Burn

Dr. Shukri
 Burn
• Burns frequently affect children and young adults.
• In children less than 8 years of age, the most
common burns are scalds, usually from the spilling of
hot liquids.
• In older children and adults, the most common burns
are flame-related, usually the result of:
– House fires,
– The ill-advised use of flammable liquids as
accelerants, or
– are smoking- or alcohol-related.
• Work-related burns
– Chemicals or hot liquids, followed by electricity.
 Etiology
• Cutaneous burns are caused by:
– The application of heat, cold, or caustic chemicals
to the skin.
– When heat is applied to the skin, the depth of
injury is proportional to:
• The temperature applied,
• Duration of contact, and
• Thickness of the skin.
 Cont……
1. Scald Burns
– Scalds, usually from hot water, are the most
common cause of burns in civilian practice.
– Water at 60◦C (140◦F) creates a deep partial-
thickness or full-thickness burn in 3 seconds.
– At 69◦C (156◦F), the same burn occurs in 1 second.
2. Flame burns
– Flame burns are the second most common
mechanism of thermal injury.
– Although the incidence of injuries caused by
house fires has decreased with the use of smoke
detectors.
3. Flash Burns
– Flash burns are next in frequency.
– Explosions of natural gas, propane, butane,
petroleum distillates, alcohols, and other
combustible liquids, and electrical arcs cause
intense heat for a brief time period.
– Clothing, unless it ignites, is protective.
4. Contact Burns
– Contact burns result from contact with hot metals,
plastic, glass, or hot coals.
– They are usually limited in extent, but are
invariably deep.
 Burn Center Referral Criteria
• Injuries as those requiring referral to a burn
center after initial assessment and
stabilization at an emergency department:
– Partial-thickness and full-thickness burns >10%
TBSA in children younger than 10 or older than 50
years of age.
– Partial-thickness and full-thickness burns totaling
greater than 20% TBSA in other age groups.
– Partial-thickness and full-thickness burns involving
the face, hands, feet, genitalia, perineum, or major
joints.
– Full-thickness burns greater than 5 percent TBSA in
any age group.
– Electrical burns, including lightning injury.
– Chemical burns.
– Inhalation injury.
– Burn injury in patients with preexisting medical
disorders that could complicate management,
prolong the recovery period, or affect mortality.
– Any burn with concomitant trauma (e.g.,
fractures) in which the burn injury poses the
greatest risk of morbidity or mortality.
– Burn injury in children admitted to a hospital
without qualified personnel or equipment for
pediatric care.
– Burn injury in patients requiring special social,
emotional, and/or long-term rehabilitative
support, including cases involving suspected child
abuse.
 INITIAL EVALUATION (primary survey)

• Initial evaluation of the burned patient

involves four crucial assessments:
– Airway management
– Evaluation of other injuries,
– Estimation of burn size, and
– Diagnosis of CO and cyanide poisoning.
• With direct thermal injury to the upper airway
or smoke inhalation, rapid and severe airway
edema is a potentially lethal threat.

• Signs of impending respiratory compromise may

include:
– A hoarse voice
– Wheezing, or
– Stridor
• Burned patients should be first considered
trauma patients.
 Concurrently with the primary survey

• Burn larger than 40% total body surface area

(TBSA)
– Large-bore peripheral intravenous (IV) catheters
(2 in number).
– Fluid resuscitation
– If peripheral access cannot be easily
• Central venous access and intraosseous (IO)
• Hypothermia is a common prehospital
complication that contributes to resuscitation
failure.
– Cooling should be avoided in patients with
moderate or large (>20% TBSA) burns.

Rarely, IV resuscitation is indicated in patients with

burns smaller than 15% who can usually hydrate
orally.
• Psychological response
– Anxiety
• Conservative benzodiazepine is recommended.
 EMERGENCY CARE
1. Care at the Scene
• Airway
– Flames or exposed to a smoky fire (suspicion of
smoke inhalation)
• Attention must be directed to the airway.
– Unconscious patient or respiratory distress,
• Endotracheal intubation should be performed by
appropriately trained personnel.
 2. Other Injuries and Transport
• Once an airway is secured, the patient is
assessed for other injuries.
• Emergency medical personnel should place an
intravenous line and begin fluid administration
with lactated Ringer (LR) solution
 3. Cold Application
• Small burns, particularly scalds, may be
treated with immediate application of cool
water.
– cooling reduces skin temperature enough to
prevent further tissue damage.
– Iced water should never be used, even on the
smallest of burns.
 Emergency Room Care
• Airway
• Breathing
• Circulation
ABC protocol must be strictly followed.
a. Emergency Assessment of Inhalation Injury

• History
• Examination
– Inspection of the mouth and pharynx
• Hoarseness and expiratory wheezes are signs of
potentially serious airway edema or inhalation injury.
• Carboxyhemoglobin levels
b. Fluid Resuscitation in the Emergency Room

• As burns approach 20 percent TBSA, local pro-

inflammatory cytokines enter the circulation and
result in a systemic inflammatory response.

• The micro-vascular leak, permitting loss of fluid and

protein from the intravascular compartment into the
extravascular compartment, becomes generalized.
 b. Cont…
• Intravenous LR solution
– Parkland/Baxter formula
• Foley catheter placed and urine output
monitored hourly.
– 30 mL/h in adults and 1.0 mL/kg per hour in young
children.
• Tetanus prophylaxis
• Gastric decompression
– NGT
• Pain control
– Intravenous, intramuscular or subcutaneous
• Psychosocial care
– The patient and family must be comforted and
given a realistic assessment regarding the
prognosis of the burns.
 Care of the Burn Wound
• After all other assessments have been completed,
attention should be directed to the burn itself.
• Escharotomy
– Thoracic escharotomy.
• The adequacy of oxygenation and ventilation must be
monitored continuously throughout the resuscitation
period.
• Ventilation compromised
– Due to deep circumferential burn
» Increase arterial PCO2 and requires ventilation
increase
 Escharotomy of the extremities

• circumferential burn on an extremity

– Produce significant vascular compromise
• unrecognized and untreated
permenant and serious neuromuscular and
vascular deficits
• Circumferential burn
– Monitor closely
• Skin color, sensation, capillary refill, and
peripheral pulses must be assessed hourly.
Escharotomy
– cyanosis, deep tissue pain, progressive
paresthesia, progressive decrease or absence of
pulses, or the sensation of cold extremities.
– Escharotomies may be done as bedside
procedures with a sterile field and scalpel or
electrocautery.
– Local anesthesia is unnecessary as full-thickness
eschar is insensate
• Digital escharotomy is controversial in its
efficacy and rarely required.
 BURN SEVERITY

• The severity of any burn injury is related to the size

and depth of the burn.
– Burns are the only truly quantifiable form of
trauma.

Treatment plans, including initial resuscitation and

subsequent nutritional requirements, are directly
related to the size of burn.
 Burn Size
• Rule of nines
– Each upper extremity accounts for 9% of the TBSA.
– Each lower extremity accounts for 18%
– The anterior and posterior trunk each account for
18%
– The head and neck account for 9%
– The perineum accounts for 1%.
For smaller burns, an accurate assessment of size can
be made by using the patient’s palmar hand surface,
including the digits, which amounts to approximately
1% of TBSA.
 Burn Depth
• Determinants of mortality:
– Burn size
– Patient age
– Depth of the burn

Burn depth is also the primary determinant of

the patient’s long-term appearance and
functional outcome.
• Burns heal within 3weeks
– Heal without hypertrophic scar or functional
impairment
• Burns heal longer than 3 weeks
– Produce unsightly hypertrophic scars, functional
impairment, and provide only a thin, fragile
epithelial covering for many weeks or months.
– Early excision and grafting is the choice
 Burn classification

• According to depth:
– First degree
• Epidermal
– Second degree
• Superficial and deep partial thickness
– Third degree
• Full-thickness
– Fourth degree
• All layers of the skin, subcutaneous fat and
deeper structures
 Other classification
1. Shallow burns
– Epidermal burns (first-degree).
– Superficial partial-thickness (second-degree).
2. Deep burns
– Deep partial-thickness (second-degree).
– Full-thickness (third-degree).
– Fourth-degree
• Second degree
1. Superficial partial-thickness
• Upper layers of dermis, and characteristically
form blisters with fluid collection at the interface
of the epidermis and dermis.
• Blisters removed
– The wound is pink and wet
• Heals within 3 weeks
• Rarely cause hypertrophic scar
2. Deep partial-thickness (second-degree)
– Deep partial-thickness burns extend into the
reticular layers of the dermis.

– They also blister, but the wound surface is usually

a mottled pink-and-white color immediately after
the injury because of the varying blood supply to
the dermis.

– If not excised and grafted, and if infection is

prevented, these burns will heal in 3–9 weeks
 Assessment of Burn Depth
• Standard technique
– Clinical observation of the wound.
 THE PHYSIOLOGIC RESPONSE TO BURN
INJURY
• Systemic inflammatory response syndrome (SIRS)
summarizes that condition.
– The cardiovascular manifestations of SIRS largely
disappear within 24–72 hours.
• The patient remains in a hyper-metabolic state until
wound coverage is achieved.
 Burn shock
• Burn shock is a complex process of circulatory
and microcirculatory dysfunction that is not
easily or fully repaired by fluid resuscitation.
 FLUID MANAGEMENT
• Proper fluid management is critical to survival
following major thermal injury.
– An aggressive approach to fluid therapy has led to
reduced mortality rates in the first 48 hours
postburn.
• 50% of deaths occur
– Within first 10days after burn
• Multiple organ failure syndrome (due to
inadequate fluid resuscitation and maintenance
 Burn Resuscitation

• First 24–48 hours after injury.

• Maintain end-organ perfusion
 Resuscitation
• Parkland or Baxter formula:
– 4 ml/kg per % burn of Lactated Ringer’s
• Half in the first 8 hours
• The remaining half is given over the subsequent
16 hours.
• Continuation of fluid volumes should depend
on:
– The time since injury
– Urine output, and
– Mean arterial pressure (MAP).
• Target of 60 mmHg in critically ill patient.
 Other adjuncts are being increasingly used
during initial burn resuscitation.
• High-dose ascorbic acid (vitamin C)
– May decrease fluid volume requirements and
ameliorate respiratory embarrassment during
resuscitation.
• Plasmapheresis
– Decreased fluid requirements and increased urine
output in patients who require higher resuscitative
volumes
 Special Considerations in Burn Shock
Resuscitation
• Pediatric fluid resuscitation.
– children require relatively more fluid for burn
shock resuscitation than adults, with fluid
requirements for children averaging approximately
6 mL/kg/ % TBSA.
– Urine output (1.0–1.5 mL/kg body weight per h)
required to ensure adequate end-organ perfusion
in children.
– Commonly require formal resuscitation for
relatively small burns of 10–20 percent TBSA.
 Cont……
• Inhalation injury.
– Inhalation injury undoubtedly increases the fluid
requirements for successful resuscitation following
thermal injury.
• 1.5 times compared to patients without inhalation
injury.
 INHALATION INJURY
• Mortality for inhalation injury has been
reported to be as high as 25%, with this
increasing to 50% in patients with ≥20% TBSA
burns.
• Pneumonia rate in patients with inhalation
injury has been reported to be three times
higher than those without inhalation injury.
• Pneumonia has been associated with:
– Increased length of stay
– Increased ventilator days, and
– Need for tracheostomy
– Subsequent development of the adult respiratory
distress syndrome (ARDS) is common

The combination of burns, inhalation injury, and pneumonia

increases mortality by up to 60% over burns alone.
• When ARDS complicates burns and inhalation
injury, mortality approaches 66%.
 Smoke inhalation
• Causes injury in two ways:
– Direct heat injury to the upper airways
– Inhalation of combustion products into the lower
airways.
• Direct injury to the upper airway causes
airway swelling that typically leads to maximal
edema in the first 24 to 48 hours after injury
and often requires a short course of
endotracheal intubation for airway
protection.
• Combustion products found in smoke, most
commonly from synthetic substances in
structural fires, cause lower airway injury.
• These irritants cause:
– Direct mucosal injury, which in turn leads to
mucosal sloughing, edema, reactive
bronchoconstriction, and finally obstruction of the
lower airways.
 Carbon monoxide
(CO) poisoning.
• This clear, odorless gas has an affinity for
hemoglobin is approximately 200 to 250 times
more than that of oxygen.

• Carboxyhemoglobin decreases the levels of

normal oxygenated hemoglobin and can
quickly lead to anoxia and death.
• Unexpected neurologic or cardiac symptoms
should raise the level of suspicion, and an
arterial carboxyhemoglobin level must be
obtained because pulse oximetry can be
falsely elevated.
 CO poisoning therapy
• Gold standard:
– Administration of 100% oxygen.
• To reduce the half life of CO from 250 minutes
in room air to 40 to 60 minutes.
 TREATMENT OF THE BURN WOUND

• Silver sulfadiazine is one of the most widely

used in clinical practice.
– Silver sulfadiazine has a reputation for causing
neutropenia, but this association is more likely
due to neutrophil margination from the
inflammatory response following burn injury.
• Mafenide acetate (cream or solution)
– Is an effective topical antimicrobial
• Used in both treating and preventing wound
infection
• Silver nitrate
– Has broad-spectrum antimicrobial activity as a
topical solution.
 NUTRITION
• The hypermetabolic response in burn injury
may raise baseline metabolic rates by as much
as 200%.
– This can lead to catabolism of muscle proteins and
decreased lean body mass that may delay
functional recovery.
• Early enteral feeding for patients with burns
>20% TBSA is:
– Safe
– May reduce loss of lean body mass
– Slow the hypermetabolic response
 SURGERY
• Full-thickness burns with a rigid eschar can
form a tourniquet.
– Leading to compromised venous outflow and
eventually arterial inflow.
• Resulting compartment syndrome
– Circumferential extremity, abdominal and
thoraxic burns
• Warning signs of impending compartment
syndrome may include:
– Paresthesias
– Pain
– Decreased capillary refill, and
– Progression to loss of distal pulses
• Abdominal compartment syndrome should be
suspected with:
– Decreased urine output
– Increased ventilator airway pressures, and
– Hypotension.
• Thoracic compartment syndrome:
– Hypoventilation
– Increased airway pressures, and
– Hypotension
• Escharotomies
– Rarely needed within the first 8 hours.
• should not be performed unless indicated
because of the terrible aesthetic sequelae.
– Performed at bedside.
 Grafting
• Burn excision and wound coverage should
ideally start within the first several days.

• In larger burns, serial excisions can be

performed as patient condition allows.
 Grafting cont….
• Full thickness burns
– Split thickness skin graft
• Meshed
– Provides larger area off wound coverage
– Allow drainage
• Non-meshed
– ensure optimal appearance and function
» Areas of cosmetic importance such as the face,
neck, and hands should be grafted with
nonmeshed.
• Non-meshed
• Full thickness graft
• Flap