BURNS Burn patient mortality:

 CO poisoning- Tx: 100% O2 inhalation

INITIAL EVALUATION  Cyanide poisoning
4 crucial assessment: -Tx: Sodium Thiosulfate
 Airway management Hydroxocobalamin (immediate therapy)
 Evaluation of other injuries 100% O2 inhalation
 Estimation of burn size
 Diagnosis of CO and cyanide poisoning CLASSIFICATION OF BURNS
Flame Burns
*Direct thermal injury to the upper airway or smoke - most common
inhalation --> rapid and severe airway edema - higher mortality
Tx: intubation and establishing an early airway - inhalation injury and/or CO poisoning
Electrical Burns
*Signs of impending respiratory compromise -Cardiac arrhythmias
-hoarse voice Compartment syndromes
-wheezing / stridor Concurrent rhabdomyolysis
- dyspnea -ECG
Tx: elective endotracheal intubation -low-voltage injury with normal ECG pt may not be
admitted
Primary survey -high-voltage injury- for admission due to
-Burned patients should be first considered as trauma compartment syndrome and rhabdomyolysis
patients -long term neurologic and visual symptoms
-Large-bore peripheral IV catheters should be placed and Chemical Burns
fluid resuscitation should be initiated -less common but pontentially severe burns
-2 large-bore IV are ideal for burn >40% TBSA -initial therapy:
-Central venous access provide useful info as to volume -careful removal of the toxic substance
status -irrigation of the affected area with water
-IV resuscitation is rarely indicated in patients with burns (30 mins) except for powder/ powder
<15% who can usually hydrate orally forms of lye to avoid activating
-Pediatric: burns >15% may require intraosseous access aluminium hydroxide with water
Secondary survey -FORMIC ACID
-Performed on all burn patients; evaluation of other - causes hemolysis and hemoglobinuria
injuries -HYDROFLOURIC ACID
-Urgent radiology studies -hypocalcemia
HYPOTHERMIA- common prehospitall complication that -tx: Calcium-based therapy:
contributes to resuscitation failure Topical Calcium Gluconate
Tx: wrapped with clean blankets; cooling blankets is - wounds
contraindicated with patients with moderate or large IV Calcium Gluconate
burns (>20% TBSA) - systemic symptoms
-effective tx for progressive tissue
Acute burn injury injury and intense pain
-should never receive prophylactic antibiotics -needs continuous cardiac monito
-Tetanus booster should be administered in the ER -persistent refractory hypocalcemia with
-pain management and anxiolytics (Benzodiazepines) electrocardiac abnormalities
tx: emergent excision of burned area
RULE OF NINES
-quick and effective estimate of burn size as a percentage
of TBSA in order to estimate fluid requirement
Anterior trunk – 18%
Posterior trunk – 18%
Lower ext – 18% each
Upper ext – 9% each
Head – 9%
Pubis – 1%
BURN DEPTH CLASSIFICATION RESUSCITATION
-by Dupuytren (1832) PARKLAND OR BAXTER FORMULA
- 3-4 mL / kg / % burn of Lactated Ringer’s
First-degree (superficial) solution
-painful and do not blister -half is given during first 8 hours after burn
- other half is given over the subsequent
Second -degree (Partial-thickness) 16 hours
-Superficial (depth of involved dermis) *Children <20 kg
-Deep - weight-based maintenance IV fluid with glucose
-dermal involvement supplementation + resuscitation fluid with LR
-weeping and blisters, extremely painful
*BP and urine output – gauge burn resuscitation
Third-degree (Full-thickness) MAP 60mmHg- ensues end –organ perfusion
-leathery, painless, non-blanching Urine output goal – 30 mL/hour (adults)
1-1.5 mL/kg/hour (pedia)
Fourth-degree (affect underlying soft tissue)
*Serum Lactate
-better predictor of mortality in severe burns
3 Zones of Tissue Injury Base Deficit
 Zone of Coagulation -predicts organ dysfunction and mortality
-most severely burned portion
-center of the wound *Hypertonic Solutions
-coagulated, necrotic, 3rd – 4th degree burn -transiently decrease initial resuscitation volumes
-need excision and grafting -downside: causing hyperchloremic acidosis
 Zone of Stasis
-peripheral *High-dose ascorbic acid (Vit. C)
-vasoconstrictionischemia - decrease fluid vol requirements and ameliorate
- 2nd-degree burn respiratory embarrassment during resuscitation
Superficial – heal with expectant mgt
Deep – require excision and grafting *Plasmapheresis
 Zone of Hyperemia -decrease fluid requirements in patients who
- Heal with minimal or no scarring and is most require higher volumes than predicted to maintain
like a superficial or first-degree burn adequate urine output and MAP
-filter out inflammatory mediators decreases
Note: vasodilation and capillary leak
*Burn wound evolve over 48-72 hours after injury
*Full-thickness biopsy *Ultrasound
- effective ways to determine burn depth – make rapid, non-invasive assessments during
-limitation: painful, potentially scarring acute changes in clinical condition
*Laser Doppler
-measure skin perfusion to predict burn depth TRANSFUSION
with a positive predictive value of upto 80%
*Non-contact Ultrasound *Blood transfusions are considered to be
-painless modality to predict non-healing wound immunosuppressive decrease infection and shorter time
to recurrence after oncologic surgery
PROGNOSIS
BAUX SCORE *Increases number of transfusions were assoc. with
Formula: Mortality risk = Age + %TBSA increased infections and higher mortality in burn patients
INHALATION INJURY MAFENIDE ACETATE
-commonly seen in tandem with burn injury increase -cream or solution, effective topical antimicrobial
mortality -effective even in the presence of eschar and can
- decreases lung compliance and increase airway be used in both trating and preventing wound
resistance work of breathing, increase metabolic demands infections
Decreases PaO2 : FiO2 ratio (<200) -solution: antimicrobial for fresh skin grafts
- inhalation injury, increased fluid needs - absorbed systematically
-Burn + Inhalation Injury + Pneumonia = 60% mortality -SE: pain to partial-thickness burns, metabolic
-Burn + Inhalation Injury + ARDS = 66% mortality acidosis from carbonic anyhydrase inhibition
- >60% TBSA + Inhalation Injury + ARDS = 100% mortality
-Smoke inhalation causes injury in 2 ways: SILVER NITRATE
-broad spectrum antimicrobial activity as a topical
 Direct heat injury to upper airways swelling  solution
maximal edema in first 24-48 hours -solution must be diluted (0.5%) and prolonged
Tx: short course endotracheal intubation topical application leads to electrolyte
extravasation with resulting hyponatremia
 Inhalation of combustion products into the lower -rare complication: Methemoglobinemia
airwayscause mucosal sloughing, edema, -inexpensive, causes black stains
reactive bronchoconstriction, and finally
obstruction of the lower airways DAKIN’S SOLUTION (0.5% sodium hypochlorite sol.)
-used as inexpensive topical antimicrobial
-treatment:
 Aggressive Pulmonary Toilet BACITRACIN, NEOMYCIN, POLYMIXIN B
 Routine use of nebulized bronchodilators -topical ointments for smaller burns or larger
(Albuterol) burns that are nearly healed
 Nebulized N-acetylcysteine -useful for superficial partial-thickness facial burns
-antioxidant free radical scavenger as they can be applied and left open to air without
decrease s the toxicity of high O2 conc. dressing coverage
 Aerosolized Heparin -used with greasy gauze to meshed skin grafts
-prevent formation of fibrin plugs and -AE: Nephrotoxic
decrease formation of airway casts
 Intrabronchial surfactant MUPIROCIN
-salvage therapy in patients with severe -for methicillin-resistant Staphylococcus aureus
burns and inhalation injury (MRSA)
 Inhaled Nitric Oxide
-useful as last effort in burn pts with ACTICOAT, AQUACEL Ag, MEPILEX Ag
severe lung injury who are failing other -silver-impregnated dressings
means of vent. support -increasingly being used for donor sites, skin
grafts, partial-thickness burns
TREATMENT OF BURN WOUNDS -more comfortable,reduce number of dressing
SILVER SULFADIAZINE changes and shorten hosp. length of stay
-one of the most widely used in clinical practice
-wide range of antimicrobial activity BIOBRANE
-prophylaxis against burn wound infections rather -biologic membrane
treatment of existing infections -provide a prolonged barrier under which wounds
-inexpensive, easily applied, soothing qualities may heal
-destroys skin grafts -typically used only on fresh superficial partial-
-contraindicated on burns or donor sites in thickness burns that are clearly not contaminated
proximity to newly grafted areas due to its occlusive nature
-retard epithelial margination in healing partial-
thickness wounds
-SE: Neutropenia
NUTRITION  Unfortunately the use of both prophylaxis and
 Hypermetabolic response in burn injury may raise therapeutic heparin may be associated with heparin
baseline metabolic rate as much as 200%, w/c leads induced thrombocytopenia
to catabolism of muscle proteins and decreased lean  Thrombotic complications onclude DVT, pulmonary
body mass that delay recovery. embolus, and even arterial thrombosis requiring limb
 Early enteral feeding for patients with burns larger amputation
than 20% TBSA is not only safe , but may help prevent  Burn px often req. Central venous access for fluid
loss lean body mass resuscitation and hemodynamic monitoring.
 If enteral feeds are started w/in few hours after
admission, gastric ileus can often be avoided SURGERY
 Metoclopramide can promote GI motility, advancing  Full thickness burns with a rigis eschar can form a
the tube into small bowel with nasojejunal feeding tourniquet effect as the edema progresses, leading to
can be attempted. compromised venous outflowand and arterial inflow.
 Immune modulating supplements such as glutamine  Compartment syndrome- common in circumferential
may decrease infectious complications and mortality extremity burns
in burn px via prevent’n of T-cell suppression  Abdominal and thoracic compartment syndrome may
 Formula for calculating caloric needs: also occur
Harris-Benedict equation  Warning signs of compartment syndrome include:
Curreri formula Paresthesias
 Harris-benedict= calculate caloric needs using factors Pain
such as geder, age, height and weight. Decreased capillary refill
It uses activity factor for specific injuries Loss of distal pulses
and for burns basal energy expenditure is  Abdominal compartment syndrome should be
multiplied by 2 suspectedwith decrease urine output, increased
Inacurate in burns of less than 40% ventilator airway pressures and hypotension
 Curreri formula- this formula estimates caloric  Thoracic compartment syndrome- hypoventilation,
needs =25kcal/kg per day+40kcal/% TBSA per day increased airway pressure amd hypotension
 Titrating caloric needs closely is important because  Escharotomies are rarely needed within the first 8hrs
overfeeding patients will lead to storage of fat instead following injury and should not be performed unless
of muscle anabolism indicated bec. Of terrible aesthetic sequelae
 Beta blocker use in pediatric patients decreases HR  Extremity incisions are made on the lateral and medial
and resting energy expenditure and abrogates CHON aspects of the limns and extend onto the thenar an
metabolism hypothenar eminences of the hand.
 Anabolic steroid oxandrolone has demonstrated  Early excision and grafting in burned patient did not
improvements in lean body mass and bone density in only improve mortality but also decreased
severely burnd patients reconstruction surgery, improved hospital length stay
 Insulin itself may have a metabolic benefit with and reduce cost of care
improvements of lean body mass  Excision is performed with repeated tangential slice
 Oral hypoglycemic agents such as metformin also help using a Watson or Goulian blade until only nonburned
to avoid hyperglycemia and may contribute to tissue remains
prevention of muscle catabolism  Excision to fat or fascia may be necessary in deeper
burns
COMPLICATIONS IN BURN CARE  The disadvan. of tangential excision is a high blood
 Ventilator-associated pneumonia, as with all critically loss, though this may be ameliorated with
ill patients, is a significant problem in burn patients epinephrine clysis soln. Underneath the burn
 Simple measures such as elevating the head of the  Fibrinogen and thrombin spray sealant also has
bed and maintaining excellent oral hygeine and beneficial effects on both hemostasis and raft
pulmonary toilet are recommended to help decrease adherence to wound bed.
the risk of pneumonia  Electrocautery is used to excise the burned tissue and
 Deep vein Thrombosis has been commonly believed underlying SC tissue down to muscle fascia
to be a rare phenomenon in burn px.  For excision of burns of burns in difficult anatomic
 Heparin is given for prophylaxis in this population areas such as the face, eyelids or hands, a pressurized
water dissector may offer more precision but is time
consuming
  Tight fitting pressure garments provide vascular
supportin burns
WOUND COVERAGE  Psychological rehabilitation is equally important in the
 Split thickness sheet autografts harvested with a burn px.
power dermatome make the most durable wound
coverings. PREVENTION
 In larger wounds, meshing of autografted skin  Installation of smoke alarms
provides a larger area of wound coverage.  Regulation of hot water heater temperature
 Areas of cosmetic importance such as the face, neck  Community based programs emphasizing education
and hands should be grafted with nonmeshed sheet and home inspection
grafts to ensure optimal appearance
 Integra- a bilayer product with porous collagen-
chondroitin 6-sulphate inner layer that is
attached to an outer sheet of silastic By:
-The silastic barrier helps prevent fluid loss and Dahren Gloria
infectionthe inner layer becomes vascularized, Monica Claudine Reas
creating artificial neodermis
-approximately 2wks the silastic layer is removed
and a thin autograft placed over the neodermis.
-Fatser healing of the donor site, less
hypertrophic scarring and improved joint fxn.
 Epidermal skin substitute such as cultured epithelial
autografts are an option in patients with massive
burns and very limited donor site
 Thighs make convenient anatomic donor sites, w/c
are easily harvested and hidden from aesthetic
standpoint
 Thicker skin of the back is useful in older px, who have
thinner skin elsewhere
 Buttocks are excellent donor site in infants and
toddlers
 Scalp is an excellent donor site since it is thick and
consist of many hair follicles thus heals quickly
 Epinephrine clysis is necessary for harvesting the
scalp, for both hemostasis of this hypervascular area
and also to create a smooth surface area

REHABILITATION
 Rehabilitation of burn px is integral part of clinical care
 Physical and occupational therapy is mandatory to
prevent loss of physical fxn.
 Px w/ mechanical ventilation should have passive
range of motion done at least twice a day
 Px should be taught exercise they can do themselves
to maintain full range of motion
 Px with foot and extremity bur shoud be instructed to
walk independently w/o the help of crutches to
prevent extremity swelling, desensitize burned areas
and prevent disuse atrophy.
 If postoperative immobilization is used for graft
protection, the graft should be evaluated early and at
frequent intervals so that the active exercise can be
resumed at the earliest possible occasion