Anaesthetic management in a patient of burns injury

1. J J M MEDICAL COLLEGE
DEPARTMENT OF ANAESTHESIOLOGY
A PRESENTATION BY
DR. KSHAMA BALAKRISHNA
POST GRADUATE
MODERATOR
DR. R. B. RAVISHANKAR MD, DA
PROFESSOR
ANAESTHETIC MANAGEMENT OF A PATIENT
OF BURNS
12.07.2019

2. INTRODUCTION
 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.
 According to the WHO, an estimated of 1,80,000 deaths every
year are caused by burns.
 Non- fatal burn injuries are a leading cause of loss of DALY
(disability adjusted life years).
 A vast majority of these occur in low- income and middle- income
countries.

3. CLASSIFICATION:
 Thermal burns- dry and wet
 Electrical burns
1. Low tension (<1000V)- cellphone and charger related injury
2. High tension (>1000V)- flame, flash, current
3. Lightening (>2000V)– direct strike, side flash
 Chemical burns- acid burns, alkali burns
 Radiation burns- a, b, g, x-rays

4. PATHOPHYSIOLOGY
 Inflammation and circulatory changes
 Injury to airway and lungs
 Immune system response
 Gastrointestinal tract
 Renal system
 Haematological system

5. INFLAMMATORY AND CIRCULATORY
CHANGES
 Massive release of inflammatory mediators  increased capillary
permeability  loss of water, electrolytes, proteins from
intravascular compartment  severe hemoconcentration
 Protein leakage  hypoproteinemia  increased oncotic pressure
in interstitial space  tissue edema
 Stimulation of pain fibres and alteration of proteins by heat 
release of neuropeptides and activation of complement
 Depressed cell membrane potential  impaired function of Na+-
K+ ATPase  Na+ and water accumulation  cell swelling

6. INFLAMMATORY AND CIRCULATORY CHANGES

7. EBB PHASE
(first 24hrs)
• Hypotension
• Low CO
• Metabolic acidosis
• Hypoventilation
• Hyperglycaemia
• Low O2
consumption
• Impaired
thermoregulation
FLOW PHASE
(catabolic)
Hypermetabolic
phase
• Increased CO
• Increased HR
• Better O2
consumption
• Supranormal
increases of
temperature
• Days to weeks
FLOW PHASE
(anabolic)
Healing and
rehabilitation
• Anabolism
• Normal function
restores
• Weeks to months
PATHOPHYSIOLOGY

8. Warning signs
 Burns around neck and face
 H/O being trapped in a burning room
 Change in voice
 Stridor
 Soot in sputum
 Respiratory Distress
If airway oedema suspected, immediate intubation must be
carried out. Mucosal oedema can ensue rapidly, particularly
with fluid resuscitation.
INJURY TO AIRWAY AND LUNG

9. ABOVE LARYNX
- Direct injury to nose,
mouth, tongue, palate,
larynx
- Saturated vapours
more injurious
- Upper airway oedema
peak at 24hrs, subside
<1st week
BELOW LARYNX
- Better heat exchange
mechanisms
- Steam can cause loss
of respiratory
epithelium and form
casts

10. INJURY TO AIRWAY AND LUNGS
Incomplete products of
combustion
Bronchospasm, mucosal
oedema ulceration
Impaired cilia,
mucosal damage
Inflammatory response
NH3, NO2, SO2,
Chlorine, Acrolein
Necrotic debris,
proteinaceous fluid,
cast formation
Pneumonitis- Alveolar injury,
impaired surfactant production
Atelectasis, V/Q
mismatch
Pneumonia,
sepsis, death

11. METABOLIC POISONING
CO POISONING
 Manifestations - nausea and vomiting, headache, hypotension,
convulsions, coma
 0.1% CO- 50% carboxyHb
 240 times higher affinity to Hb, shift to left of ODC
 Inhibits Cytochrome oxidase- tissue hypoxia, metabolic acidosis
 Pulse oximetry - overestimate the true oxygen saturation. ABG
analysis recommended.
 Treatment- 100% oxygen; if HbCO levels >25–30% should be
ventilated.

12. CYANIDE POISONING
 Binds to Fe3+ in Cytochrome A3
 Lactic acidosis persists despite adequate fluid resuscitation
MECHANICAL BLOCK OF RIB MOVEMENT
 large full-thickness burn across the chest
 Thick burned skin over the chest
 Requires excision/ escharotomy
MECHANICAL VENTILATION
 Lung protective ventilation (6mL/kg) and low plateau pressures
(<30cm of water)
 Routine ventilator- associated pneumonia prevention strategies
should be implemented.
 Mucolytics like N-acetylcysteine - airway clearance

13. IMMUNE SYSTEM RESPONSE
 Global suppression of immune system, decreased opsonisation
 Loss of skin (mechanical barrier )
 Suppression of cell mediated response- susceptibility to
bacterial and fungal infections
 Need for invasive lines- IV cannula, urinary catheter,
central lines, tracheostomies - portals of infection
 Bacterial-colonized eschar overlying a wound full of
proteinaceous fluid- risk for infection

14. ANAEMIA
Loss from
wound site
RBC
survival
Reduced
production
Haemolysis
 Hemoconcentration during 1st 48hrs
 HCT- poor guide to assess need for transfusion
 Platelet count and coagulation derangements- consumptive
coagulopathy with activation of thrombotic and fibrinolytic
system
HEMATOLOGY

15. RENAL SYSTEM
 RAAS activation- Na+ and water retention with exaggerated
loss of K+, Mg2+, Ca2+
 Drugs, myoglobin, sepsis related nephrotoxicity- kidney injury
 Extensive tissue necrosis, haemolysis- hyperkalemia
Hypovolemia
Reduced
CO
Decreased
RBF

16. GASTROINTESTINAL TRACT
Ischemia
of gut
mucosa
Inflammatory
stimulus
Microvascular
damage
 Acute gastric dilatation within 2-4days
 Paralytic ileus – decompression with NG tube
 Failure of enteral feeding and translocation of gut bacteria
 Curling’s ulcer
 Abdominal compartment syndrome
 Acute pancreatitis, acute acalculous cholecystitis

17. THERMOREGULATION
 Loss of vasoactivity, pilorection, sweating and insulation,
which are chief thermoregulatory functions of the skin.
 Daily loss from evaporation from the burn surface
accounts for 4000 mL/m2 in children and 2500 mL/m2 in
adults.
 Strategies to prevent hypothermia- warmed room
(ambient temperature 28–32.8 C), warmed inspired air,
warming blankets, and warmed fluids

18. ATTENDING TO A PATIENT OF BURNS
PRE- HOSPITAL CARE
 Rescuer safety
 STOP, DROP and ROLL
 CAB, rapid survey of other
injuries
 Cool the wound
 Oxygenation
 Elevation
HOSPITAL CARE
 A- Airway control
 B- Breathing and ventilation
 C- Circulation
 D- Disability including assessment
of neurological status
 E- Exposure in a controlled
environment
 F- Fluid resuscitation

19. ASSESSMENT OF THE BURN WOUNDS
1. Measurement of the wound:
 Wallace rule of nines
Total BSA is divided into multiples of 9
BACK FRONT
Head and neck 9%
Upper extremities 9% each
Chest ( anterior and
posterior)
9% each
Abdomen 9%
Lower back 9%
Lower extremities 18% each
Perineum 1%

20.  Lund and Browder chart- TBSA according to sections of
anatomy and proportional to age of the patient
ASSESSMENT OF THE BURNS WOUND
Gluteal areas
2.5% each

21.  Palmar surface
Patient’s palm = 1% of patient’s TBSA
Quick method, if burns upto 15% of TBSA
II. Depth of the wound:
ASSESSMENT OF THE BURNS WOUND

22. Superficial Superficial partial
thickness
Deep partial
thickness
Full thickness
Layers affected Epidermis Epidermis,
papillary dermis
Epidermis, upto
reticular dermis
Epidermis, dermis,
deeper structures
Adnexal skin
structures
Preserved Preserved Damaged Damaged
Appearance Erythemat
ous
Pink and moist,
mottled,
blistering+
Pale and dry Dark, leathery
Capillary return Blanching
+
Blanching+ Non- blanching, fixed
capillary staining
after 48hrs
Non- blanching+,
thrombosed vessels
under skin
Sensation Painful Painful No pain, only
pressure
Painless
Epithelialization Rapid Rapid Slow Slow and minimal
Healing <7days, no
scarring
10-14 days, no
scarring
Weeks to months,
hypertrophic scar
Severe scarring and
contracture
Treatment Non-
surgical
Non- surgical Excision and grafting Excision and grafting

23. SUPERFICIAL SUPERFICIAL PARTIAL THICKNESS
DEEP PARTIAL THICKNESS FULL THICKNESS

24. JACKSON’S BURN WOUND MODEL

25. WHAT IS A MAJOR BURN?
 Full thickness burn injuries > 10% TBSA
 Partial thickness burn injuries >20% TBSA in extremes of age,
>25% TBSA in adults
 Burns involving- face, hands, feet, genitalia, perineum, major
joints
 Inhalational injuries
 Chemical burn injuries
 Electrical burn injuries
 Burn injuries in a patient with co-existing medical disease
 Burns associated with trauma

26. ROLE OF AN ANAESTHESIOLOGIST
 Initial resuscitation- securing airway, gaining vascular access
 Intensive care management
 “Perioperative- care consultant”
 Surgical management of a burns patient
1. Excision of damaged tissues, wound debridement
2. Wound dressings
3. Reconstructive surgical procedures
 Other surgical procedures in a case of post burns contracture

27.  Initial Management of
Inhalational injury
 Propped up position- 30-90
degrees
 High flow humidified oxygen
 Bronchodilators and
physiotherapy
 Fiberoptic bronchoscopy in
intubated cases - better
diagnosis and enables
pulmonary toileting.
AIRWAY MANAGEMENT

28. AIRWAY MANAGEMENT
Early intubation considered if
 Presence of stridor
 GCS <8
 Hypoxia or hypercapnia
 Full-thickness neck burns
 Deep facial burns
 Oropharyngeal edema
 TBSA >40% (massive edema likely to follow during fluid
resuscitation)
Use of direct laryngoscopes, LMAs, Bullard laryngoscopes
Choice of intubation technique depends on expertise of the operator

29. Succinylcholine can be safely used <24hrs , after which risk of release
of potassium from extrajunctional A-ch receptors persists upto a year.
Direct surgical approach to airway
 Needle cricothyroidotomy
 Surgical cricothyroidotomy
 Tracheostomy
High incidence of complications- hence, last resort
AIRWAY MANAGEMENT

30. VASCULAR ACCESS
 Ideally, 2 large bore IV lines to be secured away from burned tissue
 If other sites not available, securing in burned skin is justified
provided eschar is still sterile ( early post burn)
 Priority- unburned tissue>> burned tissue>> central venous access
 For rapid initiation of fluid resuscitation – large bore IV access
preferred over central venous catheter
 Preferred sites- Subclavian vein > IJV > femoral vein
 Groins are usually spared so femoral venous cannulation is often
possible

31. FLUID RESUSCITATION
Principle- Intravascular volume must be maintained following a burn,
in order to provide sufficient circulation to perfuse not only the vital
organs, but also the peripheral tissues and especially the damaged
skin.
 Recommendation : In adults, if burns >15% TBSA or 10% with
smoke inhalation. In children, burns >10% TBSA
 Oral resuscitation- oral fluids with added salt, to avoid
hyponatremia and water intoxication.
 Parkland formula- fluid resuscitation for initial 24hrs
Percentage of burned surface area x weight (kg) x 4
half transfused over 1st 8hrs, remaining over next 16hrs

32. A 32-yr-old man weighing 80 kg with a 30% flame burn was
admitted at 23:00 h. His burn occurred at 22:00 h. He has already
received 1000 ml of crystalloid from the emergency services.
 Total fluid requirement for first 24 h= 4 ml(30% TBSA)(80 kg)=
9600 ml
 Will receive 4800 ml during 0–8 h and 4800 ml during 8–24 h
 4800 (for first 8 h)–1000 (fluid already received)= 3800 ml
 Burn occurred at 22:00 h, so 8 h point is 06:00 h. Patient arrived
at 23:00 h, so need 3800 ml over next 7 h.
 3800/7= 543 ml/hr from 23:00 to 06:00 h
 4800/16= 300 ml/hr from 06:00 to 22:00 h the next day.
CASE SCENARIO

33.  Crystalloid resuscitation, fluid of choice- Ringer’s lactate
 In children, maintenance fluids with Holliday Segar formula
(100ml/kg x 24hrs for 1st 10kg) + (50ml/kg x 24hrs for next 10kg)+ (20ml/kg x
24hrs for each kg above 20 kg body weight)
 Hypertonic saline- produces hyperosmolarity and hypernatremia which
reduces fluid shift from intracellular to extracellular space.
 Colloid resuscitation-recommended after 12hrs of burns, commonly used-
Human albumin solution
Muir and Barclay formula
0.5 x percentage of burned surface area x weight
Periods of 4/4/4, 6/6 and 12 hours respectively, one portion to be given in
each period
4hr 4hr 4hr 6hr 6hr 12hr
0 4 8 12 18 24 36

34. MONITORING OF RESUSCITATION
 Urine output: Adult- 0.5-1ml/kg/hr; Child- 1-2ml/kg/hr
 If not, then infusion rate increased by 50%
 Inadequate U/O with signs of hypoperfusion, give a bolus of
10ml/kg
 If U/O > 2ml/kg/hr – over-resuscitation, decrease infusion rate
 However, in a case of electrical burns with massive rhabdomyosis,
U/O has to be maintained at 1.5-2ml/kg/hr as myoglobinuria can
cause ARF.
 ABG analysis
 CVP monitoring and TEE in patients with cardiac dysfunction

35. ANAESTHESIA FOR A PATIENT OF BURNS
 Recent approach, early excision and wound
coverage
 Risk reduced- wound infection and sepsis
 Risk involved- physiological insult of surgery to a
patient who may well be deteriorating rapidly
from their initial injuries
 The most important and difficult clinical
decisions are often made by the team at this
stage.

36. ESHCHAROTOMY AND FASCIOTOMY
 A circumferential full thickness burn acts like a
tourniquet as the limb swells  limb ischemia
 Early signs- numbness and tingling
 4 Ps- Pain, pallor, paraesthesia, pulselessness
 Requires decompression of compartment making
radial incisions and blunt dissection with a
haemostat
 4-14days post- burn after resuscitation done or
<5days before bacterial colonization under eschar

37. Incisions are made
at the anterior
axillary line from the
level of the 2nd rib to
the level of the 12th
rib. They are joined
transversely so the
chest wall can
expand

39. CHALLENGES IN ANAESTHESIA
 Airway maintenance, choice of anaesthesia, hemodynamic
stability, thermoregulation, pharmacological agents
 Premedication: Antisialogogue- Inj. Glycopyrrolate 0.2mg IV,
narcotic analgesic Inj. Morphine 0.1mg/kg IV or Inj. Fentanyl
1mcg/kg IV, Inj. Midazolam 0.05mg/kg IV
 Aspiration prophylaxis: H2 receptor antagonist, Prokinetics
 Monitoring: Temp, SpO2, ECG (needle probes), ETCO2, CVP, U/O
 Adequate preoxygenation- high metabolic rate, tachycardia,
increased oxygen demand

40. Induction agents:
 Inhalational induction preferred to maintain airway
 Thiopentone/ Propofol better avoided or use at titrated doses
to avoid hypotension
 Ketamine- sole anaesthetic 1-2mg/kg, with oxygen (30-50%)
with nitrous oxide
 During ongoing resuscitation, possible sepsis, potential full
stomach- GA with ETT intubation and controlled ventilation
with post-operative elective ventilation. Ketamine or Etomidate
preferred in such cases
 Airway- ETT, LMA. Fiberoptic assisted awake intubation
 Inj. Ketamine infusion at 4mg/kg/hr can be used for
maintenance of anaesthesia

41. Use of Relaxants:
 Succinylcholine- significant transient increase in serum K+
levels (as high as 13 mEq/L), resulting in V Fib and cardiac
arrest.
 Hyperkalemic response begins 24- 48hrs post-burn and can
persist as long as 1- 2yrs, irrespective of degree and size of
burn injury.
 Gronert and Theye postulated that the abrupt release of K+ is
from the hypersensitive muscle membranes. Stimulation of
extrajunctional A-ch receptors on the muscle membranes of
burned patients mediate potentially lethal efflux of K+.

42. What are extra-junctional
receptors ?
 They differ from junctional receptors
 Upregulation due to deficient stimulation of
the skeletal muscle
 Shorter half-life (<24 hours)
 Highly sensitive to A-Ch and suxamethonium
 Open for longer duration but ion
conductance is smaller
 Concentrated around the end plates, but can
also be found anywhere on the
(postjunctional) muscle membrane
 Similar pentameric structure, but have the
foetal d subunit increased of the normal
adult e subunit
Foetal
(postjunctional)
Mature
(junctional)

43. POST BURNS CONTRACTURE NECK
PROBLEMS FACED
 Grossly restricted neck movements
 Patients are likely to be malnourished, anaemic and
hypoproteinemic
 Restricted mouth opening and narrowed nasal passages.
 Difficult laryngoscopy and endotracheal intubation
 Compromised airway
 Poor oral hygiene in patients

44. Mild- Scar apparent during neck extension
with the loss of the cervico-mental angle; neck
extension- 95 to 110
Moderate- Scar apparent in resting position,
which hinders neck extension; neck
extension- 85 to 95°
Severe- Neck in flexed position and limiting
any neck movement; neck extension is <85°
CLASSIFICATION- Based On Severity

45. BASED ON SCAR
 Linear scar- scar tissue is a fibrous tissue line.
 Band scar- scar width forms <50% of the anterior surface of the
neck.
 Broad scar- scar width forms >50% of the anterior surface of the
neck.

46. RELEVANT EXAMINATION
1. Contracture- location, duration,
consistency, extent
2. Mouth opening, mandibular movement
3. Patency of nasal passage
4. Difficulty in breathing
5. Can he blow air through mouth and
nose?
PREPARATION OF THE PATIENT
1. Improve oral hygiene
2. Correct anaemia and hypoproteinemia
3. H2 receptor antagonists, prokinetics
4. Anti emetics
5. Aggressive treatment of upper and
lower respiratory tract infections
PRE-OP WORKUP
1. CBC, Blood grouping
2. RFT, Sugars, S. electrolytes
3. Chest X-Ray, ECG
4. Serology

47. ANAESTHETIC CONSIDERATIONS
 Goal - total control of the airway
 Preserve spontaneous respiration till trachea is intubated
 Consider using nasopharyngeal airway, oro-pharyngeal
airway, and laryngeal mask airway where ever feasible
 Consider superficial cervical plexus block if contracture is
situated in between sternomastoids
 I.M Ketamine is a more useful option than I.V. Ketamine
in a dose of 2-5 mg/kg

48. AIRWAY MANAGEMENT OPTIONS
 TIVA - maintenance with combination of IV
Ketamine 0.4mg/kg, Propofol 1mg/kg
 Blind nasal intubation
 LMA insertion ( difficult in microstomia)
 Awake intubation with topical anaesthesia/ regional
anaesthesia
 Awake Fiberoptic intubation ( patency of external nares-
necessary)
 Patient can be maintained with volatile anaesthetic and
preferably muscle relaxants are avoided

49. AWAKE ENDOTRACHEAL INTUBATION
1. Topical anaesthesia
 Lidocaine- 4% solution and 10% spray
 higher doses can be used than the recommended 2 mg/kg (lesser
systemic absorption)
 Along with vasoconstrictor agents such as xylometazoline and
phenylephrine
 Application techniques
i. Spray from container
ii. Local anaesthetic soaked in ribbon gauze
iii.McKenzie technique
iv.Inhalation of nebulized lidocaine
v. Spray as you go” via epidural catheter

50. AWAKE ENDOTRACHEAL INTUBATION
2. Regional anaesthesia techniques
i. Glossopharyngeal Nerve Block
ii. Superior Laryngeal Nerve Block
iii. Recurrent Laryngeal Nerve Block

51. TUMESCENT TECHNIQUE
 Solution- Lignocaine, adrenaline, hyaluronidase and saline/water.
 0.5% Lignocaine solution with 1 in 1, 00,000 adrenaline
{25 ml 2 % lignocaine + hyalase 1 to 2 ml + 1ml of 1 in 1, 00,000
adrenaline + distilled water to a total volume of 100ml }
 Advantage:
1. Release of contracture without much blood loss.
2. Hydrostatic cleavage of operative field and better dissection.
3. Poor vascularity of scar tissue and use of adrenaline- decreased
risk of toxicity

52. Substance Initial
Concentration
Quantity Final
Concentration
Lidocaine 2% 4mL 0.2%
Adrenaline 1:1,000 44 drops or 0.2mL 1:200,000
NaHCO3 8.4% 4 mL 0.84%
Saline 0.9% 40.0 mL 0.71%
TUMESCENT TECHNIQUE
Rule of four for anaesthetic solution
The concentrations of each component is given by:
Final concentration of the substance (FCS) = concentration of the
substance (CS) x volume of the substance (VS) / volume of solution
(VSOL)
Lidocaine 2% 10.0 mL
Adrenaline 1:1,000 0.4 mL
NaHCO3 8.4% 4.0 mL
Saline 40.0 mL

53. SKIN BANK
 Skin banks are facilities that stockpile skin and its derivatives
and provide them on request
 This skin bank is essential for the treatment of seriously
burned patients because it provides the Burns Centre with
homologous skin
 Both autologous and homologous skin are cool-treated and to
be used within a period of not more than 3 weeks.
 In deep and extensive burns, there is often a lack of suitable
autologous donor areas. In such cases, the best possible
coverage continues to be homologous skin, despite its
limitations (immunogenicity and the risk of the transmission
of infectious disease).

54. CONCLUSION
 Anaesthesia providers play a key role in overcoming the
hurdles in the management of such cases by securing airway
and maintenance of respiration, gaining vascular access for fluid
resuscitation and providing anaesthesia/ analgesia in early
surgical procedures and wound dressings. Hence, it is
important to understand the physiological and pathological
changes related to it.
 Anaesthesiologists must also be familiar with the various
techniques to deal with patients with post burns contracture
neck who may come for reconstructive surgeries or other
surgical procedures.

55. REFERENCES
 Bailey and Love’s Short Practice of Surgery- 27th edition
 Wylie Churchill-Davidson’s a Practice of Anaesthesia- 7th edition
 Paul G. Barash Textbook of Clinical Anaesthesiology- 8th edition
 Tintinalli’s Emergency Medicine- 9th edition
 Stoelting’s Anaesthesia and Coexisting Diseases- 2nd South Asian
Edition
 http://dx.doi.org/10.1016/j.ccc.2016.06.001 criticalcare.theclinics.com
 Curr Anesthesiol Rep (2016) 6:16–21
 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 12
Number 3 2012
 Annals of Burns and Fire Disasters Vol. XVI n. 4 December 2003
 RACE- 2016 and 2007
 https://anaesthesianews.wordpress.com