Burns and Thermal Injuries

IntroductionSkin is the largest organ in the body and

isolates chemically, thermally, biologically and mechanically the inside from the outside.

Initial Assessment of Burns

Primary Survey:

A. Airways:• Secure the airway first. • Get history as much as reasonably possible before intubation • Soot or singed nasal hairs?

B. Breathing: • High flow Oxygen for all. • Listen: verify breath sounds • Assess rate & depth.

C. Circulation:• Monitor Blood Pressure, Pulse, and Skin color. • Establish IV access.• Warm IV fluids.• Monitor peripheral pulses in circumferential burns.

D. Disability:• Associated Injuries? • CO poisoning? • Substance abuse? • Hypoxia? • Pre-existing medical condition.

E. Exposure: • Remove clothes and jewelry. • Ensure warm environment.• Clean dry blankets.• It is OK to use water to stop the burning process and clean but not at the expense of reducing body core temperature.

• Secondary Survey:

– Repeat primary survey.– Complete History of Present Illness (HPI).• What type of burn (flame, chemical, scald) • Duration of exposure • What time did burn occur? • What treatment already provided? (chemical brushed off, water to cool, etc) • Did burn occur in house fire/enclosed space? (think inhalation injury)

Order labs and x rays CBC, KFT, LFT, Chest X-ray (CXR) Blood gas Insert Foley EKG (especially in electrical injury)

Special considerations; • Abuse patterns

– Children, elderly

• Concomitant trauma

– C-spine precautions

– Trauma protocols if trauma is majority of injuries

Major Steps in Burn TreatmentIV fluids for burns > 10% TBSAWound cleaning, dressing, and serial

assessment (Use Hibiclens and sterile water (not saline – it stings more when mixed with Hibiclens).

Supportive measuresTransfer or referral of selected

patients to burn centersSurgery and physical therapy for deep

partial thickness and full-thickness burns

Commence Fluid ResuscitationAdults

Fluid resuscitation is recommended for the following injuries:

– Adults (>15%TBSA burn) – Children (>10%TBSA burn)The goal of fluid resuscitation is to

anticipate prevent hypovolemic shock.A variety of fluids have been

recommended for use, such as plasma, human albumin solution (HAS), dextran and Hartmann’s solution.

Commence Fluid ResuscitationAdults Formula:The amount of fluid given in the first 24h (mls)= 3 – 4 mls/kg/TBSA%

Rate:½ in the first 8h¼ in the second 8 hrs¼ in the third 8 hrs

Commence Fluid ResuscitationChildren

Maintenance fluids should also be added over and above the Modified the formula for children weighing less than 30kgs.

Use 5% Dextrose in Lactated Ringer's (D5LR): hypertonic (pH: 4-6.5)

– Each 100ml contains 5g of Dextrose Monohydrate, 600mg of Sodium Chloride, 310mg of Sodium Lactate Anhydrous, 30mg of Potassium Chloride, and 20mg of Calcium Chloride Dihydrate.

Rule of Nine

Inhalation Injury

First Degree Burn A first degree burn is confined exclusively to

the outer surface and is not considered a significant burn.

No skin barrier functions are altered. The most common form is sunburn which heals

by itself in less than a week without a scar.

Second Degree Burn Second degree burns cause damage to

the epidermis and portions of the dermis.Since it does not extend through both

layers, it is termed partial thickness. There are a number of depths of a second

degree or partial thickness burn which are used to characterize the burn.

Third Degree BurnFull thickness bunsBoth layers of skin are

completely destroyed leaving no cells to heal.

Any significant burn will require skin grafting.

Small burns will heal with scar.

Entire destruction of the epidermis and dermis, leaving no residual epidermal cells to repopulate.

Thank you

Ahmad Thanin