Burns
Mechanisms:
Scalds (liquid, grease, steam)
Spill
immersion
Contact burns
Fire
Flash
Flame
Chemical
Electrical
Radiation
Important because severity of injury differs depending on a number of factors
1. Heat Capacity of the material causing the burn: basically the amount of heat a material can
hold and transfer when in contact with another surface.
2. temperature of material causing the burn
3. Duration of contact
4. Heat transfer
5. Tissue conductivity
Immersion scalds, prolonged contact burns, flame and electrical burns cause the most severe
burns
Categorization of burns
Superficial (1st degree)
 Cause – sunburn, UV, short flash fire
 Involvement – epidermis
 Clinical Findings – erythema, mild edema, pain
 Healing Time – 3-7 days, no scar, no pigment changes
Superficial Partial Thickness (Superficial 2nd degree)
 Cause – scalds, spills, flashes of flame
 Involvement – epidermis and superficial dermis
 Clinical Findings – pink/red, blisters, weeping, painful with moderate
edema
 Healing Time - <3 weeks, minimal scar or
pigment changes
Deep Partial Thickness (Deep 2nd Degree)
 Cause – Immersion, scalds, flame
 Involvement – epidermis and deeper dermis
 Clinical Findings – Cherry red or pale, pain
 Healing Time - >3 weeks, hypertrophic scar,
?grafting
Full Thickness (3rd Degree)
 Cause – Flame, electrical, chemical
 Involvement – Total destruction of epidermis and dermis, may involve
subcutaneous tissue
 Clinical Findings – Tan/pearly white, leathery,
parchment like, anaesthetic
 Healing Time – Requires grafting
Sub dermal (4th Degree)
 Cause – prolonged exposure to thermal source
 Involvement – extensive destruction down to muscle, tendon, bone
 Clinical findings – charred, anesthetic
 Healing time – requires extensive reconstruction, possibly amputation
3 zones of injury
Zone of coagulation
Central
Area of most intense injury
Usually appers white or charred
Zone of stasis or ischemia
Usually red and may blanch
May or may not survive
Zone of hyperemia
Peripheral
Red and blanchable
Dynamic process for 24-48 hrs post burn
Capillary occlusion
Systemic complications from burns
SIRS
Increased vascular permeability (may develop ARDS)
Decreased myocardial contractility
Hemolysis
Hypermetabolic state
Infection
Hypothermia
Hypovolemia
Third spacing peaks at 6-12 hours)
Evaporative loss from damaged skin
Incresaed minute ventillation
Estimating TBSA of burn:
Or rule of 9’s:
Adult
Head = 9
Arm = 9
Anterior torso = 18
Posterior torso = 18
Leg = 18
Genital= 1
Pediatric
Head = 18
Arm = 9
Anterior torso = 18
Posterior torso = 18
Leg = 14
Genital = 1
Fluid resuscitation in burns
Based on TBSA of burn. Superfical burns NOT included
Indicated for burns of >20% TBSA in adult or >10% TBSA in peds or if evidence of hypovolemic
shick
Parkland : 4ml/kg/%TBSA = total volume of fluid
Give ½ in first 8hours from the time of injury and second ½ over the next 16 hours
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Ringer’s Lactate is preferred solution (isotonic, lower sodium load, metabolized lactate
buffers the metabolic acidosis)
In pediatrics also include maintenance fluids of D5.45NS as they do not have the
glycogen stores to prevent hypoglycemia given hypermetabolic state OR use Galveston
formula 5000ml/m2 of TBSA burned + 2000ml/m2
Monitor urine output to maintain 0.5-1ml/kg/hr
Over-resuscitaiton can lead to extremity and abdominal compartment syndrome
Airway management
airway can be compromised from:
 Tissue edema from inhalation injury (tongue and oral mucosa can become edematous
within minutes to hours from time of injury)
 Compression from circumferential burn to the neck
Indications for intubation:
 Any evidence of upper airway edema clinically
 Circumferential neck burn
 Severe systemic burn
 Evidence of edema on bronchoscopy
Pulmonary complications from burns:
 Pulmonary edema from inhalation injury
 ARDS
 Loss of chest wall compliance secondary to burns (injured collagen becomes rigid)
Analgesia
Topical
 Can use on <28% TBSA, most effective on small burns
 Use max 2g lidocaine to avoid systmeic toxicity
J Burn Care Rehabil 1989;10:63-8
Systemic
 NSAID
 Opioids
 Ketamine
Children with severe burns admitted to hopsital had decreased rates of PTSD if pain is
controlled
J Burn Care Rehabil 2002;23:135-156
Criteria for referral to burn centre
 All partial thickness burns> 10% TBSA in peds/elderly or > 20% In adult
 All burns involving feet, hands, eyes, ears, face or genitalia
 Burns crossing major joints
 Full thickness burns in any age group
 All inhalation injuries
 Electrical / Chemical burns
 Complicated burns with fractures or other types of trauma
 Patients with pre-existing medical conditions that could complicate management
 Burn injury in patients who will require special social, emotional or long term rehabilitative
intervention
Treatment of wounds
Check tetanus status
Superficial Burns
 Moisturizer
 Aloe vera gel
Superfical Partial Thickness Burns
 Silver-based hydrofiber (Aquacel Ag) plus bulky gauze (allowed to dry and adhere)
 Topical antibiotic ointment (Polytopic)
o Facial burns (no cover dressing – applied multiple times/day)
 May cover if larger area – difficult though
o Add cover dressing for other areas (Mepilex)
o Suggest using soft silicone wound contact layer (Mepitel) if using gauze
Deep Partial Thickness
 Aquacel Ag plus hydrocellular foam (Mepilex)
o 2-3 days between dressing change
 Flamazine (Silver Sulfadiazine)
o With Mepilex
o With burn gauze (suggest using Mepitel as wound contact layer)
o Requires daily dressing changes or q2days if less exudate
o Caution: Pseudo-eschar development in wound bed – needs vigorous cleansing
– painful !!
 Acticoat
o Consider using hydroactive gel (Purilon) to keep product moist and active under
hydrocellular foam
o 2-3 days between dressing changes
 May need consult from Plastic Surgery (difficult to tell early on)
Full Thickness
 Referral to Plastics for assessment
 Circumferential burns may require escharotomy
 Flamazine plus foam or gauze
 Acticoat plus occlusive dressing
 Requires excision and grafting
Subdermal
 Will likely require escharotomy and eventually excision and grafting
 May require amputation
 Interim dressings usually Flamazine although does not penetrate thick eschar very
well