Management of burn

1. Early Management of
Burn
Supervisor: Mr Naveen, Dr Zahir
Presenter: HO Mary Chan

2. Outline
• Definition
• Classification
• Complications
• Assessment
• Management
• Case study

3. Definition
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. (WHO ,
2018)

4. BURNS
ELECTRICAL
INJURIES
THERMAL
INJURIES
CHEMICAL
INJURIES
RADIATION
INJURIES
INHALATION
INJURIES
- SCALDS
- FLAME
- CONTACT

5. Types of burns
• Scald burn
• frequent home injuries ; hot water, liquids such as grease
• Flame burn
• gasoline, kerosene, burning materials
• Chemical burn
• acid burn most common, alkaline cause more severe burn
• Electrical burn
• worse than the other types ; with an entrance and exit wounds ; may cause cardiac
arrhythmia, rhabdomyolysis & bowel ischaemia
• Radiation burns
• from radioactive radiation or nuclear exposure

6. Classification Of Burns
Burns
First Degree
(superficial)
Second
Degree
Superficial Deep
Third
Degree

12. • occurs when someone is
trapped in an enclosed
space with toxic gas or
fumes from a fire or
chemical leak.
• invoke an inflammatory
response in the respiratory
system causing laryngeal
oedema.
• present with burnt skin and
soot around the
face(particularly the mouth
and nostrils).
INHALATIONALINJURIES

13. Complications
Local
1. Wound infection
• Due to extensive epidermal loss & presence of necrotic tissue
• Main organisms : Strep. pyogenes, Pseudo. aeruginosa
• Increases risk of sepsis
• Can cause organ failure & mortality
2. Scarring & contractures
• Except for the superficial dermal burns, all deeper burns (2nd degree deep dermal
and full thickness) heal by scarring
• Also can causes keloids

14. • Systemic
1. Fluid loss
• Extensive burns can cause substantial fluid losses
• Due to inflammation & damaged of blood vessels result in low blood volume (hypovolemia)
• Prevents heart from pumping enough blood to the body
• Inflammatory exudation of protein-rich fluid into extracellular space leads to local edema and
blisters
2. Sepsis
• Chest infection ( inhalation injury )
• Septicaemia ( wound infection )
3. Respiratory failure
• Breathing hot air or smoke can burn airways and cause breathing difficulties
• Smoke inhalation can cause bronchoconstriction & ARDS
4. Psychological disturbances
• flashback, sleep disturbance, anger, panic attacks, avoidance behaviour

15. Assessment of Burn Wound
1. Burn size
• Influence the size of inflammatory response
• Measured as percentage of total body area
• Rule of nines
• Lund and Browder chart
• Palm method
•
•
2. Burn depth
Influence healing time/ scarring
Superficial / Partial / Full thickness burns (1st / 2nd / 3rd
degree)

16. Wallace’s
RulesofNines
Children have
different body
surface area
proportions than
adults.
•Smaller hips and legs
•Larger shoulders and
heads

17. Lund and
Browder chart

A more precise method of estimating the
extent of a burn is the Lund and Browder
method

It recognizes that the percentage of TBSA
of various anatomic parts, especially the
head and legs, and changes with growth.

By dividing the body into very small areas
and providing an estimate of the proportion
of TBSA accounted for by such body parts,
one can obtain a reliable estimate of the
TBSA burned.

Usually used to estimate extent of burn in
children, according to their age.

18. Palm Method
• In patients with scattered burns, a method to estimate the percentage
of burn is the palm method.
• The size of the patient’s palm is approximately 1% of TBSA.
• Used for small burn wound.

19. Emergency Procedures at the
Burn Scene
• Extinguish the flames
• Cool affected area as soon as possible
(within 3 hours from time of burn) for
20 minutes with cool running water
• Remove restrictive objectives (e.g. cloth:
can constrict circulation)
• Cover the wound (prevent hypothermia)

20. • For mild pulmonary injury, inspired air is humidified and the
patient is encouraged to cough so that secretions can be
removed by suctioning.
• For more severe situations, it is necessary to remove
secretions by bronchial suctioning and to administer
bronchodilators and mucolytic agents.
• If edema of the airway develops, endotracheal intubation may
be necessary.

21. Airway
Signs of airway burn/
inhalation injury: stridor, hoarseness, black
sputum, respiratory distress or facial swelling
Sign of oropharyngeal burn: intraoral oedema
and erythema
Significant neck burn
If above present, consider early intubation
If suspicion of airway burns or carbon monoxide
intoxication apply high flow oxygen
Protect the cervical spine with immobilisation if
there is associated trauma
Breathing
Full thickness and/or circumferential chest burns
may require escharotomy to permit chest
expansion
Circulation
Assess peripheral pulses & blood pressure
Iv fluid administration as required
IV or IO access (preferably 2 access)
Start IV fluids administration using Parkland formula
Disability
If altered conscious state, consider airway support
Assess neurovascular status if limb involved
Exposure - burn assessment and initial
management
Assessment of burn depth
Burns are dynamic wounds, it is difficult to
accurately estimate the true depth and extent
of the wound in the first 48-72 hours
Do NOT include area with epidermal burn
(erythema only)
MANAGEMENT

22. Management of fluid loss and shock
• Assessment of both the TBSA burned and the depth of the burn is completed after soot and
debris have been gently cleansed from the burn wound.
• An indwelling urinary catheter is inserted to provide more accurate monitoring of urine
output and renal function for patients with moderate to severe burns.
• Fluid Replacement Therapy:
The adequacy of fluid resuscitation is determined by:
• Urine output at least 30 to 50
mL/hour
1 ml/kg/hr (children) OR
0.5ml/kg/hr (adult)
• systolic blood pressure more than 100 mm Hg
• pulse rate less than 110/minute.

23. • The estimated fluid requirements for the first 24 hours are
calculated based on the extent of the burn injury.
Parkland Formula:
• 4 mL × kg body weight × % TBSA burned (adult)
• 3 mL × kg body weight × % TBSA burned (children)
• Use Hartmann solution
• Day 1: Half to be given in first 8 hours; half to be given
over next 16 hours
• Calculated from the time of burn (not time of arrival to A&E)
• Day 2: Depends on patient’s vital signs and urine output.
• The formula above is a guide,
• each patient needs close monitoring & adjust accordingly

24. Conditions leading to shock

25. Escharatomy
• done in majorburn with generalized
edema, circumferential burn and full
thickness burn (painless)
• To prevent compartment syndrome (constricting
circulation, impaired tissue perfusion )
• To prevent respiratory compromise (inflexible
eschar and edema over chest and abdomen can
prevent chest wall motion and thus limit
ventilation )
• Eschar is removed down to subcutaneous or
fascia until soft tissue

26. Escarotomy – throughoutthelength of
eschar

27. Case study
Patient A, 11M, Female
NKMI/NKDFA
1st hospitalisation
CW: 9.2kg
HOPI
1/ Alleged right hand dipped into hot porridge on
26/4/22 at 11:30am
- was taken care by mother
- just cooked porridge and placed on dining table
- while waiting for it to cool down pt played around
the table
- child's hand dipped into the hot porridge for few
seconds
post trauma sustained:
- peeling and redness of skin
- vesicles started after few minutes
Mother ran tap water onto the child's hand for few
minutes then dipped in basin of water
also put on condensed milk over the burn site
at night put on Amway cream - Alano
claimed skin dried up after applying
Went to GP and treated as second degree burn
wound dressing done, given TCA on Thursday to
review symptoms and wound dressing
given topical cream and Amway cream
became shrunken and dried
29/4/2022
Went to GP for dressing today, but referred to here
for further management
prescribed with syr augmentin 3mls BD X5/7 and syr
PCM 2.5mls QID

28. • Otherwise
• no fever
• no URTI
• active as usual
• good oral intake
• no GI losses
• no abd pain
• PU/BO regular

29. ED assessment,
Vital Signs Chart
Temperature 36.7 ° C
Pulse 149 /min
Respiration 35 /min
Systolic Blood Pressure 90 mmHg
Diastolic Blood Pressure 65 mmHg
MAP 78 mmHg
SPO2 100 %
Lungs clear
CVS DRNM
Per abd soft non tender
Right hand examination
blisters seen over dorsal and ventral aspect of hand
+ circumferential
+ involving flexure area
+ yellowish crusty lesion seen
+ erythematous
Impression: Second degree burn of right hand
(1.5%)
PLAN
Syr PCM 15mg/kg STAT
IVD HSD5 46cc/hr (TF120cc/kg/d)
FBC, RP, SE
Referred to surgical for 2nd degree burn

30. Upon surgical review
Alert, cheerful
pink
warm peripheries
good pulse volume
CRT<2s
Lungs : clear
CVS : DRNM
Per abd: soft non tender
Right hand examination
multiple blister seen over dorsal and ventral aspect
of hand
with contact bleeding
no pus discharge
burn up to MTPJ
Preprocdure:
given oral chloral hydrate 267mg and IV midazolam
0.9mg
Wound scrubbed down until area of dermis
exposed
Then covered with bactigrass and wrapped in
bandage
Impression:
2nd degree burn of right hand: TBSA 1%
Plan:
Admit ward 5B
Refer paeds surgical team - case d/w Dr A
Start NP3L in view of sedation given during
procedure (supplemental oxygenation)
Allow orally once fully conscious
For full maintainance drip (46cc/h) TF 120cc/kg/d
Daily normal saline and bactigrass dressing
Syr PCM 15ml/kg

32. Investigations 29/4/2022 1/5/2022
FBC Hb
Hct
Plt
WCC
10.1
30.5
407
7.57
11.9
36.3
266
4.36
RP Urea
Na
K
Creatinine
1.9
134
4.2
37
SE
CRP
Mg
Ca
PO4
0.88
2.42
1.74
7.0
Blood culture Aerobe
Anaerobe
NG D5
NG D5

33. After admitted to ward 5A, overnight pt has spike of temp T 38.9C
Subsequently started on :
• Syrup PCM 135mg QID (15mg/kg)
• Syrup Cloxacillin 135mg QID (15mg/kg)
Otherwise, the child
• Breastfeeding as usual, no vomiting
• BO x2

34. 30/4/2022 1/5/2022 2/5/2022 3/5/2022
Plan:
- Allow orally as
tolerated
- Cont full
maintainance drip
(46cc/hr)
- Daily normal saline
and bactigrass
dressing
- Syr PCM 135mg QID
(15ml/kg)
- Syrup Cloxacillin
135mg QID (15mg/kg)
- cont tepid sponging
- Allow orally as
tolerated
- Reduce to half
maintenance 23cc/hr
- cont Syr PCM &
Syrup Cloxacillin
--------------------------------
Case d/w Dr A Mo Paeds
surgical (burn unit)
- observe for 1 more day
- Cont Syrup cloxacillin
and syrup PCM
- Cont dressing
bactigrass and splinting
- KIV discharge cm if well
- if discharge, discharge
with syrup cloxacliin to
complete for 1 week
Progress,
Another temp spike
39.3 degree
Septic workup, FBC,
CRP taken
Right hand dressing
intact, not tight, not
soaked
CRP 7
WCC 4.36
--------------------------------
Plan
- To observe for at least
24hour since last
temperature spike
- Trace septic workup
- Cont Syr PCM &
cloxacillin
- tepid sponging if temp
spike
- Cont dressing
bactigrass and splinting
Comfortable under RA
active as usual
tolerating breastfeeding & solid food
afebrile >24hrs, last temp spike 39.3 at 12am 2/5/22
Wound inspection: all fingers on right hand pink, CRT <2s ,
clean and no discharge, no bleeding , done aquacell
dressing
------------------------------------------------------------------------------
*case progress and updated to Dr A MO Paeds surgical
- ivo their side clinic is fully booked , for the patient to
follow up at SOPD clinic on friday 6/5/22
to update Dr A MO Paeds surgical HTA regarding the clinic
follow up findings and progress
otherwise for now, can allow discharge *
Plan
Allow discharge with
-- Syr PCM 135mg QID (15ml/kg) QID x1/52
-- Syrup cloxacillin 135mg QID x 3/7
TCA SOPD on Friday 6/5/22
Update back Dr Anfar MO PAEDS Surgery HTA on friday
6/5/22 for the latest progress and findings

35. During clinic follow up,
6/5/2022
IMP:
Post-alleged scalded injury D11 sustained second degree burn of right hand, TBSA 1%
- Alleged right hand dipped into hot porridge on 26/4/22
Wound inspection: wound healed, no discharge
All fingers pink, CRT <2s
No fingers contracture
Updated to to Dr A MO Paeds surgical
Plan:
Cont aquacel ag dressing + splinting
TCA SOPD next Tuesday - to update back paeds surgical
TCA 10/5-pt defaulted