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Burn Management. Tad Kim, M.D. Connie Lee, M.D. UF Surgery. Skin. Epidermis: barrier Dermis: durable & elastic. Burn Pathophysiology: Tissue Repair. Initial hemostatic response = coagulation and microvascular constriction Resuscitative phase = vasodilatation and capillary leak

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Burn management

Burn Management

Tad Kim, M.D.

Connie Lee, M.D.

UF Surgery


Skin

  • Epidermis: barrier

  • Dermis: durable & elastic


Burn pathophysiology tissue repair
Burn Pathophysiology: Tissue Repair

  • Initial hemostatic response = coagulation and microvascular constriction

  • Resuscitative phase = vasodilatation and capillary leak

  • Epithelialization = restoration of fluid maintenance, temperature regulation, and microbial barrier function

  • Fibrogenesis = a/w wound appearance and strength


Burn pathophysiology systemic response
Burn Pathophysiology: Systemic Response

  • Accelerated intravascular volume depletion

  • Inadequate tissue perfusion

  • Risk of multiorgan dysfunction


Burn pathophysiology metabolic response
Burn Pathophysiology: Metabolic Response

Hypermetabolism:  glucose metabolism, lipolysis, and proteolysis

Neuroendocrine response:  catecholamines,  thyroid hormones,  cortisol


Burn pathophysiology zones of tissue injury
Burn Pathophysiology: Zones of Tissue Injury

  • Central zone of coagulation (full-thickness)

  • Zone of stasis (partial-thickness)

  • Zone of hyperemia (superficial partial-thickness)


Zones of injury
Zones of Injury

Orgill D. NEJM 2009;360:893-901


Burn classification
Burn Classification

Superficial (1°): epidermis (sunburn)

Partial-thickness (2°):

Superficial partial-thickness: papillary dermis

Blisters with fluid collection at the interface of the epidermis and dermis. Tissue pink & wet.

Deep partial-thickness: reticular dermis

Blisters. Tissue molted, dry, decreased sensation.

Full-thickness (3°): dermis

Leathery, firm, insensate.

4th degree: skin, subcutaneous fat, muscle, bone



Criteria for referral to a burn center
Criteria for Referral to a Burn Center

Orgill D. NEJM 2009;360:893-901


Initial assessment
Initial Assessment

  • Airway

  • Breathing

  • Circulation

  • Disability

  • Exposure

  • Initial burn treatment: remove burn source


Assessment airway
Assessment: Airway

Airway at risk secondary to:

Direct injury

Fluid resuscitation

Edema from inflammatory response

Clues to airway injury: history, facial burn, carbonaceous sputum, hoarseness, stridor, wheezing

Intubate based on respiratory and mental status


Inhalation injury
Inhalation Injury

  • Carbon monoxide poisoning

  • Upper airway thermal injury

  • Lower airway burn injury

  • ARDS


The rule of nines and lund browder charts
The Rule of Nines and Lund–Browder Charts

Orgill D. N Engl J Med 2009;360:893-901


Fluid resuscitation
Fluid Resuscitation

Resuscitation based on burn size

Parkland formula

4 x Wt(kg) x %TBSA = mL/24 hours

Deliver 1/2 volume over 1st 8hrs

Deliver 2nd half over next 16 hours


Fluid resuscitation complications
Fluid Resuscitation Complications

  • Overresuscitation complications:

    Poor tissue perfusion

    Compartment syndrome

    Pulmonary edema

    Pleural effusion

    Electrolyte abnormalities


General management
General Management

  • Neuro

  • CV

  • Respiratory

  • GI

  • FEN

  • HEME/ID

  • Activity


Wound management general
Wound Management: General

  • Clean & debride wound

  • Prophylactic systemic abx unnecessary

  • Topical abx delay wound colonization and infection

  • Escharotomy/fasciotomy may be required (circumferential burns, deep burns, compartment syndrome)


Wound management topical antibiotics
Wound Management: Topical Antibiotics

Mafenide acetate (Sulfamylon) for ears

Good at penetrating eschar & is painful

Broad spectrum

Side effect: metabolic acidosis via carbonic anhydrase inhibition

Bacitracin for face

Gram-positive bacteria

Silver sulfadiazine (Silvadene) for trunk & extremities

Broad spectrum, esp. Pseudomonas

Does not penetrate eschar very well

Side effects: neutropenia/thrombocytopenia


Excision and grafting
Excision and Grafting

Orgill D. N Engl J Med 2009;360:893-901


Wound management burn excision grafting
Wound Management: Burn Excision & Grafting

  • Early excision & grafting improved burn patient mortality & functional outcome

  • Initial excision should occur soon after resuscitation

  • Full-thickness skin grafts (FTSG)

  • Split-thickness skin grafts (STSG)

  • Human allograft

  • Porcine xenograft

  • Dermal substitutes: Integra


Electrical burns
Electrical Burns

Categories: high voltage (>1000 volts), low voltage, lightning

High voltage: requires trauma evaluation

Local injury, deep injury, fractures, blunt injuries

Risk of rhabdomyolysis, compartment syndrome, cardiac injury

Low voltage: common in children

Local injury

Late complications: cataracts, progressive demyelinating neurologic loss


Chemical burns
Chemical Burns

Empirical treatment

End the exposure

ABCDE

Alkalis generally cause worse damage

Initial treatment for acid or alkali: irrigation with water

Dry powder should be brushed off

Hydrofluoric acid: can cause severe hypoCa


Take home
Take Home

Always start with ABCDE for trauma/burns

The airway is at risk in burn patients

Parkland formula for initial resuscitation

Rule of Nines

Keep burns clean with soap & topical abx

Early burn excision & grafting saves lives


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