THE INITIAL ASSESSMENT

AND MANAGEMENT OF
MAJOR AND MODERATE
BURNS
Glenn Angelo S. Genuino, MD,FPCS,FPAPRAS
PLASTIC RECONSTRUCTIVE SURGERY
BURN SURGERY, COSMETIC SURGERY
UP-PGH
Manila Doctors Hospital
Makati Medical Center
Asian Hospital and Medical Center
St. Lukes Medical Center

OBJECTIVES

To discuss key points in the initial

ASSESSMENT of acute burn injury
To enumerate key points in the initial
MANAGEMENT of acute major burn injury
including
Airway management
Fluid resuscitation
Wound management

To discuss PRINCIPLES OF REFERRAL and

TRANSPORT of major burn patients

DIAGNOSIS

DIAGNOSIS
Size
extent

of body surface burned

TBSA

Total body surface area

Depth
1st,

2nd, 3rd degree

EXTENT OF BURN
rule of nines
Lund and Browder chart
Hand size

DEPTH

FIRST DEGREE (Superficial burn)

SECOND DEGREE (Partial thickness)

Superficial

partial thickness
Deep partial thickness

THIRD DEGREE (Full thickness)

FIRST DEGREE BURNS

Superficial, only the epidermis is involved

Local pain, erythema
No blister formation
Systemic response is absent or
mild
Require no treatment
-except for large burns of infants
or the elderly
Oily ointments / lotions that exclude air from the
burned area
-may give considerable relief

SECOND DEGREE BURNS

SUPERFICIAL partial-thickness
DEEP partial-thickness

SUPERFICIAL PARTIAL-THICKNESS
BURNS

Epidermis and dermis

Appear red, moist
Blister formation
Tactile and pain sensors are intact
Heal in 14 to 21 days with minimal
scarring

DEEP PARTIAL-THICKNESS
BURNS

Entire epidermis and most of dermis, leaving

only the skin appendages intact
Mottled appearance with areas of waxy-white
injury
Surface is dry and anesthetic
Heals spontaneously in 4-6 weeks

with unstable epithelium, late hypertrophic scarring,

marked contracture formation

THIRD DEGREE (FULL THICKNESS)

BURNS

Destruction of epidermis, dermis, and underlying

subcutaneous tissue

Appear white, cherry red, black

Thrombosed blood vessels may be visible

Elasticity of burned dermis is destroyed

Dry, leathery texture

MAJOR BURNS

Size-partial thickness

Size-full thickness
Primary areas involved

(face,

>25% adults
>20% children
>10%

perineum, hands, feet, joint areas, neck)

Inhalation injury
(+)
Associated injuries
(+)
Co-morbid factors
(+)
Treated in specialized burn unit

MODERATE BURNS

Size-partial thickness

15-25% adults
10-20% children
Size-full thickness
2-10%
Primary areas
not involved
Inhalation injuries
(-)
Associated injuries (-)
Co-morbid factors (-)
Treatment is done in general hospital

MINOR BURNS

Size-partial thickness

<15% adults
<10% children
Size-full thickness
<2%
Primary areas not involved
Inhalation injuries
(-)
Associated injuries (-)
Co-morbid factors (-)
Treated as
outpatient

INITIAL ASSESSMENT,
MANAGEMENT
AND STABILIZATION OF
MODERATE
AND MAJOR BURNS

THE PRIMARY
SURVEY

PRIMARY SURVEY
A Airway
B Breathing
C Circulation
Spine immobilization
Cardiac status
D Deficit (Neurologic)

E Expose &
Examine
F - Fluid
Resuscitation

AIRWAY, BREATHING
the compromised airway

chin thrust
Jaw lift
oral pharyngeal airway in the unconscious patient

auscultate for breath sounds in both lung fields

assess rate and depth of respiration
high flow Oxygen is started at (100%FiO2)
NON-REBREATHER BAG

circumferential FT burns of the upper trunk

ESCHAROTOMY
INHALATION INJURY

FACTORS SUGGESTING INHALATION

INJURY
1. Victim and fire in closed space
2. Flame burns of face, nose or mouth
3. Singed nasal hairs
4. Soot in nose, mouth, pharynx or sputum
5. Hoarseness, cough, wheeze, dyspnea
6. Hypoxemia or carboxyhemoglobin on
admission

GOLD STANDARD FOR DIAGNOSIS OF

INHALATION INJURY

FIBEROPTIC

BRONCHOSCOPY

ENDOTRACHEAL INTUBATION
For

expected swelling of upper airway,

performed BEFORE occlusion of airway
EARLY INTUBATION
AVOID tracheostomy

CIRCULATION

SYSTEMIC
Urine output
Pulse rate?
Blood pressure?

PERIPHERAL
skin color
sensation
peripheral

pulses
capillary refilling
compartment syndrome

Urine output: 30-50 cc/hr in adults, 1.2

cc/kg/hr in children
Sensorium: clear
Pulse: <120/minute
HCO3: >18 meq/liter
Cardiac output: >3.1 liters/m2

 INSERT

FOLEY CATHETER

COMPARTMENT SYNDROME
ESCHAROTOMY
FASCIOTOMY

DISABILITY
Assess

level of consciousness

A - Alert
V - respond to Verbal stimuli
P - respond to Painful stimuli
U - Unresponsive

EXPOSE
remove

all clothing and jewelries (e.g., rings,

watches)
clothing adherent to the burn should be left
untouched
ASSESS EXTENT TBSA

FLUID RESUSCITATION

Use 2 large bore IV cannulas

Peripheral
if possible not in burned areas

PARKLAND FORMULA
(BAXTER)
4cc x

kg body weight

in 1st 8 hours
in next 16 hours

TITRATE!

%TBSA

WHICH PATIENTS REQUIRE FLUID

THERAPY

>20% TBSA
Age < 2 y.o., > 60 y.o
Electrical injury
Individual considerations
Delayed

treatment
Alcoholics
Previous illness

THE SECONDARY
SURVEY

SECONDARY SURVEY
A. Circumstances of Injury
cause

of burn
did injury occur in a closed space?
is there a possibility of smoke inhalation?
were chemicals involved?
was there related trauma?

B. Medical History
A - Allergies
M - Medications/Tetanus Immunization
P - Previous Illness/Past Medical History
L - Last meal or drink
E - Events preceding the injury

C. OTHER MANAGEMENT
PRINCIPLES

INSERT NASOGASTRIC TUBE

>

20% TBSA

TETANUS PROPHYLAXIS
PAIN RELIEF
EMOTIONAL/PSYCHOSOCIAL
SUPPORT

BASELINE STUDIES
Hematocrit
Electrolytes
BUN
Urinalysis
CXR

REFERRAL AND
TRANSPORT

REFERRAL CRITERIA

2nd and 3rd degree burns of

>

2nd and 3rd degree burns

>

10% BSA <10 and >50 y/o

20% BSA other age groups

2nd and 3rd degree burns in serious threat

of functional or cosmetic impairment that
involve
face,

hands, feet, genitalia,

perineum and joints

REFERRAL CRITERIA

3rd degree burns >5% BSA in any age group

Significant electrical burn injuries including
lightning injury

Chemical burns
Circumferential burns of extremity or chest
BI in patients with pre-existing medical
disorder

Any burn patient with concomitant trauma

Burned children

Severe exfoliative diseases

TRANSPORTATION

2 Phases
Initial

transport

from the scene to the nearest medical facility

Secondary

transport

Referral to the burn center

INITIAL TRANSPORT

minimize contamination
baseline vital signs should be obtained
if far - IV line should be secured and electrolyte
solution started
O2 should be administered to all patients with
flame burns
cardiac monitoring should be done to all
electrical injury patients due to dysrrhythmias
avoid too rapid cooling -- dysrrhythmias

SECONDARY TRANSPORT

Secure an adequate number of IV routes

2

IV sites are necessary

Adequate height of IV column in ambulance:

Placement of NGT is important
Maintenance of core temperature
Endotracheal intubation must be done
before transporting the patient if indicated

Patients with major burns should be

accompanied by a
physician,

and
experienced nurse or a
paramedic trained in advanced life support
techniques

Use of portable cardiac monitors

particularly in electrical injury patients is
helpful.

NUTRITION

EARLY FEEDING
Maintenance

of intestinal mucosa
Better long term results