Management of the

burn patient

NATHAN STEWART
ADAPTED FROM PRESENTATION BY DR ALAN PHIPPS
 In 1997-2005 the rate of total Burn Injury related
deaths for Australia was 0.5 per 100,000 persons.
 In 2003-04 the age-adjusted hospitalisation rate of
fire, burn and scald related injury in Australia was
31.9 cases per 100,000 population per year.
 During the period of 2001-02, throughout Australia,
burns and scalds were responsible for 6,248
hospitalisations in public hospitals with the
average length of stay being 7.1 days incurring an
estimated cost of $132 million.
Progress in Burn Care 3

Fluid resuscitation
Dedicated burns units
Antimicrobials
Intensive care
Nutrition
Early excision
Skin cover
Specialisation
Classification of burns 4

Thermal

 hot

 cold
 Classification of burns 5

Thermal

 immersion
 cascade scalds
 Classification of burns 6

Thermal

 contact
 flame
 flash
Classification of burns 7

Chemical

 acid
 alkali
 organic chemicals
Classification of burns 8

Electrical

 low voltage
 high tension
 lightning
 Classification of burns 9

Friction

Radiation
Everybody

Every intervention influences the scar worn for life,

therefore, everyone who assists in the management
of that patient becomes a member of the burn care
team
First Aid for burns 11

Remove from burn source

Cold water - except when in contact with electricity
This has the most effect on the final outcome!
Still some effectiveness up to 4 hours post burn.

At least 20 minutes of cold running water.

Remove clothes. Need to avoid Hypothermia though!

Gels e.g. Burnshield
Cling film & dry clean sheet
No ointments, creams, powders, butter, etc. etc.
 12

Minor
burns
 Minor burns 13

Defined by exclusion of
 area more than 5% of body surface
 deep
 infected
 problem area - face, hands, perineum, feet
 inhalation injury
 other injury or underlying medical problem
 suspected non-accidental injury
Dressings for Burns
 15

Major
burns
Burns Resuscitation:
At the Scene
 Remove Patient & Self from Injury Source
 Extinguish actively burning material &
Cool burn (Tap Water)
 ABC: Airway, Breathing, Circulation (ATLS)
 Brief HISTORY: Time of Injury - For resuscitation
Nature of Injury- Flame, Indoors, Chemicals
 Brief EXAMINATION: Burn Size (% Total Body Surface
Area)
Burn DEPTH: Erythema (ignore)
Superficial Partial Thickness
Deep Partaial Thickness
Full Thickness
Burns Resuscitation:
In the A&E Department
 ATLS: ABC & Secondary Survey
 Brief HISTORY & EXAMINATION
 Airway/ Breathing Control
 FLUID RESUSCITATION - IVI*
 Baseline Investigations:
 FBC Chest Xray
 U&Es Blood Gases
 Carboxyhaemaglobin Toxicology
 Calculate the burn depth
Burns Resuscitation:
In the Burns Unit
 ATLS: ABC + Secondary Survey
 Full HISTORY:
 Full EXAMINATION: % Burn (TBSA)
Body Mass (Kgm)
 Resuscitation History: Fluids -
Crystalloid
- Colloid
 Reveiwed Protocol: Trials, Advances, Units, etc.
 MONITORING
Burns Resuscitation:
Monitoring
 Physiology: URINE OUTPUT
Haematocrit
Blood Gases
Urine Osmolality
Electrolytes & Urea
Nutritional Status
Cardiovascular Function
Burn Resuscitation:
A Team Effort
 Anaesthetist  Specialist Nurse
 Surgeon  Physiotherapist
 Intensivist  Occupational Therapist
 Microbiologist  Theatre Nurse
 Paediatrician  Ward Clerk
 Haematologist  Secretary
 Chemical  Play Therapist
Pathologist  etc
 etc
 Burn Resuscitation:
Airway
 HISTORY  EXAMINATION
Confusion / Altered
Consciousness
Fire in an ENCLOSED SPACE
e.g. House fire Burns to Face / Oropharynx
Car fire
Hoarseness / Stridor / Exp
Toxic fumes (Industrial)
rhonchi

Soot in nostrils or Sputum

Dysphagia / Drooling
Lower airway/pulmonary 22

problems
Primary burn damage

Pulmonary oedema

ARDS
Burn Resuscitation:
Airway
INVESTIGATIONS

 Blood Gases
 Carboxyhaemaglobin
 Chest X-ray
Burn Resuscitation:
Airway
TREATMENT
 FiO2 40 - 60% ? 100%
 Nebulisers - Saline
- Salbutamol / Terbutaline
 Oro/Nasal Intubation
 Tracheostomy
Burn Resuscitation:
Breathing
 COAD - Hypoxic Drive

 MECHANICAL:
 Upper Airway Swelling
 Chest Wall Constriction
Burn Shock 26

Likely if burned area more than

 15% body surface in adults

 10% body surface in children (and elderly)

Burn Resuscitation:
Shock

Definition
(Dietzman & Lillehei (1968))

The inability of the circulatory system to meet the

needs of tissues for oxygen & nutrients and the
removal of their metabolites.
Parkland formula 28
for fluid resuscitation
4ml Hartmann’s solution per 1% burn per
kg body weight

 half in first 8hrs post-burn

 half in the following 16hrs

= 0.25ml/%burn/kg/hr in first 8 hrs from

time of burn

colloid in second 24hrs

Burn Resuscitation:
Burn Depth

 Erythema - ignore
 Superficial Partial Thickness
 Deep Partial Thickness
 Full Thickness
Rule of nine 30
 Management of the 31

burned patient
Full “primary and secondary” surveys
Check for other injuries
Managing the burn wound 32
- considerations

Surgery vs. spontaneous healing

Mechanisms of healing
Pathological zones in the burn
Determination of burn depth
Influence of dressings
Depths of burn 33
Assessment of burn depth 34

Clinical examination: 50-75% accurate

Pinprick test

Repeated examination
Assessment of burn depth 35

Easy when very superficial

or full-thickness

Harder when intermediate

or mixed
Why excise the burn? 36

Burn wound is a focus for sepsis

Burn stimulates inflammatory mediators
Deep burns cannot heal without grafts
Possible effect on future scar quality
but
Non full-thickness burns may heal spontaneously
Superficial burns heal with acceptable scars
Excised burn wound must be closed
Major burn surgery is hazardous
Timing of surgery 37

“Ultraconservative”
Conservative
Early
Acute
Urgent surgery 38

High-tension electrical injury

Deep encircling burns - escharotomy

 limbs
 trunk
For small burns 39

Excision and grafting

as soon as clearly non-healing
Early excision of burns 40
Tangential excision to viable tissue on day 3-5

Janzekovic (1970)
Jackson & Stone (1972)
Tangential burn excision 41
and split skin grafting
Excision to fascia 42
Early burn surgery 43

Superior outcomes where suitably equipped

 mortality
 length of hospital stay
 morbidity during acute burn
 scar quality
Desirable surgical 44

management
Excision of all non-shallow burns as soon as
practicable in as few stages as possible

Closure of excised wounds with autograft, allograft

or artificial material

Definitive wound closure

Large area burns - the 45

problem
Area / mass of necrotic tissue
Shortage of donor sites
Infection
Systemic effects (SIRS, ARDS)
Associated problems of inhalation
Scar management 46

The potential problem

Scar management 47

Pre-emptive measures
 prompt surgery
 splintage & physiotherapy

Pressure garments and conformers

Silicone gel and contact media
Medical and surgical treatment
Scar management 48

Splintage
Pressure garments 49

Almost universally used

Apparently effective
Many published observations
Pressure garments 50

Aids to compliance
Conformers and splints 51
Silicone gel 52
Mechanism not fully known - not pressure