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Burns: An Introduction

• Burn injury: Tissue damage from heat, electricity, radiation, chemicals, or friction.
• Severity varies by depth, size, and affected area.
• Injuries can result in pain, swelling, blistering, scarring, infection, and organ dysfunction.
• Treatment options vary depending on the burn's degree and cause.
• Some injuries can be managed at home, while others require specialized medical attention.

Burn Unit Organization and Personnel: A Multidisciplinary Approach

• Surgeons, nurses, and specialists form a multidisciplinary team.
• This includes expertise in fluid resuscitation and early wound management.
• Critical care forms part of the specialist treatment
• Burn unit directors and qualified surgeons required in burn unit
• Dedicated nursing personnel are essential
• Access to physical and occupational therapists important
• Social workers, dietitians, pharmacists are important
• Respiratory therapists, psychiatrists, and psychologists needed
• Prosthetists are involved in aftercare and treatment

How Burns Disrupt Skin Function

• Burns lead to disrupted skin.
• They become barriers to microorganisms.
• They impact temperature regulation, fluid retention, sensory, and cosmetic appearance.

Pathophysiology of Burns

• Thermal burns lead to abruptly exceeding biologic tolerance causing damage to the skin and underlying tissues.
• Capillary leak with subcutaneous tissue damage results in inflammatory reactions.
• Intravascular fluid loss, increased temperature raise concern especially for admitted patients.
• "Burns are the most catabolic injury that humans can sustain."

Major Problems Encountered

• Fluid loss leads to dehydration and shock, with losses depending on % of the burnt area.
• For every 1% of surface area burned, expect a loss of approximately 4 mL of water.
• Loss of barrier from tissue loss leads to increased risk of infection.
• Severe burn patients have multiple entry points for microorganisms making them prone to infection.
• Burns cause an inability to maintain body temperature.
• Burns also lead to physical and functional deformities = contractures.
• Abuse should be suspected even in small burns to children.
• Comorbidities present another challenge for injured patients.
• Burn contractures are scar tissue that limit range of motion.

Guidelines for Referral to Burn Center

• Partial-thickness burns greater than 10% TBSA require referral.
• Burns involving the face, hands, feet, genitalia, perineum, or major joints need referral.
• Third-degree burns in any age group require specialized care.
• Electrical, chemical, and inhalation injuries should be referred.
• Referrals for burn injury in patients with complicated preexisting medical disorders
• Transfer patients with burns and trauma after stabilization.
• Qualified personnel needed for the care of burned children in hospitals.
• Referral is essential for burn patients needing special social, emotional, rehabilitation.
• TBSA = total body surface area.

Classifying Burns by Cause and Type of Injury

• Flame damage: from superheated oxidized air through convection and radiation.
• Scald damage: from contact with hot liquids.
• Contact damage: from hot or cold solids.
• Chemical damage: from noxious chemicals.
• Electrical damage: from electrical current running through tissues.
• Flame, scald, contact burns induce cellular damage mainly via transfer of energy.
• Transfers cause coagulative necrosis (except for cold).
• Electrical/chemical cause direct injury to cellular membranes in add. to energy transfer.

Jackson's Burn Injury Zones

• Zone of coagulation: Area of most severe burn injury.
• Cells directly disrupted, no capillary blood flow, and tissue appears whitish.
• Gray area of potentially salvageable tissue due to vascular damage.
• Zone of hyperemia: Outermost area with viable tissue and vasodilatation surrounding wound.
• Reddish in appearance, and most cells survive here

Injury from Heat

• Heat denatures proteins; this leads to cell necrosis and loss of plasma membrane integrity.
• Skin appears dry and leathery, is not painful, does not blanch, and may feel firm and waxy.
• Dead tissue and dried secretions provide temporary wound coverage/protection.

Stages of Burns

• Stage of shock occurs at the beginning
• Followed by the stage of Eschar formation.
• Final stage is the one of healing and reconstruction

Phases of Burn Care

• Emergent phase lasts 24-48 hours.
• Acute phase lasts from 48 hours to wound closure.
• Chronic phase addresses functional regain

Thermal Burns

• Flame: Common cause of admissions; high mortality rate
• Scalds: Related to hot water and steam.
• Contact: From hot object.

Chemical Burns

• Acids cause coagulation necrosis.
• Alkalis cause liquefactive necrosis.
• Initial therapy: Water irrigation for 30 minutes

Electrical Burns

• Associated with cardiac and compartment syndrome.
• ECG recommended.
• Vigilance needed for vascular and neurologic compromise.

Inhalation Burns

• Inhalational burn is a very severe type of injury that can occur when breathing in smoke in an enclosed area.
• Smoke inhalation can cause carbon monoxide poisoning, respiratory tract irritation, and asphyxia.

Inhalation Treatments

• Bronchodilators assist smoke inhalation.
• Nebulized heparin and acetylcysteine clear airway.

Classification of Inhalation Injury

• Upper airway injury is due to thermal burns obstructing the airway.
• Lower airway/lung parenchyma injury is due to chemical and particulate irritants.
• This results in inflammation, ventilation/perfusion mismatch, atelectasis, bronchospasm.
• Systemic injury leads to lactic acidosis, neurological damage, and cardiovascular insults.

Initial Patient Management

• Initial steps include intubation (if burns are 50% BSA), check. for additional injuries
• Insert IV line, Foley Catheter and NGT tube.
• Do not start DVT prophylaxis to avoid further bleeding out

Airway Assessment

• Assess for acute burns and swelling, and intubate for obstruction, edema, hypoxemia, altered mental status.

Immediate Concerns in Burn Care

• Airway obstruction, carbon monoxide poisoning, smoke-inhalation injury, fluid requirements.
• Indicators for intubation: Burns >40% Total Body Surface Area (TBSA), burns to the head and mouth.
• Also consider clinically significant smoke-inhalation injury and altered LOC.
• Carbon monoxide poisoning requires 100% O2.
• Assess surface-area by Rule of Nines or Lund-Browder chart.
• Use Parkland or Brooke formula with adjustments based on urine output.

Trauma Management

• Preparation, triage, primary survey (ABCDEs), and resuscitation.
• Adjuncts to primary survey/resuscitation; secondary survey.
• Monitoring, reevaluation, and definitive care are very essential.

Burn Assessment

• Assess extent/depth of burn injuries, and evaluate other injuries/abuse

Trauma Resuscitation Checklist

• Immobilize C-spine, secure airway, provide O2, place IV/IO access
• Order blood and determine GCS- complete Primary and Secondary Survey

Suspect Associated Injuries

• Explosion, falls motor vehicle crashes high voltage electrical
• Treat associated injuries first, before the burn!
• Treat burns more broadly if complex

Patient Burn History

• Type of burn, substances, and associated trauma
• Time of injury, space, and smoke amount
• Allergies, Medications, Prior illnesses, Last meal, Events

Primary and Secondary Burn Scene Care

• Turn off gas and remove from source.
• Keep low to avoid smoke.
• Position airway, start/CPR if needed, get clothing off, soak clothing, transport
• Ventilate area as needed

Burn Depth and Classification

• Superficial (1st degree): Confined to dermis, red, painful, blanches, heals in days.
• Partial thickness (2nd degree): Limited to papillary dermis.
• Erythematous, painful, blanching, blistering, and often leaves hair follicles intact.
• Counted in TBSA

Full-Thickness Burns (3rd Degree)

• Extends through the epidermis and dermis into the underlying fat.
• Skin is painless, hard, leathery eschar, and black, white, or cherry red.
• No epidermal or dermal keratinocytes remain, so skin grafting required.
• Skin does not blanch, and is included in TBSA calculations.
• Note: Critical monitoring is 3 days

Fourth/Fifth/Sixth Degree Burns

• Fourth: Affects underlying soft tissue with blackened and burned parts, remove with surgery
• Fifth: Affects through muscle to the bone
• Sixth: Charring bone is uncommon

Initial Trauma Approach

• Follow ATLS guidelines with primary/secondary surveys and ABCDEs.
• Treat life-threatening injuries before proceeding.
• Definitive and Tertiary surveys may happen as needed

Airway management

• Assure cervical spine protection.
• Patent airway before circulation.
• Administer oxygen.

Inhalation Support

• Monitor for stridor, hoarseness, singed eyebrows, and soot.
• Apply a hard cervical collar to immobilize the neck.

Breathing Assessment

• Once secure airway obtained, ensure adequate oxygenation/ventilation through the assessment of oxygen saturation.
• Monitor respiratory rate looking for signs of trauma.

Circulation Steps

• Stabilize airway, adequate ventilation, and focus on circulatory status.
• Assume there is hemorrhagic shock.
• Find bleeding: chest, retroperitoneum, pelvis, etc.
• HR: 60 for carotid, 70 for femoral, 80 for radial
• Skin Assessment: Colour/ Capillary Refill
• Administer correct IV
• Isotonic Crystalloid: 20 mL Bolus

Disability

• Determine Glasgow Coma Scale (GCS) includes the eye movement score, verbal, motor
• Disability: GCS and treatment hypoglycemia; seizure control
• Must maintain airway

Secondary Survey

• Thorough Hx
• Allergies, Medications, Prior illnesses, Last meal, Events

Rule of Nines

• Head: 9%
• Each arm: 9%
• Front/back of torso: 18% each
• Each leg: 18%
• Groin: 1%

Lund-Browder Chart

• Takes age into account, the % Tbsa for children is more accurate
• Takes into account body zones which vary with age

Berkow Diagram

• Used to estimate burn size from specific anatomical parts

Assessment Findings

• First degree: Tissue damage restricted to Epidermis
• Second degree: Involves Epidermis and part of Dermis (can be either superfiscial or deep partial thickness)
• Third degree: subcutaneous tissue and underlying muscle damage
• Fourth degree: Complete removal of everything. to bone

Immediate Concerns

• Administer 100% oxygen to prevent carbon monoxide poisoning.
• Surface-area estimated by using Rule of Nines or Lund-Browder chart.
• Fluid requirements determined by using Parkland Formula or Brooke formula (but can be adjusted if not meeting expected urine output).

Resuscitation Fluid

• Parkland is 4 mL/kg/ %TBSA burned
• Titrate hourly to urine output

Fluid Resuscitation

• Most deaths from inadequate fluid.
• Insert IV access, but 1st choice is least burnt area. if that doesnt work, try femoral or jugular
• If none work, then IO: Proximal tibia and Distal femur.
• 4mL/kg/TBSA with half given in 1st 8 hrs, and half given in 16 hours.
• Best formula use (for initial 24 hours),
• Next, the Glasgow needs to be the Galveston Formula

Choice of Fluid

• Parkland and Baxter: Lactated Ringer's
• Modified Brooke: Hartmans/Ringer's Lactate
• Galveston use PALS with D5% Lactated Ringer's

Pediatric Needs

• For paediatric patients, use more dextrose to prevent hypoglycemia

Wound management

• Clean area
• Bathe with warm water
• Unroof blisters, remove dead skin, and wash with betadine

Burn Wound Dressings

• Silver sulfadiazine: doesn't penetrate the eschar; painful to apply daily; inhibits epithelialization
• Bacitracin: Gram positive coverage; painful daily dressing changes.
• Silver nitrate: Effective to use against all microbes; associated with methemoglobinemia

Burn Wound Care

• Cleaning and debridement
• Use dressings to protect from damaged epithelium; bacteria; offer comfort; minimize evaporative heat loss; offer comfort

Escharotomies

• Surgical release of eschar done on the skin to improve the blood flow to the other parts
• Complications: Blood Less/Hypotension/More Edema/Hyperemia
• Additional fasciotomies may be required

Recommended Escharotomies

• In limbs requiring escharotomies, make incisions on the medial and lateral sides of the extremity.
• Use H2O or CO2 extinguisher;
• The objective of nutrition therapy in burn patients is to prevent malnutrition, which affects organ function, healing, and immunity.

Energy Expenditure Equations

• Curreri provides a slightly different way to estimate caloric/protein intake/etc and is based on 25 kcal/kg/day plus 40 kcal per %TBSA burned per day, which covers the maintenance and burn-related needs.
• More common, but not necessarily accurate on children.

Resuscitation Formulas

• Parkland is 4 cc/kg/% TBSA burned.
• Brooke is 2 cc/kg/% TBSA burned.
• Galveston is 5000 cc/m² burned, plus 1500 cc/m² total surface area (pediatric).

Burn Wound Dressings

• Salves consist of silver sulfadiazine, bacitracin, neomycin, and polymyxin B.
• Solutions consist of silver nitrate, mafenide acetate, Dakin’s solution, and Domboro’s solution.
• Antimicrobial dressings consist of silver-containing dressings.

Biologic Coverings

• Xenograft: Occlusive closure of the wound, some immunologic benefits
• Allograft: Some stuff as above

Formulas to predict calorie needs in severely burned children.

• Infants (0-12 months) have maintenance needs of 2100 kcal/% TBSA burned/24 hours, and burn wound needs of 1000 kcal/% TBSA burned/24 hours

Burn Key points

• When estimating smaller, irregularly placed burns, consider area to be 1%
• The zone of congestion is where no cells remain after the injury
• The area known as stasis, is were some 2nd and 3rd-degree burns remain
• The TBSA chart uses heat radiation and hot vapor in enclosed areas and cause Carbon Monoxide poisoning

Management of blisters

Pop, remove water, wet to dry

• A big cause of death in burn victims: Inadequate Fluid treatment
• Watch electrolyte levels
• Fluid loss for surface is 4mg per sq meter
• Debride as needed with betadine cleaning, antibacterial or longer sterile wrap

Rule or Nine

• Split back and front into 18%, groin 1%, top is 9% each arm 9% each leg 9%
• First 2 days keep it alone
• Third day pop and get it over with (keep the skin to protect)
• Water out of blisters contains bacteria -> Irrigate with wet to dry dressing.
• Contraindications for fluid intake IV: No, never on a genital injury
• Never place an NGT if trauma has basal skull fracture Note: The "Lifted from lecturer ppt" message indicates that information used to create the bullet point was taken directly or modified from a lecture, without any additional sources.