1. THE BURN MANUAL

2. Diagnosis and Management of Acute Burns
Initial/Resuscitative Period
(first 48 hours)
Definitive Management Period (after 48 hours)
Assessment of burn injury
Classification of burn injury
Criteria for admission
Initial ER management
Fluid resuscitation
Monitoring
Excision and grafting
Control of infection
Nutrition
Rehabilitation
Complication

3. Initial Rescucitation

4. Assessment of a burn injury
Complete history
Eg: burn injury in an enclosed space – risk for inhalational injury
Classify as to type of burn
Scald burn: caused by hot liquids ( hot water, soups, sauces) which are thicker in consistency, remain in contact with the skin for a longer period of time
Flame burn: house fires, improper use of flammable liquids, kerosene lamps, careless smoking, vehicular accidents, clothing ignited from stove

5. Flash burn (under flame burn): explosions of natural gas propane, gasoline and other flammable liquids causing intense heat for a very brief period of time.
Contact burn: results from hot metals, plastic, glass or hot coals; usually limited in extent but very deep

6. 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 tan the skin creating an impermeable barrier limiting 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
Electrical burns: injury from electrical current classified as high voltage or low voltage (high voltage 1000 V)

7. 3. Estimate the Burn Size
Expressed as %BSA; count only areas with partial (2nd degree) or full thickness ( 3rd degree) burns
Accurately done using the Lund and Browder charts
Rule of Nines obtains a rough estimate of the areas involved but not accurate in children due to the large surface are of the child’s head and the relatively smaller are of lower extremities.
In electrical injuries, the %BSA does not correspond to the extent of injuries of the underlying soft tissues.
- may have normal looking skin over it

9. 4. Assess the Burn Depth First Degree Burns – will heal in 7-10 d
Important in estimating burn size and fluid requirement in determining the need for surgery and in evaluating the progress of the patient
First Degree Burns – will heal in 7-10 d
Ex: sunburn

10. Partial Thickness Burns
Second degree burns
Extends to the dermis but not through full thickness of the skin
Heals from epithelialization from surviving epidermal elements
(+) blanching when pressed
Superficial partial thickness burns: with blisters;underlying skin is moist, pinkish, painful; will heal in 2-3 weeks
Deep partial thickness burn: white to pale pink; moist to dry to waxy, slightly anesthetic, will heal in 3-5 weeks resulting in hypertrophic scarring and potential contracture
Both types of partial thickness burns can convert to full thickness burns, signifying worsening of the patient’s condition

11. Full Thickness Burns Burns extending through full depth of the skin
May appear white, brown or gray with a waxy, leathery feel, skin is anesthetic
Presence of visible thrombosed veins [pathognomonic]
Heals by granulation and will require future skin coverage for wound coverage

12. 5. Check for other injuries/medical problems
These problems play a role in the origin of burn and will have to be integrated in the management of burn
Eg: seizure disorders, diabetesdisorders, fractures, blunt abdominal injuries

13. Classification of Burn Injury
MINOR
MODERATE
MAJOR
CHILDREN
partial thickness burn
<10% BSA
10-20% BSA
>20%BSA
Full thickness burn
<2% BSA
2-10%BSA
>10%BSA
ADULTS
<15%BSA
15-25%BSA
>25%BSA
<2%BSA
AGE
Patients <2yrs with minor injury
Patients <10yrs with major injury
INVOLVEMENT OF HANDS, FACE, FEET, PERINEUM
(-)
Moderate injury involvement
ELECTRICAL INJURY
(+)
CHEMICAL INJURY
Inhalational Injury
Not suspected
Major Associated medical Illness
Associated fractures, multiple trauma

14. Criteria for Admission to the Burn Unit
Acute burn patients with moderate and major injuries
Acute burn patients <2y/o regardless of % TBSA
Acute burn patients with injuries to the hands, face, feet and perineum
Acute electrical burn patients
Acute chemical burn patients
Acute burn patients with smoke inhalation injury, other associated medical illness, or multiple trauma

15. Criteria for Admission to the Burn Unit
Patients with massive exfoliative disease, such as:
Toxic Epidermal Necrosis (TENS)
Steven Johnson Syndrome (SJS)
Staphylococcal Scalded Skin Syndrome (SSSS)

16. Initial Labs CBC Blood typing RBS, BUN, Crea, Na, K, Cl, Albumin
ABG (if inhalational injury is suspected)
Other labs:
Chest X-ray
ECG (for electrical burns)
Urinalysis (for electrical burns, urine myoglobin & pH also included)

17. Initial ER Management: MINOR Burns
Cool wound with tap water
Administer tetanus prophylaxis
TT booster if not received for the past 5 years
0.5cc TeAna and 3000 u ATS (adults)
Clean wound with soap and water/betadine scrub
Debride dead tissue
Big blister unroof
Small blister aspirate

18. Initial ER Management: MINOR Burns
Apply bland ointment (i.e., Bacitracin, Trimycin, Vaseline) and non-stick porous gauze and wrap with gauze
NO systemic prophylactic antibiotics are given
Oral/IM analgesics during wound cleaning
Send patients home with oral analgesics and instructions to clean the wound OD to BID and apply ointment and gauze.

19. Initial Management: MAJOR & CRITICAL Burns
Wear sterile gloves
Remove all burnt clothing
Check & secure airway. Suspect inhalational injury if with:
Burn to face
Sooty phlegm
Singed nostril hairs
Hoarseness or stridor
History of burn in enclosed space
or unconscious at scene
Circumferential chest burn

20. Initial Management: MAJOR & CRITICAL Burns
Intubate if with:
Burns 50% BSA
Suspected inhalational injury
Smoke inhalation
Do complete PE, check for other injuries
Insert IV line for fluid resuscitation
Insert foley catheter (to monitor UO).
Insert NGT (to decompress stomach). Start IV PPI (to avoid Curling’s ulcer).

21. Initial Management: MAJOR & CRITICAL Burns
Weigh patient and record. If not possible, estimate:
For children: Wt (kg) = [2 x (age in years)] + 5
For adults: Wt (kg) = 0.9 x [ht in cms – 100]
Administer ATS and TeAna
Check pulses, assess adequacy of chest expansion
Absent pulses or limited chest excursion is a surgical emergency and an indication for escharotomy

22. Initial Management: MAJOR & CRITICAL Burns
Escharotomy
Extremities
Prep with betadine soap
Cut through entire depth of skin along medial and lateral aspects of involved extremity. Avoid injuring the ulnar nerve and the peroneal nerve; facilitate separation of the skin by blunt dissection.
Chest
Cut along both anterior axillary lines and along the costal margin producing a W- shaped incision
Facilitate separation of skin by inserting your finger and bluntly dissecting through the cut skin.

23. Initial Management: MAJOR & CRITICAL Burns
Refer all pediatric patients to Pedia for co- management. Patients with other medical problems should also be referred accordingly.
No prophylactic antibiotics are given, unless there are concomitant medical conditions that indicate its’ early use.

24. Fluid Resuscitation

25. Fluid Resuscitation
Most common cause of mortality in the first 48 hours is inadequate fluid resuscitation
(Minor: inc OFI, Moderate to Major: IV route)
Start ASAP in the ER and even before other diagnostic exams

26. Fluid Resuscitation: PARKLAND FORMULA
Day 1
Adults:
Plain LR 4mL/kg BW per % BSA burned to be given:
½ during the first 8 hours
½ during the next 16 hours
Children:
D5 LR 3mL/kg BW per % BSA burned to be given:
+ maintenance
Cardiac, elderly patients: 2mL/kg BW per % BSA
Inhalational, electrical injury: 6mL/kg BW per % BSA

27. In the presence of increased capillary permeability, colloid content of resuscitation fluid exerts little influence on intravascular retention during the initial hours post-burn, hence, crystalloid fluids are given.

28. Fluid Resuscitation: PARKLAND FORMULA
Day 2
Adults / children:
D5NR(adults), half normal saline (children) and colloid sufficient to maintain good urine output

29. Fluid Resuscitation
Colloid may be given in the form of plasma albumin or cryoprecipitate
Most protocols start colloid infusion after the first 24 hrs (capillary permeability thought to be restored by then)
For massive burns, colloid infusion can be started as early as 12 hours post-burn (to decrease total fluid requirements and lessen edema)

30. Fluid Resuscitation Regulate fluids to maintain adequate urine output
Adults: 0.5 mL/kg BW/hr
Children: 1.0 mL/kg BW/hr up to 30 kg BW
Age influences relationship of body fluids to size: children have larger BSA per body volume
Fluid calculations – not absolute and should not be given by rate
Excessive urine volumes  overcorrection and run the risk of fluid overload;
Smaller volumes  inadequate resuscitation
UO monitoring should be done strictly Q1

31. Fluid Resuscitation For electrical injuries:
Adjust fluid volume to maintain UO of mL/hr (target UO: 1-2 cc/kg BW)
Mannitol g may be infused to promote diuresis
If UO and pigment clearing do not respond to fluid resuscitation, 12.5g osmotic diuretic mannitol may be added to each liter of resuscitation fluid
NaHCO3 can be added to maintain a slightly alkaline urine (pH>5.5) to promote solubility of heme pigments

32. Wound Dressing

33. Wound Dressing Debridement/Initial Dressing: Sterile technique
Cut hair or items that may reach any burned or dressing area
Full body bath with soap and water
Debride burned areas; visualize all affected areas. Reassess depth and %BSA of burn wounds
Wash with betadine soap, rinse with sterile water
Dress

34. Silver Sulfadiazine (Flammazine, Silvadene, Silversurf)
For full thickness burns, applied as sandwich dressing
May cause transient leucopenia
MOA: silver ion binds with the DNA of the organism and release sulphonamide which interferes with the metabolic pathway of the microbe
Effective against: Pseudomonas aerugenosa, Enterics, S. aureus, Klebsiella sp
Maximum of 2 weeks bec it retards wound healing
Leaves a yellow green pseudo-eschar which must be scraped off during dressing

35. Silver Sulfadiazine + Cerium nitrate (Flammacerium)
Topical antimicrobial
Applied in cases wherein early excision-grafting cannot be done (mass burn, extensive burns)
Reduces mortality by neutralizing toxin present in burned skin
Mechanism of action:
Cerium induces calcification of the dermal collagen remaining in the wound which produces the typical tanned, leathery crust

36. Silver Nitrate (not used anymore)
Used as 0.5% solution
Gauze dressing must be wet, solution loses effectivity when dry
Creates a brownish black discoloration with anything it comes in contact with (will peel off with the burned skin)
Bacteriostatic for S. aureus, E. Coli, P. aeruginosa
Does not injure regenerating epithelium in the wound
Caution with children as it tends to leach out electrolytes (Na, Cl)

37. Dakin’s Solution Sodium hypochlorite 0.025% solution:
15 mL Sodium hypochlorite (Zonrox) mL NSS
Must be used within hours after it is prepared
Used in preparing granulation tissue for grafting
Bactericidal to S. aureus, P. aerugenosa, and other G(-) and G(+) bacteria

38. Monitoring
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 complex and precarious physiologic state, which has to be optimized to maximize chances of a positive outcome.

39. Monitoring At the ER: Check VS, UO, consciousness, pulmonary status Q1
Hgb, typing, Na, Cl, BUN, Crea, RBS
CXR and ABG (for inhalational injury)
ECG, urine myoglobin (for electrical burns)

40. Monitoring During fluid resuscitation:
Check signs of adequate hydration
Weigh patient daily
Vital signs hourly
Monitor peripheral perfusion hourly (pulses, capillary refill)
Presence of Hgb and myoglobin in urine of electrical burn patient suggest delayed or inadequate fluid resuscitation

41. Monitoring During fluid resuscitation:
Pulmonary status every 4-5 hours
Daily determination of Hgb, Hct, WBC, Na, K, BUN, crea
Status of wound daily during dressing change

42. Monitoring Post resuscitative period: Vital signs every 4 hours
Daily determination of weight, BUN, crea, Na, K
Assess burn status daily
Burn biopsies (not swabs) twice a week
Blood CS once a week if wound is infected or patient is septic
Weigh patient daily

43. Definitive Management
Priority in the 1st 48 hours—maintain intravascular volume Once addressed, definitive management ensues Classical Method: Allow eschar to spontaneously separate (3 weeks), wait until bed is ready for grafting, then place skin graft

44. Definitive Management
Present trend: Early excision (within 7d post burn) of burn wound, followed by skin grafting - improve survival and shorten hospital stay - adopted strategy by the PGH Burn Unit

45. Excision and Grafting

46. Excision and Grafting
To remove full thickness and deep partial burns until clean viable bleed is encountered and a skin graft is placed immediately to cover the wound
Early excision – done within 7 days
wound is not yet colonized by microorganisms, reducing the chances of infection and promoting good graft take

47. Preparation for OR prerequisites
Stable vital signs
Not in septic shock
Afebrile
Blood available for OR use ( mL/%BSA)
Normal albumin
No contraindications for surgery

48. Conduct for OR OR table covered by sterile linen Keep OR warm
Prep patient using betadine soap and paint for the donor site and betadine soap for the wound
Prep the donor site
Drape donor site separate from the burn wound

49. Tangential Excision
Principle: to excise the wound in thin layers using a blade held at very acute angle with the skin surface
Goal: to remove non viable tissue leaving as much dermis as possible (excellent surface for grafting)

50. Fascial Excision Best used when excising large flat areas
When excision of the burn wounds has to be done with minimum blood loss
Less bloody than tangential excision, but with cosmetic effect defect
Limited use in extremities due to problems of edema distal to the area of excision, presence of avascular fascia and presence of superficial nerves

51. Skin Graft Harvesting
Preferred areas are thighs, buttocks, and abdomen
The only area in which color match between donor and recipient site is of significant concern is the face and neck.  Upper chest and upper back are a good color match for face and neck.

52. Stages of skin graft revascularization/’take’
Imbibition
First hours
A fibrin network forms between the graft and wound bed and binds both layers initially
Survival of graft is dependent on diffusion of nutrients through plasma exudates from the wound bed
Possible barriers between graft and wound bed: hematoma, seroma, pus, non-viable tissue from inadequate excision
Inosculation
48-72 hours
Old capillaries from the wound graft link with vessels on the graft, causing revascularization

53. Stages of skin graft revascularization/’take’
Neovascularization
Direct ingrowth of host vessels into the skin graft
Under ideal conditions, full circulation achieved within 4-7 days
Maturation
Months to 1-2 years
New collagen bridges form between the wound bed and the graft
Reinnervation of graft occurs within 2 months to years

54. Applying Skin Graft
Best to place grafts on the wound at the time of excision 
Since the graft itself controls hemostasis and protects the wound, it makes little sense to wait 24-48hrs until bleeding has stopped
This approach requires an additional procedure and there is a significant risk of the wound bed becoming desiccated or reinfected
Better to have a slight overlap of skin on the wound rather than to leave excised wound uncovered.  Hypertrophic scarring will result and most evident at the edges of the graft, especially if a ridge of open wound is left to heal primarily.

55. Care of the Skin Graft
First graft opening: 3-5th day post op. Open early if suspecting infection
Remove bulky dressing slowly, not disturbing any graft using copious amounts of sterile water
Graft uptake: Pinkish color of graft with adherence to skin bed

56. Wash area gently with betadine soap and rinse with water
Wash area gently with betadine soap and rinse with water. Dress graft with bulky wet dressing
Staples can be removed at first dressing change
Can be dressed everyday if not infected
If with good take, skin graft can be left open on the 7th post op day.

57. Nutrition
Patients with Burns have a hypermetabolic response, which persist until burns are covered
Curreri’s Formula
Adult (25 x kg) + (40 x %BSA Burn)
Children (60 x kg) +(35 x %BSA Burn)
Rough Guide: 2,500 cal/d in adults, proteins= 2g/kgBW
At Burn Unit, 6 egg whites/day
Carbs = 60%, fats = rest
Give Vit C and Zinc Supplements

58. Complications Sepsis ARDS Contractures
Most common cause of death in burns
Suspect in the presence of: fever, hypotension, conversion from PT to FT burns, ecthyma gangrenosum
Start antibiotics
ARDS
Setting of electrical/Inhalational/pulmonary injury
Progressive hypoxemia unresponsive to inc FiO2
Xrays may be normal in early phase
Manage with intubation: 100% FiO2
Contractures
Prevented with proper posture and splinting, coordinate with Rehab

59. Pain Control Meperidine 50mg IV q6 Nalbuphine q4
Narcotics are not given IM since absorption is erratic

60. Criteria for Discharge
No existing complications of thermal injury such as inhalational injury
Fluid resuscitation completed
Adequate pain tolerance
Adequate nutritional intake
No anticipated septic complications

61. Thank You! 