Lecture By Dr.Jasim Moh'd Jesraha Plastic Surgeon King Saud Medical City.

1. Management of
Burn Wounds
Dr/ Bassim Mohamad Gesraha
Plastic Surgeon
King Saud Medical City

2. Outline
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What do superficial and deep burns look like?
What patients can be treated as inpatients?
Who will need skin grafting?
What is new in burn care?

3. Goals of Management
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Patient safety
Patient comfort
Spontaneous healing without scars
Minimal cost to patient
Maintain patient independence
Early return to function

4. Initial Burn Evaluation
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Burn size and depth
Mechanism
Time of injury
Circumstances of
accident
• Potential for inhalation
• Associated trauma
• Very young or elderly
• Other medical
conditions
• Tetanus status
• Substance abuse
• Living situation
• Work history

5. Burn Depth
• Old terminology
– First degree - never blisters
– Third degree - never heals
– Second degree - everything else
• Modern terminology
– Superficial - heals without hypertrophic scars
– Deep - prolonged healing, with marked scars

6. Skin Layers and
Depth of Burn Injury
Epidermis
Upper Dermis
Lower Dermis
Subcutaneous
Tissue
1° - Superficial
Superficial
Partial
Thickness
Deep
Partial
Thickness
3° - Full
Thickness

7. First Degree Burn
Sunburn

8. Sunburn Treatment
• UV radiation
• Oral ibuprofen for 24 hours rapidly
reduces pain, redness and peeling
• Topical lotion is soothing
• > 30% TBSA sunburns do not respond
to NSAIDS, may require hospitalization

9. Superficial Second Degree Burn
Scald

10. Scald Burn First Aid
• Immediately remove clothing
• Cool the burn, but don’t use ice
• Typically burns are superficial in
exposed areas, deeper where hot liquid
pools
• Immersion burns are of greatest concern

11. Deep Second Degree Burns

14. Third Degree Burns
Flame
Chemical
Electrical

15. Full Thickness
Burns
• Burns are waxy white or hard and
leathery with no pain sensation
• Escharotomy is needed if third degree
burns are completely circumferential
• Small third degree burns - refer for
elective skin grafting

16. Skin Grafting Decisions
Superficial (first degree)
Partial thickness (second degree)
Superficial
Heal in
< 3 weeks
Deep
Full thickness (third degree)
Early
grafting

17. Estimating Burn Size
• Rule of the palm - the patient’s
palm with fingers equals one
percent TBSA

18. Estimating Burn Size
• Rule of 9’s – Head = 1 entire arm = 9%
– Ant. trunk or back = 18%
– Entire leg = 18%

19. Lund and Browder Most Accurate
A
1 1/2 2
A
1
13
2
1 1/2
1 1/2 2
1 1/2
B
1 1/2
1 1/2
1 1/2 B B 1 1/2
C C
C C
1 3/4
2
21/2 21/2
1
B
13
Areas change with growth
1
1 3/4
Age
Half of Half of
in years
head one thigh
(A) (B)
Half of
one leg
(C)
Infant
1
5
10
15
Adult
2 1/2
2 1/2
2 3/4
3
3 1/4
3 1/2
9 1/2
8 1/2
6 1/2
5 1/2
4 1/2
3 1/2
2 3/4
3 1/4
4
4 1/4
4 1/2
4 3/4

20. Burn Admission - Physical Criteria
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Burns which require fluid resuscitation
Chemical burns like hydrofluoric acid
High voltage conduction injuries
Burns with associated trauma
Intoxication or clinical depression
Uncontrolled pain
Inhalation injury

21. Inhalation
Injury
• Occurs with closed space or clothing fires,
not flash injuries outdoors
• Hoarseness, stridor, carbonaceous sputum,
elevated CO, acute chest infiltrates, or
hypoxia suggest the diagnosis
• Burned nasal hair or facial hair is an
insignificant finding

22. Outpatient Selection Criteria
• Mechanism of injury
– Scalds
– Flash burns
– Small contact burns
• Consider outpatient referral
– Low voltage electrical injuries
– Some chemical burns

23. Electrical Burns
• Low voltage (<1,000 V)
– Minimal visible damage
– High incidence of PTSD and incapacitating
atypical pain of delayed onset
• High voltage (>1,000 V)
– Deep injury from muscle heating
– Often require fasciotomies

24. Chemical Burns
• Acids crosslink dermis
– Tannic acid makes leather from rawhide
• Alkalis cause liquefaction necrosis
• Wash at scene while removing all clothing
• Document agent, concentration, area
affected, initial temperature of liquid and
duration of contact

25. Chemical Burns
• Wash massively with water
• Check skin pH for acid/alkali injuries
• Topical calcium gel for HydroFloric burns
– No pain medication - marker for inactivation
– Persistent pain after 2 hours of topical calcium
- refer for intra-arterial calcium
– Large area or high concentration of HF
- calcium gluconate drip is life-saving

26. Time to Burn Mortality
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First hour
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First Day
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Hypovolemic shock, neck swelling and occlusion of
airway
First week
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Incineration, anoxia, carbon monoxide poisoning
Renal failure, inhalation injury
Delayed
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Sepsis, extreme malnutrition, rare complications

27. Initial
Cares
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Adequate pain control
Clean technique
Shave hair
Selective deflation or
debridement for
blisters

28. Indications for Early Escharotomy
• Circumferential third degree burns of digit
or extremity
• Loss of pulse or capillary refill distal to
deep burn
• Third degree burns of the chest which limit
chest wall motion and ability to ventilate the
patient

29. How Do We Calculate the Fluid Volume?
• Obtain the weight of the patient
• Calculate the burn size as % total burn
surface area (%TBSA)
• For resuscitation only calculate the second
and third degree burns
• Generally resuscitation is not needed for
burns less than 15-20%TBSA

30. Parkland Resuscitation
Example:
4 ml x Wt (Kg) x %TBSA
100 Kg man, 40% TBSA
4 X 100 X 40 = 16,000 mL
total
1,000 mL / hr in 1st 8 hrs
500 mL / hr in next 16 hrs

31. How Much is Enough Fluid?
• Goal is to give best tissue
perfusion
• Urine flow of 0.5-1 ml/Kg/Hr
• Adequate blood pressure
–MAP >60 mmHg
• Decreasing tachycardia

32. How Long is Resuscitation Given?
• Goal is to reduce IV fluid rate
to maintenance rate
• Minimize fluid overload
• Maintain good vital signs and
urine flow
• Begin nutritional intake

33. Excessive Resuscitation
Complications
• Facial swelling
• Respiratory distress/pulmonary edema
• Increased ventilator days
• Extremity compartment syndrome
• Abdominal compartment syndrome

34. Blister Management Options
• Leave intact - will limit motion, become
messy when leaking
• Completely debride - increased pain,
must not allow to desiccate
• Deflate blisters - minimal pain,
excellent ROM, limited quantity of
topical agent needed, remove at 2 weeks

35. Acute Pain Control
• Intravenous morphine sulfate
– Repeat doses until pain breaks
– May require large amount
• Cool burns for a limited time
• Dress wounds early to alleviate pain

36. Tetanus/Antibiotics
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Immunization in last 5 years adequate
Re-immunize after 1 year if dirty wound
Add Hypertet if never immunized
Prophylactic antibiotics are ineffective

37. Principles of Wound Management
• Keep exposed dermis moist
– Reduces pain
– Prevents desiccation
– Topical antimicrobials reduce infection
• Increase protein intake to speed healing
• Continue range of motion exercises

38. Dressings
• Functional
• Inexpensive

39. Local Wound Care
• Wash daily, remove loose dead skin, and
apply occlusive dressings to unhealed areas
• For face burns, shave beard daily, apply
bacitracin to keep wounds moist
• Moderate fevers are expected
• Observe for redness beyond burned areas
• Apply hand lotion to pink healed skin

40. Traditional Topical Agents
• None - appropriate for first degree burns
• Silver sulfadiazine
Covered dressing
• Bacitractin
Open

41. Silver Sulfadiazine
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Most soothing agent
Not very cheap
Turns yellow on contact with serum
Melts, so occlusive dressings are
required
• Change once daily

42. Bacitracin
• Adheres even without occlusive
dressings - easy to use on face burns
• Cheap, readily available
• Prolonged use often causes a papular
rash

43. What’s New for Burns
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Acticoat
Aquacel Ag
Mepelex Silver
MEBO
etc., etc.

44. Acticoat
• Rather expensive
• Two silver impregnated non-stick sheets
with center absorbent pad (like Telfa)
• Water releases elemental sliver
• Usually changed every three days
• Can dry out a wound unless moistened
t.i.d. or covered with an Unna dressing

48. Aquacel-AG
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Silver impregnated alginate pad
Rather expensive
Can be left for > 7 days
Cannot be applied over dead tissue
Contracts as it absorbs fluid, must
overlap wound 2 cm
• Inflexible, do not use across joints

50. Mepelex Silver
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Silver impregnated open cell foam pad
Rather expensive
Can be left for > 7 days
Cannot be applied over dead tissue
Does not contract as it absorbs fluid
Flexible, easy to use across joints
Easily removed

52. Temporary Skin Indications
• Biobrane or other synthetic materials
– Coverage of clean superficial wounds
– Superficial second degree burns
– Donor sites

53. Temporary Skin Indications
• Fresh or frozen cadaver skin
– Temporary wound closure in unstable or ill
burn patients or those with only small
donor sites
– Coverage of face burn bed before
autografting
– Protection for widely meshed autograft

54. Permanent Skin Materials
• Autotransplanted skin grafts - the gold
standard
– No rejection, superb viability
– Sheet grafts are ideal - avoid mesh pattern
• Cultured epidermal autografts
• Synthetic dermis replacement - Integra
• Processed cadaver dermis - MatriDerm

55. Permanent Skin Materials
• Primary epidermal closure:
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Cultured epidermal autografts alone
• Dermal replacement or regeneration,
followed by epidermal grafting:
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Dermal template matrix – Integra,
MatriDerm
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Processed cadaver dermis -

56. The Perfect Autograft
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Thick enough to be durable
Thin enough to heal without donor site scars
Donor near wound for good color match
Large enough to avoid seams or meshing
Small enough so donor minimally increases
burn size

58. Autograft Challenges
• Graft too thin - not durable
• Graft too thick - poor donor healing and site donor
scars
• Distant donor - poor color match
• Meshed grafts - permanent mesh pattern
• Donor too large - increases total wound size
• Massive burns - donor skin inadequate to permit
patient survival

59. Future Options
• Cultured split thickness autografts
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A living bilayer skin of cultured
fibroblasts and patient’s epidermis, a
cultured composite skin

60. Future Options
• Fetal epidermal stem cells
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Researchers have used cells extracted
from amniotic fluid to make epithelial stem
cells

61. Future Options
• Adult stem cells
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Advanced Cell Technology Inc. has
engineered stem cells from adult human
skin

62. Future Options
• Cultured composite skin
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A living bilayer skin of cultured
fibroblasts and cultured autogenous
epidermis

63. Future Options
• Fetal epidermal stem cells
•
cultured fetal cells grown in collagen
sponges were applied to full thickness
wounds of newborns, which healed without
scars

64. Future Options
• Cultured fetal tissue constructs
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cultured human mesenchymal stem cells
are grown in collagen sponges and applied
to full thickness wounds
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The fetal cells engraft and close the
wounds with heterologous skin

65. Questions?

66. Thanks