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ACUTE BURN

Dr. Mgs. Roni Saleh, SpBSpBP(K)

I. Phatophysiology
A.

B.

C.

The severity of the burn is determined


by temperatur and length of exposure to
the heat source.
Skin has a large water conten; therefore,
it overheats slowly and cools slowly.
Heat continues to penetrate deeper
tissue layers even after the external heat
source is removed. Immediate cooling
may reduce underlying tissue
temperature, but it has a limted role in
large burns because it may reduce the
patients core temperature.

I. Pathophysiology (Contd)
D. Three areas of injury
1. Central zone of coagulation: Nonviable,
irreversibly injured tissue.
2. Middle zone of stasis: Initially characterized
by dilated blood vessels and capillary
diffusion. After 24 to 28 hours, dilated
capillaries become occluded, with resulting
conversion of this zone of tissue to
coagulation. Injury in this zone may be
reversible with appropriate treatment
(cooling, fluid resuscitation, critical care).
3. Outer zone of hyperemia: Composed
mostly of viable, edematous tissue.

I. Pathophysiology (Contd)
E.

Progressive changes in microcirculation


1. There is an initial, sudden decrease in blood
flow.
2. Arteriolar vasodilation follows.
3. Increase capillary permeability leads to
ederma formation, which is greatest at 8 to
12 hours.
4. Endogenous mediators (histamine, serotonin,
kinins) increase capillary permeability,
leaking protein into the intersitial space.
5. Hypoproteinemia decreases intravascular
oncotic pressure, resulting in a shift of fluid
into the interstitium (i.e., third spacing)

II. Initial management


A.

History
1. Identity the source: Hot liquid,
chemicals, flame, superheated
air/steam, explosion, etc.
2. Duration and location of exposure:
Closed space; potential for smoke
inhalation
3. Concomitant drug or alcohol ingestion
4. Associated injury mechanism:
Esplosion, jump/fall, motor vehicle
crash, etc.

II. Initial Management (Contd)


B.

Airway and breathing


1. Early intubation
a.

b.

c.

Frequently necessary to prevent airway


obstruction due to progressive airway
edema.
Most patients with extensive (>50%)
burns requre intubation
Use humidified oxygen.

2. Chest and abdominal wall burns can


severely limit chest wall excursion and
impair ventilation. Escharotomies may
be necessary

II. Initial Management (Contd)


C.

Circulation

1.

2.

Intravenous access: Ideally, several peripheral largebore intravenous lines should be place through
nonburned tissue. Central lines are the next best
option.
Intravenous fluid administration

a.
b.

D.

Isotonic salt solutions are used for resuscitation and


maintenance.
Glucose should be avoided. Burn patients are frequently
glucose intolerant and hyperglycemic due to the stress
response. The resulting osmotic diuresis can lead to
spuriously high urine output.

Disability : A rapid, thorough baseline


neurologic examination should be performed.
This is especially important in the setting of
blunt trauma, head injury, carbon monoxide
exposure, and/or the need for sedation.

II. Initial Management (Contd)


E.

Initial wound care

1.

Stop the burning process

a.

b.

2.

3.
4.
5.
6.

Flame burns: smoldering or burning materials must be extinguished and


removed, since they can retain heat and exacerbate the burn injury.
Irrigate the wounds with normal saline if any foreign material remains.
Chemical burns: Remove all clothing and begin gentle, copious irrigation
with warm normal saline. Avoid the use of neutralizing solutions.

Cover: Clean, dry, nonadherent dressings are used to protect the


wound and prevent hypothermia.
Analgesia.
Tetanus prophylaxis.
Prophylactic intravenous antibiotics are not indicated.
Criteria for admission to a burn center.
a.

b.
c.
d.
e.

If 10 to 40 years old: Greater than 15% total body surface area (TBSA)
second-degree burns or greater than 3%. TBSA third-degree burns
should be treated on an inpatient basis.
If younger than 10 years or older than 40 years: Greater than 10% TBSA
second-or third-degree burns.
Burns involving the face, hands feet and/or perineum
Circumferential extremity burns.
Electrical burns

III. Inhalation Injury


A.

Etiology
1. Chemical irritants in smoke affect the distal
airways, resulting in an intense inflammatory
response, which can lead to adult respiratory
distress syndrome (ARDS) and/or systemic
inflammatory response syndrome (SIRS).
2. Direct thermal injury: inhalation of
superheated air or water vapor can cause a
thermal burn to the airway mucosa.
3. Oropharyngeal and supraglottic edema
caused by thermal injury can progress to
airway obstruction

III. Inhalation Injury (Contd)


B.

Evaluation

1. Maintain a high index of suspicion.


2. Signs and symptoms
a.
b.

c.
d.

History of burn in a closed space


Presence of facial burns and/or oral carbon
deposits.
Singed facial hair/nares, hoarseness, or wheezing.
Unconsciousness.

3. Nasopharyngoscopy: Can be used to directly


evaluate the larynx and vocal cords for
injury.
4. Bronchoscopy: Via the endotracheal tube, if
symptoms warrant.

III. Inhalation Injury (Contd)


C.

Treatment

1. Intubation, mechanical ventilation


a.

b.

Early intubation is essential. Patients with


inhalation injury often present as conscious, awake,
and comfortable initially. Upper airway edema can
progress rapidly to complete airway obstruction.
Ventilator management goals: Maximize
oxygenation while avoiding oxygen toxicity (keep
FiO2 <0.7) and barotrauma.

2. Bronchodilators: Useful in treating


bronchospasm associated with smoke
inhalation.
3. Steroids: Have not been shown to be
beneficial in avoiding pulmonary
complications with burns

III. Inhalation Injury (Contd)


D.

Carbon Monoxide (CO) poisoning

1.

2.

CO is generated by fire. When inhaled and absorbed, it


preferentially binds with hemoglobin, displacing oxygen and
blocking oxygen binding sites, causing a substantial
reduction in oxygen delivery.
Signs and symptoms

a.
b.
c.
d.
e.

3.

CO level
a.
b.
c.

4.

Pulse oximetry is unreliable


Cherry red skin
Hypoxemia
Mental status changes or a history of a loss of consciousness
Persistent acidosis in the presence of normovolemia
May be normal or minimally elevated, even with significant
exposure.
20% to 40% Associated with severe neurologic symptoms.
Greater than 60% Commonly fatal

Treatment
a.
b.

100% oxygen administration: Displaces CO from hemoglobin


Hyperbaric therapy: Consider if the patient is at risk for CO
exposure and has mental status changes

IV. Burn Wound Assessment


A.

Area
1. Patients palm is approximately 1 %of
TBSA
2. Adult: Rule of 9s
a.

b.

Arm, anterior/posterior legs, head = 9%


each.
Anterior/posterior torso = 18% each

3. Children: The head has a


proportionately larger surface area.

IV. Burn Wound Assessment


(Contd)
B.

Depth: Initial estimates may be


inaccurate, since the depth of the
burn can progress over time.
1. Superficial first degree
a.
b.
c.

d.
e.

Example: sunburn
Confined to the epidermis
Skin: Mildly erythematous
Pain: Resolves in 48 to 72 hours
No scarring

IV. Burn Wound Assessment


(Contd)

IV. Burn Wound Assessment


(Contd)

IV. Burn Wound Assessment


(Contd)
2.

Partial Thickness-second degree


a.
b.
c.
d.
e.

3.

Entire epidermis and variable thickness of dermis


Skin: painful, red, edematous, blistered
Superficial: Dermal appendages intact; heals in less than
3 weeks, usually with minimal to no scarring
Deep: less pain, heals in weeks to months with scarring
The most important distinction is between superficial and
deep partial-thickness burns, since excision and grafting
is performed for deep partial-thickness burns, since and
usually not for superficial partial-thickness injuries.

Full thickness third degree


a.

b.

The epidermis and dermis are destroyed, no dermal


appendages remain, and there is no possibility of
spontaneous regeneration.
Skin: Not painful. It has a leathery, waxy, charred
appearance with thrombosis of vessels.

V. Fluid Resuscitation
A.

No formula uniformly predicts fluid


requirements accurately for every
patient. The physician must repeatedly
assess each patients ongoing
fluidrequirement to maintain an
adequate circulatory volume. All
resuscitative endpoints (e.g., physical
examination, distalperfusion, urine
output, central wedge pressure) are
important.

V. Fluid Resuscitation (Contd)


B.

Modified Brooke (Parkland) formula

1. First 24 hours requirement = 4 cc %TBSA X


patients weight (kg).
2. Administer half of the above volume during
the first 8 hours (calculated from the time of
injury, not the time of hospital admission),
and the other half over the next 16 hours.
3. The adequacy of resuscitation is best judged
by hourly urine output (30-50 cc/hr in adults,
or 1 mL/kg/hr in children).
4. High-voltage electrical burns or deep tissue
burns: There is a high risk for myoglobininduced acute tubular necrosis.
a.
b.

c.

Maintain urine output at 2 mg/kg/hr.


Alkalinize the urine: add bicarbonate to intravenous
fluid (50 mEq/L).
Monitor urine myoglobin levels

V. Fluid Resuscitation (Contd)


C.

D.

Colloid administration : Not


recommended in the first 24 hours
after a burn. Increased capillary
leak causes the colloid to become
trapped in the interstitial space,
increasing third spacing and edema.
Hyponatremia and hyperkalemia
are common: Follow serial
electrolyte levels.

VI. Burn Wound Care


A.

Infection
1. Bronchopneumonia is the leading
cause of death.
2. Burn wound sepsis, septic
thromboplebitis, and bacterial
endocarditis are also common
infections in the burn patient.
3. Pseudomonas, Enterococcus, and
methicillin-resistant staphylococus are
the main offending organisms.

VI. Burn Wound Care (Contd)


B.

Topical antimicrobial agents


1. Silvadene (1% silver sulfadiazine)
a.
b.

c.
d.
e.

Widely available.
Broad gram-negative and gram-positive
coverage.
Moderate wound penetration
Can damage the cornea
May cause leukopenia

VI. Burn Wound Care (Contd)


2. Sulfamylon (10% mafenide acetate)
a.
b.
c.

d.
e.

Broad-Spectrum coverage
Excellent wound penetration
The best topical agent for exposed
cartilage (e.g., the ear and nose).
Painful
Can cause acidosis due to carbonic
anhydrase inhibition. Its use should be
avoided in burns greater than 20% TBSA.

VI. Burn Wound Care (Contd)


3. Silver nitrate (0.5% solution)
a.
b.
c.
d.

Broad-spectrum coverage.
Poor eschar penetration
Costly, messy
Can cause hyponatremia

4. Bacitracin zinc ointment


a.

b.
c.

Effective against gram-positive organisms


only.
Does not penetrate burn eschar
Commonly used for facial burns

VI. Burn Wound Care (Contd)


C.

Excision and grafting

1.
2.

Tangential burn wound excision and skin graft coverage is


performed following hemodynamic stabilization, often
beginning within 2 to 4 days of injury.
Tangential excision

a.
b.
c.

Thin-layer sequential excision of all nonviable tissue until a


viable tissue level is reached
Skin grafting on fat can be tenuous due to its poor blood supply
and difficulty in delineating a healthy level.
Delayed grafting
1)
2)

d.

Performed in cases of inadequate donor sites for graft harvest


Cover wounds first with cadaveric allograft or a nonbiologic dressing
to protect against fluid losses and burn wound infection.

Operative blood loss can be considerable. The recommended


limit for excision in a single session is approximately 10 % to
20% TBSA or less than 10 units of packed red blood cells
trasfusion.

VI. Burn Wound Care (Contd)


3. Grafting techniques
a.

b.

c.

Graft thickness: Generally 12 to 14/1000th inch.


The thinner the graft, the more likely the take, but
more significant is the degree of secondary
contraction. Use 16 to 20/1000th-inch thickness
for the face, if possibe.
Meshing : Usually at a 1:1.5 ratio. Meshing the
graft increases the surface area that can be
covered, and can decrease hematoma and seroma
collection beneath the graft. Higher mesh ratios
can be used, as necessary (e.g., 1:2, 1:3, or 1:4).
Unmeshed sheet grafts are typically used on
cosmetic or functional areas, such as the face,
breast, and hands.

VI. Burn Wound Care (Contd)


4. Graft failure
a.

b.
c.

d.
e.

f.

Inadequate wound debridement prior to


graft application is the primary cause.
Infection
Seroma, hematoma
Lack of moisture
Shear: Improper padding, dressing, or
patient positioning.
Poor nutritional or overall physiologic
status (e.g., poor visceral protein levels or
sepsis).

VII. Circumferential Burns


A.

B.

C.
D.

Circumferential burns: Result in limited ability for


expansion of tissues with edema. This can cause
supraphysiologic pressures to develop, causing tissue
ischemia and necrosis.
Physical signs are often obscured by the burn injury or
tissue edema. Doppler examination is unreliable in
estimating tissue perfusion.
Burned extremities should be elevated.
Escharotomy: incision of burned skin to relieve
constriction.

1.
2.
3.

Electrocautery incision is the method of choice, and can be


performed at bedside because the burned skin is anesthetic.
Arms and legs: Medial and lateral incisions; may include
digits.
Chest and upper abdomen: Bilateral midaxillary releases can
be connected with a horizontal incision to form an H.

VII. Circumferential Burns (Contd)

VIII. Burns of The Face, Eyes, And


Ears
A.

B.
C.
D.

E.

The central face has deeper skin appendages, resulting in


a greater healing capacity.
Use unmeshed sheet grafts, applied by aesthetic units.
Attempt to perform facial grafting less than 2 weeks from
the time of injury to decrease scarring.
Eyes: Lid edema usually protects the eyes in the early
stages. As edema subsides and wound contraction
occurs, keratitis and corneal abrasion are common risks.
Temporary tarsorrhaphy and/or surgical release may be
required.
Ears: Twice per day sulfamylon application is the
treatment of choice. Avoid any external pressure to the
ear. Supurative chondritis requires urgent debridement.

IX. Burns of The Hands and Feet


A.
B.
C.
D.
E.

F.

G.

Always perform a complete hand examination.


Maintain a low threshold for escharotomies and
fasciotomies, as these procedures save extremities.
Superficial burns: Elevation, topical antimicrobials, and
passive range of motion for each joint twice per day.
Appropriate splinting is crucial to prevent contractures.
Deep partial- and full-thickness burns: Early excision and
sheet g rafting are preferred. Immobilize for 5 days, then
start occupational therapy
Palmar skin is thick. Only 20% of palmar burns
ultimately require resurfacing. A conservative approach is
recommended to preserve thick fascial attachments.
Burns of the feet are managed similarly to hand burns.

XI. Nutrition
A.

A hypermetabolic response is common with all large


burns.

1.
2.

3.
4.

The metabolic rate is proportionalto the size of the burn, up


to 60% TBSA, remaining constant thereafter.
This response begins soon after injury, reaching a plateau
by the end of the first week. Most burns of more than 30%
TBSA require intensive nutritional support until wound
healing is complete.
Energy expenditure is unpredictable.
Harris-Benedict equation

a.
b.

B.
C.
D.

24-hour caloric requirement = (25 kcal X kg body weight) + (40


kcal x %TBSA)
Frequently undercalculates the real metabolic needs.

Protein: 2.5 to 3 g/kg per day are recommended. In


children, requirements are 3 to 4 g/kg per day
Intestinal feeding should be performed early.
Prealbumin levels are drawn to monitor adequate
nutrional progress in patients with large burns.

XII. Electrical Injuries


A.

B.

Low-voltage injuries can be locally destructive


without systemic sequelae
High-voltage injuries (>1,000 volts): Can result
in extensive internal destruction.
1.
2.
3.
4.

Entrance and exit wounds: Usually less than 10% to


15% TBSA.
Deep tissue injury is cause by the passage of current
through tissue. The damage is analogous to a
massive crush injury with intact skin
Injury is proportional to tissue resistance: bone >
muscle > nerve.
A full trauma workup is paramount. Associated injuries
from a fall or tetanic contraction of muscles
(paravertebral) are common.

XII. Electrical Injuries (Contd)


C.

D.

Significant cardiac damage is extremely


rare. Cardiac monitoring should be
instituted during the first 24 to 48 hours.
Muscle damage

1. Should be suspected with myoglobinuria


and/or pigmenturia.
2. Maintain a high urine output.
3. Apply Sulfamylon for eschar penetration
4. Compartment syndrome.
a.
b.

c.

Continually reevaluate the peripheral circulation.


Measure compartment pressures with a Stryker
instrument or arterial line setup with a large-bore
needle (normal: <15 mm Hg; abnormal: >30 mm
Hg).
Fasciotomy: Perform in the operating room

XIII. Chemical Burns


A.
B.
C.
D.

Usually deeper than they appear.


Injury is due to a chemical reaction rather than thermal
injury.
In general, dilution, not neutralization, is the key to
management.
Specific agents.

1.

Hydrofluoric acid

a.

b.

2.

Phenol
a.
b.

c.
d.

3.

Liquefaction necrosis in subcutaneous tissue and deeper .


10% calcium gluconate: Infiltrate subcutaneously after topical
dilution with water if pain persists. It is also available as a
topical gel.
Poorly soluble in water.
Has an analgesic effect.
Some systemic absorption is possible, causing arrhythmias.
Wash with polyethylene glycol if available.

White phosphorus
a.
b.

Chemical and thermal burns


Copper sulfate: Facilitates removal of the particles (following
copious water lavage).

Pearls
1.

2.

3.

4.

5.

Use formulas only as a guide to fluid


replacement. Monitor fluid status on an ongoing
basis via urine output and other measures.
Be wary of inhalation injury and have a low
threshold for early endotracheal intubation.
Have a low threshold for obtaining an
ophthalmologic evaluation for burns involving
the face.
Watch for myoglobinuria and reanl failure in
electrical burns.
Look for circumferential burns and consider
early escharotomies.