THE BURN MANUAL

1. Montarde, Maybelle Omana, James Pantig, Francesca Mae Pastoral, Avigail Martha THE BURN MANUAL

2. Diagnosis and Management of Acute Burns Initial/Resuscitative Period Definitive Management Period Excision and grafting Control of infection Nutrition Rehabilitation Complication • Assessment of burn injury • Classification of burn injury • Criteria for admission • Initial ER management • Fluid resuscitation • Monitoring

3. Initial Resuscitative Period

4. Assessment of a burn injury 1. Complete history 2. Classify as to type of burn • Scald burn: caused by hot liquids ( hot water, soups, sauces)which are thicker in consistency, remain in contact with the skin for a loner period of time • Flame burn: house fires, improper use of flammable liquids, kerosene lamps, careless smoking, vehicular accidents, clothing ignited from stove

5. Flash burn: explosions of natural gas propane, gasoline and other flammable liquids causing intense heat for a very brief period of time. • Contact burn: results from hot meals, plastic, glass or hot coals; usually limited in extent but very deep • Chemical burn: caused by strong alkali or acids; these cause progressive damage until chemical is deactivated with reaction with tissue or reaction with water • Acid burns: more self limiting than alkali burns; acid tend to tan the skin creating an impermeable barrier which limits further penetration of the acid • Alkali burns: combine with cutaneous lipids to create soap and thereby continue to dissolve the skin until they are neutralized • Electrical burns: injury from electrical current classified as high voltage or low voltage

6. 3. Estimate the burn size • Expressed as %BSA • Count only areas with partial (2nd degree) or full thickness ( 3rd degree) burns • Accurately done using the Lund and Browder charts • The Rule of Nines obtains a rough estimate of the areas involved but not accurate in children due to the large surface are of the child’s head and the relatively smaller are of lower extremities. • In electrical injuries, the %BSA does not correspond to the extent of injuries of the underlying soft tissues.

7. 4. Assess the burn depth • Important in estimating burn size and fluid requirement in determining the need for surgery and in evaluating the progress of the patient • First Degree Burns • are red and painful with no blisters • Ex: sunburn

8. Partial Thickness Burns • Second degree burns • Extends to the dermis but not through the full thickness of the skin • Heals from epithelialization from the epidermal elements surviving • (+) blanching when pressed • Superficial partial thickness burns: with blisters; underlying skin is moist, pinkish, painful; will heal in 2-3 weeks • Deep partial thickness burn: white to pale pink; moist to dry to waxy, slightly anesthetic, will heal in 3-5 weeks resulting in hypertrophic scarring and potential contracture • Both types of partial thickness burns can convert to full thickness burns, signifying worsening of the patient’s condition

9. Full Thickness Burns • Defined as burns extending through the full depth of the skin • May appear white, brown or gray with a waxy, leathery feel, skin is anesthetic • Presence of visible thrombosed veins is pathognomonic • Heals by granulation and will requires future skin coverage for wound coverage

10. 5. Check for other injuries/medical problems • Play a role in the origin of burn and will have to be integrated in the management of burn

11. Classification of Burn Injury

12. Criteria for Admission to the Burn Unit • Acute burn patients with moderate & major injuries • Acute burn patients < 2 years old regardless of % TBSA • Acute burn patients with injuries to the hands, face, feet and perineum • Acute electrical burn patients • Acute chemical burn patients • Acute burn patients with smoke inhalation injury, other associated medical illness, or multiple trauma • Patients with massive exfoliative disease, such as: • Toxic Epidermal Necrosis (TENS) • Steven Johnson Syndrome (SJS) • Staphylococcal Scalded Skin Syndrome (SSSS)

13. Initial Labs • CBC • Blood typing • RBS, BUN, Crea, Na, K, Cl • ABG (if inhalational injury is suspected) Other labs: • Chest X-ray • ECG (for electrical burns) • Urinalysis (for electrical burns, urine Hgb & pH also included)

14. Initial ER Management: MINOR Burns • Cool wound with tap water • Administer tetanus prophylaxis • Clean wound with soap & water, or with betadine scrub • Debride dead tissue • Small blister -> leave for 2-3 days • Big blister -> aspirate

15. Initial ER Management: MINOR Burns • Apply bland ointment (i.e., Bacitracin, Trimycin, Vaselin) & non-stick porous gauze & wrap with gauze • No systemic prophylactic antibiotics are given • Oral/IM analgesics during wound cleaning • Send patients home with oral analgesics and instructions to clean the wound OD to BID

16. Initial Management: MAJOR & CRITICAL Burns • Wear sterile gloves • Remove all burnt clothing • Check & secure airway. Suspect inhalational injury if with: • Burn to face • Sooty phlegm • Singed nostril hairs • Hoarseness or stridor • History of burn in enclosed space or unconscious at scene • Circumferential chest burn

17. Initial Management: MAJOR & CRITICAL Burns • Intubate if: • With burns 50% BSA • With suspected inhalational injury • With smoke inhalation • Do complete PE, check for other injuries • Insert IV line for fluid resuscitation • Insert foley catheter • Insert NGT. Start IV H2-blockers.

18. Initial Management: MAJOR & CRITICAL Burns • Weigh patient and record. If not possible, estimate: • For children: Wt (kg) = [2 x (age in years)] + 5 • For adults: Wt (kg) = 0.9 x [ht in cms – 100] • Administer ATS, TeAna • Check pulses, assess adequacy of chest expansion • Absent pulses or limited chest excursion is a surgical emergency & an indication for escharotomy

19. Initial Management: MAJOR & CRITICAL Burns Escharotomy • Extremities • Prep with betadine soap • Cut through the entire depth of skin along the medial & lateral aspects of involved extremity. Avoid injuring the ulnar nerve and the perineal nerve. Facilitate separation of skin by inserting your finger and bluntly dissecting through the cut skin. • Chest • Cut along both anterior axillary lines and along the coastal margin producing a W-shaped incision

20. Initial Management: MAJOR & CRITICAL Burns • Refer all pediatric patients to Pedia for co-management. Patients with other medical problems should also be referred accordingly. • No prophylactic antibiotics are given, unless there are concomitant medical conditions.

21. Fluid Resuscitation • Most common cause of mortality in the first 48 hours is inadequate fluid resuscitation • Start as early as possible in the ER and even before other diagnostic exams

22. Fluid Resuscitation:PARKLAND FORMULA Day 1 • Adults: Plain LR 4mL/kg BW per % BSA burned to be given: • ½ during the first 8 hours • ½ during the next 16 hours • Children: D5 LR 3mL/kg BW per % BSA burned to be given: • ½ during the 1st 8 hours • ½ during the next 16 hours • + maintenance

23. In the presence of increased capillary permeability, colloid content of resuscitation fluid exerts little influence on intravascular retention during the initial hours postburn • Hence, crystalloid fluids are given

24. Fluid Resuscitation:PARKLAND FORMULA Day 2 • Adults / children: • D5W (adults), half normal saline (children) and colloid sufficient to maintain good urine output

25. Fluid Resuscitation • Colloid may be given in the form of plasma albumin or cryoprecipitate • Most protocols start colloid infusion after the first 24 hours (capillary permeability thought to be restored by then) • For massive burns, colloid infusion can be started as early as 12 hours post-burn (to decrease total fluid requirements and lessen edema)

26. Fluid Resuscitation • Regulate fluids to maintain adequate urine output • Adults: 0.5 mL/kg BW/hr • Children: 1.0 mL.kg BW/hr • Excessive urine volumes signify overcorrection and run the risk of fluid overload; smaller volumes signify inadequate resuscitation • Urine output monitoring should be done strictly every hour

27. Fluid Resuscitation • For electrical injuries: • Adjust fluid volume to maintain UO of 75-100 mL/hr • Mannitol 12.5-25g may be infused to promote diuresis

28. Fluid Resuscitation • If UO and pigment clearing do not respond to fluid resuscitation, 12.5g cosmetic diuretic mannitol may be added to each liter of resuscitation fluid • NaHCO3 can be added to maintain a slightly alkaline urine

29. Wound Dressing Debridement/Initial Dressing: • Sterile technique • Cut hair or items that may reach any burned or dressing area • Full body bath with soap and water • Debride burned areas, making sure to visualize all affected areas. Reassess depth and %BSA of burn wounds • Wash with betadine soap, rinse with sterile water • Dress

30. Wound Dressing Silver Sulfadiazine (Flammazine, Silvadene, Silversurf) • For full thickness burns, applied as sandwich dressing • Changed once or twice a day • By itself retards wound healing • May cause transient leucopenia

31. Wound Dressing Silver Sulfadiazine (Flammazine, Silvadene, Silversurf) • Mech of action: silver ion bings with the DNA of the organism and release sulphonamide which interferes with the metabolic pathway of the microbe • Effective against: Pseudomonas aerugenosa,enterics, Staph aureus, Klebsiella sp

32. Wound Dressing Silver Sulfadiazine + Cerium nitrate (Flammacerium) • Topical antimicrobial • Applied in cases wherein early excision-grafting cannot be done (mass burn, extensive burns) • When combined with burned skin, forms a pliable leathery layer acting as a protective barrier against contamination • Reduces mortality by neutralizing a toxin present in burned skin

33. Wound Dressing Silver Sulfadiazinen+ Cerium nitrate (Flammacerium) • Mechanism of action: Cerium induces calcification of the dermal collagen remaining in the wound which produces the typical tanned, leathery crust

34. Wound Dressing Silver Nitrate • Used as 0.5% solution • Gauze dressing must be wet, solution loses effectivity when dry • Creates a brownish black discoloration with anything it comes in contact with (will peel off with the burned skin)

35. Wound Dressing Silver Nitrate • Bacteriostatic for S. aureus, E. Coli, P. aerugenosa • Does not injure regenerating epithelium in the wound • Caution with children as it tends to leach out electrolytes (Na, Cl)

36. Wound Dressing Daikin’s Solution • Sodium hypochlorite 0.025% solution: 15 mL sodium hypochlorite (Zonrox) + 935 mL NSS • Must be used within hours after it is prepared • Used in preparing granulation tissue for grafting • Bactericidal to S. aureus, P. aerugenosa, and other G(-) and G(+) bacteria

37. Monitoring At the ER: • Check vital signs, urine output, consciousness, pulmonary status hourly • Hgb, typing, Na, Cl, BUN, Crea, RBS • CXR and ABG for those suspicious for inhalational injury • ECG, urine Hgb and myoglobin for electrical burns

38. Monitoring During fluid resuscitation: • Check signs of adequate hydration • Weigh patient daily • Vital signs hourly • Monitor peripheral perfusion hourly (pulses, capillary refill) • Presence of Hgb and myoglobin in urine of electrical burn patient suggest delayed or inadequate fluid resuscitation

39. Monitoring During fluid resuscitation: • pulmonary status every 4-5 hours • Daily determination of Hgb, Hct, WBC, Na, K, BUN, crea • Status of wound daily during dressing change

40. Monitoring Post resuscitative period: • vital signs every 4 hours • Daily determination of weight, BUN, crea, Na, K • Assess burn status daily • Burn biopsies (not swabs) twice a week • Blood CS once a week if wound is infected or patient is septic

41. Definitive Management Priority in the 1st 48 hours- maintain intravascular volume Once addressed, definitive management ensues Classical Method: Allow eschar to spontaneously separate (3 weeks), wait until bed is ready for grafting, then place skin graft

42. Definitive Management Present trend: Early excision (within 7 days post burn) of burn wound, followed by skin grafting - shown to improve survival and shorten hospital stay - adopted strategy by the PGH Burn Unit

43. Excision and Grafting

44. To remove full thickness and deep partial burns until clean viable bleed is encountered and a skin graft is placed immediately to cover the wound • Early excision – done within 7 days • When the wound is not yet colonized by microorganisms, reducing the chances of infection and promoting good graft take

45. Preparation for OR prerequisites Stable vital signs Not in septic shock Afebrile Blood available for OR use (200-400ml/%BSA) Normal albumin No contraindications for surgery

46. Conduct for OR OR table covered by sterile linen Keep OR warm Prep patient using betadine soap and paint for the donor site and betadine soap for the wound Prep the donor site Drape donor site separate from the burn wound

47. Tangential Excision • The principle is to excise the wound in thin layers using a blade held at very acute angle with the skin surface • The goal is to remove non viable tissue leaving as much dermis as possible which is an excellent surface for grafting

48. Fascial Excision • Best used when excising large flat areas • When excision of the burn wounds has to be done with minimum blood loss • Less bloody than tangential excision, but with cosmetic effect defect • Limited use in extremities due to problems of edema in the area distal to the excision, the presence of avascular fascia and presence of nerves of superficial locations

49. Skin Graft Harvesting • Preferred areas are thighs, buttocks, and abdomen • The only area in which color match between donor and recipient site is of significant concern is the face and neck.  Upper chest and upper back are a good color match for face and neck.

50. Applying Skin Graft • It is best to place grafts on the wound at the time of excision • Since the graft itself controls hemostasis and protects the wound, it makes little sense to wait 24 to 48 hours until bleeding has stopped • This approach requires an additional procedure and there is a significant risk of the wound bed becoming desiccated or reinfected • It is better to have a slight overlap of skin on the wound rather than to leave excised wound uncovered.  Hypertrophic scarring will result and most evident at the edges of the graft, especially if a ridge of open wound is left to heal primarily.