TYPES OF BURNS

 Thermal: transfer of heat; Scalding (heat from liquid)

 Electrical: conduction of electricity; nerves and ms have high conductance
 Flash: sudden exposure to high heat (gas explosion); inhalational, eye injuries
 Chemical: remove toxic substance, irrigate affected area with water for 30 mins
 Others: Freeze, radiation, friction
INITIAL MANAGEMENT
FIRST AID: remove (cause/ person)  cool down (↓↓burn depth)  irrigate with water
PRIMARY SURVEY
 Airway: 100% humified O2 face mask (always)
 Breathing/ Ventilation: chest expand? Breathing? Talk to px; Chest Escharotomy (life-saving
 Circulation: BP not accurate; HR may be elevated despite good hydration; capillary refill
 Cervical Support: immobilize neck to prevent further injury
SECONDARY SURVEY
 IV Access: fluid resuscitation essential to ALL
 Wound Care: Thermal (cover, no ice), Electrical (check heart), Chemical (water)
 Pain Control: for 1st and 2nd degree burns
 AMPLE History: Allergy, Medications, Past illnesses, Last meal, Event/Environment related to injury
FLUID RESUSCITATION
 Total Body Surface Area (TBSA): erythema not included!
o Rule of 9’s: med-large burns in ADULTS
o Lund and Browder: most accurate; compensates for size variations; CHILDREN
 Calculation – 1st 24 hours: (half in first 8 hours, remaining half over subsequent 16 hours); CRYSTALLOIDS
o Parkland’s Formula
 Adult: Plain Lactated Ringer’s 2-4mL x kg x TBSA burn
 2-10 y/o: Dextrose w/ Lactated Ringer’s 3-4mL x kg x TBSA burn
 <2 y/o: D5 0.3% NaCl 3-4mL x kg x TBSA burn
o Consensus Formula: Plain Lactated Ringer’s 2-4mL x kg x TBSA burn
 Monitoring
o Overhydration  lung congestion, ↑interstitial edema, diastolic overload
o Underhydration  circulatory collapse, acute tubular necrosis, liver failure, electrolyte imbalance
o Urine Output: Adult(0.5cc/kg/hr), Children (1cc/kg/hr)
o w/ myo- or hemoglobinuria: give mannitol 12.5 g/L, NaHCO3 cockail
 Calculation – 2nd 24 hours: CRYSTALLOIDS +/- COLLOIDS
o Adult: D5W + 5% albumin
o Children: Half normal saline + 0/3-0/5 colloid
ANATOMY OF BURNS
BURN DEPTH: full thickness biopsy, Laser Doppler, noncontact UTZ

 Superficial Epidermal: erythema; no blister

 Superficial Partial Thickness: pink, painful; blistering common; heals 7-21 d
 Deep Partial Thickness: white or fixed red; sensation diminished; heals 21-35 d; excise and graft
 Deep Full Thickness: dry, leather; painless excise and graft
PATHOPHYSIOLOGY OF BURNS
 Zone of Coagulation/ Necrosis: needs excision and STSG
 Zone of Ischemia/ Stasis: can lead to necrosis
 Zone of Hyperemia: will heal
WOUND CARE
GENERAL APPROACH

 Burn Wound Edema: biphasic (rapid to gradual); ↑ capillary permeability

 Blisters: <3cm (leave alone, cover, protect) >3cm(puncture drain, never unroof)
 Eschars: excise and graft!;
 Wound Dressings
PROPER TECHNIQUE

 Sterile
 Gentle
 Early Skin Grafting
 Never Hesitate to Amputate
TREATMENT
TOPICAL ANTIBIOTIC AGENTS: S. aureus & opportunistic G(-) species (Proteus, Klebsiella, Pseudomonas)

 1% Silver Sulfadiazine (broad spec) white cream painLESS POOR Eschar ! Leukopenia
 Mafenide (broad spectrum) Water soluble painFUL GOOD Eschar ! Metabolic acidosis
 0.5%Silver Nitrate: Leaches electrolyte; stains; ! HYPOnatremia
 Calcium Nitrate with Silver Sulfadiazine: bacteriostatic
 Nitrofurazone: GOOD activity against S. aureus
BIOLOGICAL AND PHYSIOLOGICAL CONSEQUENCES
 Acute Pulmonary Edema: ventilatory support and inotropes
 Acidosis: due to dehydration
 HyperK: due to cell injury
 HypoN: relative
 Decreased: leukocyte, Ig, Helper T-cells, Fibronectin
 Increased: complement activation, IL1, TNF, Suppressor T-cells, Serum Glucose
SPECIFIC ANATOMICAL BURNS

 Face: elevate head 30o for extensive edema formation

 Eyes: irrigate with saline; ophthalmic ointments, AVOID steroids
 Ears: examine ear canal and era drum before swelling occurs
 Hands: MACROgranulation (not suitable for graft, high bac load) vs MICROgranulation (suitable, low)
 Feet: elevate
 Genitalia and Perineum: insert catheter to maintain potency
NUTRITION IN BURN PATIENTS
 Ebb Phase: 1st 24 hrs; body responds to correct fluid resuscitation
 Flow Phase: gradual INCREASE in CO2, HR, O2, temp, consumption
 Anabolic Phase: Peak 14days; normalize body disposition
 Calculation of Caloric Needs
o Harris-Benedict: gender, age, ht, wt INACCURATE for <40% TBSA
o Currei: 25kcal/kg/day APPROPRIATE fro <40% TBSA
o Indirect Calorimetry