BURNS

EMMANUEL G. DIAZ, MD, MHA, FPCS, FACS

WHY IS THIS TOPIC IMPORTANT? • Direct contact of the skin to the heat
✓ This has caused many injuries, loss of life & property source
✓ Rough estimate of 1.5-2M per annum in the Philippines; CONTACT • Depth and severity of injury is also
half of that in more advanced countries like USA determined by amount or duration of
✓ Bi-modal incidence: younger age group (<10 y/o) & exposure to the heat source
senior age group (60 y/o & above) • Common in factory workers and
✓ Majority of injuries happen at home, residences, production plants of paints, acids,
condominiums, buildings & factories chemicals, etc.
✓ 60-70% mortality in some situations • Less common but can potentially be
✓ FunFact: Because of the numerous fire incidences at the CHEMICAL severe burns
country during this time of the month, March has been • Can either be:
declared the “Fire Prevention Month” ✓ Alkali burns: more severe and can
WHAT IS A BURN? penetrate up to the bones
❖ A burn is an injury to the integumentary system as a ✓ Acid burns: less severe
result of exposure to extreme temperature (hot or • May be coming from:
cold), chemicals, radiation or electric current ✓ Low voltage source
o Hot: more commonly seen in our country ✓ High voltage source
o Cold: “frostbites”; more common in countries with ✓ Lightning
winter season • Can cause much more subdermal
❖ NOTE: Burn patients should be first considered trauma damage
patients, especially when details of the injury are • Potential for cardiac arrhythmias and
unclear. compartment syndromes with
concurrent rhabdomyolysis
ETIOLOGY OF BURNS • Important to consider: Electrical burns
ELECTRICAL
should call our attention because it
• Most common household injury that
belies the amount of extent of injury
occurs locally
based on what you see. It may be an
• If >15% TBSA burn, it becomes a
“innocent looking” point of entry, but
systemic problem  needs to be
you may end up having a dead patient
SCALD treated properly & accordingly
because of the associated cardiac
• More common especially in young arrhythmias, renal failure and massive
children tissue injury! Therefore, do not
• E.g. boiling water poured into a body underestimate the severity of an
part electrical burn.
• Those who were caught in a burning • Not common but may be devastating,
house, office, condominium and even RADIATION as experienced by people in Japan and
in factories Chernobyl
• Depth and severity of injury is
determined by the amount or duration CLASSIFICATION OF BURNS
of exposure to the heat source
FLAME
• Most common cause for hospital BASED ON SEVERITY
admission MINOR BURNS < 15% TBSA
• Highest mortality rate primarily MODERATE 15-25% TBSA (Adults)
related to their association with BURNS 10-20% TBSA (Pedia)
structural fires and the accompanying deep burns > 10% TBSA or involving face,
MAJOR BURNS
inhalation injury and/or CO poisoning hand, feet, perineum, joints *

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 BASED ON DEPTH
Epidermal 1st degree burn
SHALLOW
Superficial Partial
BURNS 2nd degree burn
Thickness
Deep Partial
2nd degree burn
Thickness
DEEP BURNS
Full Thickness 3rd degree burn
4th degree burn

Minor burns are rarely admitted to the hospital. It is

only the moderate and major burns that are commonly
admitted.
* Take note of the critical areas: face, hand, feet, 1ST DEGREE BURNS (SUPERFICIAL)
perineum, joints. If these are not managed adequately, it
would develop permanent deformities. Even if it’s not an This is a sunburn. Notice
extensive burn, if it involves these critical body parts, they that there is involvement
need IN-HOSPITAL treatment. of the superficial layer of
the skin of the upper back,
TRADITIONAL CLINICAL showing marked erythema
NOMENCLATURE DEPTH immediately after sun
NOMENCLATURE FINDINGS
✓ Erythema exposure, as demarcated
✓ minor pain by the patient’s clothing.
✓ lack of
blisters 2ND DEGREE BURNS (PARTIAL)
SUPERFICIAL st Epidermal (initially
1 degree involvement This shows blisters with
THICKNESS painful but
fades with clear fluid and intact skin.
spontaneou The dermis is already
s healing in involved.
3-4 days)
✓ Blisters
✓ clear fluid
PARTIAL Superficial ✓ pain
THICKNESS 2nd degree (papillary) (Notorious
(Superficial) dermis burns because 3RD DEGREE BURNS (FULL)
they are very
painful!) This burn is a little bit
✓ Whiter extensive since there is
appearance already admixed with the
✓ with blister fluid. Notice the
PARTIAL Deep decreased involvement of the entire
THICKNESS 2nd degree (reticular) pain layer of the skin
(Deep) dermis ✓ difficult to
distinguish
from full
thickness
✓ Hard
✓ leather-like
4TH DEGREE BURNS
Dermis, eschar
Blackish in color, showing all
underlying ✓ purple fluid
the digits and palmar surface
tissue and ✓ no
FULL 3rd or 4th with exposure of tendons. It gets
possibly sensation
THICKNESS degree fascia, (insensate)
so burned to the bone that
sometimes the only remedy is
bone, or ✓ obliterated
amputation.
muscle pain
receptors
already)

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 FOUR FACTORS THAT DETERMINE BURN DEPTH o There is a separate parameter for pediatrics
(children < 2 years old) due to differences in body
❖ Temperature of the source
surface area
o The hotter the source, the deeper the depth!
o A crude but quick and effective method of estimating
❖ Duration of contact
burn size
o The longer the duration (e.g. unconscious patients),
o Each body part is divided into factors of nine.
the deeper the depth!
❖ Thickness of the skin
o Depends on the area of the body that was burned
(e.g. face [thin] versus palms [thick])
❖ Heat dissipating capability of the skin

INDICATIONS OF IN-HOSPITAL BURN WOUND CARE

❖ Partial/Full thickness burns >15%
o if >15% TBSA burn systemic response
needs monitoring and subsequent care
o Commonly included here are: scalds, flames, and
contact
❖ Burns in critical areas
o These involves area will result into a considerable
amount of deformity and disability  needs proper
monitoring and treatment to prevent complications
❖ Electrical burns
o Especially high-voltage electricity
o “What you see is what you do not get” particularly
cardiac and renal complications  needs admission
and proper monitoring
❖ Chemical burns
❖ Inhalation injury ADULT (%) PEDIA (%)
❖ Co-existing morbidities HEAD 9 20
o Examples are head injury, fractures, hypertension, ANTERIOR TRUNK 18 13
POSTERIOR TRUNK 18 13
diabetes mellitus, heart conditions, cancer, etc
UPPER EXTREMITIES 18 13
o These patients sometimes get admitted not because
LOWER EXTREMITIES 36 30
of the burn per se but because of alterations brought
PERINEUM 1 1
about by pre-existing medical conditions
NB: Palmar Surface with digits approx. 1% TBSA.
Remember that not all types of burns are admitted to the
NOTE 1: Comparing adult versus pediatric, focus on
hospital. The ones listed above are the criteria for admission
the % of HEAD. The % TBSA is more than twice
to specialized case in the hospital.
For MINOR and SUPERFICIAL BURNS, you just give them in pediatrics!
FIRST AID then send them home. NOTE 2: Superficial or first-degree burns should not be
included when calculating the percent of
TBSA, and thorough cleaning of soot and
ASSESSMENT OF SIZE OF BURN
debris is mandatory to avoid confusing areas
❖ Clinical observation of Total Body Surface Area (TBSA)
of soiling with burns.
burned
NOTE 3: If the burns are scattered all over different
o Visual observation of the patient by simply removing
parts of the body (e.g. in the face, trunk,
his/her clothing, and then try to assess the extent of
upper limbs and back), we use the PALMAR
the burn in the body part
METHOD such that the size of the patient’s
❖ Rule of Nines (for adults)
palm [not the surgeon’s palm size],
o More commonly used in adults (gold standard)
corresponds to 1% of TBSA burn). Used for
example when there is a burn localized to the
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 example when there is a burn localized to the JACKSON’S ZONES OF BURN INJURY
RUQ of the abdomen. If the burn is the size of
the patient’s palm, count the burned area as
1% TBSA.
NOTE 4: This can be used to approximate the amount
of fluids that will be infused.

❖ Lund & Browder chart (for children)

o More commonly used in children / pediatric cases
This is used because there is a discrepancy between
the body size of a pediatric patient when compared
to the average size of an adult

PATHO-PHYSIOLOGIC RESPONSE TO BURNS

❖ Thermal energy causes coagulation necrosis and loss of
capillary integrity leading to loss of plasma volume from
the intravascular space into the injured tissue
❖ Progressive hypovolemia, burn shock and death
❖ Systemic Inflammatory Response Syndrome (SIRS)
By knowing these zones, we will be able to institute corrected
The stress response is practically the same in burns measures so that patients with hyperemia will not progress to
and patients with major traumas. It follows the same coagulation. This means that a patient with a 10% burn will not
sequence: the interplay of metabolic, endocrine, end up with a 20% burn because it was not treated adequately.
neurologic factors, release of enzymes, and
catecholamines that leads to hypovolemia  ZONE OF COAGULATION
hypotension  septic shock  death if not treated ❖ Area with most injury or the zone of massive damage
immediately. ❖ Irreversible
❖ Candidates for debridement and skin grafting
From Past trans:

ZONE OF STASIS
❖ Just peripheral to the zone of coagulation
❖ There is thrombosis, continuous inflammation 
hypoxia in the tissues
❖ If left untreated, it can progress to coagulation
❖ making the non-viable area bigger

ZONE OF HYPEREMIA
❖ Least injured area
❖ Reddish or erythematous
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❖ Subtle hypoxic changes that are reversible o Exception: 1st degree patients don’t need to have
fluid resuscitation because they will heal
spontaneously without needing hospital treatment.
o DO NOT USE GLUCOSE-CONTAINING
RESUSCITATIVE SOLUTIONS because many of the
TREATMENT OF BURN INJURY burn patients have stress-induced hyperglycemia.
o Hence, we give PLAIN LACTATED RINGER’S
AT BURN SITE…
SOLUTION.
❖ Extinguish burning source ❖ Tetanus prophylaxis
o In treating burns, STOP THE BURNING FIRST. o A MUST!
• For chemical burns, use clean water o Covers active and passive immunization
• For flame burns, secondary to chemicals, cover o Tetanus Ig and Toxoid
the patient first with anything that is available ❖ O2 supplementation
i.e. a pillow, a blanket, banana leaves, or a o In your clerkship rotation, this is the first thing you
newspaper. can do.
❖ ABC’s of trauma o Hypoxic states (e.g. smoke inhalational injury
o Airway  make sure it’s patent secondary to CO toxicity)
o Breathing  should be spontaneous o Very important in wound healing
o Circulation  if burn wound is profusely bleeding, o NOTE: Did you know that smoke inhalation is the
stop it so circulation will not be interfered. leading cause of death due to fires?
❖ Transfer to hospital
o There must be some way to transport the patient to
institute an in-hospital care
❖ Tap water application
o If there is a clean water beside you, you can
neutralize it and use it. ❖ Gastric decompression / PPI
o Imperative for major burn patients because they are
IN-HOSPITAL CARE…
predisposed to ileus  distention of the stomach 
❖ ABC of trauma additional pain for the patient
o In certain situations, some patients have o There is hypersecretion of gastric acid, therefore,
manifestations of respiratory compromise NGT should be in place to:
o If upon history taking, a patient was trapped in a ✓ relieve the gas that is distending the stomach
closed space, and there are signs of potential ✓ evacuate food particles that can predispose the
inhalational injury (as evidenced by carbon deposits patient to aspiration pneumonia
on the face, burned nasal air, carbon particles in the o Also, place the patient in NPO (nil per os) or “nothing
mouth, edema of the face & lips, etc.), this would call through the mouth”
for an emergency endotracheal intubation. o The acidity is usually taken care of by proton pump
Consequently, this patient would be needing inhibitors (PPI) such as ranitidine, omeprazole,
respiratory support (ambu-bag or assisted esomeprazole, and lansoprazole.
ventilatory support/mechanical ventilator) ❖ Pain control
o The use IV analgesics is very critical such as in the
cases of 2nd degree burns and burns which have >
15% TBSA which are usually painful
o Never use OPIOIDS! (e.g. morphine, demerol)
➢ they can cause respiratory depression
(Remember burn patients are already in a state
❖ Fluid resuscitation of respiratory distress!)
o A must because there is an excessive fluid loss and ❖ Burn wound care
patients are in the brink of hypovolemia o Involves early wound cleaning and debridement
o Must have patent IV lines o Clean the wound before 24 hours

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 o The issue about releasing and unroofing blisters has patient’s arrival to the ER! In this case, there is no
always been in question need to regulate IV fluid, meaning, you don’t need to
o Rule of thumb: If the blister is intact, do not unroof start counting the time as soon as patient arrives; run
or puncture it because there is still that protective a fast drip instead and monitor accordingly if patient
function of the skin. is responding through the different hydration
o However, if the need arises because the massive parameters.
blisters need to be cleaned, it must be done in a
sterile setting (referring to the operating room) When you say “FAST DRIP”, it is the diameter of the
❖ Nutritional support venous set (the appliance you connect to the IV fluid
o As early as 48 hours bottle for it to go to the patient’s body). It is as if you
o Has now taken the central role in patients with are pouring water to the patient’s system. No need to
major trauma and burns which is characterized by a count the number of drops anymore.
hypercatabolic state
o If the patient is placed on NPO for a long time
because of associated ileus, many of them go to
starvation level  wound healing becomes affected
❖ Reconstructive surgery
o Comes after acute treatment is given
o Goal is to restore function and aesthetic appearance
❖ Psychiatry
o For patients with major burns
❖ Rehabilitation SAMPLE CASES
o Immediate and ongoing physical and occupational
CASE 1
therapy is mandatory to prevent loss of physical
❖ Patient is brought to the emergency room. The incident
function
happened the night before admission because the patient
o Given at the period of healing to prevent
lives in a faraway farmland. Hence, it took the patient
complications
more than 24 hours to reach the ER. Given that the
computed fluid is 6L, how will you be infusing it?
FLUID RESUSCITATION IN BURNS
❖ Answer: In the clinics, many of the patients do not come
immediately to the ER. Many of the patients come a day
Parkland’s Formula (MEMORIZE):
after. During the 1st 8 hours, the assumption is that the
Volume in 24 hrs = 4 ml x body wt (kg) x % TBSA injury happened a short interval from the time of the
To calculate for % TBSA = Refer to Rule of Nines
Once you have computed for the total volume of fluid needed,
incident until the patient was brought to the facility. If it
infuse Plain Lactated Ringer’s Solution, the IV fluid of choice. happened 24 hours ago, you need to hurry up because
your patient is in the brink of hypovolemic shock. The best
Plain Lactated Ringer’s Solution (non-glucose containing): to use is the double IV line. Use a large bore intravenous
½ of computed fluid = give for the 1st 8 hours catheter (sizes ranging from 16-18) because you need to
½ of computed fluid = next 16 hours hurry up in infusing the fluid because in the next several
urine output monitoring = 30 ml/hr (adults) hours, the kidneys are ready to shut down due to
= 1 ml/hr (children) hypovolemia.

NOTE 1: Plain lactated Ringer’s Solution is isotonic and is CASE 2

needed by a hypovolemic burn patient. ❖ Patients were in a factory and the hospital was just outside
NOTE 2: Point of reference is the time of the injury. The rule the factory that was burning. Patients came in to the ER
above is only applicable for patients who were taken with 40%-70% burns. The medical team had to infuse
to the ER immediately after the burn injury. For fluids right then and there. Others made it but some
example, a patient comes to the ER eight (8) hours survived because of the extent of the injury.
post burn already  2-3 functional IV lines may be ❖ The good thing about this is that the hospital is just near
used  you have to run FAST DRIP using pulmonary
the factory. This made immediate treatment possible.
capillary wedge to catch up with the DELAY of

Page 6 of 11
From past trans: ❖ You need to have those monitoring parameters
❖ You need to have a good medical history and physical
examination as well. Use your clinical eye. Without the
patients verbalizing it, you will realize just by
observation.
o E.g. A patient has kidney disease and has
❖ Most practical and simplest is by an inserting an undergone a kidney transplant presenting with the
indwelling foley catheter, then take note of the urine classic moon facies classic with sparse hair,
output multiple pimples, etc.  you should already
suspect chronic kidney disease for this patient
❖ Another parameter is the central venous pressure
❖ If you can’t get a detailed clinical history, you have to
(corresponds to right atrial pressure), which is inserted
play it by ear, slowly and carefully, to prevent additional
in the peripheral veins or neck veins danger to the patient.
❖ Reading of pulmonary wedge pressure is also reflective
of hydration status
o Measured by wedging a pulmonary catheter with INHALATIONAL INJURY
an inflated balloon into a small pulmonary arterial ❖ It is only through good clinical history & thorough PE that
branch. you can suspect, if not diagnose outright concomitant
o It is also the most accurate way of determining inhalational injury
hydration because it measures the left side of the ❖ Can come into 2 forms:
heart (measures the cardiac output, giving an idea 1. Burn of the upper respiratory tract down to the
of what the total volume of the patient is). bronchus
2. Carbon Monoxide poisoning
o If patient was found in an enclosed burning
room, it takes only 3 minutes to increase
carboxyhemoglobin levels to 30%
o At 30% = beginning neurologic dysfunction (E.g.
disorientation, dizziness)
❖ A 70kg male burn patient should have at least 30-35ml
o At 40% = loss of consciousness
urine output per hour
o At 60% or more = death
❖ Take note, there is a higher urine output expected in
o Treatment: Giving 100% OXYGEN (*Gold
children (about 1ml/kg/hour).
standard)
❖ If no urine comes out, it means more fluid should be
❖ SIGNS OF INHALATIONAL INJURY:
infused. This should be done with care because the
✓ Acrid smell of smoke in clothes
already injured lung can be flooded with fluid, leading
✓ History of burning in a closed room
to overhydration, and consequently, pulmonary
✓ Singed nasal hair
edema.
✓ Carbonaceous sputum
✓ Hoarseness
✓ Stridor
❖ NB: Bronchoscopic examination within 24 hours
o Used in patients who are in an enclosed building or
house
o Maybe utilized to view the extent of the burn injury
of the nasal and parenchymal mucosa
o Can also be used to evacuate foreign bodies that
may have been lodged in the respiratory airway such
as food particles, or thick sputum with carbon
deposits
❖ This patient will then need a cardiologist, a
nephrologist, or diabetologist, and so forth, but the
captain of the ship is still of course, the Surgeon.

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 ❖ Biologic (dermal) substitutes
o For covering of debrided wounds, or burns
secondary to unroofed blisters in order to prevent
weeping and fluid losses

SURGICAL WOUND CARE FOR BURNS

❖ Split thickness skin grafting
o used to resurface large wounds, line cavities,
resurface mucosal deficits, close flap donor sites,
and resurface muscle flaps
o they are more fragile
❖ Full thickness autograft (FTAG)
o have a better color match to the recipient site due to
their thicker nature and inclusion of additional
dermal structures.
o They tend to contract to a much lesser degree than
STSGs, providing optimized cosmetic and functional
results
❖ Cultured Epidermal Autograft (CEA)
o Less probability of rejection
❖ Escharotomy
BURN WOUND CARE o making an incision along the longitudinal axis of the
❖ Initial cleaning with soap & water extremity that is circumferentially burnt because the
o NSS and ordinary soap are used in the ER’s eschar has compressive effect
❖ Wound dressing daily with topical cream application o purpose is to prevent compartment syndrome
o wounds are cleaned and covered or dressed to (happens if burn wound is not opened up) and allow
lessen pain, prevent extravasation of fluid, decrease flow of blood to the peripherally extremities
evaporative water loss and protect the wound from ❖ Escharectomy
further contamination that can lead to infection o removal of the eschar (leathery, hard, blackish,
o RULE OF THUMB: Cover the wound in the first 48 remnant of the burn tissue) that tends to constrict a
hours especially if the patient presents to you with particular extremity that can lead to compartment
unruptured blisters. Unruptured blisters are fluid syndrome
collection under the burned but intact skin. You need o If eschar is not removed, infection will be harbored
to open these blisters up immediately. But after 48 under the dead skin.
hours, these blisters need to be removed  do ❖ Fasciotomy
debridement  cover with dressing o Deeper than escharotomy
o We usually do open dressing: we clean the wound o Done to release the increasing pressure in the
 cover with topical antimicrobial  put light neuromuscular bundle of a particular extremity
dressing (a single strip of sterile gauze or silver o a procedure that excises open the fascia of the
impregnated wound dressings) on top particular muscle bundle, thereby allowing blood
o NO NEED TO DO COMPRESSION! flow to a particular body part
❖ Excision & skin grafting
o In patients with massive deep facial burns BURN WOUND INFECTIONS
o As early as 48 hours, we do excision of the deep ❖ Gram negative bacteria
burns in the face and cover it with full thickness or o Specimen collection using cotton swab
split thickness skin graft. o Identify specific bacteria  S. aureus (more
❖ Sequential wound debridement common), P. aeruginosa (more concern about this),
o Done depending on the extent of the burn S. pyogenes (these three are normal bacterial skin
o every 2-3 days of wound debridement (for massive flora)  burn-wound sepsis
wounds) that needs regular monitor cleaning and ❖ Wound culture and sensitivity test
monitoring
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 o Good in the initial stages for one to be able to they are less irritating. Those with (*) are the most
determine the specific antibiotic that will fit the commonly discussed. The rest are now taking the central
control for the infection that the patient is having role because they are less toxic, easy to apply and readily
o Specimens can come from the throat, burned skin, available.
blood, or urine.
MEMORIZE!
❖ Clinical manifestations:
o Fever
o Thrombocytopenia
o Hypotension
o Oliguria
o Sensorial changes

TOPICAL ANTIMICROBIALS IN BURN INJURY

❖ Silver sulfadiazine cream *
o Most commonly used and preferred in clinical
practice
o Distinct advantage of soothing effect
o Inexpensive, easily applied, pain markedly lessened
o Reputation for causing NEUTROPENIA!
❖ Mafenide Acetate cream *
o For eschar penetration
❖ Silver nitrate solution *
o Rarely used nor because of the complications that
comes with it
❖ Gentamicin cream
o used for facial burns
❖ Povidone-Iodine solution/ointment
o Readily available as solution or ointment BURN INJURY COMPLICATIONS
o may be used as first aid for minor cuts, grazes, burns,
abrasions and blisters BURN WOUND SEPSIS
❖ Mupirocin cream ❖ Most commonly encountered complication due to
o indicated for Methicillin Resistant S. Aureus (MRSA) bronchopneumonia, thrombophlebitis, pyelonephritis and
❖ Bacitracin cream invasive wound infection
o used for facial burns
PNEUMONIA
o for burns that are nearly healed, small or large
❖ Sodium hypochlorite solution ❖ Common to those with inhalational injuries (“post injury
o Chlorine bleach solution mixed with NSS pneumonia”) and those who have not received early
o studies locally and in our institution has proven its rehabilitation
efficacy, to be equally potent as other antimicrobials ❖ Severely burned patients who require mechanical
in controlling infection of a burn wound ventilation (even without inhalation injury) show high
❖ Silver impregnated dressing pneumonia rates because of serious immunodepression
o “Acticoat” has an antimicrobial protective barrier; after the burn trauma
can last for 3-5 days; costly (not manufactured here
THROMBOPHLEBITIS
in the Philippines)
o These help reduce the number of dressing changes ❖ Due to several factors including high skin inoculum of
and may be more comfortable for the patient, but organisms, hyperalimentation, use of broad spectrum
should not be used in wounds of heterogeneous antibiotics, and impairment of local defense due to loss of
depth, as they prevent serial examinations of the skin integrity
wound ❖ Commonly encountered due to giving IV fluids directly at
NOTE: Bacitracin, Polymyxin & Gentamicin = are antimicrobials the burned body site
that work best on sensitive tissues such as facial burns;
Page 9 of 11
CURLING’S ULCER ❖ Intensive metabolic and nutritional supplementation
o Due to hypercatabolic state of burn patients
❖ An acute peptic ulcer of the duodenum
❖ Prompt wound care & debridement of necrotic tissues
❖ A common complication if burn patients are not fed early
o To prevent complications of the burn injury
(parenteral feeding if the patient cannot swallow)
❖ May develop as a result of ischemia and necrosis of the PRETEST ANSWERS
gastric mucosa due to reduced plasma volume in burn
patients PRETEST #1
❖ Proton Pump Inhibitors (PPIs) and antacids can help AB, 24 y.o., male, mechanic was involved in a boiling truck
radiator explosion. VS: BP = 140/90, RR = 20, PR = 100, T = 37.5ºC,
COMPARTMENT SYNDROME BWT = 55 kg
❖ Can develop if you do not perform timely escharectomy, PE revealed erythematous face with blisters and dirty
blistered areas over the anterior trunk and both anterior aspect
escharotomy and fasciotomy
of the upper extremities.
❖ A life-threatening condition of the limbs which occurs
after an injury, when there is COMPRESSION OF THE ANSWER: Rule of Nines (TBSA) = 4.5 + 18 + 4.5 + 4.5 = 31.5%
NEUROMUSCULAR BUNDLES in the extremities and Using Parkland’s Formula = 4 ml x 55kg x 31.5
trunk. There is insufficient blood supply to the muscles & Total Fluid Requirement s in 1st 24 hrs = 6,930 ml
nerves due to increased pressure within one of the body's IVF needed in the First 8 hrs = 3,465 ml
Succeeding 16 hrs = 3,465 ml
compartments such as an arm, leg or other enclosed
space within the body What would you do if your patient does not know his/her
❖ According to the book, in an “abdominal compartment body weight or the patient is unconscious?
syndrome”, there is increased airway pressures with ❖ The ideal way is to know the IDEAL BODY WEIGHT for
hypoventilation and decreased urine output and a particular person which you have to compute.
hemodynamic compromise ❖ Another way is comparing your body weight to the
patient’s body weight.
HYPERTROPHIC SCAR/KELOID FORMATION ❖ Sometimes, stretchers have weighing scale.
❖ In major burns with deep involvement, YOU NEED TO DO
COMPRESSION in the healing phase so that the scar will PRETEST #2
not be prominent.
❖ Hypertrophic scars and keloids can develop if you don’t BA, 31 y.o., female, escaped from burning furniture factory.
apply compression stockings and dressings on prominent VS: BP 130/90, RR = 22, BWT = 48 kg, PR = 105, T = 37.8ºC
burns on major joints. PE revealed blisters on her face with black hard leathery skin
over her entire back, both upper extremities and lower legs and
MARJOLIN’S ULCER feet.
❖ An aggressive ulcerating squamous cell carcinoma ANSWER: Rule of Nines (TBSA) = 4.5 + 18 + 9 + 9 + 9 + 9 = 58.5%
presenting in an area of previously traumatized, Using Parkland’s Formula = 4 ml x 48kg x 58.5
chronically inflamed or scarred skin secondary to deep Total Fluid Requirement s in 1st 24 hrs = 11,232 ml
burns. IVF needed in the First 8 hrs = 5,616 ml
Succeeding 16 hrs = 5,616 ml
CONTRACTURES
❖ Usually seen in flexor surfaces, neck, axilla, antecubital ❖ The common mistake you encounter is in the assessment.
Note that you do not convert percentages to whole
area, knee, ankles, and digits
numbers.
❖ Debilitating and deforming
❖ Rule of 9’s is an estimate – can be a little a higher or little
❖ A permanent shortening of a muscle or a joint lower.
❖ In the clinics, when you get to estimate, it is better to
FACTORS THAT DETERMINE TREATMENT SUCCESS OF
underhydrate (give less fluids) than to overhydrate a
SEVERE BURN INJURIES patient with infused fluids. This is because given a patient
❖ Vigorous fluid resuscitation with major burns, there would be more fluid than what is
o Must be timely and adequate required and you overhydrate the px, overhydration will
❖ Adequate pulmonary ventilation cause the lungs to be flooded which eventually renders it
o Especially if patient has > 50% burns dysfunctional or non-functional  complications set in.

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This was not discussed in the lecture but came out in the past-E. patient’s own body; most commonly used sites are:
COMPARING BIOLOGICAL DRESSINGS anterior/lateral/posterior side of the thigh/butt skin
TYPE DESCRIPTION AND USES harvest and graft it to the burnt area.
• Obtained at autopsy up to 24
hours after death END OF TRANSCRIPTION
• Applied in the operating room
or at the bedside to debrided,
untidy wounds
• Available as fresh NAGMAHAL.
Cadaver
cryopreserved homografts in
tissue banks nationwide
NASAKTAN.
(organic, homograft)
• Provides protection, UMIYAK.
especially to granulation
tissue after escharotomy BUMANGON.
• May be used in some patients
as a test graft for autografting NAGING M.D.
• Covers excised wounds
immediately Transcription Team 2019
• Applied in the operating room Transcribed by: Phoebe Grande
or at the bedside References: 2017 ppt, 2016 trans,
• Comes fresh or frozen in rolls Recording
Pigskin or sheets Remarks: BLUE texts from the
(organic, heterograft • Can cover and protect past trans. RED texts
or xenograft) debrided, untidy wounds, are MUST KNOWS.
mesh autografts, clean BLACK texts are from
(eschar-free) partial thickness the ppt & recordings.
burns, and exposed tendons
• Available from the obstetric
department
• Must be sterile and come
from an uncomplicated birth;
serologic tests must be done
• Bacteriostatic condition
Amniotic membrane
doesn’t require antimicrobials
(organic, homograft)
• May be used to protect partial
thickness burns or
(temporarily) granulation
tissue before autografting
• Applied by the physician to
clean wounds only
• Comes in sterile, pre-
packaged sheets in various
sizes and in glove form for
hand burns
Biobrane • Used to cover donor graft
(biosynthetic sites, superficial partial
membrane) thickness burns, debrided
wounds awaiting autograft,
and meshed autografts
• Provides significant pain relief
• Applied by the nurse
NOTE: The most common is Autograft  use of a microtome,
or dermatome in order to harvest normal skin from the

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