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Date

Jeffrey S Litt DO
Burn and Wound Program Director
University of Missouri - Columbia
Briefly recount key moments in burn history and epidemiology
Clinically differentiate Superficial, Partial, and Full Thickness Burns and
discuss emerging technologies to assist in that differentiation
List the different ways to determine burn size
Describe fluid resuscitation of burn patients and controversies/
complications of resuscitation
Explain the initial goals and topical treatments of burn wounds
Review characteristics and treatment of inhalation injuries
Review child abuse burn clinical characteristics

Burn treatment modalities have been documented as far back as
>3500 yrs with Neanderthal cave paintings
Smith papyrus of 1500 BC documents ancient Egyptian use of a
salve of honey and resins for burn and wound care
Hippocrates, Paracelsus, Galen and others propagated varied burn
treatments/salves involving the usage of pig fat, vinegar, honey, tea,
mud, excrement, etc.
Ambroise Pare (1510-1590) described early burn excision, based on
the works of Guy du Chauliac (ca 1300-1368).
Guillaume Dupuytren (1777-1835) developed first burn classification
schema of 6 degrees, subsequently modified into current 3-degree
classification in place today.
Most major advances have occurred in last 50-60 yrs
including:
Fluid resuscitation
Infection control and treatment
Burn hypermetabolism and nutritional support
Excision and grafting techniques and skin
replacements/substitutes
Inhalation injury treatment
Underhill Rialto Theater, 1921
Blalock - 1931
Cope and Moore Cocoanut Grove Club, 1942
Texas City Disaster - 1947
Evans Brooke Army Hospital 1952
Baxter and Shires, 1968 Parkland
Consensus - 1979
App 1.2 million burns/yr (decreasing incidence)
App 500,000 seek medical attention; 40,000 hospitalized
3500 10000 deaths annually (est)
90% preventable; 50% associated with substance abuse
2nd most common cause of trauma-related death
10
20
30
40
50
60
70
80
90
100
1940 1950 1960 1970 1980 1990 2000
Burn size
(%TBSA)
Year
Penicillin
Broad spectrum
antibiotics
Modern fluid
management
Early excision
& grafting
Skin substitutes ?
Prehospital Care
1. Remove patient from source of burn
2. Universal precautions by caregivers
3. Remove all clothing and objects (especially rings, jewelry,
watches, belts) that can retain heat or lead to tourniquet
effect
4. Early cooling (watch for hypothermia which may lead to
V-fib and asystole)
5. Cover with warm dry dressing prior to transfer
6. Chemical burns - IRRIGATE, IRRIGATE, IRRIGATE
7. Do NOT neutralize chemical burns
8. Electrical burns - make sure source of electricity turned
off prior to attempts at removal of patient
9. Begin Parkland resuscitation for burns >20% TBSA




ABA Burn Center Referral Criteria

1. Partial thickness burns greater than 10% total body surface area (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 preexisting 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 risk, the
patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician
judgment will be necessary in such situations and should be in concert with the regional medical control
plan and triage protocols.
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.
1. Save Life
2. Save Limb
3. Save Function
4. Preserve Cosmetics
Depth: .5mm (eye lids) - 1.5mm (soles of feet) in depth
Barrier that helps regulate body temperature and
protects the body from injuries such as infection and
dehydration
Depth: 1mm - 4mm
Contains dermal appendages, hair follicles, sweat and
subaceous glands, lymphatic vessels, blood vessels,
and nerves
Superficial (1st degree)
Superficial-Partial Thickness (2nd degree)
Deep-Partial Thickness (2nd degree)
Full Thickness (3rd degree)
4th Degree (typically electrical injury)
Common etiology:
sunburn, cold
low-intensity flash caused by flame or an electrical spark
brief contact with hot liquids or steam
exposure to mildly caustic chemicals, i.e. cleaning supplies,
chlorine
Inflammation with no excoriation
Symptoms:
erythema that blanches easily to pressure, tingling, pain,
warmth to palpation, and minor localized edema
blisters are not usually associate with a 1st degree burn,
however; they can appear (small/dry) 24hr after injury
Common etiology: (similar to 1st degree but with
extended time of exposure)
contact with flames
chemical exposure
contact with hot liquids
cold exposure
Damage to the dermis with excoriation
Symptoms:
wet secondary to weeping of fluid
blanch with application of pressure but very painful to touch
and sensitive to exposure
red in appearance
blisters are common and appear quickly
Healing:
typically heal within 2-3 weeks with appropriate wound care
no scarring
no autografting required
Common etiology: (same as superficial-partial
thickness)
contact with flames
chemical exposure
contact with hot liquids
cold exposure
Similar to superficial-partial thickness, may only be a
few tenths of a millimeter deeper. Can be difficult to
differentiate, therefore; sometimes referred to as
being of indeterminate depth
Symptoms:
may appear wet or dry, red or mottled
blanch very slowly (if at all) with pressure, very painful to touch
and sensitive to exposure
potential to convert to full thickness
Healing:
should re-evaluate wound weekly for 2-3 weeks for
determination of final depth and likelihood of surgical
intervention
Will frequently benefit from application of xenograft, allograft,
and possible autograft
Common etiology:
prolonged exposure to chemicals, flames, or contact with
surfaces (road rash, mufflers)
prolonged cold exposure (frostbite)
contact with high voltage electricity (may be 4th degree if
involves muscle, bone, etc)
Damage to epidermis, dermis, and subcutaneous
tissues
Symptoms:
painless to wound bed (NOT surrounding tissue!)
appears mottled, grey, white, or black due to lack of blood flow
with no blanching to palpation
appears firm, dry, and leathery secondary to damage to
collagenous structures
Healing:
early excision of dead tissue is key
will require surgical debridement and application of autograft
to optimize function, minimize scar formation
if no graft or amputation - infection, prolonged wound, scarring
Visual tool approximates burn size
Adults: Head 9, Trunk 36, Arm 9, Leg 18, Genitals 1
Children: Head 14, Trunk 36, Arm 9, Leg 16
Infants: Head 18, Trunk 36, Arm 9, Leg 14
Only count 2nd and 3rd degree burns
Least effective method of measuring burn size
Used to approximate size of smaller burn wounds; is
not uniform to all patients
The size of the patients palm and outstretched digits is
approximately 1% TBSA (total body surface area)
Only count 2nd and 3rd degree burns
Lund-Browder
most specific measurement tool for determining size of burn
Guides fluid resuscitation
Takes into account the age of the patient
Takes proportions of the body into account
Only Count 2nd and 3rd degree burns
Grading system of 4-5 degrees well-known to most physicians and lay-
persons.
The depth of a burn wound and/or its healing potential are the most
important determinants of the therapeutic management and of the
residual morbidity or scarring.
Traditionally, burn surgeons divide burns into superficial which heal
by rapid re-epithelialization (sup/sup pt) with minimal scarring and
deep burns requiring surgical therapy (deep pt/full).
Clinical assessment remains the most frequent technique to measure
the depth of a burn wound although this has been shown to be
accurate in only 6075% of the cases, even when carried out by an
experienced burn surgeon.
Thermography using infra-red photography inversely
correlates skin temperature with degree of damage.
Interference by pseudoeschar/ointments, etc
Vital Dyes:
IV Fluoroscein
Indocyanine Green
Angiography
Laser Doppler
Imaging
Upwards of 90%
sensitivity for
assessing wound
depth (depending
on study)
Expensive
Videomicroscopy: Uses a microscope to assess capillary pleuxus
Seemingly more sensitive and specific than LDI
Limited system availability
Advances in wound coverage have included many skin
substitutes/dermal templates to assist with coverage.
None have proven consistently better than any other
Large TBSA burns still remain a challenge in coverage
Integra
Bi-layer dermal analogue with a lattice of fibers from bovine collagen covalently linked to
chondroitin 6 sulfate
Epidermal component is medical grade silicone (100 um thick)
Dermal component becomes adherent to wound, and silicone layer protects from bacterial
contamination and desiccation
Dermis becomes populated with native cells and vascular components
Fibroblasts replace the bovine collagen to produce the final dermis (theoretically resembling
regimented
normal pattern, rather than the appearance of scar dermis)
I mesh the Integra 1:1 for better egress of fluid and penetration of topical silver (prefer to cover with
WoundVAC)
Silicone layer removed after 2 to 3 weeks and thin skin graft applied
No rejection or toxicity has been observed as artificial dermis is biodegraded, metabolized, and
absorbed by the host
Disadvantages are cost ($1200 to $3700) and the need for at least 2 surgical procedures

Integra
A technique for harvesting cells fir delivery to the wound as a
suspension.
Facilitates rapid epithelialization.
Used in conjunction with STSG; assists in rapid closure and improves
quality of outcomes.
Process takes app 30 minutes.
Thin STSG taken from donor site and mixed with enzymatic
preparation to allow cellular dissociation at dermal/epidermal
junction.
Sample moved to separate fluid filled dish and cells are scraped off
sample.
Fluid is then collected, filtered to remove keratin debris, and then
sprayed onto wound using supplied syringe.

Resuscitate burns greater than 18-20%TBSA
Consensus Formula (formerly known as Parkland
Formula) 4ml (Lactated Ringer) x kg x TBSA
1st 1/2 of fluid given in 1st 8hr from injury
2nd 1/2 of fluid given in remaining 16hr from injury
Modified Brooke Resuscitation: 2ml - 6ml of LR x kg
x TBSA
Titrate to .5ml - 1ml urine/hr
(too much UOP is just as bad as not enough)
Fluid resuscitation is aimed at physiologic support throughout the initial 24 - 48
hr period of hypovolemia.
Hypovolemia caused by inflammation:
Histamine
Serotonin
Thromboxanes
Prostaglandins
Microvascular changes and loss of capillary integrity
Extra-vascular fluid sequestration
Massive whole-body fluid shifts in large burns
Immune/Inflammatory derangement
Burn Resuscitation formulas/substances
Fluid creep development
Markers of resuscitation
ACS
Adequate resuscitation has been succeeded by fluid
creep,producing excessive resuscitation in the
apparent belief that if some fluid is good, lots of fluid
will be even better. The consequences of too much
fluid can be life-threatening. Especially when they take
the form of the abdominal compartment syndrome .
B. Pruitt
Complications may include:
Pulmonary edema,
Gastrointestinal dysfunction,
Abdominal and
Extremity compartment syndromes,
Delayed wound healing,
Increased incidents of infection,
Elevated orbital pressures
and multiorgan failure.
Few centers use colloid as initial resuscitative fluid; many use it as a
rescue therapy.
Other rescue therapies explored include plasma exchange, with good
results
Adequate endpoints of resuscitation are not entirely clear.
Historically, UOP is the classic measure of adequate resuscitation. Interestingly,
however, Dr. Baxter never described UOP as a specific parameter in the original
studies.
Utilized correction of the depressed cardiac output (CO) as well as the deficits in
the extracellular fluid (ECF) volume space and plasma volume as the reported
endpoints.
The 11 human subjects usually achieved UO > 50 mL/h within 2-6 hours of
injury but this was not a formally reported variable.
In the description that followed of the clinical series of 277 human burn patients
with 20% > 70 % TBSA burns in this same article, the UO response was again not
specifically reported.
In fact, to quote Dr. Baxter, in 1979 : urine volume, about which we could argue
all day, is an inaccurate sign, and yet it is the best clinical sign we have. This, of
course, with 1979 technology
Unroof blisters vs. not
Unroof -- pain but allows visualization of wounds,
application of topical treatment, release of
inflammatory cytokines in blister fluid
Unhealthy tissue needs to be removed ASAP, <24hr if
able
Medical Debridement
typically performed in hydrotherapy room upon admission
decontamination of chemical/gasoline for no less than 20-30
minutes
unroofing blisters, removal of eschars, initial cleansing of
wounds, application of topical medications
Surgical Debridement
typically performed in operating room once wounds declared
ready for surgery
excision of all damaged tissue (eschar, fat, muscle, limbs) until
healthy tissue is reached
1. Antimicrobial layer
2. Non-adherent layer
3. Anti-sheer layer
4. Compression layer
Silver Sulfadiazine
Mafenide Acetate
Bacitracin/Bactroban
Silver impregnated dressings (i.e. acticoat)
Inhalation Injury (~7% of patients in NBR)
Hx: closed space fire, meth lab explosion, or
petroleum product combustion
Upper airway injury: acute mortality
facial/intraoral burns, naso/oropharyngeal soot, sore throat,
abnormal phonation, stridor
Lower airway injury: delayed mortality (honeymoon
period)
dyspnea, wheezing, carbonaceous sputum, COHb,
PaO2/FiO2
Will increase resuscitation volumes
Clinical dx - bronchoscopy confirmation
Intubate EARLY!!! Orotracheal
Surgical airway uncommon
Probably the main factor responsible for mortality in thermally
injured patients
Inhalation injury increases burn mortality by 20%
Pneumonia independently increases the mortality by 40%
Children and elderly are especially prone to injury/pneumonia
due to limited physiologic reserve
Improvements in mortality from inhalation injury mostly due to
improvements in critical care
Treatment of inhalation injury has not kept pace with
improvements in care of cutaneous burns
Multiple mechanisms in addition to thermal injury that
contribute
Lack of uniform criteria for diagnosis
No standardized quantifying system
Little evidence based medicine-mostly based on case reports,
animal data, and anecdoctal experience
Few multi-center trials in burn care
No class I evidence for any treatment modalities
Clinical Indications for Intubation:
Stridor
Hoarseness
Dysphonia
Massive burns requiring aggressive crystalloid resuscitation (not absolute)
PaO2<60
PaCO2>50 (acutely)
Consider possibility of CO or HCN poisoning in structural fires
Hgb has >200x affinity for CO over O2
CO t1/2 at normal pressure/O2 is app 2.5 hrs
O2 therapy can decrease t1/2 life
HBO can decrease to app 40 min, but not standard of care
Intubation and 100%FIO2 typically adequate
COHgb checked; if elevated checked frequently

COHgb Level Symptoms
0 - 5 Normal Value
15 - 20 Headache, Confusion
20 - 40
Disorientation, fatigue, nausea, visual
changes
40 - 60
Hallucinations, combativeness, coma,
shock
> 60 Cardiopulmonary arrest, death
Controversial
Very rare event with little human data available
Cyanide can be produced by the combustion of natural or synthetic household
materials, including synthetic polymers, paper, wool, silk, polyurethane, and
more
Hypoxia, elevated lactic acid, and metabolic acidosis are considered hallmarks
of cyanide toxicity, but are more likely the result of an oxygen poor environment
in a typical house fire, CO poisoning, underresuscitation, and associated trauma
Hyperbaric oxygen therapy is not advocated

Cyanide antidote kit
Sodium Thiosulfate acts as sulfur donor to enhance endogenous elimination
of CN
Sodium Nitrate and Amyl Nitrate both act to induce methemoglobinemia.
Methbg does not bind CN with a high-affinity, so less CN is transported to the
tissue
Side effect is hypotension and reduced O2 carrying capacity
Hydroxocobalamin (Cyanokit)
Natural form of vitamin B12
detoxifies CN through the irreversible formation of cyanocobalamin which is
excreted in the urine (chelates cyanide)

How new definition will lead to improvement sin care, reduction in
VAEs, or otherwise impact critical care of the burn unit are still
unclear. Data still needs to be collected and analyzed.
Early Intubation
Aggressive Pulm Toilet/Bronchial Hygiene
Consider non-traditional ventilatory strategies (i.e. APRV, HFPV)
Consider Tx Bronchoscopy
Inhaled pharmacological txs
Long-term sequelae

Burns make up 10% of all child abuse cases
Most victims under the age of 10 with the majority under the age of 2
Inflicted burns often leave characteristic patterns
Burn pattern inconsistent with account of injury
Look for clean lines of demarcation
Are the burns located on the buttocks, area between the legs, wrists, ankles,
soles, or palms?
Are other injuries present? (healed burn, bruises, fractures)
Often delay in seeking medical attention
Immersion burns are most common (look for sparing on buttocks & popliteal fossa,
and look for splash marks)
Contact burns (burn often mirrors branding object like curling iron, steam iron,
cigarette lighter, etc.)

Accounts for app 15% of
burn injuries in children
Suspect based on H&P
Delayed presentation
Conflicting histories
Previous injuries
Sharply demarcated
margins of burns
Uniform depth
Absence of splash marks
in scald burns
(stocking/glove
presentation)

Any suspicion needs
appropriate work-up
by trained personnel.
If unable to
appropriately
evaluate, needs timely
transfer per ABA
criteria
Child Abuse
xxxxx
xxxxx
xxxxxxx
xxxxxxxxx
Child Abuse
e
xxxxx
xxxxxx
ABLS delineates well will be
offering course at MU over next
several months

Evaluate as a trauma
ABCs (Stop the burning)
Universal Precautions
Decontaminate if chemical
Stabilize hemodynamically *************** resuscitate
with IV crystalloid (LR > NS) **************
Provide analgesia (IV)
Intubate if clinically (by story AND PE) suspect inhalation
injury, particularly with large burns requiring significant
resuscitation
Dress with warm, clean linen (sheets will do)
Adjuncts (do not delay transfer):
Place foley for resuscitative-size burns
Place NGT (OGT if intubated) for burns >20%
Assess extrmities that are burned (circumferential especially)
Frequent VSs

ABA Burn Center Referral Criteria

Burn injuries that should be referred to a burn center include:

1. Partial thickness burns greater than 10% total body surface area (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 preexisting 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
risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit.
Physician judgment will be necessary in such situations and should be in concert with the regional
medical control plan and triage protocols.
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.
Burn Injuries are complex and multi-factorial, requiring standardized
and specialized care in Burn Centers for optimization of outcomes.
Any question or concern regarding a patient with a burn injury of
whatever type should have a discussion with a burn center, and
possible transfer.
University of MO George David Peak Memorial Burn Care Center is
available for consultations 24/7 and are always willing to be of
assistance in whatever fashion we can.
(573)882-6985

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st
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(2008); 761 769
Donaldson IML (2004). Ambroise Pars account in the Oeuvres of 1575 of new methods of
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Burn Resuscitation; Alvarado, R; et al; BURNS 35 (2009); 4-14
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Evolution of Burn Resuscitation in Operation Iraqi Freedom; Chung, KK; et al; J Burn Care Rehabil
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al; J Trauma. 2009;66:329336
Esophageal echo-Doppler Monitoring in Burn Shock Resuscitation: Are Hemodynamic Variables
the Critical Standard Guiding Fluid Therapy? Wang, GY; et al; J Trauma. 2008;65:13961401
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2009;67: 358365
The Phenomenon of Fluid Creep in Acute Burn Resuscitation; Saffle, JR; J Burn Care Res
2007;28:382395