Burns Evaluation: Dr. Mahmoud W. Qandeel

Burns Evaluation
Dr. Mahmoud W. Qandeel

Outlines
• Introduction
• Pathophysiology
• Evaluation of burn
• Burn management
• Inhalational burn
• CO poisoning
• Chemical burn
• Electrical burn
• Cold Injuries

I. Introduction
There is no greater trauma than a major burn injury ( Sabiston ,

19th edition - 2012 )

Epidemiology
 Tissue injury : thermal, electrical, or chemical .
 Can be fatal, disfiguring, or incapacitating .
 Bimodal distribution of death .
 ~ 1.25 million burn injuries per year :

◦ 45,000 hospitalized per year .
◦ 4500 die per year (3750 from housefires) .
 3rd largest cause of accidental death .

Risk Factors
• Fire/Combustion:
– Firefighter
– Industrial Worker
– Occupant of burning structures
• Chemical Exposure:
– Industrial Worker
• Electrical Exposure :
– Electrician
– Electrical Power Distribution Worker
Skin
Function: Injury:
– Protects underlying tissues from injury . – Infection .
– Temperature regulation . – Inability to maintain normal water
– Watertight seal, keeping body fluids in . balance .
– Sensory organ . – Inability to maintain body
temperature .

II. Pathophysiology

Local Changes
• Coagulative necrosis.
• Damage depends on :
- Temperature .
- Duration .
- Specific heat .

• Zone of coagulation :
- Irreversible tissue damage .
• Zone of stasis :
- Decreased tissue perfusion .
- Vascular damage and vessel leakage.
• Zone of hyperemia :
- Vasodilation .
- Clearly viable tissue .

Wound excision
until fine punctate
bleeding occurs

Systemic Changes
• Inflammation and Edema
• Effects on the Renal System
• Effects on the Gastrointestinal System
• Effects on the Immune System
• Hypermetabolism

Inflammation and Edema
• Release of inflammatory mediators & vasodilation .

• Changes in Starling forces & permeability .
• Local & systemic edema .
• Cardiopulmonary alterations .

Effects on the Renal System
• Decreased RBF & GFR .(Oliguria /Anuria) .
• ATN & ARF if left untreated :

- 88% adult mortality .
- 56% pediatric mortality .
• Early resuscitation :
- Decreases renal failure .
- Improves mortality .

Effects on the Gastrointestinal System
• Mucosal atrophy .
• Changes in digestive absorption .
• Increased intestinal permeability .
• Changes in gut blood flow .
• Bacterial translocation .

Effects on the Immune System
• Proportional to burn size > 20% TBSA .
• Global depression in immunity .
• Infectious complications .
- Bacterial , viral & fungal .

Hypermetabolism
• Tachycardia, increased CO .
• Increased oxygen consumption .
• Proteolysis and lipolysis .
• Severe nitrogen loss .

III. Evaluation of Burns

Types of burns
• Thermal burn: Most common
– Scald
– Flame
– Flash
– Contact
– Frost bite
• Inhalational burn
• Electrical burn
• Chemical burn
Thermal burns
Scalds
• Most common type of burn injury
• Usually from hot water.
• Exacerbated by overlying garments that prolong contact
• Common burn injury seen in child abuse: Distribution exhibits a “dip” line pattern.

Flame
• Second most common type of burn injury
• Full-thickness burns are common given
the flammability of overlying garments.
Flash
• Related to the explosion of flammable liquids and gases
Contact
• Result from contact with heated or cooled objects.
• Seen frequently in industrial and trauma-related accidents

Burn Evaluation
• Depth (Degree)
• Extent (TBSA)
• Age
• Parts of body burned
• Past Medical History
• Concomitant injuries and illness
• Presence of inhalation injury

Burn depth

➢ First degree—only the epidermal layer is involved.
– Painful to palpation
– Pink in appearance without blistering
– Sunburn, UV light, mild radiation
– Blanches to the touch .
– No scarring .
➢ Second degree (partial thickness)—the dermal layer is only

partially involved.
– Very Painful to palpation
– White to pink in appearance;
blebs and blisters may be present.
– Deeper burns result in the destruction of
epidermal appendages.
– Scaring.
➢ Third degree (full thickness)—entire dermal layer affected
– All dermal appendages destroyed.
– The area is insensate.
– White, black, or red in appearance with a dry
and leathery (inelastic) texture
➢ Fourth degree - the underlying fascia, muscle, and/or bone is involved.

1st degree
• Sunburn is a very superficial burn.

• Maintain hydration orally.
• Heals in 7 days- generally no scarring
• Topical creams provide relief.
• No need for antibiotics . Dr. Mahmoud W. Qandeel
2nd degree

2nd degree
• Blisters are typical of deeper partial thickness burns.

• Don’t be in a hurry to break the blisters.
• Heals in 14-21 days
• Blisters provide biologic dressing and comfort.
• Once blisters break, red raw surface will be very painful.
3rd degree
• Yellow, “leathery” appearance; or charred

• Often have no sensation (nerve endings destroyed)
• Outer edges might be partial thickness.
• Initial management same as partial thickness.
• Later will need skin grafts.
Escharotomy Eschar

TBSA
The estimate of the TBSA of the burn injury is the sum of second- and third-degree
burns only.
Size estimation
The “rule of 9s” approximates the size of the affected area.
(1) 9% head and neck

(2) 9% each upper extremity
(3) 18% each lower extremity
(4) 18% anterior trunk
(5) 18% posterior trunk
(6) 1% perineum
Children have a proportionally larger head and trunk with a smaller lower
body

IV. Management

Prehospital
• Remove victims & stop burning .

• 100% oxygen . ( ? Inhalation )
• Extinguishing & removal of clothing & jewelry.
• Decrease the depth of the wound by pouring water .

Management in emergency room
• Resuscitation
– Oxygen
– IV access
– Fluids: Parklands fomula
– Foley’s catheter
– NG tube
– Escharotomy
• Continuous pulse oximetry
• Laboratory evaluation
• Moist dressing
• Analgesia
• Topical antimicrobial agents
• Tetanus prophylaxis
• Critical care issues: stress ulcer prophylaxis, VTE and sepsis
Initial Assessment
• Primary and secondary survey . C-spine protection .
• Suspect inhalation induced airway obstruction:

- Facial burns .
- Singed nasal hairs .
- Carbonaceous sputum .
- Tachypnea .
- Progressive hoarseness due to edema .

Wound Care
• Protection from the environment :
- Minimizing heat loss .
- Diminishing pain .
• By dry dressing , sheet & blankets .

• Avoid S.C & IM narcotics .

Resuscitation
• Consider Fluid Therapy for :
– >10% BSA 30
– >15% BSA 20
– >30-50% BSA 10 with accompanying 20
• LR using Parkland Burn Formula :

– 4 (2-4) cc/kg/% burn
– 1/2 in first 8 hours
– 1/2 over 2nd 16 hours
– Objective :
• HR < 100/minute
• Normal sensorium (awake, alert, oriented)
• Urine output - 30-50 cc/hour (adult); 0.5-1 cc/kg/hr (pedi) .
– Start through burn if necessary, upper extremities preferred .

– Monitor for Pulmonary Edema

wt in kg x % burn x 2 - 4cc / kg / %
100 kg patient with 50% TBSA burn:

100 x 50 x 2 = 10,000cc = 10 liters RL
This is calculated for the first 24 hours post-burn.

Give half of this in first 8 hours.
Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially

• Patient age :
– Less than 2 or greater than 55
– Have increased incidence of complication
• Burn configuration :
– Circumferential burns can cause total occlusion of circulation to an area
due to edema .
– Restrict ventilation if encircle the chest .
– Burns on joint area can cause disability due to scar formation .

Pertinent History
– How long ago?

– What care has been given?
– What burned with?
– Burned in closed space?
• Products of combustion present?
• How long exposed?
• Loss of consciousness?
– Past medical history?

Analgesia
Morphine Sulfate
• 2-3 mg repeated q 10 minutes titrated to adequate ventilations
and blood pressure .
• 0.1 mg/kg for pediatric .
• May require large but tolerable total doses .

Burn Wound
– Low priority - After ABC’s and initiation of IV’s
– Do not rupture blisters .
– Cover with sterile dressings
• Moist: Controversial, limit to small areas (<10%) or limit time of application .
• Dry: Use for larger areas due to concern for hypothermia .
• Cover with burn sheet .

Nutrition
• Severe burn increase BMR 200%.
• Curreri Formula:
– EMR= 25 kcal x kg + 40 kcal x %BSA
• Protein:
– 1.5 -2 g/kg/ day
• Target: prevention of body weight loss of > 10% of basal.
• Loss > 40% leads to death.
When to admit a burn case to burn centre?
1. Partial- and full-thickness burns of more than 10% TBSA in patients younger than
10 or older than 50 years.
2. Partial- and full-thickness burns of more than 20% TBSA in any other age group.
3. Full-thickness burns greater than 5% in any age group.
4. Involvement of the face, hands, feet, or perineum.
5. Presence of electrical, chemical, or inhalation injury.
6. High-risk factors—age older than 65 years, younger than 3 years; preexisting
medical problems; multi-trauma.
7. Suspicion of abuse or neglect.

V. Inhalational Injury

Inhalational burn
Suspect inhalation injury if the following are present:
1. Closed-space injury (e.g., house fire)
2. Presence of facial burns,
3. Singed nasal hairs,
4. Bronchorrhea,
5. Carbonaceous sputum,
6. Wheezing and rales,
7. Tachypnea,
8. Progressive hoarseness, and
9. Difficulty clearing secretions

Pathophysiology
• Mainly by inhaled toxins not heat .

• Edema &increase in lymph flow .
• Increase in lung neutrophils .
• Production of cytotoxic substances .
• Epithelial damage & exudate formation .

Clinical Picture
• 1st stage : acute pulmonary insufficiency :
- Airway obstruction .
• 2nd stage :Parenchymal damage : 72-96 hrs

- Similar to ARDS .
• 3rd stage :bronchopneumonia : 3-10 days .

Supraglottic Injury
– Susceptible to injury from high temperatures .

– May result in immediate edema of pharynx and larynx :
• Brassy cough .
• Stridor .
• Hoarseness .
• Carbonaceous sputum .
• Facial burns .

Subglottic Injury
– Rare injury .
– Injury to Lung parenchyma .
– Usually due to superheated steam, aspiration of scalding liquid .
– May be immediate but usually delayed
• Wheezing or Crackles .
• Productive cough .
• Bronchospasm .

Clinical Indications for Intubation
CRITERIA VALUE
PaO2 (mm Hg) <60
PaCO2 (mm Hg) >50 (acutely)
PaO2/FIO2 ratio <200
Respiratory/ventilatory failure Impending
Upper airway edema Severe

Inhalation Treatments of Smoke Inhalation Injury
TREATMENT TIME/DOSAGE
Bronchodilators (Albuterol) q2h

5000 to 10,000 units with 3 mL
Nebulized heparin
normal saline q4h
Nebulized acetylcysteine 20%, 3 mL q4h
Hypertonic saline Induce effective coughing
Epinephrine Reduce mucosal edema

CO Poisoning
• Seen in inhalation injury and it is a major contributor to mortality.

• Carbon monoxide (CO) displaces oxygen and binds hemoglobin, forming
carboxyhemoglobin.
• CO has a 200 times greater affinity for hemoglobin and cytochromes than
oxygen.
• Poor oxygen delivery is the result.
• Oxygen saturation levels are normal despite high levels of carboxyhemoglobin.

Treatment 100% O2 reduces half-life of CO. Dr. Mahmoud W. Qandeel
VI. Chemical Burns

• Usually associated with industrial exposure .
• First Consideration:
– Does the patient need decontamination before treatment?
• Burning will continue as long as the chemical is on the skin .

Acids
– Immediate coagulation-type necrosis creating an eschar though

self-limiting injury
• coagulation of protein results in necrosis in which affected cells or tissue
are converted into a dry, dull, homogeneous eosinophilic mass without
nuclei .

Alkali & dry chemicals
• Bases (Alkali) :
– Liquefactive necrosis with continued penetration into deeper tissue
resulting in extensive injury
• characterized by dull, opaque, partly or completely fluid remains of tissue .
• Dry Chemicals :
– Exothermic reaction with water

Chemical Burn Management
 Liquid Chemicals :
◦ wash off with copious amounts of fluid .
 Dry Chemicals :
◦ brush away as much of the chemicals as possible .
◦ then wash off with large quantities of water .
 Flush for 20-30 minutes to remove all chemicals .

Chemical Burn Management
• Do not attempt neutralization :
– can cause additional chemical or thermal burns from the heat of
neutralization .
• Assess and deliver secondary care as with other thermal and

inhalation burns .

• Hydrofluoric acid burns represent a distinct clinical scenario.
• In addition to being a corrosive agent, fluoride causes a severe, deep
liquefaction necrosis.
• Copious irrigation will attenuate the initial chemical burn, but

neutralization with calcium or magnesium is occasionally necessary to
halt further necrosis.

VII. Electrical Burns

• Usually follows accidental contact with exposed object
conducting electricity .
– Electrically powered devices .
– Electrical wiring .
– Power transmission lines .
• Can also result from Lightning .

• Damage depends on intensity of current .

 Voltage simply determines whether current can enter the body .
◦ Ohm’s law: I=V/R
 Electrical follows shortest path to ground .

 Low Voltage
◦ usually cannot enter body unless:
 Skin is broken or moist .
 Low Resistance (follows blood vessels/nerves) .
 High Voltage
◦ Easily overcomes resistance .

• Most damage done is due to heat produced as current flows
through tissues .
• Skin burns where current enters and leaves can be almost trivial
looking .
– Everything between can be cooked .
• Higher voltage may result in more obvious external burns .

• Alternating Current (AC) :
– Tetanic muscle contraction may occur resulting in:
• Muscle injury
• Tendon Rupture
• Joint Dislocation
• Fractures
– Spasms may keep patient from freeing oneself from current .

– Cardiac arrhythmias ,apnea & seizures .

• Outer skin might not appear too bad.
• But heat was conducted along the bone.
• Causes the most damage.
• Burns from inside out.
• Usually requires fasciotomy

• Lightning :
– HIGH VOLTAGE .
– Injury may result from

• Direct Strike
• Side Flash
– Severe injuries often result

• Direct strike: lightning directly hits the person
– Orifice entry: may occur if lightning strike occurs near the head entering eyes,
ears and mouth to flow internally
• Side splash: lightning jumps from the location of primary strike to a nearby person
• Contact injury: injury that occurs when a person is touching an object on the
pathway of lightning
• Ground current: lightning strikes nearby and the current travels through the ground
to the person

• Muscle pains, broken bones, cardiac arrest, confusion, hearing loss,
seizures, burns, behavioral changes, and ocular cataracts
• Characterized by a unique pattern of skin lesions.

• These tree-like lesions resemble feathering or ferning, and are also
called “Lichtenberg figures"

• “Flash” burns may refer to those that suddenly
flare up, then die down quickly.
• Patients may have burnt facial hair and carbon

on lips.
• Patients with this kind of facial burn will

probably NOT need an artificial airway.
• Give humidified oxygen while under close

observation.

Electrical Burn Management
• Make sure current is off .

– Do not go near patient until current is off .
• ABC’s .
– Ventilate and perform CPR as needed
– Oxygen
– ECG monitoring
• Treat dysrhythmias

Electrical Burn Management
• Rhabdomyolysis Considerations
– Fluid .
– HCO3
– Forced diuresis By Mannitol
– Dopamine?
• Assess for additional injuries .

• Consider transport to trauma center .

Any patient with an electrical burn regardless of how
trivial it looks needs to go to the hospital.
There is no way to tell how bad the burn is on

the inside by the way it looks on the outside .

VIII. Cold Injuries

COLD INJURY FACTORS
• Temperature • Immobilization
• Duration of exposure • Moisture
• Environmental conditions • Vascular disease
• Open wounds

**
TISSUE-FREEZING INJURY FROSTIBITE
• 1ST Degree • Hyperemia, edema

• 2nd Degree • Vesicles, partial-thickness skin necrosis
• 3rd Degree • Full-thickness skin necrosis
• 4th Degree • Skin, muscle, bone necrosis

MANAGEMENT
• Do not delay
• Remove clothing
• Warmed blankets
• Re-warm frozen part

MANAGMENT
• Preserve damaged tissue

• Prevent infection
• Elevate and expose injured
• Analgesics / tetanus / antibiotics

HYPOTHERMIA
• Core temperature < 35 degrees

• Rapid / slow drop in core temperature
• Elderly and children at greater risk

Clinical finding
• Core temperature < 35 degree
• Depressed level of consciousness
• Gray, cyanotic, variable vital signs
• Absence of cardiorespiratory activity

Not Dead Until Warm & Dead

Burns Evaluation: Dr. Mahmoud W. Qandeel

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Burns Evaluation

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

There is no greater trauma than a major burn injury ( Sabiston ,

Dr. Mahmoud W. Qandeel

 ~ 1.25 million burn injuries per year :

 3rd largest cause of accidental death .

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Release of inflammatory mediators & vasodilation .

Dr. Mahmoud W. Qandeel

• ATN & ARF if left untreated :

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

➢ Second degree (partial thickness)—the dermal layer is only

➢ Fourth degree - the underlying fascia, muscle, and/or bone is involved.

Dr. Mahmoud W. Qandeel

• Sunburn is a very superficial burn.

Dr. Mahmoud W. Qandeel

• Blisters are typical of deeper partial thickness burns.

• Yellow, “leathery” appearance; or charred

Dr. Mahmoud W. Qandeel

(1) 9% head and neck

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Remove victims & stop burning .

Dr. Mahmoud W. Qandeel

• Suspect inhalation induced airway obstruction:

Dr. Mahmoud W. Qandeel

• By dry dressing , sheet & blankets .

Dr. Mahmoud W. Qandeel

• LR using Parkland Burn Formula :

– Start through burn if necessary, upper extremities preferred .

Dr. Mahmoud W. Qandeel

100 kg patient with 50% TBSA burn:

This is calculated for the first 24 hours post-burn.

Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

– How long ago?

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Mainly by inhaled toxins not heat .

Dr. Mahmoud W. Qandeel

• 2nd stage :Parenchymal damage : 72-96 hrs

• 3rd stage :bronchopneumonia : 3-10 days .

Dr. Mahmoud W. Qandeel