Burn Management

Functions
Skin is the largest organ of the body
Essential for:

Thermoregulation
Prevention of fluid loss by evaporation
Barrier against infection
Protection against environment provided
by sensory information

Types of burn injuries

Thermal: direct contact with heat

(flame, scald, contact)

Electrical
A.C. alternating current (residential)
D.C. direct current (industrial/lightening)
Chemical
Frostbite

Classification
Burns are classified by depth, type and

extent of injury
Every aspect of burn treatment depends on

assessment of the depth and extent

First degree burn

Involves only the

epidermis
Tissue will blanch with
pressure
Tissue is erythematous
and often painful
Involves minimal tissue
damage
Sunburn

Second degree burn

Referred to as partial

thickness burns
Involve the epidermis and
portions of the dermis
Often involve other
structures such as sweat
glands, hair follicles, etc.
Blisters and very painful
Edema and decreased blood
flow in tissue can convert
to a full-thickness burn

Third degree burn

Referred to as full-

thickness burns
Charred skin or
translucent white color
Coagulated vessels visible
Area insensate patient
still c/o pain from
surrounding second
degree burn area
Complete destruction of
tissue and structures

Fourth degree burn

Involves

subcutaneous tissue,
tendons and bone

Burn extent
% BSA involved

morbidity

Burn extent is calculated only on individuals

with second and third degree burns
Palmar surface = 1% of the BSA

Measurement charts
Rule of Nines:

Quick estimate of percent of burn

Lund and Browder:

More accurate assessment tool

Useful chart for children takes into
the head size proportion.

account

Rule of Palms:

Good for estimating small patches of burn wound

Lab studies
Severe burns:
CBC
Chemistry profile
ABG with
carboxyhemoglobin
Coagulation profile

U/A
CPK and urine

myoglobin (with
electrical injuries)
12 Lead EKG

Imaging studies
CXR
Plain Films / CT scan: Dependent upon

history and physical findings

Criteria for burn center

admission
Full-thickness > 5% BSA

Circumferential burns of

thorax or extremities
Partial-thickness > 10% BSA
Significant chemical injury,
Any full-thickness or partial-

electrical burns, lightening

injury, co-existing major
trauma or significant preexisting medical conditions

thickness burn involving

critical areas (face, hands,
feet, genitals, perineum, skin
Presence of inhalation injury
over major joint)
Children with severe burns

Initial patient treatment

Stop the burning process
Consider burn patient as a multiple trauma patient until

determined otherwise

Perform ABCDE assessment

Avoid hypothermia!
Remove constricting clothing and jewelry

Details of the incident

Cause of the burn
Time of injury
Place of the occurrence (closed space,

presence of chemicals, noxious fumes)

Likelihood of associated trauma
(explosion,)
Pre-hospital interventions

Airway considerations
Maintain low threshold for

intubation and high index of

suspicion for airway injury
Swelling is rapid and

progressive first 24 hours

Consider RSI to facilitate

intubation cautious use of

succinylcholine hours after
burn due to K+ increase

Prior to intubation attempt:

have smaller sizes of ETT

available
Prepare for cricothyrotomy

for tracheostomy
Utilize ETCO2 monitoring

pulse oximetry may be

inaccurate or difficult to apply
to patient.

Airway considerations
Upper airway injury (above the glottis): Area

buffers the heat of smoke thermal injury is

usually confined to the larynx and upper trachea.

Lower airway/alveolar injury (below the

glottis):
- Caused by the inhalation of steam or chemical
smoke.
- Presents as ARDS often after 24-72 hours

Criteria for intubation

Changes in voice
Wheezing / labored

respirations
Excessive, continuous
coughing
Altered mental status
Carbonaceous sputum
Singed facial or nasal hairs
Facial burns
Oro-pharyngeal edema /
stridor

Assume inhalation injury

in any patient confined in

a fire environment
Extensive burns of the
face / neck
Eyes swollen shut
Burns of 50% TBSA or
greater

Pediatric intubation
Normally have smaller airways than adults
Small margin for error
If intubation is required, an uncuffed ETT should be

placed
Intubation should be performed by experienced
individual failed attempts can create edema and
further obstruct the airway
AGE

+
4

= ETT size

Ventilatory therapies
Rapid Sequence Intubation
Pain Management, Sedation and Paralysis
PEEP
High concentration oxygen
Avoid barotrauma
Hyperbaric oxygen

Ventilatory therapies
Burn patients with ARDS requiring

PEEP > 14 cm for adequate ventilation

should receive prophylactic tube
thoracostomy.

Circumferential burns of the chest

Eschar - burned, inflexible,

necrotic tissue

Compromises ventilatory

motion

Escharotomy may be

necessary

Performed through non-

sensitive, full-thickness
eschar

Carbon Monoxide Intoxication

Carbon monoxide has a binding affinity for
hemoglobin which is 210-240 times greater than
that of oxygen.
Results in decreased oxygen delivery to tissues,
leading to cerebral and myocardial hypoxia.
Cardiac arrhythmias are the most common fatal
occurrence.

Signs and Symptoms of Carbon

Monoxide Intoxication
Usually symptoms not present until 15% of

the hemoglobin is bound to carbon

monoxide rather than to oxygen.
Early symptoms are neurological in nature

due to impairment in cerebral oxygenation

Signs and Symptoms of Carbon

Monoxide Intoxication
Confused, irritable,

Dilated pupils

restless
Headache
Tachycardia,
arrhythmias or
infarction
Vomiting /
incontinence

Bounding pulse
Pale or cyanotic

complexion
Seizures
Overall cherry red
color rarely seen

Carboxyhemoglobin Levels/Symptoms
05
15 20
20 40

Normal value
Headache, confusion
Disorientation, fatigue, nausea, visual
changes

40 - 60

Hallucinations, coma, shock state,

combativeness

> 60

Mortality > 50%

Management of Carbon Monoxide

Intoxication
Remove patient from source of exposure.
Administer 100% high flow oxygen

Half life of Carboxyhemoglobin in patients:

Breathing room air
120-200 minutes
Breathing 100% O2
30 minutes

Circulation considerations
Formation of edema is the greatest initial volume

loss

Burns 30% or <

Edema is limited to the burned region

Burns >30%

Edema develops in all body tissues, including nonburned areas.

Circulation considerations
Capillary permeability increased
Protein molecules are now able to cross the

membrane
Reduced intravascular volume
Loss of Na+ into burn tissue increases osmotic

pressure
this continues to draw the fluid
from the vasculature leading to further edema
formation

Circulation considerations
Loss of plasma volume is greatest during

the first 4 6 hours, decreasing

substantially in 8 24 hours if adequate
perfusion is maintained.

Impaired peripheral perfusion

May be caused by mechanical compression,

vasospasm or destruction of vessels

Escharotomy indicated when muscle

compartment pressures > 30 mmHg

Compartment pressures best obtained via

ultrasound to avoid potential risk of microbial

seeding by using slit or wick catheter

Fluid resuscitation
Goal: Maintain perfusion to vital organs
Based on the TBSA, body weight and

whether patient is adult/child

Fluid overload should be avoided

difficult to retrieve settled fluid in tissues

and may facilitate organ hypoperfusion

Fluid resuscitation
Lactated Ringers - preferred solution
Contains Na+ - restoration of Na+ loss is

essential
Free of glucose high levels of circulating

stress hormones may cause glucose

intolerance

Fluid resuscitation
Burned patients have large insensible fluid

losses

Fluid volumes may increase in patients

with co-existing trauma

Vascular access: Two large bore peripheral

lines (if possible) or central line.

Fluid resuscitation
Fluid requirement calculations for infusion

rates are based on the time from injury, not

from the time fluid resuscitation is
initiated.

Assessing adequacy of
resuscitation
Peripheral blood pressure:

may be difficult to obtain

often misleading

Urine Output: Best indicator

unless ARF occurs

A-line: May be inaccurate due

to vasospasm

CVP: Better indicator of fluid

status

Heart rate: Valuable in early

post burn period should be

around 120/min.
> HR indicates need for > fluids

or pain control
Invasive cardiac monitoring:

Indicated in a minority of
patients (elderly or pre-existing
cardiac disease)

Parkland Formula
4 cc R/L x % burn x body

wt. In kg.

of calculated fluid is

administered in the first 8

hours

Balance is given over the

remaining 16 hours.

Maintain urine output at 0.5

cc/kg/hr.

ARF may result from

myoglobinuria
Increased fluid volume,

mannitol bolus and

NaHCO3 into each liter
of LR to alkalinize the
urine may be indicated

Galveston Formula
Used for pediatric

patients
Based on body surface

area rather than weight

More time consuming

L/R is used at 5000cc/m2

x % BSA burn plus

2000cc/M2/24 hours
maintenance.
of total fluid is given in
the first 8 hrs and balance
over 16 hrs.
Urine output in pediatric
patients should be
maintained at 1 cc/kg/hr.

Effects of hypothermia
Hypothermia may lead to acidosis/coagulopathy
Hypothermia causes peripheral vasoconstriction

and impairs oxygen delivery to the tissues

Metabolism changes from aerobic to anaerobic

serum lactate

serum pH

Prevention of hypothermia
Cover patients with a dry

sheet keep head covered

Pre-warm trauma room
Administer warmed IV

solutions
Avoid application of

saline-soaked dressings
Avoid prolonged

irrigation

Remove wet / bloody

clothing and sheets

Paralytics unable to

shiver and generate heat

Avoid application of

antimicrobial creams
Continual monitoring of

core temperature via foley

or SCG temperature probe

Pain management
Adequate analgesia imperative!
DOC: Morphine Sulfate
Dose: Adults: 0.1 0.2 mg/kg IVP
Children: 0.1 0.2 mg/kg/dose IVP / IO
Other pain medications commonly used:
Demerol
Vicodin ES
NSAIDs

GI considerations
Burns > 25% TBSA subject to GI complications

secondary to hypovolemia and endocrine

responses to injury

NGT insertion to reduce potential for aspiration

and paralytic ileus.

Early administration of H2 histamine receptor

recommended

Antibiotics
Prophylactic

antibiotics are not

indicated
in the early postburn
period.

Other considerations
Check tetanus status administer Td as

appropriate

Debride and treat open blisters or blisters

located in areas that are likely to rupture

Debridement of intact blisters is

controversial

The most important function of the skin is to act as a barrier

against infection. The skin prevents loss of body fluids, thus
preventing dehydration. The skin also regulates the body
temperature by controlling the amount of evaporation of fluids
from the sweat glands. The skin serves a cosmetic effect by
giving the body shape.
When the skin is burned, these functions are impaired or lost
completely. The severity of the skin injury depends upon the
size of the injury, depth of the wound, part of the body injured,
age of the patient, and past medical history. Because of the
importance of the skin, it becomes clear that injury can be
traumatic and life threatening. Recovery from burn injury
involves four major aspects: burn wound management,
physical therapy, nutrition, and emotional support.

1. Treatment should begin immediately to cool the

area of the burn. This will help alleviate pain.
2. For deep partial-thickness burns or fullthickness burns, begin immediate plans to
transport the victim to competent medical care.
For any burn involving the face, hands, feet, or
completely around an extremity, or deep burns;
immediate medical care should be sought. Not
all burns require immediate physician care but
should be evaluated within 3-5 days.
3. Remove any hot or burned clothing.

4. Use cool (54 degree F.) saline solution to cool the area for 15-30

minutes. Avoid ice or freezing the injured tissue. Be certain to

maintain the victims body temperature while treating the burn.

5. Wash the area thoroughly with plain soap and water. Dry the area
with a clean towel. Ruptured blisters should be removed, but the
management of clean, intact blisters is controversial. You should
not attempt to manage blisters but should seek competent
medical help.
6. If immediate medical care is unavailable or unnecessary,
antibiotic ointment may be applied after thorough cleaning and
before the clean gauze dressing is applied.

Scalding-typically result from hot water, grease,

oil or tar. Immersion scalds tend to be worse than
spills, because the contact with the hot solution is
longer. They tend to be deep and severe and should
be evaluated by a physician. Cooking oil or tar
(especially from the mother pot) tends to be fullthickness requiring prolonged medical care.
a. Remove the person from the heat source.
b. Remove any wet clothing which is retaining heat.
c. With tar burns, after cooling, the tar should be
removed by repeated applications of petroleum
ointment and dressing every 2 hours.

Flame
a. Remove the person from the source of the heat.
b. If clothes are burning, make the person lie down to keep
smoke away from their face.
c. Use water, blanket or roll the person on the ground to
smother the flames.
d. Once the burning has stopped, remove the clothing.
e. Manage the persons airway, as anyone with a flame burn
should be considered to have an inhalation injury.

Electrical burns: are thermal injuries resulting

from high intensity heat. The skin injury area
may appear small, but the underlying tissue
damage may be extensive. Additionally, there
may be brain or heart damage or musculoskeletal
injuries associated with the electrical injuries.
a. Safely remove the person from the source of the
electricity. Do not become a victim.

b. Check their Airway, Breathing and Circulation

and if necessary begin CPR using an AED
(Automatic External Defibrillator) if available and
EMS is not present. If the victim is breathing, place
them on their side to prevent airway obstruction.
c. Due to the possibility of vertebrae injury secondary
to intense muscle contraction, you should use
spinal injury precautions during resuscitation.
d. Elevate legs to 45 degrees if possible.
e. Keep the victim warm until EMS arrives.

Chemical burns- Most often caused by strong

acids or alkalis. Unlike thermal burns, they can cause
progressive injury until the agent is inactivated.
a. Flush the injured area with a copious amount of water
while at the scene of the incident. Dont delay or waste
time looking for or using a neutralizing agent. These
may in fact worsen the injury by producing heat or
causing direct injury themselves.

Pathophysiology: Summary
Increased capillary leak, with protein and

intravascular volume loss

Hypermetabolic response, similar to SIRS
loss of lean body mass, protein catabolism

Cardiac output decreased initially, then

normalizes
depressed contractility/increased SVR/afterload
anticipate, identify, & treat low ionized calcium

Pathophysiology: Summary
Usual indices (BP, CVP) of volume status

unreliable in burn patients; urine output best

surrogate marker of volume resuscitation
ADH secretion may be confounding variable

ARF rare unless prolonged hypotension

exception: soft tissue injury with pigmenturia
kaliuresis may require brisk K+ replacement
hypertension (with encephalopathy) may occur

Pathophysiology: Summary
Pulmonary dysfunction results from

multiple etiologies
shock, aspiration, trauma, thoracic restriction
inhalation injury; increases mortality 35-60%
diffuse capillary leak reflected at alveolar level

CNS dysfunction may result from

hypovolemia/hypoperfusion, hypoxia, or
CO exposure

Pathophysiology: Summary
High risk of gastric stress ulceration
Increased gut permeability, with increased

potential for bacterial translocation

protective role of early enteral feeding

Gut dysmotility due to drugs, or disuse

Early, mild hepatic dysfunction common; late

or severe dysfunction heralds increased

morbidity

Pathophysiology: Summary
Anemia is common
initially due to increased hemolytic tendency
later due to depressed erythropoietin levels,
and ongoing acute phase iron sequestration
may be exacerbated by occult bleeding, or
iatrogenicity related to fluid management

Thrombocytopenia early; thrombocytosis

then supervenes as acute phase response

Pathophysiology: Summary
Immunologic dysfunction is pleiotropic
normal barrier, immune functions of skin lost
immunoglobulin levels depressed, B-cell
response to new antigens blunted
complement components activated, consumed
normal T4/T8 ratios inverted
impaired phagocyte function
immunologic dissonance

Initial Management: ABCDEs

Airway
Breathing
Circulation
Depth of Burn
Extent of Injury(s)
Pediatric (special) issues

Initial Airway Managment

Evaluate, and ensure airway patency
Determine the need for an artificial airway
intact airway reflexes?
risk factors for airway burns/edema?
Perioral burns, carbonaceous sputum subjective dysphagia,
hoarseness or changes in phonation

erythema to edema transition may be rapid

Ensure adequate air exchange, thoracic excursion

with tidal breaths

Breathing Assessment/Support
Ensure adequate oxygenation
ABG with carboxyhemoglobin level preferred
humidified 100% FiO2 emperically

Assess for possible inhalation injury

history of an enclosed space, carbonaceous
sputum, respiratory symptoms, altered LOC
younger children at greater risk

NMB for intubation: avoid succinylcholine

Breathing Assessment/Support
NG tube placement
thoracic decompression; reduce aspiration risk

Ventilatory support recommended for

circulatory insufficiency, or GCS<8

decreased airway protective reflexes
risk of inhalation injury/CO exposure
risk of concomitant injury/trauma requiring
evaluation/support

Initial Management:
Circulatory
Assess capillary refill, pulses, hydration
Evaluate sensorium
Place foley to assess urine output
Achieve hemostasis at sites of bleeding
Venous access, depending upon BSA

involvement; avoid burn sites if possible

Begin emperic volume resuscitation

Initial Depth Assessment

Assess depth of injuries:
First degree burn
restricted to superficial epithelium
pain, erythema, blistering
treatment rarely required (IV hydration)

Second degree (partial thickness, dermal) burn

through epidermis into a variable portion of dermis
infection, malnutrition, hypoperfusion may cause
conversion to full thickness (3rd degree) burn

Degree of Burn Wound Depth

Refer to handouts:
figure 2 in outline
back of last page, power point transcript

Initial Depth Assessment

Assess depth of injuries:
Third degree (full thickness)
full thickness injury extending through all layers into
subcutaneous fat
typically requires some degree of surgical closure

Fourth degree
third degree with extension into bone/joint/muscle

Note circumferential burns, compartment

syndrome risk; consider escharotomy need

Initial Management: Extent

Expressed as percentage of total BSA
Only 2nd & 3rd degree burns mapped

Once adult proportions attained (~15 yo),

rule of nines may be used

For children less than 15 years of age, age
adjusted proportions must be used
fluid replacement is based upon BSA estimates

Must rule out concomitant other injuries

BSA estimation: Rule of 9s

Management: Pediatric Issues

Hypothermia
increased insensible fluid loss from burn

Hypoglycemia
stress response; smaller glycogen stores

Vaccination
adequate tetanus prophylaxis mandatory

If injury pattern not consistent with history,

consider possibility of child abuse

Burn Injury Classification:

Minor Burns
Total involved BSA<5%
No significant involvement of hands, feet,

face, perineum
No full thickness component
No other complications
May typically be treated as outpatients

Burn Injury Classification:

Moderate Burns
Involvement of 5-15% BSA, OR any full

thickness component
Involvement of hands, feet, face, or
perineum
Any complicating features (e.g., electrical
or chemical injury)
Should be admitted to the hospital

Burn Injury Classification:

Severe Burns
Total burn size >15% BSA
Full thickness component >5% BSA
Hypovolemia requiring central venous

access for resuscitation

Presence of smoke inhalation or CO
poisoning
Should be admitted to an ICU

Survival Data: BSA and age

BSA involved

Airway compromise?
Respiratory distress?
Circulatory compromise?
Yes

No

Intubation, 100% O2
IV access, fluids

Multiple trauma?
Yes

No

Evaluate &
treat injuries

Burns >15%, or
complicated burns?
No

Circumferential full
thickness burns?
Yes

Escharotomy

Yes

IV access; fluid
replacement

No

Burn care, tetanus prophylaxis, analgesia

Burn Injury: Fluid Resuscitation

Oral/enteral fluid replacement an option in

unextensive, uncomplicated burns

Multiple formulas/approaches available
Baxter/Parkland formula, Carvajal formula,
Muir Barclay formula, University of Wisconsin
formula

In the field/pre-transfer, reasonable to begin

IV fluids (LR), at 20cc/kg/hour (for 1-2 hrs)

Burn Injury: Fluid Resuscitation

HMC approach: modified Parkland formula
Deficit: (3 cc/kg) x (wt in kg) x (% BSA) as LR
50% over 1st 8 hours, 50% over ensuing 16 hours
Subtract documented fluids given en route or in ER

Maintenance: D5.25NS, customarily calculated

Overaggressive volume resuscitation may

result in iatrogenic complication

pulmonary edema, compartment syndrome

Fluid Resuscitation Reminders:

Titrate IV fluids to achieve desired rehydra-

tion, quantified mainly by urine output

mucous membranes, skin turgor, fontanelle,
tears, pulse rate, sensorium, capillary refill

Kaliuresis can be profound; IV replacement

may be required
Increased ADH release (pain/anxiety) may
confuse picture

Burn Injury: Nutritional Support

Essential for wound healing, graft survival;

prevents at risk partial thickness injury

from converting to full thickness injury
Enteral feeds preferred over TPN
may prevent gutbacterial translocation
early (within 4 hours) institution of enteral
feeds may achieve early positive N2 balance
may be precluded by paralytic ileus

Burn Injury: Nutritional Support

Hypermetabolic state favors breakdown/use

of fat and protein; rate of loss of lean body

mass can be slowed by approximating
positive nitrogen balance; high protein
content of enteral formula therefore favored
Enteral formulas should be lactose free, and
less than 400 mOsm/L
Multiple formulas for caloric requirements

Burn Injury: Nutritional Support

Curreri Formula:
calories/day=(wt in kg) (25) + (40) (%BSA)
needs periodic recalculation as healing occurs
probably overestimates caloric needs

Weight loss of more than 1% of baseline wt

per day should not be tolerated for more

than ~5 days before progressing to the next
level of nutritional support

Burn Injury: Wound

Management
Escharotomy/fasciotomy may be necessary

within hours
neurovascular compression; chest wall motion

Surgery for wound closure is necessary for

full thickness injury, or areas of deep partial

thickness that would heal with delay or scar
In life threatening burns, urgency to graft
before substantial colonization occurs

Burn Injury: Wound

Management
Integra
inert material mimicking the structure of dermis
collagen strands provide ordered matrix for
fibroblast infiltration/native collagen deposition
allows harvesting of thin epidermal layer for
graft, with more rapid healing at donor sites

Appropriate tetanus prophylaxis mandatory

Consider relative risk of DVT, prophylaxis

Burn Injury: Pain

Management
Treatment, dosing titrated to achieve effect
IV morphine remains the gold standard
tolerance may occur if therapy is prolonged
discontinuation of opiates should be anticipated
and tapered as wound healing occurs

Use opiates cautiously in infants who are not

mechanically ventilated
Consider role of anxiolytics

Burn Injury: Pain

Management
PCA may be an option in older patients
Ketamine may be useful during procedures
profound analgesia, respiratory reflexes intact
HTN, emergence delirium, hallucinations
midazolam 0.1 mg/kg to reduce ketamine edge

Propofol, other modalities

Do not overlook analgesia/sedative needs of

patients receiving neuromuscular blockade

Burn Injury: Topical Antibiosis

Colonization via airborne &/or endogenous

gram+ flora within the 1st week is the rule;

subsequent colonization tends to be gramComplications of topical agents
hyponatremia, hyperosmolarity, metabolic
acidosis, methemoglobinemia

Silvadene resistance universal for E. clocae

S. aureus common, Pseudomonas occasional

Burn Injury: Infection

Types of infections in burn patients
burn wound invasion/sepsis, cellulitis,
pneumonia, supparative thrombophlebitis,
miscellaneous nosocomial infections

Organisms causing burn wound invasion

pseudomonas-45%, mycotic 19%
other gram negatives-16%, mixed bacterial-8%
mixed bacterial/mycotic-10%, Staph-1-3%

Burn Injury: Wound Sepsis

Characterized by gray or dark appearance,

purulent discharge, systemic signs of sepsis

If true burn wound sepsis, wound culture
should yield >105 organisms/gram of tissue
Gram negative bacteremia/sepsis
think wound, lungs

Gram positive bacteremia/sepsis

think indwelling lines, wound

Burn Injury: Prevention

Pre-emptive counseling of families essential
water heater temperature from 54oC to

49oC (130120oF) es time for full thickness scald from <30 seconds to 10 minutes
Cigarette misuse responsible for >30% of
house fires
Smoke detector installation/maintenance

Burn Injury: Prevention

Burn prevention has far greater impact on public health

than refinements in burn care

Burn risks related to age:
infancy: bathing related scalds; child abuse
toddlers: hot liquid spills
school age children: flame injury from matches
teenagers: volatile agents, electricity, cigarettes
introduction of flame retardant pajamas

Burn Injury: Summary

Many risk factors age dependent
Pediatricians primary role: prevention
High risk of multiple organ system effects,

prolonged hospitalization
Initial care: ABCs, then surgical issues
special attention to airway, hemodynamics

Chronic care issues: scarring, lean mass loss