Burns

Academy of Traumatology (India)

Under the auspices of the

International Association for the Surgery of Trauma

and Surgical Intensive Care
NTMC
IATSIC 2005

Objectives
Management principles
Estimate burn size and depth
Initiate specific patient care
Identify special problems
Identify those needing specialist burn centre
management
NTMC
IATSIC 2005

Management Principles

A-B-C approach
Early airway management
Good oxygenation of tissues
Normovolaemia
Maintain electrolytes
Temperature control

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IATSIC 2005

Management - Airway
Who needs to be intubated?

Respiratory distress

Facial burns with singed hair

Carbonaceous (black) sputum

Red swollen mouth

Intubate early while you still can

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IATSIC 2005

Management - Breathing

Oxygen
Ensure adequate gas exchange
Ventilate if necessary
Carboxy-haemoglobin levels

Affinity 250 times more than haemoglobin

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IATSIC 2005

Management - Circulation
Large bore i.v. access
Ringers lactate
Guide to fluid requirements:

Parkland formula (4 ml /Kg /% BSA)

Initial monitoring with haematocrit

Urine output (minimum 1 ml /Kg /hr)

CVP monitoring
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IATSIC 2005

Management - Exposure
Stop the burn

Remove all clothing, jewellery

Copious washing in chemical burns

Prevent hypothermia

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IATSIC 2005

Assessment of Burn
History

Mechanism of injury
Open flame
Explosion
Smoke inhalation

Associated injuries

Previous medical history

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IATSIC 2005

Assessment of Burn
Examination
Size of burn

Rule of Nines
Lund and Browder charts

Size of palm
Equivalent to 1% of body surface area

Depth of burn
Associated injuries
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IATSIC 2005

Assessment - BSA
18%
9%
18%

14%

9%

9%
9%

9%

1%

1%
15.5%

15.5%

18%

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IATSIC 2005

18%

Assessment - Depth
Text

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IATSIC 2005

Assessment - Depth
First degree

Pain, redness

Second degree

Severe pain, red or mottled, blisters or weeping

appearance

Third degree

Painless, leathery, dry

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IATSIC 2005

Patient Management
Resuscitation and assessment
Plan for treatment

Reassess A-B-C
Calculate fluid requirements
Analgesia
Dressings
Surgical intervention as required
Consider transfer to specialist care
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IATSIC 2005

Definitive Care
Skin cover
Initially with dressings
Remove dead tissue
Early tangential excision
Early cover
Sepsis control
Antibiotic prophylaxis not indicated
Treatment is culture dependent
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IATSIC 2005

Special problems
Circumferential burns
Carbon monoxide (CO) inhalation
Chemical burns
Electrical burns

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IATSIC 2005

Circumferential Burns
Remove any constriction
Surgical consultation

Circulatory assessment

Neurological signs

Escharotomy
Fasciotomy
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IATSIC 2005

Carbon Monoxide Inhalation

Hypoxia due haemoglobin binding
Carboxy-haemglobin levels if available
Pa02 and oxygen saturation unreliable
Management

100 % Oxygen

Intubation and ventilation

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IATSIC 2005

Chemical Burns
Protection of
of medical
medical staff
staff
Protection

Duration and concentration of exposure

Brush off dry powder
Copious washing for prolonged periods
of time
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IATSIC 2005

Electrical Burns
Index of suspicion
tip of the iceberg phenomenon

ECG monitoring
Rhabdomyolysis

i.v. fluids
Urine output minimum 2ml /Kg per hour
Monitor serum potassium levels
Mannitol 1 Gm /Kg.
Bicarbonate
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IATSIC 2005

Specialist Care
Consider transfer if large BSA involved

Full vs partial thickness

Inhalation burns
Specific areas of the body
Chemical and electrical burns
Extremes of age
Co-morbidities
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?
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IATSIC 2005

Summary
Treat A-B-C-D-E first
Calculate fluid needs

Assess progress

Definitive care

Transfer as required

Skin cover

Sepsis control
NTMC
IATSIC 2005