetanus prophylaxis

Compartment syndrome:a) Clinical Manifestations

6 P’s: Pulselessness Paresis/Paralysis Pallor Paresthesia

Pain Poikilothermiab) Definitive Treatment: ESCHAROTOMY

FASCIOTOMY

Inhalation injury:1. Carbon Monoxide Poisoning

Effects: a) prevents reversible displacement of O2b) decrease O2 unloading at tissue levelc) less effective intracellular respirationd) directly toxic to cardiac & skeletal

musclesTreatment: Hyperbaric Oxygen ???

2. Thermal Airway Injury Manifestations:

- mucosal & submucosal erythema- edema, hemorrhage & ulceration- potential for upper airway obstruction

Treatment: Endotracheal Intubation

3. Smoke InhalationFactors:

a) Type and amount of smoke inhaled b) Size of particulatesc) Duration of Toxic Exposured) Magnitude of thermal injury

Clinical Manifestations:

a) dyspneab) burned vibrissaec) carbonaceous sputum

Diagnosis: a) Chest X-rayb) Bronchoscopyc) Arterial blood gas

Management: a) Endotracheal intubation b) Mechanical ventilation

Electrical Burns:Classification:

Low voltage: <1,000 voltsHigh voltage: >1,000 volts

Mechanisms of injury: a) Direct contact b) Conduction arc c) Secondary ignition

Physiologic Alterations: a) Arrhythmias b) Acute Renal Failure c) CNS & PNS Deficits d) Hemorrhage & Hematomas

Chemical Burns:Factors to consider:

a) Contact timeb) Chemical involved

Primary Management: Rapid termination of burning process

Burn Wound CareSalient Aspects:

Debridement of necrotic tissueDaily dressing of burn woundSurgical Management:

a) Tangential excisionb) Fascial excision

Topical Antimicrobials a) Aqueous silver nitrate b) Mafenide acetate c) Silver sulfadiazine d) Povidone-iodine

Nutritional SupportState of hypermetabolism

- exaggerated energy expenditure- massive nitrogen loss

Formula: TCR = 25 kcal/kg BW + 40 kcal/%TBSA

Route:Total Enteral Nutrition (TEN) Adv: maintain integrity of GI tract

reduce bacterial translocation & sepsisBurn Wound InfectionClinical Manifestations

1. Conversion from partial to full thickness2. Dark-brown/blackish discoloration

3. Neo-eschar formation4. Rapid eschar separation5. Violaceous wound margins6. Metastatic septic lesions

Burn ComplicationsA) Distant infections

1. Pneumonia2. Bacterial Endocariditis3. Urinary Tract Infection4. Suppurative chondritis

5. Vascular Catheter-Related InfectionB) Other complications

1. Curling’s ulcer2. Acute Acalculous Cholecystitis3. Myocardial Infarction

Burn wound coveragea) Temporary

1. Biologic wound coveringsAllograftXenograftAmnion

2. Hydrocolloid dressings

b) Permanent1. Skin Grafting

a) Split-thickness b) Full-thickness2. Skin Flaps3. Skin Substitutes

a) AlloDerm b) INTEGRA4. Cultured Skin

a) Apligraf b) Epicel

Chronic Phase1. Rehabilitation:

Range of motion exercises Ambulation training

Return to functional status2. Psychological Support:

Anxiety, Depression, DenialWithdrawal, Regression

3. Reconstruction:Burn contracturesKeloidsHypertrophic scarsMarjolin’s ulcer