BURNS AND GRAFTS VMMC Surgery

Gio Santos, MD September 3, 2021

BURNS • For me to remember these, I divide them into

QUESTION 1: Burn Center Referral groups
You are a physician in a rural setting with no immediate o Depth of burn
access to a tertiary hospital, when you were called in ▪ Partial thickness >10% TBSA or
the middle of the night as there were 4 patients who any full thickness burns
were caught in a fire. All of these patients require ▪ Burns in special/crucial areas
specialized care at a burn unit/center, EXCEPT: o Type of burn
a. 18/F with superficial burns around 15% TBSA ▪ Electrical burn
involving her lower extremities ▪ Chemical burn
b. 45/M with superficial thickness burns of around ▪ Inhalational injury
3% on both his hands o Other diseases
c. 44/F with full thickness burns on his feet around ▪ Preexisting medical disorders or
5% TBSA comorbidities
d. 20/M with superficial partial thickness burns ▪ Concomitant trauma
around 5% TBSA but with singed eyebrows o Special cases
▪ Children
GUIDELINES FOR REFERRAL TO A BURN CENTER ▪ Those that require special
Partial-thickness burns greater than 10% TBSA intervention
• Partial thickness burns should be referred to a burn
center while option A presented a patient with QUESTION 2: Burn = Trauma
superficial burns only 44/M arrives at the ER after being rescued from a
o Superficial burns are the 1st degree burns, like burning building. on quick examination, the patient was
a sunburn and you can treat these on an awake and coherent, with multiple burn injuries over his
outpatient level. body. He had singed eyebrows and had stridor. Which of
Burns involving the face, hands, feet, genitalia, perineum, the following will you do first?
or major joints a. Estimate body surface area involved and
• These are the crucial areas compute resuscitation using the Parkland
Third-degree burns in any age group formula
• Any full-thickness burn will require referral since they b. Examine airway and intubate as needed
require advance reconstructive measures such as skin c. Dress wounds with silver sulfadiazine
grafts or flaps d. Extract CBC and electrolytes, order a CXR
Electrical burns, including lightning injury
Chemical burns In this case, there are singed eyebrows and stridor, you
Inhalation injury would think of inhalational injury. We should examine
the airway first and intubate if needed.
• Like in option D where patient had singed eyebrows,
we would consider inhalational injury for
investigation because this would require a higher form • BURN = TRAUMA
of care • Follow your trauma life support guidelines
Burn injury in patients with complicated preexisting medical • Check your ABCs: Advanced trauma life support
disorders o AIRWAY
Patients with burns and concomitant trauma in which the ▪ Flame burns (look for signs of
burn is the greatest risk. If trauma is the greater immediate burns in an enclosed space,
risk, the patient may be stabilized in a trauma center before signs of inhalational injury)
transfer to a burn center. • Singed eyebrows
Burned children in hospitals without qualified personnel for • Singed hair
the care of children • History shows incident
Burn injury in patients who will require special social, occurred in an enclosed
emotional, or rehabilitative intervention. space
o BREATHING
▪ Flame burns with inhalational
injury
▪ Electrical burns with
circumferential thoracic full
thickness burns

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 BURNS AND GRAFTS VMMC Surgery
Gio Santos, MD September 3, 2021

• Check for thoracic full •Superficial burns on the anterior surface of the
thickness burns since left upper extremity
compartment syndrome o This is 0% because it’s a superficial burn
can occur where there o So, superficial burn is a first degree,
is: NOT COUNTED
o Difficulty • Superficial partial thickness burns on the
breathing anterior and posterior trunk
o Shallow o 18 + 18 = 36%
breathing • Full thickness burns of the anterior portion of
o CIRCULATION his right lower extremity
▪ Compartment syndrome o This is 9%
o SECURE IV ACCESS immediately o So, 36% + 9% = 45%
• Check for concomitant injuries Again, remember that superficial burns/first degree
o Electrical burns burns are not included for computation of the %TBSA.
▪ Always remember that
electrical burns are usually How about for pediatric patient?
accompanied by certain trauma • We use the Lund-Browder Pediatric Burn Chart
• Nakuryente, nahulog • We use a different burn chart because
galling sa poste children’s, toddler’s, or neonate’s heads are
• Nawalan ng malay and bigger compared to their whole body
nagfaint, nafall, check o The head can range from 12 to 15%
for head injuries o So each age level have different values
o Blast injuries per area
▪ Mga nasabugan ng LPG • What if you have no access to a Lund-Browder
chart?
QUESTION 3: %TBSA o We can do PALM METHOD
50/M comes in due to an electrical burn at work. o We use the palm of the child patient
Superficial burns on the anterior surface of the left which is around 1% of their body
upper extremity, superficial partial thickness burns on o The adult palm is about 5%
the anterior and posterior trunk, full thickness burns of
the anterior portion of his right lower extremity. What
is the estimated body surface area involvement?
a. 54%
b. 49.5%
c. 45%
d. 27%
RULE OF 9s

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 BURNS AND GRAFTS
Gio Santos, MD
QUESTION 4: Pathophysiology of Burns
25/F arrives at the ER due to significant scald burns after
jumping into a tub of boiling water thinking it was a
jacuzzi. She came in with hypotension, prompting you to
immediately do resuscitation. What was the most likely
cause of this hypotension?
a. Insensible losses from the skin
b. Septic shock from infected burn wounds
c. Hypovolemic shock
d. Cardiogenic shock from an arrythmia
PATHOPHYSIOLOGY
• Combination of distributive and hypovolemic
shock
o These are the 2 types of shock that
happens in our burn patients
o Distributive shock such as septic shock
and anaphylactic shock, wherein your
blood vessels dilate to a point that the
intravascular fluid seeps out into the 3rd
space
o So, hypovolemia in burns, the fluid
seeps out into the 3rd space, there will
be edema
▪ Which is why our goal for our
burn patients is to hydrate and
give IVF ASAP
• NOT caused by evaporation of fluids from the
wounds
o Option A is actually a misconception,
they said that fluid evaporates from the
wounds, that is not true.
• Burn wounds are sterile wounds
o Infections are not expected to occur within
1-2 weeks of the disease if wounds are cared
for properly
o Option B, septic shock is not the case or
acute burn injuries
o Burn wounds are sterile wounds
o We only expect them to get infected if they
were not tended to properly around 1 week
to 2 weeks post-injury
o For example, a patient was referred to you,
Doc we have a patient 3 days ago nasunog
and naghahypotension, feeling naming
infected ang sugat.
o 3 days post-injury I do not expect the wounds
to be infected unless they are full thickness
burns and hindi naalagaan.
o So, usually infection is 1 week to 2 weeks
after injury IF hindi naalagaan.
• Sudden cardiac arrest due to burns are usually
associated with electrical injuries → arrythmia
o Option D, this only occurs when we have a
case of electrical burns.
o So, when the patient is electrocuted, the
electric current that flows through the body
can affect the internal current of the heart
Rhea Uy & Xymber Pascua
VMMC Surgery
September 3, 2021
QUESTION 5: Fluid Resuscitation
Which of the following will you use to guide the
resuscitation of a burn patient?
a. Use plain LR for patients below 2 years old
b. Maintain urine output at 10cc/hr for adults
c. Use Holiday Segar formula for initial
resuscitation of patients with significant burns
d. 2mL/kg/% TBSA
So, for Option A, first usually for adults we usually give
Plain LR because this is most similar to the intravascular
content
• Sodium = 142
• Potassium = 4
• Calcium = about 4 or 5
• Plain NSS which contains only sodium and
chloride
o Compared to Plain LR which contain
about sodium of 130, with calcium and
lactate which is similar to the content
of the intravascular volume
• Why is option A wrong although it is giving plain
LR?
o For children, especially infants 2-3
years old, we use dextrose containing
fluid because they still lack glycogen
stores thus, they are not as ready as in
adults.
o So, when there is injury, the body will
deplete the free glucose which will
activate the body to respond to use
glycogen stores but for children, they
don’t have a large store of glycogen and
that’s why we give dextrose containing
fluid.
Option B, in Schwartz’s it says urine output of about
30cc/hr for adults or 0.5 to 1cc/kg/hour which is more
accurate for me.
• 10cc/hr is too low, patient has inadequate
hydration
Option C, using Holiday Segar for significant burns, this
is actually a computation for maintenance fluid.
• We use the Holiday Segar formula to compute
for fluid resuscitation IF the computed value
using Holiday segar is more than that computed
in Parkland formula.
• But for significant burns, kulang na kulang ang
holiday segar
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 BURNS AND GRAFTS VMMC Surgery
Gio Santos, MD September 3, 2021

FLUID RESUSCITATION: QUESTION 6:

• PLAIN LACTATED RINGER’S SOLUTION You have a 34/M, 50kg scald burn patient at the ER who
o Mostly resembles electrolyte content of arrived 2 hours post-injury. He sustained 2nd degree
bodily fluids burns on the anterior surface of his right lower
o Use of colloids and albumin in the extremity, whole left upper extremity and whole
emergency setting is still controversial anterior trunk. Using the Parkland formula, how will you
• DEXTROSE containing fluids for children order his resuscitation?
o GLYCOGEN stores are not as developed a. IVF: 450cc/hr for 6 hours then 168.75cc/hr for
as in adults the next 16 hours
• URINE OUTPUT MONITORING b. IVF: PLR 337.5cc/hr for 8 hours then 168.75cc/hr
o Adults: 0.5 – 1.0 mL/kg/hr or approx.. for the next 16 hours
30cc/hr c. IVF: PLR 450cc/hr for 8 hours then 225cc/hr for
o Pedia: 1.0 – 1.5mL/kg/hr the next 16 hours
d. IVF: PLR 600cc/hr for 6 hours then 225cc/hr for
Parkland formula is not the only formula for computation of the next 16 hours
fluid resuscitation. This table below is from the American So, how much percent us this?
Burns Association. • 2nd degree burns on the anterior surface of his
Formula Electrolyte Colloid Crystalloid right lower extremity – 9%
Colloid formula • Whole left upper extremity - 9%
Brooke Lactated Ringer’s at 0.5mL/kg/% 2L 5% dextrose • Whole anterior trunk. – 18%
1.5mL/kg/% TBSA TBSA burn
burn • So, this is 36% TBSA
Evans 0.9% NaCl at 1mL/kg/% TBSA 2L 5% dextrose COMPUTATION:
1mL/kg/% TBSA burn burn • 4 x weight in kg x % TBSA
Slater Lactated Ringer’s Fresh frozen 2L 5% dextrose
2L/ 24hr plasma at
• 4 x 50 x 36 = 7200 fluid given in the first 24 hours
75mL/kg/24 hr • Ideally, you will give 3600 given in the first 8
Crystalloid formula hours, next 3600 in the next 16 hours
Modified Lactated Ringer’s at • You have to take note that the patient in the
Brooke’s 2mL/kg/% TBSA case arrived 2 hours post-injury
burn
Lactated Ringer’s at 20-60% Titrated to
o So, hahabulin mo yung first half in the
Parkland
2mL/kg/% TBSA estimated urinary output remaining 6 hours
burn plasma volume of 30mL/hr o Always take note of the hours arrived
Hypertonic saline formula post-injury, they always use this as a
Hypertonic Maintain urine trick question
saline solution output at 30mL/hr
• 3600/6 = 600cc/hr for the next 6 hours
(Monafo) • 3600/16 = 225cc/hr for the net 16 hours
Modified Lactated Ringer’s +
hypertonic 50 mmol/L NaHCO3
(Warden) for 8h to maintain For a patient who arrived with uncoordinated transfers,
UO at 30-50mL/h Doc may dumating na pasyente from East Avenue. Hindi
namin alam kung nahydrate yun. ASSUME THE PATINET
Lactated Ringer’s to
maintain UO at 30- WAS NOT HYDRATED.
50mL/h beginning
8h post-burn If patient arrives >8hrs, dumating na siya 17th or 18th hour
Dextran Dextran 40 in saline Fresh frozen post-injury, you will consider here the URINE OUTPUT
formula at 2mL/kg/h for 8h plasma at • Urine output should be monitored vigilantly, hourly.
(Demling) 0.5mL/kg/h for If mababa ang UO then itaas mo ang fluid mo.
Lactated Ringer’s 18h beginning 8h
titrated to maintain post-burn • There are patients who have 80-90% burns and
urine output at umabot yan ng 1500cc/hr. That’s 2 Plain LR bottles
30mL/h o You can place 2 lines na, 750 each
• Modified Brooke’s, ito yung kinikilala ng ABA. o Watch out for congestion
• Colloids are still debatable in the resuscitation • URINE OUTPUT MONITORING
of burn patients o Adults: 0.5 – 1.0 mL/kg/hr or approx..
• Ideally, crystalloid muna 30cc/hr
o There are researches now in the usage o Pedia: 1.0 – 1.5mL/kg/hr
of albumin to lessen fluid giving but still
debatable
o So, always crystalloid muna
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 BURNS AND GRAFTS VMMC Surgery
Gio Santos, MD September 3, 2021

QUESTION 7: Description of Burns • Superficial burns are your 1st degree burns which
You have a scald burn patient at the ER who sustained a are epidermal burns, sunburns, don’t need
superficial partial thickness burn in his right thigh. You treatment. Kahit aloe vera pwede.
call Dr. Alcantara to refer the patient to him. He then • 2nd degree burns are divided into 2:
asks you to describe the wound. How would you describe o Superficial partial thickness
it? o Deep partial thickness
a. Pale pink in color with blisters, tender to touch, o Both of them can blister
(+) blanching o Difference between these 2 is the blanching
b. Whitish in color, lathery, nontender, (-) ▪ Blanching: when you press on the
blanching wound it becomes white and when
c. Reddish, dry wound with slight tenderness released it will regain color.
d. Dark pink, slow capillary refill, diminished ▪ This represents your blood supply,
sensation capillary refill

CLINICAL PRESENTATION OF THERMAL BURN WOUNDS

Depth of Skin Examples Signs Sensation Self-healing Skin Visible

Burn Involvement capacity healing scarring
time
Epidermal Epidermis Brief flame or Dry and red, Tender and Excellent with use Within 7 Unusual
burn flash; Sunburn blanches with painful when of occlusive days
pressure, no exposed to air. dressing
blisters

Superficial Epidermis and Scald (spill or Pale pink with Very painful Excellent with Within 14 Can have color
partial- part of the splash), short fine blistering, proper days match defect.
thickness papillary flash blanches with management Low to
burn dermis pressure moderate risk
of
hypertrophic
scarring

Deep Epidermis, Scald (spill), Dark pink to May be painful Should not be left 14 to over Moderate to
partial- the entire flame, oil or blotchy red, or to heal by itself, 21 days high risk of
thickness papillary grease capillary refill reduced/absent but instead should hypertrophic
burn dermis down sluggish to none. sensation probably be scarring
to reticular In child, may be submitted to
dermis dark lobster red surgery
with mottling

Full Entire Scald White, waxy or Insensate No healing Never. Yes.

thickness thickness of (immersion), charred, no capacity and as Replaced by
burn the skin and flame, steam, blisters, no such should scar and
possibly oil, grease, capillary refill. always be contracture
deeper chemical May be dark submitted to
lobster red.

• Mas panget ang blanching, mas blotchy red ang
kulay
• Superficial partial thickness are very painful
since dermal layer where nerve endings are
exposed
• Sa deep partial thickness medyo masakit but not
as much as superficial partial
Rhea Uy & Xymber Pascua
• While in full thickness, wala na pain since sunog
na lahat ng nerve endings
o Full thickness are those na leathery and
matigas.
o Yung naninigas yung panget kasi we will
need to excise those
• Deep partial and full thickness burns need to be
referred to burn centers because they will need
reconstruction procedures such as skin grafting
• Huwag matakot hawakan si burn patient. Full
inspection and examination is still warranted.
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 BURNS AND GRAFTS VMMC Surgery
Gio Santos, MD September 3, 2021

QUESTION 8: Zone of Burn Wounds One week later, nangitim ulet and we attribute that to
Which of the zones of burn wounds are you most damage to blood vessels.
concerned with when starting resuscitation? • Electrical burns can actually make your blood
a. Zone of Coagulation vessels lose their property to dilate, and they
b. Zone of Stasis become stenotic.
c. Zone of Hyperemia • So, mawawalan talaga ng blood supply. So,
d. Zone of Nelligan naputol ang kamay ni patient, both hands.

ZONES OF BURN INJURY QUESTION 10:

• ZONES OF COAGULATION
o Innermost zone
o Irreversible tissue loss
o Most severely burned tissue
• ZONE OF STASIS
o Middle zone
o Decreased vascular perfusion
o Resuscitation can influence survival
o This is the zone we want to save during
resuscitation
o If resuscitation is adequate, this zone of
stasis will not convert into a zone of
coagulation
• ZONE OF HYPEREMIA
o Most likely recover
QUESTION 9: Electrical Burns
Which of the following has least resistance in conducting
electricity?
a. Blood vessels
b. Muscle
c. Nerves
d. Bone
ELECTRICAL BURNS
• High resistance = higher chance of injury
o Bone, tendon, joints, skin
o Pag high resistance, mas hindi lalampas
ang current, so mas maiipon ang current
in this area
o Mapapansin niyo, yung mga
nakukuryente, they have cutaneous
lesions or even fractures although this
is rare
• Low resistance = less chance of injury
o Blood vessels, nerves, muscle
o Just because they are low resistance
and have a lower chance of injury, it
doesn’t mean that they don’t get
injured.
I had a patient before, nagcompartment syndrome.
Nakuryente, pumasok sa left hand, lumabas sa right
hand. Nagcompartment syndrome, nagfasciectomy kami
kasi panget na ng kulay ng hand, after the operation,
gumanda ang kulay ng hand so mukhang nasave.
Which ancillary procedure will you request to check for
rhabdomyolysis in electrical burn patients?
a. Ultrasound of involved areas
b. Serum protein
c. Urinalysis
d. ABG
Rhabdomyolysis is lysis of your muscle cells. So,
pumuputok, namamatay yung muscle cells.
URINALYSIS & ECG
• Urine myoglobin → released by the breakdown
of muscle cells
o Increase urine output to 100cc/hr for
adults
o Kung walang urine myoglobin, look for
protein in the urine
▪ +1, +2, +3, kabahan ka na,may
form of rhabdomyolysis na and
pasyente
o Refer to nephrology
▪ This is because the myoglobin is
excreted thru urine and in turn
this can damage the kidneys.
• Arrythmia secondary to interaction of external
source of current to internal electric system of
the heart
o Refer to cardio
QUESTION 11: Inhalational Injury
Which is true about inhalational injury?
a. The gold standard of diagnosis is a Chest CT scan
b. CO binds to deoxyhemoglobin at 40 times
greater affinity than O2
c. CO only leads to extracellular hypoxia
d. Inhalational injury comes hand and hand with CO
poisoning
• Okay, so gold standard for diagnosis is NOT a CT
scan, nor is it a chest xray.
o It’s BRONCHOSCOPY

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 BURNS AND GRAFTS VMMC Surgery
Gio Santos, MD September 3, 2021

• OPTION B is the correct answer CO binds to • A strong indication that pulmonary edema is
deoxyhemoglobin at 40 times greater affinity developing is when the resuscitation fluid
than O2. requirement to maintain urine output far
o So, inaagawan niya yung O2 to combine exceeds Parkland formula guidelines
with your deoxyhemoglobin and thus, o Kunware, wala naman siya ng sunog na
hindi nadidistribute ang O2 to other hair sa face pero nagreresuscitate ka
parts of the body. nang nagreresuscitate pero hindi nag-
• Option C is not true, CO only leads to iimprove ang status ng pasyente. High
extracellular hypoxia. suspicion na yan for pulmonary edema
o CO leads to both intracellular and due to inhalation injury.
extracellular hypoxia • EARLY INTUBATION - management
o Extracellular hypoxia, which happens • CO POISONING
intravascularly, yan yung sa o Binds to deoxyhemoglobin at 40 times
deoxyhemoglobin. greater affinity than molecular oxygen
o Intracellularly also affects in oxygen (O2)
producing proteins o Can occur with or without inhalational
• Option D, Inhalational injury comes hand and injury
hand with CO poisoning, this is false. o Treatment
o Not all patients with CO poisoning will ▪ 100% oxygen with a non-
have inhalational injury rebreather facemask
o So, pwedeng nalalanghap niya lang pero ▪ Displaces carbon monoxide from
hindi sunog ang baga. hemoglobin much faster than
atmospheric oxygen
INHALATIONAL INJURY
• Upper and lower airway injuries can result from
inhalation of chemically reactive smoke and/or ANSWERS:
other products of combustion 1. A
• High index of suspicion! 2. B
3. C
SIGNS OF INHALATIONAL INJURY 4. C
➢History of flame burns or burns in an 5. C
enclosed space 6. D
➢ Full-thickness or deep dermal burns to face, 7. A
neck, or upper thorax 8. B
➢ Singed nasal hair 9. D
➢ Carbonaceous sputum or carbon particles in 10. C
oropharynx 11. B
- So, for high index of suspicions for inhalational
injury, tatanungin niyo kung may mga flame burns,
yung sunog ang mukha. Or kung hindisunog ang
mukha nila, nangyare ba sa enclosed space, nagtago
ba sila sa banyo, pero usually yung mga nagtatago
sa banyo, namamatay e.
- Singed nasal hair and eyebrows din.

• Burn patients with inhalation injuries exhibit

significantly higher mortality rates than
comparable TBSA burn patients without
inhalation injury
o Smoke inhalation account for more than
50% of fire-related deaths
• Diagnosis: BRONCHOSCOPY (gold standard)
• Bronchial edema and sequestration of fluid in
pulmonary alveolae

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