P.04 Burns PDF

PCC SOM 2026 SURGERY 1 P.04 BURNS SURGERY LECTURE LECTURER: DR. ABRAHAM CINIO DATE: JANUARY 27, 2024 TOPIC OUTLINE I. INTRODUCTION II. ETIOLOGY & CLASSIFICATIONS OF BURN III. PHYSICAL EXAMINATION (P.E.) IV. PRIMARY SURVEY V. SECONDARY SURVEY VI. BURN ASSESSMENT VII. FLUID RESUSCITATION VIII. NUTRITI...

PCC SOM 2026 SURGERY 1 P.04 BURNS SURGERY LECTURE LECTURER: DR. ABRAHAM CINIO DATE: JANUARY 27, 2024 TOPIC OUTLINE I. INTRODUCTION II. ETIOLOGY & CLASSIFICATIONS OF BURN III. PHYSICAL EXAMINATION (P.E.) IV. PRIMARY SURVEY V. SECONDARY SURVEY VI. BURN ASSESSMENT VII. FLUID RESUSCITATION VIII. NUTRITION INTRODUCTION A burn injury is a type of tissue damage that results from exposure to heat, electricity, radiation, chemicals, or friction. Burn injuries can vary in severity, depending on the depth, size, and location of the affected skin and tissues. Burn injuries can cause pain, swelling, blistering, scarring, infection, and organ dysfunction. Burn injuries require different treatments, depending on the degree of the burn and the cause of the injury. Some burn injuries can be treated at home, while others need medical attention and specialized care. PHYSIOLOGIC FUNCTION of SKIN DISRUPTED by BURNS Barrier to microorganisms Temperature regulation Fluid retention Sensory Cosmesis PATHOPHYSIOLOGY of BURNS Thermal burns, in particular, cause damage to the skin and occasionally underlying through abrupt temperature change that exceed biologic tolerance → membrane disruption, protein denaturation, and necrosis. May cause severe inflammatory reactions: o Capillary leak – because of exposed dermis and maybe subcutaneous tissues o Intravascular fluid loss o High fevers – this is a concern especially if patients are admitted. o Organ malperfusion – blood flow to one or more organs is reduced or blocked. o Multiple system organ failure (MSOF) – a life-threatening condition where two or more organs fail to function properly. Thermal burn injury → cell damage → cell death o Cellular and tissue injury secondary from exposure to extreme temperatures. o Cellular injury starts at temperature above 44°C. Most cell damage are seen at the capillary endothelium o Damaged capillaries will leak, as a result, water, electrolytes and plasma proteins are lost. Metabolic Response: o Hypermetabolism – increase glucose metabolism, lipolysis, and proteolysis o Neuroendocrine response – increase catecholamines, Thyroid hormone, ↑Cortisol. o Thyroid hormone is may be due to sepsis Note: “Burns are the most catabolic injury that humans can sustain.” MAJOR PROBLEMS ENCOUNTERNED IN BURN PATIENTS Fluid loss → Dehydration → Shock o Fluid loss will depend on the percentage of the burnt area, so we expect that for every 1% of surface area, it loses around 4 mL of water. Tissue loss → Loss of Barrier → Infection o Patients with severe burns have several entry points for microorganisms, so they are very prone to infection NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 1 | 18 PCC SOM 2026 SURGERY 1 Infection Inability to maintain body temperature Physical & functional deformities = contractures P.04 BURNS GUIDELINES FOR REFERRAL TO BURN CENTER Electricity and chemical burn injuries cause direct injury to cellular membranes in addition to the transfer of heat. The response of local tissues can lead to injury in the deeper layers. The area of cutaneous injury has been divided into three zones: o Zone of coagulation o Zone of stasis o Zone of hyperemia Jackson levels of burn injury 1) Zone of coagulation o Necrotic area of burn where cells were directly disrupted o Occupies the central area o Area of most severe burn injury o No capillary blood flow o “Whitish” ETIOLOGY AND CLASSIFICATION Burns are classified into 5 different causal categories and depths of injury: (Source: Sabiston Textbook of Surgery 21st edition, page 486) Flame, scald, and contact burn injury induce cellular damage primarily by the transfer of energy inducing coagulative necrosis (except for cold injuries, which do not engender protein denaturation). 2) Zone of stasis o The area immediately surrounding the necrotic zone (zone of coagulation) o Has a moderate degree of insult with decreased tissue perfusion (blood flow) o Depending on the wound environment, can either survive or go on to coagulative necrosis o Associated with vascular damage and vessel leakage o Salvageable by appropriate resuscitation 3) Zone of hyperemia o Outermost area surrounding the zone of stasis o Characterized by vasodilatation from inflammation surrounding the burn wound. o This region contains the clearly viable tissue from which the healing process begins and is generally not at risk for further necrosis. o “Reddish” NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 2 | 18 PCC SOM 2026 SURGERY 1 ADDITIONAL NOTES THERMAL BURNS 1) FLAME BURNS - Most common cause of hospital admission, accompanied by inhalation injury and highest mortality. 2) CONTACT 3) SCALD BURNS - Burns related to hot water; common in children. CHEMICAL BURNS Secondary to exposure to high acid and alkali concentration 3% of admitted burn patients Can potentially result in severe burns ACID ALKALI Can result in coagulation Liquefactive necrosis necrosis (except hydrofluoric acid which also cause Formic acid – causes hemolysis liquefactive necrosis) and hemoglobinuria ✓ Initial therapy is to irrigate the affected area with water for a minimum of 30 minutes ❖ Hydrofluoric acid behaves like an alkali that can cause severe hypocalcemia. ✓ If swallowed, drink large amounts of water and milk or antacids to dilute the acid. ✓ If poured on your skin or eyes, immediately flush the affected area for at least 30 minutes and apply calcium gluconate gel if available.  Do NOT induce vomiting or take baking soda P.04 BURNS ELECTRICAL BURNS 3% of US hospital admission Has direct effects on the body such as the heart. The heart is an electrical organ with nerves and areas offering the least resistance (blood vessels). SPECIAL CONCERNS OF ELECTRICAL BURNS 1. Cardiac arrhythmia - Baseline ECG is recommended in all patients 2. Compartment syndrome and rhabdomyolysis - Common in high-voltage injuries; muscles are literally destroyed that causes edema and results to compartment syndrome - Vigilance for neurologic or vascular compromise, & fasciotomies should be done even in cases of clinical suspicion 3. Long-term neurologic symptoms and cataract development - Neurologic and Ophthalmologic consultations should be obtained to define baseline function. INHALATIONAL BURNS Inhalational burn injury is a very severe type of injury that can occur when you breathe in smoke in an enclosed area. Smoke can cause three life-threatening conditions: o Carbon monoxide poisoning o Irritation or inflammation of the respiratory tract that leads to respiratory depression o Asphyxia NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 3 | 18 PCC SOM 2026 SURGERY 1 P.04 BURNS PHYSICAL EXAM ABC’s same as for any other trauma patient (Airway, Breathing, Circulation). Burn wound extent Burn wound depth Do not debride or dress burns until examination is complete Get the patient’s weight PRIMARY SCENE CARE Note: ABC’s are part of primary survey, while complete PE and history are part of secondary survey. BURNS: SUSPECT ASSOCIATED INJURIES Explosion Falls Motor vehicle crash with fire High voltage electrical Most important: Do NOT become a victim yourself! Turn off gas or pump or electric power, etc. if possible. Remove patient from heat source (push with dry nonconductive material if in contact with electricity). Immediately move patient from the vicinity if there is a danger of explosion. Keep low to avoid smoke; use protective breathing apparatus if available. Put fire out; extinguish burning clothing (H2O or CO2 extinguisher). First thing to do: Assess if the scene is safe! SECONDARY SCENE CARE Note: Treat the associated injuries first: Do not focus on just the burn! The burn patient initially should be treated as a trauma patient (not a dermatology patient) A major burn causes multi-organ dysfunction and is not just a skin injury; these patients can be the sickest & complex you may ever care for. BURNS: HISTORY Type of burn (flame, chemical, electrical, flash) Substances involved Associated trauma If in closed space Time of injury Duration of contact with smoke “AMPLE” – useful means of remembering key elements of the history, and it stands for: o Allergies o Medications o Prior illness/ Past medical history o Last meal (time) or other intake o Events preceding the injury o “S” is often added for ‘Signs and symptoms’ to make it S.A.M.P.L.E. Position airway; start O2 and/ or CPR if needed. Get off all potentially affected clothing. Soak clothing or the burn area if heat transfer is still possible; continue to irrigate copiously if it is a chemical burn. Ventilate the area if there is smoke present. Arrange a transport. Immobilize the neck & back, etc., if needed. Note: Secure the neck with a neck brace or cervical collar if there is a suspicion of spinal injury. For referral of patients called by the EMT/EMS to your hospital, the first thing to do is to protect yourself first by wearing PPEs. BURN DEPTH Classified by penetrance from the surface to the epidermis, dermis, subcutaneous fat, and underlying structures. NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 4 | 18 PCC SOM 2026 SURGERY 1 1) Superficial burns/ 1st-degree burns o Injury confined to the dermis o Painful, erythematous (red), and blanch to the touch with an intact epidermal barrier. o Example: Sunburn o Usually heals within few days o Does not result to scarring o Treatment is aimed at comfort with the use of topical soothing salves and oral NSAIDs o NOT counted in calculations of total burn surface area (TBSA) 2) Partial-thickness burns/ 2nd-degree burns o Divided into superficial and deep o Superficial partial-thickness burns ▪ Limited to the papillary dermis ▪ Erythematous (red), very painful, blanch to touch, and often blister. ▪ Hair follicles remain viable and intact ▪ Example: Scald injuries and flash flame burns ▪ Heals within 7 to 14 days ▪ With minimal scarring ▪ Counted in calculations of TBSA o Deep partial-thickness burns ▪ Burn within the reticular dermis ▪ Appear paler and more mottled ▪ Do not blanch to touch ▪ Remain painful to pinprick P.04 BURNS ▪ ▪ ▪ Heals within 15 to 21 days Often with severe scarring as a result of loss of dermal integrity. Counted in calculations of TBSA 3) Full-thickness burns/ 3rd-degree burns o Extend through the epidermis and dermis into the underlying fat o Characterized by a hard leathery eschar that is painless and black, white, or cherry red in color depending on the temperature of the source. o Loss of pinprick sensation → painless o No epidermal of dermal keratinocytes remain; thus, these wounds must heal by re-epithelialization from the wound edges. o Requires skin grafting o Counted in calculations of TBSA Blanching of the skin means that the skin turns white or pale when lightly pressed. This is a sign that the blood flow of the skin is reduced. Note: Critical monitoring of a burn patient is 3 days. NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 5 | 18 PCC SOM 2026 SURGERY 1 INTRODUCTION TO APPROACH TO A PATIENT WITH TRAUMA (BURNS) (Scwartz’s 11th ed. Page 183 & Surgery Platinum 1st ed. Page 147) The Advanced Trauma Life Support (ATLS) course of the American College of Surgeons Committee on Trauma was developed in the late 1970s, based on the premise that appropriate and timely care can improve the outcome for the injured patient. ATLS provides a structured approach to the trauma patient with standard algorithms of care; it emphasizes the “golden hour” concept that timely, prioritized interventions are necessary to prevent death and disability. Trauma is defined as cellular disruption caused by an exchange with environmental energy that is beyond the body’s resilience which is compounded by cell death due to ischemia or reperfusion. The ATLS provides a structured approach to trauma: o Primary survey or concurrent resuscitation o Secondary survey or diagnostic evaluation o Definitive or diagnostic evaluation o Tertiary survey P.04 BURNS o Disability and Neurologic status o Exposure/Environmental ✓ Note: Although at times restoring Circulatory volume may proceed active Airway intervention. ✓ Note: Life-threatening injuries must be identified and treated before progressing to the secondary survey. ❖ The purpose of Primary Survey is to rapidly identify and manage impending or actual life threats to the patient. PRIMARY SURVEY The first step in patient management is performing the primary survey (concurrent resuscitation), the goal of which is to identify and treat conditions that constitute an immediate threat to life. ATLS course refers to the primary survey as assessment of the “ABCDEs” o Airway management with cervical spine protection o Breathing o Circulation with hemorrhage control AIRWAY MANAGEMENT with CERVICAL SPINE PROTECTION The first priority in the primary survey is ensuring a patent airway. This is crucial because O2 delivery to the blood depends on a patent airway, and without O2, the cardiovascular system cannot function properly. At the same time, all patients with blunt trauma require cervical spine immobilization until injury is excluded. This is accomplished by placing: o Cervical collar, or NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 6 | 18 PCC SOM 2026 SURGERY 1 P.04 BURNS o Placing sandbags on both sides of the head with the patient’s forehead taped across the bag.  Cervical collars are NOT recommended for penetrating neck wounds because they provide no benefit and may interfere with assessment and treatment. Must ensure patency of airway and consider airway protection. o Visual inspection: airway cleared of any debris, blood and foreign bodies o Administration of oxygen is needed o Application of hard cervical collar or sandbags on both sides of the neck to immobilize neck (except with penetrating trauma) Manual airway maneuvers: serve to elevate the tongue out of the hypopharynx o Jaw thrust (Esmarch maneuver) o Chin lift o Head tilt is inappropriate with cervical spine control INDICATIONS FOR EMERGENCY ENDOTRACHEAL INTUBATION ✓ Acute airway obstruction ✓ Hypoventilation ✓ Severe hypoxemia despite supplemental oxygen ✓ Altered mental status (e.g., GCS 60 mmHg o Palpable femoral pulse: SBP >70 mmHg o Palpable radial pulse: SBP >80 mmHg Pail skin or nail bed capillary refill time >2 seconds indicates poor peripheral perfusion Differential for shock BREATHING & VENTILATION Once secure airway is obtained, adequate oxygenation and ventilation must be ensured. Airway patency alone does not ensure adequate ventilation. Assess for respiratory rate and oxygen saturation. Inspect for external signs of trauma and asymmetric chest movements. Venous access APPROACH TO SHOCK Hemorrhagic or blood loss Cardiogenic (tension pneumothorax, tamponade, blunt cardiac injury, ACS) Neurogenic IV catheterization with two largebore (14-16 gauge) catheters Venous cutdown (basilic or saphenous vein) Insertion of central line (internal jugular, subclavian or femoral vein) Intraosseous route (either the proximal tibia or distal femur) NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 7 | 18 PCC SOM 2026 Initial fluid resuscitation Hemorrhage control SURGERY 1 P.04 BURNS 20 mL/Kg IV bolus isotonic crystalloid (plain lactated ringer’s) Assessment of response to fluid resuscitation Facilitate blood transfusion as needed Temporize with direct pressure, tourniquets, or tying blood vessels Surgical intervention DISABILITY and NEUROLOGIC STATUS The Glasgow Coma Scale (GCS) score should be determined for all injured patients. It is calculated by adding the scores of the best motor response, best verbal response, and the best eye response. Consider spinal injury in appropriate cases (e.g., priapism, loss of anal sphincter tone & bulbocavernosus reflex) Scores range from 3 (lowest) to 15 (normal). Mild head injury Moderate injury Severe injury 13 – 15 9 – 12 ✓ Treat increased intracranial pressure (e.g., sedation, mannitol, hypertonic saline, surgical decompression) Kindly refer to Schwartz’s, Sabiston’s, and Platinum Surgery for further readings and complete understanding. I simply summarized most parts in the lesson. Thank you! ^_^ SECONDARY SURVEY ≤8 Once the immediate threats to life have been addressed, a thorough history is obtained, and the patient is examined in a systematic fashion. The patient and surrogates should be queried to obtain an AMPLE history: o Allergies o Medications o Past illnesses or pregnancy o Last meal and time of meal o Events and Environment related to the injury It is a rapid, systematic, and head-to-toe examination approach to the injured patient. Aside from history and physical examination, it includes special procedures such as radiography, laboratory tests, scans, and peritoneal lavage BURN ASSESSMENT This is a process of evaluating the severity and extent of a burn injury, as well as the potential complications and treatment options. The depth and degree of the burn, which indicate how much of the skin and underlying tissues are damaged. The size and location of the burn, which determine the percentage of the total body surface area (TBSA). MANAGEMENT OF DISABILITY: ✓ Airway maintenance ✓ Supportive: seizure control, treat hypoglycemia NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 8 | 18 PCC SOM 2026 SURGERY 1 P.04 BURNS OVERVIEW OF BURN INJURY MANAGEMENT RESUSCUTATIVE PERIOD (First 48 HOURS) ✓ Assessment of burn injury ✓ Classification of burn injury ✓ Criteria for admission ✓ Initial (ER) management o Fluid resuscitation o Wound dressing o Monitoring DEFINITIVE MANAGEMENT PERIOD (>48 HOURS) ✓ Excision and grafting ✓ Control of infection ✓ Nutrition ✓ Rehabilitation ✓ Complication Zones can be broken down into smaller sections or added together (i.e., front & back of the arms are 4.5% each) Example: an adult with burn injury to both legs (18% x 2), groin (1%), chest (9%), and abdomen (9%) would involve 55% of the body. ASSESSMENT OF BURN INJURY ESTIMATION OF BURN SIZE Burn size is expressed as percent total body surface area burned (%TBSA). Count only those areas with partial (second degree) or full thickness (third degree) burns. For estimating smaller, irregularly placed burns: consider the area of the open hand (including the palm an extended fingers) of the patient to be approximately 1% of TBSA. Other tools are available to estimate burn size (see below): RULE OF NINES or RULE OF WALLACE Assesses the percentage burn, used to help guide fluid resuscitation. Rough estimate only (not accurate on children). The number corresponds to the % involvement (usually 9%) for that body part: o Each arm = 9% o Each leg = 18% o Front of torso (chest & abdomen) = 18% o Back of torso (upper & lower back) = 18% o Head = 9% o Groin = 1% NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 9 | 18 PCC SOM 2026 SURGERY 1 P.04 BURNS LUND-BROWDER CHART More accurate method of assessing burn extent for children. Takes into consideration the age of the patient, with decreasing %BSA for the head and increasing %BSA for the legs as the child ages. There are three zones of the body that varies depending on age (e.g., head, thighs, & lower legs). Example: A 5-year-old female with burns in her right buttocks and entire right thigh has a 10.5% BSA involvement (8% for entire right thigh and 2.5% for right buttocks). ASSESSMENT OF BURN DEPTH BERKOW DIAGRAM TO ESTIMATE BURN SIZE (%) BASED ON AREA IN AN ISOLATED BODY PART For estimation of the extent of burn, one should use a burn diagram in which the % of BSA represented by anatomic parts at various ages is reflected. Example: A 6-year-old male was seen at the ER for burn injury. Half if his anterior trunk is burned. Using the chart below, %BSA burned is 6.5% (1/2 of 13%) (Source: Surgery Platinum 1st edition, page 163) NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 10 | 18 PCC SOM 2026 SURGERY 1 P.04 BURNS CLASSIFICATION OF BURN INJURY Secondary Survey (burn-specific): o History o Detection of the mechanism of injury o Time of injury o Consideration of abuse o Height and weight o Possibility of Carbon Monoxide intoxication o Facial burns o Tetanus immune status FLUID RESUSCITATION BURN SEVERITY CATEGORIZATION & MANAGEMENT Most common cause of mortality in the 1st 48 hours following a burn injury is inadequate fluid Patients with moderate and major burns will require fluid resuscitation via intravenous route (those with minor burns are encouraged to increase oral intake) The calculated fluid requirement should only serve as a general guideline to the amount of fluid needed, and end-points of resuscitation need to be monitored (sensorium, temperature, urine output, pulse, blood pressure, base deficit). Most common formula used is the Parkland or Baxter formula (for initial 24 hours): o INITIAL EMERGENCY ROOM MANAGEMENT Application of Emergency Room Management Primary Survey and Concurrent Resuscitation: o A: Airway o B: Breathing o C: Circulation o D: Disability o E: Environment control and exposure o F: Fluid resuscitation o IV fluid required is 3 to 4 mL/Kg per %TBSA burned (Lactated Ringer’s) ▪ Half given during the first 8 hours after burn ▪ Remaining half over subsequent 16 hours Calculate fluid loss from the time of injury, and take into account the fluid administered by prehospital personnel for fluid replacement NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 11 | 18 PCC SOM 2026 SURGERY 1 P.04 BURNS For children, use the Galveston formula (for initial 24 hours): o 5,000 mL per BSA (m2) per %TBSA burned + 2,000 mL per BSA (m2) D5% Lactated Ringer’s ▪ Half given during the first 8 hours after burn ▪ Remaining half over subsequent 16 hours o Add dextrose to the resuscitation fluid in children to prevent hypoglycemia, because children have smaller glycogen stores than adults o The standard Parkland formula commonly underestimates fluid requirements in a burned child Fluid needs for the Second 24 hours Postburn: o After the capillary leak has reversed itself, colloids (5% albumin in Ringer’s lactate or fresh frozen plasma 0.5%mL/Kg/%TBSA burned/day) are administered in the second 24 hours following burn. o Colloid volume is subtracted from the calculated crystalloid rate o Amount of crystalloids (D5 Water for adults, D5 ½ or ¼ Normal Saline for children) depends in the maintenance requirements plus the amount of transcutaneous evaporative losses from burn wounds (1 mL/Kg/%TBSA/day). o Amount is titrated to maintain normal urine output and mean arterial pressure (MAP) o Optimal MAP (for adequate end-organ perfusion) = 60 mmHg o Urine output goals: ▪ Adults: 0.5 mL/Kg/hr ▪ Children: 1-1.5 mL/Kg/hr WOUND DRESSING Performed in the sterile areas Give patient a full body bath using warm water & soap Debride the burned areas, removing dead skin and unroofing blisters Wash the burn areas with betadine soap and rinse with sterile water Dress wounds with a topical antibacterial or another dressing modality. (See appendix for a larger image) WOUND CARE After the airway is used and resuscitation is underway, attention must be turned to the burn wound. Treatment depends on the characteristics and size of the wound, and all treatments are aimed at a rapid and less painful healing. Burn wound treatment involves 3 stages: Assessment, Management, and Rehabilitation: o After assessing the extent and depth of the wounds, proceed to wound management. o Thoroughly clean and debride the wounds during this phase. Dressing functions: NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 12 | 18 PCC SOM 2026 SURGERY 1 P.04 BURNS o Dressings serve multiple functions: ▪ Protect damaged epithelium ▪ Minimize bacterial and fungal colonization ▪ Provide splinting action to maintain function ▪ Reduce evaporative heat loss and cold stress ▪ Offer comfort over painful wounds Choice of Dressing o Tailor dressing choice to wound characteristics: ▪ Superficial epidermal wounds – No dressing needed; topical salves keep skin moist ▪ Partial-thickness wounds – Daily dressing changes with topical antibiotics, cotton gauze, and elastic wraps or longer dressings containing silver. ▪ Deep partial-thickness or full thickness wounds – Consider excision and grafting; initial dressing should control bacterial proliferation and provide occlusion. ESCHAROTOMIES TOPICAL ANTIMICROBIAL AGENTS USED IN BURN CARE Antimicrobials are used to prevent and treat invasive wound infections in burn patients. They can be given topically or systematically, depending on the type and extent of the burn wound. Topical antibiotics can be classified into salves, soaks, and antimicrobial dressings, each with its own pros and cons. Salves are applied directly to the wound with cotton dressings, but may lose their effectiveness over time and cause shearing and pain during dressing changes. Soaks are solutions poured into cotton dressings, but may cause skin maceration and require constant monitoring of the solution level. Antimicrobial dressings are impregnated with silver or other agents, but may need to be kept moist and changed less frequently. Escharotomies are surgical procedures (can be done at bedside) to release the burn eschar that constricts the circulation or ventilation of the affected body parts. They are indicated for deep partial-thickness or full-thickness burns that encompass the circumference of an extremity or the trunk. They are performed by incising the eschar longitudinally along the lateral and medial aspects of the extremity or the chest. They aim to restore the venous outflow and arterial inflow to the distal beds or to improve the chest excursion and tidal volume. They are usually done at the bedside with a scalpel or electrocautery unit, and may be followed by excision and grafting of the wound. They may cause complication such as blood loss, transient hypotension, reactive hyperemia, and further edema formation in the muscle. NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 13 | 18 PCC SOM 2026 SURGERY 1 P.04 BURNS They may require additional fasciotomies if the muscle compartment pressures remain high after the escharotomy. However, this formula may overestimate the actual energy expenditure, which is: Pediatric burn patients (>40% TBSA) Convalescent burn patients 1.3 x predicted basal energy expenditure 1.1 x predicted basal energy expenditure Curreri formula is another common method to estimate caloric requirements in burn patients. It is based on 25 kcal/kg/day plus 40 kcal per %TBSA burned per day, which covers the maintenance and burn-related needs. It was derived from nitrogen balance data in severely burned adults, but may not be suitable for children. The recommended formulas for children vary by age group: (See appendix for a larger image) NUTRITION Severe burn causes hypermetabolism, which is a state of increased O2 consumption, metabolic rate, urinary nitrogen excretion, and lipolysis. Hypermetabolism is proportional to the size of the burn and can last for 9 to 12 months after injury. Hypermetabolism leads to high energy utilization and depletion of carbohydrate, fat, and protein stores, resulting in malnutrition and its complications. Malnutrition affects the function of many organs, the healing of the wound, and the immunity of the patient. Malnutrition can be prevented by providing adequate exogenous nutritional support, which is the main goal of nutrition therapy in burn patients. Caloric requirements in burn patients can be estimated by using the Harris-Benedict formula, (2 x basal energy expenditure). REFERENCES  Schwartz’s Principles of Surgery 11th ed., pages 183 and 251  Sabiston Textbook of Surgery 21st ed., page 484  Surgery Platinum 1st ed., page 161 NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 14 | 18 PCC SOM 2026 SURGERY 1 P.04 BURNS CHECKPOINT! TRUE or FALSE 1) Burns are NOT the most catabolic injuries that humans can sustain. 2) Contact burn includes burn injury caused by a hot water, soups, and sauces. 3) There are 3 areas/zones of cutaneous injuries and it includes: zone of coagulation, zone of necrosis, and zone of hyperemia. 4) Flame burns are the most common cause for hospital admission. 5) Initial therapy of chemical burns is to irrigate the affected area with water for a minimum of 30 minutes. 6) According to Schwartz’s, there are 3 special concerns associated with electrical burns, and this include: cardiac arrythmia, compartment syndrome and rhabdomyolysis, and long-term neurologic symptoms and cataract development. 7) In Primary Scene Care, the first thing to do is to wear proper protective equipment or PPE. 8) The goal of Secondary Survey is to identify and treat conditions that constitute an immediate threat to life. 9) The expected urine output goal for an adult burn patient is 1-1.5 mL/Kg/hr, while a pediatric burn patient is 0.5 mL/Kg/hr. 10) An escharotomy is contraindicated if the burn is superficial or is expected to heal without this surgical intervention. 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) TRUE OR FALSE ANSWERS FALSE (Burns are the most catabolic stress state, leading to significant lean body mass loss. This is due to the hypermetabolic response following a burn injury, which can last for up to two years post-burn. This response includes increased energy expenditure, insulin resistance, and increased protein breakdown. It’s important for burn patients to receive adequate nutrition to support healing and recovery). FALSE (Contact burn results from hot metals, plastic, glass or hot coals, while Scald burns are caused by hot liquids like hot water, soups, and sauces). FALSE (The 3 zones of cutaneous injuries include the zone of coagulation or necrosis, zone of stasis, and zone of hyperemia). TRUE TRUE TRUE FALSE (the first thing to do in Primary Scene Care is to assess if the scene is safe). FALSE (the role of Primary Survey is to identify and treat conditions that constitute an immediate threat to life). FALSE (in adults = 0.5 mL/Kg/hr, while in children = 1-1.5 mL/Kg/hr) TRUE (An escharotomy is only indicated for full-thickness or 3rd degree circumferential burns that cause significant swelling and compromise blood flow or respiratory function. A superficial burn does NOT require an escharotomy, as it does NOT cause a loss of skin elasticity or a risk of tissue necrosis). CHECKPOINT! CASE ANALYSIS #1 L.L.M. is a 25-year-old female lab technician, she accidentally spilled a hot, corrosive chemical on her leg at work. She was rushed to the ER where the doctor identified it as a 2nd degree chemical burn. 1) What common lab practice should L.L.M. have done prior to hospitalization? a) Apply ice to the affected area b) Apply butter to the burn c) Cover the burn with a cotton bandage d) Flush the affected area with water for 30 minutes 2) If you were the attending ER doctor for this patient and you identified the patient’s injury as a 2nd degree chemical burn, what classic findings would you look for that would identify her burn as a 2nd degree burn? Select all that apply. A) Red, blistered skin B) Severe pain and sensitivity to touch C) Swelling D) Wet or moist appearance to the skin E) Mottled, pink to red coloration 3) How could she have prevented her chemical burn on her leg? Choose the best answer. a) Use proper protective equipment b) Store the chemical on a locked cabinet or out of the reach of children c) Use the chemical in a well-ventilated area or with a mask d) Do not use chemicals at all 1) 2) 3) CASE ANALYSIS #1 ANSWERS D. Flush the affected area with water for 30 minutes All of the above (a, b, c, d, and e) A. use of proper protective equipment NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 15 | 18 PCC SOM 2026 SURGERY 1 P.04 BURNS CHECKPOINT! CASE ANALYSIS #2 A 25-year-old male was involved in a motor vehicle accident along Magsaysay Avenue, he was rushed by the EMTs to PCDH, and you were the E.R. doctor on duty. You assessed the patient that he sustained burns on his face, anterior chest, abdomen, and both arms with a score of 3 on Glasgow Coma Scale. He weighs 80 Kg and is 6 feet tall. Using the rules of nines, answer the following questions: 1) What is the estimated %TBSA burned? 2) What is the initial fluid resuscitation requirement for the first 24 hours using the Parkland formula? 3) What type of fluid should be used for resuscitation and why? 4) What are the potential complications of fluid resuscitation in this patient? CASE ANALYSIS #2 ANWERS 1) %TBSA = 40.5% Face = 4.5% Anterior chest = 9% Abdomen = 9% Left arm = 9% Right arm = 9% 2) 4 mL lactated Ringer’s X body weight of patient in Kg X %TBSA 4 mL X 80 Kg X 40.5% = 12,960 mL for 24 hrs Half of it in the 1st 8 hours = 6,480 mL Half of it in the remaining 16 hours 3) Lactated Ringer’s solution is a commonly used crystalloid fluid for resuscitation in burn patients, as it resembles the electrolyte composition of plasma and is isotonic. 4) Fluid overload, electrolyte imbalances and compartment syndrome NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 16 | 18 PCC SOM 2026 SURGERY 1 P.04 BURNS NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 17 | 18 PCC SOM 2026 SURGERY 1 P.04 BURNS NOTE TAKER: CHOMENWEY | DOMINGO | MARIANO | MARTINEZ | MEDRANO | PADAGAS | SANTIAGO Page 18 | 18