Acute Management in Burns

Dr. Rishi Kumar Gupta
SR
Department Of Plastic Surgery
GMCH, Guwahati
Acute Management Of Burns

Introduction
• The goal of burn management is to achieve wound closure at the earliest. The
efforts in this direction must begin at the first interaction between the victim
and the health care worker.
• Hospitalization is divided into 4 general phases:
1. Initial evaluation and resuscitation
2. Initial wound excision and biologic closure
3. Definitive wound closure
4. Rehabilitation and reconstruction.

• The early management extends from first aid at site to complete resuscitation
of the patient and remains the chief determinant of final outcome especially in
a patient with major burn.

FIRST AID: THERMAL BURNS
• The role of a burn specialist in carrying out first aid in burns is to educate the
masses about the basics of burn injuries and do’s and don’ts.

FIRST AID: CHEMICAL BURNS
• Remove the cause of the burn
• Antidotes
• Remove clothing or jewellery that has been contaminated by the chemical.
• Wrap the burned area loosely with a dry, sterile dressing or a clean cloth.
• Patient with even a minor chemical burn on the eye, hands, feet, face, groin or
buttocks or over a major joint should be treated at a burn center.

FIRST AID: ELECTRICAL BURNS
• High-voltage electrical injuries are classified as major burns due to associated
massive tissue damage.
• Since bone has the highest resistance to electrical current, conduction through
bone produces the greatest amount of heat. For this reason, damage to
muscle by electricity is greatest at tendinous attachments and periosteal
regions.
• Massive muscle destruction causes myoglobinemia. Precipitation of myoglobin
in the renal tubules can produce acute tubular necrosis and acute renal failure.

• In addition, high-voltage electrical burns are commonly associated with
dislocations, fractures, vertebral injuries, myocardial damage, neurological
sequel and intra-abdominal injuries due to concomitant trauma.
• The most common cause of early mortality is cardiopulmonary arrest due to
induced fibrillation.

• While helping someone with an electrical burn and waiting for medical help, following
steps are recommended:
1. Look first. Do not touch.
2. Turn off the source of electricity if possible.
3. Check for signs of circulation breathing, coughing or movement. If absent, begin
cardiopulmonary resuscitation (CPR) immediately.
4. Prevent shock. Lay the person down with the head slightly lower than the trunk
and the legs elevated.
5. Cover the affected areas.

Burn Surface Area Assessment
• An accurate estimate of the size of the burn is important for treatment and
transfer decisions.
• The size or extent of the burn can be estimated in a number of ways.
• When calculating burn area, erythema should not be included.
• This may take a few hours to fade, so some overestimation is inevitable if the
burn is estimated acutely.

Palmar Surface
• The surface area of an individual’s palm
(including fingers) is roughly 0.8% of
total body surface area 3, though it is
taken as 1% for all practical purposes.
• Palmar surface area can be used to
estimate relatively small burns (< 15% of
total surface area) or very large burns (>
85%, when unburnt skin is counted) or
areas of irregular or non-confluent burns.

Burn Unit Admission Criteria
• A burn unit may treat adults or children or both.
• Burn injuries that should be treated at a burn unit include the following:
1. Partial thickness burns greater than 10% total body surface area (TBSA)
2. Burns that involve the face, hands, feet, genitalia, perineum or major joints
3. Full thickness burns in any age group
4. Electrical burns, including lightning injury
5. Chemical burns
6. Inhalation injury

7. Burn injury in patients with pre-existing medical
disorders that may complicate management, prolong recovery
or affect mortality
8. Any patient with burns and concomitant trauma.
9. Burned children in hospitals with out qualified
personnel or equipment for the care of children.
10. Burn injury in patients who require special social,
emotional or long-term rehabilitative intervention.

OUTPATIENT WOUND CARE STRATEGIES
The components of outpatient burn care include:
1. Patient and family teaching,
2. Wound cleansing,
3. Choice of topical agent or membrane dressing,
4. Pain control,
5. Early return instructions,
6. Follow-up clinic visits,
7. Long-term follow-up.
Wound cleansing and dressing techniques must be taught to whosoever will be doing the dressing
changes. Documenting this teaching is ideal.

INPATIENT MANAGEMENT
• A major burn is defined as a burn covering 25% or more of total body surface
area (more than 20 % for children), but any injury over more than 10% should
be treated similarly. Rapid assessment is vital.

Early Management of Major Burn

• The burn wound should never take precedence over potential life threatening
conditions.
• Primary Survey :
1. A- Airway
2. B- Breathing
3. C- Circulatory

Secondary Survey
• D- Neurological Disability
• E—Exposure with environment control
• F—Fluid resuscitation

A- Airway Patency
• Heat affects primarily the oral and nasal cavity, supraglottic area of the
pharynx and causes edema and mechanical upper airway obstruction.
• The initial smoke injury occurs shortly after exposure within 30 minutes to 1
hour, but the ensuing intense inflammatory reaction evolves over a period of
hours to days resulting in lung damage.
• The initial edema usually wears off within a day or two and is evident by air
leak by the sides of the endotracheal tube.

• Inhalation injury should be suspected in all of the following situations:
• Individuals who sustained injury in a closed space,
• Patients with extensive burns or with burns of the face,
• Patients who were unconscious at the time of injury,
• Patients with singed nasal and facial hair, hoarseness or
wheezing and
• Patients who are coughing up carbonaceous sputum.
• Explosions with burns to head and torso,
• Carboxyhemoglobin level > 10%.

• Definite indications for endotracheal intubation are:
1. Deep facial burns - especially of the mouth and oropharynx. Development of edema may impair
patency in the near future.
2. Massive body burns, especially in the presence of circumferential chest burns, as ventilatory
support is needed.
3. Severe inhalation injury.

• Prolonged and multiple attempts at intubation can further aggravate the
hypoxia and may precipitate cardiac arrest.
• So in the absence of expertise, the option of a tracheostomy should be
exercised even if the incision has to be made through burnt skin.
• The early addition of bronchodilators, usually by aerosol, is especially
advantageous in managing the bronchospasm seen after chemical injury.
• Nebulisation with Heparin + Saline helps in limiting the alveolar damage.

B- Breathing
• Detection of wheezing or rales suggests either inhalation injury with
bronchospasm or aspiration of gastric contents.
• In a patient with burn, the respiratory effort and hence the gas exchange may
be inadequate due to:
1. Mechanical restriction of breathing
2. Blast injury
3. Smoke inhalation
4. Carboxyhemoglobin

Carboxyhemoglobin
• Carbon monoxide binds to deoxyhemoglobin with 40 times the affinity of
oxygen. It also binds to intracellular proteins, particularly the cytochrome
oxidase pathway.
• These two effects lead to intracellular and extracellular hypoxia.
• Pulse oximetry cannot differentiate between oxyhemoglobin and
carboxyhemoglobin and may, therefore, give normal results.
• However, blood gas analysis can reveal metabolic acidosis and raised
carboxyhemoglobin levels but may not show hypoxia.

• Treatment is with 100% oxygen, which displaces carbon monoxide from bound
proteins six times faster than does atmospheric oxygen.
• Patients with carboxyhemoglobin levels greater than 25-30% should be
ventilated.
• It takes longer to shift the carbon monoxide from the cytochrome oxidase
pathway than from hemoglobin.
• Hence, oxygen therapy should be continued until the metabolic acidosis has
been corrected.

C – Circulatory
• Circulatory status is evaluated with pulse rate and blood pressure and when
indicated venous access is established with two wide bore intravenous lines in
upper limbs in unburnt area.
• Initial fluid of choice is crystalloid.
• Colloids should be considered in patients not responding to Crystalliods.
• Profound hypovolemia is not the normal initial response to a burn.

• If a patient is hypotensive it may be due to delayed presentation,
cardiogenic dysfunction or an occult source of blood loss (chest, abdomen or
pelvis).
• In patients with circumferential deep partial or full thickness burns of
extremities and electrical injury, assessment of distal circulation is mandatory
for detection of compartment syndrome.
• The circulatory compromise can occur later as edema develops after initiation
of fluid resuscitation.

Secondary Survey
• The burn specific secondary survey should include :
(1) Determination of the mechanism of injury
(2) Evaluation for the presence of inhalation injury and carbon monoxide intoxication
(3) Examination for corneal burns
(4) Consideration of the possibility of abuse and
(5) Detailed assessment of the burn wound.

Fluid resuscitation
• This is based on the estimation of the burn area.
• A urinary catheter is mandatory to monitor urine output in all adults with burns
covering > 20% of TBSA.
• Children’s urine output can be monitored with external catchment devices or
by weighing nappies provided the injury is < 20% of total body area.

• Fluid losses from the injury must be replaced to maintain homeostasis.
• The Main aim of resuscitation is to maintain tissue perfusion to the zone of
stasis and so prevent the deepening of burn.
• This is not easy, as too little fluid can cause hypoperfusion whereas too much
may lead to edema causing tissue hypoxia.
• The greatest amount of fluid loss in burn patients is in the first 24 hours after
injury.
• For the first 8 to 12 hours, there is a general shift of fluid from the intravascular
to interstitial fluid compartments.

• Colloids have no advantage over crystalloids in maintaining circulatory volume
in this situation.
• Some resuscitation regimens introduce colloid after the first eight hours, when
the loss of fluid from the intravascular space is decreasing.

• The following facts need to be considered while planning fluid resuscitation.
1. Burn patients may have substantially higher fluid requirements than other
trauma patients depending on the surface area involved.
2. Fluid needs to be titrated to maintain adequate output and special care needs
to be taken when myoglobinuria is present.
3. The greatest loss of fluids occurs in first 48 hours.
4. The fluid should be administered at constant drip rate and surges should be
avoided. If indicated, aliquots of 250 ml of Lactated Ringer’s may be
administered.

5. The fluid volume for each patient should be adjusted according to urine output
(30-35 ml per hour minimum) and hematocrit (32%). Insert urinary catheter.
6. In children, provision for the daily maintenance requirement (weight or surface
area based formula) on top of the calculated amount should be made if Parkland
formula is being used.
7. Sodium-salt solutions (crystalloids) are the essential components of fluid
resuscitation.
8. The Most appropriate fluid is Ringer lactate because its composition is the
closest to that of extracellular fluid. Also lactate is a source of base due to its
conversion to bicarbonate in the liver.

• Lactated Ringer’s solution without dextrose is the fluid of choice except in
children under 2 years, who should receive 5% dextrose Ringer’s lactate.
• Generally at the end of 24 hours, Colloid infusion is begun at a rate of 0.5 ml ×
total burn surface area (%) × body weight (kg) besides maintenance crystalloid
(usually dextrose-saline) infusion.

• High tension electrical injuries require substantially more fluid (up to 9 ml × %
burn area × body weight) in the first 24 hours and a higher urine output (1.5-2
ml/kg/ hour).
• Inhalational injuries also require more fluid.

• Choices for Venous Access
• First choice: Peripheral vein; unburnt area
• Second choice: Central vein; unburnt area
• Third choice: Peripheral vein; burnt area
• Worst choice: Central vein; burnt area

Common Pitfalls in Initial Fluid Resuscitation
1. Initial Under Resuscitation
2. Initial Over Resuscitation
3. Striving for Ideal Numbers
4. Consideration of Fluid alone for Treatment of Impaired Perfusion
5. Use of Urine Output alone as Monitor for Volume Restoration
6. Failure to Secure Intravenous Lines

9. Fluids should be free of glucose (exception being small children), since
glucose intolerance is characteristically present due to high circulating levels of
stress hormones.
10. The time frame of fluid resuscitation is to be calculated from the time of burn
and NOT from the time of initiation of therapy.

Monitoring
• Oxygenation
• Baseline body weight
• Arterial Pressure
• Pulse Rate
• Urine Output
• Intake-Output
• Blood Gases

• ECG monitoring
• Body temperature
• CVP Monitoring
• Cardiac Output

Laboratory parameters
• Plasma Proteins: A marked decrease
in plasma proteins occurs early post
burn.
• Plasma Myoglobin: The plasma value
of myoglobin is obtained in very deep
burns, especially electrical burns.
Myoglobin, released from deeply
injured muscles, affects renal function.
A higher urine output should be
maintained (2-5 ml/kg/hour).

Initial Management of Burn Wound

• After ensuring airway patency, adequacy
of respiration and initiation of fluid
resuscitation, attention is directed to
complete evaluation of the extent and
depth of the burn wound.
• Till such time, care should be taken to
avoid hypothermia due to exposure.
• Based on the depth of involvement, the
burn wound is classified.

For in-patients, the protocol
followed at the author’s unit is as
follows:

Partial thickness burn wound:
• Wounds are cleaned with 0.5% chlorhexidine solution and normal saline.
• Blisters are deroofed and loose skin removed for ease of dressing, except for
palmar blisters (painful), unless these are large enough to restrict movement.
• Wounds over face and hands and all burns in children are covered with
collagen sheet if the patient is received within 6 hours of burn injury.
• Once collagen is firmly adherent, secondary dressings are not needed.

• Once collagen is firmly adherent,
secondary dressings are not needed.
• The author uses banana leaf dressing with
1% Silver- sulfadiazine (SSD) for dressing
of all other partial thickness wounds.
• This is covered with sterile Gamgee cotton
pads and bandaged firmly.

• B. Full thickness burn wounds:
• In the author’s unit, if early excision is planned, full thickness burn wounds
receive exposure treatment with application of povidine-iodine ointment two or
three times a day after cleaning of the wound with 0.5% Chlorhexidine
solution.
• If early excision is not feasible, the wounds are dressed with banana leaf
dressing with povidine-iodine ointment as the topical agent. At most other
places the wounds are dressed with 1% SSD.

• C. Infected wounds:
• Exposure treatment with povidine- iodine cream in the authors unit. Many
other units prefer closed dressing with antimiciobial agent as per organism
grown.

• Surgical procedures such as fasciotomy/escharotomy may be needed early in
patients with full thickness circumferential burns of extremities or chest wall.
• Impaired Chest Wall Compliance
• Respiratory excursion can be markedly impaired by a circumferential deep
partial or full thickness burn of the chest wall.
• The loss of elasticity in the burns of the chest wall markedly increases the work
of breathing.
• As more subeschar edema develops, significant respiratory effort is required
just to maintain adequate gas exchange.

• Symptoms may not be clearly evident until edema development peaks at
about 10 to 12 hours.
• The first clinical evidence of the chest wall restrictive defect is often labored
breathing followed by a rapid respiratory deterioration, particularly in the
patient who is not receiving ventilatory support.
• Patient with non-circumferential full thickness or partial thickness burn is
monitored closely for evidence of respiratory restriction.
• Escharotomies are usually not required in a partial thickness burn unless the
edema is so massive that the burned skin is tight.

• For circumferential full thickness burn, chest wall escharotomy is performed
early.
• Even with an escharotomy, the restrictive process can be of such magnitude
that hypoventilation is clearly evident.
• In these patients, endotracheal intubation and positive-pressure ventilation
should be initiated before obvious pulmonary deterioration.

• Impaired Distal Perfusion and Need for Escharotomy:
• A full thickness burn tissue has complete loss of elasticity.
• Hence, as subeschar edema develops under the burnt tissue, the tissue pressure
increases.
• Fluid resuscitation leads to the development of burn wound edema and further swelling of
the tissue beneath this inelastic burnt tissue.
• With circumferential full thickness burn of extremity, this increase in tissue pressure initially
decreases the venous return.
• This further augments the tissue pressure and leads to impairment of arterial flow causing
ischemia

• Only the burnt tissue is divided, not any underlying fascia, differentiating this
procedure from a fasciotomy.

Principles of Escharotomy
• The escharotomy incisions should be
located as shown.
• Incisions are made along the midlateral
or medial aspects of the limbs, avoiding
any underlying structures.
• For the chest, longitudinal incisions are
made at each mid-axillary line to the
sub costal region.
• The lines are joined up by a chevron
incision running parallel to the sub
costal margin. This creates a mobile
breast plate that moves with ventilation.

2. Anaesthesia is not required as the full thickness burn is insensate.
3. The procedure should preferably be performed in operation theater, but can be
performed bedside with all aseptic precautions.
4. The incision should be deep enough to allow separation of the edges permitting
bulging of viable tissue.
5. Pain and significant bleeding is indicative of excessively deep incision.
6. Escharotomy must extend completely through length of burnt tissue crossing the
joints till healthy skin is reached.
7. Escharotomies are best done with electrocautery, as they tend to bleed.

8. Dressing should be applied using a topical agent and nonadherent wound
cover.
9. Monitoring of distal perfusion should be continued after escharotomy and if the
impairment persists, existing escharotomies should be extended or additional
escharotomies should be performed.

Fasciotomy
• Treatment of the high-voltage electrical burn victim should include prompt
initiation of aggressive fluid resuscitation and serial assessment of distal
vascular integrity.
• Development of compartment syndromes should be anticipated. Deeper
muscle groups sustain the greatest injury.
• Urgent surgical intervention for fasciotomies and muscle compartment
explorations under regional or general anesthesia is often indicated.

INITIAL MANAGEMENT OF
BURNS INVOLVING SPECIAL
AREAS

Face Burns
• Suspect inhalation injury in patient with burns of face.
• After proper cleansing, apply collagen sheet in a patient with superficial partial
thickness burns, if seen within 6 hours of injury.
• Deep partial or full thickness wounds may be treated by exposure with silver
sulfadiazine cream smear or may be covered with face mask of nonadherent
dressing and Gamgee cotton pads.
• 30° propped up position. Insert Ryle’s tube for feeding.

Eye Burns
• History of mode of burns and eye examination.
• Observe for singed eyelashes, eyebrows, eyelid edema, conjunctival lacerations,
corneal opacity, any foreign body, pupil size and reaction to light.
• If chemical injury is suspected, irrigate the eye with Normal Saline 0.9% for 15-20
minutes.
• Application of ophthalmic antibiotic ointment 6-hourly reduces risks of corneal drying
and infection.
• Cover the eye with eye shield and NOT with gauze and cotton pad.
• Repeat examination daily to look for corneal ulcer, abscess or other complications

• In the event of corneal injury or with severe burns of the eyelids, an
ophthalmologist’s consultation should be obtained.
• Early tarsorrhaphy should be avoided as it increases lid deformity and
prevents serial examinations of the corneal surface.

Ear Burns
• Examine the auricle for edema, tenderness and look for discharge from canal.
• If blisters are present, puncture them and expel the fluid out but avoid
removing any skin which is still firmly attached
• Avoidance of any pressure on the burned auricle is essential (no pillows).
Pressure is the biggest co-factor in the production of chondritis.
• Apply paraffin gauze into the canal and apply povidone iodine ointment on the
burnt pinna. Wrap the ear with nonadherent dressing and Gamgee cotton pad
and apply mastoid bandage gently.

• Most ear burns respond well to conservative treatment, although occasionally
immediate coverage of exposed cartilage with a temporoparietal facial flap and
skin graft may be required to salvage the pinna.

Hand Burns
• Hand burns assume a high priority from the onset of care.
• During the first 24-48 hours, adequate blood flow must be ensured. The
consistency, the temperature and the presence of pulsatile flow detectable by
Doppler ultrasonography monitoring of the digital pulp should be regularly
performed.
• If any doubt exists, escharotomy or fasciotomy should be performed.
• While dressing a hand burn, each finger should be wrapped individually with
nonadherent tulle grass and web spaces should be separated.

• The hands should be splinted in a position of function: the
metacarpophalangeal joints at 70-90°, the interphalangeal joints in extension,
the first web space open and the wrist at 20° of extension.
• Deep dermal and full-thickness burns should undergo early excision and sheet
autograft closure.

Perineal Burns
• Admission of this patient is necessary for specific care.
• Assess extent and depth of the burns. Look for the skin loss and edema.
• Per-urethral catheterization is essential to avoid contamination by urine.
• Apply a layer of Silverex ointment over burnt area and cover it with double
layer of paraffin gauze and Gamgee or keep it exposed.

EARLY REHABILITATIVE CARE
• Rehabilitative care should commence on the day of the injury and the goals of
burn patients’ rehabilitation are:
1. To limit or prevent loss of motion.
2. To prevent or minimize anatomic deformities.
3. To prevent loss of lean muscle mass.
4. To ensure return of the patient to work or normal activity
as soon and as completely as possible.

MEDICAL RECORDS
• Most of the burn patients are medicolegal cases and are to be informed to the
law enforcement authorities and meticulous medical records are of significant
value in the court of law.
1. Record the time of burn, exact incident and persons present at the site.
2. Name and relation of person bringing the patient to hospital and providing
information.
3. Record details of pre-hospital treatment, co-morbid conditions.
4. Record the actual incident in notes and not just–‘scalds with hot tea’ or ‘flame
burns with kerosene’.

5. If the patient wishes to change the statement, record the new statement and
place signature with name, date and time. Inform the police constable on duty
about the patient’s wish to change statement.
6. Inform the expected prognosis and patient’s condition to the close relatives and
record it on the case paper with the signature of the relative and name with date
and time.
7. Detailed orders including special instructions, wound management plan and
monitoring instructions should be recorded.
8. Details of procedures performed during resuscitation and reports of
investigations should be recorded.

Acute Management in Burns

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