management of a burn patient

burn management

1. MANAGEMENT OF A BURN PATIENT
Dr sumer yadav

2. Aim of burn care
•Rescue
•Resuscitate
•Refer
•Resurface
•Rehabilitate
•Reconstruct
•Review

3. Principles of BURN MANAGEMENT
•Airway management-quick and appropriate
•Prompt and accurate fluid resuscitation
•Removal of dead burnt skin and replacement
with homograft(cadaveric skin from SKIN BANK)
or biologic skin substitutes
•Appropriate adequate nutrition
•Good chest PT
•Replacement of homograft with autograft or
cultured skin(cultured keratinocytes)

4. Which burn patients need
HOSPITALISATION?
•We go by the AMERICAN BURN ASSOCIATION
GUIDELINES

6. Management of the Patient With
a Burn Injury
6
•Burn care must be planned according to the burn depth
and local response, the extent of the injury, and the
presence of a systemic response.
•Burn care then proceeds through three phases:
–Emergent/resuscitative phase (on-the-scene care),
–Acute/intermediate phase, and
–Rehabilitation phase.
•Although priorities exist for each of the phases, the
phases overlap, and assessment and management of
specific problems and complications are not limited to
these phases but take place throughout burn care.

7. Table: phases of burn care
7
Phase Duration Priorities
Emergent or
immediate
resuscitative
From onset of injury to
completion
of fluid resuscitation
·First aid
·Prevention of shock
·Prevention of respiratory distress
· Detection and treatment of concomitant
injuries
·Wound assessment and initial care
Acute From beginning of diuresis
to near
completion of wound
closure
·Wound care and closure
·Prevention or treatment of
complications, including infection
·Nutritional support
Rehabilitati
on
From major wound closure
to return
to individual’s optimal level
of physical
and psychosocial
adjustment
·Prevention of scars and contractures
·Physical, occupational, and vocational
rehabilitation
·Functional and cosmetic reconstruction
·Psychosocial counseling

8. INTENSIVE BURN CARE UNIT(IBCU)

9. INTENSIVE BURNS CARE UNIT(IBCU)

10. LEVELS OF ICU CARE
•Level - I – provides
monitoring, observation
and short term
ventilation.
•Level - II – Provides
Observation,
Monitoring & Long
Term Ventilation With
Resident Doctors.
• Level - III – provides
all aspects of intensive
care including invasive
haemo dynamic
monitoring & dialysis.

11. History
•Type of burn:
–Flame (open flame, closed space)
–Chemical (type of chemical)
–Scald (type of liquid)
–Electrical (voltage, arcing/flame, contact time)

13. A: Airway
History & Physical: Inhalational injury
•Fire in a closed space.
•Full-thickness/ deep
chemical burns to face,
neck.
•Singed nasal hair.
•Carbonaceous sputum.
•Carbonaceous particles in
oropharynx.

14. A: Airway
•Burned airways swell
rapidly.
•Intubate patient as
early as possible
before airway
swelling.

15. A: Airway
•Indications for intubation:
–Oropharyngeal erythema/ swelling on direct
visualization.
–Change in voice, harsh cough.
–Stridor.
–Dyspnea, tachypnea.

16. B: Breathing
•Circumferential full-
thickness burns may impair
ventilation.
•Blast injuries can cause
pneumothorax, lung
contusions.
•Noxious chemical (plastic)
can cause a chemical
pneumonitis.
•Carbon monoxide poisoning
(if COHb > 15-40%
ventilate).

17. C: Circulation
•BP, HR, color of unburnt skin
•2 large bore I.V.s in unburnt skin
•Draw bloodwork.
•Insert urinary catheter.
•Insert nasogastric tube, if necessary
•Doppler exam of circumferentially burnt
extremities

18. ASSESSMENT OF BURNS
•TBSA(Total body surface area)
•Decides fluid requirements and nutritional needs
•Wallace’s rule of nines
•Lund and Browder chart
•DEPTH
•Dictates local and surgical wound management

19. Management of fluid loss and shock
Fluid Replacement Therapy:
•The total volume and rate of intravenous fluid
replacement are gauged by the patient’s
response.
•The adequacy of fluid resuscitation is determined
by:
–Output totals of 30 to 50 mL/hour
–systolic blood pressure exceeding 100 mm Hg
and/or
– pulse rate less than 110/minute.
19

20. Assessing adequacy of
resuscitation
•Peripheral blood pressure: may
be difficult to obtain – often
misleading
•Urine Output: Best indicator
unless ARF occurs
•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)

21. Conditions Leading to Burn Shock
21

22. Management of fluid loss and shock
Fluid Requirements:
•The projected fluid requirements for the first 24
hours are calculated by the clinician based on the
extent of the burn injury.
•Some combination of fluid categories may be
used:
–Colloids (whole blood, plasma, and plasma
expanders) and
– Crystalloids/electrolytes (physiologic sodium
chloride or lactated Ringer’s solution).
22

23. Management of fluid loss and shock
Fluid Requirements:
•Adequate fluid resuscitation results in slightly
decreased blood volume levels during the
first 24 post-burn hours and restores plasma
levels to normal by the end of 48 hours.
•Oral resuscitation can be successful in adults
with less than 20% TBSA and children with
less than 10% to 15% TBSA.
23

24. 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

25. Guidelines and Formulas for Fluid
Replacement in Burn Patients
Consensus Formula
•Lactated Ringer’s solution (or other balanced
saline solution): 2–4 mL× kg body weight × %
total body surface area (TBSA) burned.
•Half to be given in first 8 hours; remaining half to
be given over next 16 hours.
25

26. Guidelines and Formulas for Fluid
Replacement in Burn Patients
•The following example illustrates use of the
formula in a management of a 70-kg patient
with a 50% TBSA burn:
•Steps
–1, Consensus formula: 2 to 4 mL/kg/% TBSA
–2, 2 × 70 × 50 = 7,000 mL/24 hours
–3, Plan to administer: First 8 hours = 3,500
mL, or 437 mL/ hour; next 16 hours = 3,500
mL, or 219 mL/hour
26

27. Guidelines and Formulas for Fluid Replacement in Burn Patients
Evans Formula
•1. Colloids: 1 mL × kg body weight × % TBSA burned
•2. Electrolytes (saline): 1 mL × body weight × % TBSA burned
•3. Glucose (5% in water): 2,000 mL for insensible loss
•Day 1: Half to be given in first 8 hours; remaining half over next 16
hours
•Day 2: Half of previous day’s colloids and electrolytes; all of
insensible fluid replacement
•Maximum of 10,000 mL over 24 hours. Second- and third-degree
•(partial- and full-thickness) burns exceeding 50% TBSA are calculated
•on the basis of 50% TBSA.
27

28. Guidelines and Formulas for Fluid
Replacement in Burn Patients
Brooke Army Formula
•1. Colloids: 0.5 mL × kg body weight × % TBSA
burned
•2. Electrolytes (lactated Ringer’s solution): 1.5 mL
× kg body weight × % TBSA burned
•3. Glucose (5% in water): 2,000 mL for insensible
loss
28

29. Guidelines and Formulas for Fluid
Replacement in Burn Patients
Parkland/Baxter Formula
•Lactated Ringer’s solution: 4 mL × kg body
weight × % TBSA burned
•Day 1: Half to be given in first 8 hours; half to
be given over next16 hours
•Day 2: Varies. Colloid is added.
29

30. Guidelines and Formulas for Fluid
Replacement in Burn Patients
Hypertonic Saline Solution
•Concentrated solutions of sodium chloride (NaCl) and
lactate with concentration of 250–300 mEq of sodium
per liter, administered at a rate sufficient to maintain a
desired volume of urinary output.
•Do not increase the infusion rate during the first 8 post
burn hours.
•Serum sodium levels must be monitored closely.
•Goal: Increase serum sodium level and osmolality to
reduce edema and prevent pulmonary complications.
30

31. Pediatric Fluid resuscitation
•Use Parkland formula + MAINTENANCE fluid
•For maintenance fluid, hourly rate of
4 mL/kg for first 10 kg of body weight plus
2 mL/kg for second 10 kg of body weight plus
1 mL/kg for >20 kg of body weight
•End point: urine output of 1.0-1.5 mL/kg/hr
•Maintenance fluid given is D5W/ iso-p (child’s liver
not fully matured- limited glycogen stores).

32. Fluid resuscitation
•Need to replace losses to maintain homeostasis.
•Formulas are ONLY GUIDELINES.
•Monitor physiologic parameters.
•Maintain adequate tissue perfusion to prevent
increase in depth of burn.
•Too little fluid Hypotension renal failure, etc.
► ►
•Too much fluid Edema Tissue hypoxia
► ►

33. Fluid resuscitation
•Fluid resuscitation should be started when
–>15% TBSA burns in an adult
–>10% TBSA in children and elderly
•First 8-12 hrs: intravascular volume shifts to
interstitial space.
•Fast fluid boluses are of no benefit.
•Colloids: Questionable in first 24 hrs (capillary
leakage)

34. Fluid Management
• Start with RL in adults and Isolyte P in
children
•After 24 hrs start DNS
•If not adequate urine output in 12 hrs start
colloids FFP
•More fluids required in Electric Burns and
Inhalation Injury
•Always central line (sometimes even thro
burnt tissue) for initial resuscitation

36. Electrical injury resuscitation
•Fluid needs greater
•9 mL x TBSA burn (%) x body weight (kg) in
first 24 hrs
•If myoglobinuria, may require bicarbonate
infusion to alkalinize urine to pH > 8
•End point: urine output of 1.5-2 mL/kg/hr

37. Electrolyte Abnormalities
•HYPOKALEMIA- seen more often than
Hyperkalemia
•Commonest cause of non infective paralytic
ileus
•Serum K <3mEq/l KCl at 10mEq/hr
•Serum K <2mEq/l KCl at 40mEq/hr
•Daily Ser Electrolytes in first 3 days

38. Electrolyte Abnormalities
•HYPOCALCEMIA-most commonly due to
Hypoalbuminemia
•Lowering of Ser Albumin by 1g/ml lowers Ser
Calcium by 1g/ml
•Alkalosis also lowers Ser Ca by increasing
protein binding
•Correction required only if symptomatic
•Associated Hypomagnesemia needs
simultaneous correction to prevent tetany
and arrhythmias

39. Reducing the HYPERMETABOLIC
RESPONSE
•Temperature regulation
•Nutrition
•Pharamacological manipulation-Propranolol
40 mg BD and Oxandrolone 5mg BD
•Early excision and homografting

40. 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

41. 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

43. Role of LMWH
•Incidence of Deep Vein Thrombosis is
significant enough to warrant routine use of
LMWH
•Incidence of Pulmonary embolism is reduced
significantly
•Daltaparin or Enoxiparin
•Fragmin or Clexane
•This is stopped once patient is mobile

44. INTRAABDOMINAL HYPERTENSION
and
INTRAABDOMINAL
COMPARTMENT SYDROME

49. Abd compartment syndrome-
LAPAROTOMY

50. Nutrition
•Aggressive nutritional support to
counterbalance the effect of
Hypermetabolism and Protein catabolism
following Burns
• ENTERAL feeding is preferred over
PARENTERAL feeding

51. Nutritional support
•Calorie : Nitrogen = 100 : 1
•Protein requirement
–Adult: 2g/ kg/ day
–Child: 3g/ kg/ day
•Fat emulsion
–4g/ kg/ day max.
•Carbohydrate (glucose)
–6.2mg/ kg/ min. max.

52. Nutritional support
•Burns patient is hypercatabolic – up to 150-
200% above baseline.
•Nutrition needed for burns >20% TBSA.
•Curreri formula
–Adult: 25kcal/kg/day + 40kcal/ % TBSA burn
–Child: 60kcal/kg/day + 35kcal/ % TBSA burn

53. NUTRITION
•Burn patient caloric requirement 3000-
5000calories per day
•Early feeding
•Nasogastric tube No 10
•Hourly tube feeding
Butter milk diet 1cal/cc
Eggs 4
Bananas 4
Sugar 4Tbs
Curd 1 litre

54. BUTTERMILK DIET(BMD)
•Eggs- 4 /Protein
powders(Whey protein
or Soya protein)
•Bananas- 4
•Sugar- 4 Tbsf
•Curds (Yoghurt) -1000cc
•Mixed with water to
1600cc

55. Antibiotic Protocol
•FRESH BURN
•Start with a 3
rd
gen Cephalosporin with an
aminoglycoside
•INFECTED OLD BURN
•Start with a semisynthetic Penecillin like Pipra
and Tazobactum or a Carbapenem
•LATER go by wound swabs culture and sensitivity

56. Pain Management
•Continuous infusion round the clock of
Tramadol 100mg
Ketamine 100mg
Midazolam 10mg
•In a 50cc syringe in a syringe pump
•Resting Pain-At 4-6cc per hour to start and then
titrate with pain response
•Procedural Pain-During dressing 30-40cc per hour
and titrate

57. Chest Physiotherapy

58. Limb Physiotherapy

59. Initial burn wound management
•Early transfer to burn centre (within first 24 hours):
–Remove smoldering, non-adherent clothes.
–No debridement or topical agents needed.
–Clean, dry sheets,
–Wet dressing cause heat loss.
•If transfer is delayed > 24 hours:
–Unroof blisters >2 cm, cleanse with chlorhexidine
–Silver sulfadiazine cream OD or Povidone Iodine solution
and Vaseline gauze

60. Procedures
•Tracheostomy
•Central line
insertion
•Escharotomy
•Debridement.
Dr. Sunil Keswani, National
Burns Centre, www.burns-
india.com,
[email protected]

61. Burn wound management
•Circumferential
extremity burns:
–Edema under eschar
–Remove all rings, jewelry
–Elevate, active motion
–Check skin color,
sensation, capillary refill,
Doppler pulses q1h
–Rule out hypotension,
arterial injury

62. Burn wound management
•Bedside escharotomy
•3rd degree burns
insensate
•Use electrocautery
•Mid-medial or mid-
lateral, across joints
•Recheck pulses - may
have to do opposite side
of limb

63. Esharotomy-LINES OF INCISION

64. Fasciotomy
•Pain
•Pallor-look at capillary refill
time-if less than 2 secs-
VENOUS OBSTRUCTION and
if more than 5 secs –
ARTERIAL OBSTRUCTION
•Pressure
•Pulselessnes
•Paresthesia
•Paralysis
•Poikilothermia
•Progression
•Compartmental
pressures above
25mm Hg warrant
a FASCIOTOMY
•There are devices
to measure this
pressure
•Or use DOPPLER to
decide

65. Fasciotomy In Burns

66. Fasciotomy-methodology

67. Leg-FASCIAL COMPARTMENTS

69. Burn wound management
Specific anatomical areas:
Face - watch for airway compromise
Eyes - fluorescein exam, copious irrigation,
antibiotic ointment,mydriatics
Ears - external canal, TM (children, perf in blast
injury)
Genitalia, perineum - insert Foley to stent urethra
 treat scrotal edema conservatively
 diverting colostomy NOT automatically indicated in perineal
burns

71. SURGICAL TECHNIQUES-ACUTE BURNS
EARLY EXCISION
Tangential excision and grafting-within first
72 hrs
Cadaveric skin from SKIN BANK
DELAYED EXCISION
Fascial excision and grafting-after 72hrs
Cadaveric skin from SKIN BANK

72. Early excision Vs Delayed excision
•Always early excision if patient comes early
enough and facilities exist
•Early enough is upto 72 hrs postburn
•Early excision decreases the chances of Sepsis
and facilitates early moblisation and better
and more predictable functional recovery.
•Delayed excision is generally at 3 weeks or
later

73. Early Excision
•Within the first 3-5days
•After 5 days chances of Sepsis higher and
bleeding more
•15% of BSA is excised at a time
•Coverage of excised area by Meshed
Homograft is mandatory

74. Order of excision
•Areas easy and quick to excise: trunk and
legs
•Joints and throats
•Hands and face

75. Early Excision
•Blood Loss
–Clear pre-operative plan
–Excision prior to wound hyperemia
–Elevation of extremities
–Tourniquet control
–Dilute Epinephrine tumescent fluid
–Epinephrine soaked sponges

76. Early Excision
•Procedure (En Bloc)
–For deeper burns
–Skin and fat excised in one session
–Less time consuming
–Excision down to the natural cleavage plane
–Down to fat or Fascia

77. Meshed graft Vs Meek Micrografting
Vs Sheet Graft
•Acute burns always meshed or meek
micrografting for better takes
•Reconstructive procedures like overgrafting
and release of contractures always sheet
grafting for better cosmesis
•Meek micrografting gives wider coverage and
more predictable takes than mesh grafting but
more expensive

78. Dermatome with blade

79. DERMATOME-HARVESTING GRAFT

80. Fascial excision

81. Integra and ACTICOAT

82. Case -2 skin grafting

86. Cultured autologous keratinocytes
•Grown in vitro and then applied to wounds
•Take of cultured epithelial autografts depends
on the wound bed
•Expensive
•Skilled labour and quality control,
•3–5 weeks to produce 1.8m2 confluent sheets
of cells from a 2 cm2 biopsy
•Fragile sheets
•Blistering, infection, and contractures.

87. Wound Closure
•Suggested Clinical Indications for CAE
–burn injuries >90% broad
–70-90% more limited
–<70% no clear indication

88. PITFALLS IN BURN MANAGEMENT
• Early tracheostomy
•Prompt adequate resuscitation
•Infection control practices
•Pain relief
•Early enteral nutrition
•Early mobilisation and Intensive chest PT
•DVT prophylaxis

89. PITFALLS IN BURN MANAGEMENT
•Escharotomy
•Fasciotomy
•Early excision and use of banked skin
•Fascial excison and use of banked skin or
autografts
•Early rehabilitation-
physical,social,psychological

90. TEAM APPROACH TO BURNS
•Plastic Surgeon
•General Surgeon
•Ophthalomologist
•ENT surgeon
•Intensivist
•Nephrologist
•Anesthesiologist
•Cardiologist
•Psychiatrist
Nurses
Microbiologist
Physiotherapist
Occupational therapist
Psychological Counsellor
Social Worker
Dietitian
Prevention team

91. thanks