BURN

S
REPORTER: JOHN JEREMIAH B. CRUZ, M.D
3rd Year Surgical Resident
BGH-MC

MODERATOR: GENE L. ESTANDIAN, M.D, FPCS, FPSGS

Surgical Consultant (PLASTICS SURGERY)
BGH-MC
1
1. INTRODUCTION
2. INITIAL EVALUATION
2

3. BURN
3
CLASSIFICATION AND
DEPTH
4. RESUSCITATION
4
5. TREATMENT

5
6. “NEW NORMAL”

6
 I
“A burn is defined as damage to the

1
N
skin and underlying tissues caused by T
heat, chemicals, or electricity. “ - ABA R
O
D
U
C
T
I
O
N
 I

1
Historically carried a poor N
prognosis. T
R
O
D
Increased survival due to: U
1. Advances in fluid C
resuscitation T
2. Advent of early I
excision of the burn O
wound N
 Burn
I

1
Centers in
N
the
T
Philippines
R
:
1. Philippine General O
Hospital D
2. Jose Reyes Memorial U
Medical Center
C
3. East Avenue Medical
Center T
4. Southern Philippine I
Medical Center O
5. Quirino Memorial N
Medical Center
 I
N

1
I
A. Airway Management T
I

2
A
L

B. Evaluation of other Injuries E

V
A
L
U
A
C. Estimation of Burn Size T
I
O
N
 I
N

1
I
A. Airway Management T
I

2
A
L
Signs of Impending Respiratory
Compromise: Adult E
V
• Subjective complaint of Dyspnea A
• Hoarseness of Voice L
• Wheezing U
• Stridor A
• Perioral Burns and Singed nasal hairs T
I
O
N
 I
N

1
I
A. Airway Management T
I

2
A
L
Signs of Impending Respiratory
Compromise: Pedia E
V
• Hoarseness of Voice A
• Increased work of breathing L
• Tachypnea U
• Use of accessory muscles or sternal A
retractions T
I
O
N
 I
N

1
What if airway is I
T
compromised? I

2
A
L

E
V
Z A
L
U
A
T
- OROTRACHEAL INTUBATION I
- NASOTRACHEAL INTUBATION O
N
 I
N

1
B. Evaluation of other I
injuries T
I

2
A
L

E
“ Burned patients are trauma patients V
A
and evaluated with a primary survey in L
accordance with Advanced Trauma Life U
Support guidelines” A
T
I
O
N
 The Primary survey consists of the following: I
N

1
A
Airway maintenance I
with cervical spine T
protection
I

2
B
Breathing and A
ventilation L

C
Circulation and Cardiac
Status with V
hemorrhage control A
Disability, Neurological L

D Deficit and Gross

Deformity assessment
U
A
T

E Exposure and
Environmental Control
I
O
N
 I
C. Estimation of Burn Size N

1
I
T
I

2
A
L

E
V
A
L
U
A
T
I
O
N
 I
C. Estimation of Burn Size N

1
I
T
I

2
A
L

E
V
A
L
U
A
T
I
O
N
 I
C. Estimation of Burn Size N

1
I
T
I

2
A
L

E
V
A
L
U
A
T
I
O
N
 I
C. Estimation of Burn Size N

1
I
T
I

2
A
L

E
V
A
L
U
A
T
I
O
N
 B

1
A. Thermal - Flame burns are the most common U
- Flame cause for hospital admission of burns, R
- Contract and have the highest mortality. N

2
- Scald
C
L
A

3
- make up 3% of U.S. hospital admissions with S
special concerns S
- B. Electrical
High voltage = >1000V
I
F
I
C
ACID: COAGULATION NECROSIS (Except
A
HYDROFLUORIC ACID), causes tanning of the T
C. Chemical skin resulting to impermeable barrier I
ALKALI: LIQUEFACTIVE NECROSIS O
N
 INVOLVED B

1
DEPTH SYMPTOMS/ U
STRUCTURE REMARKS R
1. Superficial (first- Epidermis - painful but do not blister N

2
degree) - not included on fluid
requirement computation C
2. Partial-thickness - extremely painful are L
(second-degree) weeping and with A

3
a. Superficial Superficial Dermis blisters S
- Blanching when pressed S
b. Deep I
Deep Dermis - Can result to
contractures F
I
C
Full-thickness (third- Up to Subcutaneous Fat -leathery, painless, and A
degree) nonblanching T
I
Fourth- degree Up to underlying Soft O
tissues N
S B

1
uperficial thickness burn U
R
N

2
C
L
A

3
S
S
I
F
I
C
A
T
I
O
N
S B

1
uperficial thickness burn U
R
N

2
C
L
A

3
S
S
I
F
I
C
A
T
I
O
N
F B

1
ull thickness burn U
R
N

2
C
L
A

3
S
S
I
F
I
C
A
T
I
O
N
So what is the use of classifying injury based on depth?
B

1
U
R
N

2
C
L
A

3
S
S
I
F
I
C
A
T
I
O
N
B

1
U
R
N

2
C
L
A

3
S
S
I
F
I
C
A
T
I
O
N
B

1
U
R
N

2
C
L
A

3
S
S
I
F
I
C
A
T
I
O
N
 R

1
Parkland Formula (3-4 ml/kg/%TBSA/24 hours) E
- 1st half is given during the 1st 8 hours after burn S
and 2nd half given over the subsequent 16 hours

2
U
S
C

3
Modified Brooke Formula (2 ml/kg/%TBSA/24 hours) I
T
A

4
“Consequently, crystalloid fluid is the cornerstone of T
resuscitation for burn patients. Lactated Ringer’s (LR) is I
the fluid of choice for burn resuscitation because it is O
widely available and approximates intravascular solute N
content”. -ABA
 R

1
“It is important to remember that any formula for burn
resuscitation is merely a guideline, and fluid must be E
titrated based on appropriate response to therapy.” - S

2
Schwartz U
S
Common Parameters for Titration for Burn Resuscitation: C

3
• Blood Pressure I
• Urine Output T
Adults: 0.5 ml/kg/hour (or 30-50 ml/hour)
A

4
Young Children (weighing ≤ 30kg): 1 ml/kg/hour
Pediatric (Weighing > 30 kg,up to age 17): 0.5 ml/kg/hour T
Adult patients with high voltage electrical injuries with I
evidence of myoglobinuria: 75 – 100 ml/hour until urine O
clears. N
• Critically Ill patients: MAP of 60mmHg
Medication Advantages Disadvantages

1
A. Silver - Wide range of - Used as prophylaxis rather than
Sulfadiazin
e
antimicrobial activity treatment of existing infection
- Inexpensive, easily applied - Causes Neutropenia T
and with soothing qualities - Causes Allergic Reaction to
R

2
- Not absorbed systemically Sulfa component
- Destroys Skin grafts
- Delays healing in partial
thickness wounds
E
A

3
B. Mafenide - Effective even if with - Painful if applied to partial
Acetate Eschar
- Used as prevention and
thickness wounds
- Can cause Metabolic Acidosis
T
treatment for ongoing M

4
infection
- Can be used for fresh skin
grafts
E
C. Silver - Has broad spectrum - Can cause hyponatremia and N

5
Nitrate antimicrobial activity rarely methemoglobinemia
- Inexpensive - Causes Black/Dark stains T
Medication Advantages Disadvantages

1
D.
Bacitracin,
- Useful for smaller burns or - Can cause nephrotoxicity
nearly healed burns and - Cannot be used in large burns T
Neomycin, Superficial Partial
R

2
polymyxin thickness burns
- Useful in Meshed skin
grafts E
A

3
E. Silver
Impregnate
- Can be used for donor
sites, skin grafts, and
- Limits serial wound examinations T
d Dressing partial thickness burns M

4
(Aquacel - Can be used to avoid daily
Ag) dressing change
E
F. MEBO
(Moist
- - Promotes cell
regeneration and wound
- Expensive
N

5
Exposed
Burn
healing
- Less dressing changes T
Ointment (every 3-4 days)
 1
N

B
E

2
W
URN SURGICAL
MANAGEMENT N

3
O
R

4
M
EW NORMAL IN THE BURN
A
OPERATING ROOM
L

5
6
 General wound care recommendations:

1
Superficial Partial thickness burns
N
E

2
W
• SPT’s and donor sites of split thickness skin
N

3
grafts can benefits from closed/occluded
dressings for long period (about a week) O
• Humid, heat preserving modern R

4
dressings are preferred (e.g. Foam, M
hydrocolloid, hydrofiber) A
• Moist dressing/conventional for low-
L

5
resource settings (e.g. Silver sulfadiazine
wet-to-dry dressing)

6
 General wound care recommendations:

1
Superficial Partial thickness burns
N
E

2
W
• If infection is being entertained (eg.
N

3
Delayed presentation, use of inappropriate
burn first aid such as wounds covered with O
sand, dirt or toothpaste: R

4
• Dressing should be done more often M
(every 2-3 days) to allow inspection and A
cleansing with proper
L

5
antimicrobacterial solutions

6
 General wound care recommendations:

1
Deep Partial and Full thickness burns
N
E

2
W
• Closed/Occluded dressings is the rule for DPT’s and full
thickness burns
N

3
• DPT/FT’s avascular nature predisposes these burns to
bacterial colonization and subsequent infection
• Eschar remains soft allowing tangential excision O
• Protect the eschar from infection R

4
• Prolongs contact of antimicrobial agent with the
eschar M
• Prevents desiccation, fluid and heat loss
• Consensus: use of antimicrobials dressing (Silver, Povidone)
A
L

5
favored over antibiotics creams
• Less bacterial resistance
• Once eschar has separated, these wounds can be
dressed/prepared as raw area wounds with closed dressing

6
Burn Surgical Management

1
N
E
• Burn wound excision

2
• Early Excision and grafting W
• Reduce infection rate
• Reduce length of hospital
N

3
stay
• Improve survival
O
R

4
• Wound closure/reconstruction M
• Skin Grafting
• Flap Surgery A
L

5
• Application of skin substitutes
• Scar management and
resurfacing

6
Tangential Excision

1
• Most common Technique N
• Sequential debridement of burn
tissue until a layer of viable
E

2
vascularized tissue is encounter W

3
O
R

4
M
A
L

5
6
Fascial Excision

1
• Enbloc removal of skin and
subcutaneous tissue up to the
N
investing fascia using electrocautery E

2
• Ideal for large, deep and life
threatening burn wound W

3
O
R

4
M
A
L

5
6
 Controlling blood loss

1
N
E

2
• Subcutaneous infiltration of diluted W
epinephrine
N

3
• Application of topical epinephrine
• Use of tourniquet on limb surgery O
• Hypothermia should be controlled R

4
• Limb elevation M
• Skin stage excision A
L

5
6
 1
N
E

2
W

URN N

3
O

C
R

4
M
LOSURE A
L

5
6
 PLANNING

1
N
E

2
W
• Extent of excision should be planned to
allow the greatest use of available N

3
autograft donor sites O
• Need for stage procedure especially if R

4
autografts are the only option for M
closure on low resource setting A
L

5
6
 Autografts

1
N
E

2
W
SPLIT THICKNESS SKIN FULL THICKNESS SKIN
N

3
GRAFT GRAFT
O
R

4
M
A
L

5
6
 Autografts

1
N
E
SPLIT THICKNESS SKIN GRAFT

2
W

• Contains epidermis and various layer of N

3
dermis O
• Contract significantly
R

4
• Donor site heals by reepithelialization (may
be reharvested)
M
• Thighs, abdomen, scalp, back A
L

5
6
 Autografts

1
N
E
SPLIT THICKNESS SKIN GRAFT

2
W

3
O
R

4
M
A
L

5
6
 Autografts

1
N
E
FULL THICKNESS SKIN GRAFT

2
W
• Contains entire epidermis and dermis
N

3
• Better cosmetic results, reduced scarring, less
contraction O
• Eyelid burns, finger, face/hands R

4
• Donor site close primarily M
• Back of ear, clavicle, inguinal, lower A
abdomen L

5
6
 Autografts

1
N
E
FULL THICKNESS SKIN GRAFT

2
W

3
O
R

4
M
A
L

5
6
 Meshed Grafts

1
N
E

2
W

3
• Ideal for large burn with limited donor site
• Allows expansion for wider coverage O
• Allows seroma/hematoma to drain R

4
• Poor cosmetic result (Net Appearance) M
• Not to be applied to the face, neck and hand A
L

5
6
Meshed Grafts

1
N
E

2
W

3
O
R

4
M
A
L

5
6
Meshed Grafts

1
N
E

2
W

3
O
R

4
M
A
L

5
6
Meshed Grafts

1
N
E

2
W

3
O
R

4
M
A
L

5
6
Meshed Grafts

1
N
E

2
W

3
O
R

4
M
A
L

5
6
Meshed Grafts

1
N
E

2
W

3
O
R

4
M
A
L

5
6
 Sheet Grafts

1
N
E

2
W

3
• Better cosmetic and functional outcome O
• Best for face/neck, hands R

4
• WOF: Seroma/Hematoma formation
• Except dorsum of hand and forearm
M
A
L

5
6
 MEEK micrografts

1
N
E

2
W
• Similar to meshed in advantages and
N

3
disadvantages
• Autografts cut into small squares and O
applied on the pleated gauze R

4
• Technique to expand available skin 4x, 6x to M
9x, minimizing donor site A
L

5
6
MEEK micrografts

1
N
E

2
W

3
O
R

4
M
A
L

5
6
Skin Substitutes

1
N
• For partial thickness wounds/donor
site
E

2
Temporary
Substitute/Dressings
• Maintain a wound environment W
conducive to healing
• Provide barrier to infection
• Facilitate replacement of native skin
N

3
O
• For Full thickness defects
Permanent Substitutes • Dermal substitutes R

4
•
•
Aides in fast skin coverage M
Usually need STSG
• Result in better skin coverage A
L

5
• Layered skin grown from a small
Full Composite skin donor site
• Composed of both epidermis and

6
dermis
 Allografts (Cadaveric)

1
N
E

2
• Culture studies done -> growth reported and graded W
for quality
• Grade A,B,C depending on the site for infection N

3
• Key indications:
• Applied to debrided acute burns areas where O
there are insufficient autografts R

4
• Applied on top on meshed autografts to M
decreased amount of graft loss
• Undergoes graft take as per autograft, before being A
L

5
rejected and sloughed off around 2-3 weeks after
• Short life: 7 days but can be preserved for about 12
months

6
 Sandwich Technique

1
N
E

2
W
• Widely meshed
autograft is covered
N

3
with meshed
cadaveric allograft O
to prevent graft loss R

4
• Allograft sloughed-
off in 2-3 weeks M
revealing A
vascularized L

5
autografts

6
 Xenograft/Biobrane

1
N
E

2
W
• Temporary wound coverage (not a true skin
substitute)
N

3
• Partial thickness burn -> allows faster
healing and less pain O
• Excised burn -> temporary coverage prior to R

4
skin grafting M
• Allows fibrin to permeate the mesh and A
ingrowth of host fibroblasts L

5
6
 Biobrane check

1
N
E

2
W
• Checked for adherence after 3-4 days
• Once adherent, patient can take a shower
N

3
• WOF: infection underneath the biobrane
O
R

4
M
A
L

5
6
 Dermal Matrices

1
N
• Dermal scaffold for cell and tissue regeneration allowing E

2
vascular ingrowth
• Composition: W
• Collagen
• Chondroitin-6-sulfate
N

3
• +/- synthetic cover (Silicone)
• Originally developed for burn reconstruction
• Applications for exposed:
O
• Bone without intact periosteum R

4
• Tendon without paratendon
• Cartilage without perichondrium M
• Advantages: A
• Better skin quality
L

5
• Greater thickness and elasticity (vs STSG alone)
• Can cover a larger area
• Can temporize wounds until STSG donor site becomes

6
available
 1
N
E

2
W

3
O
R

4
M
A
L

5
6
 Dermal Matrices

1
N
E

2
W
• Needs METICULOUS wound care
(Higher rate of local infection -> N

3
loss/no revascularization O
• Expensive/ not accessible R

4
M
A
L

5
6
 Take home points

1
N
E

2
• Cleansing, debridement and topical wound care is W
generally sufficient on healing of superficial burn.
Deep burns require surgery.
N

3
• Early excision and grafting -> reduces mortality,
shortens hospital stay O
• Control blood loss R

4
• Excised wound should be closed with autografts or
skin substitute at the time of surgery as much as M
possible A
• Large burn -> paucity of donor site. Techniques in L

5
expanding the available skin.

6
T T
H H
A A
N N
K K

Y Y
O O
U U