Assessment and initial care of

burn patients

Robert Riviello, MD, MPH

University Teaching Hospital, Kigali

Brigham and Women’s Hospital, Boston

Burn patient is a trauma…

• Stop burn process

• A-B-C

• Primary/secondary

survey

• History

History

• How did the burn

occur ?

• Inside vs outside

• Did the clothes catch

on fire ?

• Temperature of the

liquid

• How much liquid

• Was cloth removed

• Abuse ?

• What was the agent ?

• Duration of contact

• What decontamination

occurred

• What kind of electricity

was involved, voltage ?

• Pathway of voltage

• LOC, CPR ?

Flame/Scald Chemical/Electric

Severity of Burn

• Extent of burn

– Rule of 9s

– Scattered burns

• Depth of burn

– Temperature

– Duration of contact

– Thickness of the dermis

– Blood supply

• Comorbidities

• Age

1% Estimation (palm + fingers)

Burn Center Referral Criteria

• Partial thickness burns >10% TBSA

• Burns of face, hands, feet, genitalia, perineum, over major joints.

• 3rd degree burn in any age group

• Electric burns including lightening

• Chemical burns

• Inhalation injury

• Any patient with concomitant trauma in which the burn posses the greatest risk of morbidity or mortality

• Children

• Burn injury to patients who will require special social, emotional or long-term rehabilitative intervention.

Management Principles

• Start fluid resuscitation

• Monitor extremity perfusion

• Continuous airway assessment

• Pain management

Fluid Resusitation

• Parkland Formula for >20% TBSA burns

• LR = fluid of choice

• Parkland Formula:

4cc x TBSA burn x wt (Kg) = total fluid amt

Example: 4cc x 50 x 85kg = 17,000

Replace ½ (8500) in first 8hr = 1,062/hr x 8 hrs

Replace next ½ (8500) in next 16hr = 530cc x 16hr

Inhalation injury

• Carbon monoxide

poisoning

• Inhalation injury

above the glottis

• Inhalation injury

below the glottis

Carbon monoxide poisoning

• CO binds to hemoglobin 200x more than

oxygen tissue hypoxia

• CO T1/2 = 4h on room air, can be decreased to

1h on 100% oxygen

• Cherry discoloration

• Absent tachypnea or cyanosis

• O2 sat normal

Carbon monoxide poisoning

• CO levels

– 5-10% present in smokers, people exposed to heavy

traffic

– 15-20% headache, confusion

– 20-40% disorientation, fatigue, nausea, visual

changes

– 40-60% hallucinations, combativeness, coma,

obtundation and LOC

– >60% mortality > 50%

Inhalation injury above the glottis

• Thermal or chemical

• Except of rare occasions, thermal injury is

limited to above glottis

– Nasopharynx, oropharynx, larynx

• Swelling – may start after fluid resuscitation

Intubate early

Succinyl choline (rapid sequence) is safe

• 4 y.o. male with facial

burn following a house

fire

• Singed eyebrows,

eyelashes and facial

burns

• Lips swollen

• Carbonaceous sputum

Inhalation injury below the glottis

• Almost always chemical

– Aldehydes, sulfur oxides, phosgenes

• Smaller airways, terminal bronchi

• Resulting injury causes:

– Impaired ciliary activity

– Inflammation/edema/increased blood flow

– Hypersecretions

– Ulcerations

– Spasm

– Impaired immune response

Inhalation injury management

• 100% Oxygen

• Intubate if

– Decreased level of consciousness

– Stridor, retraction, respiratory distress

– Progressive hoarseness

– Carbonaceous/pink, frothy sputum

– High CO

– Clue: enclosed space injury

Cyanide Poisoning

• Similar s/s to CO poisoning

• Inhalation/toxicity 2/2 burning nitriles, polurethane,

formaldehyde, wool, silk

• Found in pesticides, tobacco, almonds, cassava, apple

seeds, apricot

• Think w/ neurological side effects and metabolic acidosis

Cyanide symptoms

• LOW LEVEL

• Lethargy

• Headache

• vertigo

• Confusion

• LONG STANDING LOW

LEVELS

• Paralysis

• Hypothyroidism

• Miscarriages

High level Cyanide

• Onset: seconds to

minutes

• Apnea, seizures, LOC,

coma, pulmonary

edema, cardiac arrest

• High exposure could

mean convulsions and

death within 1-15

minutes

Cyanide Signs

• Metabolic acidosis

• Venous O2 above normal

• Hypotension

• Pink coloration

• Bitter almond odor

Testing/Treatment

• ABG

• Serum cyanide

• Urine thiocyanate

• Treat before testing if

clinical suspicion

• 100% O2 face mask

• Intubation if indicated

• Amyl nitrate (inh)

• Na Nitrite IV

• Hydroxycobalamine

70 mg/kg IV

(typical adult dose 5g)

Compartment Syndrome

• * Pain (PROM)

• Paraesthesias

• Pallor

• Poikilothermia

• Pulselessness

Chest/Abdomen Compartment

Syndrome

Chest/Abdomen shield

The skin functions altered by burn

• Protection from desiccation

• Protection from bacterial invasion

• Protection from toxins

• Fluid balance: avoiding evaporation

• Neurosensory

• Social-interactive

• Protection from

trauma due to

elasticity, durability

• Fluid balance via

regulation of blood

flow

• Thermoregulation thru

control of skin blood

flow

• Growth factors,

epidermal regeneration

Epidermis Dermis

• Wash

• Debride blisters/loose skin

• Closed dressing / Xeroform

• Temporary skin substitute (biobrane)

• Pain control

• Clinic 1-2 days

• Heals in 2 weeks

2nd Degree

Superficial 2nd degree

Deep 2nd degree Wash

Debride blisters/loose skin

Closed dressing

Clinic 3-4 days

Heals in 4 weeks +/-

Consider grafting

Deep 2nd degree

Conversion

(pre)

Conversion

(post)

• Wash, remove char

• Silver sulfadiazine BID, closed

dressings

• Early excision and grafting

• Prophylactic IV Abx not

indicated

3rd Degree

Deep 3rd Degree

3rd Degree

3rd – Graft - Final Outcome

• Tendon

• Muscle

• Bone

• Frequent need for

amputations

4th Degree burn

4th Degree burn

Chemical burns

• Alkalis

• Acids

• Organic compounds

• Concentration

• Volume

• Duration of contact

• Mechanism of action of the agent

Cement burn

Alkalis or acid

• Protein denaturation

• Tan to gray surface discoloration

• Extreme pain

• Treatment

– Vigorous water lavage (50min-avoiding

hypothermia)

Gasoline immersion

• Superficial skin injury – erythema

• Systemic injury from absorbed hydrocarbons • Kidney - Lipid degenerative changes in prox tubules

• Lungs – surfactant denaturation atelectasis, lipoid

pneumonia

• CNS – edema, seizures, coma

• Liver – lipid degenerative changes, hepatitis

• Treatment

– Water immersion

– Hydration + pulmonary support

Hydrofluoric Acid

• Deep skin burn (deceiving – may look benign !)

• Systemic effects due to hypocalcemia, calcium

binds to fluoride ion

• 1% TBSA burn may be lethal (dysrythmias)

• Treatment

– Water lavage

– Calcium gluconate – gel in glove, injection, …

Acid Burn

Lithium burns/explosions

• Lithium commonly used in batteries for laptops, cellphones, button batteries (ie singing greeting cards)

• Also used in nuclear weapons, 7Up, and colas!

• Can overheat, overcharge causing extremely high currents = short circuit = shock equal to a stun gun

Lithium

• Alkali

• Flammable

• Reactive to water

• MSDS sheets: irrigate with water for eyes, skin. If particles evident rinse off with mineral oil.

• Emergency optho consult

• Ingestion: damage to esophagus/lung

Tar Burns

• Contact burn

• No systemic effects, non-

toxic

• Treat by initially cooling,

then immerse in greasy

agent (aquaphor, vaseline,

mineral oil, triple

antibiotic) then peel off.

Electrical Burns

• High voltage >1000

• Entrance – exit site

• Thermal, arc, flash

• Electrical current

pathway: organ/tissue

damage

• Associated trauma

Electrical Injury

Compartment Syndrome as

complication from Electrical Injury

Electrical-complications

• Respiratory arrest

• Seizures, coma

• Muscle necrosis –

compartment

syndrome

• Ventricular fibrilation

• Hemolysis

• Retinal detachment

• Renal failure

(myoglobinuria)

• Limb loss

Lightning Burn

• 80-100 deaths/yr

• 30% mortality

• Superficial fern-like

burns

• Immediate deep

polarization of

mycardium-asystole

Burn Dressings • To dress or not to dress? Open vs. closed

• Open technique allows for constant observation of wounds

• Good for PT/OT: better ROM

• Hypothermia

• Requires frequent reapplication of antimicrobials; painful

• Unaesthetic for visitors and patient

Burn Dressings

• Closed (occlusive)

– Retains body temperature and fluids

– QD or BID dressing changes; wound debridement by virtue of dressing removal

– Keeps grafts in place

– Aesthetically more acceptable

– Impedes ROM

– Labor-intensive

Topical Agents • Silver Sulfadiazene

• Manefate Acetate

• Bacitracin/Triplemix

• Betadine

• Acticoat

• Aquacel Ag

Silvadene • Silver Sufadiazene-Thermazene, the white cream

• For deeper 2nd degree, non-epitheliazing

• Allows for slow release of silver

• Low toxicity, moderate tissue penetration

• Softens the eschar to the point of liquefaction

• Continued use can impede epitheliazation

Silvadene

Silvadene (cont) • Effective against gm+ and gm- and some fungi,

Staph Aureus, Pseudomonas and Candida Albicans

• Transient leukopenia is attributed to bone marrow suppression, WBC <2 , but spontaneously resolves

• Yellow/green exudate can be misinterpreted as infection

Sulfamylon • Manefate Acetate-the other white cream, can also be

used as 5% solution

• Not a true sulfonamide-but those with a sulfa allergy may have a reaction

• Antibacterial spectrum similar to silvadene, but has better pseudomonas coverage

• Has better eschar penetration, more effective with thicker eschar

Sulfamylon (cont)

• Less macerating, delays eschar separation

• Pain can occur with application to areas of partial thickness

• Can lead to bicarbonate (HCO3) wasting causing metabolic acidosis resulting in tachypnea and metabolic alkalosis

Full Thickness

Bacitracin/Triplemix • Petroleum based for superficial second degree

• Effective against gm+

• Renal function should be monitored when used over large area

• Yeast overgrowth can occur

Partial Thickness/ 2nd Degree

Betadine • Povodine-Iodine

• Effective for gm+, gm-, fungi and yeast, less effective against pseudomonas than sulfamylon

• Occasional pain with application

• Does not penetrate eschar well, delays separation

• Slows the development of granulation and epithelial tissue

Acticoat

• 3 layer dressing incorporates a silver coated polyethylene mesh

• Protects the wound from bacteria by the release of silver ions to the wound site

• Can be left in place up to 3-5 days

• Must be kept moist with sterile water, use over large areas can cause hypothermia

Aquacel Ag

• Benefits of Silver on a hydrofiber

• Absorbent

• Partial Thickness (light second degree)

Skin Substitutes

Dermal Coverage options

Allograft

Xenograft

Xenograft

• Several types used throughout the years, frog skin used in Brazil

• Pigskin since the ‘60’s, most common xenograft in U.S.

• For use on clean wounds/granulating tissue

• Available frozen and meshed

Xenograft • Epidermis removed in processing, cannot

obtain blood supply from wound so will slough

• Can remain in place 3-6 days dependant upon the wound

Allograft

• Cadaver skin, amnion

• Popular since the 50’s for excised and granulation tissue

• Bi-layer allows for some re-vascularization and maintains viability and some incorporation of dermal layer

• promotes development of granulation tissue

Allograft • Prevents wound desiccation

• Protects exposed tendons and vessels

• Epidermis will eventually reject

• Must be kept frozen

• Often difficult to obtain

Biobrane

• By-laminar construction with silicone bonded to nylon fabric and collagen peptides from porcine dermal collagen

• Provides a barrier function and controls vapor loss

• Effective on excised wounds, donor sites and grafts

• Provides no anti-microbial coverage, but minimizes proliferation

• Decreases pain, allows for mobility especially with the glove

• Needs removal with signs of infection

Esthetic and functional

recovery

Treatment — Reconstructive

Ladder

When no tx available

3rd Degree Need for skin grafting

http://www.ilstraining.com/bmwd/

bmwd/bmwd_it_04.html

Negative Pressure Wound

Therapy

Negative Pressure Wound

Therapy