Question

Patient presents with severe burns covering 35% of his body when he was trapped inside a burning building. Wife informs health care team about his height, weight (6 foot tall and weight 175lbs). What would be the initial concerns of the health care team and the measures you may take soon after arrival at the hospital?

Answer 1

Optimal fluid resuscitation of burn patients with burns greater than 20% total body surface area is critical to prevent burn shock during the initial 24 hours to 48 hours postburn. The initial concerns of the health care team for a 6 ft. 175 lb. man is to restore lost fluids and electrolyte balances. The team must provide an intravenous solution. This solution will aid in the “restoration of fluids, treating infections, repairing wounds, draining abscesses, and removing dead tissue”. Once the patient is stable, the focus turns to nutrition. The teams’ priority would be to “preserve lean tissue, maintain immune defenses, and promote healing”. The health team must consider the weight and height of the individual to identify the patient’s nutrient needs. This will also inform the team if the patient is underweight, obese, or normal weight. Most resuscitation formulas incorporate the patient's weight when estimating 24-hour fluid requirements. Classification of patients into body mass index (BMI) categories of underweight (BMI: <18.5), normal (BMI: 18.5-24.9), overweight (BMI: 25.0-29.9), or obese (BMI: >30.0). We also need to calculate the percent difference from ideal body weight (IBW) and compared 24-hour fluid volumes received.

A burn is the partial or complete destruction of skin caused by some form of energy, usually thermal energy. Burn severity is dictated by:

• Percent total body surface area (TBSA) involvement
  • Burns >20-25% TBSA require IV fluid resuscitation
  • Burns >30-40% TBSA may be fatal without treatment
  • In adults: "Rule of Nines" is used as a rough indicator of % TBSA
  • In children, adjust percents because they have proportionally larger heads (up to 20%) and smaller legs (13% in infants) than adults

Residents in training, medical students and other staff in surgical sector, emergency room (ER) and intensive care unit (ICU) or Burn Unit face a multitude of questions regarding burn care. Treatment of burns is not always straightforward. Furthermore, National and International guidelines differ from one region to another. On one hand, it is important to understand pathophysiology, classification of burns, surgical treatment, and the latest updates in burn science. On the other hand, the clinical situation for treating these cases needs clear guidelines to cover every single aspect during the treatment procedure. Thus, 10 questions have been organised and discussed in a step-by-step form in order to achieve the excellence of education and the optimal treatment of burn injuries in the first 24 hours. These 10 questions will clearly discuss referral criteria to the burn unit, primary and secondary survey, estimation of the total burned surface area (%TBSA) and the degree of burns as well as resuscitation process, routine interventions, laboratory tests, indications of Bronchoscopy and special considerations for Inhalation trauma, immediate consultations and referrals, emergency surgery and admission orders. Understanding and answering the 10 questions will not only cover the management process of Burns during the first 24 hours but also seems to be an interactive clear guide for education purpose.

A clear guide has been structured for the above target group, which includes 10 questions that should be asked and well answered to cover the treatment of burn patients in the first 24 hours. Herein, the following questions should be taken in consideration:

1. Does the patient meet the criteria for injuries requiring referral to the Burn Unit?
2. How to perform the Primary Survey and Secondary Survey?
3. How to estimate the total burned surface area (%TBSA) and the degree of burns?
4. What are the main aspects of Resuscitation?
5. What are the routine interventions that should be performed for each case of burn injury during admission to the Burn Unit?
6. What kind of laboratory tests should be done?
7. Does the patient have Inhalation Injury and is Bronchoscopy indicated for all patients?
8. What kind of consultations should be carried out immediately?
9. Does the patient need Emergency Surgery or not?
10. What kind of admission orders should be written?

Furthermore, many hospitals around the world do not have a specialised burn unit and, thus most of the treatment process occurs in the emergency room (ER).

10 questions as practical guide:

1. Does the patient meet the criteria for injuries requiring referral to the Burn Unit?

A clear answer should be given in the pre-hospital setting. This must be well performed by the referral person or the transporting physician. It is not meant that a patient with burn injury should immediately be moved to a burn unit. In the case of a burn center not being able to accept a patient, the initial treatment process can also be conducted in the emergency room (ER) until the transport to the burn unit takes place.

The main criteria for referral to a burn unit include the following:

Second and third degree burns greater than 10% TBSA in patients younger than 10 years and older than 50 years.

Second and third degree burns greater than 20%.

Third degree burns greater than 5%.

Burns to face, hands, feet, genitalia, perineum and major joints.

Electrical burns (including lightning injury)

Chemical burns

Inhalation injury

Patients with pre-existing conditions

Circumferential third degree burns to extremity or chest

Burns involving concomitant trauma with a great risk of morbidity and mortality (i.e. explosion trauma).

2. How to perform the Primary Survey and Secondary Survey?

The burn injury itself has a secondary role in the moment of primary survey. Directly on admission Advanced Trauma Life Support (ATLS) guidelines must be performed and the following points must be checked:

Airway: Early recognition of airway compromise followed by prompt intubation can be live saving. If there is soot in the mouth consider early intubation even if the patient is breathing normally.

Breathing: Determine if the patient is moving air or not.

Circulation: Obtain appropriate vascular access and a monitor device to control heart rate and blood pressure.

Disability: Detect if there are any other manifestations including fractures and deformities, abdominal injury or neurological deficit.

Exposure: The patient should be completely exposed and should be out of clothes. Exposure of all orifices must be conducted in this part.

Fluid resuscitation: A mainstay in the treatment. This point is discussed in the third question after the calculation of the total burned surface area (%TBSA) but the guidelines of Acute Trauma Life Support (ATLS) should be followed in order to maintain the circulation process.

Note that a child is prone to hypothermia due to its high surface to volume ratio and low fat mass. Ambient temperature should be from 28° to 32°C (82° to 90°F). The patient’s core temperature must be kept at least above 34°C.

Secondary survey is designed as a burn-specific survey. It is performed during admission to the burn unit. Full history should be approached including:

Examination of the cornea is important as well as the ear in case of explosion trauma. A systemic overview should be performed in this phase including a fast run on the abdomen, genital region, lower and upper limbs (think: X-Ray C-Spine, Thorax, and Pelvic). If the patient is a child, look for signs of abuse.

Detection of the mechanism of injury.

Time of injury.

Consideration of abuse.

Height and weight.

Possibility of carbon monoxide intoxication based on the history of burns in a closed area as well as the presence of soot in mouth and nose.

Facial burns.

3. How to estimate the total burned surface area (%TBSA) and the degree of burns?

Total body surface area (TBSA) is an assessment measure of skin burns. In adults the "rule of nines" is used to determine the total percentage of the burned area for each major section of the body. However, this rule cannot be used in pediatric burns. The Lund-Browder chart is one of the most accurate methods to estimate not only the size of the burn area but also the burn degree in each part. The use of this chart has shown an easy access and fast readability in the clinical practice as well as its use in pediatric burns. It is available in many centers and also available online. Note that an internet address has been added at the end of this article to make it accessible for education purposes. Accurate estimation must be performed in order to estimate the amount of intravenous fluids, referral indications to the burn unit and indication of surgery as well as the estimation of prognosis.

Rule of Nines for Establishing Extent of Body Surface Burned

Anatomic Surface	% of total body surface
Head and neck	9%
Anterior trunk	18%
Posterior trunk	18%
Arms, including hands	9% each
Legs, including feet	18% each
Genitalia	1%

The degree of burns is calculated to estimate the prognosis as well as the type of treatment and consequently the type of surgery that should be conducted. Burns are classified to:

First degree burns: typical redness and pain of the affected skin. Minor epithelial damage occurs without formation of blisters. Typically occurs with sunburns.

Superficial second degree burns: complete epithelial damage and only papillary dermal damage occurs. This degree leaves no neurovascular damage. Thus, it causes pain, bleeds and presents with blisters. Epithelial repair occurs within 14 days. It mostly leaves no scars after healing. Sometimes discoloration stays.

Deep second degree burns: complete epithelial damage and damage of the reticular dermis present. It results in neurovascular damage. Thus, it generally presents without bleeding or sensation and appears white in colour. Blisters can also be present but are bigger than in superficial second degree burns. Healing can occur but takes longer than 14 days and results in scars.

Third degree burns: involving the epidermis, dermis and subcutaneous tissue. The skin appears leathery consisting of thrombotic vessel.

Forth degree burns (debatable): it is a third degree burn with involvement of the underlying fascia, muscles and even bones.

Superficial burn injury (First degree).

Superficial partial-thickness burns (Superficial second degree).

Deep partial-thickness burns (Deep second degree).

Full-thickness burns (Third degree).

Fourth degree burns (debatable classification as some references do not support this degree.

4. What are the main aspects of Resuscitation?

Calculation of the total burned surface (% TBSA) area is essential in this part. Charles Baxter, MD, at Parkland Hospital, Southwestern University Medical Center, designed in the 1960s the Parkland formula to calculate the fluid needs for the first 24 hours. Although many modifications of this formula have been proposed this formula is still one of the easiest ways to calculate the fluid volume for burn patients.

4 mL × Patient's body weight × TBSA = Volume to be given in the first 24 hours

50% of this volume is infused in the first 8 hours, starting from the time of injury, and the other 50% is infused during the last 16 hours of the first day.

The type of fluid administration is a debatable question. Lactated Ringer has been commonly used and is even used up to date. On the other hand, many centers suggest balanced electrolyte solutions like Ringer-acetate to prevent the high dose administration of lactate. According to our experience and to the best of our knowledge, we believe that balanced electrolyte solutions are a safe option and therefore they are recommended in our center. Furthermore, specific burn populations usually require higher resuscitation volumes sometimes as much as 30-40% higher (close to 5.7 mL/kg/%TBSA) than predicted by the Parkland formula.

Overall, the use of Parkland formula is just a process of estimation. Clinically, fluid needs of an individual, after the use of any suggested formula, should be at least monitored by several important factors such urine output, blood pressure and central venous pressure. An important point and considered to be the goal in fluid resuscitation is to maintain a urine output of approximately 0.5 ml/kg/h in adults and between 0.5 and 1.0 ml/kg/h in patients weighing less than 30 kg. Failure to meet these goals should be addressed with gentle upward corrections in the rate of fluid administration by approximately 25%.

Due to the capillary leak, most burn centers advise not to use colloids and other blood products within the first 24 hours. If used in the early phase (up to 12 h), it can lead to a prolonged tissue oedema and consecutive lung complications. Furthermore colloids are not associated with an improvement in survival, and are therefore more expensive than crystalloids. Liberati et al advocated that there is no evidence that blood products (including human albumin) reduce mortality when compared with cheaper alternatives such as saline.

Maintenance dose is provided after the first 24 hours. It can be calculated as follows:

100ml/kg:for the first10kg50ml/kg:for the second10kg20ml/kg:every kilogram above20kg

Special considerations for children:

Modified Parkland Formula is used for this category of patients as follows :

4mL×Patient's body weight×TBSA×Maintenance fluid=Volume to be given in the first 24 hours

5. What kind of routine interventions should be performed for each case of burns during admission to the Burn Unit?

Injured patients differ in term of burns size and depth. Pre-existing conditions play an important role in this phase. Central venous catheter and arterial line are indicated if the patient is hemodynamically unstable or if frequent blood gas analysis is required. Furthermore, nasogastric tube and urinary catheter are indicated in patients with 20% TBSA or more. Nasogastric tube will initiate immediate feeding and decrease the possibility of ileus or aspiration. Urinary catheter that is equipped with a temperature probe is preferred.

Before washing the patients, swabs for microbiological examination should be taken from different areas including burn areas, mouth, nose and the inguinal area. It should be made clear that the patient is washed properly with warm water and then re-evaluated regarding the total burned surface area (TBSA) as well as the degree of burns. A definite evaluation of the total burned surface area (TBSA) can only be made when the patient is washed completely and the wounds can be judged properly. In this phase, indication for surgery is made including escharotomy, debridement and in certain situations skin grafting.

6. What kind of laboratory tests should be done?

Basic laboratory tests include the following:

Complete blood count (CBC) and Arterial blood gas (ABG) analysis,

Urea and Electrolytes (U&E),

Prothrombin time (PT) / Partial thrombin time (PTT) and International Normalized Ration (INR),

Sputum Culture and Sensitivity,

Creatine Kinase (CK) and C-reactive protine (CRP),

Blood glucose,

Urine drug test,

Human chorionic gonadotropin (B-HCG): if the patient is female,

Albumin test.

Thyroid values and myoglobin measures.

7. Does the patient have Inhalation Injury and is Bronchoscopy indicated for all patients?

Burns occurring in closed areas and all burns that are affecting the head are subjected to inhalation injury. If Carbon monoxide (CO) intoxication is suspected, perform arterial blood gas (ABG) analysis to detect carboxyhemoglobin (COHb), immediate supply of 100% oxygen, chest X-Ray and discuss the possibility of hyperbaric oxygen (HBO) therapy. COHb higher than 20% or cases presented with neurological deficits are absolute indications for HBO, whereas COHb amounts of 10% and higher are seen as relative indications for HBO. Overall, intubated burn patients provide a good access for bronchoscopy. In this case, fiberoptic bronchoscopy can be used to evaluate the extent of airway oedema and the inflammatory process that is caused by any form of inhalation injury including the carbon monoxide (CO) intoxication. On the other hand, the role of bronchoscopy is debatable in terms of the therapeutic aspect as well as its invasive procedure.

8. What kind of consultations should be carried out immediately?

Depending on the secondary survey, several consultations may be necessary. In case of facial burns, consult:

Otolaryngology (ENT) department: to exclude burns of the upper airway, laryngeal oedema or in case of explosion rupture of the tympanic membrane.

Ophthalmology: to exclude erosion or ulceration of the cornea.

Follow the same procedure as performed in the primary survey. As guided by the Advance Trauma Life Support (ATLS), consult or re-consult if already performed:

Trauma surgery,

Abdominal surgery and

Neurosurgery.

9. Does the patient need Emergency Surgery or not?

Debridement:

The term ''Debridement'' is not merely a surgical procedure. Debridement can be performed by surgical, chemical, mechanical, or autolytic procedures. Surgical modalities including early tangential excision (necrectomy) of the burned tissue and early wound closure primarily by skin grafts has led to significant improvement in mortality rates and substantially lower costs in these patients. Furthermore, in some circumstances, escharotomy or even fasciotomy should be performed.

Indications of surgical debridement:

Dermal substitutes or matrices can be used if a large burn area exists. Here are some examples:

Note that in many occasions, an immediate coverage of wounds cannot be achieved. In this case, a temporary coverage is favoured. After stabilization of patient and wound bed, a planned reconstruction takes place to close wounds permanently. In this point, some methods can be performed including:

1. Deep second degree burns.
2. Burns of any type, that are heavily contaminated
3. Third degree circumferential burns with suspected compartment syndrome (think of: Escharotomy)
4. Circumferential burns around the wrist (think of: Carpal tunnel release)

Benefits of surgical debridement:

1. To reduce the amount of necrotic tissue (beneficial for prognosis)
2. To get a sample for diagnostic purposes (if needed).

Complications of debridement:

1. Pain.
2. Bleeding.
3. Infection.
4. Risk of removal of healthy tissue.

Contraindications:

1. Low body core temperature below 34°C.
2. Cardiovascular and respiratory system instability.

Any trainee should be aware of the following terms:

Tangential excision: Tangential excision of the superficial (burned) parts of the skin

Epifascial excision: This technique is reserved for burns extending at least to the subcuticular level.

Subfascial excision: indicated when burns extend vey deep and reach the fascia and muscles. It is needed only in special cases.

Escharotomy: Indicated for third-degree and second degree deep dermal circumferential burns. This is used to prevent a soft tissue compartment syndrome, due to swelling after deep burn. An escharotomy is performed by making an incision through the eschar to expose the fatty tissue below. Note that escharotomy lines on the thumb and little finger, as an international standard, should be always performed on the radial side and not on the ulnar side. Escharotomy incisions for the index finger, middle finger and ring finger are performed along the ulnar side.

Fasciotomy: Fasciotomy is a limb-saving procedure when used to treat acute compartment syndrome. An incision is made in the skin that extends into the fascia where it will relieve pressure. Note that Carpal Tunnel Syndrome (CTS) can result from the circumferential burns around the wrist by consecutive swelling.

After any selected procedure from the above category, the resulted wound should be covered. Autografts, i.e. split thickness skin grafts (autologous skin transfer), remain the mainstay of treatment for many patients

Biobrane: Biosynthetic wound dressing constructed of a silicone film with a nylon fabric.

Suprathel: Innovative skin substitute made of polylactide for the treatment of superficial dermal wounds especially the superficial second degree burns.

Alloderm: Cultured and processed dermis used under skin graft to reproduce the layered structure of dermis and epidermis in a graft

Integra: Bilayer wound matrix comprised of porous matrix of cross-linked bovine tendon collagen and glycosaminoglycan and a semi-permeable polysiloxane (silicone) layer. Must be used in a two-step-procedure.

Matriderm: Three dimensional matrix consisting of collagen and elastin. Its use guides autologous cells for the construction of a "neo-dermis". Can be used in a single-step as well as in a two-step-procedure.

Allografts: Cadaver Skin used for temporary cover.

Xenografts: Graft taken from other species (bovine of swine) can be used as temporary cover.

10. What kind of admission orders should be written?

Routine admission orders include:

Vital signs: Continuous monitoring of Heart rate, Blood pressure, Pulse pressure, Respiratory rate, Temperature and Central venous pressure.

Documentation of allergies

Diet: Nil per os (NPO) if burn more than 30% during the first 24 hours. Nasogastric tube will initiate immediate feeding and decrease the possibility of ileus or aspiration.

I.V. fluids: follow the Parkland formula.

Decubitus precautions.

Consultation: Psychiatry or Psychology (only if patient is awake).

Multivitamins and Traces: Vitamine C, ZnSo4, Selenium and Vitamine E.

Tetanus prophylaxis.

Ulcer prophylaxis.

Analgesia: the choice is dependent on burn size, depth, age and other trauma factor such as blunt trauma and fractures.

Additional medications (for mechanically ventilated adults with smoke inhalation injury): nebulized heparin sulfate mixed in 3 ml normal saline every 4 hours and 3 ml 20% nebulized N-acetylcysteine plus 0.5 ml albuterol sulfate every 4 hours for 7 days.

Understanding and answering the above stated 10 questions will not only cover the management process of Burns during the first 24 hours but also should be an interactive clear guide for education purpose. Burn cases can extremely differ and, thus trainee, medical students and personnel in surgical sector, emergency room (ER) and intensive care unit (ICU) or Burn Unit face a multitude of questions regarding these critically ill patients. We found that this method serves good purposes and increases not merely the quality of treatment but also enhances education.