BURNS

(ppt, recording)
Aniceto B. Guinto, MD, MHA, FPCS, FPALES, FPSGS
Assistant Professor, Department of Surgery
Metropolitan Medical Center

Objectives
• Enumerate and discuss the classification of burns Opthalmic complications like CATARACT formation is
• Discuss burn depth, burn zones and estimation of common
burn size *Upon admission, should be referred to ophthalmologist,
• Initial evaluation of burn injury neurologist or basal function assessment.
• Management of burn patient, resuscitation,
ventilatory support, wound care, nutritional CHEMICAL BURNS- less common but could cause
severe burns.
support and surgical intervention
o most important aspect in
• Complication of burn care
management is to remove
• Rehabilitation the toxic substances
immediately
CLASSIFICATION OF BURNS o by irrigating the involved
part of the body by at least
ELECTRICAL BURNS- 4% 30 mins with running
water. (can’t be done in all
types, except if secondary
o entry point -most to concrete powder or any
commonly the HANDS form of light you cannot
o exit point - the use water because it will
contralateral hands, feet activate AlOH- remove it
,nose ,ears, head without using water.)
o associated with
compartment syndrome

o can be absorbed in the

*in this patient the exit point is in the scalp body and could cause
systemic derangement.
Full Thickness Burn Formic acid- could cause
-scar will serve as a tourniquet during swelling HEMOLYSIS which is a
-impede venous drainage, eventually the arterial supply= metabolic derangement
NECROSIS of the involved part Hydrofluoric acid- could
cause METABOLIC
*All electrical burn patient should undergo ECG. ACIDOSIS

*Low voltage electrical burns with normal ECG, there’s no

need for admission.
*High voltage electrical burns, they need to be admitted
even though the ECG is normal because you have to
monitor the progression of the swelling ,involvement of
extremities which lead to compartment syndrome.
THERMAL BURNS- most common
a.) Scald burns
-very common secondary to hot water,beverages, hot oil or
steamed, or contact point to the radiator of the engine

b.) Flame burns

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- most common cause of hospital admission -capillary pressure test is NORMAL
-assoc. with inhalation injury because it is common in
structural fire like in building houses. b.) Deep partial thickness
A B -involves the epidermis and the deeper layer of
the dermis (reticular layer)
-involves extensive blister formation, removing it
would expose the reddish color dermis
-punctuate hemorrhages due to exposure or
extravasation of blood from the BV
-or it can be pale due to destruction of BV
-it is less painful because of the destruction of the
nerve
-hallmark is when you do capillary pressure test, it
is DELAYED
BURN DEPTH
Third degree
1832 Guillame Dupuytren –classified degree of burn (FULL
burns THICKNESS)
o involves the
epidermis, dermis,
and subcutaneous
tissue
o painless,
leathery like and
non-blanching

Fourth degree
burn
o involves the
epidermis, dermis,
subcutaneous
First degree burn ( SUPERFICIAL) tissue, muscle and
o involves epidermis area only the bones
o with redness, painless, no blister formation
ex. Sunburn (fig.) electrical burn
Second degree burn ( PARTIAL THICKNESS)
o involves the epidermis and dermis
o hallmark is presence of blister formation
A B ZONES OF INJURY

a.) Superficial partial thickness

- epidermis and superficial part of dermis
(papillary layer) Zone of coagulation
-hallmark is blister formation, removing it would o most extremely affected
expose the pinkish color dermis which is painful o coagulation necrosis of the tissue
due to exposure of nerve endings o resembles 3rd degree and 4th degree burn
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 Zone of stasis Palm (1%)- using it as a means of measurement is
o resembles 2nd degree burn because of another method to estimate the burn size
ischemia
Zone of hyperemia Lund and Browder Chart-specially for pediatric
o least involves patients, accurate estimation of burn injuries
o resembles 1st degree burn

ESTIMATION OF BURN SIZE

Rule of 9- crude and accurate

o 1st degree burn is not included

UPPER LOWER
ADULT Back= 1% Perineum= 1%
Head= 9% Right leg= 18%
Right arm= 9% Left leg= 18%
Left arm= 9%
Back= 18%

CHILD Right arm= 9% Perineum= 1%

Left arm= 9% Right leg=13.5%
Back= 18% Left leg= 13.5%
Head= 18%
*Head in pediatric patient is 18% because it is larger than
the surface body area

INITIAL EVALUATION OF BURN INJURIES

Just by history burn patients are associated with poor

prognosis but nowadays because of advancement of IV
fluids, ICU setting, early debridement of burn injuries and
culture of epithelial cells from burn injury, survival rate is
increased compared before.

Guidelines for Referral to a Burn Center

o A burn center may treat adults, children, or both.
Burn injuries that should be referred to a burn
center include:
1.) Partial thickness burns greater than 10 % total body
surface ( TBSA)
2.) Burns that involve the face, hands, feet, genitalia,
perineum, or major joints.
3.) Third degree burns in any age group.
4.) Electrical burns, including lightning injury.
5.) Chemical burns.
6.) Inhalation injury.
7.) Burn injury in patients with pre-existing medical
disorders that could complicate management,
prolong recovery or, affect mortality.
8.) Any patient with burns and concomitant trauma
(such as fractures) in which the burn injury poses
the greatest risk of morbidity or mortality. In such
cases, if the trauma poses the greater immediate
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 risk, the patient may be initially stabilized in a
trauma center.
9.) Burned children in hospitals without qualified
personnel or equipment for the care of children.
10) Burn injury in patients who will require
special social, emotional, or rehabilitative
intervention.
o Extensive burns of 40% or more total body surface
area, they need a central line, for CVP monitoring ,
hydration purposes.
o Pediatric patients sometimes you cannot insert IV
lines because of edema fluid, the next option is
intraosseus, using the tibia, eyes.

Airway management
o Primary Survey- to identify life threatening injuries
(ABCDE)
o Inhalational injury could compromise and cause
swelling in the airway
o Aside from asking hey hey are you okay, you assess
the airway by inspection, physical signs like oral
burns or at the nasal hair that warrants oral
examination at the laryngeal, or pharyngeal area.
o But if the findings are normal, patient may still
need intubation specially if symptoms like
hoarseness, coarse voice, dyspnea and stridor it
warrants immediate endotracheal intubation
o For patients with multiple injuries, do endotracheal
intubation which is the most common method to
secure airway. Other injuries
o Specially inhalational injuries.
o X RAY in emergency rooms should be
done.
o Patient may also be associated with
jumping of fold during burns but in non-
emergent, skeletal X RAY is not warranted
because it could delay the resuscitation,
you could perform it later on.
CO and cyanide poisoning
a.) CO- It’s a common inhalational injury. It is odourless,
tasteless, and colourless. “Silent Killer”
o Its affinity is 200-250 times more compared to
o If with multiple injuries like fracture to the oxygen.
mandibular area endotracheal intubation is not o Less oxygen in the blood may cause cyanosis and
possible, instead perform nasotracheal intubation. demise of the patient.
Immediate cricothyroidotomy, tracheostomy may
delay the securing of airway.

Fluid Resuscitation
o All burn patient may not need IV fluid. It depends
on the percentage of burn area
o 15% or less may not need IV fluid resuscitation
because you may correct through oral intake.
o For pediatric,15% total body surface area of
burns,they need IV fluid resuscitation.
o 40 % total body surface are of burns will need
double line with large bore needle.
o Ideal location of IV insertion pediatric- UPPER o Diagnosis
EXTREMITIES. Yes, you could insert it in the burn aside from signs and symptoms you can
area, the problem is to how to secure the IV line. use the pulse oximeter, it can give you
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 false elevated oxygen so you’ll have a high
index suspicion.
o 100% mortality rate - Cardiac arrest secondary to
carbon monoxide poisoning. Hard to revive for
even any type of resuscitation.
o Treatment:
100 % oxygen, it will decrease the half life
of CO to 40- 60 mins.
IV prophylactic antibiotics- should not be given for
it could increase bacterial and fungal resistance of
the patient.
Tetanus vaccine- active and passive immunization.
Benzodiazepine
o first choice analgesia or narcotics.
o You have to control the pain in burn patients
because most of them have anxiety,
depression.

MANAGEMET OF BURNS

CONTINOUS RESUSCITATION

Some would suggest hyperbaric

oxygenation but it is not practical for it is
expensive and it may not be suitable for px
with large burn areas.
b.) Cyanide poisoning- common secondary closed
space burns inhalational injury (also for CO),

Concept
o You have to admit the patient if the
patient is admissible. Hydrate the patient
continuously because of the third space
loss of the plasma or exudate into the
interstitium space.
Calculation of Fluid

Ex. 70 kg patient adult with 30 % TBSA flame burn

o Diagnosis
Persistent ST elevation or ECG 1st 10 kg x 100 = 1000
Persistent metabolic acidosis Next 10 kg x 50= 500
Nausea, vomiting, convulsion and death (remaining weight) 50 kg x 20= 1000
o Treatment
100% oxygen Maintenance: 2. 5 L of IV fluids per day
Hyroxocobalamin- best for emergency
situations because it forms a complex and Fluid requirements:
the cyanide is excreted through the
kidneys. (first choice)
Sodium Thiosulfate- forms a nontoxic
cyanide but it takes longer.(succeeding
medication)
Hypothermia
o Part of the first aid management.
o Burn patients should be wrapped with blanket to
prevent hypothermia because it is one important
cause of failure of resuscitation
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 o Inflammatory mediators to prevent further
o Most common formula vasodilatation and edema formation.

4ml x 30% x 70 kg= 8400 ml VENTILATORY MANAGEMENT

8400 ml ÷ 2 = 4200 ml

*4200 ml first 8 hrs, 525cc/hr

*4200 ml next 16 hrs, 263 cc/hr

o Regulation of IV line, LACTATED RINGERS

*4200 ml ÷ 8 hrs = 525 cc/hr

*4200 ml ÷ 16 hrs =263 cc/hr

o Don’t overload because after several hours the leak

closes so patient needs lesser volume.

Parameters
o Overhydration is accosiated with complications.
o Hydration depends on:
Time Smoke inhalation = 35%
Ex. Time of injury- px sustained burns at 6 am , arrived at Smoke inhalation + pneumonia = mortality 60%
the ER at 9 am. Inhalational injury + pneumonia + ARDS = 66%
All of them + >60% TBSA + II + ARDS = 100
3pm = 8 hrs after 6 am but patient arrived at 9 am so:

*4200 ml ÷ 6 hrs not by 8 hrs

MAP= 60 mmHg
Urine Output

Adult: 30 cc/hr
Pediatric: 1-1.5 cc/kg/hr

10 kg pediatric patient = 10 -15cc/hr

Colloids
o Can be used instead of Lactated Ringers solution
after first 24 hrs.
o High molecular weight fluids
o It will stay in the intravascular, attract fluids and
increase systemic blood pressure.
o Based on a study, it will not increase the survival
rate of the patient instead it will increase the
morbidity and mortality.
o Still, Lactated Ringers solution is the most
commonly used.
Vitamin C
o Cofactor in hydroxylation of proline for production
of collagen.
o Increases wound healing.
o High dose would decrease IV fluid requirements.
Plasmapheresis
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Smoke inhalation- can cause injury in 2 ways
o Direct inhalation injury in the upper airway
causes swelling
maximal edema reaches 24- 40 hrs that’s
why patient need emergency intubation to
secure the airway
o Inhalation of combusted materials that cause
injury in lower airway
Can cause direct injury to the mucosa that
cause inflammation then inflammatory
mediators could cause edema.
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 Edema fluid is a risk factor for the dev’t of
pneumonia.
Eventually could get obstructed causing
poor gas exchange then hypoxemia.
Bronchoscopy
o Carbon deposits in the mucosa
o Bronchorrea
o Edema fluids
o Sloughing of mucosa
o Aspiration is positive for bacteria or dev’t of
pneumonia upon injury

*It is an invasive procedure.

*Aside from X RAY CT scan is an ancillary procedure or
alternative instead of bronchoscopy
Treatment
o High frequency percussive ventilation
Improves ventilation
Improves oxygenation
Decreases pulmonary pressure
o Phasitron
Inspiratory and expiratory bulb attached
to the ET tube
o Oral hygiene and frequent suctioning of the
secretion of the patient every 15 mins. (Pulmonary
toilet)
o Bronchodilators and acetylcysteine
To remove adherent secretions
o Heparin
To prevent obstruction of the airway
o Surfactant
Increases surface tension of the alveoli
o Nitric Oxide
For patients not responding to ventilator
support and other methods.
Increases blood flow by vasodilatation.
Last option.
WOUND CARE
Silver Sulfadiazine
o Most commonly used- cheaper, easy to apply, has
soothing effect, not absorbed systemically.
o Disadvantage- you cannot use it in skin graft nor
apply it on the donor’s site, and it prevents
epithilialization of partial thickness burn.
o Has a broad spectrum antibacterial activity
o More of prophylaxis for burn infections, not for
therapeutic indications.
Mafenide acetate
o Broad spectrum antibacterial cream
o Can be applied on skin graft
o Has good eschar penetration (thick necrotic
tissue).
o Disadvantage- very painful on application, can be
absorbed in the circulation and could cause
metabolic acidosis.
Silver nitrate
o 0.5 % solution
o Very cheap and broad spectrum activity.
o Disadvantage- it is absorbed in the circulation and
could cause electrolyte imbalance particularly,
hyponatremia, methemoglobinuria, and could
cause black stain which is a hard to remove in
beddings, hospital gowns, etc.
Neomycin, Bacitracin, Polymyxin
o For smaller wounds
o For face wounds
o Cannot be applied in large wounds because they
are absorbed systematically and could cause
nephrotoxicity.
Mupirocin
o Indicated for MRSA

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 APPLICATION *You can give it through osterized feeding, and it depends
on the percentage of protein, carbohydrate and fats.

SURGICAL INTERVENTION

After initial resuscitation the patient is stabilized

hemodynamically, the next step is to excise the burn injury
with wound coverage because it will increase the healing
process and it will help in better cosmetic purposes. It is
done in the first several days. Admit the patient once
stabilized, then proceed to the surgical procedure which is
BURN DEBRIDEMENT done under general anesthesia.
-By using cotton swabs, tongue depressor and sterile
glove. Burn Excision
-Apply large amount then cover it by “wet to dry
o Watson and Goulian are the most commonly used
dressing”. (2x a day for 1 wk)
o WET- should be first, for the purpose of
making the burn environment moist because
it increases wound healing by 50 %.
o DRY- then cover it with dry dressing,

*Debride the burn wound with plain NSS without

anesthesia
*Aquacel Silver – after you apply it for several hrs it turns
into gel, making the environment moist. Also good for
Pseudomonas infection.

NUTRITIONAL SUPPORT
It is very important because it will increase the
immune system of the patient as well as the
healing process.
200% = increase of Basal Metabolic Rate of burn
patients
If with >20% TBSA enteral feeding (NGT most
common) is safe to:
o decrease the hypermetabolic state
o Increase the immune system
o Prevent loss of muscle tissue
Tangential excision
o end point is presence of punctuate hemorrhages
meaning the tissue is normal.
o Disadvantage- blood loss, so patient may need
blood transfusion.
o Epinephrine- injected in the SQ tissue to prevent
massive blood loss. Could also be application of
gauze with epinephrine.
Rheumatic/Tourniquet technique- in the
extremities to prevent blood loss, sometimes
Heparin Spray.

*The problem is how many kilo calorie we should give to

the patient. Estimation of caloric requirement is challenging
Harris-Benedict Equation
o Most commonly used for non- burn patients =
25kcal/kg/d

BURN patients: 25kcal/kg/d + 40kcal/%TBSA

Ex. 70 kg patient with 30% TBSA

*25 x 70=1,750 + 40 x 30=1,200

*1,750 + 1,200 = 2,950kcal/day

Cautery- for deep wounds involving the fascia,
and SQ to minimize bleeding

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 High pressure water- for eyes, periorbital area,
hands and other delicate part of the head and Alternatives- for extensive burns when there’s no
neck, bit it is very expensive. more donor site available

*Patient can undergo burn excision under general

anesthesia 5 to 7 times as long he/she can still tolerate it.
Every other day or everyday. Specially for 20 % or greater.
Full thickness burn- skin graft is ideal which can
provide adequate coverage and better cosmetic
results.
o Autografts (same patient) – ideal
o Donor site-
thigh (easy to harvest, hidden)
back (elderly)
gluteal (pediatric)
scalp – thick, and hair follicles could stimulate
healing.
Skin graft
o Dermatome –harvesting apparatus by split
thickness, getting the epidermis
o Cannot be done if there is still infection.
o Can be done when granulation tissue is adequate,
color is red. *Patient may reject these skin grafts.

Compartment syndromes-full thickness burn, rigid

eschar
o Tourniquet like effect that impedes venous
drainage and arterial supply
o Paresthesia, pain
o If it progresses patient may lose the extremities

o Harvest skin graft and cover the donor site with

hydrocolloid dressing, healing process is
epithelization.
Mesh skin graft- to cover large burn wounds. It
could also drain fluids under the graft.
o Hands, face, neck- poor cosmetics results
o Treatment:
Escharotomy

- eschar only, done at the bed side usually in the ER.

Performed >8 hrs because of the edema effect.
-Upper extremity: incision on the medial or lateral aspect of
the extremity down to the hpothenar.
Fasciotomy

- down the fascia to release the pressure. Cosmetic results

are not good.

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 Thoracic Compartment Syndrome
o Hypotension
o Increased airway pressure
o Hpoventilation
*Incision: Bilateral Anterior axillary line,
Subclavicular line, Bilateral Subcostal line
Abdominal Compartment syndrome
o Hypotension
o Increased airway pressure
o Decreased urine output
*Incision: extend down to axis
COMPLICATIONS IN BURN CARE
Ventilator Associated Pneumonia
-common in inhalational injury
-elevate the head, oral hygiene, frequent
aspiration of the secretion.
Abdominal Compartment Syndrome
-due to overhydration that could cause edema of
the mesentery, omentum and bowels
o Causing:
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Increased IAP=hypotension due to
decreased venous return
Decreased Urine output due to
impingement of renal artery
Increased Pulmonary pressure for
Bilateral distended abdomen will push the
diaphragm.
o Treatment: Decompressive Laparotomy by
opening the abdominal wall releasing the pressure
but the problem is Bowel evisceration. To cover
the bowels you could use vagotomy and it is
sutured on the skin.
*If the patient survived and no more edema fluids the
bowel will decrease in size, granulation tissue will form
under the bowel. Incisional hernia could be a problem
Increase Intraocular pressure
-damage to optic nerve can cause blindness
-release pressure by lateral canthomy
Deep Vein Thrombosis (25%)
o Due to immobilization
Catheter Related Bloodstream Infections
o Due to anatomic relation of burn wound to IV line
REHABILILATION
It should be initiated upon admission
Psychological Rehabilitation
o Usually they have depression, anxiety,
psychological distress (34%) , they worry about
their appearance, anxiety to return to the
community
o Psychologist, Psychiatrist- support the patient and
teach coping mechanism techniques.
Physical Therapy
o Patient cannot perform active movements and
should at least have passive movement s 2x a wk.
*If patient can now perform active movements you have to
encourage them to move or walk specially if burns at the
lower extremities by using crutches.
*Early ambulation is important to prevent DVT, muscle
atrophy, swelling, resynthesize skin.
o Garments are important in healing wounds due to
good support,and neovascularization.
Hypertrophic Scar
- develops within 3 months, painful, pruritis,
elevated
o Causes:
overproduction of inflammatory
mediators
oversynthesis of collagen
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 abnormal ECM

o Treatment-
topical corticosteroids (1st line
intralesional (2nd line)
compressive dressing
Carbon dioxide laser-to make the scar
black and reactivation of
metalloproteinases (w/c degrades
collagen)
Pulse dye laser- photothermolysis of
haemoglobin by obliterating small BV,
scar becomes flat, no more tenderness.

You can supplement it with notes from

Schwartz Chapter 8 for better learning.

Thanks!

Contracture scar
o Common for full
thickness burns on
joints
o Treatment:
rehabilitation of
6 months to 1 year
failure of rehab
refer the patient
to plastic surgeon
for reconstruction.

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