Burns Management

Burn Assessment - Sizing Up Scorch

• Depth Classification:
  • 1st (Superficial): Epidermis. Red, painful, no blisters. Heals 3-6 days.
  • 2nd (Partial Thickness):
    • Superficial (IIa): Papillary dermis. Blisters, painful, blanches. Heals 7-21 days.
    • Deep (IIb): Reticular dermis. Mottled, ↓pain, ±blanching. Scarring. Heals >21 days.
  • 3rd (Full Thickness): All layers. Leathery, insensate. Needs grafting.
  • 4th: Extends to muscle/bone.
• TBSA Estimation (Total Body Surface Area):
  • 📌 Rule of Nines (Adults): Head/Neck 9%, Arm 9% (x2), Ant. Trunk 18%, Post. Trunk 18%, Leg 18% (x2), Perineum 1%.
  • Lund-Browder Chart: Most accurate, esp. children (age-adjusted).
  • Rule of Palms: Patient's palm + fingers ≈ 1% TBSA (small/patchy burns).

⭐ For children, head is larger TBSA% (infant ~18%), legs smaller; Lund-Browder chart crucial for accuracy.

Burn Pathophysiology - Systemic Havoc

• Burn injury → Massive inflammatory mediator release (cytokines, PGs).
• Key Events:
  • ↑ Capillary permeability → Intravascular fluid loss → Edema & hypovolemic shock ("Burn Shock").
  • Systemic Inflammatory Response Syndrome (SIRS) triggered.
• Consequences:
  • CV: ↓CO (early), then hyperdynamic; myocardial depression.
  • Resp: Airway edema, ARDS, inhalation injury risk.
  • Metabolic: Hypermetabolism (↑REE 2x), catabolism, insulin resistance.
  • Immune: Immunosuppression → Sepsis risk.
  • Renal: AKI (hypoperfusion, rhabdomyolysis).
  • GI: Ileus, Curling's ulcers.

⭐ Curling's ulcer, an acute peptic stress ulcer, is a known GI complication in severe burns, due to reduced plasma volume leading to ischemia and mucosal damage in the stomach or duodenum.

Initial Burn Care - Dousing the Flames

• Stop the Burning Process: Remove clothing, cool with tepid water (not ice) for ≤ 10 mins.
• ABCDE Approach:
  • Airway: Assess for inhalational injury (soot, hoarseness, stridor). Intubate early if suspected.
    • Indications for intubation: facial burns, stridor, respiratory distress, ↓ GCS, circumferential neck burns.
  • Breathing: Administer 100% humidified oxygen. Assess for escharotomy needs (circumferential chest burns).
  • Circulation: Secure IV access (preferably 2 large-bore cannulas through unburnt skin). Commence fluid resuscitation.
    • Parkland Formula: $4 \text{ mL} \times \text{TBSA } (%) \times \text{Body Wt (kg)}$. Give 50% in first 8 hrs (from time of burn), rest over next 16 hrs.
  • Disability: Assess GCS, pupils.
  • Exposure/Environment: Remove constricting items. Keep patient warm to prevent hypothermia (target core temp >35°C).
• Initial Wound Care: Cover with clean, dry sheets or sterile dressings. Avoid topical antibiotics initially.
• Analgesia: IV opioids.

⭐ In children, maintenance fluids must be added to resuscitation fluids. Urine output target: 0.5-1 mL/kg/hr in adults, 1-1.5 mL/kg/hr in children <30kg.

Burn Anesthesia - OR Hot Seat

• Pre-op:
  • Assess %TBSA, airway (inhalation injury: soot, stridor), fluid status.
  • Anticipate difficult airway; early intubation if inhalation injury.
• Airway:
  • Challenging: edema, contractures.
  • Options: Fiberoptic, video laryngoscopy, smaller ETT.
  • ⚠️ Secure ETT firmly.
• Anesthetics:
  • Ketamine: excellent (analgesia, stable hemodynamics).
  • Avoid Succinylcholine >24h post-burn (↑K+ risk).
  • Volatiles: cautious. Opioids: ↑ dose.
  • NDMRs: resistance common.
• Intra-op:
  • Fluid: Parkland ($4 \text{ mL} \times \text{kg} \times % \text{TBSA}$). UO: >0.5-1 mL/kg/hr.
  • Temp: Maintain normothermia (warm OR, fluid/air warmers).
  • Pain: Multimodal (opioids, ketamine).
  • Monitor: Standard + invasive (A-line, CVP).
• Key Risks: Inhalation injury, sepsis, hypothermia, ↑K+ (Sux).

⭐ Succinylcholine is contraindicated 24 hours to 2 years post-burn due to risk of life-threatening hyperkalemia.

High-Yield Points - ⚡ Biggest Takeaways

• Airway management is paramount, especially with inhalational injury; early intubation often vital.
• Parkland formula (4ml x %TBSA x kg) guides fluid resuscitation; 50% in first 8h.
• Succinylcholine contraindicated >24h post-burn (risk of hyperkalemia).
• Aggressively maintain normothermia to prevent severe hypothermia.
• Multimodal analgesia is key for severe burn pain.
• Increased metabolic rate and protein catabolism demand nutritional support.
• Rule of Nines for rapid TBSA estimation.