BURNS

Priscilla Tulong
Dewa Ayu Praba
Intan Permata Syari
Leonardho Bayu
Indri .T
 Background
Burn injury historically carried a poor
prognosis.

With advances in fluid resuscitation and the

advent of early excision of the burn wound,
survival has become an expectation even
for patients with severe burns.
 Initial Evaluation
Initial evaluation of the burned patient
involves four crucial assessments:

airway management
evaluation of other injuries,
estimation of burn size, and
diagnosis of CO and cyanide poisoning.
 Airway Management
With direct thermal injury to the upper
airway or smoke inhalation, rapid and
severe airway edema is a potentially lethal
threat.

Perioral burns and singed nasal hairs are

signs that the oral cavity and pharynx
should be further evaluated for mucosal
injury, but these physical findings alone do
not indicate an upper airway injury.
 Airway Management
Signs of impending respiratory compromise may
include:
a hoarse voice
wheezing, or
stridor;
subjective dyspnea is a particularly concerning symptom
and should trigger prompt elective endotracheal intubation.

In patients with combined multiple trauma,

especially oral trauma, nasotracheal intubation may
be useful but should be avoided if oral intubation is
safe and easy
 A primary survey should be conducted in
accordance with ATLS guidelines.

Concurrently with the primary survey, large-

bore peripheral intravenous (IV) catheters
should be placed and fluid resuscitation
should be initiated; for a burn larger than
40% total body surface area (TBSA), two
largebore IVs are ideal
 Rarely, IV resuscitation is indicated in patients
with burns smaller than 15% who can usually
hydrate orally.
Pediatric patients with burns larger than 15%

may require intraosseous access in emergent

situations if venous access cannot be attained.
An early and comprehensive secondary survey

must be performed on all burn patients, but

especially those with a history of associated
trauma such as with a motor vehicle collision.
 Urgent radiology studies, such as a chest x-ray,
should be performed in the emergency department,
but nonurgent skeletal evaluation (i.e., extremity x-
rays) can be done in the intensive care unit (ICU) to
avoid hypothermia and delays in burn resuscitation.

Hypothermia is a common prehospital complication

that contributes to resuscitation failure. Patients
should be wrapped with clean blankets in transport.
Cooling blankets should be avoided in patients with
moderate or large (>20% TBSA) burns.
 Patients with acute burn injuries should never
receive prophylactic antibiotics.
A tetanus booster should be administered in the

emergency room.
Also consider treatment of long-term anxiety :

anxiolytic such as a benzodiazepine with the initial

narcotics.
Most burn resuscitation formulas estimate fluid

requirements using the burn size as a percentage of

TBSA (%TBSA).
The rule of nines is a crude but quick and effective

method of estimating burn size.

 In adults :

the anterior and posterior trunk each account for

18%
each lower extremity is 18%
each upper extremity is 9%, and
the head is 9%.
Guidelines for referral to a burn center
Partial-thickness burns greater than 10% TBSA
Burns involving the face, hands, feet, genitalia, perineum, or
major joints
Third-degree burns in any age group
Electrical burns, including lightning injury
Chemical burns
Inhalation injury
Burn injury in patients with complicated pre-existing
medical disorders
Patients with burns and concomitant trauma in which
the burn is the greatest risk. If the trauma is the greater
immediate risk, the patient may be stabilized in a trauma
center before transfer to a burn center.
Burned children in hospitals without qualified personnel for
the care of children
Burn injury in patients who will require special social,
emotional, or rehabilitative intervention
TBSA = total body surface area.
 An important contributor to early mortality in
burn patients is carbon monoxide (CO)
poisoning resulting from smoke inhalation.

Unexpected neurologic symptoms should raise

the level of suspicion, and an arterial
carboxyhemoglobin level must be obtained
because pulse oximetry can be falsely elevated.

Administration of 100% oxygen is the gold

standard for treatment of CO poisoning and
reduces the half-life of CO from 250 minutes in
room air to 40 to 60 minutes on 100% oxygen.
 Patients who sustain a cardiac arrest as a
result of their CO poisoning have an
extremely poor prognosis regardless of the
success of initial resuscitation attempts.

Hydrogen cyanide toxicity may also be a

component of smoke inhalation injury.

Afflicted patients may have a persistent

lactic acidosis or ST elevation on
electrocardiogram (ECG)

Cyanide inhibits cytochrome oxidase, which

is required for oxidative phosphorylation
 Treatment consists of
Sodium thiosulfate, hydroxocobalamin, and 100%
oxygen. Sodium thiosulfate works by transforming
cyanide into a nontoxic thiocyanate derivative,
but it works slowly and is not effective for acute
therapy.
Hydroxocobalamin quickly complexes with
cyanide, is excreted by the kidney, and is
recommended for immediate therapy.

In the majority of patients, the lactic

acidosis will resolve with ventilation, and
sodium thiosulfate treatment becomes
unnecessary.
 Classification of Burns
Burns are commonly classified as
Thermal
electrical, or chemical burns, with thermal burns
consisting of flame
contact, or
scald burns.
 Electrical burns make up only 4% of U.S. hospital
admissions but have special concerns including the
potential for cardiac arrhythmias and compartment
syndromes with concurrent rhabdomyolysis.

A baseline ECG is recommended in all patientswith

an electrical injury, and a normal ECG in a low-
voltage injury may preclude hospital admission.

Because compartment syndrome and rhabdomyolysis

are common in high-voltage electrical injuries,
vigilance must be maintained for neurologic or
vascular compromise, and fasciotomies should be
performed even in cases of moderate clinical
suspicion.
 Long-term neurologic and visual symptoms
are not uncommon with high-voltage
electrical injuries, and ophthalmologic and
neurologic consultation should be obtained
to better define a patients baseline
function.
 Chemical burns are less common but
potentially severe burns.

The most important components of initial

therapy are careful removal of the toxic
substance from the patient and irrigation of
the affected area with water for a minimum
of 30 minutes, except in cases of concrete
powder or powdered forms of lye, which
should be swept from the patient to avoid
activating the aluminum hydroxide with
water.
 The offending agents in chemical burns can
be systemically absorbed and may cause
specific metabolic derangements.

Formic acid has been known to cause hemolysis

and hemoglobinuria, and hydrofluoric acid causes
hypocalcemia.
Hydrofluoric acid is a particularly common
offender due to its widespread industrial uses
Calcium-based therapies are the mainstay of
treating hydrofluoric acid burns, with topical
application of calcium gluconate onto wounds19

and IV administration of calcium gluconate for

systemic symptoms
 Patients undergoing intra-arterial therapy
need continuous cardiac monitoring.
Persistent refractory hypocalcemia with
electrocardiac abnormalities may signal the
need for emergent excision of the burned
areas.
 Burn Depths
burn wounds are commonly classified as
superficial (first-degree), partial-thickness
(second-degree), fullthickness (third-degree),
and fourth-degree burns, which affect
underlying soft tissue.

Clinically, first-degree burns are painful but do

not blister, second-degree burns have dermal
involvement and are extremely painful with
weeping and blisters, and thirddegree burns
are leathery, painless, and nonblanching

RESUSCITATION
The most commonly used formula, the Parkland or Baxter formula,
consists of 3 to 4 mL/kg/% burn of lactated Ringers, of which half
is given during the first 8 hours after burn and the remaining half is
given over the subsequent 16 hours.

A classic study by Navar et al showed that burned patients with

inhalation injury required an average of 5.76 mL/kg/% burn. 3.98
mL/kg/% burn for patients without inhalation injury
The burn (and/or inhalation injury) drives an inflammatory
response that leads to capillary leak; as plasma leaks into the
extravascular space, crystalloid administration maintains the
intravascular volume.

Continuation of fluid volumes should depend on the time since

injury, urine output, and mean arterial pressure (MAP).

As in any critically ill patient, a target MAP of 60 mmHg ensures

optimal end-organ perfusion. Goals for urine output should be 30
mL/h in adults and 1 to 1.5 mL/kg/h in pediatric patients.
 One theory is that increased opioid analgesic use
results in peripheral vasodilation and
hypotension and the need for greater volumes of
bloused resuscitative fluids
The use of colloid as part of the burn

resuscitation has generated much interest over

the years. In late resuscitation when the capillary
leak has closed, colloid administration may
decrease overall fluid volumes and potentially
may decrease associated complications such as
intra-abdominal hypertension.
However, albumin use has never been shown to

improve outcomes in burn Patients and has

controversial effects on mortality in critically ill
patients.
 TRANSFUSION
A large multicenter study of blood
transfusions in burn patients found that
increased numbers of transfusions were
associated with increased infections and
higher mortality in burn patients, even
when correcting for burn severity.
 INHALATION INJURY AND
VENTILATOR MANAGEMENT
Inhalation injuries are commonly seen in
tandem with burn injuries and are known to
increase mortality in burned patients.
Treatment of inhalation injury consists

primarily of supportive care. Aggressive

pulmonary toilet and routine use of
nebulized bronchodilators such as albuterol
are recommended.
TREATMENT OF THE BURN
WOUND
Multitudes of topical therapies exist for the
treatment of burn wounds.
Silver sulfadiazine is one of the most widely
used in clinical practice. Silver sulfadiazine has
a wide range of antimicrobial activity, primarily
as prophylaxis against burn wound infections
rather than treatment of existing infections.
For smaller burns or larger burns that are
nearly healed, topical ointments such as
bacitracin, neomycin, and polymyxin B can be
used.
SURGERY
Full-thickness burns with a rigid eschar can form a
tourniquet effect as the edema progresses, leading to
compromised venous outflow and eventually arterial
inflow.
The resulting compartment syndrome is most common

in circumferential extremity burns, but abdominal and

thoracic compartment syndromes also occur.
Warning signs of impending compartment syndrome

may include paresthesias, pain, decreased capillary

refill, and progression to loss of distal pulses; in an
intubated patient, the surgeon should anticipate the
compartment syndrome and perform frequent
neurovascular evaluations.
 Escharotomies are rarely needed within the
first 8 hours following injury and should not
be performed unless indicated because of
the terrible aesthetic sequelae.
The strategy of early excision and grafting

in burned patients revolutionized survival

outcomes in burn care. Not only did it
improve mortality, but early excision also
decreased reconstruction surgery, hospital
length of stay, and costs of care.
 Once the initial resuscitation is complete and the
patient is hemodynamically stable, attention
should be turned to excising the burn wound. Burn
excision and wound coverage should ideally start
within the first several days, and in larger burns,
serial excisions can be performed as patient
condition allows.

It is appropriate to leave healthy dermis, which will

appear white with punctate areas of bleeding.
Excision to fat or fascia may be necessary in
deeper burns.
Rehabilitation
Rehabilitation is an integral part of the clinical
care plan for the burn patient and should be
initiated on admission.
Patients should be taught exercises they can do

themselves to maintain full range of motion.

Once patients have recovered from their acute

burns, many face management of the

hypertrophic burn scars. Treatment for these
scars has included nonsurgical therapies such
as compression garments, silicone gel sheeting,
massage, physical therapy, and corticosteroid
 Laser-based therapies provide addition
treatment options for symptomatic
hypertrophic scars. Two of the most
common ones are the pulsed dye laser
(PDL) and the ablative carbon dioxide (CO2)
laser.
Thank You