PLASTICS 3 (BURNS)

Subspec
Dr kho
OCT 2016

o Below- lower
SKIN LAYERS  Smoke inhalation
 Epidermis
 Dermis DIRECT THERMAL INJURY
o Superficial papillary  Limited to Upper airway
o reticular  Airway edema-potentially lethal-if edema is severe air
 Subcutaneous fat will not pass through so patient will die
 Within 48 hours- can sometimes extend to 72 hours
TRADITIONAL CLASSIFICATION  Lower airway- seldom
 1ST DEGREE- up to the epidermis o Enters airway slowly so there is a chance for
 2ND DEGREE- the heat to dissipate by the time that it
o Superficial- until papillary lowers to the glottis
o Deep- until reticular level o Have the glottis to protect the lower
 3RD DEGREE - fat airways- has reflex mechanism
ADDITION: o Only way to get direct thermal injury will be
 4TH DEGREE- fascia muscle bone tendon direct the face to the skin – no time for the
heat to dissipate and the glottis to protect
NEWeR CLASSIFICATION the airway
 1st degree- superficial (epidermis)  Extremely rare
 2nd degree- partial thichness  Heat dissipation in ora\nasopharynx
o Superficial partial thickness  Reflex closure of the vocal cords
o Deep partial thickness  Steam or exploding gas
 Full thickness- subcutaneous fat fascia muscle bone
*more accepted HISTORY
 Cant get inhalational injury from eg hot liquids
*at the ER whenever there is a burn patient- start to manage  Can get direct thermal injury from flames eg house on
patient before transferring to burn unit fire
 History will be enclosed space and patient were
INITIAL EVALUATION sleeping during the household fire
 Evaluation of injuries  On history exam patients affected on the central area
 Inhalation injury of face
 Compartment syndrome  Look inside the mouth- sputum is black – suspect
 Estimation of burn size  Hoarseness- like asthma attack
 Need to act fast due to respiratory compromise
TRAUMA PATIENTS
PHYSICAL EXAM
Primary survey  Perioral burns and singed nasal hairs
ATLS guidlines o Evaluate oral cavity and pharynx
 Hoarseness wheezing stridor dyspnea
A - Airway o Impending respi compromise
B - Breathing
C - Circulation DIAGNOSIS
D - Disability  Direct visualization of the upper airway
E – Examine o Direct endoscopy- ask ENT
 Fiber optic bronchoscopy-better option
INHALATIONAL INJURY o Can visualize both upper and lower
 common o Need TCVS or pulmo
 1\3 all major burns
 3x hospital stay TREATMENT
 Increased mortality  Observation
 Supplemental oxygen
TYPES OF INHALATIONAL INJURIES  Pulmonary toilet
 Direct thermal injuries  Bronchodilators as needed
 Smoke inhalation  ET as indicated – in toxic patients
 Carbon monoxide poisoning o Problem is airway edema
o If no tests can be given better intubate the
patient better since of there is no edema
can remove ET in 24-48 hours and no harm
done
o More harm if there is late intubation
 Resolution usually within days

*can divide to upper and lower

 Glottis- dividing landmark
o Above- upper
 Direct thermal injury

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 SMOKE INHALATION
 Damages respiratory physiology TREATMENT
TOXIC PRODUCTS OF COMBUSTION  100% oxygen
-lung injury from toxins to smoke  T1\2 of COHb
o Room air: 250 min for half life of
carboxyhemoglobin
o 100%O2: 40-60 min
Compounds Source Effect Timing
 Hyperbaric oxygen- controversial

• Ammonia Clothing, Mucous Early on set COMPARTMENT SYNDROME-watched out for

Furniture,Wool membrane (first several
• Sulfur Dioxide  Increased pressure within a confined space
, Silk irritation, hours)
• Chlorine  Three causes
Bronchospasm,
o Circumferential FT burns
Bronchorrhea
o Electrical injury
o Systemic inflammation-in patients with
• Hydrogen Polyvinyl, Severe mucosal Delayed severe burns
Chloride Chloride, damage; ulcers, often  40% and higher total body
Furniture (wall, mucous 1-2
• Phosgene surface area
floor plugging,
coverings) mucosal slough, CIRCUMFERENTIAL BURNS
pulmonary  Neurovascular compromise
edema  Check for arterial occlusion (6 P’s)
o PAIN
• Acetylaidehyde Wallpaper, Severe mucosal Delayed o PARESTHESIA
Lacquered damage; ulcers, often
• Formaldehyde o PARALYSIS
wood, Cotton, mucous 1-2 o PULSE
• Acrolein Acrylic plugging, o PALOR
mucosal slough, o POIKILOTHERMIA
pulmonary *not done anymore- rely on the pulse oxymeter
edema
EXTREMITY COMPARTMENT SYNDROME
• Cyanide Polyurethane Tissue Hypoxia Immediate
 Pressure ≥ capillary perfusion pressure
Upholstery
o ≥\= 30mmHg
 Pulse oximeter
• Carbon Monoxide Any Tissue Hypoxia Immediate o Oxygen saturation ≤ 95%- if not there could
combustible be compartment syndrome
substance
 Neuromuscular damage irreversible
o Withn 4-8 hours
INHALATION OF TOXINS  ESCHAROTOMY\FASCIOTOMY- to relieve pressure
 ↓ lung compliance o ESCHAROTOmy- eschar is black- dead skin
 ↑ airway resistance opening
 ↑overall metabolic demands  To relieve pressure so that the
 ↑ mortality neurovascular pressure will not
be compressed
DIAGNOSIS  Can done at bedside- painless
 Can do it on one side either
 History
midlateral or mid medial then
 Clinical findings
check the PO2 if okay do it on
 ABGs
next side
 Fiberoptic bronchoscopy
 If lacking do fasciotomy
-UPPER EXTREMITIES
TREATMENT
-Midlateral and midmedial lines
 Supportive o Avoid ulnar nerve posterior to medial
 Fluid resuscitation epicondyle
o Avoid common peroneal nerve posterior to
CARBON MONOXIDE POISONING fibular head
 Most common cause of death in inhalation injury
 CARBON MONOXIDE THORACIC COMPARTMENT SYNDROME
o Binds with Hb to form carboxyhemoglobin  Circumferential FT burn of the thorax
o Affinity for Hb 200-250x ≥ 02  Patient not able to expand chest because of the full
thickness burns
DIAGNOSIS  S\Sx
 Neurologic symptoms- main manifestation of patients o Hypoventilation
 Arterial carboxyhemoglobin level o Increased airway pressure
o Pulse oxymetry is falsely elevated o Hypotension
 THORACIC ESCHAROTOMY
LEVELS OF CARBOXYHEMOGLOBIN o Bilateral anterior axillary line and subcostal
 ≤ 10% margins
o No symptoms
 20% ABDOMINAL COMPARTMENT SYNDROME
o Headache N\V  Circumferental FT burn of the abdomen
o Loss of normal dexterity  Compromised blood supply to kidney and has
 30% decreased UO
o Weak  S\SX
o Confused o Decreased urine output
o Lethargic o Increased ventilator airway pressure
 40-60% o Hypotension
o Coma  ABDOMINAL ESCHAROTOMY
 ≥60% o Downward extension of the anterior axillary
o Fatal incisions

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*INTUBATION- need to make sure that there is compartment  Clothing ignition
syndrome o FT burns 6x increased
*escharotomy and fasciotomy only done if needed o Mortality 4x

ESTIMATION OF BURN SIZE FLASH BURNS

 Rule of 9s  3rd most common
 Lund and browder  Explosions
 Palm method  Intense heat for a brief period
 Exposed area
RULE OF NINES  Superficial or Partial thickness

CONTACT BURNS
 Hot objects
 Limited to extent-usually big toe

2. ELECTRICAL INJURY
 Many problems in electrical injury and not only burns
 Have to look for other injuries
VOLTAGE
 Low or high
o 1000 volts

ELECTRIC CURRENT
 Current strength
o Tingling sensation \perception
 1-4 mA
o Let-go current (men)
 7-9mA
o Skeletal muscle tetany
 15-20 mA
o Respiratory muscle paralysis*
 20-50mA
o Ventricullar fibrillation
 50-120mA
 Common household*
o Circuit breakers
 15-30mA

TYPES OF CURRENT
*can be used in ER setting and seeing several patients at one time  Direct current
*once settled down in the ward and ER estimate again using the o better
LUND and BROWDER o Large single muscle contraction throws
victims away
*LUND AND BROWDER o Brief duration of contact
 connected to age  Alternating current (indirect)
o 3x more dangerous
 More accurate
o Cyclic flow causes muscle tetany
 Just consider the partial and full thickness\ across all
o Prolonged exposure
age groups it is 2 1\2%
RESISTANCE
*PALM METHOD
 LOW
 Misnomer
o BV
 Include the palm and fingers
o Muscles
 Has to be the hand of the patient
o Nerves
 HIGH
CLASSIFICATION OF BURN WOUNDS
o Bone
 Thermal
o Fat
o Scald burns
o Skin
o Flame burns
o Heavily calloused areas of the skin
o Flash burns
 Water decreases resistance
o Contact burns
 Electrical
TYPES AND EXTENT OF INJURY
 Chemical
 FACTORS
o Duration of contact
1. THERMAL INJURY
 The longer the more severe
SCALD BURNS
o Pathway of flow
 Most common
 50% in children THERMAL BURNS
o ≤8 y\o  Most severe sequelae after arrythmias
 PT or FT burns  May appear minor despite significant deep tissue
o 60.0 degrees in 3 sec injury
o 65.5 degrees in 2 sec
 May require fasciotomy or amputation
o 69.0 degrees in 1 sec
*brewed coffee- 82 degrees
DIRECT CURRENT INJURY
 Know point of entry and point of exit
FLAME BURNS
 Burns to the skin and deeper tissues
 2nd most common
o Most severe at source and ground contact
 Most common cause for hospital admissions
point
 Highest mortality – because of inhalational injury o Source usually hands or head while ground
 House fires is feet

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 TYPES:
ELECTRIC ARCS 1. ACID BURN
 Current sparks between objects of different electric  More superficial burn
potential  Commonly seen in household cleaning agent
 Can reach 2500-5000 degress c  Sulphuric Nitric hydrochloric acids
o Cleansing agents
FLAME BURNS  Eschar formation
 Ignition of clothing-increased chances of full thickness  More superficial
burns  Coagulation necrosis
o Limits tissue penetration
FLASH BURNS  Denature proteins
 heat from nearby electrical arc
o current does not enter the body 2. ALKALI BURN
o splashes over the surface  Common agents found
 diffuse superficialpartial  Fat saponification
thickness burns o Facilitates penetration and increases injury
CONTACT BURNS  Sodium hydroxide
 branding o Decloggers paint removers
 Calcium hydroxide
CARDIOVASCULAR o Cement
 most important  PATHOLOGY:
 either patient will die on the spot or the patient will o Liquefactive necrosis
survive and small chances of dying lateron due to heart
problems TREATMENT
 dangerous in elderly and pts with heart problems  Irrigate with distilled water or saline
 asystole o 30 min acid
o high voltage AC or Dc o 2 hours saline
 ventricular fibrillation  Neutralizing agents no advantage
o low voltage AC  Further treatment based on presentation
 long term complications rare  RULES:
o 30 min for acid-
PULMONARY o Longer for alkali
 respiratory arrest o Still irrigate if pain is still felt
o chest paralysis from tetanic contractions
o injury to respiratory center in the brain BURN DEPTH

NEUROLOGICAL
 seen later
 brain damage
 delayed transverse myelitis
 anterior spinal artery syndrome
 damaged peripheral nerves
 chronic pain syndromes
 post traumatic stress disorders

OPTHALMIC
 cataracts 5-7 % within 1-2 years
 delayed
 seldom seen right away

MUSCULOSKELETAL
 fractures
 compartment syndrome BURN DEPTH
o because current passes through the body
 Proportional to temperature
o problem: the current entered the extremity
o The higher the temp the bigger the burn
the bone would resist the current so heat
 Duration of contact
will be on the bone the muscles next to he
 Thickness of skin
bone will be cooked
 Burn wounds evolve over 48-72 hours
 massive deep tissue necrosis
 Serial examination is the most effective way to
o rhabdomyolysis
determine burn depth
o acidosis and myoglobinuria
o debridment and or amputation  Extremes of ages the very young the very old

ACUTE KIDNEY INJURY JACKSONS PARADIGM OF BURNS

 hematuria
o hemoglobinuria and or myoglubinuria
o important to treat to prevent acute tubular
necrosis
 urine output
o 1ml\kg BW\hr
 Sodium bicarbonateor mannitol

3. CHEMICAL BURNS
EXTENT OF INJURY
 Concentration
 Duration
 Quantity
1. ZONE OF COAGULATION
 Part most exposed to injury

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  Central area of injury  Capillary refill decreased or (-)
 Most exposed  Discomfort
 Necrotic  Heals in 3-9 weeks
 Joint function may be impaired
2. ZONE OF STASIS  Hypertrophic scarring common
 Middle zone  Thin fragile epithelium
 critical  May treat as FT burn
 Marginal perfusion
 Questionable viability FULL THICKNESS
 Adequate management  All layes
 With adequate Fluid resuscitation and Local wound  White cherry or black
healing- it will join the zone of hyperemia and survive  Charred vessels- PATHOGNOMONIC
 Inadequate rescusitation and poor wound healing –  Eschar
will join the zone of coagulation and have a bigger o Leathery firm and depressed
necrotic area  Rarely blanches on pressure
 Insensitive
3. ZONE OF HYPEREMIA  Heals by
 redness o contraction (contracture)
 Outermost o skin grafting
 Similar to uninjured tissue
 Increased blood flow due to response to injury PROGNOSIS
*some burns evolve after 48-72 hours  Highest predictive value for mortality
o Age
BURN DEPTH o % TBSa
o More important
 Inhalation injury
 Coexsistent trauma
 Pneumonia

CASE

An adult patient weighing 70kg suffered 2nd degree burns

involving the right upper extremity, half of the anterior trunk and
the entire back. Compute for the Total Body Surface Area burns.

Ans: 36% TBSA burns

GUIDELINES FOR REFERRAL

Criteria for transfer to a burn center

 Second-degree burns > 10% TBSA
 Third-degree burns
 Burns that involve the face, hands, feet, genetalia,
perineum, and major joints.
 Chemical burns
 Electrical burns including lightning injuries
 Any burn with concomitant trauma in which burn pose
the greatest risk to the patient
 Inhalation injury
 Preexisting medical disorders that could complicate
SUPERFICIAL management prolong recovery or affect mortality
 Hospitals without qualified personel or equipment for
 Epidermis
the care of critically burned children
 Appears red
 For patients below 10 years old and greater than 50 –
 Patients complain of pain
burns will be 10% higher
 Erythematous
 Burns between 10-50y\o-20% TBSA will warrant
 Quite painful
referral
 Heals within 7 days
FLUID RESUSCITATION
SUPERFICILA PARTIAL THICKNESS
PRIMARY GOAL
 BLISTERS- pathognomonic
 Restore and preserve end organ perfusion
 Pink and wet
 Blanches with pressure BURN SHOCK
 Less pain- injured nerve endings  Hypovolemic shock with ARF (≤ WWII)
 Hypersensitive- o Leading cause of death
 Heals in 2-3 weeks  1st 24-48 hours
 No functional impairment o Hypovolemia is maximal
 Hypertrophic scarring- rare o Fluid rescucitation crucial
 Hypopigmentation  Decreased mortality rates in 48 hours

DEEP PARTIAL THICKNESS HEMODYNAMIC CHANGES

 Reticular-  ↑ Extracellular fluid (edema)
 Destroys most skin appendages  ↓plasma volume
o Important because it is the adnexal glands  ↓cardiac output
that would give rise to the epithelial cells  Oliguria
 Blisters
 Mottled pink and white –indicative of lack in blood PATHOPHYSIOLOGY OF BURN SHOCK
supply  Increased selective microvascular permeability
o Seen when blisters are rmoved o Minimal edema formation

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 o B\n 8-12 hours in smaller burns TOPICAL ANTIMICROBIALS
o B\n 12-24 hours in major burns

CRYSTALOID RESUSCITATION Silver Silver Sulfadiazane

Mafenide Acetate
 Most extensively used Nitrate(banned) (available)
 Parkland formula (ADULTS)
o LRs
Bacteriostatic Most commonly
o 4 ml\kg\TBSA burn
Broad-spectrum used
o 1\2 over 1st 8 hours
Gm (+) & (-) Bacteriostatic
o 1\2 over next 16 hours Broad antimicrobial
Weak anti fungal Good bacterial
CHILDREN- less than 15 y\o or less than 13 kgs Does not penetrate
Penetrates eschar coverage
 Plus maintenance D5 0.3 NSS\24 hours eschar
& cartilage Anti fungal
o 100 ml\kg for 1st 10 kg Leeches electrolytes
Carbonic anhydrase Doesn't penetrate
o 50 ml\kg for 2nd 10 kg Hyponatremia
inhibition eschar
o 20 ml\kg for over 20 kg Hypocalcemia
Hyperchlomeric Transient
*children easily go to hypoglycemic episodes- does not Hypokalemia
metabolic acidosi neutropenia &
have enough glycogen reserves in the liver – need D5 Methemoglobinemi
Clinically not Thrombocytopenia
containing a
significant Painless
*adults- no need to give D5
Painful Bacterial resistance
o TRAUMA- pts are hyperglycemic (will
7% Hypersensitivity Destroys grafts
exacerbate)
o Will cause hyperosmolar diuresis
 DAY 2-chance to correct electrolyte imbalance
o D5W OCCLUSSIVE DRESSING
o Adjust rate as necessary to maintain
adequate UO
o Colloid infusion
 DAY 3+
o MAINTENANCE IV
 CHECK SERUM ELECTROLYTES
 Timing
o From the beginning
o After 24 hours
 Albumin
o Principal colloid used
o PROBLEm: if colloids are given in the 2st 24
hours the pores are bigger the more the
colloids will go outside
o Given after 24 hours
 Capillary permeability will be in
normal size *wounds should be kept moist
o Others: plasmenate hetascharch FFP
 Optimal amount if any undefined FULL THICKNESS GRAFTING
 No supporting level 1 data  Skin grafting
 Reconstruction
CRYSTALLOID FORMULAS
 Colloid formulas EARLY EXCISION AND GRAFTING
o Evans  3-7 days → 10 days
o Brooke  ↓↓↓burn mortality
o Slater  ↓hospital stay
 Crystalloid formulas  ↓duration of illness
o Parkland or baxter  ↓ septic complications
o Modified brooke  ↓need for major reconstruction
 Hypertonic saline formulas  ↓ hospital costs
o Monafo  Improved form and function
o Warden  Close wound before maximal inflammatory response
 Dextran formula *need to give tetanus
*pain meds should be strong to control the pain
ADEQUACY RESCUCITATION
 PARAMETERS SKIN GRAFT
o BP  Sheet of skin transplanted to another site
 MAP 60 mmHg o Freed from BS
o UO  Superficial defects
 0.5 ml\kg\h adults
 1.0 ml\kg\hr children
CLASSIFICATION OF
BLOOD TRANSFUSION SKIN GRAFTS
 Increased infection and mortality
 7g\dl in burned children= threshold Type Description
 Transfuse only when there is physiologic need
Split Thickness Thin (Thierish-Ollier)
TREATMENT OF BURN WOUND
 Superficial Intermediate (Blair-brown)
o +\- 7 days
 Superficial PT
Thick (Padgett)
o 2-3 weeks
o No functioning impairement
Full Thickness Entire dermis
o Hypertrophic scarring rare
(Wolfe-Krause)
o Hypopigmentation
o Burn wound care

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 o 25%= 1.5
1. Curreri formula 2. Harris Benedict o 50% = 2

ER = (24 kcal X 80 kg) CURRENT FORMULA

+ (40 kcal X 17) BEE = 66 + (13.7 X 80) + (5 X 16) - (6.8 X  ≤ 40% TBSA
= 2600 kcal 49)  Adults
= 1643.8 kcal o 25 kcal\kg\day +40 kcal\ %TBSA
TEE:
 Children
= 1643.8 X 1.05 (ventilated) X 1.5
(burns) o 60 kcal\kg\day +35 kcal\% TBSA
= 2589 kcal
ENERGY REQUIREMENT

MESHED STSG AVERAGE:= 2600+2589

 To expand surface area 2
 When a large area must be resurfaced =2594.5 kcal= 2500 kcal

GUIDE TO TETANUS PROHYLAXIS INDIRECT CALORIMETRY

 Has the patient completed a primary tetanus dipthria  Calculate resting energy expenditure
o If YES- was the most recent dose within the  Not proven to be more beneficial than the predictive
past 5 years equations
 YES- vaccine tetanus
 NO- Administer vaccine today REHABILITATION
o If NO \ UNKNOWN- administer vaccine and  GOALS
tetanus immunoglobulin o Maintain function
o Prevent complications of immobility
PAIN CONTROL  Begins on day of admission
 Intravenous  Positioning very important
o SQ abd IM erratic
 Best treatment: prevention
 Benzodiazepenes
 IVopiod
o First line of choice SUMMARY: KEYS POINTS
o Orphine
o Fentanyl Criteria for burn center
o Hypotension Intubate for inhalation injury
Fluid resuscitations
NO SYSTEMIC ANTIBIOTICS No antibiotics initially
 Burn wound is clean is heat cleaned the bacteria Burn wound care
 At least for the 1st 24-48 hours it is relatively clean Early excision and grafting
 increased WBC- due to wound healing (neutrophils) Rehabilitation
o can have inflammation without infection
 actually promoting resistant bacteria- eventually the
patient will need antibiotics by day 5 or 6
o not given at day 1- can make the body
resistant by the time it needs it

NUTRITIONAL SUPPORT
 Significant systemic complications
o Weight loss ≥ 10% of ideal lean BW
 Commonly seen in Burns ≥ 20%
TBSA

ROUTE OF ADMINISTRATION
 ≤20% tbsa BURNS
o High calorie
o High protein
o Oral diets
 Major burns
o Gastric or duodenal feeding tubes
o Patients need to eat 24\7 due to high
caloric demand
 Severe burns
o Gastroparesis
o Postpyloric feeding

LONGS MOD OF HARRIS- BENEDICT EQ

 Caloric requirements (kcal\day)
 BMR
o Men
 =66.47 + 13.75(W) +5.0 (Ht)-
6.76 (A)
o women
 655.1 +9.56 (W) + 1.85 (Ht) -4.68
(A)
o Where
 W- wt- kg
 H- height cm
 A- arge years
 BMR x stress factor
o 10% burn TBSA= 1.25
o 40% = 1.75

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