BURN

MANAGEMENT
PREPARED BY : LATIPAH BINTI LATIP
OBJECTIVE

• 1. Triage
• 2. Primary survey: ABCDE’s of resuscitation
• 3. Secondary Survey
• 4. Determine amount of resuscitation fluid required
• 5. Determine the need for urgent procedures and investigations
• 6. Determine the need to transfer the patient or to continue managing the patient.
• 7. Ongoing assessment and evaluation
• 8. Wound Management
 TRIAGE GUIDELINES
AT HOSPITAL EMERGENCY & TRAUMA DEPARTMENT

• 1. Triage
• Appropriate triage according to severity of burn
• Cases triage to Critical / Red Zone are:
•  Inhalational Injury
 Moderate to Severe burn > 20% TBSA
 Electrical Burn with Cardiovascular involvement
 AMERICAN BURN ASSOCIATION
SEVERITY CLASSIFICATION
MINOR MODERATE MAJOR
Adult < 10% TBSA Adult 10-20% TBSA Adult > 20% TBSA
Young or old < 5% TBSA Young or old 5-10% TBSA Young or old > 10% TBSA
< 2% TBSA full thickness 2-5% TBSA full thickness 5% TBSA full thickness
burn of non critical sites burn (critical & non burn (critical & non
critical sites) critical sites)

High voltage electrical High voltage electrical

injury burn
Possible inhalation injury Known inhalation injury
Circumferential burn Significant burn to face,
joints, hand or feet and
Critical sites are : joints, face, hand, foot genitalia
and perineum
Other health problems Associated injuries
 TRIAGE GUIDELINES
AT HOSPITAL EMERGENCY & TRAUMA DEPARTMENT

4. Determine
2. Primary survey:
3. Secondary amount of
1. Triage ABCDE’s of
Survey resuscitation fluid
resuscitation
required

6. Determine the
need to transfer 5. Determine the
7. Ongoing
8. Wound the patient, or to need for urgent
assessment and
management continue procedures and
evaluation
managing the investigations
patient.
 STEP 1: ABDCE’S OF RESUSCITATION
(PRIMARY SURVEY)
1. Airway (with cervical-spine control) 3. Circulation 5. Exposure
•  Ensure the airway is clear •  Recordable blood pressure? Is there bleeding? •  Remove all clothing and
•  Chin lift / Jaw thrust Capillary refill? jewellery

•  Evidence of inhalation injury? •  Start IV fluids if >15%TBSA burn in adults, •  Log-roll with stabilization of C-
spine.
•  (Ref to Inhalation Burn in STEP 4) • >10%TBSA burn in children (ref to STEP 3)
•  Ensure patient is kept warm with
•  Early pain management
blankets / radiant warmers.
2. Breathing
• (*Burn victims are prone to
•  Expose the chest • 4. Disability – Establish a quick neurological status develop hypothermia. Resuscitati
on areas at ETD are usually air-
•  Look at chest wall expansion, listen to air entry. •  A: Alert conditioned!)
•  Is the patient tachypneic? Chest wall expansion restrictive?
•  V: responds to Vocal stimuli
•  Give 100% O2 for all burn patient with >20% TBSA or involving
•  P: responds to Painful stimuli
• flame / flash mechanisms.
•  U: Unresponsive

• Examine pupillary light response

STEP 2: SECONDARY SURVEY
SECONDARY SURVEY INCLUDES AN ASSESSMENT; WHICH IS CARRIED OUT AFTER LIFE THREATENING CONDITIONS HAVE
BEEN EXCLUDED OR TREATED

Four main components: • 2. Determine mechanism of

injury – flame, scald (hot water/
1. History
soup/ oil), contact,
(AMPLE): Allergies, Medications,
chemical (alkali / acid), electrical
Past illnesses, Last
burn.
meal, Event / Environment
during injury. Need to include • 3. Examination (head to toe, log-
Salient points in Burn History
points below: roll, exclude any other injuries,
1. Time of incident; duration of exposure
2. Cause of incident perform rectal examination)
3. What immediate treatment was done? Was
appropriate First Aid given?
4. In cases of flame burn: did it occur in an enclosed
• 3. Re-evaluation
space?
5. Any possibility of concomitant trauma (e.g. In MVA
cases, blast injury, fall from height of a burning
building)
STEP 3 : DETERMINE THE AMOUNT OF
RESUSCITATION FLUID REQUIRED
You need to know:
1. The patient’s weight (or estimate) in kg.
2. The TBSA (Total Body Surface Area).
Superficial burn ( 1st degree : Erythema over an intact skin, without any blister ) is NOT INCLUDED in
determining TBSA. Only partial thickness (Second degree) and full thickness (3rd degree) burn are
included.
3 ways to determine TBSA
• 1. Lund & Browder Chart (refer to Burn Chart, page 13)
• 2. Wallace’s rule of 9s (or the Pediatric Modification, page 13)
• 3. The Palm method: the whole palm of the patient (including fingers) is approximately 1% of
the patient’s TBSA.
STEP 3 : DETERMINE THE AMOUNT
OF RESUSCITATION FLUID REQUIRED
3. Indications for IV fluid resuscitation (and catheterization for urine output monitoring):
• Adults: Burn >15% TBSA.
• Children: Burn >10% TBSA.
• The aim of fluid management in severe burn injuries is to maintain tissue perfusion
and prevent end-organ ischemia in the earliest phases of burn shock.
• Two large-bore IV cannula (14-16G) should be inserted, preferably in an unburned
area.
• After determining the patient’s weight and the TBSA, use the Parkland formula to
determine the amount of fluid required for resuscitation.
• Withhold oral intake: It is advisable not to give the victim anything to drink / eat as
this may result in vomiting, especially if the TBSA burnt is >25%.
 STEP 3 : DETERMINE THE AMOUNT OF RESUSCITATION
FLUID REQUIRED
ANATOMY AND PATHOPHYSIOLOGY

These mediators increase

local and systemic This extensive capillary
Severe burn injuries This response can begin
capillary permeability, leak results in large fluid
trigger activation of the within minutes and
leading to the rapid shifts, intravascular fluid
complement system and
displacement of depletion, and rapidly transpires over
release of inflammatory
intravascular significant edema of both
and the first 24 hours after
fluids, electrolytes, and burned and non-burned
vasoactive mediators. the injury occurs.
plasma proteins into the tissue.
interstitial space.

This phenomenon, known Massive systemic fluid

as “burn shock,” is a loss, accompanied by Maximum intravascular
combination of decreased cardiac output hypovolemia
distributive, hypovolemic and increased vascular
and cardiogenic shock, resistance, eventually and edema formation
and is treated with lead to critical peaks at about 8–12
aggressive fluid hypoperfusion and hours post-injury.
resuscitation. subsequent tissue injury.
BURN CHART
 THE PARKLAND FORMULA
THE PARKLAND FORMULA FOR THE PARKLAND FORMULA FOR
ADULT CHILDREN (<30KG)
1st 24 Use warm Hartmann’s solution or warm Ringer’s 1st 24 Use warm Hartmann’s solution or warm Ringer’s Lactate
hours Lactate hours (RL) PLUS maintenance fluid
4 x Patient’s weight (kg) x TBSA % For Hartmann’s or RL
- 1⁄2 of the volume to be administered in the FIRST = 3 x Patient’s weight (kg) x TBSA %
8 HOURS FROM THE TIME OF INJURY - 1⁄2 of the volume to be administered in the FIRST 8 HOURS FROM
- 1⁄2 of the volume to be administered in the NEXT THE TIME OF INJURY
16 HOURS - 1⁄2 of the volume to be administered in the NEXT 16 HOURS.
2nd 24 Give half of the previous day’s total volume using 1ST 24 For maintenance fluids, use warm Dextrose 5% in half saline
hours warm Hartmann’s and Colloids (e.g. Gelafundin) in hours (please see below for infusion rate, according to body weight)
equal amounts
Or
2nd 24 Give half of the previous day’s volume using warm Hartmann’s and
0.5ml of 5% Albumin x Body weight (kg) x TBSA /
hours Colloids (e.g. warm Gelafundin) in equal amounts AND 0.45% saline
24hrs = ___ ml albumin IV infusion x 24hours
in D5% for maintenance
OR
0.5ml of 5% Albumin x Body weight (kg) x TBSA / 24hrs AND 0.45%
saline in D5% for maintenance
MAINTENANCE FLUID INFUSION RATE (USING BURN RESUSCITATION FLUID AND TARGET
WARM 0.45% SALINE IN DEXTROSE 5%) URINE OUTPUT BY BURN TYPE AND AGE
Body 100:50:20 4:2:1 rule
weight rule (over (over 1
(kg) 24 hours) hour)
< 10kg 100Mg/kg/day 4ml/kg/hr

11-20 kg 50Mg/kg/day 2ml/kg/hr

>20 kg 20Mg/kg/day 2ml/kg/hr

DETERMINING BURN DEPTH / THICKNESS
OF BURN
FIRST DEGREE BURN – SECOND DEGREE BURN -
(NOT INCLUDED IN DETERMINING TBSA) (SUPERFICIAL DERMAL BURN)
SECOND DEGREE THIRD DEGREE BURN (FULL
BURN – (DEEP DERMAL BURN THICKNESS BURN)
STEP 4: DETERMINE THE NEED FOR
URGENT
PROCEDURES AND INVESTIGATIONS
• Common problems:
• 1. Burn in the Limb & Chest
• 2. Low urine output
• 3. Inhalation burn
• 4. Dark coloured urine
STEP 4: DETERMINE THE NEED FOR
URGENT
PROCEDURES
•
AND INVESTIGATIONS
1. BURN IN THE LIMBS AND CHEST
• Circumferential full thickness burn and deep
dermal burn which occur in the limbs are at
risk of compromising distal circulation.
• Full thickness burn on the chest may impede
normal chest-wall excursion and ventilation.
• An escharotomy may be required to allow
perfusion in the limbs and chest expansion.
• This can be done at the bed-side at
Emergency Department without taking the
patient to OT, but must be performed under
sterile conditions.
STEP 4: DETERMINE THE NEED FOR
URGENT
PROCEDURES AND
ESCHAROTOMY DIAGRAM
INVESTIGATIONS
POST ESCHAROTOMY
STEP 4: DETERMINE THE NEED FOR
URGENT
PROCEDURES AND INVESTIGATIONS
• 2.URINE OUTPUT
• What is adequate urine output?
•  Adults: 0.5 – 1 ml/kg/hour (e.g. 30 – 60 cc in a 60kg person)
•  Children: 1 ml/kg/hour (range 0.5-2.0 ml/kg/hour) in < 30kg
• If urine production is inadequate:
• i. Re-evaluate TBSA
• ii. Give extra warm fluids (Hartmann’s or RL): two methods of doing this:

give boluses of 5-10ml/kg of patient’s body weight, or

Increase the next hour’s fluids to 150% of the planned volume.
STEP 4: DETERMINE THE NEED FOR
URGENT
PROCEDURES AND INVESTIGATIONS
• 3. INHALATION BURN
• Suspect inhalation burn based in history, examination, and also investigations.
• History: burned in an enclosed area
• Examination: SOB, horseness of voices, tachypnoea, burn from the neck level
and above, burnt hair and eyebrow, soot and carbon deposits in the mouth and
nostrils
• Investigations : ABG, Chest xray ( both maybe normal in the 1ST 24 HOURS)
• Management is expectant and supportive . Intubate EARLY If suspected and if
patient is planned for transport.
STEP 4: DETERMINE THE NEED FOR
URGENT
PROCEDURES AND INVESTIGATIONS
• 4. DARK COLOURED URINE
• The urine turns into a dirty red or brown colour, a condition due to
haemochromogenuria.
• Acute renal failure will ensue if not treated. Large amounts of fluid
resuscitation may be required.
• 1. Increase fluid resuscitation to produce urine output at
least 2ml/kg/hour, or 75-100ml/ hour in adult
• 2. Send urine for analysis to detect haemoglobin and/or myoglobin.
STEP 5: DETERMINE THE NEED TO TRANSFER THE
PATIENT, OR TO CONTINUE MANAGING THE PATIENT

• Burn > 10 % TBSA in patients younger than 10 years and older than 50 years
• Burn > 15% in patients aged between 10 to 50 years’ old Full thickness burn > 5 % TBSA in patients of any
age
• Full thickness burn > 5 % TBSA in patients of any age
• Burn in special areas: face, hands, feet, genitalia, or perineum and major joints
• Electrical burn including lightning injuries and Chemical burn
• Burn involving inhalation injury
• Circumferential burn of the extremities and/or chest
• Burn involving concomitant trauma in which the burn poses greatest risk of morbidity and mortality
• Burn in patients with preexisting medical conditions that may complicate management and/or prolong
recovery or affect mortality (e.g., diabetes, COAD, coronary artery disease, pregnant, ESRF, under alcohol
influence)
STEP 6: ONGOING ASSESSMENT AND
EVALUATION
• BASELINE INVESTIGATION
• FBC, HT, BUSE, RBS, LFT ( albumin & protein), ABG , CHEST XRAY, ECG, Urine analysis
• MONITORING
• Strict careful monitoring is essential for all burn patients. Use of an ICU chart is compulsory.

 Hourly Temperature, Pulse, and Blood Pressure, Respiratory Rate & *Pain Score (*if not intubated)
 Hourly Urine Output (via CBD) and 4 hourly urine-analyses. Also note colour of urine
 Hourly Central Venous Pressure (CVP) reading
 Hourly Intravenous and Oral Fluid intake
 Respiratory rate Arterial Blood Gases 6 hourly for inhalation burn
 Glasgow Coma Scale /AVPU
 2 hourly dextro-stix/glucometer reading
STEP 6: ONGOING ASSESSMENT
AND EVALUATION
OTHER MEDICATION
ANALGESIA TO CONSIDER

• Do pain score assessment • Anti-Tetanus Toxin 0.5cc

• SEDATION SCORE • IV Ranitidine 50mg stat and TDS for

adult patients with >20% TBSA
burn.
• For children, based on body weight.
STEP 6: ONGOING ASSESSMENT
AND EVALUATION
• CANNULATION FOR IV ACCESS
• In severe burn with hypovolemic shock, getting an IV access is a
challenge.
Choice of IV cannulation for aggressive fluid resuscitation
• Peripheral vein access --> External jugular/ femoral vein access -->
intraosseous access--> central vein access
STEP 7: WOUND MANAGEMENT

• The choice of burn wound dressing in the IMMEDIATE period depends on:

• 1.Whether the patient is to be transferred immediately to a burn care facility, or

• 2. Whether there will be any delay in referring the patient, or

• 3. Definitive management is panned at primary hospital/center (for minor burn only, not requiring
transfer )

• Choice of cleansing agent:

 Chlorhexidine aqueous (1:1000) or

 Warm Normal Saline.

This is to be done for ALL burn patients BEFORE transfer, under strict aseptic precautions and with
adequate analgesia.

All dirt, debris and loose skin are removed.

The open method is used on the face and perineal burn. Cleanse with Normal Saline, and apply CMC.
STEP 7: WOUND MANAGEMENT

• IF PATIENT IS PLANNED FOR TRANSFER WITHOUT DELAY

• TO THE NEAREST BURN CENTER:

 Cover wound with BURNHIELD (Hydrogel, wet sachet which provides essential
physical protection for emergency care of burn and scalds.
OR
 Cover wound with clean, dry cloth (e.g. dry gauze), and then with sterile towel. Keep
patient warm with layers of blanket. Elevate affected limbs.
OR
 Cover wound with clean kitchen cling-film (Plasticized polyvinyl-chloride or PVC
film). Keep the patient warm with layers of blanket. Elevate affected limbs.
STEP 7: WOUND MANAGEMENT

•  IF THERE IS AN EXPECTED DELAY IN TRANSFERRING THE PATIENT:

• 1. Clean the burn wound
2. Apply a film of Silver Sulphadiazine cream (SSD) over the wound.
FIRST LAYER: Apply non-adherent dressing (e.g. Jelonet, Parrafin Gauze) over
the film of SSD.
SECOND LAYER: Apply dry gauze (2-3 layers) over the first layer OR gamgee;
depending on the amount of exudates produced.
THIRD LAYER: Bandage the affected area loosely. Do not compromise the distal
circulation in the limbs.
STEP 7: WOUND MANAGEMENT

• BURN BLISTERS
SCALP BURN Shave, Clean and Expose
• Do not break any Watch out for pressure sores!

blisters: Management of the burn FACE Clean and expose

blisters has been controversial. GENITAL/PERINEAL Catheterise, B.D dressing or PRN

REGION when soiled, cover burn area with
• Opinions vary from immediate SSD cream and leave wound exposed
HANDS Clean and dress with SSD
removal, delayed removal or leaving Dress the fingers separately
them intact. Encourage hand physio early
Elevate limb
• The decision to de-roof/puncture/ EYELIDS Referral to opthalmologist to rule out
corneal/ eyeball injury
aspirate the blisters should be left to
EARS Ckean, dress and keep wound well
the burn specialist. padded *CMC/MEBO
UPPER AND LOWER Remember to elevate the affected
LIMBS limb
STEP 7: WOUND MANAGEMENT
CHEMICAL BURN

• Chemical burn is deeper than initially appear and • 5) if a victim has combined facial and eye
may progress with time. burn, the eye takes the precedence and the
victim should be first seen by
• Treatment:
an Ophthalmologist and later by the Burn /
• 1) ABCDEs of resuscitation Plastic Surgeon.

• 2) Remove contaminated clothing and brush off • 6) Inspect nails, hair and web spaces
any debris
• 7) Wound closure is the same as for
• 3) Irrigate with copious amount of water for 1-2 thermal burn
hours under low pressure

• 4) If eyes are affected, wash with Normal Saline /

Ringer

• Lactate and refer to Ophthalmologist early.

• Tilt the head of the victim to- wards the side of the
affected eye to prevent the chemical from entering
the canaliculi and nasolacrimal ducts.
STEP 7: WOUND MANAGEMENT TREATMENT
ELECTRICAL BURN

• Often encountered as small punctate burn on skin with extensive deep tissue damage which requires
debridement.
• Watch for:
• ‣ Muscle damage: Compartment syndrome: CONSIDER ESCHAROTOMY / FASCIOTOMY EARLY
• ‣ Cardio-pulmonary injuries  always need to do an ECG. Involve Cardiology team.
• ‣ Renal  Acute Tubular Necrosis (ATN) due to toxic effect of myoglobin released from damaged
muscles. Involve Nephrology team.
• ‣ Fractures and Dislocations  Especially the spine and shoulder
• ‣ Abdominal  Intraperitoneal damage and gut necrosis
• ‣ Vascular: Vessels thrombosis  Tissue Necrosis
• ‣ Neurological  Seizures
STEP 7: WOUND MANAGEMENT
TREATMENT
• ‣ A, B, C, Primary and Secondary survey, treat associated injuries
• ‣ Monitor for Myoglobinuria, Urinary Output, Compartment Syndrome
• ‣ Wound Management: as in Step 7
• ‣ Non-viable tissue need to be debrided early and every 48 hours on a
PRN basis to prevent sepsis
• ‣ major amputations are frequently required
REFERENCES

• ATLS 10TH EDITIONS

• Burns Protocol Hosp Melaka 2017 llustrated
• Parkland Formula by Mitali Mehta; Gregory J. Tudor. (NIH)
• Management of Burns by David G. Greenhalgh, M.D.