1. Burns
Nicole Baier, MD

2. Statistics
In US:
1.2 million burns each year
60,000 hospitalizations
6000 deaths
2nd leading cause of unintentional death in children (after MVA)
Pediatric incidence by type of burn:
Scald burns: 85%
Flame burns: 13%
Remaining 2%: electrical and chemical burns

3. The Skin Barrier to: Fluid loss Entry of infection Heat loss epidermis3

4. Burn Classification 1st degree (superficial) Epidermis only
Erythematous, painful
No blistering 4

5. Classification 2nd degree (partial thickness)
Injury to epidermis and variable portion of dermis
Moist, pink or red, blanches to touch
Vesicles and blisters
Extremely painful
Heal spontaneously 5

6. Classification 3rd degree (full thickness) Entire epidermis and dermis
No residual epidermal cells – require skin grafting
Leathery, white or black or brown
Not painful (no viable nerve endings)
High risk of scarring 6

7. Classification 4th degree
Involve underlying structures (tendons, nerves, muscles, bone, fascia)
Reconstructive surgery often necessary 7

8. Estimation of Burn Size
Used to calculate fluids for IVF resuscitation
Only 2nd and 3rd degree burns considered
Adults: Rule of nines
Pediatric: Lund-Brower chart
Estimate: palm of patient’s hand = 1% BSA

9. Burn Diagrams

10. Acute Assessment AIRWAY Airway edema caused by inhalational injury
Direct thermal injury – supraglottic
Suspicion increased if:
Facial/ oral burns
Soot in mouth/nose
Singed nasal hairs
Wheezing, stridor, or hoarseness noted
Intubation should be performed quickly as edema can progress rapidly (over initial hours)

11. Acute Assessment BREATHING– Initial findings
Early hypoxia may result from:
Airway obstruction
Impaired chest wall compliance (circumferential burns)
Decreased ambient FiO2 (10-15%)
Carbon monoxide
Cyanide
Produced when wool, silk, nylon, polyurethane burn
Disrupts mitochondrial oxygen use by complexing with cytochrome
CO and CN are responsible for majority of early mortality at scene
Children more susceptible to toxicity of inhaled materials due to higher minute ventilation

12. Carbon Monoxide Affinity for hemoglobin 250x > O2
Decreases oxygen carrying capacity
Shifts oxyhemoglobin dissociation curve to left
Binds to myoglobin and mitochondrial cytochrome oxidase
Interfere with cell oxygen use and energy production
Measured with co-oximetry
20-30% = headache, dizziness
40-50% = altered LOC
>50% = coma, death
Treatment: 100% oxygen
½ life in room air: 4-6 hours
½ life in 100% FiO2: minutes

13. Acute Assessment BREATHING – Later findings
Chemical irritants injure tracheobronchial tree and lung parenchyma
Lower airway edema
Respiratory epithelium sloughs - cast formation causes airway obstruction
Manifests as: bronchospasm, post-obstructive atelectsis
Patients also at risk for:
Surfactant deficiency due to damage to type II pneumocytes
ARDS
After 72 hours: nosocomial pneumonia may develop
Restrictive lung disease may develop in survivors

14. Acute Assessment CIRCULATION In 50% BSA burn: Hypovolemic shock
1 minute after burn, cardiac output is ½ of preburn state
At 1 hour, cardiac output is 1/3 of preburn state
Hypovolemic shock
Loss of skin integrity increases evaporative losses 6-7X
Increased vascular permeability leads to interstitial edema and intravascular volume loss
Maximal at 30 minutes
Capillary integrity restored 8-12 hours post-injury
Myocardial depression also occurs
Thought to be due to TNF release

15. Acute Management CIRCULATION
Burns >15% BSA require IV fluid resuscitation to maintain perfusion
Time to IV access is a major predictor of mortality in pediatric patients who have burns greater than 80% TBSA
IV preferably placed in nonburned tissues

16. Acute Management CIRCULATION Parkland Formula:
Used to determine resuscitation fluids = LR
4 mL x weight (kg) x % TBSA burned
½ over 1st 8 hours, ½ over remaining 16 hours
Added to maintenance dextrose-containing fluids
Monitor hemodynamics, urine output and adjust fluids accordingly

17. Question
You have a 14 month old, 11 kg infant who was involved in a house fire and has second degree burns to both of her hands, feet, her right lower arm and both lower legs. What IV fluids should she receive over the 1st 24 hours? 17

18. Burn Diagrams 18

19. Answer Calculate % BSA: Parkland Formula: = 26% TBSA Burn
Both hands: 3 x 2 = 6%
Both feet: 3.5 x 2 = 7%
Right lower arm = 3%
Both lower legs: 5 x 2 = 10%
Parkland Formula:
4 mL x 11 kg x 26% = 1144 mL fluid resuscitation requirement
572 mL over 1st 8 hours = 61 mL/hr of LR
572 over remaining 16 hours = 35 mL/hr of LR
Maintenance Fluid Requirement
44 mL/hr of D5 ½ NS
= 26% TBSA Burn 19

20. Other initial management
Remove all clothing that is hot/ burned/ exposed to chemicals
Prevent continued skin damage
Wound treatment
Clean with mild soap and water
Apply cool saline-soaked gauze – decreases pain
Do not apply ice – produces hypothermia, worsens damage
Covering with a sheet may decrease pain by decreasing environmental exposure 20

21. Electrical injuries
Minor surface burns may hide massive coagulation necrosis of muscle and deep tissues
Risk of rhabdomyolysis
Risk of cardiac abnormalities
Asystole, ventricular tachycardia/ fibrillation
Atrial and ventricular ectopy, 1st and 2nd degree heart block, bundle branch blook, prolonged QT
Non-specific ST-T changes and interval delays most common

22. Electrical Injuries
Tissue injury is directly proportional to resistance
Nerves, muscles, blood vessels have lowest resistance
Electricity preferentially flows through these structures
More severe damage
Increased resistance:
Skin
Tendons
Bone
Fat
Water decreases resistance, therefore moist areas (eg, axillae) tend to sustain more damage

23. Electrical Injuries Type of current
AC (household electricity) is more dangerous
Continual muscle contraction and relaxation results in muscle tetany
Eg, a 60 Hz alternating current changes direction 120x/ second
DC (lightning strikes) produces muscle contraction only at beginning and end of current flow

24. Electrical Injuries Current Pathway
Current may flow in 1 of 3 pathways:
Hand to hand
60% mortality rate due to:
Spinal cord transection at C4-C8
Suffocation due to chest wall muscle tetany
Myocardial muscle damage
Hand to foot
20% mortality rate due to cardiac arrhythmias
Foot to foot
5% mortality rate

25. Additional Management for Electrical Injuries
Obtain EKG
Consider obtaining cardiac enzymes
Monitor patients with medium and high-voltage injuries on monitor for hours 25

26. Compartment Syndrome
Most common early cause of diminished pulses is inadequate resuscitation
High index of suspicion for elevated compartmental pressures in circumferential burn
Emergent escharotomy or fasciotomy is indicated for limb salvage in pulseless extremity
Thoracic escharotomies are occasionally required to improve chest-wall compliance and facilitate ventilation

27. Ongoing Management Hypermetabolic state
Increase in metabolism over 1st 5 days – then plateau through remainder of acute admission and into rehab
Due to surge of catecholamines, cortisol, aldosterone, growth hormone
Insulin secretion decreased, tissues insulin resistant
Degree correlates with extent of injury 27

28. Hypermetabolic State Manifestations
Tachycardia, increased cardiac output
Hyperthermia
Baseline temp reset to 38.5⁰C
Increased gluconeogenesis, protein catabolism, lipolysis
Resting energy expenditure 2-3 x normal
May be associated with:
Impaired wound healing
Sepsis
Loss of lean body and muscle mass 28

29. Hypermetabolic State In burn injuries > 40% TBSA:
Resting metabolic rate at 33°C is:
180% of basal rate at admission
150% at full healing of the wound
140% 6 months after the injury
120% at 9 months post injury
110% after 12 months
Hart DW, Wolf SE, Mlcak R, et al. Persistence of muscle catabolism after severe burn. Surgery 2000; 128: 312–319. 29

30. Hypermetabolic state Long-term consequences Profound muscle wasting
Decreased bone mineral density
Retarded linear growth in children
In 80 patients with > 40% TBSA burn:
Profound growth arrest noted during postburn year 1
Growth improved to normal by postburn year 3
Rutan FL, Herndon DN. Growth delay in postburn pediatric patients. Arch Surg 1990; 125: 30

31. Ongoing Management Feeds started EARLY Within 6 hours of admission
Require up to 50% more calories than at baseline
Hypermetabolic state
Pain and anxiety increase physiologic demands
Greater heat loss occurs in young infants with larger surface area-to-mass ratios
Reduces bacterial translocation and sepsis
TPN avoided due to infectious complications
Goal: full feeds by hours

32. Infectious Concerns Risk of infection related to:
Loss of skin barrier
Wound colonization is universal by 1-2 weeks post-injury
Presence of inhalational injury - compromises normal clearance mechanisms
5x higher rate of pneumonia
Immunosuppression
Impaired cellular and humoral immune response
Infection now responsible for 50-60% of deaths in burn patients

33. Topical Therapies Bactroban Silvadene (silver sulfadiazene)
Used for superficial burns, primarily on face
Silvadene (silver sulfadiazene)
Bacteriocidal
Cannot be used in those with sulfa allergies
Causes neutropenia and thrombocytopenia

34. Topical Therapies Sulfamylon (mafenide acetate)
Better penetration of deep burns, eschars, and cartilage
Bacteriostatic
Better gram negative coverage (pseudomonas)
Causes fungal overgrowth
Painful
Carbonic anhydrase inhibitor – causes metabolic acidosis

35. Surgical Wound Management
Early excision and closure of full thickness burn wound
If wound >50% TBSA is totally excised and covered with autograft within 2–3 days:
Metabolic rate 40% less compared with wound coverage 1 week post injury
Hart DW, Wolf SE and Chinkes D, et al. Determinants of skeletal muscle catabolism. Ann Surg 2000; 233: 455–465. 35

36. Surgical Wound Management
Other benefits of early wound excision
Decreases pain
Provides barrier to fluid and heat loss, bacterial invasion
Decreases length of stay
Accelerates recovery
Fewer septic complications
Decreased morbidity and death 36

37. Surgical Wound Management
Serial wound excision and grafting is the standard of care for full-thickness burns
When the burned area exceeds donor site supply (burns >30% BSA), homografts from donors or skin substitutes are used
Taken back to OR weekly to replace homografts with autografts as donor sites heal 37

38. Criteria for Admission
>15% BSA
3rd degree burns
Electrical burns
Inhalational injury
Burns to hands, feet, face, genitalia, joint surfaces
Suspected abuse or neglect
Inadequate home situation

39. Outpatient Treatment Leave blisters intact Dress burns with silvadene
Wash wound and change dressings BID
Pain control with tylenol or tylenol with codeine

40. Identifying abusive burns
15-20% of burn injuries are the result of abuse
Suspicious patterns:
Glove or stocking burns of hands and feet
Deep burns on trunk or back
Small-area full-thickness burns (cigarette)
Circumferential burns
Burns localized to the perineum or buttocks
Symmetric burns

41. Burn Prevention Preset water heaters to max of 120⁰ F
Duration of exposure required to produce full-thickness burn:
120⁰ F: 10 minutes
130⁰ F: 30 seconds
140⁰ F: 5 seconds
150⁰ F: 2 seconds
158⁰ F: 1 second
Federal Flammable Fabric Act
Requires sleepwear to be flame retardant
Use of smoke detectors