A 22/M was brought to the ER after sustaining flame burn after Circulation and Cardiac Status
a house fire. He has burns around his mouth, his voice is hoarse, PRIMARY SURVEY
but breathing is unlabored. What is the appropriate next step in Fluid management: based on weight and burn size
the management? Fluid boluses is unnecessary unless hypotension or
other signs of hypovolemia (may exacerbate edema)
a. Immediate endotracheal intubation Oral resuscitation in burns <30% TBSA
b. Examination of the oral cavity and pharynx, with laryngoscope Evaluate perfusion of all extremities
if available o Check:
Place on supplemental oxygen capillary refill time,
d. Start fluid resuscitation Doppler,
O2 saturation
Primary Survey Circumferentially burned extremities
Initial Assessment and Stabilization Tourniquet effect due to
Airway management nonexpendable eschar
Breathing and ventilation
Circulation and cardiac status COMPARTMENT SYNDROME:
Disability, neurologic deficit and gross deformity Pain
Exposure Poikilothermia
Pallor
Airway Management Paresthesia
PRIMARY SURVEY Pulselessness
UTMOST PRIORITY !!! Paralysis
Airway injury: DO ESCHAROTOMY!
a. Supraglottic injury (results in edema from direct
thermal insult) Disability, Defect and Deformity
b. Subglottic injury with parenchymal injury (due to PRIMARY SURVEY
involvement of toxic gases or soot) Associated injury, substance abuse, hypoxia, pre-
c. Singed facial hair, carbonaceous sputum, soot in or existing conditions
around the mouth, hoarseness, stridor, increased work Glasgow Coma Scale (GCS)
of breathing, inability to tolerate secretions
Exposure
Early intubation: PRIMARY SURVEY
Symptomatic inhalation injury Completely expose, remove any contaminants
Any thermal injury to the face, mouth or oropharynx Limit hypothermia
that threatens airway patency o Warmed environment and clean blankets
o Especially in pediatric patients
Management Thermal injuries
Jaw thrust maneuver o Cool water for 3-5 minutes
Chin lift o Avoid ice and cold water (may cause
Oral airway device conversion of burn, coagulopathy, cardiac
Endotracheal intubation arrhythmias and death)
Breathing and Ventilation Secondary Survey
PRIMARY SURVEY Examination of nonburn-related life-threatening
Auscultate bilateral breath sounds, respiratory rate, injuries
depth of respiration Imaging, laboratory analysis, adjunctive measures
Circumferential burns of the trunk or neck: do bedside (IFC, NGT, etc.)
escharotomy
QUESTION
Circulation and Cardiac Status A 27/M came in at the ER due to flash burn 2 hours postinjury,
PRIMARY SURVEY when an LPG tank suddenly exploded. He had SPT-DPT
In major burns: place on cardiac monitor, continuous circumferential burn on his left lower extremity, lateral side of
pulse oximeter, blood pressure the left upper extremity and anterior trunk. Using the Rule of
Nines, compute for the %TBSA.
Blood pressure, heart rate, unburned skin color
a. 22.5%
100-120 bpm is considered within normal limits (due to
b. 40.5%
increased catecholamine response)
c. 36%
Higher heart rate: hypovolemia, other trauma,
d. 31.5%
inadequate pain management
Peripheral, central or intraosseous routes: for access,
.
may be placed through burned tissue if necessary
Circumferential on left leg 18% Over-resuscitation >> compartment syndrome
Lateral side of the left arm 4.5% (extremities and abdomen), acute respiratory distress
Anterior trunk 18% Under-resuscitation >> burn shock, organ failure >20%
18 + 4.5 + 18 = 40.5% TBSA, have t capillary permeability > decreased
intravascular volume (first 24 hours)
Early resuscitation prevents hypoperfusion, renal
failure and death
Adult with burns >20% TBSA and children with burns
>10% TBSA should formally be resuscitated with salt-
containing fluids
Parkland and Modified Brooke formulas
A 7/F came in at the ER due to scald burn 10 mins. postinjury,
when hot soup spilled on her. Assessment was 15% TBSA SPT-
DPT irvolving the right arm, right leg and abdomen. Wt: 16 kg
What is the choice of IV fluids?
a. PNSS
b. PLRS: resuscitation
Philippine Hospitals with Burn Unit c. D5LR: maintenance
Jose R. Reyes Memorial Medical Center d. Dextran
Philippine General Hospital
Quirino Memorial Medical Center
The Medical City Pampanga
Southern Philippines Medical Center
Burn classification
Thermal burns
Flame, contact, or scald
Flame burns most common cause of hospital
admissions
Highest mortality
Electrical bums
Cardiac arrhythmias, compartment syndrome,
rhabdomyolysis
Baseline ECG recommended
Neurologic and ophthalmologic consultation
Three zones of tissue injury
Zone of coagulation
Most severely burned
Affected tissue is coagulated and necrotic
Similar to 3md or 4th degree
Will need excision and grafting
Zone of stasis
Variable degrees of vasoconstriction and resultant
ischemia
Appropriate resuscitation and wound care to prevent
conversion
Similar to 2nd degree burn
Zone of hyperemia
Heals with minimal or no scarring
Similar to 1 degree burn
Resuscitation
For adequate perfusion, avoid over- and under-resuscitation
Resuscitation o <5 mmHg: normal
In pediatrics, o Up to 12 mmHg: accepted in cases of trauma
Add maintenance fluids + source of glucose (hepatic o 12-25 mmHg: close observation
glycogen stores will be depleted after 12-24 hours of o >25 mmHg: warrants intervention
fasting)
Unchecked fluid resuscitation can lead to airway Fasciotomy
compromise, edema of extremities, abdominal Commonly performed in high-voltage electrical injuries
compartment syndrome, multiple organ failure For compartment syndrome
May be indicated when compression persists after
Inhalation Injury escharotomy
DIAGNOSIS AND MANAGEMENT Pain on passive muscle stretching
3 main components:
1. Carbon monoxide poisoning or hydrogen cyanide Wound Care
poisoning Characteristics of an ideal dressing
o Diminished consciousness Provide an optimum environment for moist wound
o Measurement of blood carboxyhemoglobin healing
o High-flow O2 via nonrebreathing mask at 8- Allow gaseous exchange of oxygen, carbon dioxide
15LPM for at least 6 hours, hyperbaric and water vapor
oxygen, hydroxocobalamin Provide thermal insulation
Impermeable to microorganisms
2. Obstruction of the upper airway Free from particulate contaminants
o Blistering of mucosal membrane, hoarseness, Non-adherent
stridor Safe to use
o In children: brassy cough, wheezing, Acceptable to the patient
breathlessness, desaturation High absorption properties
Cost-effective
3. Smoke inhalation Allows monitoring of the wound
Provide mechanical protection
o Soot in the oral cavity, hoarseness, wheeze,
Nonflammable
cough, tachypnea, hypoxemia
Sterile
o Detection of soot in sputum, damaged
Available in all settings
mucosa below the larynx on bronchoscopy
Requires infrequent changes
Ready to use to reduce dressing time
Escharotomy
When circumferential or near circumferential eschar of
Graft donor site: polyurethane, hydrocolloids,
the extremities compromises the underlying tissues of
hydrogels, iodine or silver-based dressings
the circulation distal to it
Partial thickness burns: foams, alginates, iodine or
When eschar on trunk or neck compromises aeration
silver-based dressings
and breathing
Blisters: de-roofing is not supported by scientific
Generally indicated after initiation of fluid therapy
evidence
Compartmental pressure: o May do de-roofing
o <25mmHg = adequate tissue perfusion
To visualize and assess the wound
o >40mmHg = absolute indication underneath
Deep enough to reach a healthy tissue at the base If large vesicles impede the mobility
Should extend 1cm in healthy skin or in a superficial and comfort of the patient
burn, proximal and distal to the eschar
Complications: bleeding, incomplete release May snip open, evacuate contents and leave the walls
Evidence of success: to drop as "biologic dressing"
o Bulging of subcutaneous fat from the base of Leave the dressing as long as possible
incision In cases of dirty or contaminated wounds, change the
o Absence of fibrous bands in the incision dressing more frequently
o Profuse exudation of edema fluid from the Cleansing with gentle washing is the MOST
wound
IMPORTANT component of burn wound cleansing
o Disappearance of clinical and investigational o Beneficial effect of using antiseptics or
indications antimicrobial agents for cleansing is unclear
Raw areas are dressed with a closed technique
Abdominal escharotomy
(biologic dressings)
Evidence of intraabdominal hypertension or signs of
Biofilms increase the risk of infection
abdominal compartment syndrome
Can also be seen in over-resuscitation Treatment of the burn wound
Decreased minute ventilation, oliguria
Determination of intravesical pressure
Silver sulfadiazine o wound healing and some may covert to full
Wide range of antimicrobial activity thickness
Primarily as prophylaxis o Require aggressive and monitored scar-
Inexpensive prevention therapies
Easily applied
Soothing qualities Antibiotic stewardship
Avoid the use of prophylactic systemic antibiotics for
Mafenide acetate acute burns
Effective in the presence of eschar Increase the risk of emergence of resistant strains of
Both treating and preventing wound infections microorganisms, diarrhea, infection with Clostridium
Excellent antimicrobial for fresh skin gratts difficile, allergic reactions and hepatic, renal or bone
Pain on application marrow toxicity
Antibiotics should be started immediately once
Silver nitrate diagnosis of infection or sepsis is made
Broad spectrum antimicrobial activity o A 6-hour delay increases mortality
Prolonged topic application leads to electrolyte
extravasation with resulting hyponatremia Nutrition
Methemoglobinemia Significant changes in metabolism when burn size is
Causes black stains >30% TBSA
Nutritional support should be provided during the
Silver impregnated dressings acute phase of recovery
For donor sites, skin grafts, partial thickness burns Enteral nutrition is preferred over parenteral nutrition
Avoid daily dressing changes Conventional oral feeding is ultimately preferred
Patients with >20% TBSA, provide high protein diet
with adequate calories
Debridement and Skin Grafting o Adults: 1.5-2g protein/kg/day
Early excision o Children: 3g protein/kg/day
removal of necrotic tissue (burn eschar) before
spontaneous sloughing or invasive infection within the
first few days after injury or 7-10 days
Delayed excision
after sufticient time has elapsed, to determine how
much of the burn will heal by secondary intention
without need for surgery
after 10 days but before three weeks
Tangential excision
sequential approach where thin slices of necrotic
tissue are progressively removed to viable tissue
Fascial excision
removal of burn wound + subcutaneous tissue at a pre-
determined deep level, carried out down to the level of
deep fascia
Late grafting
grafting of burns after debridement of slough from
granulation by a variety of curettage, excision or
avulsion techniques, in delayed burn wound
management
Nonsurgical Management of Burn Scars
Superficial burns require topical emollients, sun
protection and massage after healing
Deep dermal burns are at risk of developing excessive
scarring
o If treated nonsurgically, the whitish, waxy
eschar prolong
