DR. ALFREDO T.

RAMIREZ BURN CENTER

Department of Surgery
Philippine General Hospital

SERVICE MANUAL

1
 MESSAGE

Welcome to your clinical rotation in the Alfredo T.

Ramirez Burn Center of the Philippine General Hospital
and College of Medicine of the University of the
Philippines. Established by Dr. Alfredo T. Ramirez in
1967, this Center, originally a two, then five-bed facility
until April of 1993, became a ten-bed intensive care
facility, known as the PGH Burn Unit. It was
subsequently named after its founder. ATR, as he was
fondly called, envisioned this Burn Center to provide
comprehensive and multidisciplinary care for all victims
of burn injury that may come this way. As such, we gladly
welcome all persons who, in their own respective fields,
are interested in the optimal care of our burn patients.
And because the Burn Unit tends to be a very busy
place, we hope that this manual will help to familiarize
you with the surroundings, the organization, and the
responsibilities of all burn care personnel.

THE ATR BURN CENTER STAFF

2
 PREFACE

In spite of the remarkable progress made in the management of

burn injuries, a serious burn, certainly a unique from of trauma, is still
the most severe and devastating injury that can be inflicted upon an
individual. Some authors have described burn injuries as the worst of
all tragedies an individual can experience. For a number of centuries,
all but the smallest of burns have resulted in death. In fact, burn
cases were often dismissed by medical communities as hopeless
cases. However, in the past four decades, mortality related to age
and size of burn injuries has been significantly reduced. Length of
hospital stay and morbidity statistics for burn victims has also
markedly improved. One of the key components mentioned as
responsible for this improvement has been the development of
specialized burn units.
It is generally recognized that specialized burn facilities provide
the least expensive method of taking care of severe burns. Although
the per diem cost in the burn center may be greater than the
community hospital, the facilities and organization will be able to take
care of the patient so efficiently so much so that the perios of
hospitalization is shortened. In addition, chances of survival are much
greater in a specialized burn unit. With this in mind came the
development of the Burn Unit and consequently, the concept of the
BURN TEAM.
And as such, with the hope of providing the Burn Center staff a
comprehensive reference for its day-to-day activities, this manual was
formulated. Providing the reader with key topics as scope of work,
manpower responsibilities, the Center’s activities, physical plant and
work areas, and basic treatment protocols, he is thus rendered a
comprehensive view of a working system that has evolved through
the years and has elevated the level of burn care the medical
profession could offer.

3
MATTERS PERTAINING
TO THE

PHYSICIAN
STAFF

DIVISION STAFF

4
 CONSULTANT STAFF

The consultant staff is composed of highly trained, well-motivated, and

competent plastic, reconstructive and burn surgeons. The members of the
consultant staff are all adequately trained in the areas of acute and reconstructive
burn surgery, and in intensive care management of the acutely burned individual.
It is the prime responsibility of the individual consultant to pursue, at its
highest level, the vision and mission of the Division. The Division Chief shall
provide the leadership in this collective effort. The Consultant Staff may change
or modify the general objectives of the Center as they see fit.

1. Qualifications
a. The consultant must be
i. A graduate of an accredited training program in General Surgery
or Plastic Surgery.
ii. A Diplomate of the Philippine Board of Plastic Surgery or the
Philippine Board of Surgery.
iii. Of good moral character.
iv. Acceptable to the entire consultant staff.
b. It is preferred that the consultant be
i. A Fellow of the Philippine Association of Plastic, Reconstructive
and Aesthetic Surgeons
ii. A Fellow of the Philippine College of Surgeons
iii. A graduate of a fellowship program in Burns

2. Duties of the Consultant Staff

a. Must participate actively in the pursuit of the Division’s objectives.
b. A designated consultant is on-call everyday. All consultants rotate and
go on bi-monthly duties.
c. The Consultant-of-the-Month automatically becomes the Consultant-in-Charge
(CIC) of all admissions (charity and walk-in private) during the said month of
rotation. He must be informed by the Senior Resident of the admissions,
discharges, and progress of the in-patients on a daily basis and actively guides
the residents in the management of the cases. Operations on interesting
cases should, at the least, be assisted by the Consultant-in-Charge.
d. A consultant must assist the Senior Resident in the performance of his
initial major operations.
e. All consultants are expected to be present during the Division Conference.

3. The present consultant staff is composed of

Division Chief: Glenn S. Genuino, MD, FPAPRAS, FPCS
Members: Jeane J. Azarcon, MD, FPAPRAS, FPCS
Jose Joven V. Cruz, MD, MPH, FPAPRAS, FPCS

RESIDENT STAFF

5
 The Resident Staff is composed of the Senior Resident (5 th year Plastic
Surgery Resident), Vice-Chief (4th year Plastic Surgery Resident), and Burn
Rotator (2nd or 3rd year General Surgery Resident).

All residents are subject to the rules and regulations enumerated in the
Guidelines on Discipline for Surgical Residents as promulgated by the Residency
Training Committee of the Department of Surgery, Philippine General Hospital. In
addition, pursuant to the university goals of attaining the highest level of training,
service, and research, the division has formulated the following policies to serve
as guidelines for residents.

1. General Guidelines
a. All residents are required to be knowledgeable of and adhere strictly to
the treatment protocols described in this manual.
b. Every resident must be familiar with the details of all the patients
admitted to and referred to the Service (both charity and private cases).
c. While in the operating room, the following rules are to be observed
i. Reporting on time during OR days is 6:30 AM and cutting time
should be at 7 AM.
ii. Proper OR decorum and the wearing of proper OR attire is to be
observed at all times.
iii. Whenever a consultant of the service is to perform an operation,
it is mandatory for the Senior Resident or Vice-Chief to assist
him.
d. While in the Burn Center, appropriate footwear should be worn (there
would be specially designated footwear for use solely within the
Center). The wearing of street shoes inside the Burn Unit is to be
discouraged and is only allowed in conjunction with shoe covers.
e. The residents of the services shall be responsible for cleanliness and
orderliness of the Burn Center / Skin Bank Office and its equipment. No
book in the Burn Center Library or any other equipment is to be
brought out without the permission of the Division Chief.
f. Residents are encouraged to do Burn research activities under the
supervision of consultants.
g. All residents are required to attend and participate in the Burn
Conference. All clinical data and examination relevant to the cases for
presentation should be made available. Cases for section audit should
also be presented thoroughly.
h. Attendance and active participation of residents in all service activities
is expected.

2. Specific Duties, Responsibilities, and Privileges

a. Senior Resident – This role shall be fulfilled by the 5th year Plastic
Surgery resident assigned to the Burn Center.

6
i. He is the most senior resident and shall have command
responsibility for all the activities of the Division and the progress
of all patients.
ii. He shall represent the Division in all Departmental activities in
the absence of the Division Chief or Consultants.
iii. He is responsible for supervising the training and performance of
the junior residents and interns. To this end, he makes daily
teaching rounds on all patients of the service.
iv. He supervises the junior residents in the pre-operative and post-
operative care of patients. He also supervises operations
performed by his junior residents.
v. He should be informed of and accordingly decides on all
admissions, discharges, operations, treatment, and referrals
from other services.
vi. He should be in close contact with the Consultant-in-Charge
regarding patient progress and treatment plans and refer clinical
decisions in difficult cases.
vii. For his training, he will be guided by consultants of the Division.
He is expected to assist the Consultants in their operations
wherever possible.
viii. He is responsible for the schedule of operations and the
assignment of certain cases to his junior residents, with the
approval of the Consultant-in-Charge and / or the Division Chief.
ix. He will preside over the Weekly Division Pre-operative / Post-
operative Conference. In the said conference, he will present
the Weekly / Monthly Census.
x. He is expected to be at the forefront of all research projects of
the Division.
xi. He shall evaluate the performance of his junior residents and
interns and make the necessary recommendations.
xii. He shall check all the Division Logbooks, weekly and monthly
census reports, and monthly financial reports prior to
submission or filing.
xiii. He shall check and verify all Progress Notes written by the
Postduty resident.
xiv. He shall do the rounds of all private patients in the Division.
xv. He is responsible for all entries in the ISIS database for all
private patients.
xvi. He should be ready to assume the position of Vice-Chief, in
addition to his own, in cases wherein no Vice-Chief is available
for the period of his rotation.
xvii. He shall be in charge of all financial matters pertaining to the
Burn Center in consultation with the Division Chief. In line with
this, he shall prepare the financial report every month.

7
b. Vice-Chief – This role shall be fulfilled by the 4th year Plastic Surgery
resident assigned to the Burn Unit.
i. He assists the Senior Resident in discharging his supervisory
function. He sees to it that the orders are properly carried out by
the burn rotator and inters in the pre- and post-op care of service
patients.
ii. He directly supervises the burn rotator and the interns in the care
of outpatient cases and informs the Senior Resident of all cases
that need admission.
iii. He shall be on-call everyday to the burn rotator and should
facilitate the logistics in case of an admission.
iv. He shall submit the schedule of elective and emergency
operations to the Department of Anesthesiology, LCB-OR and
ORSA. He should confer with the anesthesiologists when
necessary.
v. He shall be responsible for the discipline of the burn rotator and
interns and make the necessary recommendations.
vi. He should check accuracy and completeness of all logbook
entries, census reports, burn registry forms and chart orders
made by the burn rotator. He shall be in charge of the safe
keeping of logbooks.
vii. He shall be responsible for properly orienting the interns. He
shall also conduct teaching rounds with them, in the absence of
the Senior Resident.
viii. He shall perform emergency procedures (ie. escharotomies,
etc) and should be present even after office hours should the
burn rotator require assistance in the care of difficult cases.
ix. He shall be assigned to perform operations commensurate to his
skills and capabilities.
x. He shall handle the ATM card fro the Burn Emergency Fund /
Petty Cash and shall be responsible for its security. He should
likewise prepare monthly financial reports on the said fund and
submit this to the Service Senior.
xi. He should be ready to carry out the duties and responsibilities of
the burn rotator in periods wherein no burn rotator was assigned
to the Burn Unit.
xii. He shall call (on a daily basis) the Consultant-in-Charge and the
Division Chief for consultation regarding all OR cases
scheduled.
xiii. He shall countercheck all entries in the Burn Registry Form.
xiv. He shall perform all duties of the Senior Resident in the
absence of such.

8
c. Burn Rotator – This role is fulfilled by the 2nd or 3rd year General
Surgery Resident assigned to the Burn Unit.
i. He is personally responsible for the work-up, pre-opeative
preparation of the patient for surgery, including completeness of
OR needs. He shall also assist in the operation and be
responsible for the post-operative care of all service patients. He
is thus the designated Resident-in Charge of all patients of the
service.
ii. He shall ensure proper accomplishment of all Division logbooks.
iii. He shall prepare the weekly and monthly census to be used for
the Division Conference and should submit a copy to the
Service Senior for verification. He is responsible for all entries of
Charity patients in the ISIS database.
iv. He is responsible for all entries in the Burn Registry Form.
v. He should be familiar with the details of all cases under the
service.
vi. He is expected to do rounds, give necessary orders concerning
service patients every morning prior to reporting to the OR and
give a progress report on the patients to the Senior Resident.
vii. He shall be responsible for the proper disposition of
histopathological or intra-op specimens taken from the patients.
viii. He shall secure the consent for autopsy for mortalities of the
service. If he is unable to secure a consent, he should refer
the matter to his Vice-Chief, Senior Resident or Consultant to
take appropriate action.
ix. He shall accompany all service patients for autopsy.
x. He is responsible for the completeness of the chart and its proper
arrangement.
xi. He shall be responsible for supervising the interns during the
outpatient clinics and should ensure that the proper entries are
made in the outpatient record cards.
xii. He is required to accompany the patient during the performance
of special procedures (ie. bronchoscopy, CT scan, etc).
xiii. He shall inform the Vice-Chief of all new patients and referrals
as soon as possible.
xiv. He is expected to monitor his critical / serious patients at all
times.
xv. He shall participate in the teaching rounds with the interns.
xvi. He may be allowed to perform burn operations under the
supervision of the Senior Resident.

9
DUTIES
There shall be a Burn Resident-on-Duty daily who shall answer all
referrals from the Acute Care Unit, private floors, wards, and Burn Center. The
Service will follw a three-day rotation with the following schedule:
Day 1 Burn Rotator
Day 2 Burn Rotator
Day 3 Vice-Chief

Other specific duties of the “ON-DUTY” resident

1. He shall do the early morning rounds on all charity patients of the
service.
2. He shall write the daily PROGRESS NOTES of all patients of the
service.
3. He shall refer to the Senior Resident / Vice Chief all new referrals, and
admissions that come in during the tour of his duty.
4. He shall call on a daily basis the Consultant-in-Charge for consultation
regarding
a. new admissions
b. “dynamic” patients of the service
c. new referrals

RESIDENT’S PROGRESS NOTES

Progress notes, following the designated format, shall be witten for all
patients of the service on a daily basis. This is to be written on a separate set of
sheets in a designated portion of the patient’s chart. The postduty resident is
responsible for the progress notes.

PRE-OPERATIVE RIC NOTES

Pre-operative RIC notes (a checklist), following the designated format ahll
be accomplished by the RIC (ie. the Burn Rotator) for all patients who are to
undergo an operation. As part of this, the CONSENT FORM shall be
appropriately explained to the patient by the RIC and the surgeon to perform the
said operation.

10
MATTERS PERTAINING
TO

DIVISION
ACTIVITIES

11
 DIVISION OF ACTIVITIES

The activities of the division are divided into the following:

1. Operations
2. Rounds
3. Conferences
4. Outpatient Clinics

OPERATIONS

Elective operations are performed on the following days:

Cutting Time Last Stitch

Monday Burn OR 6:30 AM 11:45 AM
Tuesday Burn OR 6:30 AM 11:45 AM
Wednesday LCB-OR 6:30 AM 11:45 AM
Thursday Burn OR 6:30 AM 11:45 AM
Friday LCB-OR 9:00 AM 1:45 PM

Emergency operations are performed as necessary.

ROUNDS
1. Daily Rounds
a. The post-duty resident does early morning rounds on all the charity
in-patients of the service and all referral patients.
b. The resident staff does “quick rounds” (6-7 AM) on all patients with
the post-duty resident leading the way. He will inform the senior
resident of important developments on the patients during his tour
of duty or points that he picked up during his early morning rounds.
Necessary orders can therefore be made by the senior residents
which shall be carried out by the interns while the senior residents
are in the operating room.
c. In the afternoon, after the OPD Clinic, the senior resident will
conduct rounds with the entire team, including the interns. Matters
on patient management, plans of treatment, prioritization of
operations and other matters pertaining to each individual patient
will be taken up in detail. This will also serve as the teaching rounds
for the junior residents and interns.
2. Rounds with the Consultant-in-Charge
The consultant-in-charge does weekly rounds with the entire service on a
designated day and time.
3. Rounds with the Division Chief
The Division Chief does rounds with the entire team on Wednesdays,
12:00 pm to 1:00 pm prior to the Division Conference.
4. Interns Rounds with the Senior Resident
The senior resident does bedside rounds with the interns on the day prior
to the Weekly Division Preoperative/Postoperative Conference. He shall

12
 discuss with the interns all matters pertaining to the comprehensive care
of the burn patient.

CONFERENCES
1. Division Conference
a. The division holds a weekly conference every Wednesday at 3:00
to 5:00 PM.
b. The census for the previous week is presented followed by detailed
discussions on the morbidities and mortalities. All patients currently
under the care of the service are subsequently discussed with the
emphasis on management and plans.
c. A lecture on a pre-assigned burn topic is delivered by one of the
members of the resident staff or an invited resource speaker. This
shall be alternate with the Division Journal Club where a designated
pre-evaluated Journal article pre-approved by the CIC is presented
for Critical Appraisal.
d. Attendance is expected from the entire Burn Team which consists
of:
i. Consultant staff
ii. Resident staff
iii. Burn Unit Nurses
iv. Representative/s from the Department of Rehabilitation
Medicine
v. Representative/s from the Department of Psychiatry
vi. Representative/s from the Medical Social Service
vii. Representative/s from the Dietary Department
viii. Representative/s from other services as deemed necessary
e. CONDUCT OF THE WEEKLY PREOPERATIVE/
POSTOPERATIVE CONFERENCE
i. SENIOR RESIDENT
1) Presides/initiates
2) Presents weekly/monthly census
ii. INTERN
1) Introduces patient
2) Gives pertinent HISTORY
a) HPI
b) Days post-burn
c) PAST MEDICAL HISTORY
d) ALLERGY HISTORY
e) Other pertinent data in patient’s history
iii. ROTATOR
1) Gives current status of the patient, if with attendant
medical, nutritional, psychosocial problem (progress
notes)
iv. VICE-CHIEF
1) Gives current surgical/wound status

13
 2) Presents surgical plans
2. Departmental Conferences
The Department of Surgery conducts its weekly conferences on
Wednesdays at 1:00 – 3:00 PM. The entire consultant staff and resident
staff are expected to attend.
3. Discharge Conference
a. This conference is held every Thursday afternoon at 2:00 – 4:00
PM.
b. All inpatients and/or their watchers, especially those are near
discharge, should attend.
c. The conference is conducted by the Vice-Chief, supported by the
Burn Rotator, senior residents and interns.
d. General matters pertaining to grafted site, and/or healed burn
wound care are discussed with the attendees based on discharge
pamphlet.
e. Specific home instructions per patient are also taken up with the
patient and watchers concerned.
4. Intern’s Case Management Conference
a. The interns are to have a preceptorial session with the consultant-
in-charge once a week, on a time designated.
b. A pre-assigned case will be discussed as regards the Initial
Assessment and Management of the Acutely Burned Patient with
emphasis/focus on
i. PRIMARY SURVEY
ii. SECONDARY SURVEY
c. The hypothetical scenario would be that the patient just stepped
into the Emergency Room. The question to be tackled would be
“How would you go about in the INITIAL ASSESSMENT AND
MANAGEMENT of this patient?
5. Division Business Meeting
a. To be held once a month on the first division preop/postop of the
month
b. To be presented by the Division Chief

OUTPATIENT CLINIC
Patients on follow-up after discharge and those demand deemed
manageable on an outpatient basis are seen daily at the Burn Unit. The OPD
hours are as follows:

Mondays, Tuesdays, Thursdays and Friday

12 – 1 PM Registration
1 PM OPD Clinic
Wednesdays, Saturdays, Sundays and Holidays
No clinic except for walk-in patients/acutely burned patients. (1-3 days
postburn)

14
 All patients consulting at the OPD will be seen and managed. Under no
circumstances shall a patient consult and not be attended to because of
lack of time. The OPD Clinic will only end when all patients have been
properly assessed and treated.
 All walk-in or acutely burned patients are managed and charted initially at
the ACU by the SOD. They are referred to the burn unit for follow-up and
further treatment. The chart is printed at the ACU and brought by the
patient on follow-up.
 On discharge, all admitted patients are requested to photocopy 2 copies of
the discharge ISIS abstract, front of chart, Burn registry forms and OR
techniques. One set of papers is the patient’s copy, while the 2nd set stays
at the burn unit and is transferred at the OPD files for use on the patient’s
follow up.
 All walk-in/ER patients are encoded into the ISIS system by the interns
daily.
 On initial consult of walk-in/ER patients, the rotator/vice chief makes sure
that the Lund & Browder chart and 2 copies of the Burn Registry form are
filled up for each patient. One copy of the Burn Registry form is attached
to the chart, while one copy is filed properly and compiled monthly.
 Acutely burned patients’ files are kept at the unit until they may be
discharged from the clinic. At this point, their charts may then be endorsed
to the burn center ward clerk, who then forwards the charts to the OPD
records section. If the patient consults after several weeks or months, their
charts may be retrieved from the records section.
 All patients are asked to provide needs for the daily dressing:
o pNSS 1L
o rolled gauze
o sterile gloves
o Povidone Iodine 7.5% scrub
o Silver sulfadiazine ointment
o elastic bandage
o ointments, hydrocolloid/hydrofiber dressing, etc.

15
MATTERS PERTAINING
TO

DIVISION
RECORDS,
FINANCES

16
DIVISION RECORDS
The Division Records shall be based on the Department’s policies on record
keeping, including the ISIS. The recording system is devised to sit into the
Department’s ISIS as well as provide all necessary data the Division wants to have,
with the least effort and time consumed.
1. Service logbook (Admissions log)- this book shall contain the following data as
generated by ISIS, printed monthly and compiled quarterly:
a. Case number
b. Name,age, sex, civil status, address
c. Date of admission
d. Operations done (including surgeon and date of operation)
e. Morbidities
f. Final diagnosis
g. Outcome (Home, mortality, home-againsst-advice, absconded, or transferred)
2. Operation log – this book shall contain the following data as generated by ISIS,
printed monthly and compiled quarterly:
a. Date of operation
b. Case number
c. Patient location
d. Present diagnosis
e. Operation done
f. Donor site used (quantified in square inches) (encoded in findings in ISIS)
g. Recipient/grafted sites (quantified in square inches) (encoded findings in
ISIS)
h. Histopathologic findings
i. Outcome (improved, morbidity, mortality)
3. Conference/Journal Club/ Bedside rounds Attendance logbook- this book shall be
used during the Division’s weekly Tuesday conference. It shall contain the
following data:
a. Consultant staff present
b. Resident staff present
c. Representatives from Rehabilitation Medicine
d. Representatives from Psychiatry
e. Nursing staff present
f. Interns
g. Topic of journal (if journal club)

DIVISION REPORTS

1. Division reports- these are the reports deemed necessary and required by
the Division of Burns
a. Weekly census-see sample census
b. Monthly census- this shall contain the following:
1. Number of admissions
2. Number of discharges
3. Number of operations
4. Number of morbidities
5. Number of mortalities
6. Number of OPD consults
7. Number of referrals

17
 2. Monthly Financial report- this shall contain a summary of the accounting of
the Burn Emergency Fund
3. Financial Logbooks/Journals- there shall be maintained two (2) logbooks
recording financial matters of the Division
a. Logbook on Sevice Funds
a.1. This shall contain recordings of all input (esp from service cases and
appropriations from consultant’s contributions) and expenses of the
Division
a.2. This shall be regularly updated by the Vice-chief
b. Logbook on the “Burn Emergency Fund”/Petty Cash

DIVISION FINANCES

The Burn Center is appropriated the amount of Php 99,407.93 per month, Php
97,614.67 for medical supplies, Php 831.93 for office supplies and Php 961.33 for
housekeeping. This translates to only approximately Php 300.00 appropriation per day
per patient. Seeing the gross lack of this fund, the division will seek a 75 % donation for
all service cases and 10 % donation for all private patients. This fund is for use of
patients in cases of extreme emergency especially during times when the social service
arm of the hospital is not available and for the administrative expenses of the Burn
Center. This fund will be under the care of the Chief of the Division and disbursement will
be decided by a majority vote of the consultants of the division.

All donations to the Burn Center will be coursed through 2 tracks. The choice of
which will be determined by the prospective donor after proper explanation by any staff
member of the division.

Track 1 will be a direct donation to the trust fund of the Burn Center, which is
manintained by the Accounting office of the PGH. Disbursement of this will be the sole
decision of the Medical Social Service of the PGH, upon the recommendation of the
medical staff of the Burn Center. Auditing of this fund is the responsibility of the
accounting office of the PGH.

Track 2 will be a donation to the Foundation for the Advancement of Surgical

Education Inc. (FASE Inc.). After 3 working days, the donation will then be transferred to
any of the 2 accounts of the Burn Center medical staff (ECPI and PNB). Use of this fund
is strictly for patients’ emergency needs only. Disbursement will be decided upon by the
consultant on duty for that period upon the recommendation of the Senior Residnet of
the Division. Auditing of the funds shall be on a quarterly basis by the senior resident
and counterechecked by the chief of the division.

DIVISION LOGO WORDING

“ATR BURN CENTER, DEPARTMENT OF SURGERY, UP-PGH”

18
MATTERS PERTAINING
TO

THE BURN
INTERNSHIP
ROTATION

19
DUTIES AND RESPONSIBILITIES OF THE BURN INTERN

Each intern will rotate with the division of the Burn for a period of one (1) week.
During this time, he/she is expected to actively participate in the activities of the
Division:

1. Burn Staff
Consultant Staff:
Dr. Jeane Azarcon
Dr. Glenn Genuino
Dr. J,J. Cruz
Residents: 1 Plastic Surgery Senior resident (5 th year)
1 Plastic Surgery Junior resident (4 th year)
1 GS rotator

2. Schedule of Activities
OFFICE HOURS
Monday to Friday 7:00-5:00PM
Saturday, Sunday and Holidays 7:00-until OPD is done

Elective Dressing of Ward OPD Service

Surgery in-patients Work Rounds
(starts
7AM)
Sunday   
Monday Burn unit    1pm 
Tuesday Burn unit   3pm 
Wednesday LCB   3pm 
Thursday Burn unit   1pm 
Friday LCB   1pm 
Saturday   1pm 

indicates activities which should be done daily

In addition, Preceptorials, bedside rounds with Division chief and Division
conference are held on Wednesdays

3. Daily Activities

a. Wound dressing of In-patients

 This starts daily at 7am and is usually done by the nurses on duty at
the unit. The student-in-charge of each patient is expected to assist
when change of dressing and wound care is being rendered.
 During this time, the IIC is expected to note the appearance of the
wounds, which he/she will, in turn, illustrate in the Progress notes for
the Day. Please note the description of the Wounds. Make a
comparison with the previous, and if theres is any conversion of the
wound.

20
 b. Elective Surgery
 This is done daily, venue is indicated in the schedule aboce.
 Cutting time is at 6:30 AM
 Note: The intern-in-charge of the patient for elective surgery
must come in at 6 am for the first case. At least 2 interns are
expected to assist per case.

c. Ward Work
 1-3 patients are assigned per student. Every 3 days, the block is
expected to rotate the patient assignments to better acquaint
themselves with the in-patients.
 Each student-in-charge is expected to perform the following:
1. All laboratory work-ups of each patient
2. Follow-up results of previously done lab work-ups
3. Assist in patient monitoring
4. Send inter/intra-departmental referrals
5. Update the ISIS abstract
6. Database for each patient:
 Clinical Abstract
 Incoming and Outgoing notes
 Burn registry
 Discharge summary
 Lab summary sheet per chart
 Daily progress notes: Must be problem-based in
format, mentioned in order of priority.

d. Wet Clinics
 Held from Monday to Saturday, with schedule as noted above.
 During this time, wound care is performed for patients with minor
injuries not requiring admission to the unit.
 Tips to remember:
1. Proper wound care involves preparation of a sterile
field, instruments and dressings to avoid infection.
2. Use only a pick-up to remove blisters and dead
skin. Avoid too vigorous cleansing
3. Save on our supplies: Use only cotton balls for
scrubbing the wounds with Betadine soap and not
sheets of OS. Avoid too liberal application of
Flammazine.

4. Intern’s Case Management Conference

i. The interns are to have a preceptorial session with the consultant-in-charge
once a week, on a time designated. * The use of Powerpoint and LCD (or a
laptop if LCD is not available) is HIGHLY RECOMMENDED.
ii. A pre-assigned case will be discussed as regards the Initial Assessment and
Management of the Acutely Burned Patient with emphasis/focus on
1. PRIMARY SURVEY
2. SECONDARY SURVEY
iii. The hypothetical scenario would be that the patient just stepped into the
Emergency Room. The questions to be tackled would be “How would you go

21
 about in the INITIAL ASSESSMENT AND MANAGEMENT of this patient?
 Format of the presentation:
PRIMARY SURVEY
AIRWAY assessment management
BREATHING A M
CIRCULATION A M
CERVICAL A M
DEFICITS A M
EXPOSURE A M
FLUIDS A M

SECONDARY SURVEY
Pertinent History
ALLERGIES
MEDICATIONS
PREVIOUS ILLNESS
LAST MEAL
EVENTS SURROUNDING INJURY

5. Wednesday Bedside Rounds

 The division chief conducts this in the Burn Unit every Wednesday usually at
12-1 pm.
 Students who are assigned to each patient are asked to present the clinical
histories of their patients, including their course in the wards and present
management.

6. Daily Teaching Rounds

 Conducted by the senior residents, this focuses on the daily monitoring and
progress of each patient, and it includes the interpretation of the different
laboratory work-ups done for each patient.
 In addition, the peri-operative and post-operative care of the patients are also
discussed.
 This is done daily to update the service ON THE PATIENTS’ CONDITION.

7. Lecture Series
 Each intern is assigned a chapter of TOTAL BURN CARE by Herridon to
report to the group.
1. SIRS
2. ARDS
3. NUTRITION
4. FLUID RESUSCITATION OF ACUTE BURN PATIENTS
5. INFECTION
6. WOUND CARE AND DRESSINGS

8. DIVISION CONFERENCE
 Held Wednesdays at 3 PM, CHAIRMAN’S OFFICE, DEPARTMENT OF
SURGERY or as otherwise announced.
 IICs are expected to present the pertinent history of their patients.

22
 9. ATTIRE: All interns are required to be in SCRUBS and OR footwear while within
the Burn Unit.

10. ER Duties
 Tour of duty is from 6 pm to 6 am
 BE SURE TO REVIEW YOUR PRIMARY AND SECONDARY SURVEY
BEFORE GOING ON DUTY

11. End of rotation exam

 Focus will be on ACUTE BURN CARE
 This is included on the Departmental final exam

12. SPECIAL PROJECT: To be assigned at the end of the rotation

REFERENCES
i. The Burn Module
Each intern is provided a copy which contains the following:
a. Sample forms of the Daily Progress Note, Burn Registry Form and
Lund & Browder charts
b. Service Manual of the Division of Burns
c. Copy of the Duties and Responsibilities of the Burn intern
d. Copy of the BURN-HANDOUT. Prepared by the consultant staff, the
manual covers the topics deemed as must-know for any intern who
rotates in the Division.
ii. Selected chapters from “TOTAL BURN CARE” by Herridon. A copy is
available at the Division office.

23
 APPENDIX
ATR BURN CENTER
Miscellaneous Forms

24
PROTOCOLS FOR MANAGEMENT

A. Laboratory Work-up
1. Initial labs for flame burns upon arrival at the ER
 CBC with platelet count
 Bun, Crea, Na, K , Cl, alb
 PT/PTT
 CXR
 Typing
 ABG (for consideration of inhalational injury)
2. Initial labs for electrical burns
 CBC with platelet count
 Bun, Crea, Na, K , Cl, alb
 PT/PTT
 CXR
 Typing
 ABG (for consideration of inhalational injury)
 12-L ECG
 Urine myoglobin
 For acutely injured (48 hrs post burn) and critically ill patients the ff should
be done daily
 CBC
 Serum electrolytes
 ABG
 For chronic patients, the ff should be done every four to five days:
 CBC
 Serum electrolytes
 Albumin
 For intubated patients (to monitor tube position)
 Daily CXR
B. Weiging of patients should be done at the emergency room. Adults should be
weighed once a week and pediatric patients twice a week.
C. Patients’ intake should be monitored by a dietician.
D. Dressing changes/Wound care
 Wound dressings of patients admitted in the burn unit should be done
every morning so the wounds can be assessed by the burn resident. Silver
sulfadiazine is the topical antibiotic of choice. Sandwich type dressing is
the technique of choice.
 Dressing changes of stable patients will be done in the hydrotherapy area.
After the patient’s bath, the nurse in charge will see to it that prior to
dressing; the immediate area where the dressing will be performed is
relatively dry.
 Allow fifteen to thirty minutes between dressings of patients to give time to
clean the hydrotherapy area.
 Critically ill, intubated and grossly infected patients should be dressed at
bedside. All anticipated needs for bedside dressing should be brought into
the room prior to performance of dressing.
 Peripheral patients shall be dressed only after all the inpatients are done.
 Universal precautions and strict aseptic techniques shall be observed at all

25
 times.
UP-Philippine General Hospital
Department of Surgery
Division of Burns

Census
Date

Residents

Team Captain

Vice Chief

Rotator

Interns

Charity Census
Admissions
Emergency
Elective
Discharges
Operations
Elective
Emergency
Referrals
Ward
ER
Morbidities
Mortalities
OPD
New consults
Total consults
In-patients
Peripherals (borrowed beds)

Pay Census
Admissions
Discharges
Operations
Elective
Emergency
OPD
Referrals
Morbidities
Mortalities
In-patients

26
MORTALITY

MORBIDITY

Ward Patients
Sample:
SALES, Dwiight 6/M Admitting diagnosis:
Granulating wounds 52% TBSA head,
DATE OF INJURY: 01-02-06 neck, anterior and posterior trunk, B upper
DATE ADMITTED: 02-21-06 extremities, L thigh secondary to flame
burns
168th PBD
12oth HD Operation:
28th POD 1. Debridement (Velasco 02-24-06, 02-
28-06, 03-08-06, 03-28-06, 04-05-06,
Ht: 117 cm 05-02-06)
Wt: 17 kgs 2. Release of L lower lid ectropion,
IBW: 20 kgs Debridement, STSG 10% anterior
trunk, L arm and forearm (Velasco/
Total Caloric Requirement: 3200 Cruz 05-25-06)
kcals
Present Working Impression:
Plan: for debridement, STSG Grafted burn wounds 10% TBSA anterior
back trunk, L arm and forearm
Donor: L thigh and leg Granulating wounds 15% TBSA head,
posterior trunk
Focal seizures probably 2 to cerebral
atrophy
(SPACE FOR ROTATOR’S NOTES)

1. Total caloric requirements computed using Currerri formula.

2. Plan for each includes area to be operated on and planned operation.
Include planned donor sites for each patient.
3. For admitting diagnosis:
a. Mechanism of burn (flame, electrical, scald, contact, etc.)
b. TBSA
i. Total TBSA SPT/DPT/FT and areas involved
ii. Granulating wounds
c. Co-morbidities (e.g. CAP, DM, HPN, etc.)
d. Other injuries
i. Trauma
ii. Inhalational injury
4. Operations
a. Itemize operations done, date, surgeon
5. Present Working Impression:
a. Present status of wounds: Granulating? Healing? Healed? Grafted?
b. Present Problems (e.g. co-morbidities, infections, etc.)

27
*include pictures of patients on admission and latest pictures

FORMAT of RESIDENT’S PROGRESS NOTES

Name of Patient: Age/Sex: Date:

Location:
Diagnosis:

S> (SUMMARY/ short telegraphic notes on previous 24 hours)

“This is the patient’s

______ postburn day
______ hospital day
______ postop day

e.g. “underwent tangential excision, stsg; was weaned off ventilator;

had spiked a fever…”

(PERTINENT LABS)
Latest/date of results

Hgb

WBC Plt count

Hct

BUN Na Cl Gluc
Crea K HCO3

U/A:
CXR:
Blood C/S:
Etc.

O> GCS score

BP= (range) e.g. 120-140/60-80
HR= (range) e.g. 88-92
RR= (range) e.g. 16-20

Tmax= (previous 24 hours)

CVP= (range)
TFI=
TFO=
U.O.= cc/hr

28
 Brief pertinent PE

A/P
PROBLEM I AIRWAY/BREATHING
e.g. current ventilator settings
MV mode
FiO2=
RR=
TV=
PEEP=
Latest ABG
pH/ pCO2/ pO2/ HCO3/ O2 sat

ETA level
ETA GS/CS (latest)

P> for weaning

PROBLEM II CIRCULATION
CVPrange (past 24 hours) =
BP range (past 24 hours) =
HR range (past 24 hours) =
TFI =
TFO =
Fluid balance =
On inotropics (drug/dose)

P>

PROBLEM III INFECTION

Latest Wound GS/CS
On Cefta D1
Amik D1

P>

PROBLEM IV PSYCHOSOCIAL
PROBLEM V REHAB
PROBLEM VI WOUND
Areas which still need grafting ____ %
Areas which still needs to be excised/debrided ____ %
Grafted areas and percent take ____ %
Type of dressing:

29
 FORMAT OF PREOPERATIVE RIC NOTES

Pt is for OR ____________________________________________________

o CONSENT
o _____ units pRBC
o _____ units FFP

NPO post ___________________

IVF: #1 _________________
#2 _________________
ABW _______________________
Blood Type __________________

CXR:
PT:
PTT:

Other pertinent labs:

__________________________
RIC Signature and Full Name

__________________________________________________
Senior Resident Signature and Full Name

30
 UP-PGH ATR Burn Center
SUMMARY OF LABORATORY RESULTS

Patient: Age: Sex: Ward ____ Bed ____ CN:

RIC: SIC: Dx:

BLOOD TYPE:

HEMATOLOGY:
Date
WBC 4-11x109/L
RBC 4-6x109/L
Hgb 120-180g/L
Hct 0.370-0.540%
MCV 80-100fL
MCH 27-31pg
MCHC 320-360g/L
RDW-CV 11-16%
Platelets 150-450x109/L
Neut% 0.5-0.7
Lymph% 0.2-0.5
Mono% 0.02-0.09
Eo% 0.0-0.06
Baso% 0.0-0.02
Retic ct

Peripheral Blood Smear:

PROTHROMBIN TIME:
DATE
Protime Ctrl 12-15 secs
Patient
Activity
INR 1.0

ACTIVATED PARTIAL THROMBOPLASTIN TIME:

Date
Control
Patient
Px:Ctrl Ratio

ARTERIAL BLOOD GASES:

Date
FiO2
Temp
Hb
pH 7.35-7.45
PCO2 35-45mmHg
PO2 90-100mmHg
HCO3 22-28mEq/L
TCO2
ABE
SBE
SBC
O2 sat’n

BLOOD CHEMISTRY:
Date
Glucose 4.1-6.1mmol/L
BUN 3.2-8.0 mmol/L
Creatinine 53-133umol/L
B:C ratio

31
Crea Cl
Sodium 135-145mmol/L
Potassium 4.0-4.5mmol/L
Chloride 99-110mmol/L
Calcium 2.20-2.62mmol/L
Corrected Ca
Magnesium 0.70-1.05/1.4-2.1
Phosphates 0.9-1.55/0.42-1.97
Total protein 64-83g/L
Albumin 38-51g/L
Globulin 23-35g/L
AST (SGOT) 0-34U/L
ALT (SGPT) 0-30U/L
Alk phos 36-92umol/L
Ttl bilirubin 0-17.1umol/L
Dir bilirubin 0-3.42umol/L
Ind bilirubin 3.4-13.7umol/L
HDL 0.91-1.56mmol/L
LDL 1.1-3.8mmol/L
Cholesterol 3.22-7.7mmol/L
Triglycerides 0.41-2.37mmol/L
Urate 0.13-0.44mmol/L
Amylase 1-63U/L
CK-total 21-23 U/L
CK-MB 0-6U/L
CK-MM 8-97U/L
Ketone

URINE STUDIES
URINALYSIS:
Date
Color Yellow
Transparency Clear/hazy
SG 1.016-1.022
pH 4.6-6.5
Sugar (-)
Albumin (-)
RBC 0-2/hpf
WBC 0-5/hpf
Casts hyaline, coarse,
fine, granular,
RBC, WBC, waxy
Crystals Small amounts
Epith cells Small amounts
Bacteria (-)
Mucus threads Small amounts
Ketones (-)
Hyphal element (-)

24-HOUR URINE CHEMISTRY:

Date
Total volume 500-2000cc
Creatinine 0.65-0.70g/L
Total protein 0-0.1g/24hour
Na+ 80-216mmol/L
K+ 25-100mmol/L
Mg++ 0.99-10.50mmol/L
Cl- 80-340mmol/L
Uric acid 4.42-5.9mmol/24hr
Ca++ 2.5-7.5mmol/24hr
Phosphorus 22.4-33.6mmol/24hr
Amylase 64.75-490.25U/L

32
FECALYSIS:
Date Color Consistency Parasites (-/+) RBC WBC Occult Blood Others

Gram Stain:
Date Specimen PMN’s Organisms AFB

Culture (and sensitivity) Studies:

Date Specimen Growth Organisms Sensitive Interim Resistant

RADIOGRAPHS:
Date: Date:
File No: File No:
Impression: Impression:

Date: Date:
File No: File No:
Impression: Impression:

Date: Date:
File No: File No:
Impression: Impression:

ELECTROCARDIOGRAMS:
Date: Date:
Impression: Impression:

33
Date: Date:
Impression: Impression:

Date: Date:
Impression: Impression:

OTHER LAB RESULTS:

34
 ALFREDO T. RAMIREZ BURN CENTER
Division of Burns
UP-PGH Department of Surgery

Date/Time of Consult: _______hours/days post burn

Name:
(last name) (first name) (middle
name)
Address: Contact #

Date of Injury: Physical Examination: Personal and Social History:

Time of Injury:
Place of Injury:
Mechanism of Injury: Past Medical History:
[ ] Allergies: _____________
[ ] Asthma
[ ] HTN
[ ] Heart Disease
[ ] Others: _____________

Lund and Browder Chart for Estimating Area of Burns

Area 0-1 yr 1-4 yrs 5-9 yrs 10-14 yrs 15 yrs Adult SPT DPT FT TBSA
Head 19 17 13 11 9 7
Neck 2 2 2 2 2 2
Ant trunk 13 13 13 13 13 13
Post trunk 13 13 13 13 13 13
R buttock 2.5 2.5 2.5 2.5 2.5 2.5
L buttock 2.5 2.5 2.5 2.5 2.5 2.5
Genitalia 1 1 1 1 1 1
R U arm 4 4 4 4 4 4
L U arm 4 4 4 4 4 4
R L arm 3 3 3 3 3 3
L L arm 3 3 3 3 3 3
R hand 2.5 2.5 2.5 2.5 2.5 2.5
L hand 2.5 2.5 2.5 2.5 2.5 2.5
R thigh 5.5 6.5 8 8.5 9 9.5
L thigh 5.5 6.5 8 8.5 9 9.5
R leg 5 5 5.5 6 6.5 7
L leg 5 5 5.5 6 6.5 7
R foot 3.5 3.5 3.5 3.5 3.5 3.5
L foot 3.5 3.5 3.5 3.5 3.5 3.5

Total:

ASSESSMENT:
Burn diagram

PLAN:
Medications:

Daily Wound Care:

Follow-up on:

35
 UNIVERSITY OF THE PHILIPPINES
PHILIPPINE GENERAL HOSPITAL
Department of Surgery
ATR BURN UNIT

Date/Time of Consult: _______hours/days post-

burn
Name: Age/Sex: CN:
(last name) (first name) (middle name)
Address: Contact #
Date of Injury: Time of Injury: Place of Injury:
Mechanism of Injury:

Physical Examination: [ ] Allergies: _____________

[ ] Asthma
[ ] HTN
[ ] Heart Disease
[ ] Others: _____________

Lund and Browder Chart for Estimating Area of Burns

Area 0-1 yr 1-4 yrs 5-9 yrs 10-14 yrs 15 yrs Adult SPT DPT FT TBSA
Head 19 17 13 11 9 7
Neck 2 2 2 2 2 2
Ant trunk 13 13 13 13 13 13
Post trunk 13 13 13 13 13 13
R buttock 2.5 2.5 2.5 2.5 2.5 2.5
L buttock 2.5 2.5 2.5 2.5 2.5 2.5
Genitalia 1 1 1 1 1 1
R U arm 4 4 4 4 4 4
L U arm 4 4 4 4 4 4
R L arm 3 3 3 3 3 3
L L arm 3 3 3 3 3 3
R hand 2.5 2.5 2.5 2.5 2.5 2.5
L hand 2.5 2.5 2.5 2.5 2.5 2.5
R thigh 5.5 6.5 8 8.5 9 9.5
L thigh 5.5 6.5 8 8.5 9 9.5
R leg 5 5 5.5 6 6.5 7
L leg 5 5 5.5 6 6.5 7
R foot 3.5 3.5 3.5 3.5 3.5 3.5
L foot 3.5 3.5 3.5 3.5 3.5 3.5

Total:

ASSESSMENT:

Burn diagram
PLAN:
Medications:

Daily Wound Care:

Follow-up on:

36
 UNIVERSITY OF THE PHILIPPINES
PHILIPPINE GENERAL HOSPITAL
Department of Surgery
ATR BURN UNIT

FOLLOW-UP FORM
S> Date/Time of Consult: __ days post Last seen:
burn ______
Name: Age/Sex: CN:
(Last name) (First name) (Middle
name)
Last Working Impression:

ROS: [] fever []good wound healing []others:

O> Physical Examination

A>

P>

S> Date/Time of Consult: __ days post Last seen:

burn ______
Name: Age/Sex: CN:
(Last name) (First name) (Middle
name)
Last Working Impression:

ROS: [] fever []good wound healing []others:

O> Physical Examination

A>

P>

37
 UP-PHILIPPINE GENERAL HOSPITAL
Department of Surgery
Division of Burns

MGA PAALALA SA PAG-ALAGA SA SUGAT

Pangalan: ___________________________________ Edad: ________

Petsang naadmit: _____________________ Petsang umuwi: ________

Mga tinapalan ng balat (grafted areas):

a. Saan-saan?
_______________________________________________________________
b. Hugasan araw araw ng sabon at malinis na tubig. Tuyuin mabuti.
c. Lagyan ng _____________________ ointment
d. ☐ Balutan ng
☐ Manipis na gas ☐ Rolled gauze/Elastic bandage
☐ Iwanang bukas
e. ☐ Ibalik ang splint or “ Jobst garments”

Mga pinagkunan ng balat o naghilom na sugat (donor sites and healed burn wounds):
a. Saan – saan? ______________________________________________
_________________________________________________________
b. Hugasan araw-araw ng sabon at malinis na tubig. Tuyuin.
c. Pahiran ng petroleum jelly/lotion dalawang beses sa isang araw

Iba pang mga sugat (example: granulating wound etc)

a. Saan-saan? ________________________________________________________
__________________________________________________________________
b. Hugasan araw araw ng sabon at malinis na tubig. Tuyuin.
c. ☐ Modified Daikin’s dressing
1. Maghalo ng 15cc zonrox sa 985 cc ng malinis na tubig. Maaring
tumagal ito ng 2 araw
2. Gamitin ang tubig upang basain ang unang ballot ng gasa sa
sugat
3. Patungan ng tuyong gasa at rolle gauze
4. Panatilihing basa ang ballot sa pamamagitan ng pagbasa rito
kada 3-4 oras ng tubig na may zonrox
☐ “Calmoseptine ointment” sa paligid ng sugat
☐ “Merthiolate” sa sugat

IBA PANG PAALALA:

 Sa mga may dressing na DUODERM/AQUACEL/AQUACEL Ag, huwag babasain ang
sugat. Maaaringlinisin ang paligid ng sugat. Maari rin palitan ang gasa at elastic bandage
sa taas ng DUODERM/AQUACEL/AQUACEL Ag ngunit huwag gagalawin ang sugat.
 Huwag magpapaaraw. Gumamit ng paying, sombrero, pantaloon o long sleeves upang
hindi maarawan ang mga sugat.
 Panatilihing malinis ang buong katawan araw araw
 Kumain ng maraming masusustansyang pagkain
 Laging isuot ang splint/”Jobst garments”

38
 Dalhin ang discharge papers at blue card. Sa umaga ng pagbalik, pumila sa REHAB
OPD, (Padre Faura street) 7AM upang magpa iskedyul ng check up.
 Huwag kalimutan dalhin ang mga gagamitin sa paglinis ng sugat (ointment, elastic
bandage, aquacel etc) sa check up

39
_____________________________________EPIDEMIOLOGY AND PREVENTION
INTERNATIONAL SOCIETY FOR BURN INJURIES
COMPUTERIZED BURN REGISTRY DATA FORM

LAST NAME ____________________FIRST NAME__________________MIDDLE INITIAL_______

ADDRESS___________________________________________________________________________
CITY______________ PROVINCE/STATE ________________________ POSTAL CODE__________
HOSPITAL IDENTIFICATION NUMBER ________ SOCIAL SECURITY NUMBER _______
BIRTHDATE Month________ Day ______ Year _______ Age______ Sex □ male □ female
ETHNIC OROGIN _____________________________________________________________________
ADMIT DATE MONTH________ DAY _____ YEAR ________ Admission Time (24hr clock)______
ADMIT STATUS: □ Treatment as out-patient
□ Acute new admission to hospital/burn unit
□ Readmission for reconstruction/rehabilitation
□ New admission for reconstruction/rehabilitation
REFERRAL SOURCE __________________________________________________________________
DATE OF INJURY Month _______ Day ______ Year _______ Time of Injury (24hr clock) __________
POSTAL CODE/COUNTY OF INJURY EVENT ____________________________________________
PROVINCE/STATE OF INJURY EVENT ___________________________________________________
HOW DID BURN INJURY HAPPEN? ______________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

ETIOLOGY OF INJURY □ Fire/Flame □ Scald □ Contact

□ Chemical □ Skin Disease □ Electricity
□ Other Burn □ Other Non-Burn □ Unknown
PLACE □ Indoors □ Outdoors □ Unknown
LOCATION OF INJURY □ Home □ Other private dwelling □ Work □ Other building
□ Conveyance □ Other □ Unknown
CIRCUMSTANCES □ Accident □ Work-related □ Non Work-related
□ Suspected assault □ Suspected self-inflicted □ Suspected arson
□ Unknown □ Other
PRE-INJURY CONDITIONS □ None □ Pulmonary □ Substance Abuse
□ Neurologic □ Abdomen/GI □ Smoking
□ Vision □ Genitourinary □ Psychiatric
□ Hearing □ Musculoskeletal □ Infection
□ Cardiovascular □ Metabolic/Endocrine □ Other________

40
EPIDEMIOLOGY AND PREVENTION
PRE-EXISTING DISABILITY: □ YES □ NO
AREAS BURNED: COMPLETE AT TIME OF
DISCHARGE

Partial Thickness _________________________

Full Thickness___________________________
Total Burned Surface Area_________________

LUND-BROWDER CHART
Relative Percentage of Body Surface Area
affected by Growth

Age in years 0 1 5 10 15 Adult

A- head (back or front) 9½ 8½ 6½ 5½ 4½ 3½
B- 1 thigh (back or front) 2¼ 3¼ 4 4¼ 4½ 4¾
C- 1 leg (back or front) 2½ 2½ 2¼ 3 3¼ 3½

INHALATION INJURY: □ YES □ NO

TOTAL SURGICAL PROCEDURES ______________ TOTAL BURN PROCEDURES ______________
NUMBER OF DAYS WITH VENTILATOR SUPPORT _______________________
ASSOCIATED INJURIES/COMPLICATIONS

□ NONE □ PULMONARY/THORACIC □ INFECTION

□ NEUROLOGICAL □ ABDOMEN/GI □ PSYCHIATRIC
□ EARS □ MUSCULOSKELETAL □ MULTITRAUMA
□ CARDIOVASCULAR □ METABOLIC/ENDOCRINE □ AMPUTATION
□ OTHER _________________________________
DATE OF DISCHARGE MONTH ________ DAY ________ YEAR _________

DISPOSITION: □ DIED □ LEFT AGAINST ADVICE □ DISCHARGED HOME

□ EXTENDED CARE FACILITIY □ OTHER BURN CENTER □ OTHER
CAUSE OF DEATH: □ Treatment withheld □ MSO/Metabolic □ Burn Shock
□ Pre-existing Illness □ Pulmonary Failure/Infection □ Burn Wound Infection
□ Cardiovascular Failure □ Other
HOSPITAL CHARGES ______________________ TYPE OF CURRENCY _______________________
REMARKS: ___________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

41
 UNIVERSITY OF THE PHILIPPINES
PHILIPPINE GENERAL HOSPITAL
Taft Avenue, Manila

DEPARTMENT OF SURGERY
DIVISION OF BURNS

ACUTE BURNS: DIAGNOSIS AND MANAGEMENT

I. INTRODUCTION
In spite of the remarkable progress in the management of burn injuries, a serous burn,
certainly a unique form of trauma, is one of the most severe devastating injury that can be
inflicted upon an individual. Some authors have described burn injuries as worst of all
tragedies an individual can experience. For a number of centuries, all but the smallest
burns have resulted in death. In fact, burn cases were often dismissed by medical
communities as hopeless cases. However, in the past four decades, mortality related to
age and size of burn injuries has been significantly reduced. Length of hospital stay and
morbidity statistics for burn victims have also markedly improved. And one of the key
components; mentioned as responsible for this improvement has been the development of
specialized burn units.

It is generally recognized that specialized burn facilities provide the least expensive
method of taking care of severe burns. Although the per diem cost in the burn center may
be greater than in the community hospital, the facilities and organization would take care
of the patient so efficiently that period of hospitalization would be considerable
shortened. In addition, chances for survival would be greater in a specialized burn unit.

With this vision in mind came the development of the PHILIPPINE GENERAL
HOSPITAL BURN UNIT and consequently the concept of the BURN TEAM.

And with the hope of providing the burn unit staff the backbone of the burn team with a
logical foot in its day to day activities and more so perhaps the physicians desirous of
knowledge in management protocols in acute burn care, this manual was formulated.

Providing the reader with such key topics such as the history of the burn unit, its scope of
works, the unit’s activities, a brief description of its physical plant and work areas, and
basic treatment protocols, he/she is thus rendered a comprehensive view of a working
system that evolved through the years which has augmented the level of burn care the
medical profession could offer.

II. OBJECTIVES
After reading this manual one is expected to:
A. be able to assess burns as to type, depth, and extent
B. classify burns as minor, moderate, or major
C. know the criteria for admission
D. apply the different formulas in fluid resuscitation and nutrition
E. know the principles in initial management of burn wounds
F. enumerate the different types of dressings and their indications
G. know the indications and basic principles behind the surgical techniques in burn surgery
H. know the criteria for discharge from the burn unit

42
III. DIAGNOSIS AND MANAGEMENT OF ACUTE BURNS

The management of injury encompasses several dimensions which can be roughly divided
into two phases: Initial/Resuscitative period (first 48 hours) and the Definitive management
period (after 48 hours).

Initial/Resuscitative Period Definitive Management Period

▪ Assessment of burn injury ▪ Excision and grafting
▪ Classification of burn injury ▪ Control of infection
▪ Criteria for admission ▪ Nutrition
▪ Initial (ER) management ▪ Rehabilitation
▪ Fluid resuscitation ▪ Complication
▪ Monitoring

INITIAL/RESUSCITATIVE PERIOD
A. Assessment of burn injury
1. Get a complete history regarding the circumstances surrounding the burn. A burn injury
sustained in an enclosed space raises the possibility of an inhalation injury.

2. Classify as to type of burn:

▪ SCALD BURN: burns caused by hot liquids most commonly hot water, soups, and
sauces which are thicker in consistency, remain in contact with the skin for a longer
period of time.

▪ FLAME BURN: due to house fires, improper use of flammable liquids, kerosene lamps,
careless smoking, vehicular accidents, clothing ignited from stove

▪ FLASH BURN: explosions of natural gas propane, gasoline and other flammable liquids
causing intense heat for a very brief period of time

▪ CONTACT BURN: results from hot metals, plastic, glass or hot coals; usually limited in
extent but very deep

▪ CHEMICAL BURN: caused by strong alkali or acids; these cause progressive damage
until chemical is deactivated with reaction with tissue or reaction with water.
i. Acid burns: more self limiting than alkali burns; acid tend to tan the
skin creating an impermeable barrier which limits further penetration
of the acid
ii. Alkali burns: combine with cutaneous lipids to create soap and
thereby continue to dissolve the skin until they are neutralized

▪ ELECTRICAL BURN: injury from electrical current classified as high voltage (greater
than one thousand volts) or low voltage (less than one thousand volts)

3. Estimate the burn size, express as percent body surface area burned (%BSA). Count only
those areas with partial (second degree) or full thickness (third degree) burns. Most
accurately done using the Lund and Browder charts (available at the ER and Burn
Unit). The Rule of Nines may be used to obtain a rough estimate of the areas involved,
but it is not accurate especially in children due to the large surface area of the child’s
head and the relatively smaller area of lower extremities. The palm represents
approximately 1% of TBSA.

NOTE: In electrical injuries, the %BSA involved does not correspond to the extent of
injuries of the underlying soft tissues. There may be areas of soft tissue sustaining

43
 injuries secondary to the passage of electrical current but with normal looking skin over
it.

4. Assess the burn depth. This is extremely important. The information is used in
estimating burn size and fluid requirement in determining the need for surgery and in
evaluating the progress of the patient. Don sterile gloves when examining the patient.

▪ FIRST DEGREE BURNS: are red and painful with no blisters. Sunburn is a classic
example. It is not counted in estimating burn size. This will heal in 7 to 10 days.

▪ PARTIAL THICKNESS BURNS: formerly called second degree burns. Burn injury
extends to the dermis, but not through the full thickness of the skin, and thus will heal
from epithelialization from the epidermal elements surviving; (+) blanching when
pressed.

i. Superficial partial thickness burn: with blisters; underlying skin is

moist, pinkish, painful; will heal in 2 to 3 weeks
ii. Deep partial thickness burn: white to pale pink; moist to dry to waxy,
slightly anesthetic, will heal in 3 to 5 weeks resulting in hypertrophic
scarring and potential contracture
iii. Both types of partial thickness burns can convert to full thickness
burns, signifying worsening of the patient’s condition.

▪ FULL THICKNESS BURNS: defined as burns extending through the full depth of the
skin. The appearance varies; may be white, brown, or gray with a waxy, leathery feel;
skin is anesthetic; the presence of visible thrombosed veins is pathognomonic of a full
thickness burn. This heals by granulation and will require future skin coverage for
wound coverage.

5. Check for other injuries/medical problems. Do not fail to make a complete exam and
medical history. This could play a role in the origin of the burn and will have to be
integrated in the management of the burn. Examples include seizure disorders, diabetes
disorders, fractures, blunt abdominal injuries sustained from falls in patients with
electrical injuries from high tension wires. The presence of sooty phlegm, singed nostril
hairs, burns to the face, hoarseness and stridor should raise the suspicion of inhalation
injury and appropriate measures should be undertaken.

REVIEW QUESTIONS:
1. Enumerate six (6) types of burns.
2. Describe superficial partial thickness (SPT), deep partial thickness (DPT), and full
thickness burns according to the following:
SPT DPT FT
Color
(+)/(-) blisters
Pain perception
(+)/(-) hypertrophic
scarring
Capillary refill
Re-epithelialization time

3. Name at least two (2) ways of estimating burn size.

44
B. Classification of burn injury

Minor Moderate Major

CHILDREN
Partial thickness <10% BSA 10-20% BSA >20% BSA
burn
Full thickness burn <2% BSA 2-10% BSA >10% BSA
ADULTS
Partial thickness <15% BSA 15-25% BSA >25% BSA
burn
Full thickness burn <2% BSA 2-10% BSA >10% BSA
AGE Patients <2 years Patients <10 years
with minor injury major injury
INVOLVEMENT OF (-) (-) Moderate injury
HANDS, FACE, involvement:
FEET AND
PERINEUM
ELECTRICAL (-) (-) (+)
INJURY
CHEMICAL INJURY (-) (-) (+)
INHALATIONAL Not suspected Not suspected (+)
INJURY
MAJOR (-) (-) (+)
ASSOCIATED
MEDICAL ILLNESS
ASSOCIATED (-) (-) (+)
FRACTURES,
MULTIPLE TRAUMA

Minor injuries can be treated on an outpatient basis with frequent follow-up. Moderate
and major injuries require admission into the Burn Unit.
REVIEW QUESTIONS:
Classify the following as minor, moderate or major injuries:
1. 20% TBSA, SPT burns on lights and anterior trunk of a 35-year old male.
2. 3% TBSA, SPT burns on the face of a 12-year old female.
3. 15% TBSA burns on both lower extremities of a 5-year old male.

C. Criteria for admission to the Burn Unit

1. All acute burn patients classsifed with moderate and major injuries.
2. All acute burn patients less than 2 years of age regardless of % TBSA
3. All acute burn patients with injuries to the hands, face, feet, and perineum.
4. All acute electrical burn patients.
5. All acute chemical burn patients.
6. All acute burn patients with smoke inhalational injury, other associated medical
illness, or with multiple trauma.
7. All patients with massive exfoliative disease like Toxic Epidermal Necrosis (TENS),
Steven Johnson Syndrome, Staphylococcal Scalded Skin Syndrome (SSSS), etc.

Diagnostics
During admission, draw blood for:  CBC

45
  Blood typing
 RBS, BUN, Crea, Na K, Cl
 ABG (if inhalational injury suspected)

Other examinations to be done:  CXR

 ECG (for electrical burns)
 Urinalysis (for electrical burns, also include urine
Hgb and pH)

REVIEW QUESTION:
Enumerate at least 5 criteria for admission into the Burn Unit.

D. Initial (ER) Management

Minor burns:
1. Cool the wound with tap water.
2. Administer tetanus prophylaxis. Give tetanus toxoid booster for patients who have
not received such in the last 5 years. Patients not previously immunized shoukd
receive 250 units of tetanus human immunoglobulin or 3000 units of anti-tetanus
serum (ATS).
3. Clean the wound with soap and water. You may use betadine scrub.
4. Debride dead tissue. Small blisters can be left for 2-3 days. Bigger blisters would
require aspiration. If there is doubt regarding the reliability of the patient or the status
of the wound, it is safer to debride the blister.
5. Apply bland ointment (IE, Bacitracin, Trimycin, Vaselin) and non-stick porous gauze
(sofratulle) and wrap with gauze.
6. No systemic prophylactic antibiotics are given.
7. Oral or IM analgesics may be needed during the cleaning of the wound.
8. Patients are seen home with oral analgesics and instructions to clean the wound OD
to BID, apply ointment and gauze. Follow-up may be daily to every other day to
weekly, depending on the status of the wound.

Major and critical burns:

1. Don sterile gloves when examining and handling patients.
2. Remove all burnt clothing. Use scissors to cut clothing away from the patient.
3. Check and secure airway. Suspect inhalational injury if with:
a. burn to face
b. sooty phlegm
c. singed nostril hairs
d. hoarseness or stridor
e. history of burn in enclosed space or unconscious at scene
f. circumferential chest burn

NOTE: Intubate the patient if: with burns 50% BSA, with suspected inhalational injury,
with smoke inhalation.

4. Do a complete physical examination. Check for other injuries: fractures, lacerations

signs of blunt abdominal trauma, etc.

46
5. Insert 1-2 large bore intravenous catheters for fluid resuscitation. The catheters may
be inserted percutaneously or by cutdown. Insert over unburned skin if possible. Don’t
use scalp veins.
6. Insert foley catheter to monitor urine output.
7. insert an NGT. Start H2blockers intravenously.
8. Weigh patient and record. This step is very important. In cases where it is impossible
to weigh the patient weight can be estimated using the formula:
 For children: Wt (kg)=[2x(age in years)] + 5
 For adults: Wt 9kg)=0.9x [(ht in cms)-100]
9.Administer tetanus toxoid and tetanus immunoglobulin. Give tetanus toxoid booster to
patients whio have not received such in the past 5 years. Atients not previously
immunized should receive 250 units of tetanus human immunoglobulin or 3000 units of
anti-tetanus serum (ATS).
10. Chack the pulses in all extremeties and assess adequacy of chest expansion. The
presence of circumferential burns in the extremities or chest associated with absent
pulses or limited chest excursion is a surgical emergency and an indication for
eschaotomy.

ESCHAROTOMY:
Extremities. Prep the whole extremity with betadine soap. Use sterile instruments
and technique. Using scalpel blade or electrocautery, cut through the entire depth of skin
along the medial and lateral aspects of the involved extremity. Avoid injuring the ulnar
nerve near the elbow in the upper extremity and the perineal nerve near the fibula in the
lower extremity. Facilitate the separation of the skin by inserting your finger snd bluntly
dissecting through the cut skin. There may be bleeding coming from the cut superficial
veins and this may be controlled using cautery or by packing.
Chest. Prep the anterior chest. Cut along both anterior axillary lines and along
the coastal margin producing a W-shaped incision.

11. Refer all pediatric cases to paediatrics for co-management. Patients with other
medical problems should also be reffered to the respective medical specialty concerned
for co-management.
12. No prophylactic antibiotics are given, unless there are concomitant medical
conditions which indicate its use early in the medical management.

E. FLUID RESUSCITATION
The most common cause of mortality in the 1 st 48 hours following a burn injury is
inadequate fluid resuscitation. Patients with moderate and major burns will require fluid
rescucitation via intravenous route, while patients with minor burns are encouraged to
increase oral intake. Fluid rescucitation should be started as early as possible in the ER
and even before other diagnostic exams.

The PGH Burn Unit uses the Parkland formula:

Day 1:
Adults: Plain ringer’s lactate 4ML/kg BW per % BSA burned to be given
 ½ during the 1st 8 hours
 ½ during the next 16 hours
Children: D5 Ringer’s lactate 3ml/kg BW per % BSA burned to be given
 ½ during the 1st 8 hours

47
  ½ during the next 16 hours
+ maintenance

***In the presence of increased capillary permeability, colloid content of

resuscitation fluid exerts little influence on intravascular retention during the initial
hours postburn→consequently crystalloid fluids are given.

Day 2
Adults/Children: D5W (adults), hlf normal saline (children) and colloid sufficient to
maintain good urine output.

***Collloid may be given in the for of plasma albumin or cryoprecipitate. Most

resuscitation protocols start colloid infusion after the 1 st 24 hours since it is
thought that capillary permeability is restored by then. In cases of massive burns,
colloid infusion can be started as early as 12 hours post-burn to decrease the
total fluid requirements and lessen edema.

All fluid calculations should not be taken as absolute and should not be given by
rate. They should be regulated to maintain an adequate urine output, which
should be monitored hourly. Adequate urine output is defined as:
 Adults: 0.5 ml/kg BW/hr
 Children: 1.0 ml/kg BW/hr

***Age influences relationship of fluid needs to body size since children has
greater body surface area per body volume.

Urine volomes in excess of the values given above may signify over correction
and may run the risk of fluid overload while volumes smaller may signify
inadequate fluid resuscitation. It cannot be overemphasized that regular hourly
monitor ring of urine volume goes hand in hand with initial fluid resuscitation.

NOTE: In electrical injuries, fluid volume for resuscitation should be adjusted to

maintain a urine output of 75-100 ml/hr and mannitol 12.5-25g may be infused to
promote dieresis.

If urine output and pigment clearing do not respond to fluid resuscitation, 12.5g of
cosmetic diuretic mannitol may be added to each liter of resuscitation fluid. Since
hama tigments are more soluble in alkaline medium, NaHCo 3 can be added to
IVF to maintain a slightly alkaline urine.

REVIEWER QUESTIONS:
For both adults and children....
1. Write down the formulae used in fluid resuscitation during the 1 st 24 hours.
2. What type of fluid is used during the 1st 24 hours?
3. What is the expected urine output per kgBW/hr?

F. Wound dressing

Debridement/Initial Dressing:
1. Performed in a sterile area. Don sterile gloves, and use sterile techniques.

48
 2. Undress patient. Cut hair if it will reach any burned area or otherwise complicated
dressing.
3. Give the patient a full body bath using warm water and soap.
4. Debride the burned areas, removing loose, dead skin unroofing blisters, and so
on. Make sure to visualize all burned areas. At this point it may be necessary to
reassess the depth of the burn wounds as well as the %BSA involved. Most
people, including the SOD have a tendency to estimate burn size since most of
the patients seen at the ER are still clothed.
5. Wash the burn areas with betadine soap and rinse with sterile water.
6. Dress the patient’s wounds with a topical antibacterial or other dressing modality,
as indicated.

Types of Wound dressings:

1. Silver sulfadiazine (Flammazine, Silvadene, Silversurf)
 Thick, white paste used for dressing partial to full thickness burns; applied as
sandwich dressing.
a) Place 1 layer of gauze over the burn area. This facilitates the application
of the cream.
b) Apply Silver sulfadiazine to the burn wound about 0.5-1.cm thick.
c) Cover with OS wet with sterile NSS about 1.0cm thick. This wet layer
prevents drying silver sulfadiazine, which would limit efectivity.
d) Cover with a layer of dry gauze.
 The dressing is changed once or twice a day. During removal of dressing, it is
usual to wet the last layer of gauze to facilitate its removal and to make it less
painful for the patient. Silver sulfadiazine leaves a yellow-green pseudo-eschar,
which to the inexperienced may be mistaken for the eschar itself. This pseudo-
eschar has to be scraped off using a long depressor during dressing prior to
application of the silver sulfadiazine.
 Silver sulfadiazine is a 1.0% water-soluble cream combining silver and
sulfadiazine. The Ag+ ion binds with the DNA of an organism and releases the
sulphonamide, which interferes with the intermediary metabolic pathway of the
microbe. It is effective against Pseudomonas aerugenosa, the enterics,
Staphylococcus aureus, Klebsiella sp, although resistance has been reported. By
itself, it retards wound healing.
 This agent may cause a transient leucopenia.

2. Silver sulfadiazine + Cerium nitrate (Flammacerium)

 Topical antimicrobial, which when combined with the burned skin, forms a pliable,
leathery layer , which acts as a protective mechanical barrier against bacterial
contamination. There is evidence that it reduces mortality by neutralizing a toxin
present in burned skin, and so preventing the resulting immunosuppression in
severely burned patients. This may be applied in cases wherein early excision-
grafting cannot be done (e.g. mass burn situations, extensive burns). Research
shows that cerium induces calcification of the dermal collagen remaining in the
wound, and that this produces the typical tanned, leathery crust.

3. Silver nitrate
 Used as a 0.5% solution. Gauze dressing is wet with the solution and the applied
to the patient. The agent loses effectivity when dry, and dressings have to be wet
with solution every 2 hours. The main disadvantage of using silver nitrate is the

49
 brownish-black discoloration it creates on anything it comes in contact with-skin,
dressing, linen, floors. The discoloration will peel off with the burned skin and the
discoloration can be washed off walls with hydrochlorite solution. Caution should
be used when using silver nitrate in children, as it tends to leach out electrolytes,
especially Na and Cl. Regular electrolyte determinations have to be done. This
solution does not injure regenerating epithelium in the wound and is bactriostatic
against S. Aureus, E. Coli, and P. Aerugenosa.
4. Daikin’s Solution
 Sodium hydochlorite 0.025% solution, prepared by mixing 15 ml of a
commercially-available sodium hypochlorite solution (Zonrox) and 935 ml of a
sterile saline solution (NSS). The solution must be used within hours after it is
prepared.
 It is mainly used in preparing granulation tissue for grafting. It is bactericidal to S.
Aureus, P. Aerugenosa, and other G(+) and G(-) bacteria.

REVIEW QUESTIONS:
Name the 4 types of dressings used in burns.

Burn injury is a dynamic process. The initial exposure to the wounding agent starts a
train of physiologic events that present to the physician a patient with complex and
precarious physiologic state, which has to be optimized to maximize chances of a
positive outcome. Monitoring the burn of the patient is one of the most important aspects
of burn care.

At the Emergency Room:

1. Check vital signs, urine output, level of consciousness, and pulmonary status
hourly.
2. Draw blood for Hgb, typing, Na, Cl, K, BUN, crea and RBS.
3. In cases where pulmonary or inhalational injury is suspected, do CXR and ABG.
4. In cases of electrical injury, do ECG and urine haemoglobin and myoglobin.

During the Period of Fluid Rescucitation:

1. Signs of adequate [resuscitation] hydration.
2. Weigh patient daily.
3. In cases of electrical injury, the presence of haemoglobin and myoglobin in the
urine (associated with pinkish color) suggests delayed or inadequate fluid
resuscitation.
4. Monitor vital signs hourly.
5. Monitor peripheral perfusion hourly. Elevate affected extremities and check
pulses hourly. One may check capillary refill (should be less than 2 secs) in the
fingernails of the affected extremity.
6. Daily determinations of Hgb, Hct, WBC, Na, K, BUN and crea.
7. Check pulmonary status and gastrointestinal status every 4-5 hours or so.
8. Asses status of wound daily during dressing change.

POST-RESUSCITATIVE PERIOD TO HEALING

1. VS monitoring may be decreased to q4 hrs to every shift depending on patient’s

commission.
2. Daily determination of weight, Na, K, BUN and crea.

50
3. Assess burn wound status everyday during dressing changes. Do burn wound
biopsies (not swabs) twice a week.
4. Do blood CS if wound is infected or if patient is septic once a week.
5. Weigh patient daily.

DEFINITIVE MANAGEMENT

The priority in the management of burns in the 1 st 48 hours is to maintain the

intravascular volume, which will be affected by fluid shifts arising from the increased
capillary permeability wich is found in burns. Once this problem is hurdled, attention is
now turned to the definitive management of the patient’s burn wounds.

The classical method of burn management was to allow the eschar to spontaneously
separate (usually after 3 weeks), wait until the bed is ready for grafting then place the
skin graft. The present trend is for early (within 7 days post-burn) excision of the burn
wound, followed by skin grafting. This method has been shown to improve survival and
shorten hospital stay. This strategy has been adopted by the PGH Burn Unit.

51
A. Excision and Grafting
The basic premise of excision and grafting is to remove full thickness and deep
partial burns until clean viable bed is encountered and a skin graft is placed
immediately to cover the wound.

Early Excision
This is done within the 1st 7 days post-burn, while the burn wound is not yet
colonized by microorganism; thus reducing chances of infection and promoting
good graft take

Preparation for OR- Prerequisites

1. Stable vital signs
2. Not in septic shock
3. Afebrile
4. Blood type and crossmatch for OR use. Estimated amount to replace losses
during tangential excision at 200-400 ml/% BSA excised
5. Albumin us normal (38-51g/L)
6. No medical contraindications for surgery

Conduct for OR
1. Make sure that the OR table is covered by sterile linen before the patient is
transferred onto the table
2. Keep the OR warm
3. Prep the patient using betadine soap and betadine paint for the donor sit,
betadine soap for the wound
4. Prep the donor site
5. Drape the donor site separate from the burn wound

Tangential Excision
1. Harvest the split thickness graft (STSG), expounded in a later section
2. Using a Humby knife or a mechanical dermatome. Make successive passes
over the burn wound. The goal is to seek a layer of brisk punctuate bleeding.
Whitish-gray areas do not bleed immediately after passage of the dermatome
area are still not viable and still need to be excised
3. Hemostatis is obtained by spraying the wound with a 1:100,000 epinephrine
solution (prepared by mixing 1 ampule of epinephrine containing 100 ml of
1:1000 epinephrine solution in 100 ml of sterile NSS). The wound is covered
by a sterile sheet of rubber plastic Op-site, Tegaderm or other similar
dressing
4. Apply pressure for 5-10 minutes. While waiting, one may work on other areas
so as not to waste time
5. Wash away the blood clots using NSS projected from a syringe. Points still
bleeding can be controlled by cautery
6. Apply STSG (expounded in later section)
7. Limit OR time to at most 4 hours and work on at most 10% BSA per OR.

52
Fascial Excision:
Best used when excising large flat areas e.g. trunk where heavy bleeding might
be encountered or when excision of the burn wounds has to be done with a
minimum of blood loss. The operation is less bloody than tangential excision, but
there is a cosmetic effect defect resulting from the procedure. It is of limited use
in the extremities due to problems of edema in the area distal to the excision, the
presence of avascular fascia in the joint areas (which could result in graft loss)
and the presence of nerves in superficial locations which may be injured. It is
also recommended in full thickness burns in the elderly since grafts on fat do nor
survive.
1. Harvest STSG
2. Using electrocautery, excise full thickness of eschar including the
subcutaneous fat until the fascia is encountered. Blood loss from this
procedure is much less than tangential excision as bleeding comes from the
perforators
3. Apply the skin graft expounded in a later section

Harvesting the skin graft:

1. Prep the door site with betadine soap and paint
2. Harvest the STSG using a Humby knife or mechanical dermatome with
thickness of 0.0010-0.014 inch. A good skin graft contains the dermis as
evidenced by whitened undersurface. There should be dermis remaining in
the donor site for epitheliazlization. If fatty tissues is noted where the graft is
harvested, the graft is too thick.
3. Hemostatis is secured using 1:100,00 epinephrine spray and plastic overly
followed by pressure s described in hemostatis and tangential excision
4. Cauterize any persistent bleeders
5. Dress the donor site with hydrocolloid dress or by applying one layer of mesh
gauze followed by layers of wet gauze. The wet gauze is removed after 8
hours and the donor site with a single layer of mesh is exposed for 30
minutes every hour for one day until scab will form which will later flake off as
donor site heals
6. Choice for donor sites: Thigh, leg
Back*
Scalp*
Anterior trunk
*will have to inject sterile NSS subcutaneously to elevate the skin and create
a smooth flat surface to facilitate harvesting of skin graft

Applying the skin graft:

1. In burns over joints and the face, do not mesh the skin. One may place widely
spaced nicks using a blade (No.11) to prevent serum or blood from collecting
under the graft. Otherwise skin grafts may be meshed to provide a greater
area to be covered by the skin graft
2. Make sure that the bed upon which the STSG would be applied has no active
bleeding

53
 3. Secure the grafts to the bed. One may use a stainless steel stapler or one
may suture the graft on to the bed. In the hands and the face , one must
suture the graft using chromic 4.0
4. Once graft is secure, apply a layer of non-adherent gauze (vaselinized or
sofratulle)
5. Place a layer of bulky wet dressing (cotton or gauze) to help the graft have
firm contact with the bed
6. Secure dressing using the over-bolus over flat areas or circumferential elastic
bandages over flat extremities
7. Apply splints to immobilize the joints with STSG

Care of the skin graft

1. First graft opening could be as early as the 3 rd post-op day or as late as 5th
post-op day. Open early if the skin graft is suspected to be infected as when it
has a foul-smelling odor
2. Remove the bulky dressing slowly. Take care not to disturb the skin graft.
Use copious amount of sterile water. Skin graft take is indicated by pinkish-
color of graft and adherence to graft bed. Gently wash the area wit betadine
soap and rinse with water. Dress the graft with bulky wet dressing,
3. Staples can be removed at he 1 st dressing change
4. Skin grafts can be dressed every day if not infected. If with good take, the
skin graft can be left open on the 7th post-op day. Small areas of graft loss
(about thumb size) could be cleansed by mercurochrome

REVIEW QUESTIONS
Name and differentiate 2 basic types of surgery used in the removal of burn tissue

B. Nutrition

Patients with moderate burn can be fed as early as 6-8 hours after the burn injury.
Patients with larger burns can be fed 24 hours or as soon as ileus (which is a result of
burn) resolves. Patient with burns have a hypermetabolic response and have metabolic
nutritional requirements. This hypermetabolic state persists until burn wounds are
covered. To ensure delivery of necessary calories in these patients, a nasogastric tube is
inserted.

Calculations of patient’s nutritional requirements by using Curreri’s formula:

 Adult: (25 x kg) / (40 x %BSA burn)
 Children (60 x kg) / (35 x %BSA burn)
A rough guide is to use 2500 calories/day in an adult patient. Proteins are calculated at
2g/kgBW per day. Patients in the burn unit are asked to eat 6 eggs/day cooked in
anyway they want. Give supplements of vitamin C and zinc.

REVIEW QUESTIONS
Give the formula in calculating a burn patient’s nutritional requirement

54
C. Common Complications
1. Sepsis
 Most common cause of death in burns
 Suspects sepsis if patient has fever, hypotension, conversion from
partial to full thickness burns, presence of ecthyma gangranosum in
the burn wound
 Cultures if blood may be negative if there were antibiotics previously
given
 Start antibiotics
2. ARDS
 Occurs when in the setting of electrical or inhational/pulmonary injury
 Presents as progressive hypoxemia unresponsive to increasing FiO2
 X-rays may be normal in its early phase
 Manage with intubation: 100 FiO2 and PEEP
3. Contractures
 Preventable by proper positioning and splinting
 Coordinate with rehabilitation medicine resident regarding proper
positioning

D. Pain Control
May give Meperidine 50 mg IV Q6 or Nalbuphine Q4. Do not give narcotics IM since
absorption is erratic

CRITERIA FOR DISCHARGE

1. No existing complications of thermal injury such as inhalational injury

2. Fluid resuscitation completed
3. Adequate pain tolerance
4. Adequate nutritional intake
5. No anticipated septic complcations

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56