HISTORY

“Parts of the body which have been burnt need cleansing, rather than drugs which are hot or cold”

BURN WOUND FLUID RECONSTRUCTION

MANAGEMENT RESUSCITATION Release contracture with
Rose water+ Snow Evans formula Transverse incision,
Prolonged Splintage
Blisters to be Cut and Baxter-Parkland formula(
RL) Massage and Stretch
Evacuated minor Contractures
Exposure/ Open method Monafo( Hypertonic
Saline) Skin Grafts-auto, homo,
Tannic acid- Eschar allo
formation Pinch Graft
Triple Dye- Prevent Mesh Graft
infection
Banana leaf, Boiled Potato
Peel dressings
 EPIDEMIOLOGY
• 10 lakh / Year

• 80% > Women & Children

• 20% > Men at work ( Industry)

• Women > Usually Flame / Scalds

• Children > Scalds

• Men > Flame / Chemical / Electrical

• 10% of Burns > Life threatening + Hospitalization

• 50% of Hospitalized > Succumb to their injuries

• 1-1.5 lakh people get crippled and require Multiple Surgeries and
Rehabilitation.
 ETIOLOGY
• Flame-damage from superheated, oxidized air

• Scald-damage from contact with hot liquids

• Contact- damage from contact with hot or cold solid

materials

• Chemicals- contact with noxious chemicals (acid/

base)

• Electricity- conduction of electrical current through

tissues

• Radiation
 SKIN

LARGEST IMMUNE TEMPARATURE

BARRIER:
ORGAN RESPONSE REGULATION

• 2 SQUARE • MECHANICAL • PRIMARY • ALTERING

METRE • OSMOTIC IMMUNE CUTANEOUS
SURFACE • THERMAL RESPONSE BLOOD
AREA • LANGERHAN SUPPLY
• CHEMICAL
S CELLS • SWEATING
• RADIATION
Pathophysiology of Burn Wound
BURNS

HEMOCONCENTRAT
ION

CAPILLARY BLOOD

BURNS(600
C)

PROTIENS
AND
FLUID
PATHOPHYSIOLOGY OF BURN
WOUND
• Flame, Scald, Contact-
heat transfer-
coagulation necrosis
• Chemical, electrical-cell
membrane lysis+heat
transfer-colliquation
necrosis
• Zone of stasis-moderate
injury, less perfusion
,may survive, may
necrose, vessel
damage+leak, TXA2
• Zone of hyperaemia-
vasodilatation due to
inflammation
Thermal burns - Heat denatures protein= coagulation necrosis

• Hot liquids- partial thickness burn unless

contact is prolonged
• Full thickness injuries- flame, boiling water,
grease, molten metals, melted synthetic
material likely to adhere to skin
 CHEMICAL INJURIES
Severity depends on
• Concentration
• Quantity
• Physical state
• Duration of contact
• Penetrating power- (alkali> acid)
Classification of agents:
• Oxidizing agents (sodium hypochlorite)
• Corrosives ( phenol, lye)
• Salt forming ( formic, tannic, hydrochloric acid)
• Desiccants ( sulfuric acid)
• Vessicants ( nitrogen mustard)
 ELECTRICAL INJURIES
• Entry and Exit wound reperesent deep tissue destruction.
Muscle tissue death along the path of current my be
progressiv and may not be accurately assessed until 4-5
days following injury.
• Electricity flows through the path of least resistance.
• Ascending order of resistance
Nerve<Blood<Muscle<Skin<Tendon<Fat<Bone
• Skin- 100,000 ohm, internal resistance- 300 ohm
• More the resistance, greater is the heat generated as current
flows through it
• Perspiration and moisture reduce skin surface resistance
High Voltage >600V Arc
•Flash burn-diffuse partial thickness burns
•Explosion related shock waves-blunt truma, rupture of ear
drums,contusion of internal organs
•Current flow through the body- contact- full thickness burn
 RADIATION BURN

• Ionizing radiation like Xrays, radio-isotopes

• Penetrate cells and deposit energy within them

• Inhibit mitosis

• Cutaneous injury- full thickness dermal injury, heal

slowly due to excessive cellular damage

• Systemic effects- hemorrhage, aplastic anemia,

lymphatic tissue destruction
• Hypovolemic shock, shock induced AKI->Death

• Causes:
o Increased capillary permeability
o Decreased plasma oncotic pressure
o Increased capillary hydrostatic pressure
o Reduced lympho-venous clearance
o Intracellular fluid accumulation-Impaired cell
membrane function
o Increased burn tissue oncotic pressure
o Increased evaporative loss
o Depressed myocardial function

• RBC- destruction, decreased survival

 RECOVERY FROM BURN SHOCK

• Withdraw fluid from unburnt ECF

• Splanchnic and skin vasoconstriction

• Thirst-> Ingestion and Absorption from gut

• Sodium shift forms the basis for using sodium rich

fluids for initial resuscitation
 METABOLIC RESPONSE TO BURN
INJURY
• Withdraw fluid from unburnt ECF

• Splanchnic and skin vasoconstriction

• Thirst-> Ingestion and Absorption from gut

• Sodium shift forms the basis for using sodium rich

fluids for initial resuscitation
•
 METABOLIC RESPONSE TO BURN
INJURY
• Withdraw fluid from unburnt ECF

• Splanchnic and skin vasoconstriction

• Thirst-> Ingestion and Absorption from gut

• Sodium shift forms the basis for using sodium rich

fluids for initial resuscitation
NERVOUS SYSTEM IN SKIN
 CLASSIFICATION

• 1st degree- injury localized to

epidermis
• Superficial 2nd degree- injury to
epidermis and superficial
dermis
• Deep 2nd degree- injury through
the epidermis and deep into the
dermis
• 3rd degree- full thickness injury
through the epidermis and
dermis into subcutaneous fat
• 4th degree- injury through the
skin and subcutaneous fat into
underlying muscle or bone
•1st degree •2nd Degree •3rd Degree 4th degree
•Reddened •White to red •White, dark Involves
•Painful •Intense pain brown, charred deeper tissue
•Thrombosed like muscle,
•Blanches to •Blisters bone
touch vessels
•Blanches to
•Heals in 3- touch •Pain less
7days •Heals in 7- •Healing
•No scar 14days >60days
•Heals with •Always
scarring require
surgery
 LASER DOPPLER IMAGING
• Laser Doppler Imaging (LDI) is a technique with
which a more accurate (>95%) estimate of burn
depth can be made by measuring the dermal
perfusion.
• Laser light is transmitted to the skin, either directly
(non-contact imaging) or via a fiber optic probe
(contact monitoring) to measure the microvascular
blood flow.
• Easier identification of severity of wound type.
• Focuses on depth of injury than on extent of injury.
• Guide to early excision and grafting.
Burn size

■ Wallace rule of 9
■ Palm=1%
■ Berkow formula
■ Lund and Browder chart- children
First degree burns are not taken into account for the estimation
of the extent of burn
 FIRST AID
• Put out fire- STOP, DROP, ROLL, WATER
• Prevent contamination of burn wound
• Small burns – immerse in tepid water(NOT ICE
WATER)
• Extensive wounds- DO NOT REMOVE BURNT
CLOTHING- wrap in clean towel/ sheet
• BLISTERS SHOUD NOT BE BROKEN
• ABSORBANT COTTON SHOULD NOT BE USED ON
THE WOUND
• Delay in transport >30mins- oral salt solutions
• Chemical wounds should be irrigated with copious
amount of clean water, tar burns should be cooled
with plain water.
 TRANSPORTATION
• Uncomplicated burns( BSA<30%) may tolerate 2hrs

post burn without IVF

• BSA>30% will need immediate resuscitation

 CRITERIA FOR ADMISSION
• 2ND Degree BSA>30%
• 2ND Degree in children BSA>20%
• 3RD Degree BSA>10%
• 3RD Degree in critical areas : Hands, Feet and
Perineum
• Burns complicated by Respiratory tract injury,
major soft tissue injury and fractures
• Electrical burns
• Burns complicated by other medical or surgical
conditions which need close observation.
 RESUSCITATION
GOLDEN HOUR is most likely anywhere between when
it happens and eight hours afterwards
A - AIRWAY
B - BREATHING & VENTILATION
C - CIRCULATION
D – DISABILITY: NEUROLOGICAL STATUS
E – EXPOSURE {Undress}
ENVIRONMENT {Temperature Control}

*(TT), NG tube, Foley’s, Position, Physiotherapy,

Photography
VENESECTION
 Fluid Resuscitation
FORMULA DAY 1 DAY 2
Colloid-1ml/kg/%BSA
EVAN’S ½ of DAY 1 fluid
NS- 1ml/kg/%BSA
FORMULA 5%D-2 lit Adult, prop less- Child
Colloids-0.5ml/kg/%BSA
BROOKE ½ of DAY 1 fluid
RL- 1.5ml/kg/%BSA
FORMULA 5%D-2 lit Adult, prop less- Child
5%D-100ml/hr
RL-4ml/kg/%burns
Colloid(
PARKLAND ½ in 0-8h
Plasma)-
FORMULA ¼ in 8-16h
0.5ml/kg/%BSA
¼ in 16-24h
24-32h
MUIR AND 1 ration=(BSA*kg)/2ml
3 rations/4th hrly
BARCLAY 2 rations/6th hrly
FORMULA 1ration over 12hrs PLASMA
GAVELSTON Crystalloid-5000ml/m2 BSA+
1500ml/m2 total area
 FLUID RESUSCITATION
• Day 1 crystalloids
• After 8h- colloids
• Days following burns
o Hypotonic solution to compensate for water loss
o K+: 120mEq/day in 5D
• Maintain RBS-80-120mg% K+4-5mEq/l: 50ml of 50%
dextrose with 120u/l Insulin + KCl 40mEq/lit
• Blood replacement-to maintain hematocrit around
35
• Adequate resuscitation- PR<110/min, U/O-0.5-
1.5ml//kg/hr, CVP- 7-10cm water
 INITIAL WOUND CARE
• Resuscitation>>wound care( except Chemical)

• Chemical burns- dilute, dont neutralize

• Cleanse under sedation with cetavlon

• Blisters need to be broken

• Dont use alcohol, ether, ice water

• Remove Tar with mineral oil or petroleum oint

• Closed occlusive vs Exposure technique

 INITIAL WOUND CARE
• Eye-wash with saline, Corneal ulcers- Ointment, patching;
Eyelids- Tarsorrhaphy
• Ear
• Superficial-bland ointment, exposure
• Deep- topical chemotherapy, avoid pressure
• Exposed cartilage- excise
• Hands and feet- superficial burns- topical chemotherapy,
elevation, pressure bandages
• Perineal burns- topical antibiotics, exposure, thighs
abducted. Genitalia+ buttocks- bottom suspended using a
frame
• Respiratory tract- humidified O2, bronchodilators,
epinephrine aerosol, ventilatory support
ESCHAROTOMY
• Edema within space
surrounded by inelastic
dermis
• Circumferential 3rd
degree burns
• Confirm vascular
insufficiency with
Doppler
o L-Longitudinal
incision
o A-Axillary plane
o I-into skin
o D-down to subcut
tissue
Definitive Wound
Management
■ 1st degree- bland soothing ointment
■ 2nd degree- daily dressings changes with topical antibiotic,
cotton gauze, elastic wraps, temporary biologic/synthetic
covering
■ Deep 2nd, 3rd degree require excision and grafting- occlusive
antiseptic dressing pre-op
■ Systemic antibiotic prophylaxis against S. aureus,
Pseudomonas
 BURN WOUND EXCISION
• To prevent Bacteremia>Sepsis>MODS>Death
• To reduce hypermetabolic response
• Excision
o Tangential
o Full thickness
o Fascial
• Instruments- Braithwaite, Watson, Goulian,
Humby’s knife, powered Dermatome
• Bleed- 3.5-5% blood vol/1% BSA excised
SURGICAL MANAGEMENT
OF BURN WOUND
BURN WOUND COVERAGE
BURN WOUND COVERAGE
 INHALATIONAL INJURY
Thermal injury to airway
• Volume requirements increase by 50%
• Empirical Antibiotics against MRSA,
Pseudomonas, Klebsiella
• CO poisoning
• Treatment-100% O2
 CHEMICAL BURNS

• Alkali penetrate more than Acid

• Lavage with 15-20l of tap water

• Irrigate away from non-injured area

 
 ELECTRICAL BURNS
• Burn wound
• Entry- charring, “Fir tree”-Deep>superficial
• Exit- explosion, superficial>deep
• Muscle- coagulation necrosis edema compartment
syndrome fasciotomy, amputation
• Heart
• High voltage- cardiac standstill
• AC current 100A- V fib
• Renal- ATN due to hemoglobinuria, myoglobinuria 
Mannitol diuresis
• Curling’s ulcers- associated with acute stress due to high
tension burns antacid gels, H2 blockers, cold lavage,
endoscopic cautery
 NUTRITION IN BURNS
• EARLY ENTERAL FEEDS through NGTube
• Tolerated in burn patients
• Preserve mucosal integrity
• Reduce magnitude of hypermetabolic response
• Calorie- 25kCal/kg/day+ 40kCal/BSA (Curreri)
• Protein- 1-2g/kg/day
• High carbohydrate, low fat diet
• Parenteral (when enteral is not tolerated
• Central hypertonic formulae> Peripheral isotonic
 WOUND INFECTION AND SEPSIS
• Following adequate resuscitation Sepsis, MODS are
the leading cause of death
• Wound infection, pneumonia
• Microbiology-
• Bacteria-pseudomonas, Escherichia, Klebsiella,
Proteus, Enterobacter, Providencia,
Staphylococcus aureus, group A Streptococcus
• Diagnosis- Clinical, blood and wound culture
• Antibotics
• Emperical- Aminoglycosides+ 3rd gen
Cephalosporin
• Based on culture, sensitivity
 ATTENUATION OF HYPERMETABOLIC
RESPONSE
• Non- pharmacologic:
• Nutrition
• Environmental support
• Physiotherapy
• Pharmacologic:
• Recombinant human growth factor
• Insulin like growth factor
• Oxandrolone (testosterone analog)
• Propranolol
• Insulin, Metformin, -glitazoneHyperglycemia
control
 FAQ’S
• Should we wrap and roll the patient in a blanket?
• Can ice water be used to cool burns?
• Fluid resuscitation only upto 50% BSA?
• If the patient arrives to the hospital after 8hrs, how
should the patient be resuscitated?
• When should orals be started?
• Skin banking?