BURNS

RAY RISNER C. OBENZA, MD, FPCS, FPSGS

EPIDEMIOLOGY

• Quality of Burn Care

Survival
Long-term Function
Appearance

Surgeon’s Goal
Well-healed, durable skin with normal
function and near-normal appearance
BURNS

*Depth of Injury is directly proportional to:

Temperature applied
Duration of contact
Thickness of the skin
ETIOLOGY

1. Scald Burns
- usually household from hot water
- most common among civilians injuries
especially children
2. Flame Burns
- 2nd most common mechanism
- secondary to house fires, MVA
ETIOLOGY

3. Flash Burns
- explosion of gases & other combustible liquids
- covers larger TBSA
- with thermal damage to upper airway

4. Contact Burns
- contact with hot metals, plastics, glass
- common in industrial accidents
- often 4th degree
ETIOLOGY

5. Electrical Burns
- either occupational or household injuries
- severity based on voltage, duration of
contact & resistance of the patient

6. Chemical Burns
- due to strong acids or alkalis
- industrial accidents or assaults
PHASES OF BURN INJURY

• Acute Phase
Fluids & Electrolytes
Pain Control
Burn Wound Care & Coverage
Septic Complications
Nutritional Management
PHASES OF BURN INJURY

• Chronic Phase
Rehabilitation

Reconstruction
Psychological Support
• Pathophysiology of Burn Injury
1. Coagulation Necrosis
2. Increased Capillary Permeability
3. Hemolysis
ACUTE PHASE
• Immediate Care
Rescue and First Aid = on scene
- remove source of heat
- CPR if necessary; O2 inhalation

Assessment and Resuscitation = at the ER

- ABC’s take priority
- Intubation if necessary

Preparation for transfer to a burn facility

- for burns more than 5 – 10% TBSA
• Immediate first aid measures
Cooling the burned area
- application of cool water NOT iced water

Removal of patient’s clothing

- remove source of heat & exposure of injuries

Prevention of hypothermia
- wrap patient in clean blanket
• Admission Criteria to a Burn Facility
Partial Thickness Burns =/> 15%
Full Thickness Burns =/> 5%
Burns on Face, Feet, Hands & Perineum
All Electrical & Chemical Burns
Presence of Smoke Inhalation Injury
Associated Injuries
• Admission Criteria
Child Abuse
Patients <10 y.o. & >50 y.o.
Patients w/ Associated medical illness
All infected burns
Dependent persons
• Determinant Factors for Mortality
1. Age of the patient
2. Burn size
3. Smoke Inhalation Injury
• Patient Assessment
1. History
Time of Injury
Place of Injury
Mechanism of Injury
2. Physical Exam
Primary Survey = ABC’s
2ndary Survey = Other
injuries
• Estimation of Burn Injury Severity
Burn Size:
Rule of Nines = massive burns
Patient’s Palm = patchy burns
Lund-Browder Chart = pediatrics
• “Rule of Nines” for estimating TBSA

Anatomic Area % body surface

Head 9
Rt. Upper extremity 9
Lt. Upper extremity 9
Rt. Lower extremity 18
Lt. Lower extremity 18
Anterior trunk 18
Posterior trunk 18
Perineum 1
Estimation of Burn Injury Severity

Burn Depth is dependent on:

a. Temperature of burn source
b. Thickness of the skin
c. Duration of contact
d. Heat dissipating capability of skin
Classification of Burn Depth
1. Shallow Burns
a) Epidermal Burns
(1st Degree Burns)
- do not blister but
erythematous
- relatively painful

ex. Sunburn
b) Superficial Partial-
Thickness
Burns
(2nd Degree Burns)
- form blisters, pink & wet
- hypersensitive to pain
- blanch with pressure
- spontaneously heal
< 3 weeks
Classification of Burn Depth
2. Deep Burns
a) Deep Partial-Thickness Burns
(2nd Degree)
- blisters, mottled pink and
white
- capillary refill is slow to
absent
- less sensitive to pain
- heals in 3 to 9 weeks
b) Full Thickness Burns
(3rd Degree)
- all layers of dermis
- leathery, dry white, firm
& insensate
- develop “ESCHAR”
- heal by contracture or
skin grafting
c) Fourth Degree Burns
- full thickness skin, SQ fat,
fascia & muscles
- electrical, contact, immersion
burns in an unconscious
patient
Assessment of Burn Depth

Methods:
1. Clinical observation – only 70% accurate
2. Detection of Dead cells or denatured collagen
- biopsy, ultrasound, use of vital dyes
3. Assessment of Change in Blood Flow
- fluorometry, laser Doppler, thermography
4. Analysis of Wound Color
- light reflectance method
5. Evaluation of Physical Changes
- magnetic resonance imaging
Physiologic Response to Burn Injury

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME

(SIRS)
- pathologic alterations in metabolic, cardiovascular,
gastrointestinal and coagulation systems
- hypermetabolism, increased cellular, endothelial
& epithelial permeability
- extensive microthrombosis
Physiologic Response to Burn Injury

BURN SHOCK
- circulatory dysfunction
- increase in vascular permeability & micro-
vascular hydrostatic pressure
Mediators:
1. Histamine – release mast cells which
disrupts venular endothelial junctions
2. Serotonin – increase pulmonary vascular
resistance
3. Eicosanoids – increase levels of vasodilator PG’s
• Diagnostic Work-up
Complete Blood Count
Urinalysis, BUN & Serum Creatinine
Baseline electrolytes
Arterial blood gas determination
X-rays (Chest, other areas)
Electrocardiography
Etc
• Fluid Resuscitation
Recommended Fluids:
Plain Lactated Ringer’s Solution = 1st 24 hours
Colloids or D5Water = after 24 hours
• Fluid Computation & Administration
a) 1st 24 hours
“Parkland Formula”
TFR = BW x TBSA x 4 mg/kg/%burns
(1/2 given in1st 8H; 1/2 next 16H)
b) 2nd 24 hours
D5W replace evaporative losses
Colloids maintain plasma volume
c) After 48 hours
Maintenance Fluids = 30-40 cc/kg/day
• Parameters for Monitoring Fluid Therapy
1. Urine Output
Adults: 0.5 cc/kg/hour
Pedia : 1 cc/kg/hour
2. Vital Signs
Blood pressure & Heart rate
Central Venous Pressure
3. Sensorium
• Reasons for Failed Resuscitation

1. Delayed resuscitation

2. Presence of electrical burns

3. Smoke inhalation injury

4. Coronary artery disease

Ancillary Management Measures
1. Gastric decompression

2. Pain control & sedation

3. Antibiotics

4. Tetanus prophylaxis
Compartment Syndrome

a) Clinical Manifestations
6 P’s: Pulselessness Paresis/Paralysis
Pallor Paresthesia
Pain Poikilothermia
b) Definitive Treatment: ESCHAROTOMY

FASCIOTOMY
Inhalation Injury
1. Carbon Monoxide Poisoning
Effects:
a) prevents reversible displacement of O2
b) decrease O2 unloading at tissue level
c) less effective intracellular respiration
d) directly toxic to cardiac & skeletal muscles
Treatment:
Hyperbaric Oxygen ???
Inhalation Injury

2. Thermal Airway Injury

Manifestations:
- mucosal & submucosal erythema
- edema, hemorrhage & ulceration
- potential for upper airway obstruction
Treatment:
Endotracheal Intubation
Inhalation Injury

3. Smoke Inhalation
Factors:
a) Type and amount of smoke inhaled
b) Size of particulates
c) Duration of Toxic Exposure
d) Magnitude of thermal injury

Clinical Manifestations:
a) dyspnea
b) burned vibrissae
c) carbonaceous sputum
Inhalation Injury

Diagnosis: a) Chest X-ray

b) Bronchoscopy
c) Arterial blood gas

Management: a) Endotracheal intubation

b) Mechanical ventilation
Electrical Burns

Classification:
Low voltage: <1,000 volts
High voltage: >1,000 volts

Mechanisms of injury:
a) Direct contact
b) Conduction arc
c) Secondary ignition
Electrical Burns

Physiologic Alterations:
a) Arrhythmias
b) Acute Renal Failure
c) CNS & PNS Deficits
d) Hemorrhage & Hematomas
Chemical Burns

Factors to consider:
a) Contact time
b) Chemical involved
Primary Management:
Rapid termination of burning process
Burn Wound Care

Salient Aspects:
Debridement of necrotic tissue
Daily dressing of burn wound

Surgical Management:
a) Tangential excision
b) Fascial excision
Burn Wound Care

Topical Antimicrobials
a) Aqueous silver nitrate
b) Mafenide acetate
c) Silver sulfadiazine
d) Povidone-iodine
Nutritional Support

State of hypermetabolism
- exaggerated energy expenditure
- massive nitrogen loss
Formula:
TCR = 25 kcal/kg BW + 40 kcal/%TBSA
Route:
Total Enteral Nutrition (TEN)
Adv: maintain integrity of GI tract
reduce bacterial translocation & sepsis
Burn Wound Infection

Clinical Manifestations
1. Conversion from partial to full thickness
2. Dark-brown/blackish discoloration
3. Neo-eschar formation
4. Rapid eschar separation
5. Violaceous wound margins
6. Metastatic septic lesions
Burn Complications

A) Distant infections
1. Pneumonia
2. Bacterial Endocariditis
3. Urinary Tract Infection
4. Suppurative chondritis
5. Vascular Catheter-Related Infection
Burn Complications

B) Other complications

1. Curling’s ulcer

2. Acute Acalculous Cholecystitis

3. Myocardial Infarction
Burn Wound Coverage

a) Temporary
1. Biologic wound coverings
Allograft
Xenograft
Amnion

2. Hydrocolloid dressings
Burn Wound Coverage
b) Permanent
1. Skin Grafting a) Split-thickness
b) Full-thickness

2. Skin Flaps
3. Skin Substitutes a) AlloDerm
b) INTEGRA
4. Cultured Skin a) Apligraf
b) Epicel
Chronic Phase
1. Rehabilitation: Range of motion exercises
Ambulation training
Return to functional status
2. Psychological Support:
Anxiety, Depression, Denial
Withdrawal, Regression
Chronic Phase
3. Reconstruction:
Burn contractures
Keloids
Hypertrophic scars
Marjolin’s ulcer