LECTURE 9: BURNS

Dr. Philip Michael Vilches | 25 October 2019

OUTLINE:
I. BURNS
A. Initial Evaluation
B. Signs of Impending Respiratory Compromise
C. Advanced Trauma Life Support Guidelines
D. Estimation of Burn Size
E. Carbon Monoxide Poisoning
F. Classification of Burns
G. Burn Depth
H. Prognosis
II. TRANSFUSION
III. INHALATION BURNS
A. Physiologic Effects
B. Treatment of Inhalation Injury
C. Treatment Of The Burn Wound
IV. NUTRITION
V. COMPLICATION OF BURN CARE
A. Ventilator Associated Pneumonia
B. Deep Vein Thrombosis
C. Catheter-Related Bloodstream Infections
VI. SURGERY
A. Compartment Syndrome (Warning Signs)
B. Wound Coverage
C. Rehabilitation
VII. References

BURNS Initial Evaluation

 Burn injury histologically carried a poor prognosis
 With advances in fluid resuscitation and the advent
of early excision of the burn wound, survival has
become an expectation even for patients with severe
burns.
 Burned patients should be first considered trauma
patients, especially when details of the injury is
unclear.
 American Burn Association (ABA) has emphasized
referral to specialized burn centers after early
stabilization
Four crucial assessment:
1. Airway Management
2. Evaluation of Other Injuries
3. Estimation of Burn Size
4. Diagnosis of CO and Cyanide Poisoning
Airway management
 Direct thermal injury to the upper airway or smoke
inhalation can cause a rapid and severe airway
edema; potentially lethal threat.
 Anticipating the need for early intubation and
establishing and early airway are critical.
 Perioral burns and singed nasal hairs are signs that
the oral cavity and pharynx should be further
evaluated for mucosal injury.

Signs of Impending Respiratory Compromise

 Hoarse Voice
 Wheezing
 Stridor
 Subjective Dyspnea

Jackson’s 3 zones of tissue injury

 Zone of Coagulation ( 3 / 4 degree burn )
rd th

o Most severely burned portion

o Center of the wound

Jaya, Jann | Pilapil Page 1 of 4

 LECTURE 9: BURNS
Dr. Philip Michael Vilches | 25 October 2019
o Treatment : Excision and graging

nd
Zone of Stasis ( 2 degree burn )
o Variable degrees of vasoconstriction
o Resultant ischemia
o Treatment : resuscitation and wound care

st
Zone of Hyperemia ( 1 degree burn )
o Minimal or no scarring
o Superficial

Advanced Trauma Life Support Guidelines

Primary Survey
 Placement of large-bore peripheral intravenous (IV)
catheters and fluid resuscitation should be initiated.
 Burn > 40% TBSA, two large-bore IVs are ideal.
 Central venous access – provide useful information
as to volume status; useful in severely burned
patients.
 Burns <15% hydrate orally
 Pediatric pts. >15% TBSA  intraosseous access in
emergent situations if venous access cannot be
attained.
Secondary Survey
 An early and comprehensive survey, especially
those with a history of associated trauma.
 Urgent radiology studies(E.g. CXR)  done in
ER
 Non-urgent skeletal evaluation ICU
Estimation of Burn Size
Carbon Monoxide Poisoning
 Contributor to early mortality in burn patients.
 The affinity of CO for haemoglobin is approximately
200-250 times more than that of oxygen, which
decreases the levels of normal oxygenated
haemoglobin and can quickly lead to anoxia and
death.
 Afflicted pts persistent lactic acidosis or ST
elevation ECG.
 Cyanide - Inhibits cytochrome oxidase (required for
oxidative phosphorylation).
Treatment For Cyanide Poisoning:
 Sodium Thiosulfate
 Hydroxocobalamin
 100%Oxygen

Classification of Burns

Thermal
 Flame
o Most common cause for hospital admission of
burns.
 Highest mortality.
o Contact
o Scald Burns

Electrical
 Potential for cardiac arrhythmias and compartment
syndromes with concurrent rhabdomyolysis.
 Basic ECG is recommended in all patients.

Chemical
 Less common but potentially severe.
 Initial therapy are careful removal of the toxic
substance from the patient and irrigation of the
affected area with water for a minimum of 30
minutes.

Jaya, Jann | Pilapil Page 2 of 4

 LECTURE 9: BURNS
Dr. Philip Michael Vilches | 25 October 2019
Burn Depth Physiologic Effects

Superficial (first-degree)  Decrease Lung Compliance

 Painful  Increase airway resistance work of breathing.
 Do not blister  Increases overall metabolic demands.
 Increased fluid requirement during resuscitation.
Partial-thickness (second-degree)
 Extremely painful with weeping & blisters Treatment of Inhalation Injury
 Superficial
 Deep  Supportive Care
 Aggressive pulmonary toilet and routine use of
Full-thickness(third-degree) nebulized bronchodilators.
 Leathery  Administration of intrabrochial surfactant.
 Painless
 Non-blaching Treatment Of The Burn Wound

Fourth-degree burns, which affect underlying soft  Silver Sulfadiazine

tissue. o Prophylaxis against burn wound infections.
o Not significantly absorbed systematically and
Prognosis thus has minimal metabolic derangements
o Has a reputation for causing neutropenia.
Baux Score  Mafenide Acetate
Mortality Risk = Age + % TSBA o Effective even in the presence of eschar
 Silver-Impregnated Dressing
Resuscitation
 Isotonic Crystalloid formula NUTRITION
o Parkland formula  Hypermetabolic response in burn injury may raise
o Modified Brooke formula baseline metabolic rates by as much as 200%
o Haifa formula  Early enteral feeding for patients with burns larger
 Hypertonic formula than 20% TBSA is safe
o Monafo formula o May reduce loss of lean body mass
o Warden formula o Slow the hypermetabolic response
 Colloid formula o More efficient protein metabolism
o Evans formula  Early initiation of enteral feeding for first few hours
o Brooke formula prevents gastric ileus
o Slater formula  Adjuncts such as metoclopramide promote
o Demling formula gastrointestinal motility
 Immune-modulating supplements such as glutamine
TRANSFUSION may decrease infectious complications and mortality
 Blood transfusion is considered to be  Titrating caloric needs closely is important
immunosuppressive. o overfeeding patients will lead to storage of fat
 Increased number of transfusions were associated instead of muscle anabolism
with increased infections and higher mortality in burn
patients. NUTRITION: Caloric Needs
 Harris-Benedict equation
INHALATION BURNS o Calculates caloric needs using factors such as
 Commonly seen in tandems with burn injuries. age, gender, height & weight.
 Present in as many as 35% of hospitalized burn  Curreri Formula
patients. o More appropriate for burns <40% TBSA
 Smoke inhalation causes injury in two ways: o Caloric needs estimated to be 25 kcal/kg/d + 40
o Direct injury to upper airways kcal/%TBSA/day
o Combustion products into the lower
airways. COMPLICATION OF BURN CARE
 Ventilator Associated Pneumonia
 Deep Vein Thrombosis
 Catheter Related Blood Stream Infections

Jaya, Jann | Pilapil Page 3 of 4

 LECTURE 9: BURNS
Dr. Philip Michael Vilches | 25 October 2019
Ventilator Associated Pneumonia
 Common in patients with inhalation injury, a better
nomenclature may be post injury pneumonia.
 Elevating the head of the bed and maintaining
excellent oral hygiene and pulmonary toilet are
recommended to help decrease the risk of post
injury pneumonia.
 Bedside percutaneous dilatational tracheostomy is a
facial method for performing tracheostomy and is
reported to be as safe as tracheostomy in the burn
population
Deep Vein Thrombosis
 Associated with use of both prophylactic and
therapeutic heparin.
 Maybe associated with Heparin-Associated
Thrombocytopenia (HIT)
 Although rare, a high index of suspicion for HIT
should be maintained in thrombocytopenic burn
patients, particularly if the platelet counts drop at
hospital days 7 – 10.
Catheter-Related Bloodstream Infections
 Burn patients often require central venous access
for fluid resuscitation and hemodynamic monitoring.
 Because of the anatomic relation of their burns to
commonly used access sites, burn patients may be
at higher risk for catheter-related bloodstream
infections
 Because burn patients may commonly exhibit
leukocytosis with a documented bloodstream
infection, practice has been to rewire lines over a
guidewire and then culture the catheter
 However, this may increase the risk of catheter-
related infections in burn patients and a new site
should be used if at all possible.
SURGERY
 Full-thickness burns with a rigid eschar can form a
tourniquest effect as the edema progresses, leading
to compromised venous outflow and eventually
arterial inflow.
Compartment Syndrome (Warning Signs)
 Paresthesias
 Pain
 Decreased Capillary Refill
 Progression to loss of distal pulses
 Early excision and grafting in burned patients
revolutionized survival outcomes in burn care.
Jaya, Jann | Pilapil
 Burn excision and wound coverage should ideally
start within the first several days, and in larger burns,
serial excisions can be performed as patient
condition allows.
 For patients with clearly deep burns and concern for
excessive blood loss, fascial excision may be
employed.
Wound Coverage
 In larger burns, meshing of autografted skin provides
a larger area of wound coverage.
 Epidermal skin substitutes such as cultured
epithelial autografts are an option in patients with
massive burns and very limited donor sites.
 Thighs make convenient anatomic donor sites,
which are easily harvested and relatively hidden
 The thicker skin of the back is useful in older
patients, who have thinner skin elsewhere and may
have difficulty healing donor sites from an aesthetic
standpoint
 The buttocks are an excellent donor site in infants
and toddlers
Rehabilitation
 It is an integral part of their clinical care and should
be initiated on admission.
 Immediate and ongoing physical and occupational
therapy is mandatory to prevent loss of physical
function.
 Patients who are unable to actively participate
should have passive range of motion done at least
twice a day.
 Patients should be taught exercises they can do
themselves to maintain full range of motion.
 Psychological rehabilitation is equally important in
the burn patient.
 Depression, posttraumatic stress disorder, concerns
about cosmetic appearance, and anxiety about
returning to society constitute predictable barriers to
progress in both the inpatient and outpatient setting.
 The involvement of clinical psychologists and
psychiatrists is invaluable in providing guidance and
coping techniques to lessen the significant
psychological burden of burn injury.
END OF TRANSCRIPTION
REFERENCES
 Dr. Vilches’ Lecture and PPT
Page 4 of 4