Burn management
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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

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Burn management

Burn Management

Tad Kim, M.D.

Connie Lee, M.D.

UF Surgery

Burn management


  • 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

Classification of burn depth

Classification of Burn Depth

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


  • 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


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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