Burns😊

Burns

  • Criteria for referral
    • All burnt children
    • Full thickness (third degree) burns in any age group
    • Burns involving face, hands, feet, genitalia, perineum, major joints
    • Chemical burns
    • Electrical burns
    • Inhalational injury → Immediate intubation
    • Partial thickness burns: >10% of TBSA
      • NG tube if > 15% TBSA burned (due to risk of ileus)

Airway

  • Signs of Airway Burns:
    • Closed room burns
    • Altered mental status
    • Burns involving head, face, neck
    • Burnt/singed nasal hair (most significant)
    • Carbonaceous deposits in sputum
    • Hoarseness of voice
    • If any sign present,
      • prophylactic intubation (prevents airway collapse)
  • Stages of Airway Injury (Post-Burns):
    • 1. Acute pulmonary insufficiency (breathlessness, ↓SPO2 due to CO buildup)
    • 2. ARDS-like picture (hypoxia, bilateral lung infiltrates)
    • 3. Bronchopneumonia (due to ↓immunity):
      • Early (1-3 days): Staphylococcus
      • Late (>3 days): Gram-negative bacteria

Breathing

  • Hypoxia
  • CO poisoning
  • Eschar (thickened tissue) around chest restricting movement

Circulation

  • Inflammatory Response:
    • Localized: Burns <10% TBSA
    • Generalized: Burns >10% TBSA
  • Physiology: 
    • Vasodilatation + leaky capillaries
      • → Dehydration, Edema / 3rd space loss

Burns Resuscitation

IV Fluid Replacement

  • LR: Lactated Ringer’s
High volume NS → Hyperchloremic metabolic acidosis
High volume NS → Hyperchloremic metabolic acidosis

1. Crystalloid Resuscitation Formulae:

  • Old Parkland’s Formula:
    • 4 x Body weight (kg) x TBSA burned
    • Fluid over 24 hours:
      • 1st half in 1st 8 hours of burns;
      • next half in next 16 hours
  • Galveston formula:
    • Used in pediatric burns
  • Latest Formulas:
      • Age Group
      Fluid Rates (LR)
      Urine Output Target
      Formulas
      Adults & Older Children (≥14 years)
      2 ml x kg x % TBSA
      0.5 ml/kg/hour
      Parkland’s Formula
      Children (≤14 years)
      3 ml x kg x % TBSA
      30-50 ml/hour
      Galveston formula
      Infants & Young Children (≤30 kg)
      3 ml x kg x % TBSA + solution with sugar at maintenance rate
      1 ml/kg/hour
      Galveston formula
      Electrical Injuries (3rd/4th grade, All ages)
      4 ml x kg x % TBSA
      (until desired urine output)
      1-1.5 ml/kg/hour
      (until desired urine output)
      Old Parkland’s Formula
  • In the next 24 hours:
    • Reabsorption of edema fluid and diuresis occurs.
    • RL in 5% dextrose preferred.
    • Maximum allowed IV = 12.5% Dextrose
      • Above this → Acidic pH → Thrombophlebitis

2. Colloid Resuscitation Formula:

  • Most common: Muir and Barclay formula
  • Human Albumin solution is commonly used colloid
  • Colloids given after 1st 12 hours (to decrease risk of edema)
    • 1st 12 hours → vessels are leaky → leads to protein leak → albumin and colloid loss
  • Mnemonic: Bar (barclary) il kallu (colloid) kudikkan poi → myran (Muir) Kolam (colloid) aki

Estimation of burnt surface area:

  1. Rule of Wallace/ Rule of 9:
      2. notion image
  1. Lund & Browders chart:
      • Best
  1. Rule of palm:
      • Size of burnt area = Size of palm = Approximately 1%.
  1. Berkley chart

Zones of Burns

  • Zone of Coagulation / Necrosis: 
    • Irreversible, non-salvageable
  • Zone of Stasis:
    • Well managed → Salvageable
    • Infected → Non-salvageable
    • Stasis → needs saving
  • Zone of Hyperemia: 
    • Vasodilatation, salvageable

Degree of Burns

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First degree

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Second Degree

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Third degree

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Burns Management

  • Follow ABCDEs
  • Wash with room temperature water
  • Do not burst blisters
  • Administer IV fluids
  • Avoid IM and SC injections
  • NG tube if > 15% TBSA burned (due to risk of ileus)
  • COOLING
    • Cooling burn- NOT ICE
    • Effective upto: 1 hr
    • Ideal temp: 15 degree water
  • FROSTBITE COOLING:
    • Gradual rewarming @ 40 - 42 degrees
        • notion image

If Biological Dressing Not Available

Use non-adhesive dressing like:
  • Paraffin gauze impregnated with:
    • Silver sulfadiazine (SSD) cream
    • Colloidal silver
    • Ionic silver cream
    • Silver nitrate cream

Nutrition in Burns

  • Basal Energy Expenditure (BEE/REE) is increased
  • Severe burns: 40 kcal/kg/day (2x normal)
  • Max nitrogen loss: Day 5 to 10 (at least 20% calories from proteins)
  • Davies Formula (Protein Requirement):
    • Children: 3 g/kg + 1 g% TBSA
    • Adults: 1 g/kg + 3 g% TBSA

Escharotomy

  • Indication: 
    • Eschar → compartment syndrome (>30 mmHg) → ↑↑ pain
  • Deep fascia is cut to release muscle
  • Wound extended beyond deep burn
  • Significant bleeding vessels: Diathermy
  • Post-op: Hemostatic dressing + limb elevation

Special agents :

  • Good against Pseudomonas & Gram-negative bacteria
  • Does not penetrate eschar
    • 1. Silver Sulphadiazine (1%):
      • Most common agent
      • Frequent dressing changes required
    • 2. Silver Nitrate: 
      • Stains everything black (less useful)
  • 3. Mafenide Acetate (5%):
    • Penetrates eschar
    • Problems: Painful application & metabolic acidosis
    • Maf dejiye bolo → Pain
  • 4. Cerium Nitrate:
    • Best agent
    • ↑ cell mediated immunity
    • Keriya nighty → best for burns

Causes of Death in Burns

  • Immediate: Asphyxia > Neurogenic shock
  • Early (1-3 days): Hypovolemic shock
  • Late (>3 days): Septic shock
  • Overall: Septic shock (most common organism: Pseudomonas)
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