Burns

45 year old man working on an off shore petrochemical

company is caught in a fire in a room. He suffers 40% burns
on initial assessment. What is his predicted mortality?
Mortality
50% mortality
Children 98% burns
Adult 75% burns
>64 years old 20% burns
45-64 50% burns
Children < 5y & adults > 65y highest mortality
MacLennan N. Anesthesiology 1998; 89: 749-70
Marko P et al. Curr Opin Anaesthesiol 2003; 16: 183-91
Prediction of mortality

Abbreviated burn severity index (ABSI)

Tobiasen et al. Surg Gynaecol Obstet 1982; 154: 711-4
Prediction of mortality
Plasma cholinesterase ! accuracy of ABSI
82 " 87.6%
Complete recovery to normal levels
found only in survivors
Female 2X mortality
Baux score
Age + % burn surface area
Wibbenmeyer et al. Burns 2001; 27: 583-90
How do you assess size of burns?
The Rule of Nines
Size of burns
% total body
surface area
Adults:
Head & arms 9%
each
Anterior &
posterior trunk,
each leg 18%
18
4
.
5
9
1
9
4.5
18
4
.
5
4
.
5
9 9
4.5
9 9
4.5
7
4.5
7
4.5
7
18 18
1
Rule of eleven
Infants :
Head, arms,
anterior &
posterior trunk
11%
Legs 22%
Lund-Browder Method
Most Accurate
To avoid significant
error
Based on age (growth)
Can be used for adult,
children & infants
Size of burns
Conventionally patients hand 1%
Overestimation up to 25%
Palm 0.4%
Hand 0.8%
> in obese & females
Perry RJ et al. BMJ 1996
How do you assess the depth of burns?
What is its appearance & how does it affect
the management of the wound?
Depth of burns
Difficult to determine visually
Revision after 24-72h & after 1-2 weeks
Under resuscitation can cause
deterioration to > severe grade
Superficial-Thickness Burns
1
st
degree
i.e. Classic sunburn
Erythema involving
epidermis only
Wound Appearance:
Red to pink, Mild
edema
Dry & no blistering
Pain / hypersensitivity
to touch
Superficial-Thickness Burns
Desquamation of dead skin
occurs 2-3 days post-burn
Wound Healing:
In 3 to 5 days (spontaneous)
No scarring / other complications
Superficial, Partial-Thickness Burns
2
nd
degree
Involves upper 1/3 of
dermis
Wound Appearance:
Red to pink
Blistering moist
wounds
Blanch with pressure
Mild to moderate
edema
Superficial, Partial-Thickness Burns
Extremely painful
Wound Healing:
In 2 weeks (spontaneous)
Minimal scarring
Minor pigment discoloration may occur
Deep, Partial-Thickness Burns
2
nd
degree
Involves larger portion of dermis (not
complete)
Wound Appearance:
Mottled: Red, pink or white area
Waxy
Do not blanch with pressure
Moist, no blisters
Moderate edema
Deep, Partial-Thickness Burns
Painful; usually less severe
Wound Healing:
May heal spontaneously 2-6 weeks
Hypertrophic scarring / formation of
contractures
Wound Management:
Treatment of choice: surgical excision &
skin grafting
Full-Thickness Burns
3
rd
degree
Involves entire epidermis
& dermis
Wound Appearance:
Waxy white or leathery
grey
+ Eschar (hard & in-
elastic)
Do not blanch
Severe edema
Full-Thickness Burns
Anaesthetic/ insensate/ painless
Wound Healing:
No spontaneous healing
Weeks to months with graft
Wound Management:
Surgical excision & skin grafting
Deep, Full-Thickness Burns
4
th
degree
Extends to include muscle, tendons &
possibly bone.
Wound Appearance:
Black (dry, dull & charred)
Eschar tissue: hard, in-elastic
No edema
Deep, Full-Thickness Burns
Painless & insensitive to palpation
Wound Healing:
No spontaneous healing
Weeks to months with graft
Wound Management:
Surgical excision & skin grafting
Frequently requires amputation if
extremity involved
How do you assess the severity of burns?
What is the definition of major burns?
Severity of Burns
Total body surface (TBSA) burned
Depth of burn injury
Location of burn
All burns of face, hands, feet, face or
perineum considered severe
Age
Presence of other preexisting medical
conditions or trauma
You are called to assist in the management of the patient in
the burns ICU. What would the management emphasis be?
3 Phases of Burn Care
Resuscitation
Acute
Rehabilitation
Resuscitation Phase
First 24-48h after initial burn injury or until
spontaneous diuresis occurs.
Characterized by:
Life-threatening airway problems
Cardiopulmonary Instability
Hypovolemia
Goal:
Maintain vital organ function & perfusion
Resuscitate without fluid overload
Aggressive airway management
Early identification of inhalational injury &
impact on fluid management
Protective lung strategy
Pulmonary edema
ALI
Pneumonia
Barotrauma
Acute Phase
Begins diuresis & ends when burned area
is completely covered or healed.
Top priority is burn wound management.
Aseptic technique is critical to prevent
infection & promote healing.
Management emphasis
Early burns excision & grafting
Less pain
Rapid healing
# infection rate
Adequate analgesia
Limit psychological damage
Injury may be self inflicted
Detail the management issues
in the respiratory system?
Periop management
Pulmonary injuries
Complex inflammatory process
! extravascular lung water
Hypoproteinemia
# oncotic pressure
Direct thermal injury from steam
Barotrauma from ventilation
Changes in endothelial barrier function
Respiratory
Consider early elective intubation
Cervical spine immobilization; if necessary
Difficult intubation
Swelling progress quickly with fluid
resuscitation
Especially > 30% burns
ETT position checked regularly
Displaced with maximum edema over
12-24h
Cricothyrotomy & tracheostomy
Last resort
Complication high
Nursing Management
Assess often
High-Fowlers position
Assist with removal of secretions &
suctioning

Humidified supplemental O
2
Chest PT, deep breathing & coughing
Frequent position changes.
? Bronchodilators & mucolytics agents
Inhalational
Assess for inhalation injury:
If suspected:

Administer 100 % O
2

Obtain & Monitor: HbCO levels &
ABGs
Monitor for hypoxia &/or airway
obstruction
Anticipate nasotracheal or
endotracheal intubation
Inhalational
Mortality 2X
Suspect in
Closed space
Noxious vapour
Head & neck burns
Singed nasal hair
Erythema, blistering & swelling of
oropharyngeal mucosa
Hoarseness, stridor & wheezing
Carbonaceous sputum
Unexplained hypoxaemia, labored
breathing or tachypnea
Brassy cough or drooling
CO
200X affinity to Hb
ODC shift to left
Tissue hypoxaemia
CarboxyHb difficult to diagnose
Absorb light at the same wavelength as oxyHb

Falsely high SaO

2

PaO
2
normal
Need to measure carboxyHb levels with
cooximetry

T1/2 carboxyHb related to FiO

2
4-6h on RA

40-60min on FiO
2
1.0

20-30min on hyperbaric O
2
3 atm
Symptoms of CO
CarboxyHb < 20%
Headache, tinnitus, nausea & confusion
20-40%
Weakness, drowsiness
>40%
Severe neurological dysfunction, coma
>60%
Lethal
Smokers have 5-10%
Evaluation
CXR
Insensitive
Fibreoptic nasopharyngoscopy or
bronchoscopy
Diagnose airway edema
Aid intubation
ABG
Indication for intubation
Fire in closed space
Inhalational injury
Hoarseness, stridor, wheezing
Impaired mental state
> 30% burns
CarboxyHb > 10%
Respiratory
Circumferential full thickness burns of
thorax
# chest wall compliance
Impair gas exchange
! PVR
Emergency escharotomy
Toxic chemical products
Bronchospasm
Particulate matter can cause mechanical
obstruction of airways
Polyurethane
Hydrogen cyanide
Inhibit mitochondrial cytochrome oxidase
Tissue hypoxia
Cotton
Aldehyde
Damage respiratory mucosa
Impair ciliary function
Wood
CO
How would you fluid resuscitate this
patient?
Fluid-Balance Considerations
Assessment of depth & extent of burns.
Keep patient warm
Clean technique
Inhalational injury ! requirement of fluid
resuscitation
Cleanse wound & cover quickly
Fluid-Balance Considerations
Large gauge I.V.
Appropriate invasive monitoring ? CVP ?
IA
Foley catheter & NG tube placement
Baseline: height, weight, labs & CXR
Administer: tetanus prophylaxis
Only medication given IM
Cardiovascular
1
st
12-48h
! capillary permeability
AKA Capillary Leakage Syndrome
Loss of protein rich from intravascular to
interstitial space
$ Blistering & massive edema.
Excessive insensible losses via burn wound
$ Hypovolemia
Cardiovascular
Labs: ? Hb & Hct levels
Delay in fluid resuscitation
Burn shock
More in burns > 35 % TBSA
! renal failure & mortality
Fluid replacement protocols
Parkland formula
4ml ringer lactate/kg/% TBSA burn/ 24h
Brooke formula
1.5ml crystalloids/ kg/%TBSA burn/24h
+ 0.5ml colloid/kg/%TBSA burn/24h
+ 2000ml D5%/24h
" deficit replaced in 8h
The rest over 16h
Daily maintenance given concurrently
Adequacy of Fluid Resuscitation
Haemodynamic stability
HR & BP
CVP & PAWP
Adequate urine output 0.5-1ml/kg/h
Daily Weights
Level of Consciousness
Laboratory values
Hct poor indicator of volume status
Special Considerations
Electrical Injuries
Can cause muscle
destruction, resulting
in myoglobinuria
Urine output % 100
ml/hr (adult) to
prevent ARF
May need mannitol
for osmotic diuresis
CVS
Circulating factors depress myocardial
contractility
#CO & #BP despite adequate volume
resuscitation in immediate post burn
period
Fluid-Balance Considerations
Capillary integrity reestablish 36-72h
Reabsorption interstitial fluids
# Edema
# Hb & Hct
# fluid requirement
Diuretic phase
Hyperdynamic state
!HR, !BP, !CO
# SVR
Fluid-Balance Considerations
Monitor for Electrolyte Imbalances
Hypokalemia & hyponatremia
Monitor for Fluid Overload
Especially patients with cardiac or renal
disease
Heart failure & pulmonary edema
Describe the changes in metabolism
& nutritional needs of a burns patient?
Metabolism & nutrition
Initial # metabolism
Next few days ! with resuscitation
Peak up to 2X at 7-12 days
Proportionate to % burns

!O
2
consumption & !CO
2
production
Require high-protein & high-calorie diet to
# catabolism & promote wound healing.
Metabolism & nutrition
To cope
Early wound closure
Early enteral feeding
Survival 2X parenteral nutrition
Intestinal barrier function preserved
Prevent bacteria & fungal translocation
Metabolism & nutrition
Glutamine supplement feeding
# gram negative bacteremia
Overfeeding ! mortality
Metabolic rate further ! with low ambient
temperature
Patients have impaired thermoregulation
Nurse in temperature 24-30
o
C
What are issues that may arise in the other
systems eg renal, endocrine, GIT,
haematology?
Haematology
Rbc # half life
Thrombocytopenia
Dilution in massive transfusion
! platelet aggregation & trapping in lung
DIVC from sepsis
Bone marrow suppression
! platelet count 10-14 days
Persist for months
DVT prophylaxis after acute period
# protein C, S & antithrombin III
Renal
Possible insults
Hypovolemia
Tubular obstruction due to rhabdomyolysis
& hemolysis
Rhabdomyolysis > in electrical burns
Hemolysis > in severe cutaneous burns
Nephrotoxic medications
GIT
Paralytic gastric & intestinal ileus
Aspiration risk
NG tube to vent stomach
Curling ulcer
Gastric bleed & ? Perforation
> in children

H
2
blockers or proton-pump inhibitors
GIT
Circumferential burns of abdomen
! intraabdominal pressure
# VR
Prolonged intubation
Dysphagia
TOF ( with presence of NG tube)
Endocrine
! catecholamine, corticosteroid & glucagon
Catabolic
# muscle mass & !nitrogen breakdown
# insulin, GH & testosterone
Testosterone administration anabolic
stimulus to muscle
Aggressive insulin to achieve normoglycemia
Improve outcome
What are the concerns when
burns involve the limbs?
Neuro-musculoskeletal
Vascular compromise from ! interstitial
pressure
Eschar, burn edema & circumferential
burns
Frequent neurovascular checks
Pulses, skin color, capillary refill, motor &
sensation
Doppler pulse assessments
Surgical Management: Escharotomies
Neuro-musculoskeletal
Compartment Syndrome:
Inability of fascia to expand related to
edema results in: ! compartmental
pressure, # circulation & nerve entrapment
Often a result of deep, full-thickness burns
Surgical Management: Fasciotomy
Neuropathy 11%
Older, critically ill & h/o alcohol abuse
Encephalopathy
Pain Management
Addressed early
I.V. Route Only
No IM or SQ injections
Capillary leakage results in
unpredictable absorption
Electrolytes & Acid-Base Imbalances
Hyperkalemia
Result of cellular destruction
Hyponatremia
Result of fluid shifts into interstitial space
Metabolic Acidosis

Failure to conserve HCO

3
Fluid shifts into interstitial space
Is infection an important problem in burns? What
can you do to minimize the risk of infection in this
patient? How are burn wounds dealt with?
Infection & immunity
Specific & non specific immunity deranged in >
40% burns
Infection
Delay healing
Prevent successful skin grafting
Septicemia
Most common organism
Staph, & hemolytic strep
Gram negative rods eg pseudomonas,
klebsiella
Multi resistance bacteria eg AB
Multiorgan failure
From sepsis
Leading cause of death
Endotoxins from burns wound
Pneumonia
Translocation from gut
Prevention
Aggressive resuscitation
Early & complete burn excision - most
common source until burns have healed or
closed by grafting
Infection surveillance
Directed antibiotic therapy
Routine CVP change
Prevention
Pulmonary toilet
Minimize ventilator barotrauma
Enteral feeding especially with glutamine
Control hypercatabolic state with insulin
& ? testosterone
Minimize blood product exposure with
blood conserving technique eg tourniquet
Burns wound management
Antimicrobial Agent eg Silver nitrate
Permanent Skin Grafts
Autograft
Cultured Epithelial Autografts (3/52 to grow)
Temporary Skin Grafts (Not enough donor sites)
Biosynthetic
Homograft / Allograft
Heterograft / Xenograft (Porcine most common)
Artificial Skins
Synthetic
Infection
Pneumonia
Inhalational injury ! risk 2X
Mainly endogenous oropharyngeal &
GIT flora
50% by D3
Reactivation of herpes simplex type 1 53%
in 1
st
week
How are the pharmacokinetics
affected in burns patient?
Pharmacokinetics
Acute phase
# organ blood flow
Hypovolemia & #CO
Delay absorption
# albumin
# protein binding of acidic & neutral
drugs eg benzodiazepine
! renal & hepatic drug clearance
! '1 acid glycoprotein
Binds basic drugs eg muscle relaxants
Pharmacokinetics
Hypermetabolic phase
Quicker onset of IV drugs
! hepatic & renal clearance
Phase 1 hepatic metabolism depressed
Prolong lignocaine & pethidine half life
Conjugation normal
Drugs titrated to response
The patient is due for excision & grafting of burns
wound. What are the anaesthetic considerations?
Anaesthetic considerations
Complete trauma workup
# most commonly associated injury
Early excision & grafting
May still need resuscitation
Acid base & electrolyte disturbance
Coagulopathies
Blood
Blood requirement vary with post burn time
interval
D1 0.4ml/cm
2
D2 0.7ml/cm
2
After D4 0.9ml/cm
2
Infected wound 1-1.25ml/cm
2
! requirement because regenerating
capillary on surface
Blood available in OT
Monitoring & IV
Large bore IV
? Rapid fluid delivery system
Difficult access
Protect vascular access
ECG may need needle electrode
IA
Continuous BP monitoring
Frequent blood sampling
Monitoring
CVP
Monitor central volume status
Drug infusions
Graft subclavian 1
st
for future access
PA catheter
Myocardial dysfunction
Sepsis
Persistent hypotension
Airway Issues
Inhalational injury
CO poisoning
Difficult mask ventilation
Difficult intubation
Early
Upper airway edema
Facial burns
Later
Contractures & scars
Muscle relaxant
Sux
Contraindicated after 24h till 2y
Hyperkalemia & cardiac arrest
Greater response with greater burn injury
Non depolarizing
Resistance? Reasons
Up regulation of extrajunctional
cholinergic receptors
Altered affinity of receptors
Analgesia
!! narcotic requirement
Tolerance
! Vd
Ketamine # narcotic requirement

N
2
O for change of dressing
Temperature
38
o
C most comfortable
OT 28-30
o
C
Humidified
Low flows
Radiant heat warmer
Warmed IV
Warming blankets
Minimize exposure
Remove wet drapes
Immunosuppression
Wound excellent medium for bacterial
growth
Aseptic technique
# Blood transfusion induced
immunosuppression
Tourniquet
Adrenaline saline packs
# blood loss by 50%
! blood loss
Older
Male
Large body size
Full thickness
High wound bacteria count
Operative time
Delayed primary burn excision