Burn Management

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Burn Management

• Mohamed Ahmed Sayed
• Assistant Lecturer of Plastic and Reconstructive
  Surgery
• Ain Shams University Faculty of Medicine
• dr_mohamed_a_at_yahoo.com
• http//www.geocities.com/dr_mohamed_a

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• 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 energy
• duration of exposure
• type of tissue injured

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Where do most burns occur?

• 0 - 4 years, from kitchen, bathroom.
• 5-74 years, outdoors, kitchen.
• Teenagers, suicide (females).
• gt 75 years, kitchen, outdoors.

When do most burns occur?

• Winter more than summer

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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

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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.

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Thermal Burns
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Scald Burns
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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.

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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.

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Electrical Burns
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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 voltage
• tissue resistance
• current pathways
• surface area in contact with the current
• length of time the current flow.

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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.

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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

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Cold Thermal Injury (Frostbite)
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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

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Depth of Burns
Medicolegal classification clinical
classification
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Extend of Burns
Lund-Browder Chart Rule of Nines
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Location of Burns

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

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Patient risk factors

• Associated trauma
• Inhalation injuries
• Circumferential burns
• Electricity
• Age (young or old)
• Pre-existing disease
• Abuse

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3 Phases of Burn Management

• emergent (resuscitative)
• acute
• rehabilitative

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Pre-hospital Care

• Remove from area! Stop the burn!
• If thermal burn is large--FOCUS on the ABCs
• Aairway-check for patency, soot around nares, or
  signed nasal hair
• Bbreathing- check for adequacy of ventilation
• Ccirculation-check for presence and regularity
  of pulses

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Other precautions...

• Burn too large--dont 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

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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!

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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

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

• Cardiovascular
• Respiratory
• Renal systems

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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 formulas for replacement
• Parkland formula
• Brooke formula

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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

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Wound care

• Escharotomy / Fasciotomy
• Escharectomy homograft
• Dressing / hydrotherapy
• Debridement
• Application of autograft
• Splinting
• PB contractures management

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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

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Other care measures include

• Face
• eye
• ear
• Hands arms
• Perineum
• Physiotherapy

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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.

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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

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Care of B U R N S

• B - breathing
• U - urine output
• R - rule of nines
• resuscitation of fluid
• N - nutrition
• S - shock
• silvadene

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Referral Criteria

• 2nd or 3rd Degree Burns
• gt10 TBSA
• Burns to vital organs of burn
• circumfrential burns
• Electrical Burns
• Chemical Burns
• Inhalation Injury

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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

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Questions?