Burn Management

Mohamed Ahmed SayedAssistant Lecturer of Plastic and Reconstructive Surgery

Ain Shams University – Faculty of Medicine

dr_mohamed_a@yahoo.comhttp://www.geocities.com/dr_mohamed_a

• Burn wounds occur when there is contact between tissue and an energy source, such as heat, chemicals, electrical current, or radiation.

• The effects of the burn are influenced by the:intensity of the energyduration of exposuretype of tissue injured

Where do most burns occur?

• 0 - 4 years, from kitchen, bathroom.

• 5-74 years, outdoors, kitchen.

• Teenagers, suicide (females).

• > 75 years, kitchen, outdoors.

When do most burns occur?• Winter more than summer

Major cause of fires in the home

• Carelessness with cigarettes!!

• Hot water from water heaters set at high levels above 60° C

• Cooking accidents

• Space heaters

• Gasoline, lighter fluids, etc.

• Chemicals

Types of Burn Injury• Thermal burns: flame, flash, contact with hot objects.

• Scald burns: hot fluids.

• Chemical burns: necrotizing substances (acids, alkali).

• Electrical burns: intense heat from an electrical current

• Smoke & inhalation injury: inhaling hot air or noxious chemicals

• Cold thermal injury: frostbite.

Thermal Burns

Scald Burns

Chemical Burn

examples: cleaning agents...

Remember….

• Tissue destruction may continue for up to 72 hours.• It is important to remove the person from the burning

agent or vice versa.• The latter is accomplished by lavaging the affected area

with copious amounts of water.

Smoke and Inhalation Injury• Can damage the tissues of the

respiratory tract

• Although damage to the respiratory mucosa can occur, it seldom happens because the vocal cords and glottis closes as a protective mechanisms.

Electrical Burns

Electrical Burns• Injury from electrical burns results from coagulation

necrosis that is caused by intense heat generated from an electric current.

• The severity depends on:amount of voltagetissue resistancecurrent pathwayssurface area in contact with the currentlength of time the current flow.

Electrical injury can cause:• Fractures of long bones and vertebra

• Cardiac arrest or arrhythmias--can be delayed 24-48 hours after injury

• Severe metabolic acidosis--can develop in minutes

• Myoglobinuria--acute renal tubular necrosis.

Treatment of electrical burns…

• Fluids--Ringers lactate or other fluids-flushes out kidneys--you want 75-100 cc/hr until urine sample clear

• an osmotic diuretic (Mannitol) may be given to maintain urine output

Cold Thermal Injury (Frostbite)

Classification of Burn Injury

Severity is determined by:– depth of burn– extend of burn calculated in percent of total body

surface (TBSA)– location of burn– patient risk factors

Depth of BurnsMedicolegal classification clinical classification

Erythema

Super.

Dermal

Deep

Dermal

Full

Thickness

1st

2nd

3rd

Extend of BurnsLund-Browder Chart Rule of Nines

Age in years 0 1 5 10 15 Adult

A-head (back or front) 9½ 8½ 6½ 5½ 4½ 3½

B-1 thigh (back or front) 2¾ 3¼ 4 4¼ 4½ 4¾

C-1 leg (back or front) 2½ 2½ 2¾ 3 3¼ 3½

Location of Burns

• Vital organs of burn:• Face, neck • Chest • Perineum• Hand• Joint regions• Other areas

Patient risk factors

• Associated trauma

• Inhalation injuries

• Circumferential burns

• Electricity

• Age (young or old)

• Pre-existing disease

• Abuse

3 Phases of Burn Management

–emergent (resuscitative)

–acute

–rehabilitative

Pre-hospital Care• Remove from area! Stop the burn!

• If thermal burn is large--FOCUS on the ABC’sA=airway-check for patency, soot around

nares, or signed nasal hair

B=breathing- check for adequacy of ventilation

C=circulation-check for presence and regularity of pulses

Other precautions...

• Burn too large--don’t immerse in water due to extensive heat loss

• Never pack in ice

• Pt. should be wrapped in dry clean material to decrease contamination of wound and increase warmth

Emergent Phase (Resuscitative Phase)

• Lasts from onset to 5 or more days but usually lasts 24-48 hours

• begins with fluid loss and edema formation and continues until fluid motorization and diuresis begins

• Greatest initial threat is hypovolemic shock to a major burn patient!

Management in the emergent phase is...

• Airway management-early nasotracheal or endotracheal intubation before airway is actually compromised (usually 1-2 hours after burn)

• ventilator? ABGs? Escharotomies?• 6-12 hours later: Bronchoscopy to assess lower respiratory

tact• chest physiotherapy, suction

Complications during emergent phase of burn injury are 3 major organ systems...

–Cardiovascular

–Respiratory

–Renal systems

Fluid Therapy• 1 or 2 large bore IV lines• Fluid replacement based on:

– size/depth of burn– age of pt.– individualized considerations.

• options- RL, D5NS, dextam, albumin, etc.• there are formula’s for replacement:

– Parkland formula – Brooke formula

Assessment of adequacy of fluid replacement• Urine output is most commonly used

parameter

• Urine osmolarity is the most accurate parameter

• UOP= 30-50 ml/hr in an adult

Wound care• Escharotomy / Fasciotomy• Escharectomy + homograft• Dressing / hydrotherapy• Debridement

• Application of autograft• Splinting

• PB contractures management

Wound Care continued...• Staff should wear disposable hats, gowns,

gloves, masks when wounds are exposed• appropriate use of sterile vs. nonsterile

techniques• keep room warm• careful handwashing• any bathing areas disinfected before and after

bathing

Other care measures include

• Face– eye – ear

• Hands & arms

• Perineum

• Physiotherapy

Drug Therapy

• Analgesics and Sedatives

• Tetanus immunization• Antimicrobial agents: Silver sulfadiazine

Nutritional Therapy• Burn patients need more calories & failure

to provide will lead to delayed wound healing and malnutrition.

Clinical Manifestations• Burn wound either heals by primary

intention or by grafting.• Scars may form & contractures.• Mature healing is reached in 6

months to 2 years • Avoid direct sunlight for 1 year on

burn • new skin sensitive to trauma

Care of B U R N SB -B - breathing

UU - urine output

RR - rule of nines

resuscitation of fluid

N -N - nutrition

S S - shock

silvadene

Referral Criteria

• 2nd or 3rd Degree Burns

• >10% TBSA

• Burns to vital organs of burn

• circumfrential burns

• Electrical Burns

• Chemical Burns

• Inhalation Injury

Referral Criteria

• Concomitant trauma (If Major Trauma, The Trauma Center , Not the Burn Center should be the initial stabilizing unit)

• When in doubt , consult with a burn center

Questions?