Intern - S Burn Manual

ACUTE BURNS
Interns Handbook on
Diagnosis and Management
Alfredo T. Ramirez Burn Center

Division of Burns, Department of Surgery
University of the Philippines
Philippine General Hospital
OCTOBER 2020
ACUTE BURNS: Interns Handbook on Diagnosis and Management 1 of 40

© UP-PGH ATR Burn Center
Last edited: October 2020
TABLE OF CONTENTS
MESSAGE 3
INTRODUCTION 4
OBJECTIVES 6
DIAGNOSIS AND MANAGEMENT OF ACUTE BURNS 7
INITIAL / RESUSCITATIVE PERIOD 8
CHAPTER I: ASSESSMENT OF BURN INJURY 8

CHAPTER II: CLASSIFICATION OF BURN INJURY 15
CHAPTER III: CRITERIA FOR REFERRING TO A BURN CENTER 16
CHAPTER IV: INITIAL MANAGEMENT OF MINOR BURNS 17
CHAPTER V: INITIAL MANAGEMENT OF MAJOR BURNS 18
CHAPTER VI: FLUID RESUSCITATION 21
CHAPTER VII: WOUND DRESSING 24
CHAPTER VIII: MONITORING A BURN PATIENT 30
DEFINITIVE MANAGEMENT 32
CHAPTER IX: EXCISION AND GRAFTING 33

CHAPTER X: NUTRITION 37
CHAPTER XI: COMMON COMPLICATIONS 38
CHAPTER XII: OTHER IMPORTANT CONCERNS 40

MESSAGE
Welcome to 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,

was originally a two, then five-bed facility. It expanded into an
eleven-bed intensive care facility, known as the PGH Burn
Unit, on April of 1993. It was subsequently named after its
founder. After its recent renovation in 2018, the ATR Burn
Center currently consists of a twelve-bed burn intensive care
unit with a stand-alone operating theater and a hydrotherapy
unit that caters to emergency and outpatient consultations.
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 handbook will help to familiarize you with the
surroundings, the organization, and the responsibilities of all
burn care personnel.
DISCLAIMER
This handbook is the intellectual property of the staff of the

ATR Burn Center. Reproduction of this handbook in whatever
manner or format is STRICTLY PROHIBITED unless with
permission from the ATR Burn Center. The final product took
into consideration prevailing conditions at the ATR Burn
Center. The authors are not responsible for any adverse
outcomes resulting from the use of this handbook outside the
ATR Burn Center and the Philippine General Hospital.

INTRODUCTION
In spite of the remarkable progress in the management of
burn injuries, a serious 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. 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 considerably 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
handbook 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.
CONSULTANT STAFF
Glenn Angelo S. Genuino, MD, MS, FPAPRAS, FPCS
Burn Center Director, Division Chief
Jose Joven V. Cruz, MD, MPH, FPAPRAS, FPCS

Deputy Director, Assistant Chief
Maria Adela N. Aguilera, MD, FPAPRAS, FPCS

Executive Officer, Training Officer
Jeane J. Azarcon, MD, FPAPRAS, FPCS

Gene Gerald SJ. Tiongco, MD, FPAPRAS, FPCS
Gerald Marion M. Abesamis, MD, FPAPRAS
RESIDENTS
Jonas Daniel P. Bico, MD

Mar Aristeo G. Poncio, MD
Pacifico Armando M. Cruz, MD
Clarissa Mae Gonzales, MD
Jose Paolo P. Albaño, MD
Mikhail G. Amante, MD
Isabel Acosta, MD
April Rose M. Sales, MD
VERSION NOTES:
Last updated on June 15, 2018, during the Annual Burn Workshop held at Alfonso, Cavite
Editing: October 2020

OBJECTIVES
After reading this handbook one is expected to be able to:
A. 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

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
Primary and Secondary Survey
Assessment of burn injury
Classification of burn injury
Criteria for admission
Initial (ER) management
Fluid resuscitation
Monitoring
Definitive Management Period

Excision and grafting
Control of infection
Nutrition
Rehabilitation
Complication

INITIAL / RESUSCITATIVE
PERIOD
In this period, the primary and secondary survey is done. This
is a quick and concise way to check the overall status of a burn
patient in an acute setting.
PRIMARY SURVEY SECONDARY SURVEY
AIRWAY ALLERGIES
BREATHING MEDICATIONS
CERVICAL SPINE PREVIOUS ILLNESSES
CIRCULATION LAST MEAL
COMPARTMENT EVENTS SURROUNDING
SYNDROME INJURY
DEFICITS/DEFORMITIES
EXPOSURE
FLUIDS
CHAPTER I:
ASSESSMENT OF BURN INJURY
I. 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.
II. Identify the type of burn
1. SCALD BURN
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.

2. FLAME BURN
Due to fires, improper use of flammable liquids,
kerosene lamps, careless smoking, vehicular
accidents, clothing ignited from any thermal source
FLASH BURN
A subtype of flame burns. Explosions of natural gas
propane, gasoline and other flammable liquids
causing intense heat for a very brief period of time
3. CONTACT BURN
Results from hot metals, plastic, glass or hot coals;
usually limited in extent but very deep
4. CHEMICAL BURN
Caused by strong alkali or acids; these cause
progressive damage until chemical is deactivated
with reaction with tissue or reaction with water.
• Acid burns: more self-limiting than alkali burns; acid
tend to coagulate the skin as the acid is
neutralized, creating an impermeable barrier which
limits further penetration of the acid
• Alkali burns: combine with cutaneous lipids to
create soap and thereby continue to dissolve the
skin until they are neutralized
5. ELECTRICAL BURN
Injury from electrical current classified as high voltage
(>1000 Voltage) or low voltage (< 1000 Voltage)
III. Estimate the burn size, express as percent total body

surface area burned (%TBSA).
Count only those areas with partial (second degree) or full

thickness (third degree) burns. Most accurately done using the
Lund and Browder charts (Fig. 2). The Rule of Nines (Fig. 1)
may be used to obtain a rough estimate of the areas involved,
but it is not as 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 of the patient represents
approximately 1% of TBSA
• Note: In electrical injuries, the %TBSA involved does

not correspond to the extent of injuries of the
underlying soft tissues. There may be areas of soft
tissue sustaining injuries secondary to the passage of
electrical current but with normal looking skin over it.

FIGURE 1 Rule of 9s: Quick guide to assess burn TBSA involvement

FIGURE 2 Lund and Browder Chart: accounts for age. More accurate
in assessing TBSA

IV. Assess the burn depth.
This is extremely important. This information is used in

estimating burn size and fluid requirement, in determining the
need for surgery, and in evaluating the progress of the patient.
Wear sterile gloves when examining the patient. Ensure
adequate analgesia before examining the patient.
A. FIRST DEGREE BURNS

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.
B. 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; presence of blanching when pressed.
1. Superficial partial thickness burn: with blisters;
underlying skin is moist, pinkish, painful, and
briskly blanching; will heal in 2 to 3 weeks
2. Deep partial thickness burn: white to pale pink;
moist to dry to waxy, slightly anesthetic, and with
relatively slower blanching compared to
superficial partial thickness; will heal in 3 to 5
weeks resulting in hypertrophic scarring and
potential contracture
3. Both types of partial thickness burns can convert
to full thickness burns, signifying worsening of the
patient’s condition.
C. 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.
D. FOURTH DEGREE BURNS

Usually seen in electrical injury, these are defined as
full thickness burns extending beyond the skin
affecting adipose tissue.
E. FIFTH DEGREE BURNS

affecting muscles.
F. SIXTH DEGREE BURNS

affecting bone.
V. 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.

CHAPTER II:
CLASSIFICATION OF BURN INJURY
Minor Moderate Major
CHILDREN
Partial Thickness < 10%
10-20% BSA > 20% BSA
Burn BSA
Full Thickness
< 2% BSA 2-10% BSA > 10% BSA
Burn
ADULTS
Partial Thickness < 15%
15-25% BSA > 25% BSA
Burn BSA
Full Thickness
< 2% BSA 2-10% BSA > 10% BSA
Burn
Patients < 2 Patients >10

Age years old with years old with
minor injury minor injury
Involvement of
Primary Areas
Hands, Face, (-) (-) (+)
Feet, Perineum,
and Major Joints
Electrical Injury (-) (-) (+)
Chemical Injury (-) (-) (+)

Inhalation Injury Not Not
(+)
Suspicion suspected suspected
Major Associated
(-) (-) (+)
Medical Illness
Associated
Fractures, (-) (-) (+)
Multiple Trauma

CHAPTER III:
CRITERIA FOR REFERRING TO A BURN CENTER
1. Partial thickness burns >10% TBSA

2. Burns that involve the face, hands, feet, genitalia,
perineum, or major joints
3. Full thickness burns in any age group
4. Burns caused by electric current including lightning
5. Chemical burns
6. Inhalation injury
7. Burn injury in patients with preexisting medical disorders
that could complicate management, prolong recovery, or
affect mortality
8. Any patient with burns and concomitant trauma (such as
fractures) in whom the burn injury poses the greatest risk
of morbidity or mortality. In such cases, if the trauma poses
the greater immediate risk, the patient may be stabilized in
a trauma center before transfer to a burn center
9. Burned children in a hospital without qualified personnel or
equipment for the care of children
10. Burn injury in a patient who will require special social,
emotional, or rehabilitative intervention

CHAPTER IV:
INITIAL MANAGEMENT OF MINOR BURNS
1. Cool the wound with tap water or PNSS wash

2. ABA Recommendations for tetanus prophylaxis are based
on the patient’s immunization history. All patients with
burns should receive 0.5 mL of tetanus toxoid. If prior
immunization is absent or unclear, or if the last booster
was more than 10 years ago, 250 units of tetanus
immunoglobulin is also given or 3000 units of anti-tetanus
serum (ATS).
3. Clean the wound with soap and water. You may use 7.5%
povidone-iodine solution.
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 (i.e. Bacitracin, Neomycin,
Polymyxin B, or Petroleum Jelly) or appropriate wound
care products.
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.

CHAPTER V:
INITIAL MANAGEMENT OF MAJOR BURNS
1. Wear sterile gloves and appropriate personal protective

equipment when examining and handling patients.
2. Check and secure airway. Suspect inhalation injury if with:

A. Burn to face
B. Sooty phlegm
C. Singed nostril hairs
D. Hoarseness/ Stridor
E. History of burn in enclosed space or unconscious
at scene
F. Circumferential chest burn
Intubate the patient if:

• With burns >40% BSA
• With suspected inhalation injury
• Smoke inhalation
• Decreased GCS < 9
• Extensive burns to the face and oral cavity.
3. Do a complete physical examination. Check for other

injuries: fractures, lacerations, signs of blunt abdominal
trauma, etc.
4. Remove all burnt clothing. Use scissors to cut clothing

away from the patient.
5. Insert 1-2 large bore intravenous catheters for fluid

resuscitation. The catheters may be inserted
percutaneously. Insert over unburned skin if possible.
Don’t use scalp veins. Reserve the need for central line
insertion unless absolutely necessary.
6. Insert foley catheter to monitor urine output hourly.

7. Insert an NGT. Start proton pump inhibitors 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)= [2 x (age in years)] + 8
• For adults: Wt (kg)= 0.9 x [(ht in cms)-100]
9. Administer tetanus toxoid and tetanus immunoglobulin.

Give tetanus toxoid booster to patients who have not
received such in the past 10 years. Patients not previously
immunized should receive 250 units of tetanus human
immunoglobulin or 3000 units of anti-tetanus serum (ATS).
10. Check the pulses in all extremities 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 escharotomy or fasciotomy.
11. Refer all pediatric cases to Pediatrics for co-management.

Patients with other medical problems should also be
referred to the respective medical specialty concerned for
co-management.
12. No prophylactic systemic antibiotics are given, unless

there are concomitant medical conditions which indicate
its use early in the medical management (i.e. patients with
co-morbidities such as diabetes or those with
immunocompromised conditions, extremes of ages
(pediatric patients <2 y/o or geriatric patients >60 y/o)
Prophylactic systemic antibiotics are not given routinely,

because in the pathophysiology of thermal injuries, involved
areas have leaky capillaries which would hinder the systemic
antibiotics form reaching the target area.

DIAGNOSITCS ON ADMISSION
Diagnostics During admission, draw blood for:
1. Complete Blood Count w/ Platelet Count

2. Blood typing
3. BUN, Creatinine, Serum electrolytes (Na, K, Ca, Mg),
Albumin
4. Clotting factors PT/PTT
5. Arterial Blood Gas (if with suspicion for inhalation
injury)
6. Chest X-ray
7. 12-Lead ECG (for electrical burns and cardiac patients
and elderly)
8. Urinalysis (for electrical burns; include urine myoglobin
and pH)

CHAPTER VI:
FLUID RESUSCITATION
The most common cause of mortality in the 1st 48 hours

following a burn injury is inadequate fluid resuscitation.
Patients with moderate and major burns will require fluid
resuscitation via intravenous route, while patients with minor
burns are encouraged to increase oral intake. Fluid
resuscitation should be started as early as possible in the ER
and even before other diagnostic exams.
The PGH Burn Unit uses the Parkland formula:
1ST 24 HOURS
Adults:
Plain Lactated Ringer’s Solution at 2-6 ml x kilogram body

weight x TBSA percent burn
½ during the 1st 8 hours

½ during the next 16 hours
Use 2 as multiplier for cardiac patients and elderly

Computed as cc/kg/hr and then titrate hourly
Children:
D5LR for < 2 y/o., Plain LR for older children (>2 y/o) 3-4 ml x
kg body weight x % TBSA
PLUS Maintenance (Holiday Segar Formula)

100 ml/kg for the 1st 10 kg of body weight
50 ml/kg for each kg of body weight from 11-20 kg
20 ml/kg body weight above 20 kg
Computed as ml/hr

Serial CBG determination (every 8 hours) for children (<30 kg)
as their glycogen stores are more limited, and as such, makes
them more prone to develop hypoglycemia
In the presence of increased capillary permeability, colloid

content of resuscitation fluid exerts little influence on
intravascular retention during the initial hours post burn, which
is why crystalloid fluids are given.
24TH to 48TH HOUR
Adults/Children: D5 containing crystalloid or colloid sufficient

to maintain good urine output.
Colloid may be given in the form of plasma albumin or

cryoprecipitate. Most resuscitation protocols start colloid
infusion after the 1st 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 and children >30 kg: 0.5-1.0 cc/kg/hr

Children (<30kg): 1.0 cc/kg/hr
If the urine output falls below or exceeds these limits by greater

than 1/3 for 2-3 hours, fluid infusion may be increased or
decreased by 1/3 accordingly. The goal is to decrease IVF rate
to one half of rate infused over the previous 16 hours while
maintaining adequate urine output.

Other resuscitation fluids, such as colloids/albumin, may be
used in consultation with the consultant in charge.
Age influences relationship of fluid needs to body size, since

children have greater body surface area per body volume.
Urine volumes in excess of the values given above may signify

over correction and may run the risk of fluid overload, while
lesser volumes may signify inadequate fluid resuscitation. This
can lead to conversion of a previously shallow burn wound to
a deeper one. It cannot be over emphasized that regular hourly
monitoring of urine volume goes hand in hand with initial fluid
resuscitation.
In electrical injuries that present with myoglobinuria, fluid

volume for resuscitation should be adjusted to maintain a urine
output of 1.5-2.0 cc/kg/hr
NaHCO3 can be added to maintain a slightly alkaline urine.

Give 50 mEqs bolus IV and add 50 mEqs to 1L PLR x 125-
150cc/hr. Recheck urine myoglobin after NaHCO3 drip has
been consumed. If still with persistent urine myoglobin, you
may increase to 100 mEqs NaHCO3. Increase to 150 mEqs in
1L PLR if with persistent myoglobinuria.
Mannitol 12.5-25g may be infused to promote diuresis. If urine

output and pigment clearing do not respond to fluid
resuscitation and urine alkalinization, 12.5g-25g osmotic
diuretic mannitol may be given. Referral to Renal service is
mandatory.

CHAPTER VII:
WOUND DRESSING
Debridement/Initial Dressing:
1. Performed in a sterile area. Don sterile gloves, and use

sterile techniques.
2. Undress patient. Cut hair if it will reach any burned area or
otherwise complicate 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 underestimate burn size, since most of the patients seen
at the ER are still clothed.
5. Wash the burn areas with povidone-iodine soap and rinse
with sterile water.
6. Dress the patient’s wounds with a topical antibacterial or
other dressing modality, as indicated.
DIFFERENT WOUND DRESSINGS IN BURN
Silver Sulfadiazine (Flammazine, Silvadene, Sterizol)
Thick, white paste used for dressing partial to full thickness

burns.
Applied as sandwich dressing:

1. Place 1 layer of gauze over the burn area. This
facilitates the application of the cream.
2. Apply Silver sulfadiazine over the 1st layer of gauze
about 0.5-1.cm thick.

3. Cover with OS wet with sterile NSS about 1.0cm thick.
This wet layer prevents drying silver sulfadiazine,
which would limit effectivity
4. Cover with a layer of dry gauze.
5. Secure using rolled gauze
The dressing is changed once or twice a day. During removal

of dressing, consider wetting the last layer of gauze with pNSS
or sterile water 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 tongue
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 sulfonamide ions, which
interferes with the intermediary metabolic pathway of the
microbe. It is effective against Pseudomonas aeruginosa,
enterics, Staphylococcus aureus, Klebsiella sp., although
resistance has been reported. By itself, it retards wound
healing.
This agent may cause a transient leucopenia.
Silver Sulfadiazine + Cerium nitrate (Flammacerium)
This is a 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
toxins present in burned skin; thus, preventing the resulting
immunosuppression in severely burned patients.

This may be applied in cases wherein early excision-grafting
cannot be done (e.g. massive/ 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.
MEBO (Moist Exposed Burn Ointment)
A wound ointment that promotes cell regeneration of residual

skin tissue and wound healing by keeping burn wounds in a
three-dimensional physiologically moist environment and
facilitating the liquefaction and discharge of necrotic skin
tissue
Its effects include:

1. Reduced bacterial toxicity
2. Analgesia
3. Anti-inflammatory effect
4. Cell protection (increase tension in cell membrane,
helps convert dying cells into normal ones)
5. Physiologically moist environment
6. Reduced scar formation
Can be applied using three techniques:

A. Open (directly applied, and re-applied every 4-6 hours
B. Semi-open (one layer of gauze over the wound
covered with MEBO, re-applied every 4-6 hours)
C. Closed (Gauze soaked with MEBO to be applied over
the wound and covered with non-stick/non-absorbent
secondary dressings)

Hydrocolloid and Lipidocolloid dressings (Duoderm CGF,
Duoderm Extra Thin, Suprasorb H, Urgotul, Urgotul SSD)
Comes in various forms: wafer type of dressing with gel-

forming agents, water-resistant outer layer, adherent to the
wound. It provides a moist healing environment. It can be used
for autolytic debridement. Can provide insulation and requires
less dressing changes (every 3-5 days)
URGOTUL with TLC-SAG technology (Paraffin + Hydrocolloid

particles) provides a moist environment ideal for wound
healing. Provides painless removal (non-adherent). Less
dressing change compared to SSD alone.
Nanocrystalline silver (Acticoat and Acticoat Flex)
Nanocrystalline silver works in wet surroundings by setting

silver free over a long period. It can be applied and left in place
for up to 5-7 days. It has the highest concentration of silver
compared to other dressings.
Hydrofiber (Aquacel, Suprasorb A)/ Silver-impregnated

hydrofiber (Aquacel Ag, Suprasorb A+Ag)
Fiber absorbs exudates, but maintains a moist environment

suitable for wound healing. Releases silver impregnated ions
as dressing is soaked by exudates.
Foam dressings (Betaplast, Urgotul Absorb, Allevyn,

Askina)
Provides a moist environment for healing by having an ideal

moisture vapor transmission rate compared to Hydrocolloid
(low) and gauze (high)

Negative Pressure Wound Therapy (NPWT)
NPWT enhances wound healing by multiple mechanisms
related to wound-host interactions. There are multiple physical
effects of negative pressure suction forces, topical pressure
and shearing forces. These mechanisms have to be
understood before its usage in various clinical indications.
Negative pressure suction forces have been reported to

reverse lymphatic flow, reduce bacterial count, evacuate
wound fluids, decompress tissue edema and induce
granulation tissue formation
1. Reversal of lymphatic flow

The reversal of lymphatic flow is of clinical significance,
since it aids in bacterial clearance from the wound. This
reduces the need for hospitalization, antibiotic
treatment and early recovery.
2. Induction of granulation tissue formation
May induce granulation tissue to cover exposed bones
and tendons, enabling coverage with skin grafts.
3. Reduction of tissue edema
Crush injuries, complex fractures, and burns have
increased soft tissue edema and interstitial pressure.
The integrity of the capillary basement membrane of
blood vessels is damaged during wounding, leading to
increased permeability of capillaries and edema,
followed by decreased peripheral perfusion and
ischemia. Restoration of the integrity of the basement
membrane and narrowing of the endothelial spaces are
observed following NPWT.
4. Shearing forces
The application of cyclical tensile force generates
transient, alternating hypoxia and reperfusion, that
leads to accelerated tissue growth and enhances
wound healing.

Indications:
1. Chronic wounds (e.g. wounds in diabetic patients, and
peripheral vascular disease)
2. Neuropathic and post-irradiation wound areas
3. Deep pressure sores
4. Major trauma with crush injury, extensive tissue loss
and infection
5. Postoperative wound dehiscence and infections
6. Enhancement of skin graft and flap survival
Contraindications
1. Acute uncontrolled bleeding after major trauma. A
meticulous hemostasis should be established prior to
the application.
2. Major exposed vessels and organs. It should be
ensured that there are no exposed blood vessels,
nerves, or internal organs in direct contact with the
vacuum system
3. Nonenteric fistula that are unexplored without
knowing base
4. Patients on anticoagulants
5. Osteomyelitis
6. Presence of malignancy
7. Badly infected or inadequately debrided wounds
In major burns, treatment of large areas may lead to extensive

extracellular fluid loss and electrolyte imbalance. Acute
bleeding may also be observed due to the applied negative
pressure suction forces.

CHAPTER VIII:
MONITORING A BURN PATIENT
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 a complex and
precarious physiologic state —which has to be optimized to
maximize chances of a positive outcome. Monitoring the burn
injury of the patient is one of the most important aspects of
burn care.
At the Emergency Room:
1. Check vital signs, urine output, pulmonary, and

neurologic status hourly
2. Draw blood for Hgb, typing, Na, Cl, K, BUN, Crea and
RBS.
3. In cases where pulmonary or inhalation injury is
suspected, do CXR and ABG.
4. In cases of electrical injury, do ECG and urine
hemoglobin and myoglobin.
During the Period of Fluid Resuscitation:
1. Signs of adequate hydration / resuscitation hourly

2. Weigh patient
3. In cases of electrical injury, the presence of
hemoglobin and myoglobin in the urine (associated
with pinkish color) suggests delayed or inadequate
fluid resuscitation.
4. Monitor vital signs hourly temperature every 4 hours
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 hours or so.
8. Asses status of wound daily during dressing change.
During the Period of Post Resuscitation:

1. Vital signs monitoring may be decreased to q4 hrs to
every shift depending on patient’s condition.
2. Daily determination of weight, Na, K, BUN and Crea.
3. Assess burn wound status everyday during dressing
changes. Do burn wound biopsies (not swabs) twice a
week.
4. Do Blood CS once a week if wound is clinically infected
and patient is septic.

DEFINITIVE MANAGEMENT
The priority in the management of burns in the 1st 48 hours is
to maintain the intravascular volume, which will be affected by
fluid shifts arising from the increased capillary permeability
often found in thermal injuries. 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 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.
EARLY EXCISION AND GRAFTING

This is done within the 1st 7 days post-burn, while the burn
wound is not yet colonized by microorganisms; thus, reducing
chances of infection and promoting good graft take. Leads to
reduced hospital stay and better outcomes.

CHAPTER IX:
EXCISION AND GRAFTING
The basic premise of excision and grafting is to remove full

thickness and deep partial burns, until a clean viable bed is
encountered. A skin graft is placed immediately to cover the
wound.
Preparation and 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. Normal Albumin (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 povidone-iodine soap and
povidone-iodine paint for the donor site, povidone-
iodine 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)

2. Using a Watson 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 that do not bleed immediately after passage of the

dermatome area are still not viable and still need to be
excised
3. Hemostasis 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 pNSS). 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 pNSS 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.
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 defect (contour deformity) 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 skin grafts on fat has a
poorer chance of graft take.
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 povidone-iodine soap and paint

2. Harvest the STSG using a Watson 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 epithelialization. If fatty
tissues are noted where the graft is harvested, the graft
is too thick.
3. Hemostasis is secured using 1:100,00 epinephrine
spray and plastic overlay, followed by pressure, as
described in hemostasis and tangential excision
4. Cauterize any persistent bleeders.
5. Dress the donor site with hydrocolloid dressing or by
applying one layer of mesh gauze followed by layers of
wet gauze. The wet gauze is removed after 8 hours.
The donor site with a single layer of mesh is exposed
for 30 minutes every hour for one day until a scab will
form, which will later flake off as the donor site heals.
6. Choice for donor sites: Thigh, Leg Back* Scalp*
Anterior trunk.
*Will have to inject sterile pNSS 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 will be
applied has no active bleeding.
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 3rd post-op

day or as late as 5th post-op day. Open early if the skin
graft is suspected to be infected (e.g. 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
with povidone-iodine soap and rinse with water. Dress
the graft with bulky wet dressing.
3. Staples can be removed during 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) should be managed according with the use of
silver-based dressings, or with the use of MEBO.

CHAPTER X:
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 sequelae of the burn
injury) resolves. Patients with burns have a hyper-metabolic
response and have metabolic nutritional requirements. This
hyper-metabolic state persists until the burn wounds are
covered. To ensure delivery of necessary calories in these
patients, a nasogastric tube is inserted.
Calculations of the patient’s nutritional requirements may be

obtained by using any of the following formulas applicable to
each patient:
TORONTO FORMULA
-4343 + 10.5 x %TBSA + 0.23 x previous 24 hours' caloric
intake + 0.84 x Harris-Benedict equation + 114 x previous 24
hours' maximal temperature - 4.5 x days post-burn injury
It is the preferred formula in adults because it takes into

account several factors in the computation.
CURRERI FORMULA
Adult: (25 x kg) / (40 x %BSA burn)
Children: (60 x kg) / (35 x %BSA burn)
The use of this formula is discouraged because it

overestimates the caloric requirement of patients, leading to
overfeeding syndrome.

CHAPTER XI:
COMMON COMPLICATIONS
Sepsis
Most common cause of death in burns. Suspect sepsis if

patient has fever, hypotension, conversion from partial to full
thickness burns, presence of ecthyma gangrenosum in the
burn wound
Ecthyma gangrenosum is a type of skin lesion characterized

by vesicles or blisters, which rapidly evolve into pustules and
necrotic ulcers with undermined tender erythematous borders.
In burn patients it typically presents as small, indurated black
spots on the skin. It is associated with Pseudomonas
aeruginosa septicemia in immunocompromised hosts —burn
patients being among the populations at risk. Histopathology
of ecthyma gangrenosum lesions shows vascular necrosis
with few inflammatory cells, but many surrounding bacteria.
The dictum is to start empiric antibiotics and referral to

Infectious disease is warranted. In a local study done by Dr.
Nable-Aguilera and J. So (2014) in ATR burn patients, they
found out that diabetes mellitus, burn size greater than 20% of
total body surface area, and the use of tulle dressings are
significant risk factors in developing ecthyma gangrenosum.
ARDS
Occurs in the setting of electrical or inhalation/pulmonary

injury
Presents as progressive hypoxemia unresponsive to
increasing FiO2
X-rays may be normal in its early phase
Manage with intubation: 100 FiO2, high PEEP, low tidal volume

Contractures
Preventable by proper positioning and splinting

Coordinate with rehabilitation medicine resident regarding
proper positioning

CHAPTER XII:
OTHER IMPORTANT CONCERNS
PAIN CONTROL
Opioids are the drug of choice for burns. May give Tramadol
50mg IV q8 or Nalbuphine 5mg IV q6 as needed. Do not give
narcotics IM, since absorption is erratic. All patients must be
referred to Pain Service for co-management.
REFERRALS TO OTHER SPECIALTIES
• All patients should be referred to the Department of

Rehabilitation Medicine and the Pain Service
• All pediatric patients should be referred to the Department of
Pediatrics for co-management
• All patients should be referred to Dietary (Adult) or Pediatric
Gastroenterology, and Nutrition Services
• Referrals may be made to other specialties, as deemed
necessary by the Burn Center medical staff (e.g. Psychiatry,
Child Protection Unit, Infectious Disease, Pulmonology)
CRITERIA FOR DISCHARGE
1. No existing complications of thermal injury such as

inhalation injury
2. Fluid resuscitation completed
3. Adequate pain tolerance
4. Adequate nutritional intake
5. No active infection
6. No anticipated septic complications
7. Ability to do wound care at home
8. Raw areas <10% TBSA for adults, fully epithelialized
wounds for pediatric patients less than 2 years old


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ACUTE BURNS

Alfredo T. Ramirez Burn Center

ACUTE BURNS: Interns Handbook on Diagnosis and Management 1 of 40

DIAGNOSIS AND MANAGEMENT OF ACUTE BURNS 7

INITIAL / RESUSCITATIVE PERIOD 8

CHAPTER I: ASSESSMENT OF BURN INJURY 8

CHAPTER IX: EXCISION AND GRAFTING 33

ACUTE BURNS: Interns Handbook on Diagnosis and Management 2 of 40

Established by Dr. Alfredo T. Ramirez in 1967, this Center,

ATR, as he was fondly called, envisioned this Burn Center

This handbook is the intellectual property of the staff of the

ACUTE BURNS: Interns Handbook on Diagnosis and Management 3 of 40

It is generally recognized that specialized burn facilities

With this vision in mind came the development of the

ACUTE BURNS: Interns Handbook on Diagnosis and Management 4 of 40

Jose Joven V. Cruz, MD, MPH, FPAPRAS, FPCS

Maria Adela N. Aguilera, MD, FPAPRAS, FPCS

Jeane J. Azarcon, MD, FPAPRAS, FPCS

Jonas Daniel P. Bico, MD

ACUTE BURNS: Interns Handbook on Diagnosis and Management 5 of 40

A. Assess burns as to type, depth, and extent

ACUTE BURNS: Interns Handbook on Diagnosis and Management 6 of 40

Definitive Management Period

ACUTE BURNS: Interns Handbook on Diagnosis and Management 7 of 40

PRIMARY SURVEY SECONDARY SURVEY

I. Get a complete history regarding the circumstances

II. Identify the type of burn

ACUTE BURNS: Interns Handbook on Diagnosis and Management 8 of 40

III. Estimate the burn size, express as percent total body

Count only those areas with partial (second degree) or full

ACUTE BURNS: Interns Handbook on Diagnosis and Management 9 of 40

• Note: In electrical injuries, the %TBSA involved does

ACUTE BURNS: Interns Handbook on Diagnosis and Management 10 of 40

ACUTE BURNS: Interns Handbook on Diagnosis and Management 11 of 40

ACUTE BURNS: Interns Handbook on Diagnosis and Management 12 of 40

This is extremely important. This information is used in

A. FIRST DEGREE BURNS

B. PARTIAL THICKNESS BURNS

C. FULL THICKNESS BURNS

ACUTE BURNS: Interns Handbook on Diagnosis and Management 13 of 40

D. FOURTH DEGREE BURNS

E. FIFTH DEGREE BURNS

F. SIXTH DEGREE BURNS

V. Check for other injuries/medical problems. Do not fail to

ACUTE BURNS: Interns Handbook on Diagnosis and Management 14 of 40

Minor Moderate Major

Patients < 2 Patients >10

Chemical Injury (-) (-) (+)

ACUTE BURNS: Interns Handbook on Diagnosis and Management 15 of 40

1. Partial thickness burns >10% TBSA

ACUTE BURNS: Interns Handbook on Diagnosis and Management 16 of 40

1. Cool the wound with tap water or PNSS wash

ACUTE BURNS: Interns Handbook on Diagnosis and Management 17 of 40

1. Wear sterile gloves and appropriate personal protective

2. Check and secure airway. Suspect inhalation injury if with:

Intubate the patient if:

3. Do a complete physical examination. Check for other

4. Remove all burnt clothing. Use scissors to cut clothing

5. Insert 1-2 large bore intravenous catheters for fluid

6. Insert foley catheter to monitor urine output hourly.

ACUTE BURNS: Interns Handbook on Diagnosis and Management 18 of 40

8. Weigh patient and record. This step is very important. In

9. Administer tetanus toxoid and tetanus immunoglobulin.