MANAGEMENT OF A BURN PATIENTDr sumer yadav

Aim of burn care

• Rescue• Resuscitate• Refer• Resurface

• Rehabilitate• Reconstruct• Review

Principles of BURN MANAGEMENT

• Airway management-quick and appropriate• Prompt and accurate fluid resuscitation• Removal of dead burnt skin and replacement

with homograft(cadaveric skin from SKIN BANK) or biologic skin substitutes

• Appropriate adequate nutrition• Good chest PT• Replacement of homograft with autograft or

cultured skin(cultured keratinocytes)

Which burn patients need HOSPITALISATION?

• We go by the AMERICAN BURN ASSOCIATION GUIDELINES

Management of the Patient With a Burn Injury

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• Burn care must be planned according to the burn depth and local response, the extent of the injury, and the presence of a systemic response.

• Burn care then proceeds through three phases: – Emergent/resuscitative phase (on-the-scene care),– Acute/intermediate phase, and– Rehabilitation phase.

• Although priorities exist for each of the phases, the phases overlap, and assessment and management of specific problems and complications are not limited to these phases but take place throughout burn care.

Table: phases of burn care

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Phase Duration Priorities

Emergent or immediateresuscitative

From onset of injury to completionof fluid resuscitation

First aid Prevention of shock Prevention of respiratory distress Detection and treatment of concomitant

injuries Wound assessment and initial care

Acute From beginning of diuresis to nearcompletion of wound closure

Wound care and closure Prevention or treatment of

complications, including infection Nutritional support

Rehabilitation

From major wound closure to returnto individual’s optimal level of physicaland psychosocial adjustment

Prevention of scars and contractures Physical, occupational, and vocational

rehabilitation Functional and cosmetic reconstruction Psychosocial counseling

INTENSIVE BURN CARE UNIT(IBCU)

INTENSIVE BURNS CARE UNIT(IBCU)

LEVELS OF ICU CARE • Level - I – provides

monitoring, observation and short term ventilation.

• Level - II – Provides Observation, Monitoring & Long Term Ventilation With Resident Doctors.

• Level - III – provides all aspects of intensive care including invasive haemo dynamic monitoring & dialysis.

History

• Type of burn:– Flame (open flame, closed space)

– Chemical (type of chemical)

– Scald (type of liquid)

– Electrical (voltage, arcing/flame, contact time)

A: AirwayHistory & Physical: Inhalational injury

• Fire in a closed space.• Full-thickness/ deep

chemical burns to face, neck.

• Singed nasal hair.• Carbonaceous sputum.• Carbonaceous particles in

oropharynx.

A: Airway

• Burned airways swell rapidly.

• Intubate patient as early as possible before airway swelling.

A: Airway

• Indications for intubation:– Oropharyngeal erythema/ swelling on direct

visualization.

– Change in voice, harsh cough.

– Stridor.

– Dyspnea, tachypnea.

B: Breathing

• Circumferential full-thickness burns may impair ventilation.

• Blast injuries can cause pneumothorax, lung contusions.

• Noxious chemical (plastic) can cause a chemical pneumonitis.

• Carbon monoxide poisoning (if COHb > 15-40% ventilate).

C: Circulation

• BP, HR, color of unburnt skin• 2 large bore I.V.s in unburnt skin• Draw bloodwork.• Insert urinary catheter.• Insert nasogastric tube, if necessary • Doppler exam of circumferentially burnt

extremities

ASSESSMENT OF BURNS

• TBSA(Total body surface area)• Decides fluid requirements and nutritional needs• Wallace’s rule of nines• Lund and Browder chart

• DEPTH• Dictates local and surgical wound management

Management of fluid loss and shock

Fluid Replacement Therapy: • The total volume and rate of intravenous fluid

replacement are gauged by the patient’s response. • The adequacy of fluid resuscitation is determined

by:– Output totals of 30 to 50 mL/hour – systolic blood pressure exceeding 100 mm Hg

and/or – pulse rate less than 110/minute.

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Assessing adequacy of resuscitation

• Peripheral blood pressure: may be difficult to obtain – often misleading

• Urine Output: Best indicator unless ARF occurs

• CVP: Better indicator of fluid status

• Heart rate: Valuable in early post burn period – should be around 120/min.

• > HR indicates need for > fluids or pain control

• Invasive cardiac monitoring: Indicated in a minority of patients (elderly or pre-existing cardiac disease)

Conditions Leading to Burn Shock

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Management of fluid loss and shock

Fluid Requirements: • The projected fluid requirements for the first 24

hours are calculated by the clinician based on the extent of the burn injury.

• Some combination of fluid categories may be used: – Colloids (whole blood, plasma, and plasma

expanders) and– Crystalloids/electrolytes (physiologic sodium

chloride or lactated Ringer’s solution). 22

Management of fluid loss and shock

Fluid Requirements:

• Adequate fluid resuscitation results in slightly decreased blood volume levels during the first 24 post-burn hours and restores plasma levels to normal by the end of 48 hours.

• Oral resuscitation can be successful in adults with less than 20% TBSA and children with less than 10% to 15% TBSA.

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Fluid resuscitation

• Lactated Ringers - preferred solution

• Contains Na+ - restoration of Na+ loss is essential

• Free of glucose – high levels of circulating stress hormones may cause glucose intolerance

Guidelines and Formulas for Fluid Replacement in Burn Patients

Consensus Formula• Lactated Ringer’s solution (or other balanced

saline solution): 2–4 mL× kg body weight × % total body surface area (TBSA) burned.

• Half to be given in first 8 hours; remaining half to be given over next 16 hours.

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Guidelines and Formulas for Fluid Replacement in Burn Patients

• The following example illustrates use of the formula in a management of a 70-kg patient with a 50% TBSA burn:

• Steps – 1, Consensus formula: 2 to 4 mL/kg/% TBSA– 2, 2 × 70 × 50 = 7,000 mL/24 hours– 3, Plan to administer: First 8 hours = 3,500

mL, or 437 mL/ hour; next 16 hours = 3,500 mL, or 219 mL/hour

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Guidelines and Formulas for Fluid Replacement in Burn Patients

Evans Formula• 1. Colloids: 1 mL × kg body weight × % TBSA burned• 2. Electrolytes (saline): 1 mL × body weight × % TBSA burned• 3. Glucose (5% in water): 2,000 mL for insensible loss• Day 1: Half to be given in first 8 hours; remaining half over next 16

hours• Day 2: Half of previous day’s colloids and electrolytes; all of

insensible fluid replacement• Maximum of 10,000 mL over 24 hours. Second- and third-degree• (partial- and full-thickness) burns exceeding 50% TBSA are calculated• on the basis of 50% TBSA.

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Guidelines and Formulas for Fluid Replacement in Burn Patients

Brooke Army Formula• 1. Colloids: 0.5 mL × kg body weight × % TBSA

burned• 2. Electrolytes (lactated Ringer’s solution): 1.5 mL

× kg body weight × % TBSA burned• 3. Glucose (5% in water): 2,000 mL for insensible

loss

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Guidelines and Formulas for Fluid Replacement in Burn Patients

Parkland/Baxter Formula• Lactated Ringer’s solution: 4 mL × kg body

weight × % TBSA burned• Day 1: Half to be given in first 8 hours; half to

be given over next16 hours• Day 2: Varies. Colloid is added.

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Guidelines and Formulas for Fluid Replacement in Burn Patients

Hypertonic Saline Solution• Concentrated solutions of sodium chloride (NaCl) and

lactate with concentration of 250–300 mEq of sodium per liter, administered at a rate sufficient to maintain a desired volume of urinary output.

• Do not increase the infusion rate during the first 8 post burn hours.

• Serum sodium levels must be monitored closely. • Goal: Increase serum sodium level and osmolality to

reduce edema and prevent pulmonary complications.30

Pediatric Fluid resuscitation

• Use Parkland formula + MAINTENANCE fluid• For maintenance fluid, hourly rate of

4 mL/kg for first 10 kg of body weight plus2 mL/kg for second 10 kg of body weight plus1 mL/kg for >20 kg of body weight

• End point: urine output of 1.0-1.5 mL/kg/hr• Maintenance fluid given is D5W/ iso-p (child’s liver

not fully matured- limited glycogen stores).

Fluid resuscitation

• Need to replace losses to maintain homeostasis.• Formulas are ONLY GUIDELINES.• Monitor physiologic parameters.• Maintain adequate tissue perfusion to prevent

increase in depth of burn.• Too little fluid Hypotension renal failure, etc.► ►• Too much fluid Edema Tissue hypoxia► ►

Fluid resuscitation

• Fluid resuscitation should be started when– >15% TBSA burns in an adult– >10% TBSA in children and elderly

• First 8-12 hrs: intravascular volume shifts to interstitial space.

• Fast fluid boluses are of no benefit.• Colloids: Questionable in first 24 hrs (capillary

leakage)

Fluid Management

• Start with RL in adults and Isolyte P in children• After 24 hrs start DNS• If not adequate urine output in 12 hrs start

colloids FFP• More fluids required in Electric Burns and

Inhalation Injury • Always central line (sometimes even thro burnt

tissue) for initial resuscitation

Electrical injury resuscitation

• Fluid needs greater

• 9 mL x TBSA burn (%) x body weight (kg) in first 24 hrs

• If myoglobinuria, may require bicarbonate infusion to alkalinize urine to pH > 8

• End point: urine output of 1.5-2 mL/kg/hr

Electrolyte Abnormalities

• HYPOKALEMIA- seen more often than Hyperkalemia

• Commonest cause of non infective paralytic ileus

• Serum K <3mEq/l KCl at 10mEq/hr• Serum K <2mEq/l KCl at 40mEq/hr• Daily Ser Electrolytes in first 3 days

Electrolyte Abnormalities• HYPOCALCEMIA-most commonly due to

Hypoalbuminemia• Lowering of Ser Albumin by 1g/ml lowers Ser

Calcium by 1g/ml• Alkalosis also lowers Ser Ca by increasing

protein binding• Correction required only if symptomatic • Associated Hypomagnesemia needs

simultaneous correction to prevent tetany and arrhythmias

Reducing the HYPERMETABOLIC RESPONSE

• Temperature regulation• Nutrition• Pharamacological manipulation-Propranolol

40 mg BD and Oxandrolone 5mg BD• Early excision and homografting

Effects of hypothermia

• Hypothermia may lead to acidosis/coagulopathy

• Hypothermia causes peripheral vasoconstriction and impairs oxygen delivery to the tissues

• Metabolism changes from aerobic to anaerobic

serum lactate serum pH

Prevention of hypothermia

• Cover patients with a dry sheet – keep head covered

• Pre-warm trauma room • Administer warmed IV

solutions• Avoid application of saline-

soaked dressings• Avoid prolonged irrigation

• Remove wet / bloody clothing and sheets

• Paralytics – unable to shiver and generate heat

• Avoid application of antimicrobial creams

• Continual monitoring of core temperature via foley or SCG temperature probe

Role of LMWH

• Incidence of Deep Vein Thrombosis is significant enough to warrant routine use of LMWH

• Incidence of Pulmonary embolism is reduced significantly

• Daltaparin or Enoxiparin• Fragmin or Clexane• This is stopped once patient is mobile

INTRAABDOMINAL HYPERTENSIONand

INTRAABDOMINAL COMPARTMENT SYDROME

Abd compartment syndrome-LAPAROTOMY

Nutrition

• Aggressive nutritional support to counterbalance the effect of Hypermetabolism and Protein catabolism following Burns

• ENTERAL feeding is preferred over PARENTERAL feeding

Nutritional support

• Calorie : Nitrogen = 100 : 1 • Protein requirement

– Adult: 2g/ kg/ day– Child: 3g/ kg/ day

• Fat emulsion– 4g/ kg/ day max.

• Carbohydrate (glucose)– 6.2mg/ kg/ min. max.

Nutritional support

• Burns patient is hypercatabolic – up to 150- 200% above baseline.

• Nutrition needed for burns >20% TBSA.• Curreri formula

– Adult: 25kcal/kg/day + 40kcal/ % TBSA burn– Child: 60kcal/kg/day + 35kcal/ % TBSA burn

NUTRITION• Burn patient caloric requirement 3000-

5000calories per day

• Early feeding• Nasogastric tube No 10• Hourly tube feeding

Butter milk diet 1cal/cc Eggs 4 Bananas 4 Sugar 4Tbs Curd 1 litre

BUTTERMILK DIET(BMD)

• Eggs- 4 /Protein powders(Whey protein or Soya protein)

• Bananas- 4• Sugar- 4 Tbsf• Curds (Yoghurt) -1000cc• Mixed with water to

1600cc

Antibiotic Protocol

• FRESH BURN• Start with a 3rd gen Cephalosporin with an

aminoglycoside

• INFECTED OLD BURN• Start with a semisynthetic Penecillin like Pipra

and Tazobactum or a Carbapenem

• LATER go by wound swabs culture and sensitivity

Pain Management

• Continuous infusion round the clock of Tramadol 100mg Ketamine 100mg Midazolam 10mg• In a 50cc syringe in a syringe pump• Resting Pain-At 4-6cc per hour to start and then

titrate with pain response• Procedural Pain-During dressing 30-40cc per hour

and titrate

Chest Physiotherapy

Limb Physiotherapy

Initial burn wound management

• Early transfer to burn centre (within first 24 hours):– Remove smoldering, non-adherent clothes.– No debridement or topical agents needed.– Clean, dry sheets, – Wet dressing cause heat loss.

• If transfer is delayed > 24 hours:– Unroof blisters >2 cm, cleanse with chlorhexidine– Silver sulfadiazine cream OD or Povidone Iodine solution

and Vaseline gauze

Procedures

• Tracheostomy

• Central line insertion

• Escharotomy

• Debridement.

Dr. Sunil Keswani, National Burns Centre, www.burns-

india.com, nbcairoli@gmail.com

Burn wound management

• Circumferential extremity burns:– Edema under eschar– Remove all rings, jewelry– Elevate, active motion– Check skin color,

sensation, capillary refill, Doppler pulses q1h

– Rule out hypotension, arterial injury

Burn wound management

• Bedside escharotomy• 3rd degree burns

insensate• Use electrocautery• Mid-medial or mid-

lateral, across joints• Recheck pulses - may

have to do opposite side of limb

Esharotomy-LINES OF INCISION

Fasciotomy• Pain • Pallor-look at capillary refill

time-if less than 2 secs-VENOUS OBSTRUCTION and if more than 5 secs –ARTERIAL OBSTRUCTION

• Pressure• Pulselessnes• Paresthesia• Paralysis• Poikilothermia• Progression

• Compartmental pressures above 25mm Hg warrant a FASCIOTOMY

• There are devices to measure this pressure

• Or use DOPPLER to decide

Fasciotomy In Burns

Fasciotomy-methodology

Leg-FASCIAL COMPARTMENTS

Burn wound managementSpecific anatomical areas:

Face - watch for airway compromise

Eyes - fluorescein exam, copious irrigation, antibiotic ointment,mydriatics

Ears - external canal, TM (children, perf in blast injury)

Genitalia, perineum - insert Foley to stent urethra treat scrotal edema conservatively diverting colostomy NOT automatically indicated in perineal

burns

SURGICAL TECHNIQUES-ACUTE BURNS

EARLY EXCISION

Tangential excision and grafting-within first 72 hrs

Cadaveric skin from SKIN BANK

DELAYED EXCISION

Fascial excision and grafting-after 72hrsCadaveric skin from SKIN BANK

Early excision Vs Delayed excision

• Always early excision if patient comes early enough and facilities exist

• Early enough is upto 72 hrs postburn• Early excision decreases the chances of Sepsis

and facilitates early moblisation and better and more predictable functional recovery.

• Delayed excision is generally at 3 weeks or later

Early Excision

• Within the first 3-5days• After 5 days chances of Sepsis higher and

bleeding more• 15% of BSA is excised at a time• Coverage of excised area by Meshed

Homograft is mandatory

Order of excision

• Areas easy and quick to excise: trunk and legs

• Joints and throats• Hands and face

Early Excision

• Blood Loss– Clear pre-operative plan– Excision prior to wound hyperemia– Elevation of extremities– Tourniquet control– Dilute Epinephrine tumescent fluid– Epinephrine soaked sponges

Early Excision

• Procedure (En Bloc)– For deeper burns– Skin and fat excised in one session– Less time consuming– Excision down to the natural cleavage plane– Down to fat or Fascia

Meshed graft Vs Meek Micrografting Vs Sheet Graft

• Acute burns always meshed or meek micrografting for better takes

• Reconstructive procedures like overgrafting and release of contractures always sheet grafting for better cosmesis

• Meek micrografting gives wider coverage and more predictable takes than mesh grafting but more expensive

Dermatome with blade

DERMATOME-HARVESTING GRAFT

Fascial excision

Integra and ACTICOAT

Case -2 skin grafting

Cultured autologous keratinocytes

• Grown in vitro and then applied to wounds • Take of cultured epithelial autografts depends

on the wound bed• Expensive • Skilled labour and quality control, • 3–5 weeks to produce 1.8m2 confluent sheets

of cells from a 2 cm2 biopsy• Fragile sheets• Blistering, infection, and contractures.

Wound Closure

• Suggested Clinical Indications for CAE– burn injuries >90% broad– 70-90% more limited– <70% no clear indication

PITFALLS IN BURN MANAGEMENT

• Early tracheostomy• Prompt adequate resuscitation• Infection control practices• Pain relief• Early enteral nutrition• Early mobilisation and Intensive chest PT• DVT prophylaxis

PITFALLS IN BURN MANAGEMENT

• Escharotomy• Fasciotomy• Early excision and use of banked skin• Fascial excison and use of banked skin or

autografts• Early rehabilitation-

physical,social,psychological

TEAM APPROACH TO BURNS

• Plastic Surgeon• General Surgeon• Ophthalomologist• ENT surgeon• Intensivist• Nephrologist• Anesthesiologist• Cardiologist• Psychiatrist

NursesMicrobiologistPhysiotherapistOccupational therapistPsychological CounsellorSocial WorkerDietitianPrevention team

thanks