Burn Resuscitation And Management - NEET PG Surgery

Any injury to the skin or any other organic tissue that is primarily caused by heat, radiation, radioactivity, electricity, friction or through chemical contact is called a burn. 

Burns are an essential topic for your Surgery preparation. Read this post thoroughly to understand everything you need to understand about Burns. 

Burns 

Indications of Referral to dedicated burn center

Partial thickness burn involving > 10% of TBSA

• Any full thickness burns 
• Burns involving face, hands, foot, joints and genitalia. 
• Electrical burn 
• Chemical burn
• Burn with inhalation injury 
• Burn with trauma 
• Burn with comorbidity in elderly
• Burn in children requiring special emotional care 

Pathophysiology

1. ↑ Radiant loss: Secondary to ↑ blood flow & integumentary loss
2. Heat loss: Evaporation of water from burn wound (also cause fluid loss)
3. Massive release of inflammatory mediators: leads to 
   • Vasodilation 
   • ↑ Capillary permeability – Extravastation of fluid - Edema- third space fluid loss- hypovolemia
4. Global depression of immune function 
5. Release of Catecholamines, Glucagon, Corticosteriods → Hypermetabolism → Fever
6. Curling ulcers 
   • It is a stress ulcer that occurs only when 1/3^rd of TBSA is burnt.
   • Caused due to ↓ decreased mucosal defenses due to hypovolemia (Acid secretion in stomach is normal)
   • Occurs due to increased acid secretion.

Important Information 

In patients of head injury 

Has stress Ulcer knowns as Cushing ulcers

Areas of cutaneous injury in burn 

Zone of coagulation	Zone of stasis	Zone of hyperemia
Has coagulative necrosis  Tissue is irreversibly damaged Disruption of cells occur	It is area immediately surrounding the zone of coagulation  Has moderate degree of insult with ↓ tissue perfusion Cells can survive (or) Progress to coagulative necrosis  Has vascular damage & vessel leakage	Vasodilation occurs  Has viable tissues – healing occurs from this zone.

Important Information 

• Best temperature of water used for cooling of burn wound 15ºC
• Cold water or Ice shouldnot be used as it causes vasoconstriction leading to ↓ tissue perfusion 

Burn Classification (based on depth burn)

First degree burns 

• Aka Epidermal burn
• Only epidermis is involved
• Painful & erythematous 
• No blisters formation 
• Healing occurs without scarring within 5-10 days 

Second degree burns 

• Aka Partial thickness burn 
• It is divided into 

Superficial partial thickness burn	Deep partial thickness burn
Involvement of epidermis + Papillary dermis	Involvement of epidermis + Reticular dermis  Burn surface area in mottled having whitish and pinkish area
Blisters present / Painful	No blisters / no pain
Blanch to touch	Pin prick sensation is preserved
Healing occurs without scarring (within 7-14 days)	Healing occur with scarring (3-9 weeks)

Third degree burns 

• Aka full thickness burn 
• Involvement of Epidermis + dermis + Subcutaneous fat 
• Burn surface has black colored leathery circumferential eschar – Escharotomy is done to prevent compartment syndrome.

Characteristic features: 

• No pain, no blisters, no pin prick sensation 
• Healing occurs with contracture: To prevent contracture - 

Excision of burned skin with skin grafting after resuscitation if the patient.

Fourth degree Burn 

• Involvement of Skin + underlying structures (Muscle, bone & brain)

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Causes of Death in burns

• MC cause of death at the site of burn: Asphyxia 
• MC cause of early death in burns: Hypovolemia / shock
• MC cause of late death in burns: Sepsis 
• Overall MC cause of death in burns: Sepsis 
• MC organism responsible for sepsis in burns: Pseudomonas 

Danger Signs of Airway Burns 

Burns involving head, neck & face 

• Singed / burned nasal hair
• Carbonaceous deposits in the sputum 
• Hoarseness of voice 
• H/o burns in a closed room

          Important Information 

• In all this patient’s Elective intubation is the safest 
• Delay in intubation leads to Laryngeal edema → difficulty in intubation – Emergency Cricothyroidotomy should be performed.

Management of burn patient 

Fluid resuscitation 

• Venous access in adults 
• Ideal sites: Veins of Hand, Antecubital fossa or neck 
• Saphenous vein cut down
  • Performed during difficult accessibility 
  • Preferred over Central line insertion 

IV fluid Resuscitation 

• Fluid of choice: Ringers lactate 
• Maintenance fluid of choice in children: Dextrose normal saline (DNS) as children have lesser glycogen storage 
• Other fluids used are 
  • Hypertonic saline 
  • Normal saline
  • Fresh frozen plasma
  • Human Albumin 
• Hypertonic saline is used for burn shock patients as it has higher oncotic pressure and will be retained in vascular compartment.

Calculation for fluid requirement 

Parkland Formula 

• It is Crystalloid based 
• 24 hrs. fluid requirement = 4 ml × body weight (kg) × % of burned surface area 
• Time starts when the patient gets burned 
• First degree burns are not included 
• Maximum fluid given should be taken for 50% TBSA- to avoid fluid overload 
• Half of calculated fluid is given in first 8 hours and rest half of fluid is given in next 16 hours.
• 2^nd day fluid requirement should be 40-60% of first day fluid requirement.

ATLS modification of Parkland formula 

• It is based on 
  • Age 
  • Weight 
  • Type of injury 
• Adults, children ≥ 14 years
  • 2 ml × body weight × % BSA
• Children <14 years, ≤30 kg weight
  • 3ml × body weight × % BSA
• Electrical burns (irrespective of age)
  • 4ml × body weight × % BSA

Burn resuscitation fluid rates and Target Urine output by Burn type and Age
Category of Burn	Age and Weight	Adjusted Fluid rates	Urine Output
Flame or Scald	Adult and older 14 children (>_14 years old)	2 ml LR × kg × % TBSA	0.5 ml / kg/hr 30-50 ml/kg/hr
Children (<14 years old)	3 ml LR × Kg × % TBSA	1 ml / kg / hr
Infant and young children (£ 30 kg)	3 ml LR × kg / % TBSA Plus a sugar – containing solution at maintenance rate	1 ml/kg/hr
Electrical injury	All ages	4 ml LR x Kg x % TBSA until urine clears	1-1.5 ml/ kg / hr until urine clears
LR: Lactated Ringer’s solution  TBSA: Total Body Surface Area

Brooke Formula 

• Both Crystalloid & Colloid based 
• Fluid requirement = 1.5 ml/ kg/ % TBSA of crystalloids + 0.5 ml/kg/% TBSA of Colloids + 2 liters of free water 

Galveston 

• It is a Pediatric formula 
• Fluid requirement = 5000 ml/m² of total burned surface area + 1500 ml/m² of Total body surface area 

Monitoring of fluid resuscitation 

• Best clinical indicator of tissue perfusion: Urine output 
  • Minimum U.O. after adequate tissue perfusion in adults: 1ml/min
  • Minimum U.O after adequate tissue perfusion in children: 0.5-1.0 ml/min
• In patients of Cardiac dysfunction monitoring is done by 
  • Trans – Esophageal USG (or)
  • Central line 

Estimation of burn surface area 

Determination of burn size – estimates the extent of injury 

Rule of “9”

• Given by Alfred Russel Wallace 
• Rule of 9 is followed for adults but is not very accurate for children 
• In case of children limbs are 14 percent each 

Lund & Browder chart 

• More accurate for estimation of burn surface area in Children 

Berkow’s formula 

• Also used for estimation of burn surface area in Children 

Palmar method 

• For estimation of smaller patchy burns:
  • Area of Open hand -  Accounts for 1%
• Used for 
  • Splash burns 
  • Mixed distribution of burns 

Care of burns patient 

Cool the burn wounds 

• Uses 
  • Provides analgesia 
  • Slows the delayed microvascular damage
• Cooling should be done for a minimum of 10 mins 
• Cooling is effective upto 1 hr after burns 
• Best temperature of water used for cooling of burn wound 15º C
• Tap water can also be used 
• Cold water or Ice should not be used because it increases the risk of Hypothermia 
• Cutaneous vasoconstriction; Extend the thermal damage 

1. Superficial partial thickness burns 
   • Heals without scarring within 2 weeks
   • Exposure method can be used – given Antimicrobial without dressing 
2. Escharotomy 
   • Performed for circumferential eschar 
   • Layers incised are longitudinally 
   • Skin 
   • Superficial fascia 
   • Deep fascia 

Management of burn wounds 

Exposure method 

• No dressing is done 
• Antimicrobials given 2-3 times / day
• Used for burns in Face & Head 

Disadvantages

• Increased pain & heat loss 
• Increased risk of cross – contamination 

1. Closed method 

• Occlusive dressing is applied over Antimicrobial agent 
• Changed twice daily 

Advantages 

• Decreased Pain & heat loss
• Decreased risk of cross- contamination 

Disadvantages

• Increased risk of bacterial growth – if dressing is not changed twice daily

2. Topical antimicrobials 

• Silver sulphadiazine (1%)
  • Provides Broad spectrum anti – microbial prophylaxis – mainly against Pseudomonas & MRSA
• Silver nitrate (0.5%)
  • Highly effective against Pseudomonas colonization
  • Causes “Black staining” of furniture around patients
• Mafenide acetate (5%)
  • Used in USA
  • Painful to apply
  • Usage is associated with Metabolic acidosis 
• Silver sulphadiazine & Cerium nitrate 
  • Used for full thickness burns 
  • Induces hard effect on burned skin 
  • Mainly used in elderly: Increases cell mediated immune suppression (CMI) - Cerium nitrate
  • Forms sterile eschar 
  • Boost CMI

3. Dressing materials 
   • Alginate
     • Absorptive, but non – adherent 
     • Used in high drainage wounds
   • Foam
     • Can absorb moderate or heavy exudate 
     • Used for high – drainage wounds 
     • Contraindicated in non – draining wounds
   • Hydrocolloid 
     • Facilitate Autolytic debridement – used for Bedsores & stasis ulcers 
     • Not used in high drainage wounds
   • Hydrogel 
     • Rehydrates the wound bed
     • Facilitate Autolytic debridement 
     • May macerate the wound by over – rehydration
   • Transparent film
     • Non – absorptive 
     • Facilitate Autolytic debridement 
     • Not used in high drainage wounds

Management of Chemical Burn 

1. Copious irrigation with water or saline 
   • Performed for a minimum of 20 minutes 
   • Exceptions 
   • Elemental metals: Causes exothermic reaction with water 
   • Phenol: Leads to deeper infiltration of tissues
2. Treatment should continue – until skin pH is normal
3. Remove the contaminated clothing & jewellery
4. Do not try to neutralize the chemical burn 
   • Neutralization causes Exothermic reaction – leads to further injury

Electrical Injury

In Direct current (DC)

• It is low tension / Electrical appliances injury
• It does not have enough energy to cause extensive tissue destruction 
  • Because of increased resistance – Cause small deep burn at the site of entry & exit →  fingers & toes
• Tendon & Nerve damage can occur 

In Alternate current (AC)

• Creates tetany in the muscle: Patient can’t detach from device until main power is turned off 
• Main danger: AC interferes with normal cardiac pacing without causing significant Myocardial damage, ECG is done 

Q. Al of the following are correct about management and complications of burn except

1. M/C cause of death is sepsis 
2. Exposure method is used for face and hand 
3. Silver sulphadiazine is effective against pseudomonas and MRSA
4. Galveston formula is colloid base 

Q. Which of the following patient should be referred to designated burn center for the management?

1. Burns involving the face, hand, feet, genitalia, perineum or major joints 
2. Any full thickness burn 
3. Electrical injury including lightning injury 
4. All of the above

Q. Match the following

Zone of coagulation  Zone of stasis  Zone of hyperaemia

Area immediately surrounding the necrotic zone Generally not at risk of further necrosis  Moderate degree of insult with decreased tissue perfusion  Contains clearly viable tissue from which healing process begins  Tissue is irreversibly damaged at time of injury.

1. I-E; 2-A; C:3- B, D
2. I-D; E; 2-A; C:3- B
3. I-D; E; 2 A; 3- B, C
4. I-E; 2-A; D:3- B, C

Q. Match the following

First degree burn  Superficial second degree burn Seep second degree burn  Third degree burn  Fourth degree burn

Painul  No pain Blisters  Pinprick sensation absent  Compartment syndrome  Healing without scaring  Involvement of muscle.

1. I-A, F; 2-A, C, F; 3-B;4-D, E; 5-B, G
2. I-A, 2-A, C, F; 3-B; 4-B, D, E; 5-B, G
3. I-A, F; 2- C, F; 3-B; 4-B, D, E, 5-B, G
4. I-A, F; 2-A, C, F; 3-B; 4-B, D, E; 5-B, G

Q. A 50 year old female with 50 kg body weight suffered from burns after pressure coocker blast, involving 60% of total body surface area, how much fluid should be given in first 8 hr ? 

A. 4L

B. 5L

C. 6L

D. 7L

Q. In the above ques. Calculate the second day fluid requirement?

A. 5L

B. 8L

C. 10L

D. 12L

Q. All of the following are correct about estimation of burn size except

1. In infant head and neck corresponds to 21% and each leg 13%
2. Lund and Browder chart is preferred over berkow formula for accurate determination of burn size in children 
3. Area of open hand is helpful in evaluating splash burns and burns of mixed distribution 
4. Area of open hand include the area under the palm approximately 1% of TBSA.

And that is everything you need to know about Burns for your Surgery preparation. For more interesting and informative blog posts like this, download the PrepLadder App and keep following our blog.