Management of burns

MANAGEMENT OF BURNS
Dr. Murali. U. M.S; M.B.A
Assoc. Prof. of Surgery

Learning Outcomes
 List out the Criteria for admission of Burns patient.
 Outline the fluid resuscitative methods of burns.
 Evaluate the definitive & local management of burns.
 Discuss about the effects of Non-thermal burn injury.

Objectives
 Immediate Care & Criteria
 Fluids & Others
 LocalTreatment
 Surgical options
 Non –Thermal injury

Immediate [ Pre-hospital Care ]
 Remove from source of injury
 Clothing to be removed
 Cool the burn wound – 10 mts – no
cold H2o
 Check for other injury
 Ensure rescuer safety
 Elevation

Hospital Care
 A – Airway / Assessment
 B – Breathing & ventilation
 C – Circulation
 D - Disability
 E – Exposure
 F – Fluid resuscitation
 G – Girth ( Circumference )
 H – Hand
 I - Inhalation injury

Criteria – Admission
 Airway burns of any type
 Burns in extremes of age
 Burns requiring FR & Surgery
 Pts. social background is not good
 All electric / deep chemical burns

Outcome – Major Determinants
 Percentage surface area involved
 Depth of burns
 Presence of an inhalational injury

Area – Lund & Browder Chart
Age-yrs 0 1 5 10 15 Adult
A-Head 9 8 6 5 4 3
B-Thigh 2 3 4 4 4 4
C-Leg 2 2 3 3 3 3

Area – Wallace’s – “ Rule of 9 ”

Depth of Burns
Depth Cause Surface/colour Pain sensation
Superficial Sun, flash, minor
scald
Dry, minor blisters,
erythema, brisk
capillary return
Painful
Partial
thickness-
superficial
(superficial
dermal)
Scald Moist, reddened
with broken
blisters, brisk
capillary return
Painful
Partial
thickness- deep
(deep dermal)
Scald, minor flame
contact
Moist white
slough, red
mottled, sluggish
capillary return
Painless
Full thickness Flame, severe
scald or flame
contact
Dry, charred
whitish.Absent
capillary return
Painless

Burn causes – Likely depth
Cause of Burn Depth of Burn
Scald Superficial
Flash Burns Deep Dermal
Flame Burns Mixed deep dermal + Full thickness
Alkali Burns Deep dermal + Full thickness
Acid Burns Weak – Superficial / Strong – Deep dermal
Electric Burns Full thickness

Inhalation Injury – Dangers
 Inhaled hot gases - supraglottic airway burns & laryngeal
oedema
 Inhaled steam - subglottic burns and loss of respiratory
epithelium
 Inhaled smoke particles - chemical alveolitis and respiratory
failure
 Inhaled poisons, such as carbonmonoxide, can cause
metabolic poisoning
 Full-thickness burns to the chest can cause mechanical
blockage to rib movement.

Inhalation Injury
RECOGNITION INITIAL MANAGEMENT
 A history of being trapped in the presence of
smoke or hot gases.
 Burns on the palate or nasal mucosa, or loss of
all the hairs in the nose.
 Deep burns around the mouth and neck.
 Presents as Hoarseness of voice / Stridor.
 Early elective intubation is safest
 Delay can make intubation very
difficult due to swelling
 Be ready to perform an emergency
cricothyroidotomy if intubation is
delayed

Fluid Resuscitation
 Children > 10%TBSA / Adults > 15%TBSA
 IV access - Central vein access
 Ringer lactate without dextrose fluid of
choice
 Monitor urinary output

Fluids used
 First 24 hrs = Crystalloids – given / Saline, RL, Hartmann’s fluid
( PASSTHROUGH CAPILLARY WALL EASILY )
 After 24 hrs upto 30 – 48 hrs = Colloids Plasma , Dextrans , Haemaccel
(TO COMPENSATE PLASMA LOSS )
 Blood transfusion – after 48 hrs

Parkland Formula – Commonly used
 4ml x % burn x kg = volume [ml] - 24 hrs
 Max. % = 50%
 First 8 hrs ½ of vol. – Rest in next 16 hrs
 Next 24 hrs = ½ of first day fluids

Muir & Burclay Formula – Colloids
 0.5 x % burn x wt.kg = 1 portion
 3 portions = first 12 hrs
 2 portions = second 12 hrs
 1 portion = third 12 hrs

Fluids – Children - DNS
 100 ml / kg for 24 hours for the first 10 kg.
 50 ml kg / for the next 10 kg.
 20 ml kg / for 24 hours for each kilogram over 20 kg body weight.

Other General Measures
 Monitoring the patient
 Catheterization – Monitor urine output
 Tetanus toxoid / H2 blockers
 NGT – Aspiration & Enteral feeding
 Antibiotics – Culture
 TPN – If necessary
 Intensive nursing care

Eschar - Treatment
 Charred, denatured, full thickness
deep burns with contracted dermis
 Circumferential eschar – Limbs /
Neck
↓
 Tourniquet effect – compartment
syndrome
↓
 Incising the whole length of full
thickness burns in midaxial line -
Escharotomy

Full Thickness & Deep dermal burns
 1% silver sulphadiazine cream
 0.5% silver nitrate solution
 Sulfamylon - Mafenide acetate
cream
 Cerum nitrate

Sup.Thickness & Mixed dermal burns
 Heal – irrespective of dressing
 Simple dressings –
Vaseline gauze
Silicon sheet / Hydrocolloids
 Biological
Natural – Aminio.memb
Synthetic – Biobrane

Analgesia
 No intramuscular, subcutaneous injections
 Small burns – Paracetamol, NSAID
 Large burns - Intravenous opiates

Nutrition
 Burns patients need extra feeding
 A nasogastric tube should be used in all patients with burns
over 20%TBSA
 A number of different formulae are available to calculate the
energy requirements of patients
 The nutritional balance monitored by measuring weight and
nitrogen balance

Control of Infection
 Burns patients are immunocompromised
 They are susceptible to infection from many routes
 Sterile precautions must be rigorous
 Swabs should be taken regularly
 A rise in white blood cells count, thrombocytosis and
increased catabolism are warnings of infection.

Others
 Intensive nursing care
 Physiotherapy – elevation, splintages, exercise
 Psychological - counseling

Surgery – Deep burns
 Deep dermal burns – tangential shaving & SSG
 All but the smallest full-thickness burns need
surgery
 Topical adrenaline (DILUTED) reduces bleeding
 All burnt tissue needs to be excised
 Stable cover should be applied at once to
reduce burn load

Delayed Scar Management
 Transposition flaps and Z-plasties
with or without tissue expansion are
useful
 Full-thickness grafts and free flaps –
needed for large or difficult areas
 Hypertrophy - treated with pressure
garments
 Pharma.treatment of itch is
important

Electrical Burns
 LV – injuries cause small, localized, deep burns
 Cause cardiac arrest without significant direct
myocardial damage
 HV – injuries damage by flash / conduction
(internal burn)
 Myocardium may be directly damaged without
pacing interruption
 Limbs – fasciotomies or amputation
 Look for and treat acidosis and myoglobinuria

Chemical Burns
 Acid burn occurs in skin, soft tissues and
GIT.
 Alkali burns occur in oral cavity and
oesophagus.
 Initial treatment is dilution with water
(Hydrotherapy).
 Late neutralisation is done, if required by
0.2% acetic acid in alkali burns.
Na.bicarbonate / calcium gluconate
10% gel, topical ziphrin solution in acid
burns.

Radiation Burns
 Local burns causing ulceration need
excision and vascularised flap cover-
usually with free flaps.
 Systemic overdose needs supportive
treatment.

BURNS
Breathing & Body image
Urine Output
Rule of nines & Resuscitation
Nutrition
Shock & Silverdiazine

1.What will be the % if both legs,the groin
and the front chest and abdomen were burned?
 A 35%
 B 45%
 C 55%
 D 65%

2.Which of the following statements
regarding burns treatment is false?
 A .The simplest and most commonly used crystalloid is Ringer’s lactate.
 B. Oral fluids containing no salt are essential when given as fluid replacement in
burns.
 C. Human albumin solution is a colloid which reduces protein leak out of cells,
thereby helping to reduce oedema.
 D. The Parkland formula is the most widely used formula and calculates the fluid
replacement in the first 24 h.

3. A 25-year-old man is brought to the emergency room after sustaining
burns during a fire in his apartment. He has blistering &erythema of his
face, left upper extremity, and chest with frank charring of his right
upper extremity. He is agitated, hypotensive & tachycardiac. Which one
of the following statements concerning this patient’s initial wound
management is correct?
 A .Topical antibiotics should not be used, as they will encourage growth of resistant organisms
 B. Early excision of facial and hand burns is especially important
 C. Escharotomy should only be performed if neurologic impairment is imminent
 D. Excision of areas of third-degree or of deep second-degree burns usually takes place 3–7 days after
injury
 E. Split-thickness skin grafts over the eschar of third-degree burns should be performed immediately
in order to prevent fluid loss.

4. Which one of the following statements
regarding the above burn patient is correct?
 A . High-dose penicillin should be administered prophylactically
 B.Tetanus prophylaxis is not necessary if the patient has been immunized in the
previous 3 years
 C.This burn can be estimated at 60% total body surface area using the “rule of nines”
 D.The most sensitive indicator of adequacy of fluid resuscitation is heart rate
 E.This patient should undergo immediate intubation for airway protection and
oxygen administration

3.A women weighing 45 kg, with 35% burns of II
° is brought to the casualty. What will be the
fluid resuscitative methods for next 2 days.

“ Surgical Triad ”
Measure thrice, think twice, cut once.
Thank U

Management of burns

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