Acute  

care  of  burns  pa/ents

•  Dr  Prashanth  .A.Menon  
•  Post  graduate  trainee(DNB)  
•  Narayana  Hrudayalaya  
Bangalore  
INTRODUCTION
BURNS  HAVE  A  HIGH  RATE  OF  MORTALITY  AND  MORBIDITY  
THE  MANAGEMENT  IN  THE  ACUTE  STAGE  OF  BURNS  DETERMINES  THE  
SURVIVAL  OF  THE  PATIENT  .  
WIDE  RANGE  OF  DERANGEMENTS  IN  THE  PHYSIOLOGY  OF  BURNS  
PATIENTS  WARRANTS  PROPER  UNDERSTANDING  OF  THESE  CHANGES  
AND  APPROPRIATE  CORRECTIVE  MEASURES  TO  ENSURE  FAVOURABLE  
OUTCOMES.  
Types  of  burns
•  Scalds  (hot  fluids)  
•  Flame  burns  (hot  air)  
•  Contact  burns  
•  Electricalburns-­‐  high  voltage  &flash  burns  
•  Chemichal  injury  
Classifica/on  of  burns
First  degree  burn    
•  Involves  only  the  epidermis  
•  Tissue  will  blanch  with  pressure  
•  Tissue  is  erythematous  and  oRen  painful  
•  Involves  minimal  Tssue  damage  
•  Sunburn  
Second  degree  burn
•  Referred  to  as  parTal-­‐thickness  burns  
•  Involve  the  epidermis  and  porTons  of  the  dermis  
•  ORen  involve  other  structures  such  as  sweat  glands,  hair  follicles,  etc.  
•  Blisters  and  very  painful  
•  Edema  and  decreased  blood  flow  in  Tssue  can  convert  to  a  full-­‐
thickness  burn  
Second  degree  burns
Third  degree  burn
•  Referred  to  as  full-­‐thickness  burns  
•  Charred  skin  or  translucent  white  color  
•  Coagulated  vessels  visible  
•  Area  insensate  –  paTent  sTll  c/o  pain  from  surrounding  second  
degree  burn  area  
•  Complete  destrucTon  of  Tssue  and  structures    
3rd  degree  burn
Fourth  degree  burn
•  Involves  subcutaneous  Tssue,  tendons  and  bone  
DEPTH  OF  BURNS
 Pathophysiology  of  burns
Local  responses  
Zone  of  coagulaTon-­‐complete  Tssue  destrucTon  
Zone  of  stasis  –potenTally  salvageable  area  
Zone  of  hyperemia-­‐inflammatory  
 
Systemic  responses      when    burn  involves  15-­‐20%BSA  
CVS-­‐fluid  shiRs  increased  capillary  permability  
Decreased  myocardial  contracTlity  
Peripheral  splanchnic  vasoconstricTon  
 
SYSTEMIC  RESPONSES
RS-­‐    
•  airway  obstrucTon,bronchoconstricTon  
•  Respiratory  failure  
•  Ards/pulmonary  edema  
•  InhalaTonal  injury  
•  Co/cn  toxicity  

GIT-­‐  
•   decreased  moTlity  
•  Curling  ulcer  
 
Haematological-­‐haemolysis  haemiconcentraTon  
 
SYSTEMIC  RESPONSES

METABOLISM-­‐  hypermetabolic  state  with  increase  oxygen  and  calorie  

requirements  
IMMUNOLOGICAL-­‐depressed  CMI  and  humoral  immunity  
   
EXTENT  OF  DAMAGE  DEPENDS  ON  
AGE  
GENERAL  HEALTH  
EXTENT  OF  INJURY  
DEPTH  OF  INJURY  
AREA  OF  INJURY  
PHASES  OF  BURNS
•  EMERGENT/RESUSSITATIVE  PHASE-­‐  24-­‐48HRS  
•  ACUTE  PHASE-­‐  48HRS  TO  WOUND  CLOSURE  
•  REHABILITATIVE  PHASE-­‐TILL  ACHIEVEMENT  OF  HIGHEST  POSSIBLE  
FUNCTION  
Management    of  burns
PRIMARY  SURVEY  
A-­‐    airway  with  cervical  spine  control    
B-­‐  breathing    
C-­‐circulaTon  
D-­‐  disability  evaluaTon  
E-­‐exposure  and  environment  control  
F-­‐  fluid  management  
Secondary  survey
•  Allergies  
•  MedicaTons  
•  Past  illnesses  
•  Last  meal  
•  events  
AIRWAY  AND  BREATHING
•  EVALUATE  PATENCY  OF  AIRWAY  AND  ADEQUACY  OF  BREATHING  
•  EARLY  INTUBATION  IN  UNCONCIOUSNES  ,RISK  OF  AIRWAY  BURNS  AND  
EDEMA(SIGNED  FACIAL  NASAL  HAIR,SOOTHY  SPUTUM,STRIDOR  OR  
WHEEZE,TACHYPNOEA)  
•  EDEMA  TRANSITION  MAY  BE  EARLY  OR  DELAYED  UPTO  12-­‐24HRS  
•  ASESS  FOR  INHALATIONAL  INJURY(CLOSED  SPCE  BURNS)  
•  100%  O2    
•  AVOID  SCHOLINE  
•  VENTILLATION  LOWER  TV  AND  HIGHER  RATES    
•  HEPARIN  BRONCHODILATORS  
CIRCULATION
•  ASESS  CAPILLARY  REFILL,PULSE  ,BP  
•  CATHETERISATION  TO  MONITOR  U.O.  
•  LARGE  BORE  IV  ACESS  PREFEREABLY  IN  UNBURNT  AREA  
•  STOP  ACTIVE  BLEEDING  
•  START  FLUID  THERAPY  
DISABILITY  EVALUATION
•  ALERT,VOCAL,PAIN,UNCONCIOUS(AVPU)  
•  GCS  <8  (INTUBATION)  
•  BURN  DEPTH  AND  EXTENT  ASESSMENT  
•  ASESSMENT  OF  ASSOCIATED  TRAUMA    
•  CO/CN  TOXICITY  
FLUID  MANAGEMENTS
•  PARKLAND  MOST  COMMONLY  USED  FORMULA  
•  OVERHYDRATION  INCREASES  RISK  OF  ARDS    
•  RL  IS  THE  IDEAL  INITIAL  RESUSSITATION  FLUID  
•  COLLOIDS  MAY  BE  DELAYED  TILL  CAPILLARY  INTEGRITY  ATTAINED
(USUALLY  24HRS)  
•  U.O  OF  .5ML/KG/HR  TO  BE  MAINTAINED  
•  FLUID  SCALED  UP  OR  DOWN  WITH  U.O.  
•  INVASIVE  MONITORING  OF  VOLUME  WHEN  FLUID  
REQUITEMENT>6ML/KG  OR  WHEN  DECREASED  CARDIOPULMONARY  
RESESRVE  
BSA  es/ma/on:  “Rule  of  9s”
Head  &  Neck  =  9%  
Each  upper  extremity  (Arms)  =  9%  
Each  lower  extremity  (Legs)  =  18%  
Anterior  trunk=  18%  
Posterior  trunk  =  18%  
Genitalia  (perineum)  =  1%  
LUND  BROWDER  CHART
  
 

Various  fluid  replacement  formulas

FORMULA   24HR    24HRS-­‐48HRS  
CRYSTALLOIODS   COLLOIDS  
PARKLANDS   RL  4ML/KG  BSA   20%-­‐60%  OF  CALCULATED   30ML/HR  TITRATED  TO  
VOLUME  IN  1ST  24  HRS   U  O  
EVANS   NS  1MK/KG  BSA   50%  OF  CALCULATED   50%  
2000ML  D5W   VOLUME    +2000ML  D5W  
COLLOID  1  ML/KG/HR  
SLATER   RL  2LTRS  /24HRS  
FFP  75ML/KG/24HRS  
BROOKES   RL  1.5ML/KG  BSA   50%  CALCULATED  (24HRS   50%  
COLLOID  0.5ML/KG  BSA   2000ML  D5W  
2000ML  D5W  
MODIFIED  BROOKES     2ML/KG  BSA  

METROHEALTH   RL  +50MEQ  SODA   1/2N  N  TITRATED  WITH   IUNIT  FFP  PER  LITRE  NS  
INVESTIGATIONS
•  HB%  ,HAEMATOCRIT  
•  UREA/CREATININE  
•  ELECTROLYTES  
•  ECG  
•  URINE  ANALYSIS  
•  ABG  
•  ECG  
INFECTION  CONTROL  AND  WOUND  
MANAGEMENT
PROPHYLACTIC  ANTIBIOTICS  NOT  RECOMMENDED  

TETANUS  IMMUNISATION  

DEBRIDE  AND  TREAT  OPEN  WOUNDS  AND  BLISTERS  

TOPICAL  ANTIBACTERIAL  DRESSING  

ISOLATION  ASEPTIC  PRACTICES    

WOUND  CULTURE  ANTIBIOTICS  IN  WOUND  INFECTION  

 
PAIN  MANAGEMENT
•  MULTIMODAL  ANALGESIA  
•  OPIOIDS  ARE  THE  MAIN  STAY  
•  LOW  DOSE  KETAMINE  .25MG/KG  (DELIRIUM)  
•  NSAIDS  
SURGICAL  INTERVENTIONS
•  ESCHAROTOMY  –CIRCUMFERENTIAL  CHEST  AND  EXTREMITY  BURNS  
•  TRACHEOSTOMY  
•  CHEST  TUBES  
•  WOUND  CLOSURE-­‐SKIN  GRAFTING  
NUTRITION
•  Enteral  feeds  preferred  over  TPN  
•  may  prevent  gut→bacterial  translocaTon  
•  early  (within  4  hours)  insTtuTon  of  enteral  feeds  may  achieve  early  posiTve  
N2  balance  
•  may  be  precluded  by  paralyTc  ileus    Curreri  Formula:  

•  calories/day=(wt  in  kg)  (25)  +  (40)  (%BSA)  

SPECIAL  CONSIDERATION  IN  PAEDIATRIC  
PATIENTS
•  PARKLAND  FORMULA  UNDERESTIMATES  EVAPORATIVE  LOSS  
•  GALVESTON  FORMULA    5000ML/%BSA  +2000ML        (1/2,1/4,1/4)  
•  MAINTAIN  U.O.  AT  1ML/KG/HR  
•  5%DEXTROSE  ADDED  AS  MAINTAINANCE  FLUID  WITH  RL  
    
 
 
 
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