Assessment and initial care of

burn patients
Robert Riviello, MD, MPH
University Teaching Hospital, Kigali
Brigham and Womens Hospital, Boston

Burn patient is a trauma

Stop burn process
A-B-C
Primary/secondary
survey
History

History
Flame/Scald

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 ?

Chemical/Electric

What was the agent ?

Duration of contact
What decontamination
occurred
What kind of electricity
was involved, voltage ?
Pathway of voltage
LOC, CPR ?

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

Epidermis

Protection from
desiccation
Protection from
bacterial invasion
Protection from
toxins
Fluid balance:
avoiding
evaporation
Neurosensory
Social-interactive

Dermis

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

2nd Degree

Wash
Debride blisters/loose skin
Closed dressing / Xeroform
Temporary skin substitute (biobrane)
Pain control
Clinic 1-2 days
Heals in 2 weeks

Superficial

nd
2

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)

3rd Degree

Wash, remove char

Silver sulfadiazine BID, closed
dressings
Early excision and grafting
Prophylactic IV Abx not
indicated

Deep

rd
3

Degree

rd
3

Degree

rd
3

Graft - Final Outcome

4th Degree burn

Tendon
Muscle
Bone
Frequent need for
amputations

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, nontoxic
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 60s,
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 50s 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 antimicrobial 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