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1. Burns
-Binod timalsina

2. Key points
1. Follow American Burn Association criteria for transfer of a
patient to a regional burn center.
2. Never administer prophylactic antibiotics other than tetanus
vaccination.
3. Early excision and grafting of full-thickness and deep partial
thickness burns improve outcomes.
4. Intravenous fluid resuscitation for patients with burns greater
than 20% of total body surface area (children with burns >15%
of total body surface area) should be titrated to mean arterial
pressure (MAP) greater than 60 mmHg and urine output greater
than 30 mL/h.

3. Initial evaluation
A. Airway management,
B. Evaluation of other injuries,
C. Estimation of burn size,
D. Diagnosis of CO and
E. cyanide poisoning.

5. Classification of Burns
Burns are commonly classified as
• Thermal,
• Electrical, or
• Chemical burns

6. Thermal burns
• Thermal burns consisting of flame, contact, or scald burns.
• Flame burns are not only the most common cause for hospital
admission of burns, but also have the highest mortality.
• This is primarily related to their association with structural fires
and the accompanying inhalation injury and/or CO poisoning.

7. Electrical Burns
• Electrical burns have special concerns including the potential for
cardiac arrhythmias and compartment syndromes with concurrent
rhabdomyolysis.
• A baseline ECG is recommended in all patients with an electrical
injury, and a normal ECG in a low-voltage injury may preclude
hospital admission.
• Long-term neurologic and visual symptoms are not uncommon
with high-voltage electrical injuries, and ophthalmologic and
neurologic consultation should be obtained to better define a
patient’s baseline function.

8. Chemical burns
• Chemical burns are less common but potentially severe burns.
• The most important components of initial therapy are careful
removal of the toxic substance from the patient and irrigation of
the affected area with water for a minimum of 30 minutes, except
in cases of concrete powder or powdered forms of lye, which
should be swept from the patient to avoid activating the
aluminum hydroxide with water.
• The offending agents in chemical burns can be systemically
absorbed and may cause specific metabolic derangements.
• Formic acid has been known to cause hemolysis and
hemoglobinuria, and hydrofluoric acid causes hypocalcemia.

9. Burn depth
• Superficial (first-degree),
• Partial-thickness (second-degree),
• Full thickness (third-degree), and
• Fourth-degree burns, which affect underlying soft tissue.

10. Burn depth
• Clinically, first-degree burns are painful but do not blister,
• Second-degree burns have dermal involvement and are extremely
painful with weeping and blisters, and
• Third degree burns are leathery, painless, and non blanching.

11. Burn depth

13. Management
Immediate care
Assessment of burn wound
Fluid resuscitation
Treatment of burn wound

14. Pre hospital
Ensure rescuer safety – house fire , chemical , electrical
Stop the burning process – stop, drop & roll
Check for other injuries
Cool the burn wound Cool the burn wound – minimum 10mts
to an hour
Oxygen
elevate

15. Hospital care
Airway
Breathing
Circulation
Disability
Exposure with environmental control
Fluid resuscitation

16. Airway
Burned airway causes obstruction
Endo tracheal tube for 48 hours
Symptoms of laryngeal edema appear late Intubation will be difficult after
symptoms appear
Crico thyroidotomy needed in late diagnosis
Recognition of potentially burned airway

17. Breathing
Inhalation injury
Thermal burns to lower airway
Metabolic poisoning
Mechanical block to rib movement

18. Inhalation injury
Observe anyone trapped in a fire
Presence of soot in nose & oro pharynx
Chest x-ray - patchy consolidation

19. Treatment
Secure the airway
Physiotherapy, nebulisation, warm humidified oxygen
Monitor the progress
IPPV for severe cases

20. Burns of lower airway
Steam injury
Supportive management
Like inhalational injury

21. Metabolic poisoning
Fire within a closed space
Altered consciousness
ABG Metabolic acidosis
High inspired O2 for 24 hrs if >10%
Displacement from Hb

22. Assessment of burn
wound
Size
depth

23. Size
Formally assessed in a controlled environment
Allows areas to be exposed & any soot / debris to be
washed off
Do not cause hypothermia Patients whole hand – 1% of
TBSA
Lund & Browder chart
Wallace rule of nine - approximate

24. Depth
Superficial partial thickness
Deep partial thickness
Full thickness

25. Fluid resuscitation
Maintain the intravascular volume
Needed in a child with > 10%
15% in adults If oral water should not be salt free
Stress hormones – anti diuresis
Hypo natremia & water intoxication Resuscitation volume – area burned
Maximum loss in 8hrs
Lasts 24 – 36 hrs

26. Fluids
Ringer lactate / Hartmans
Human albumin solution / FFP
Hypertonic saline

27. Parkland formula
% burns x body wt x 4
Half in first 8hrs
Half over next 16 hrs

28. Monitoring
Key is urine output
0.5 -1 ml /kg body wt / hr
If output low increase the infusion rate by 50%
Should not be over resuscitated Acid base balance
Hematocrit measurement
CVP monitoring

29. Treatment of burn wound
Eshcarotomy
Full thickness
Superficial partial

30. Eshcarotomy
Circumferential full thickness burns of limbs
Incised in mid axial line to avoid nerves
Management of burn wound same

31. Full thickness
1% silver sulphadiazine
Silver nitrate solution 0.5%
Mefenide acetate
Serum nitrate

32. Superficial burns
Honey
Boiled potato peel
Synthetic biological dressings

33. Thank you !!!