1. THE BURN MANUAL Montarde, Maybelle Omana, James Pantig, Francesca Mae
Pastoral, Avigail Martha

2. Diagnosis and Management of Acute Burns
Initial/Resuscitative Period
Definitive Management Period
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 Resuscitative Period

4. Assessment of a burn injury
1. Complete history
2. 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 loner 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: 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 meals, plastic, glass or hot coals; usually limited in extent but very deep
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 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
Electrical burns: injury from electrical current classified as high voltage or low voltage

6. 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
The 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.

7. 4. Assess the burn depth
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
are red and painful with no blisters
Ex: sunburn

8. Partial Thickness Burns
Second degree burns
Extends to the dermis but not through the full thickness of the skin
Heals from epithelialization from the epidermal elements surviving
(+) 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

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

10. 5. Check for other injuries/medical problems
Play a role in the origin of burn and will have to be integrated in the management of burn

11. 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 <2years with minor injury
Patients <10years with major injury
INVOLVEMENT OF HANDS, FACE, FEET and PERINEUM
(-)
Moderate injury involvement
ELECTRICAL INJURY
(+)
CHEMICAL INJURY
Inhalational Injury
Not suspected
Major Associated medical Illness
Associated fractures, multiple trauma

12. Criteria for Admission to the Burn Unit
Acute burn patients with moderate & major injuries
Acute burn patients < 2 years old 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
Patients with massive exfoliative disease, such as:
Toxic Epidermal Necrosis (TENS)
Steven Johnson Syndrome (SJS)
Staphylococcal Scalded Skin Syndrome (SSSS)

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

14. Initial ER Management: MINOR Burns
Cool wound with tap water
Administer tetanus prophylaxis
Clean wound with soap & water, or with betadine scrub
Debride dead tissue
Small blister -> leave for 2-3 days
Big blister -> aspirate

15. Initial ER Management: MINOR Burns
Apply bland ointment (i.e., Bacitracin, Trimycin, Vaselin) & non-stick porous gauze & 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

16. 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

17. Initial Management: MAJOR & CRITICAL Burns
Intubate if:
With burns 50% BSA
With suspected inhalational injury
With smoke inhalation
Do complete PE, check for other injuries
Insert IV line for fluid resuscitation
Insert foley catheter
Insert NGT. Start IV H2-blockers.

18. 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, TeAna
Check pulses, assess adequacy of chest expansion
Absent pulses or limited chest excursion is a surgical emergency & an indication for escharotomy

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

20. 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.

21. Fluid Resuscitation
Most common cause of mortality in the first 48 hours is inadequate fluid resuscitation
Start as early as possible in the ER and even before other diagnostic exams

22. 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:
½ during the 1st 8 hours
+ maintenance

23. In the presence of increased capillary permeability, colloid content of resuscitation fluid exerts little influence on intravascular retention during the initial hours postburn
Hence, crystalloid fluids are given

24. Fluid Resuscitation: PARKLAND FORMULA
Day 2
Adults / children:
D5W (adults), half normal saline (children) and colloid sufficient to maintain good urine output

25. Fluid Resuscitation
Colloid may be given in the form of plasma albumin or cryoprecipitate
Most protocols start colloid infusion after the first 24 hours (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)

26. Fluid Resuscitation Regulate fluids to maintain adequate urine output
Adults: 0.5 mL/kg BW/hr
Children: 1.0 mL.kg BW/hr
Excessive urine volumes signify overcorrection and run the risk of fluid overload; smaller volumes signify inadequate resuscitation
Urine output monitoring should be done strictly every hour

27. Fluid Resuscitation For electrical injuries:
Adjust fluid volume to maintain UO of mL/hr
Mannitol g may be infused to promote diuresis

28. Fluid Resuscitation
If UO and pigment clearing do not respond to fluid resuscitation, 12.5g cosmetic diuretic mannitol may be added to each liter of resuscitation fluid
NaHCO3 can be added to maintain a slightly alkaline urine

29. 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, making sure to visualize all affected areas. Reassess depth and %BSA of burn wounds
Wash with betadine soap, rinse with sterile water
Dress

30. Wound Dressing Silver Sulfadiazine (Flammazine, Silvadene, Silversurf)
For full thickness burns, applied as sandwich dressing
Changed once or twice a day
By itself retards wound healing
May cause transient leucopenia

31. Wound Dressing Silver Sulfadiazine (Flammazine, Silvadene, Silversurf)
Mech of action: silver ion bings with the DNA of the organism and release sulphonamide which interferes with the metabolic pathway of the microbe
Effective against: Pseudomonas aerugenosa, enterics, Staph aureus, Klebsiella sp

32. Wound Dressing Silver Sulfadiazine + Cerium nitrate (Flammacerium)
Topical antimicrobial
Applied in cases wherein early excision-grafting cannot be done (mass burn, extensive burns)
When combined with burned skin, forms a pliable leathery layer acting as a protective barrier against contamination
Reduces mortality by neutralizing a toxin present in burned skin

33. Wound Dressing Silver Sulfadiazinen+ Cerium nitrate (Flammacerium)
Mechanism of action:
Cerium induces calcification of the dermal collagen remaining in the wound which produces the typical tanned, leathery crust

34. Wound Dressing Silver Nitrate 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)

35. Wound Dressing Silver Nitrate
Bacteriostatic for S. aureus, E. Coli, P. aerugenosa
Does not injure regenerating epithelium in the wound
Caution with children as it tends to leach out electrolytes (Na, Cl)

36. Wound Dressing Daikin’s Solution Sodium hypochlorite 0.025% solution:
15 mL sodium hypochlorite (Zonrox) +
935 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

37. Monitoring
At the ER:
Check vital signs, urine output, consciousness, pulmonary status hourly
Hgb, typing, Na, Cl, BUN, Crea, RBS
CXR and ABG for those suspicious for inhalational injury
ECG, urine Hgb and myoglobin for electrical burns

38. 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

39. 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

40. 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

41. 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

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

43. Excision and Grafting

44. Early excision – done within 7 days
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
When the wound is not yet colonized by microorganisms, reducing the chances of infection and promoting good graft take

45. 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

46. 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

47. Tangential Excision
The principle is to excise the wound in thin layers using a blade held at very acute angle with the skin surface
The goal is to remove non viable tissue leaving as much dermis as possible which is an excellent surface for grafting

48. 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 in the area distal to the excision, the presence of avascular fascia and presence of nerves of superficial locations

49. 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.

50. Applying Skin Graft
It is 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 to 48 hours until bleeding has stopped
This approach requires an additional procedure and there is a significant risk of the wound bed becoming desiccated or reinfected
It is 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.

51. Care of Skin Graft
First opening could be as early as 3rd post op day or as late as 5th post op day. Open early if the skin graft is suspected to be infected as when it as foul-smelling odor
Remove the bulky dressing slowly. Take care not to disturb the skin graft. Use copious amounts of water. Skin graft take is indicated by pinkish color of graft and adherence to graft bed. Gently wash the area with betadine soap and rinse with water. Dress graft with bulky wet dressing

52. Care of Skin Graft Staples can be removed at the 1st dressing change
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 could be cleansed by mercurochrome

53. Nutrition Patients with Burns have a hypermetabolic response
Curreri’s Formula
Adult (25 x kg) + (40 x %BSA Burn)
Children (60 x kg) +(35 x %BSA Burn)
Rough Guide: 2,500 cal/day in adults, proteins at 2g/kgBW
At Burn Unit, 6 eggs/day
Give Vit C and Zinc Supplements

54. Complications Sepsis ARDS Contractures
Most common cause of death in burns
ARDS
Electrical/Inhalational/pulmonary injury
Contractures
Prevented with proper posture and splinting

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

56. 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

57. END.