THERMAL INJURIES

Introduction
• A burn is an injury resulting in damage to the cutaneous integrity of the skin as result of
heat (or cold)
• A burn is a complex injury involving not the skin but often multiple organ systems with far
reaching consequences
• Burns may also be associated with other traumatic injuries
• Burns are a leading cause of accidental injury and death worldwide
• Non-fatal burns are a leading cause of morbidity, including prolonged hospitalization,
disfigurement and disability, often with resulting stigma and rejection.

Epidemiology
• Burns are a global public health problem, accounting for an estimated 265 000 deaths
annually.
• The majority of these occur in low- and middle-income countries and almost half occur in
the South-East Asia Region (WHO Factsheet on Burns, 2014).
• In Sri Lanka, ∼10 000 injuries and 100 deaths are burn related, costing US$1 million
annually (Lau, 2006).
• A significant percentage of burn injuries occur in Sri Lanka due to non-accidental injury
including homicide and deliberate self-harm.
• 70% of burns treated at the Burns Unit in Colombo involve abused women.

Types of Burn Injury

• Flame Burns • Electrical Burns
• Scalds • Friction Burns
• Contact Thermal Burns • Radiation Burns
• Chemical Burns • Frostbite
– Acid and Alkali

Effects and complications of burn Injury

• Direct tissue disruption • Arrhythmias
• Hypovolaemia • Acute renal failure
• Hypoproteinaemia • Deep vein thrombosis
• Susceptibility to infection • Stress ulceration
• Inhalational injury • Scarring
• Acute lung injury • Psychological and Social issues

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Treatment/First Aid of Burn Injuries: On Site
• Treatment of burn injuries begins at site of burn
• Stop the burning process by smoldering flames
• Remove hot clothing with except those stuck to skin to allow trapped heat out
• Cooling of burn area
• Cover patient with loose dry clothing/dressing to prevent hyperthermia
• Cooling
– Ideally done on site/pre-hospital
– Irrigation
– For 20 min with clean, running water at room temperature
– Irrigate up to 1 hour for acid burns
– Even longer periods are necessary for alkali burns

Initial Management of Burn Injury

• Follows the ATLS protocols
• Initial assessment and resuscitation of burn injury is performed simultaneously with
trauma resuscitation
• Airway
• Inhalation injury, respiratory distress
• Inhalational injury is a major cause of burn mortality
• Breathing
• Circumferential burns
• Carbon monoxide poisoning
• Smoke inhalational injuries
• Circulation
• Fluid extravasation in severe burns will cause circulatory compromise
• Disability
• Exposure & Environmental control
• Cooling if not already done
• Effective up to 1-3 hours following thermal burns and in any chemical burn
especially Alkali

Inhalational Injury
• Inhalation injury can be defined as damage caused by breathing in harmful gases, vapours,
and particulate matter contained in smoke.
• Superheated smoke and gas can cause direct thermal injuries to the airways
• Additionally, particles and gases in the smoke can cause chemical injury, and systemic
toxicity to both airways and lungs.

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Airway: Features of Inhalational injury
• Persistent cough, stridor, or wheezing • Blistering or edema of the oropharynx
• Hoarseness • Respiratory distress
• Deep facial or circumferential neck burns • Hypoxia or hypercapnia
• Nares with inflammation or singed hair • Elevated carbon monoxide and/or
• Carbonaceous sputum or burnt matter in cyanide levels
the mouth or nose • History of burning in a confined space

A significant percentage of patients with inhalational injury will develop complete airway
obstruction

Carbon Monoxide poisoning

• Carbon monoxide (CO) exposure is likely in patients who were burned in enclosed areas.
• The diagnosis of CO poisoning is made primarily from a history of exposure and direct
measurement of carboxyhemoglobin (HbCO).
• Patients with CO levels of less than 20% usually have no physical symptoms.
• Higher CO levels can result in:
o headache and nausea (20%–30%)
o confusion (30%–40%)
o coma (40%–60%)
o death (>60%)

Smoke Inhalation
• Inhalation of smoke containing combusted particles and toxic fumes can result in a number
effects
o Injury to distal bronchioles causing mucosal cell death
o Alveolar injury
o Inflammatory response with capillary leakage and diffusion defects
o ARDS

Management of Inhalational Injury

• Stabilise the airway
• Oxygen & Nebulization (Saline/Bronchodilators)
• High flow 100% oxygen via non-rebreathing mask (NRBM) in suspected Carbon Monoxide
poisoning
• Prop up
• Neck collar
• Do not delay intubation if severe inhalation injury or respiratory distress is present.

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Secondary Survey: History
• Mechanism of Injury
➢ Area occurred, open or closed space
• Concomitant trauma
• History of fall
• Agent involved
➢ Flame, kerosene, chemical
• Non-accidental injury

Secondary Survey: Assessment of Burn Depth

• Superficial burns
o Epithelial injury only
o Good cosmetic outcome
• Superficial partial thickness burns
o Painful.
o Light pink and moist.
o Maybe associated with blisters.
o Capillary return present.
o Will heal spontaneously with minimal scarring.
• Deep partial thickness burns
o Dark red or white with dry surface
• Third degree burns or full thickness burns.
o Dead white or black eschar with thrombosed veins

Secondary Survey: Assessment of Burn Surface Area

• Determines the severity and critical status of the patient
• Beyond 20 % TBSA, it is a systemic disease and can lead to death
• Wallace Rule of Nines
• Lund and Browder Chart

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 Wallace Rule of Nines Lund and Browder Chart

Levels of care and criteria for transfer of each patient (National Guidelines –CSSL 2006)

• Minor burn
o Out-patient with follow up can be done in a peripheral unit or base hospital
• Major burn
o Burns 20 to 30 % without inhalation injury can be managed in a base hospital with
specialized facilities e.g. eye, ENT consult and lab, blood bank
• Burns more than 30 % or with inhalation injury
o should be managed in a general hospital

Criteria for admitting burns to a burn center (revised American Burn Association criteria)

• Partial thickness and deep burns of more than 10 % burn surface area
• Full thickness burns of any size
• Any burn involving the face, hands, feet, eyes, ears, or perineum that may result in cosmetic
or functional disability
• High voltage electrical injury including lightening
• Inhalation injury or trauma
• Chemical burns
• Burns in patients with significant co morbid conditions E.G Diabetes Mellitus, COPD, Cardiac
disease
• Adverse social circumstances

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Early Management of Patients with Burn Injury

Burn specific management

• F = Fluids
• A = Analgesics, Antibiotics
• T = Tubes –Catheter, NG tube
• T = Tetanus toxoid

Fluid Management in Burns

• A majority of burn deaths in the initial period occur due to hypovolaemia following burn
injury.
• Adequate and timely fluid resuscitation is critical to good outcomes in burns patients
• Burns less than 10% BSA can be resuscitated orally
• > 10% need resuscitation with intravenous fluids
• Secure IV access with at least two wide bore cannulae (14-18F lines) at time of admission
• Fluid resuscitation should be performed via a large peripheral vein preferably femoral.
• Burn resuscitation can be performed using both crystalloids and colloids.
• A number of different formulae are available to calculate the fluid requirement in the initial
resuscitation period- Parkland formula, Muir-Barclay formula etc.

Parkland Formula
• This formula is designed for the use of crystalloids in burn resuscitation- Ringers Lactate/
N. Saline
• It estimates the fluid requirement in the first 24 hours

2-4 ml x Kg BW x Burn Surface Area

• ½ to given in 1st 8 hours

• ½ in next 16 hours

• Assess adequacy of resuscitation

o Clinical parameters
o Urine output (0.5ml/kg/hr)

• Adjust infusion rate and volumes according to urine output

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 • Burn shock during the initial 24 to 48 hours following major burns is characterized by
myocardial depression and increased capillary permeability resulting in large fluid shifts and
depletion of intravascular volume

Pain and anxiety management

• Partial-thickness burns in particular can be excruciatingly painful.
• Intravenous (IV) morphine has been the mainstay of pain management for patients with
significant burns.
• Avoid NSAIDS due to theoretical risk of Curlings Ulcer
• Benzodiazepines can be given to reduce the anxiety associated with these injuries

Antibiotics
• Use of systemic antibiotics is controversial in the care of burns. The initial burn wound is
sterile following exposure to heat. Most western centres do not use antibiotics in the initial
care of mild to moderate burns
• However, IV antibiotics are recommended in burns > 30% TBSA
• Topical antibiotics are applied to all non-superficial burns

Initial Care of the Burn Wound

• Wounds are washed using 1% Povidone iodine scrub or Chlorhexidine scrub.

• The blisters are opened and all dead skin is removed
• Primary first line antiseptic ointment is Silver Sulphadiazine ointment
• Closed method except for face ears, perineum
• Shaving of facial, scalp, axillary groin hair and in other areas localized hair removal
• Padded gauze for absorption
• Dress digits separately
• Secure with cotton bandage to prevent slipping, control oedema and stabilize dressing
• Minimal anaesthesia
• Control Hypothermia

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Splinting

• Very important step to preventing wasting, deformity and contracture

• Shaving hair, avoiding pillows, positioning with pop and collars

Prevention of Gastrointestinal complications

• Shock from thermal burn injuries results in mesenteric vasoconstriction predisposing to
gastric distension, ulceration (so-called Curling's ulcer), and aspiration.
• A nasogastric tube recommended in patients with moderate or severe burns >20 percent
TBSA
• High-risk patients require anti-ulcer prophylaxis

Subsequent issues in the management of burns

• Fluid balance
• Nutrition
• Escharotomy
• Skin grafting
• Occupational therapy
• Psycho-social issues

Fluid Management after 24 hours

• Plasma or colloids as albumin 3ml x kg x %Burn
• Maintenance fluids-

Calculating maintenance fluid for 24 hours as dextrose saline

First 10 kg 100ml/kg
Second 10 kg 50ml/kg
Every kilogram above 20 kg 20ml/kg

• Add additional fluid for evaporation

• Adjust according to urine output
• Correct Calcium, Magnesium in large burns
• Replace Potassium from 48 to 72 hours

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Nutrition in the Burn Patient
• Energy expenditure of the extensively burned patient is high and may be several times that
of the normal basal level
• Establish feeding as early as possible after the initial period
• Use the gut i.e. Oral or NG feeding
• Various formulae maybe helpful in determining requirement of Energy & Proteins
o Curreri Formula, Harris Benedict Equation
• 1-2 g/kg/day of Protein (2-3g/kg in severe burns) which provides a calorie to nitrogen
ratio at 100:1.
• Principle: high carbohydrate, high protein diet 60 % CHO, 20 % proteins rest fats and
sugars
• Large doses Vitamin A Vitamin C vitamin B, Zn and Fe

Wound Management
• Aim of burn wound management is to achieve the best cosmetic and functional outcome
• Healing of burn wounds depend on a number of factors including burn depth as well as BSA
• Superficial burns and superficial partial thickness burns will heal without scaring and
require proper dressing. Deeper burns are ideally managed with skin grafting.
• However, the overall systemic stability of the patient will take priority in severe burns

Dressing of Burn Wounds

• Dressing
o Depends on oozing
o If wet, dressing needs to be changed to prevent bacterial colonization
• Most commonly used approach is Silver sulphadiazine covered with absorbent dressings
(gauze and cotton) supported by cotton bandage
• Scheduled dressing changes according to unit protocol
• Ideally done in theatre in the early days due to pain issues
• A number of commercially available dressings are also available including collagen,
hydrocolloid, silver dressings, foam dressings and biological dressings. There is no good
quality evidence demonstrating the superiority of one dressing over another,

Skin Grafting
• Early skin grafting is associated with significant improvement on cosmetic outcome
• Tangential excision and grafting within 24 to 48 hours in non-infected stable burns
• Can use autologous skin graft in up to 30 % TBSA in first sitting

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Physiotherapy and occupational therapy

• Encourage early mobilization

• Prop up head & neck burns and inhalation injury
• Positioning
• Avoid pillows
• Use splints POP, neck collars
• Chest physiotherapy and nebulization
• Avoid pressure sores

Scar Management
• Management of scars and pressure therapy for treatment and prevention of hypertrophic
scars is a continuous process
• Use of pressure garments for 12 to 18 months continuously for 23 hours of the day has
shown significant benefits

Psychotherapy
• Long –term sequalae of burns are permanent
• Patients suffering from the burn injury often are already suffering from serious emotional
issues- especially in non-accidental and suicidal burns
• Need significant support to return them to normal life

Bibliography
Russell RCG, Williams NS, Bulstrode CJK. Bailey & Loves’ Short Practice of Surgery. 25th Edition
American College of Surgeons Sub-committee on Trauma. Advanced Trauma Life Support: Student Course Manual. 10th
Edition. ACS 2013.
Ministry of Health, Sri Lanka. National Guidelines on the Management of Burns 2006

-Dr Dulantha de Silva

Senior Lecturer in Surgery
General Sir John Kotelawala Defence University
16.06.2023

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