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Burns

Irene Tangco, MD
UST-FMS Department of Surgery; Plastic and Reconstructive Surgery
th
(Magboo C2015 Transcribed From Lecture Notes + Schwartzs Principles of Surgery, 9 Ed.)

Burn Injury is a Chronic Disease. Admission Criteria
2 degree burns = 15%TBSA
Surgical Critical Care 3 degree burns = 5%TBSA
Keep in mind the functions of the integumentary system, the Burns on feet, face, hands, perineum more difficult to
complications on the loss or impairment of these functions need take care of; if not treated right away, may cause
to be addressed. deformity and significant loss of function
Fluid and Electrolyte Management/ Replacement o Perineum: greater chance of infection
Infection Control Electrical injury: extent may not be easily visible
Nutritional Maintenance (nutritional requirements Electric current may have gone through the tissue between
shoot up) hands & feet (e.g., may just be a spot in the hand but is
Cardiopulmonary Support really extensive)

Wound Care (avoid contractions) Inhalation injury: burns mucosa down to the lungs
edema air exchange not possible DOB

Chemical injury: depth cannot be assessed at once
Reconstructive Surgery
Patients <10 or >50 y/o: Cant take care of themselves
Skin Grafts and Skin Flaps as indicated
Those with additional medical conditions

(e.g., diabetes) or injuries (e.g., fractures) that would
Rehabilitation Surgery
compromise the patient
Involves both psychological and physical function


The Rule of Nines
Etiology
In estimating the extent of Burns (% Total Body Surface Area)
M>F
Infants (<1yo) Adult (10yo & Above)
Scalds (mainly pediatric) most common cause of burns
Head & Neck 18 9
60C or 140F (deep dermal/full thickness in 3s)
One Arm 9 9
Structure Fires
Anterior Trunk 18 18
Flammable Liquids / Gases (occupational)
Posterior Trunk 18 18
Flash burns (mostly dermal)
One Leg 13.5 18
o Generally heal even without grafts
Perineum 1 1
o Cover large skin and upper airway areas
Dont forget that we normally have Two Arms and Two Legs
Electrical Burns
In computing for Children (Age 1-9)
Open Flames (Fireworks/Explosives)
For every year of life: -1% from head and neck
second most common
+0.5 % for every leg
Chemical Burns - disintegrate skin For example: a 3 year old will have 15% TBSA corresponding to the head & neck
areas, 18% for Two Arms, 36% for the Entire Trunk, and 15% for every Leg (30%
Emergency Burn Care for Two legs), the 1% from the perineum will complete the TBSA of 100%

Halt Burning Process Immediately

o Extinguish Flames
o Wash copiously with Water
o In Chemical Burns: Dont put Acid versus Alkali or
Alkali vs Acid
Cardio-Pulmonary Resuscitation
o Especially in electrical burns, as it may stop the
heart
Hemodynamic Stabilization
O2 administration (e.g., cases of CO poisoning)
Room Temperature Water Soaks
o Decrease temperature in burnt area, so injury
does not progress
Burn Wound Coverage
o To avoid further fluid loss and contamination


Note possible variabilities: e.g., 4.5% if only the anterior or posterior

surface of the head is involved (this is just an estimation), 1% was
assigned to the Hand on this diagram. Diagram taken from Schwartzs





1st degree 2nd degree: 2nd degree: 3rd degree Second 24 hours
Superficial Deep Dermal
Epidermis Dermis still intact (can still replenish itself); Entire thickness, epidermis to
Note Urine output
partial thickness burn dermis; no skin left o With increased Urine output, decrease the Load
Surgical debridement
Sunburn, Hot liquids, flames, Hot liquids, flames, Flame, immersion burns, scalds, o Very little urine output, continue fluids
minor flash brief exposure to prolonged exposure high voltage electricity,
dilute chemicals to dilute chemicals concentrated chemicals Blood Pressure: Target MAP = 60mmHg
Pink Pink to bright red Dark red to mottled Pearly white, charred, parched
yellow white (dermis); (leathery)
Adults can be given D5 water
pinpoint areas live Colloid containing fluids IV
hair follicles
Dry, no Bullae formation Smaller bullae, Dry, non-viable, adherent o Microvascular permeability already reversed
blisters (epidermal layer ruptured or slightly epidermis, thrombosed vessels
raised), copious ruptured (black lines on skin surface); o 0.5 mL/kg BW/%TBSA affected
exudates viable tissue = bleeding areas or plasma equivalent
Painful Painful because Decreased pinprick Anesthetic (no nerve endings),
nerve endings are sensation (less deep pressure sensation Note: Children has less capability to concentrate
intact on the painful); intact deep
deeper part of the pressure urine
skin
Soft, minimal Skin thickened by Moderate edema with Inelastic, leathery
o D5 water 0.45% saline
Edema, edema, but pliable decreased elasticity
Superficial
exfoliation Inhalation Injury
Heals Heals Heals in 3 weeks Non-healing
sponta- spontaneously in May have some Carbon Monoxide poisoning
neously in 5-21 days amount of scarring
2-3 days Has 200x more affinity for Hgb compared to O2
Managemen Pain relief, Skin grafting for faster Remove eschar (dead tissue that
wont allow healing)x
Administer 100% Oxygen to displace bound CO
t: lotion and Vaseline re-epithelialization
Vaseline Surgical and prevent extensive Mesh split thickness skin graft for Upper Airway Burns (Tracheobronchial tree)
debridement (looks scarring large areas (may have
raw, moist, with cobblestoning) PE: dyspnea
Sheet graft no holes; for aesthetics
exudates) Mesh split thickness Fiber-optic Bronchoscopy- mucosa is blistered, red
(face)
skin graft to expand Scalp thicker area where skin can
be harvested with preservation of Supraglottic obstruction
follicles
Upper airway: bronchitis suctioning

Lower airway burns (Pulmonary Parenchyma)
Fluid Resuscitation
DOB with pulmonary edema sometimes pneumonia
First 24 hours
CXR: congestion
Parkland Formula

Lactated Ringers
Wound Management
We dont give D5 H2O (Dextrose containing solution),
Debridement (remove necrotic tissues)
because burned patients have very high sugar levels
o Prevent infections
Colloids are not yet given, due to its hypertonicity
o Irrigation/scrubbing
Children: do not have sufficient glycogen stores to maintain
o Surgical removal of nonviable tissues
an adequate glucose level in response to the inflammatory
Control bacterial proliferation
response; They need more fluids than the adults
Adults: - Wound biopsy: culture and sensitivity
4mL/kg body weight/%TBSA affected - Appropriate antimicrobial chemotherapy
(After debridement)
Children below 30kg:

4mL/kg body weight/%TBSA affected
o Silver sulfadiazine
Addendum (Children Above 30kg) Most popular, Widely available
Modified Parkland Formula 1% in water miscible base
These additional volumes will stack on top of the initial 4ml/kg BW Gram +/- variable, yeast
+ 100mL/kg for the first 10kg Exposed or single layer Dressing
+ 50mL/kg for the second 10kg Application is painless
+10mL/kg above second 10kg Easily applied
Wound appearance readily monitored
Half of the total computed volume: given within the initial 8 hours Neutropenic and Cytopenic
Other Half: Given over the last 16 hours Limited eschar penetration
Eschar: a dry,dark scab or falling away of dead skin

Still combined with oral antibiotics

*Sample Computations:
A 50kg 36-year old Female, presented with 2nd degree and 3rd degree burns on the Right Stainless
upper extremity, Right anterior leg and entire Right foot, and Right half of the anterior trunk o Mafenide acetate- 11.1% in water miscible phase
1. Compute for the Total Body Surface Area Burned.
Gram +/-
Burned Areas Rule of Nines TBSA Designation
R Upper Extremity 9% 9% Has very good penetration of eschar
Anterior Trunk: R HALF 18% (Entire Trunk) 9% 7% hypersolubility Reaction
R Leg: ANTERIOR 18% (Entire Leg) 9%
Not commonly used: Carbonic
R Foot Just an estimate 1%
Total 28% anhydrase inhibitors can produce
2. How will you manage the Fluid Resuscitation in this patient?
acidosis
Parkland Formula: 4mL/kgBW/%TBSA o Silver nitrate
4mL x 50 kg x 28% 0.5% aqueous solution
5,600 mL LR solution
Give 2,800 mL over the first 8 hours Gram +/-, yeast
Give remaining 2,800 mL over 16 hours Occlusive dressing
A 12 kg 3-year old Boy scalded on his Left lower extremity
Painless, no hypersensitivity
1. Compute for the Total Body Surface Area Burned. No eschar formation
3-year old = +0.5% per leg every year = 13.5 + 1.5 = 15% Causes staining on linens & expensive
3. How will you manage the Fluid Resuscitation in this patient?
Modified Parkland 4 mL/kgBW/%TBSA + Additional fluid based on weight (rarely used)
4mL x 12 kg x 15% = 720 ++ o Cerium nitrate
100mL / first 10 kg = 100 mL x 10kg = +1000mL
50mL / second 10 kg = 50 mL x 2kg = +100 mL
Total : 720mL + 1000mL + 100mL = 1,820 mL (Give 910mL first 8, remaining 910mL 16)
Clinical signs of burn wound infection Hypermetabolism
nd Constant until the burn wound spontaneously heals or is
Conversion of 2 degree burn to full thickness
closed by skin grafting
necrosis Nitrogen loss from the muscle mass is significantly affected
Focal dark brown or black discoloration of wound muscle mass is lost
e.g., most patients thin down, no matter how fat they were
Degeneration of wound with neo-eschar formation =
initially and muscle mass will shrink
dead tissue expands Cardiac output and oxygen utilization doubles
Unexpected rapid eschar formation Ideal daily calorie intake= 25 kcal/kg BW
Hemorrhagic discoloration of subcutaneous fat o 25 kcal/kg BW + 40 Kcal % TBSA burned
o e.g., burned px 10% then additional
Erythema of wound margins 40 x 10 x % burned TSBA
Erythema gangrenosum metastatic septic lesions in Enteral feeding advantageous over parenteral feeding
unburned tissue
INFECTION AND SEPSIS
Green pigment in subcutaneous fat (e.g., Increases in incidence with increase in burn size
Pseudomonas: nosocomial) Primary cause of death in children and adults (resuscitative
failure in elderly)
Highly associated with inhalation injury prone to
Electrical Injury pneumonia w/ burn injury
Tissue damage: electrical energy passes through the
o
Infection= 39 C, WBC: 16000/mm
3

body and is converted to thermal energy Sepsis (immune defense of the body is broken down)=
3
Hypothermia, WBC: 5000-16000/mm
(coagulation, necrosis and dessication in the deep

tissues) Infected Burn Wound
Hallmark: small external tissue damage but with high Definitive Treatment: expeditious wound excision
likelihood of extensive deep tissue damage out of Most acquired infection in hospitalized burn patients involve
organisms that originally colonized the wound
proportion with the visible wound C & S= takes about 3 days, hence the use of empiric
Cardiopulmonary arrest as electricity passes through antibiotics
nerves and disrupt electrical activity of the heart o Do culture right away when patient gets to
hospital
Acute renal Failure
An identified organism is treated by a single antibiotic
Nerve deficits (most common?)
Tissue damage occurs when electrical energy is
converted to thermal energy Complications
Signs: Cardiac (arrhythmias and arrest) Contracture deformities
When deep 2 or 3 burns are not skin grafted
Hypertrophic scars develop; contract that area;
Wound Management Function of joints impaired
Surgical excision of burn wound Inability to flex or extend
Early escharotomy GI
Tangential excision Curlings ulcer (stress ulcer)
Fascial excision (vascular layer) Antacids/histamine: H2 antagonists
Wound closure Acalculous cholecystitis
Skin grafting Acute pancreatitis
Skin flaps Myocardial infarction
Risk for wound infection; deeper injury Electrical burns
Current that flows to the body mainly affects
Biologic Wound Covering the conduction mechanism of the nerves then
Limit growth and proliferation of bacteria on the the muscles.
wound surface
Prevent wound dessication Other things that we use for Scars
Decrease evaporative water and heat loss Silicon sheets and silicon gel
Types: Good for keloids and hypertrophic scars
o Autograft: most appropriate; comes from the With some pressure, it can soften up keloid as long as
patient it is not so thick
o Allograft: cadaver homograft (in NSS with Serve to realign the collagen fibers
antibiotics, not formalin); temporary dressing, Tissue expander
works well to keep evaporative losses from Silicon bag inflated by saline
overcoming patient, prevents dessication, Placed under normal skin to expand it and eventually
eventually gets rejected/sloughed off by the used to cover adjacent burned areas
patients immune system (about 5 days) Remember: there should be an underlying viable
o Amnion: only for 2 degree burns, when the skin is blood supply, otherwise the grafted skin would just
able to replenish itself; very good as a temporary undergo necrosis
dressing because it keeps the body fluids in; Random flap
doesnt allow a lot of exudation, sheds off once Certain amount of skin can be predicted so that site
the skin is healed can be covered
o Xenograft: e.g., porcaine (from pig or chicken): Partial Thickness Skin Grafts
anything to cover the wound temporarily, but Full thickness skin graft for joints
rejected much faster than the allograft

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