1/15/2024

Burns (Cutaneous)
Surgery V: Skin Series
Kabarak University
Facilitator: Kinyua M.D.|
@2024|

Definition
• Acute traumatic injuries to the skin or underlying tissue
caused by exposure to thermal energy, chemicals, electrical
discharge, or radiation.
• Injuries, predominantly to the skin and superficial tissues,
caused by heat from hot liquids, flame, or contact with
heated objects, electrical current, or chemicals.

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Epidemiology
• Incidence of fire-related injuries worldwide is; 1.1 per
100,000
• Most are minor, only 2% cover > 40% total body surface area
(TBSA)
• Cause 34,000 deaths/year:
» Fatality directly correlated with % surface area burned
» ½ of patients with 60%–70% surface area burns die.
• Approximately 3000 deaths/year in the US & about 2 million
physician visits.

Cont.’
• Bangladesh, Colombia, Egypt, and Pakistan (WHO):
» 17% of children with burns have a temporary disability and 18% have a
permanent disability.
• Globally, in 2017 nearly 9 million people were recorded as
injured by fire, heat, or hot substances.
• An estimated 180,000 people die every year after burn
injuries; the vast majority in developing countries.
• The rate of child deaths from burns is over 7 times higher in
developing than in developed countries (WHO).

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Risk Factors
• Young children
o Lack of coordination, dependency, and poorly developed self-
protective mechanisms
• Age >60 years
o Lack of coordination, dependency, and poorly developed self-
protective mechanisms.
• Male sex
o Increased risk-taking behaviors and more frequent involvement in
employment with exposure to open flame or high voltage.

Etiology
• Heat (Thermal)
• Electric
• Chemical
• Radiation

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Cont.’
• Thermal burns:
» External heat source (flame, hot liquids, hot solid objects, or
occasionally, steam).
» Fires may also result in toxic smoke inhalation
» Young children, about 70% of burns caused by scalding from hot
liquids
» Older children and young working adults, flame injuries are more
likely
» Older adults, scalds and cooking accidents are most common.

Cont.’
• Electrical burns:
» Caused by low-, intermediate-, and high-voltage exposures, causing a
variety of local and systemic injuries.
» Result from heat generation and electroporation of cell membranes
associated with massive currents of electrons.
» High voltage (> 1000 volts) electrical burns often cause extensive
deep tissue damage to electrically conductive tissues, such as
muscles, nerves, and blood vessels, despite minimal apparent
cutaneous injury.

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Cont.’
• Chemical burns:
» Caused by exposure to industrial or household chemical products.
» Includes; strong acids, strong alkalis (eg, lye, cement), phenols,
cresols, mustard gas, phosphorus, and certain petroleum products
(eg, gasoline, paint thinner).
» Skin and deeper tissue necrosis caused by these agents may progress
over several hours.

Acid attack burns.

Chemical burns on the chest, back, neck and arm of a 37-year-old man who
was the victim of an acid attack.
Parts of the skin on his head and face were also burnt.

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Cont.’
• Radiation burns:
» Most commonly result from prolonged exposure to solar ultraviolet
radiation (sunburn)
» May result from prolonged or intense exposure to other sources of
ultraviolet radiation (eg, tanning beds)
» Exposure to sources of x-ray or other ionizing radiation.
» Can occur with X-rays or gamma rays used for teletherapy and
interventional radiology (Waghmare, 2013).

Note; (Pearls)
• Nonaccidental burns:
▪ Approximately 20% of burns in younger children involve abuse or
neglect.
▪ Should be considered in young children and older patients with burns.
• Events associated with a burn:
▪ Examples; (jumping from a burning building, being struck by debris,
motor vehicle crash) may cause other injuries.

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Pathophysiology
Local response:
• Skin has low heat conductivity, so most thermal burns only
involve the epidermis.
• Involves the coagulation of injured tissue, and to some degree
incites progressive microvascular reactions in the surrounding
dermis.
• Heat from burns causes protein denaturation and thus
coagulative necrosis.

Cont.’
• Around the coagulated tissue; platelets aggregate, vessels
constrict, and; marginally perfused tissue (known as the; zone
of stasis) can extend around the injury.
• In the zone of stasis, tissue is hyperemic and inflamed.
• Damage to the normal epidermal barrier allows;
» Bacterial invasion
» External fluid loss
» Impaired thermoregulation

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Cont.’
• Injured areas can be subdivided into 3 zones, like a bullseye:
1.Zone of coagulation and necrosis:
» Innermost zone
» Irreversible cell death and damage
2.Zone of ischemia:
» Decreased circulation
» Tissue may progress to necrosis.
3.Zone of hyperemia:
» Vasodilation
» Usually heals without long-term complications

Cont.’
Systemic response:
• As burns become larger than about 20% of the TBSA, a
systemic response ensues, driving fluid loss and release of
vasoactive mediators from the injured tissue.
• Clinically this results in early capillary leak, interstitial
edema, and organ dysfunction, which is addressed through
burn fluid resuscitation.
• In well-resuscitated patients, this physiology will self-
extinguish and be replaced by a hypermetabolic response;
with a near doubling of cardiac output and resting energy
expenditure over the next 24 to 48 hours.

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Cont.’
• Accelerated gluconeogenesis, insulin resistance, and
increased protein catabolism are associated with this response
and; have major implications for subsequent support of burn
patients.
• Nutritional support of this physiologic response is essential.
• Subsequent natural history of burns is driven by the wound.
• A burn wound is initially clean but is rapidly colonized by
endogenous bacteria.

Cont.’
• As these bacteria multiply, proteases liquefy the eschar,
which then separates, leaving a bed of granulation tissue or
healing burn depending on the depth of the injury.
• In healthy patients with small burns this septic process is
often well tolerated.
• However, when injuries are larger, systemic infection results,
resulting in poor survival of patients with burns involving >40%
TBSA managed without early wound excision

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Classifications
Burns are described using 2 identifiers:
• Degree: depth of burn on body
• Severity: % of TBSA burned

Cont.’ - Burn Degree

Standard clinical classification of burns according to depth:
▪ First-degree burns:
• Erythema involving the epidermis only
• Usually dry and painful
• Typical of severe sunburn.
▪ Second-degree burns:
• Superficial partial-thickness burns involving the epidermis and upper dermis
• Deep partial-thickness burns involving the epidermis and dermis
• Usually wet and painful
• Typical of scalding injury.

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Cont.’
▪ Third-degree burns:
• Full-thickness burns involving the epidermis and dermis and damage to
appendages
• Usually dry and insensate
• Typical of flame or contact injury.
▪ Fourth-degree burns:
• Involve underlying subcutaneous tissue, tendon, or bone
• Typical of high-voltage electrical injury

Degrees of thermal burns

Degree of burn Characteristics Symptoms Healing
Superficial burn (1st • Limited to epidermis • Itching to pain • Unscarred
degree) • No destruction of skin • Spontaneous recovery
• Hyperemia (red),
blanches with pressure
• Edema

Superficial partial • Limited to epidermis • Severe pain • Usually unscarred

burns (2nd degree) • Hyperemia • Spontaneous recovery
• Wet wound bed
• Intact sensibility
• Blistering

Deep superficial burns • Epidermis and dermis • Severe pain • Partial recovery with
(2nd degree) damaged scar formation
• Dry wound bed
• Bright and reddened
areas

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Full-thickness burns • Damage to all skin layers, • Painless because • Skin regeneration
(3rd degree) including superficial fascia nerve endings have no longer possible
• Grey-white discoloration of been destroyed • Need excision and
skin grafting
• No blisters

Full- • Involves muscles, tendons, • Painless • Skin regeneration

thickness/eschar or bones no longer possible
burns (4th degree) • Leather-like • Need excision and
• Charring of tissue grafting

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Cont.’ - Burn Severity

To determine the severity of the burn, calculate the percentage of TBSA
injured:
• A patient’s hand is approximately 1% of TBSA.
• Use the rule of 9s in adolescents and adults.
• Modified rule of 9s applies to patients under 15.

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Rule of 9 in adolescents and

adults used to determine the TBSA
of burn

Rule of 9 in children used to determine the

TBSA of burn:

Infant and children’s heads and legs account of a

larger and smaller proportion of total body
surface area respectively when compared to
adults. As they grow, the percent represented
by these areas changes to more closely resemble
adults.

Area A represents 8.5% TBSA in a 1 year old,

6.5% in a 5 year old, 5.5% in a 10 year old and
4.5% in a 15 year old.

Area B represents 3.25% TBSA in a 1 year old,

4.0% in a 5 year old, 4.5% in a 10 year old and
4.5% in a 15 year old.

Area C represents 2.5% TBSA in a 1 year old,

2.75% in a 5 year old, 3.0% in a 10 year old and
3.25% in a 15 year old.

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Classification of burn severity into mild, moderate, and severe

Mild Moderate Severe

Children < 5% TBSA 5%–10% TBSA > 10% TBSA

Adult < 10% TBSA 10%–20% TBSA > 20% TBSA

Elderly < 5% TBSA 5%–10% TBSA > 10% TBSA

All < 2% full thickness 2%–5% full thickness, high > 5% full thickness, high
voltage, inhalation, voltage, inhalation,
circumferential, comorbid circumferential, comorbid
disease disease

Disposition Outpatient Admission Burn unit

Clinical Case/Vignette
1. As a result of an accident in the kitchen, a 20-month-old toddler
had boiling pasta and water spilled onto her head, face, and
upper body. Physical exam reveals blistering sloughing skin with
underlying wet, tender erythema.
2. A 40-year-old electrician was servicing a high-voltage transformer
when a distant switch inadvertently sent current to the
transformer, with a resulting arc and electrocution. The worker
was thrown back by the force and his clothing was ignited.
Physical exam reveals charring of the dominant hand, with deep
arching injury across the antecubital fossa and axilla, consistent
with passage of high-voltage current. The upper torso
demonstrates leathery deep burns consistent with flame injury.

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Diagnostic Approach
• Initially sort burn patients into those who can be reasonably
managed in the outpatient setting and those who require
inpatient care.
• This important practicality is based on:
✓A proper and complete evaluation of the patient
✓A careful evaluation of the wound.
• Assess burn severity by the burn size (% total body surface
area [TBSA]) and depth (first to fourth degree).
• Associated injuries, such as inhalation injury or trauma,
adversely affect the prognosis.

Evaluation of the patient

Primary survey (ABCDE):
▪ Airway maintenance;
• with cervical spine protection if a fall or blunt force trauma is
suspected.
▪ Breathing and ventilation.
• Circumferential full-thickness burns of the trunk and neck may
impair ventilation and require close monitoring.
▪ Circulation and cardiac status.
• Increased circulating catecholamines often elevate the adult heart
rate to 100-120 bpm; higher heart rates may indicate hypovolemia
from an associated trauma, inadequate oxygenation, or unrelieved
pain or anxiety.

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Cont.’
• Abnormal cardiac rhythms may be due to electrical injuries,
underlying cardiac abnormalities or electrolyte imbalances.
• Circulation in a limb with a circumferential or nearly circumferential
full-thickness burn may be impaired by oedema.
• Typical indicators of compromised circulation (pain, pallor,
paresthesia) may not be reliable in a burned extremity.
• Absence of a radial pulse below an upper limb circumferential burn
suggests impaired circulation.
▪ Disability, neurologic deficit and gross deformity.
• Typically, the patient with burns is initially alert and oriented.

Cont.’
• If not, consider associated injury, carbon monoxide poisoning,
substance abuse, hypoxia, or pre-existing medical conditions.
• Determine the patient's level of consciousness using the AVPU
method.
• The Glasgow Coma Scale (GCS) is a more definitive tool used to
assess the depth and duration of coma and should be used to follow
the patient's level of consciousness.
▪ Exposure and environmental control.
• Expose and completely undress the patient, and examine for major
associated injuries. Stop the burning process, if applicable.
• Maintain a warm environment to prevent hypothermia.

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Cont.’
Secondary survey:
• Burn-specific;
• Begins after the primary survey is completed and after initial
fluids are started.
▪ History (injury circumstances including time and mechanism of
injury, and medical history) and accurate pre-injury weight.
▪ Complete head-to-toe evaluation of the patient.
▪ Determination of burn severity, including percentage total body
surface area burned (TBSA) and burn depth.

Cont.’
▪ Initial investigations to assess for dysfunction of other organ
systems, or establish baseline function (e.g., complete blood count
[CBC], metabolic panel including blood urea nitrogen [BUN] and
glucose).
▪ Consideration of the possibility of abuse or neglect.
▪ Consideration of associated trauma, with additional specialized tests
(e.g., blood tests, imaging) as needed.
▪ Management elements of the secondary survey include further
adjustment and monitoring of fluid resuscitation (after TBSA
determination), pain and anxiety management, psychosocial support,
and wound care.

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Evaluation for abuse or neglect

• Consider the possibility as the injury mechanism as part of the
evaluation of every burn patient.
• Although more common in young children, abuse is also seen
in the setting of domestic violence.
• File suspicious injuries with the appropriate agency.
• Data can be obtained during the initial evaluation and may be
helpful later. This includes;
» Water temperature (if there is scalding)
» Duration of contact
» Caretakers involved

Cont.’
» Conflicting reports from involved caretakers
» Delay in seeking treatment
» Prior injuries
• Important points of exam include;
» Uniformity of burn depth
» Absence of splash marks
» Sharply defined wound margins
» Porcelain contact sparing (which occurs when flesh in forced contact
with the sink or tub is protected from the surrounding hot water)

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Cont.’
» Flexor sparing
» Stocking or glove patterns
» Dorsal location of contact burns of the hand
» Localized very deep contact burns
• Stressful social circumstances are often a factor.
• Child maltreatment has been shown to be associated with
TBSA burned >20%, and with burns of the lower limbs.
• Photographic documentation is ideal.
• Admit patients to the hospital for evaluation even if the injury
is of little physiologic significance.
• Consider screening radiography.

Evaluation of the burn wound

• Make initial estimates of burn wound extent and depth.
• Note the presence of fully or near circumferential
components.
∗ NB: Decisions regarding outpatient care, hospitalization, or
transfer depend on this information.
▪ Burn extent:
o Most accurately estimated using a Lund-Browder diagram that
compensates for changes in body proportions with age.
o A simpler alternative is the Wallace's "rule of nines”

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Cont.’
▪ Burn depth:
o First-degree burns
o Second-degree burns
o Third-degree burns
o Fourth-degree burns
• Burns are commonly deeper than they appear at first exam, so often
it is prudent to describe initial impressions and re-evaluate wounds
the following day.
▪ Burn location:
o Near or completely circumferential burns should be identified for
special monitoring

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Cont.’
o If involving the torso, such wounds can interfere with ventilation, or
even contribute to intra-abdominal hypertension.
o When burns involve an extremity, limb-threatening ischemia may
occur 12 to 24 hours after the injury.
▪ Burn wound sepsis:
o Can be diagnosed by clinical exam, cultures of wound biopsies, and
burn wound histology.
o Most authors advocate diagnosis by clinical exam only
o Most common organisms are Staphylococcus aureus and Pseudomonas
aeruginosa

Cont.’
o A classification scheme includes:
» "Burn impetigo" or superficial infection with loss of epithelium (usually
associated with S aureus and Streptococcus pyogenes and is particularly
common in burns of the scalp)
» Open burn-related surgical wound infection (develops in excised wounds
and donor sites)
» Burn wound cellulitis (spreading dermal infection in uninjured skin
around a burn wound or donor site)
» Invasive burn wound infection.

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Investigations (pts with significant burns)

▪ Fluorescein staining:
• Subtle corneal burns
• Inspect the globes of the eyes prior to the development of facial
edema
• Clouded cornea suggests a serious burn
• Any suspicion of eye injury warrants an ophthalmologic consultation.
▪ CBC:
• Neutropenia and thrombocytopenia may be indicators of sepsis.
▪ Metabolic panel:
• High levels of BUN, creatinine, glucose; hyponatremia, hypokalemia

Cont.’
▪ Carboxyhemoglobin:
• Indicated if inhalation injury is suspected.
• May show high levels in inhalation injury
▪ Arterial blood gas:
• If inhalation injury is suspected.
• May show metabolic acidosis in inhalation injury
▪ CT scan; Head & Spine:
• Indicated based on injury mechanism and history.
• May show brain injury or fracture in cases of head or spine trauma

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Cont.’
▪ Wound biopsy culture:
• If sepsis is suspected.
• Positive for the causative organism in wound infection
▪ Wound histology:
• If Sepsis is suspected. May show wound infection.

Treatment Approach
Acute Burn Management:
• Should follow a systematic approach emphasizing patient
stability (ABCDE), fluid resuscitation, treatment of
associated injuries and prompt consultation with burn
specialist services where appropriate.
• Limited burn-specific initial first aid should be provided;~
» Cooling thermal burns with running water (up to 20 minutes)
» Rinsing chemical burns on the skin or in the eyes with running water.

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Cont.’
» Covering a burn with a clean wet cloth or plastic cling wrap to
protect it during transit to medical care (burns on an extremity
should be covered rather than wrapped to allow for possible
swelling).
» Do not deroof or aspirate blisters, as this may increase the risk of
infection.
• Outpatient burn management
• Inpatient and specialist burn management

Outpatient Burn Management:

• Key is careful patient selection and a well-rehearsed care
plan.
• Patients with smaller burns who have adequate support at
home.
• Most burns selected are superficial and heal within 2 weeks.
• If this is not the case, patients may benefit from specialty
evaluation.
• Wounds of the face, ears, hands, genitals, and feet have a
functional and cosmetic importance out of proportion to their
wound size.

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Cont.’
Wound care and Inspection:
• Initial treatment - consists of wound cooling, cleaning, and
dressing.
• Pain management and tetanus prophylaxis.
• Access for regular follow-up through the healing period.
• Frequency of follow-up depends on;
o Wound severity
o Patient age
o Patient comfort
o Family competence
o Availability of community nursing resources.

Cont.’
• Cleaning~
o Clean burn wounds with lukewarm tap water and a bland soap.
• Topical antibiotic prophylaxis~
o Range from aqueous solutions to antibiotic-containing ointments and
debriding enzymes.
o Silver antiseptic (several forms);
» Silver sulfadiazine cream – 1% apply OD/BD
» Aqueous silver nitrate solution
» Dressings containing nanocrystalline silver
o Wounds around the eyes can be treated with topical ophthalmic
antibiotic ointments.

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Cont.’
o Treat deeper ear burns with mafenide~
» Only agent that will penetrate relatively avascular cartilage.
» Important as infection of the cartilaginous skeleton of the external ear can
cause significant deformity.
» 8.5% - apply to affected area(s) once or twice daily
• Dressings~
o Simple gauze wraps minimize soiling of clothing and protect the
wound from trauma.
o Wound membranes - provide pain control, prevent wound
desiccation, and reduce wound colonization
o First days immediately after burning, when wound depth is unclear,
topical agents are often ideal.

Cont.’
• Dressing changes~
o Clean rather than sterile technique is reasonable.
o Accumulated exudate and topical medications should be gently
cleansed with lukewarm tap water and a bland soap.
o Soaking adherent dressings prior to removal – reduce pain.
o Gently cleanse wounds with a gauze or clean washcloth, inspect for
any sign of infection, pat dry with a clean towel, and redress.
o Patient and family should be advised to return promptly if they
notice; erythema, swelling, increased tenderness, lymphangitis,
odor, or drainage.
o Anxiety and pain: oral opioid given 30 to 60 minutes before a
dressing change.

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Cont.’
o Interval between dressing changes - Daily cleansing and a dressing
change.
• Scar management~
o Essential aspect of comprehensive burn care.
o Grading of scars is not uniformly done - subjective practice
o Laser interventions and multimodality scar management program.

Inpatient and Specialist Burn

Management:
• Admit patients who;
o Cannot take fluid by mouth
o Need burn resuscitation
o Potentially have inhalation injury
o Cannot be managed in the outpatient setting
• Patients initially managed in the clinic (outpatient) setting
will subsequently require admission if;
» Increased pain and anxiety
» Inability to keep scheduled appointments
» Delayed healing
» Signs of infection
» Wound that appears deeper than initially estimated.

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Cont.’
• Referral to a specialized burn center:
o American Burn Association (ABA)
o Following burn injuries should be referred:~
» Partial-thickness burns of >10% total body surface area
» Burns that involve the face, hands, feet, genitalia, perineum, or major joints
» Third-degree burns in any age group
» Electrical burns, including lightning injury
» Chemical burns
» Inhalation injury
» Burn injury in patients with pre-existing medical disorders that could
complicate management, prolong recovery, or affect mortality
» Burned children in hospitals without qualified personnel or equipment for the
care of children

Cont.’
» Burn injury in patients who will require special social, emotional, or
rehabilitative intervention
» Any patients with burns and concomitant trauma (such as fractures) in which
the burn injury poses the greatest risk of morbidity or mortality.
o Additional referral criteria/considerations;
» Full-thickness burns ≥ 5% TBSA burned.
» Children and older adults (>55 years of age).
» Smaller burns should be followed up in burn center outpatient settings as soon
as possible after injury, and preferably within a week.
» Consider telemedicine consultations as an alternative to immediate transfer or
outpatient referral for selected patients.
∗ Burn center transfer criteria vary and may depend on local resources
and/or configuration of specialist burn services.

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Cont.’
• Inpatient treatment:
o Involves; fluid resuscitation, wound care, critical care, and surgery.
o Divided into 4 phases:
» Initial evaluation and resuscitation
» Initial excision and biologic closure
» Definitive wound closure
» Rehabilitation and reconstruction.
o The phases overlap, and intensive care plays an important role in
the first 3 phases.

1. Initial evaluation and resuscitation

• Usually the first 24-72 hours after injury.

• Document the full extent of the injury (including nonburn
trauma) and perform fluid resuscitation.
• Patients with airway involvement or major burns generally
require intubation and mechanical ventilation, although
intubation (done selectively).
• Carbon monoxide intoxication is best treated acutely by
effective ventilation with 100% oxygen.
• Burns >20% TBSA, reduced capillary integrity becomes
clinically important, with a resulting need for fluid
resuscitation.

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Cont.’
o Burn formulas (several) are used to initiate resuscitation;
o None can be assumed to be accurate in an individual patient.
o Bedside titration of infusions, based on physiologic endpoints, is
important.
o Gentle titration is advised~
o Parkland formula (often used), and suggests; 4 mL/kg/% burn over
the first 24 hours, half in the first 8 hours.
o Young children should receive 5% dextrose in lactated Ringer
solution at a maintenance rate to ensure they do not develop
hypoglycemia.

Holliday-Segar Formula for Maintenance Fluid Requirements by Weight

Weight Water Electrolytes (mEq/L H2O

(kg)
mL/day mL/hour and mmol/L H2O)

Sodium 30
0–10 100/kg 4/kg
Potassium 20
Sodium 30
11–20 1000 + 50/kg for each kg > 10 40 + 2/kg for each kg > 10
Potassium 20
Sodium 30
> 20 1500 + 20/kg for each kg > 20 60 + 1/kg for each kg > 20
Potassium 20

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Cont.’
• Electrical:
o Cardiac monitoring, and measurement of oxygen saturation
• Successful early pain control can enhance important aspects
of long-term outcome.
• Tetanus immunization;
o Should be updated in patients with wounds deeper than a superficial
partial-thickness burn.

Cont.’
• Adequate nutritional support:
» Accelerates wound healing
» 25-40 kcal//kg/day, depending on the extent and severity of injuries
» Refined calculations equations; such as the Harris-Benedict
equation, or needs can be measured using indirect calorimetry.
» A reasonable protein target is 1.5 to 2 grams/kg/day, and trace
element and vitamin needs should also be met.
» Enteral route - effective

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2. Initial excision and biologic closure

• Identification and removal of large areas of full-thickness burn

before wound sepsis and systemic inflammation develop.
• Should be done using staged hemostatic and minimally
ablative techniques.
• Near- or completely circumferential burns should be identified
for special monitoring and possible escharotomy.
o Escharotomy; - it is important not to damage uninjured skin or
superficial neurovascular structures.
o Coagulating electrocautery; anesthesia or sedation
• Close wounds with autograft (Ideal)

Cont.’
• Temporary wound membranes can be useful for large wounds.
o Amniotic membrane can be an accessible and effective temporary
membrane, but blood-borne infectious disease screening remains a
concern.
o Changes the natural history of the injury (inevitable systemic sepsis
and inflammation)

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3. Definitive wound closure

• Duration varies depending on wound size and complexity.

• The objective is to replace any temporary membranes with
autograft and to close small complex wounds, such as on the
hands and face.
• May take many weeks if donor sites are severely limited.
• Intensive care is important.
• Strong collaboration between the surgical, medical, nursing,
and other disciplines.
• Deep venous thrombosis is a risk.

4. Rehabilitation and reconstruction

• Longest phase of care.

• Begins with early ranging and splinting, and antideformity
positioning.
• As wounds are closed and patients are moved from intensive
care, passive and active motion and strengthening become
important.
• Scar management and emotional support are extremely useful
• Planned as soon as functional or aesthetic deformities hinder
further recovery.

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Cont.’
• Long-term follow-up;
o Those with larger injuries
o Support of the family group
o Patient and family education
• Address pruritus (can be a persistent discomfort in the first
months)
• Pain and anxiety management is essential;
o Infusion of opioids and benzodiazepines (e.g., morphine sulfate and
midazolam)
o Nonpharmacologic therapies

Cont.’
o Morphine sulfate - 10-30 mg orally (immediate-release) every 4 hours
when required initially, titrate dose according to response
• Consider the psychosocial needs of the survivor during and
following hospitalization and rehabilitation.

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Treatment of Wound Infection:

• Regular monitoring - allows for the early recognition of
infection.
• Burn infections require aggressive management;
o Admission
o Intravenous antibiotics
o Observation
o Surgery excision if wounds are deep
o Penicillin G sodium:
» 4 million units intramuscularly/intravenously every 4 hours, maximum 24
million units/day

Cont.’
o Cefadroxil:
» 1 g orally/day given in 1-2 divided doses
o Vancomycin:
» 15-20 mg/kg intravenously every 8-12 hours

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Prevention
• Public Education
• Legislation
o Example - installation of smoke detectors
• Working knowledge of the local population and culture

Complications
• Sepsis
• Pneumonia
• Endotracheal intubation:
» nasal alar and septal necrosis
» vocal cord erosions and ulcerations
» tracheal stenosis
» tracheoesophageal and tracheoinnominate artery fistulae
• Sinusitis and otitis media
• Chondritis
• Hepatic dysfunction - transient hepatic blood flow deficits

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Cont.’
• Acalculous cholecystitis
• Gastroduodenal ulceration-
» Result of splanchnic blood flow deficits that degrade mucosal
defenses.
» Routine histamine receptor blockers and antacids
• UTI – catheter-related
• Respiratory failure
• Hepatic failure - complicates sepsis and multi-organ failure.
• Pancreatitis

Cont.’
• Hypertrophic scaring;
» Treatment options include compression garments, massage, judicious
steroid injections, topical silicone products, and scar release and
resurfacing procedures.
• Heterotopic ossification - around deeply burned major joints
• Transient delirium
• Seizures (hyponatremia & abrupt benzodiazepine withdrawal)
• AKI
• Acute adrenal insufficiency

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Cont.’
• Endocarditis
• Suppurative thrombophlebitis
• DVT
• Intestinal ischemia
» Can progress to infarction.
» From inadequate resuscitation and splanchnic blood flow deficits.
• Corneal abrasion
• Nerve injury
• PTSD:
» up to 30% of patients

Cont.’
» Probably exacerbated by inadequate treatment of pain and anxiety.
» Symptoms include hypervigilance, reliving the incident, night
terrors, and chronic fearfulness.
» Recognition and treatment with supportive psychotherapy and
pharmacotherapy greatly facilitate recovery.
• Compartment syndrome
• Hypertension;
» preadolescent boys, and is best treated with beta-blockers
• Marjolin ulcer;
» squamous cell carcinoma that occurs in chronic ulcerated open areas
in old burn wounds.

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Gratias tibi!

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