TOPIC: BURNS
Source: Schwartz’s Principle of Surgery, 11th Edition
Trans by: PGMI TANGO, JHOE ANNA MHARIE P.
Team Alpha
GENERAL CONSIDERATIONS
o Burn injury historically carried a poor
prognosis
o 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.
o American Burn Association (ABA) has
emphasized referral to specialized burn
centers after early stabilization
o Specific criteria should guide transfer of
patients with more complex injuries or
other medical needs to a burn center
o Burn patients are transferred longer
distances for definitive care at regional
burn centers
Involves
four
crucial
assessments:
• Airway management
• Evaluation of other injuries
• Estimation of burn size
• Diagnosis of CO and cyanide poisoning
1. Airway management
 With direct thermal injury to the upper airway
and/or smoke inhalation (perioral burns,
signed nasal hairs), rapid and severe airway
edema is a potentially lethal threat
 Anticipating the need for intubation
and establishing an early airway is critical
 Signs of impending respiratory
compromise: hoarse voice, wheezing, or
stridor
2. Evaluation of other injuries
 Burn patients should be first considered
trauma patients (especially when details of
the injury are unclear), as such, a primary
survey should be conducted
 An early and comprehensive secondary
survey must also be performed in all burn
patients
 Urgent radiology studies (i.e. CXR) should be
performed in the ER, but non urgent skeletal
INITIALevaluation
ASSESSMENT(i.e. extremity X-rays) can be
done later to avoid hypothermia and
delays in burn resuscitation
 Cooling should be avoided in patients with
moderate or large (>20% TBSA) burns.
 Patients with acute burn injuries should
never receive prophylactic antibiotics.
 Tetanus booster should be administered in
the emergency department depending on
patient immunization status
3. Estimation of burn size
 Most burn resuscitation formulas estimate fluid
requirements using the burn size as %Total
BodySurface Area (TBSA).
 Thorough cleaning of soot and debris is
mandatory to avoid confusing areas of soiling
with burns
 Superficial (first degree) burns SHOULD NOT
be included when calculating the %TBSA
Various methods for TBSA approximation use
the following:
 TOPIC: BURNS
Source: Schwartz’s Principle of Surgery, 11th Edition
Trans by: PGMI TANGO, JHOE ANNA MHARIE P.
Team Alpha

1. Palmar suface Browder chart for burns

- the surface area of a patient’s palm (including
fingers) is roughly 0.8% of to al surface area.
- can be used to estimate relatively small burns
(<15% of total surface area) or very large
(>85%).
- Inaccurate with medium sized burns

2. “Rule of nines”
 is a crude but quick and effective method of
estimating burn size
The body is divided into areas of 9% and the
total burn area can be calculated.
 Not accurate in children

3. Lund and Browder chart

 the most accurate method
 compensates for the variation in body shape
with age
 therefore can give an accurate
assessment of burns area in children

Figure 2. Rule of nines to estimate burn size BURN CLASSIFICATION

1. Thermal Burns
• Flame Burns : Most common cause
for hospital admissions and with
highest mortality
• Contact Burns
• Scald Burns

2. Electrical Burns
• 3% of hospital admissions
• Has special considerations cardiac
arrhythmia and compartment
syndrome with concurrent
rhabdomyolysis (common in high-
voltage electrical injuries)
• baseline ECG is recommended in all
Figure 3. patient
Lund and • must be checked for vascular or
nerurologic compromise
• Long-term neurologic and visual
symptoms are also common and thus,
neurologic and ophthalmologic
consultation should be done
 TOPIC: BURNS
Source: Schwartz’s Principle of Surgery, 11th Edition
Trans by: PGMI TANGO, JHOE ANNA MHARIE P.
Team Alpha

3. Chemical Burns
• 3% of hospital admissions
• Result in potentially severe burns
• acid chemical burns - result in
coagulation necrosis
• alkali chemical burns - cause
liquefactive necrosis (with an
exception of hydrofluoric acid)
• Most important component of
therapy: careful removal of the toxic
substance from the patient and
irrigation of the affected area with
water for a minimum of 30 minutes.
• Offending agents can be
systemically absorbed and may
cause specific metabolic
derangements.
Figure4: Burn depth
BURN DEPTH

Burn wounds are commonly stratified according

to depth as superficial, partial thickness, full
thickness, and fourth degree burns, which affect
underlying soft tissue

1. Superficial (First degree burn)

• Painful but DO NOT blister
2. Partial thickness (Second degree burn)
 Extremely painful with weeping and blisters
 Classified as either superficial or deep
depending on the depth of dermal
involvement
- Superficial: Heals with expectant
management
- Deep: Requires excision and skin
grafting
3. Full thickness (Third degree burn)
 Painless, hard, and non-blanching
4. Fourth degree burn
 Affects underlying soft tissue
Burn wounds are also described according to
zone of tissue injury
Jackson’s three zones of tissue injury
Following burn
Zone of Most severely burned area
Coagulation (typically the center of the
wound)
Affected tissue is coagulated
and sometimes necrotic, and
will need excision and grafting
Zone of Between the first and third
Stasis zones with local response of
vasoconstriction and ischemia
It has marginal perfusion and
questionable viability
Resuscitation and wound care
may help prevent conversion to
a deeper burn
Burn wounds evolve over 48-
72 hours after injury
Zone of Outermost area, usually heals
Hyperemia with minimal or no scarring
There is increased blood flow
in this area
 TOPIC: BURNS
Source: Schwartz’s Principle of Surgery, 11th Edition
Trans by: PGMI TANGO, JHOE ANNA MHARIE P.
Team Alpha

FIGURE 5: Jackson’s three zones of

tissue injury - Several formulas are available to compute for
the total fluid requirement but among the most
widely used one is the:
Parkland formula
consists of 3 to 4 mL/kg per % burn of Lactated
Ringer’s, of which half is given during the first 8
hours after burn and the remaining half is given
over the subsequent 16 hours

PARKLAND FORMULA
Total fluid requirement* = 4 mg/kg per
PROGNOSIS %TBSA burn
½ volume ½ during next
during first 8 16 hours
Revised Baux Score hours post- post- injury
injury
• accounts for age, burn size, and inhalation
*Use of lactated ringer’s solution
injury
• age, burn size, and inhalation injury
o Continuation of fluid volumes should
continue to be the most robust indicators
depend on the time since injury,
for burn mortality
UO, and MAP
• nonelderly patients: comorbidities such
o As the leak closes, patient will
as preinjury HIV, metastatic cancer, and
kidney or liver disease require less volume to maintain the
- influence mortality and length of stay UO and BP
o Target MAP: 60 mmHg to
ensure optimal end-organ
• Burn Injury: significantly impact the
perfusion
subsequent quality of life for survivors,
o Target UO:30 cc/h in adults
including but not limited to appearance,
and 1 to 1.5 cc/kg/hr in
mobility, functional status, and ability to work. pediatric patients
o Maintenance IV fluid with
RESUSCITATION glucose supplementation in
addition to the calculated
resuscitation fluid with LR is
Continuous Fluid Requirement in Burns given in children under 20 kg
- burn (and/or inhalation injury) drives an o They do not have
inflammatory response that leads to capillary sufficient glycogen stores
leak to maintain an adequate
glucose level in response
- as plasma leaks into the extravascular space, to the inflammation.
crystalloid administration maintains the o Blood transfusions be used
intravascular volume only when there is an apparent
physiologic need
- Therefore, if a patient receives a large fluid o
bolus in a prehospital setting or emergency
department, the fluid has likely leaked into the INHALATION INJURY
interstitium, and the patient still requires ongoing
burn resuscitation - Commonly seen in tandem with
 TOPIC: BURNS
Source: Schwartz’s Principle of Surgery, 11th Edition
Trans by: PGMI TANGO, JHOE ANNA MHARIE P.
Team Alpha
burn injuries
- Smoke inhalation is present in as
many as 35% of hospitalized burn
patients
- Drastically increase mortality in
burn patients
- 25% up to 50% for patients with
>20% TBSA burns
- Combination of burns,
inhalation injury, and
pneumonia increases mortality
by up to 60%
- There is subsequent
development of ARDS
- Causes injury in 2 ways:
1. Direct heat injury to the upper
airways
 Leads to maximal
edema in the first 24 to
48 hours after injury
 Will require short course
of endotracheal
intubation for airway
protection
2. Inhalation of combustion
products into the lower airways
 Irritants (combustion
products) cause direct
mucosal injury leading to
mucosal sloughing,
edema, reactive
bronchoconstriction, and
eventually obstruction of
the lower airways
- Physiologic effects of smoke
inhalation include decrease lung
compliance, increase airway
resistance work of breathing, increase
overall metabolic demands, and an
increase in fluid requirements
during resuscitation of patients with
burn injuries (most common)
- Staging
of Inhalation Injury
The Abbreviated Injury Score
- Commonly used scale
- a scale from 0 to 4, with 0
representing no injury and 4
representing massive injury
- High score is associated with ARDS
• Diagnosis
- clinical presentation and
bronchoscopic evaluation remains the
best tool
- Decreased PaO2:FiO2 ratio (<350)
on admission may not only predict
inhalation injury but also indicate
increased fluid needs
• Treatment
- Supportive care including
aggressive pulmonary toilet,
routine use of nebulized agents
(e.g. Salbutamol) and ventilation
for ARDS
• Associated Injuries to Inhalation Injury
1. Carbon Monoxide Poisoning
- Clear, odorless gas
- Affinity of CO for hemoglobin is 200-
250x more than that of O2, which
decreases the levels of normal
oxygenated hemoglobin and can
quickly lead to anoxia and death
- may increase cardiac and neurologic
morbidity
- Unexpected neurologic or cardiac
symptoms should raise the level of
suspicion for CO poisoning
- Treatment:
o Administration of 100%
oxygen is the gold standard,
and reduces the half-life of
CO from 250 mins in room
air to 40-60 mins
2. Cyanide Poisoning
- Cyanide inhibits cytochrome
oxidase, which in turn inhibit
cellular oxygenation
- Patients may have severe lactic
acidosis, neurologic symptoms,
pulmonary edema, or cardiac sequelae
TOPIC: BURNS
Source: Schwartz’s Principle of Surgery, 11th Edition
Trans by: PGMI TANGO, JHOE ANNA MHARIE P.
Team Alpha
(ST elevation on electrocardiogram)
- Classic signs: (rare)
o including bitter almond
breath and cherryred
skin changes
- Treatment:
Consists of sodium thiosulfate,
hydroxocobalamin, and 100% oxygen
TREATMENT OF THE BURN WOUND
 Patients with acute burn injuries
should NEVER receive prophylactic
oral/IV antibiotics
 This intervention has been clearly
demonstrated to promote
development of fungal infections
and resistant organisms
1. Silver sulfadiazine: most widely used
- Wide range of anti-microbial
activity, primarily as topical
prophylaxis against burn wound
infections rather than treatment
of existing infection
- Not significantly absorbed
systemically
- Side effects: Neutropenia
as a result of neutrophil
margination due to the
inflammatory response to
burn injury
- Destroy skin grafts and is
contraindicated on burns in
proximity to newly grafted
areas
2. Mafenide acetate
- effective even in the presence of
eschar and can be used in both
treating and preventing wound
infections
- solution formulation is an excellent
antimicrobial for fresh skin grafts
3. Silver nitrate
- broad-spectrum antimicrobial
activity as a topical solution
4. Others: Bacitracin, Neomycin
and Polymyxin B – used for
smaller burns or larger burns
that are slightly healed
NUTRITION
 Nutritional Support – more
important with large burn areas
 Burn injury causes a
hypermetabolic response
raising baseline metabolic rates
by as much as 200%, leading to
catabolism of muscle proteins
and decreased lean body mass
that delay functional recovery
 Early enteral feeding for
patients with >20% TBSA help
prevent loss of lean body mass,
slow the hypermetabolic
response, and result in a more
efficient protein metabolism
 Early enteral feeds are also
associated with shorter duration of
ICU stay and decreased rates of
wound infection
 If enteral feeds are started
within the first few hours after
admission, gastric ileus can
often be avoided
 Caloric Needs
1. Harris-Benedict Equation
- calculates caloric needs using factors
such as gender, age, height, and weight
- uses an activity factor for specific injuries,
and for burns, the basal energy
expenditure is multiplied by two
- inaccurate in burns of <40% TBSA
2. Curreri formula
- estimates caloric needs to be 25 kcal/kg
per d plus 40 kcal/%TBSA per day
COMPLICATIONS IN BURN CARE
1. Hypothermia is one of the
TOPIC: BURNS
Source: Schwartz’s Principle of Surgery, 11th Edition
Trans by: PGMI TANGO, JHOE ANNA MHARIE P.
Team Alpha
common Pre-hospital
complications that contributes
to resuscitation failure
- Patients should be kept
wrapped with clean
blankets
2. Ventilator-associated
pneumonia, like all critically ill
patients, is a significant problem
in burn patients
- Simple measures such as
elevating the head of the
bed and maintaining
excellent oral hygiene and
pulmonary toilet are
recommended to help
decrease the risk of
postinjury pneumonia
3. Massive resuscitation of burn
patients may lead to an abdominal
compartment syndrome
- Characterized by
increased airway
pressures with
hypoventilation, and
decreased urine output
and hemodynamic
compromise
- Treatment: Decompressive
laparotomy is the standard of
care for refractory abdominal
compartment syndrome but
carries an especially lethal
prognosis in burn patients
- Adjunctive measures such as
minimizing fluid, performing
truncal escharotomies,
decreasing tidal volumes,
and chemical paralysis
should be initiated before
resorting to decompressive
laparotomy
4. Burn patients may be at
higher risk for catheter-
related bloodstream
infections
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, leading to compartment
syndrome
- Common in circumferential extremity
burns
- Warning signs include
paresthesia, pain, decreased
capillary refill, and progression to
loss of distal pulses
 Escharotomies
- rarely needed within the first 8
hours following injury and SHOULD
NOT be performed unless
indicated because of the aesthetic
sequelae
 Burn excision and wound
coverage should ideally start within
the first several days, and in larger
burns, serial excisions can be
performed as the patient’s condition
allows
 Excision is performed with
repeated tangential slices until
only non burned tissue remains
 It is appropriate to leave healthy
dermis, which will appear white
with punctate areas of bleeding
WOUND COVERAGE
 Split thickness sheet autografts
make the most durable wound
coverings
 In larger burns, meshing of
autografted skin provides a larger
area of wound coverage, allowing
drainage of blood and serous fluid
 TOPIC: BURNS
Source: Schwartz’s Principle of Surgery, 11th Edition
Trans by: PGMI TANGO, JHOE ANNA MHARIE P.
Team Alpha
to prevent accumulation under the
skin graft with subsequent graft
loss
 Areas of cosmetic importance such as the
face, neck, and hands should be grafted
with nonmeshed sheet grafts to ensure
optimal appearance and function
 DONOR SITES:
- Thighs make convenient
anatomic donor sites; they
are easily harvested and
relatively hidden from an
aesthetic standpoind
- thicker skin of the back is
useful in older patients, who
have thinner skin elsewhere
and may have difficulty with
healing of donor site
- buttocks are an excellent
donor site in infants and
toddlers
- scalp is also an excellent donor
site; the skin is thick and the
many hair follicles allow rapid
healing, with the added
advantage of being completely
hidden once hair regrows.
 Commonly used donor
site dressing: simple
transparent films to
hydrocolloids, petrolatum
gauzes, and silver-impregnated
dressing
 In choosing a dressing should
balance ease of care, comfort,
infection control, and cost.
2. CONTRACTURES
REHABILITATION
 Should be initiated on admission
3. HETEROTOPIC OSSIFICATION
 Immediate and ongoing physical
and occupational therapy is
mandatory to prevent loss of
physical functions
 patients with burns over joints, such
as with hand burns:
- passive range-of-motion
exercises done
at least twice a day
 foot and extremity burns
- instructed to walk independently
without crutches or other
assistive devices to prevent
extremity swelling, desensitize
the burned areas, and
prevent disuse atrophy
- when patients are not
ambulating, they
must elevate the affected
extremity to minimize swelling
 transition to outpatient care should
also include physical and
occupational therapy, with
introduction of exercises designed to
accelerate return to activities of daily
living as well as specific job-related
tasks
LATE COMPLICATIONS
1. HYPERTROPHIC SCAR
-pruritus, erythema, pain, thickened tight
skin, and even contractures
-increased inflammatory response,
irregular neovascularization, aberrant
cytokine and Toll-like receptor
expression, abundant
collagen production, and abnormal
extracellular matrix structure.
-Treatment:
nonsurgical therapies such as
compression garments, silicone gel
sheeting, massage,
physical therapy, and corticosteroid
-result from both wound contracture and
scar contracture and prevents range
of motion of a particular joint
- pathologic development of lamellar
bone in peripheral tissue
 TOPIC: BURNS
Source: Schwartz’s Principle of Surgery, 11th Edition
Trans by: PGMI TANGO, JHOE ANNA MHARIE P.
Team Alpha

PSYCHOLOGICAL RECOVERIES

 Psychological distress occurs in >38%

of patients
 Psychological rehabilitation is equally
important in the burn patient.
 Depression, PTSD, concerns about
image, and anxiety about returning to
society constitute predictable barriers to
progress

PREVENTION

1. “The Five Step Process,”

- A systematic method of
assessing, implementing, and
evaluating burn hazards and
subsequent intervention
impact
2. The Five E’S
- engineering/environment,
Enforcement, education,
emergency response, and
economic initiative