1. THERMAL INJURY

2. OBJECTIVES Comprehend the pathophysiology of the burn wound
Review the initial care and resuscitation of the burn patient
Understand burn wound therapy
Be familiar with specific problems related to the burn patient

3. EPIDEMIOLOGY 4th Leading Cause of Unintentional Death United States
1 million burns yearly
6,000 deaths yearly (73% from house fires)
Scalds: Most frequent in < 5 and > 65 age groups
Inhalation Injury
Leading cause of death
Cigarettes are most common cause
Alcohol use is a factor

4. PATHOPHYSIOLOGY BURN CATEGORIES
Flame
Scald
Contact (cold or hot)
Chemical
Electrical

5. PATHOPHYSIOLOGY MECHANISMS OF INJURY
Categorical
Transfer of energy: Flame, Scald, Contact
Direct Injury: Chemical, Electrical
Capillary Injury
Increased Permeability
Hyperemia
Hemoconcentration

6. PATHOPHSIOLOGY MECHANISMS OF INJURY
Inflammatory Mediator Release
From mast cells, WBCs, and platelets
Result is:
Vasoconstriction
Vasodilation
Increased vascular permeability
Decreased cardiac output
Edema formation

7. PATHOPHYSIOLOGY ZONES OF INJURY
Coagulation: Necrotic area
Stasis
Area immediately around necrotic zone
Initially causes decreased tissue perfusion
Can progress to coagulation necrosis
Hyperemia
Vasodilation from inflammation around wound
Clearly viable tissue from which healing begins

8. PATHOPHYSIOLOGY DEPTH OF BURN
First Degree
Confined to epidermis
Painful, erythematous, blanches
Sunburn or minor scald
Does not result in scarring
Treatment aimed at comfort

9. PATHOPHYSIOLOGY DEPTH OF BURN
Second Degree (Superficial)
Erythematous, painful, may blanch
Scald injuries, flash flame burns
Spontaneous reepithelializes from retained epidermal structures in rete ridges, hair follicles, and sweat glands (7 to 14 days)
Long term shows slight skin discoloration

10. PATHOPHYSIOLOGY DEPTH OF BURN
Second Degree (Deep)
Into reticular dermis
Pale, mottled, does not blanch
Painful to pinprick
Healing by reepithelialization from hair follicles and keratinocytes in sweat glands (14 to 28 days)
Timely healing requires excision and grafting
Severe scarring due to loss of most of dermis

11. PATHOPHYSIOLOGY DEPTH OF BURN
Third Degree
Full thickness through dermis
Hard, leathery eschar, painless
Heals by reepithelialization from wound edges
Timely healing requires excision and grafting

12. PATHOPHYSIOLOGY DEPTH OF BURN
Fourth Degree
Involves other organs beneath skin
Muscle, bone, brain
Requires excision, grafting, flap coverage.
May require amputation

13. INITIAL CARE & RESUSCITATION PRIMARY SURVEY
ABCs
Stop the Fire
Remove burned clothing
Large-Bore IV Access
Keep warm and covered

14. INITIAL CARE & RESUSCITATION SECONDARY SURVEY
Burn Size Evaluation
Rule of Nines

15. INITIAL CARE & RESUSCITATION SECONDARY SURVEY
Other Injuries & Therapies
Traumatic injuries
CO poisoning
Inhalation injury
Tetanus
Pain management

16. INITIAL CARE & RESUSCITATION FLUID MANAGEMENT – First 24 Hours
Timing
From burn injury
Not from arrival
Who Gets Resuscitated
Adults > 15% TBSA
Children < 10 with > 10% TBSA

17. INITIAL CARE & RESUSCITATION FLUID MANAGEMENT – First 24 Hours
Type of Fluid
Adults & Children > 2: Lactated Ringers
Children < 2: D5LR
How Much

18. INITIAL CARE & RESUSCITATION FLUID MANAGEMENT – First 24 Hours
Goal/Endpoint

19. INITIAL CARE & RESUSCITATION FLUID MANAGEMENT – Second 24 Hours
Vascular Permeability
Nonburn Tissue: Normal soon after burn
Burn Tissue: Slowly over 12 – 18 hours
Re-evaluate fluid requirement based on:
Patient hemodynamic response
UOP
Addition of Colloid
Not given for < 20% TBSA
0.1 mL/kg %TBSA 25% Albumin over 1-2 hours
Maintenance Fluids
D5 ½ NS
D5 ¼ NS

20. INITIAL CARE & RESUSCITATION EMERGENT SURGICAL INTERVENTION
Extremity
Deep 2nd & 3rd degree burns encompass extremity
Tissue Pressures > 40 mm Hg
Tissue perfusion is compromised
Escharotomy and/or Fasciotomy

21. INITIAL CARE & RESUSCITATION EMERGENT SURGICAL INTERVENTION
Trunchal Eschar
Limits chest wall excursion = decreased ventilation
Increased peak airway pressures
Desaturation
Therapy: Escharotomy

22. INITIAL CARE & RESUSCITATION TRANSFER TO BURN UNIT
2nd & 3rd Degree Burns > 10% TBSA
Face, hand, feet, genitalia, perineum, or major joint involvement
3rd Degree Burns any age group
Electrical burns, including lightening injury
Chemical burns
Inhalation injury
Patients with significant comorbid conditions
Concomitant trauma in which the burn poses the greatest mortality and morbidity
Children in a hospital without qualified personnel or equipment to care for children
Patients who will require special social, emotional, or long-term rehabilitation

23. INITIAL CARE & RESUSCITATION PRIOR TO BURN UNIT TRANSFER
Keep patient warm
Cover with clean or sterile sheets
Early application of topical antimicrobial in deep partial and full thickness burns
Do NOT apply antimicrobial before communication with receiving burn unit

24. BURN WOUND THERAPY INTRODUCTION
Three Stages
Assessment
Management
Rehabilitation
Extent & Depth of wound
Clean & Debride wound
Wound coverage
Antimicrobial coverage (if indicated)
Daily wound care

25. BURN WOUND THERAPY GENERAL GUIDELINES
Functions of wound coverage
Protect & splint damaged epithelium
Reduce evaporative heat loss & minimize cold stress
Pain control
Coverage by type
1st Degree: Topical salves
2nd Degree (Superficial): Daily dressing changes & antimicrobial coverage (if indicated)
2nd Degree (Deep) & 3rd Degree: Excision and timely autografting

26. BURN WOUND THERAPY GENERAL GUIDELINES
Adjunctive Therapy
NGT Decompression: In TBSA >25% for gastric ileus (24 – 48 hours)
Foley Catheter
Stress Gastritis Prophylaxis: TBSA > 25% are at increased risk
Pain Control
Significant pain for 2nd degree burns
Use IV route
Oral and IM routes have unpredictable absorption

27. BURN WOUND THERAPY EXCISION & GRAFTING
Post-resuscitation day 1 – 7
Associated with improved survival
Benefits over serial debridement
Survival
Blood loss
Length of hospitalization
Indicated for 2rd Degree (deep), 3rd Degrees, and 4th Degree burns

28. BURN WOUND THERAPY CONTROL OF INFECTION
Removal of eschar and necrotic tissue
Improved outcome associated with:
Early excision & wound closure/coverage
Timely & effective antimicrobial use
Topical Antimicrobials
In spontaneously healing wounds:
Limits contamination
Environment for healing
Prevent burn wound sepsis
Tetanus Prophylaxis: DON’T Forget!!

29. BURN WOUND THERAPY TOPICAL ANTIMICROBIALS
Topical Agent
Advantages
Disadvantages
Silver Sulfadiazine
Broad Spectrum
(GPC, GNR, Fungus)
Painless application
Large burns
Some Pseudomonas resistance
Transient Leukopenia and/or Thrombocytopenia
Poor eschar penetration
Silver Nitrate
Excellent Spectrum
Staining
Electrolyte abnormalities (hyponatremia)
Methemoglobinemia
Sulfamylon
(GPC, GNR)
Good eschar penetration
Small burns
Painful Application
Metabolic Acidosis
Not effective against fungus

30. BURN WOUND THERAPY WOUND COVERAGE
Considerations
Accomplish ASAP after excision (1-7 days)
Autograft is best
Cadaver allograft: Temporary for large burns
Types of Coverage
Autograft
Cadaver Allograft
Xenograft (Porcine)
Synthetic: Integra, Biobrane, Transcyte

31. SPECIFIC BURN PROBLEMS INHALATION INJURY
Characteristics
Another inflammatory focus to the burn injury
Impedes normal gas exchange
Increases burn size and resuscitation volume
Hallmarks
Caused by inhaled toxins
Chemical injury
Edema and increased lung lymph flow
Separation of ciliated epithelium

32. SPECIFIC BURN PROBLEMS INHALATION INJURY
Diagnosis
History: Smoke exposure in closed space
Exam
Hoarseness, Wheezing
Carbonaceous sputum
Large burns or facial burns
Bronchoscopy: Establishes the diagnosis

33. SPECIFIC BURN PROBLEMS INHALATION INJURY
Therapy
Supplemental O2 in ALL burn patients
Chest physiotherapy and suctioning
Prophylactic intubation is prudent
Pharmacologic Triad
Bronchodilators
Nebulized Heparin
N-Acetylcysteine

34. SPECIFIC BURN PROBLEMS MYOGLOBINURIA
Characteristics
Associated with high voltage injuries
Myoglobin precipitates in and damages renal tubules
Diagnosis
Dark red urine
U/A positive for hemoglobin (no cells)
Elevated serum myoglobin
Treatment
UOP 75 – 125 cc/hr
Alkalinization: Use of sodium bicarbonate
Mannitol to induce diuresis
Monitor serum potassium

35. OTHER BURNS CHEMICAL Pathophysiology Treatment
Acid: Coagulative necrosis; confined
Base: Liquefaction necrosis; extends into tissues
Treatment
Initial Therapy: Copius irrigation with saline
Neutralization Attempts
Result in heat production
Extend injury
Once controlled, treat as regular burn injury

36. OTHER BURNS ELECTRICAL
Characteristics
Injury is MOSTLY internal
Current follows path of LEAST resistance: nerves, blood vessels, muscle
High index of suspicion for:
Compartment syndrome
Myoglobinuria
Treatment
Vigorous resuscitation (watch for myoglobinuria)
UOP greater than 1 mL/kg/hr
Monitor for arrhythmias for 24 to 48 hours
Regular burn wound care

37. SUMMARY STOP the Burning Process ABCs
Evaluate Burn & Begin Resuscitation
Evaluate and Care for Associated Injuries
Transfer to Burn Center
Definitive Burn Wound Therapy
Specific Burn Problems

38. QUESTIONS ?