of Burn

- Managing Burn Cases Made Easy -

Mirza Koeshardiandi

Ponorogo, 2 /1 /2015

Terus Aku Kudu Piye Jum ????

What is Burn ?
A burn is an injury to

the skin or other organic tissue primarily caused by

heat or due to radiation, radioactivity, electricity, friction or contact
with chemicals.

Skin injuries due to ultraviolet radiation, radioactivity, electricity or chemicals, as well as

respiratory damage resulting from smoke inhalation, are also
considered to be burns.

Skin Function
1. Protection
a barrier from mechanical impacts and
pressure, variations in temperature,
micro-organisms, radiation and chemicals

2. Regulation
Body temperature, peripheral circulation,
vitamin D synthesis, balance of water and
electrolyte

3. Sensation
Sensation as alarm of danger from outside
to prevent further damage.

Degree of burn

Degree of burn

Type of burn (severity)

Minor Burn
Partial thickness :
Adult : < 10 % of BSA
Children : < 5 % of BSA

Full thickness < 1% of BSA

NO smoke inhalation
NO other comorbidities
Metabolic problems
Trauma / injured

Suitable for outpatient management

Major Burn
Total burn > 25% of BSA
Partial thickness :
Adult : > 10 % of BSA
Children : > 5 % of BSA

Full thickness > 1% of BSA

smoke inhalation
comorbidities
Hospitalized
Resuscitation
ICU/Burn Unit

Minor Burn
First Aid :
A : Avoid from burning source, remove clothing
(heat retention)

B : Bath , water irrigation-cleaning

(hypothermia in children-monitored body
temperature)

C : Cure the pain, give analgesia, antihistamine,

cooling water, no routine antibiotics

D : Dressing, aseptic, change in 48 hrs , /3 days

Major Burn
burn covering 25% or more of total body surface area, but
any injury over more than 10% should be treated similarly.

A major burn is defined as a

7R of Care in major burn (Rescue, Resuscitate, Retrieve, Resurface,

Rehabilitate, Reconstruct, Review)
Rapid assessment is vital
In the Resuscitation phase ,
Burn surface area is more important than degree / depth of burn

7R , Care of Major Burn Injury

1. RESCUE

Holistic approach

get the individual away from the source of the injury & provide first aid. often
done by non-professionalsfriends, relatives, bystanders, etc.

2. RESUSCITATE

Immediate support for any failing organ system. Administering fluid to

maintain the circulatory system but may also involve supporting the
cardiac, renal, and respiratory systems.

3. RETRIEVE patients with serious burns may need transfer to a specialist burns unit for
further care.

4. RESURFACE This can be achieved by various means, from simple dressings to

aggressive surgical debridement and skin grafting.

7R , Care of Major Burn Injury

5. REHABILITATE

return patients, as far as is possible, to their pre-injury level of

physical, emotional, and psychological wellbeing.

6. RECONSTRUCT The operations needed to do this are often complex and may
need repeating as a patient grows or the scars re-form.

7. REVIEW

Burn patients, especially children, require regular review for many years so that
problems can be identified early and solutions provided.

What possibly happen.to the victims???

Head/Neurotrauma
Chest trauma
Abdominal trauma
Pelvic trauma
Extremities
Inhalation trauma
Toxic waste

Always assume multiple trauma / injury until it is proven !!!

Rescue
Call for help, professional help from Fire department, others
Take away individual from sources of injury.
Rescuer safety is priority, use special anti fire garment/gear/devices otherwise do
no harm.
Principle of transportation

Resuscitation
Primary Survey
Secondary Survey
Referal

Airway with C-Spine Control and susp. laryngeal oedema

Breathing with attention to tension penumothoraks,
hematothoraks, and Inhalation trauma

Circulation with Bleeding Control and

Disability with ICP control and hypoxemia,hypercarbia,CO intox.
Exposure with temperature control
Fluid resuscitation with periodic ballance
Give analgesia with titration
History taking and mechanism of injury

Resuscitation
Airway

Compromised or is at risk of compromise.

The cervical spine should be protected unless it is definitely not injured.
Inhalation of hot gases burn above the vocal cords

Fluid resuscitation Airway oedema

Patent airway on arrival occlude after admission Esp. in small children.
Senior anaesthetist airway then intubation is the safest policy.
Unnecessary intubation and sedation worsen

Decision to intubate should be made carefully.

Resuscitation
Airway

Signs of inhalational injury

History of flame burns or burns in an enclosed space

Full thickness or deep dermal burns to face, neck, or

upper torso
Singed nasal hair
Carbonaceous sputum or carbon particles in
oropharynx

Resuscitation
Airway

Indication of Intubation
Erythema or swelling of oropharynx on direct
visualisation
Change in voice, with hoarseness or harsh cough
Stridor, tachypnoea, or dyspnoea
Circular full thickness burn in :
- Neck Strangulation, edema Prior Intubation
- Chest Disturbance of chest wall movement
Dyspneu Hypoventilation Mechanical Ventilation

Circular Third degree / full thickness burn

Resuscitation
Breathing

Breathing problems affect the respiratory system below vocal cords.

Tx :100% oxygen through a humidified non-rebreathing mask on presentation.
Tx according to the cause of respiratory compromise :
1.
2.
3.

4.

Mechanical restriction of breathing (Eschar) Escharotomi

Blast Injury ( Pneumothorax, Hemothorax, Flail chest, Contusio Pulmonum) --> chest drain,
analgesia, mechanical ventilation
Smoke Inhalation (bronkospasm, inflammation, bronchorrhoea) PEEP, Oksigen, Lung
toilete, Bronchodilator, mech. Ventilation.
CO-hb , Carboxy hemoglobinemia O2 100 % + if necessary mech. ventilation

Resuscitation
Circulation

Minimal double I.V line / large bore

Blood sample and Laboratory investigation
Parkland formula + Maintenance
If profound hypotension not normal assume as syok
Elicit : cardiogenic problem, occult bleeding (thorax, abdomen, pelvis)
Electrical injury common cardiac arrythmias

If syok treat as syok :

Syok position , syok fluid replacement, bleeding control

Resuscitation
Circulation

Burn with syok (hypovolemic syok)

Syok :

20 ml/kg body weight in 20-30 minutes, kristaloid (RL,NaCl 0,9%)

No colloids for syok treatment
Transfusion (Hb <10g/dL)
Stop / control bleeding
Good Response

Burn without syok (hypovolemic syok)

Parkland formula + Maintenance

Diagnosis of Syok : Perfusion disturbance

Cold, Wet, Pale , Capillary refill time >2

Resuscitation
Disability

Degree of consciousness GCS periodically

Patient confused hypoxia, hypovolemia and neurotrauma
Routine examination pupil diameter, light reflexes elicit intracranial problems

Exposure
Examine whole patient estimate total burn area (incl. the back)
Concomitant injuries
Avoid hypothermia esp. children hypoperfusion and deepening the wound
Thermoregulation

Exposure

Resuscitation

Fluid Replacement (1st - 24 hours)

Parkland formula :

4 ml x Burn Area (%) x Body weight (kg)

50% given in 8 hours

50% given in 16 hours

Add Maintenance (for children) :

Children receive maintenance fluid in addition, at hourly rate of

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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

Resuscitation

Fluid Replacement (1st - 24 hours)

Parkland formula for high tension electrical injury :

9 ml x Burn Area (%) x Body weight (kg)

50% given in 8 hours

50% given in 16 hours

Target end points of Fluid replacement :

Urine output of 0.5-1.0 ml/kg/hour in adults
Urine output of 1.0-1.5 ml/kg/hour in children

Urine output of 1.5-2.0 ml/kg/hour in adults with electrical injury

Resuscitation

Fluid Replacement (After 24 hours)

Coloid infusion : 0,5ml x Burn Area (%) x Body weight (kg)
Add Maintenance (for Adult)

Cristaloid (Dekstrose Saline)

1,5ml x Burn Area (%) x Body weight (kg)

Add Maintenance (for children) :
Children receive maintenance fluid in addition, at hourly rate of

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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

Case 1. A 25 year old man weighing 70 kg with a 30% flame burn was
admitted at 4 pm. His burn occurred at 3 pm.

Total fluid requirement for first 24 hours

4 ml (30% total burn surface area) (70 kg) = 8400 ml in 24 hours
4200 ml in 8 hours 7 hours
600 ml/hour = 200 dpm

(4 pm 1 1 pm)
Kristaloid (RL, RA, PZ)

4200 ml in 16 hours
263 ml/hour = 88 dpm

(11pm - 3pm next day)

After 24 hours
Koloid : 0.5 ml x 30% x 70 kg = 1050 ml /24 hours (HES, Gelatine) = 14 dpm
Maintenance : 1.5 ml x 30% x 70 kg = 3150 ml / 24 hours (D5 NS) = 44 dpm

Target end points : urine 35 70 ml / hour

Case 2. A 4 year boy weighing 15 kg with a 40 % flame burn was

admitted at 4 pm. His burn occurred at 3 pm. During transportation
he received 500 ml RL.

Total fluid requirement for first 24 hours

4 ml (40% total burn surface area) (15 kg) = 2400 ml in 24 hours
1900 ml for 23 hours

500 ml in 1 hours
during transport
950 ml in 7 hours
135 ml/hour = 45 dpm

Maintenance
4 ml x 10 kg = 40 ml
2 ml x 5 kg = 10 ml

maintenance 50 ml / hour D5 NS

Target end points : urine 15 ml 22 ml / hour

950 ml in 16 hours
60 ml/hour = 20 dpm

Resuscitation
Give Analgesia

Superficial burns can be extremely painful.

large burns intravenous morphine at a dose /kg Body weight .
0.1 mg/kg body weight slow i.v. injection
titrated against pain and respiratory cardiovascular depression.
The need for further doses should be assessed within 30 minutes.
If in doubt consultation should be made to burn specialist, intensivist, anesthetist
Avoid NSAID

Resuscitation
History taking

Key points of a burn history

Exact mechanism
Type of burn agent (scald, flame, electrical, chemical)
How did it come into contact with patient?
What first aid was performed?
What treatment has been started?
Is there risk of concomitant injuries (such as fall from height, road traffic crash, explosion)?
Is there risk of inhalational injuries (did burn occur in an enclosed space)?
Exact timings
When did the injury occur?
How long was patient exposed to energy source?
How long was cooling applied?
When was fluid resuscitation started?

Resuscitation
History taking

Key points of a burn history

Exact injury
Scalds
What was the liquid? Was it boiling or recently boiled? If tea or coffee, was milk in it?
Was a solute in the liquid? (Raises boiling temperature and causes worse injury, such as boiling rice)
Electrocution injuries
What was the voltage (domestic or industrial)?
Was there a flash or arcing? Contact time
Chemical injuries
What was the chemical?
Is there any suspicion of non-accidental injury?

Resuscitation

Investigation (Laboratory, Radiograph etc)

Investigations for major burns*
General
Full blood count, packed cell volume, urea and electrolyte concentration, clotting screen
Blood group, and save or crossmatch serum
Electrical injuries
12 lead electrocardiography
Cardiac enzymes (for high tension injuries)

Inhalational injuries
Chest x ray
Arterial blood gas analysis
Can be useful in any burn, as the base excess is predictive of the amount of fluid resuscitation required Helpful for determining
success of fluid resuscitation and essential with inhalational injuries or exposure to carbon monoxide

*Any concomitant trauma will have its own investigations

Indications

A+B

Resuscitation
Primary Survey
Secondary Survey
Referal

Airway with C-Spine Control and susp. laryngeal oedema

Breathing with attention to tension penumothoraks,
hematothoraks, and Inhalation trauma

Circulation with Bleeding Control and

Disability with ICP control and hypoxemia,hypercarbia,CO intox.
Exposure with temperature control
Fluid resuscitation with periodic ballance
Give analgesia with titration
Toe Examination
HHead
istoryto
taking
and mechanism of injury

Resuscitation
Primary Survey
Secondary Survey
Referal

Airway with C-Spine Control and susp. laryngeal oedema

Breathing with attention to tension penumothoraks,
hematothoraks, and Inhalation trauma

Circulation with Bleeding Control and

Disability with ICP control and hypoxemia,hypercarbia,CO intox.
Exposure with temperature control
Fluid resuscitation with periodic ballance
Give analgesia with titration
Toe Examination
HHead
istoryto
taking
and mechanism of injury

?
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