Basic knowledge on burn care for students, teaching material.

1. Acute Burn Care
高雄醫學大學附設中和紀念醫院
重建及整形外科
李孝貞 醫師
2019.02.15

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關於燒燙傷…
• Mechanism of Thermal Injury
• Evaluation of the burn wound
• 燒燙傷的治療與照顧

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Type of Burn Injury
• Flash & Flame burns （燒傷及閃電擊傷） :
Explosion （氣爆）, most common
• Scald burns （燙傷）
• Contact burns （接觸性燙傷）
• Chemical burns （化學灼傷）
• Electrical burns （電擊傷）
• Radiation injury（輻射傷害）
• Cold Injury （凍傷）

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Flash and Flame burns
• Responsible for more than half of burn injuries
• Etiology
– House fires
– Outdoor fires with use of accelerants
• propane, gasoline, and kerosene
• Flash burn
– Typically superficial to partial dermal burns with preservation of
skin covered by clothing
• Flame burn
– Typically deep dermal or full thickness burns
• Inhalation injury likely with gasoline fire and/or house fire

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Inhalation Injury
• Facial burn, burned hair of nose, bullae in
oropharyngeal area
• Examination：
– Chest X-ray
– Bronchoscope
– Arterial blood gas
• Treatment：
– Endotracheal tube or Tracheosotmy
– COHb > 25 % → give HBO (O2 : 0.3 →6.0 ml/dL)
– half-life of COHb: (UpToDate 2014)
Room air: 300 mins
High-flow O2 with Nonrebreathing mask: 90 mins
Hyperbaric oxygen (HBO): 30 mins

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July, 2014

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健保給付標準
資料來源∕健保局全球資訊網（http：//www.nhi.gov.tw）

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Scalds
• Second most common burn injury-related admission
• Depth of scald injury depends on
– Water temperature (>110ºF or 44ºC)
– Duration of contact
• consistency of liquid (i.e. soup vs coffee vs grease)
– Skin thickness
• based on age and anatomical location
• Clothed areas may have deeper burns due to retention of
heat and longer contact with skin
– e.g. diapers or socks
• Other sources of scald burns
– Grease/oil
• typically deep dermal or full thickness burns

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Contact burns
• Typically small areas due to hot metal, plastic, glass or
coals
• Burn depth related to
– Temperature of material
– Duration of contact
– Patient-related disabilities (e.g. neuropathy)
• Commonly responsible for pediatric palm burns
• Grafting of palm can lead to life-long disability and timing
of surgery is controversial
– Early grafting restores function quickly but destroys unique
palmar nerve endings and palmar fasciocutaneous ligaments

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Chemical burns (I)
• Acids cause tanning with impermeable barrier limiting
deep penetration
– e.g. cleaning solvents
– Hydrofluoric acid burns unique in need for calcium treatment
• Topical
• Intravenous – for life-threatening hypocalcemia
• Intra-arterial – for comfort and hypocalcemia
• Alkalis combine with lipids (saponification) and dissolve
tissue
– e.g. cement or drain openers

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Chemical burns (II)
• Etiologies
– Work-related
– Assault
– Improper use of household products and harsh solvents
• Progressive damage diluted with copious H20 irrigation
– 15–20 minutes
– pH test of skin until neutral
– Attempts to neutralize causes exothermic reaction and thermal
injury

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Electrical burns (I)
• Due to very high intensity localized heat as body becomes an
‘accidental’ resistor
• Resistance:
Nerve<vessels<muscle<skin<tendon<fat<bone
• Associated injuries：
– Muscle necrosis → release myoglobulin → hematuria,
myoglobuminemia→ acute renal failure，keep urine output > 100ml/hr
– Myocardial：on EKG (arrhythmia), cardiac enzyme
– Electrolyte：Na+, K+, Ca++, Mg, ABG
– Others: fracture, nerve injury

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Electrical burns (II)
• High voltage injuries (>1000 volts)
– many work-related
– deep tissue necrosis
– arrhythmia (typically atrial fibrillation)
– cognitive deficits
– acute and delayed neuromuscular degeneration
• carpal tunnel injuries
• compartment syndromes
• early surgical intervention indicated for acidosis ± signs of
rhabdomyolysis or deterioration of neuro-sensorimotor exam
– cataract formation

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Electrical burns (III)
• Low voltage injuries (<440 volts)
– Typically small deep burns at contact points with rare
systemic injury,
– Classic pediatric injury involves oral commissure with risk
of delayed oral artery bleed

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Evaluation of the Burn Wound
• Pathophysiologic changes
• Assessment of burn depth
• Assessment of burn Area

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Pathophysiologic changes
• Jackson’s zones of Injury
– Zone of coagulation (center of wound)
– Zone of stasis (‘at risk’ for conversion)
– Zone of hyperemia (outer periphery)

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Assessment of burn depth
• First degree （一度）
– erythema （泛紅）, painful
• Second degree
– Superficial （淺二度）
blister formation, pink color, painful
– Deep （深二度）
white or fixed staining of red, blister
• Third degree （三度）
– leathery, waxy appearance, painless

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1st-degree burn
• Superficial burn
– Epidermis only
– Heals in 3–4 days
– e.g. sunburn

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2nd-degree burn
• Superficial dermal burn
– extends into the papillary dermis
– pink/moist wound, hypersensitive and blanching
– heals in 2–3 weeks
– e.g. scald burn or flash burn
• Deep dermal burn
– extends into reticular dermis
– pale/dry wound, decreased sensation, and sluggish capillary refill
– if not healed by 3 weeks grafting usually indicated
– e.g. grease burn, flash burn, prolonged scald exposure

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Superficial Second Degree Burn

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Deep Second Degree Burn

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≥ 3rd-degree burn
• Full thickness burn
– Extends through the skin to the subcutaneous area or deeper
– Black or charred, leathery, insensate
– Excise and graft early to reduce risk of infection and scarring
– e.g. flame burns, contact burns

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Third Degree Burn

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Adjuncts to clinical judgment
• Experienced burn surgeon 46–67% accurate in
determining which burns will heal on PBD 1
• Additional techniques proposed to identify non-healing
wounds:
– laser Doppler imaging
– thermography
– MRI
– biopsy
– ultrasound
– light reflectance
• No technique has proven superior to serial exams

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Assessment of Burn Area
• Rule of nine
• 1% TBSA (total body surface area):
by patient’s palm
• Children: check table

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Rule of nine
Rule of five

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燒燙傷的治療與照顧
• Pre-Hospital Management
• Emergency Care
• Monitor and Treatment in ICU

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Prehospital care
• Scald burn:
沖、脫、泡、蓋、送
• Chemical burn :
不可以『泡』
• Electrical burn :
移除電源，施救者需注意安全

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Emergency Care (I)
• As the rule of “ATLS”
• Primary evaluation : ABCDs
• Secondary evaluation : wound evaluation
• C-spine Fixation : blunt injury or high voltage electric burn
(> 1000 volts)
• Disability :
• Exposure & Exams : 除去衣物、裝飾品及眼鏡
• Wound care
– Normal Saline rinsed gauze
– Keep warm （hypothermia）

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Emergency Care (II)
• Fluid Supply :
Lactate Ringer & IV route
• Urine Monitor : on foley
• Decompression of stomach : on NG
• Temperature control （注意體溫）
• Pain control
• Lab Data：
CBC, electrolyte, BUN/Cr, clotting screen, COHb, ABG, Blood type

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Evaluation (I)
• History
– Causes
– Location (indoors vs. outdoors)
– Type of liquid involved
– Duration of extraction from fire
– Other medical problems: DM, HTN…

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Evaluation (II)
• Burn center criteria
– Adults with burn injuries > 15% to 20%
– Infants, children and elderly patients with less-extensive burn
injuries should also be monitored in an intensive care setting
– airway monitoring
– frequent neurovascular checks

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Burn Center Criteria

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Phases of Burn Care

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Fluid Resuscitation
• On 2 IV route (<30% TBSA)
• Adult :
– Parkland formula (4ml/kg/%TBSA)
– <15% TBSA – no resuscitation
• Child :
– Galveston formula :
5000ml/M2 burn + 2000 ml/ TBSA M2
– Modified hypertonic saline
• Colloid
– Add until 12~24 hours (due to capillary leak)
– albumin, FFP
– Maintain: serum albumin level: 2.0 g/dL

37. Fluid Resuscitation
Robert I Oliver, Jr: Burns, Resuscitation and Early Management, 2006
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38. 3.有關乳酸林格氏液（lactated Ringer's solution）組成成分，
下列何者正確？
A.鈉離子130 mEq/L
B.鉀離子3 mEq/L
C.鈣離子4 mEq/L
D.乳酸24 mEq/L
107年考題
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Choice of Fluids & Rate of Administration
• <40% TBSA + no pulmonary injury
→ isotonic crystalloid fluid
• >40% TBSA + pulmonary injury
– Hypertonic saline: first 8 hrs
– Lactated Ringer’s: shock resustation
• Pediatric & Elderly
– Hypertonic concentration of sodium: 180 mEq/L
• Massive burn, young pediatric or severe inhalation injury
patient
– Modified hypertonic saline: 1st 8 hours
Lactated Ringer’s + 50 mEq NaHCO3
– Lactated Ringer’s: 2nd 8 hours
– 5% albumin in LR: 3rd 8 hours

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Monitor
• Urine
– The best indicator in the first 24 hours (vs. CVP)
– Adult : 30~50 mL/h, 0.5~1 mL/kg/h (weight < 30 kg)
electric burn : 1~2 cc/kg/hr
– Child : 1-2 mL/kg/hr

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Fluid Replacement after Burn Shock
• 2nd 24 hours
– Modified Brooke formula: 0.3-0.5 cc/kg/TBSA of 5% albumin
– Parkland Formula: circulating plasma volume × 20%
• Maintain fluid (IV or enteral)
– Basal: 1500 cc/m2
– Evaporative water loss: (25 + %TBSA) ×m2 × 24
• Electrolyte
– K: 120 mEq/day in adults
– Na, Ca, Mg, P
• Monitor
– Urine: 1500-2000 cc/24 h in adult, 3-4 mL/kg/h in children

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Nutrition
• NG tube & ND tube (or NJ) insertion
• Nutrition
– ND or NJ feeding
- as early as 8 hours (by endoscope), within 48 hours
- begin rate: 20-40 ml/h
- continued during surgical procedure without increase risk of aspiration
– Adult : (Curreri’s formula)
25kcal/kg + 40kcal/kg/%TBSA
– TPN: associated with increased mortality
• Protein
– Alanine (ALA) & Glutamine (GLU)
• Vitamin C : IV 1g qd (high dose)
• PPI : prevention Curling’s ulcer (Nexum), 7-10 days, Early feeding

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Other management
• Antibiotics : （常見的死因是感染）
– wound infection appears until 5~7 days after injury
– most common: Staphylococcus
• Anti-histamine : wound itching
• Anti-anxiety and pain control
• 患肢抬高
• Blood transfusion : Hb level
(↓2-3 days post injury)

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Wound management (I)
• Face & Neck: open care
• Silver Sulfadiazine (SSD, U-burn)
– Bactericidal
– Painless
– Toxicity & side-effect are both low
– Side-effect: leukopenia （白血球低下）
– Contraindication: G6PD

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Wound management (II)
• Biological dressing
– Decrease pain, water loss change 24~72小時更換一次
• Escarotomy （焦痂切開）
– full-thickness circumferential burns of the extremity
– full-thickness burns of the chest wall when the
eschar compromises

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Wound management (II)
• Biological dressing
– 可減少疼痛、水分蒸發及當自體移植用
– 如豬皮, 約24~72小時更換一次
• Escarotomy （焦痂切開）
– full-thickness circumferential burns of the extremity
– full-thickness burns of the chest wall when the
eschar compromises（ 當引起呼吸困難時需做）
– 受傷1-2週後進行，以期早期植皮
• Skin Graft

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Biosynthetic Skin Substitue Dressing
• Mimic a function of skin by replacing the epidermis or
dermis, or both
• Allow for re-epithelization to occur while permitting a gas
and fluid exchange which in turn provides both protection
from bacterial influx and mechanical coverage (Demling
2000)
• Biobrane (Dow Hickam/Bertek Pharmaceuticals) and
Trans Cyte (Advanced Tissue Sciences) (Walmsley
2002)

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燒燙傷的患者為何要手術？
• 清除壞死組織
• 減少感染
• 重建皮膚/組織完整
• Early excision & grafting
可改善患者預後與存活率

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Advantage of Operation
• Early excision and skin grafting
– Decrease infectious complications
– Decrease length of hospital stay
– Improve survival

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• Early operative wound management
– 現代燒燙傷照護最重要的一部份
• Prompt excision and closure of burn wound
– 對大面積燒燙傷患者而言是救命的方法
• Skin substitutes and dermal replacement
– made operative wound care even more appealing for
providing temporary coverage in patients with not enough
autograft
– offer an attractive alternative to topical antimicrobial
therapy for partial thickness wounds
Purpose of Operation

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Reference:
2012, 4th Edition 2012

53. 13.根據Curreri formula，一個50公斤的病人，燒傷面積達
70﹪體表面積，一天所需的卡洛里（calorie）約多少大卡（
Kcal）？
A.3,050
B.3,650
C.4,050
D.4,550
107年考題
Curreri formula: 25kcal x body weight (kg) + 40kcal x %TBSA
Daily calorie = 25x50 + 40x70 = 4050
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54. 下列關於燒燙傷深度（burn depths）的判斷，下列敘述何者錯誤？ (105)
(A) 國中生到海水浴場玩，被太陽曬傷造成背部發紅及疼痛。發紅的皮膚受到壓
迫會變白（blanch to the touch），壓力釋放後又變紅。這是一度燒燙傷
(B) 老人家燒熱水洗澡。水太熱又忘了加冷水。一腳踏進浴缸的熱水裡被燙傷。
患處皮膚蒼白、起水泡、受到壓迫不變色（do not blanch to touch），但是碰
觸尖細物品仍會疼痛（painful to pinprick）。這是淺二度燒燙傷
(C) 機車騎士出車禍。小腿遠端內側被灼熱的排氣管壓住造成灼傷。患處皮膚形
成不痛的皮革狀焦痂（leathery eschar），這是三度燒燙傷
(D) 情侶分手，女方極度沮喪而燒炭自殺。女方昏迷後被發現，送醫成功挽回生
命。但患者在燒炭昏迷的過程中，右腳太靠近炭火，連肌肉都被烤焦了。這是
四度燒燙傷
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55. 下圖是一位80歲的病人，體重60公斤，因洗澡跌倒被熱水燙傷，意識
清醒下送往急診。請依此回答下列3題：
下列敘述那些正確？①建立輸液管道 ②此為1～2度燙傷 ③2～3度燙
傷 ④18%體表面積受傷 ⑤9%體表面積受傷 (106)
A.①②④
B.①②⑤
C.①③④
D.②③⑤
承上題，依Parkland formula，下列敘述何者正確？
A.輸液前8小時給crystalloid溶液4320 mL
B.輸液前12小時給crystalloid溶液4320 mL
C.輸液前8小時給crystalloid溶液2160 mL
D.輸液前12小時給crystalloid溶液2160 mL
承上題，若依Curreri formula，則病人一天所需的能量為多少Kcal？
A.1500 kcal
B.1860 kcal
C.2220 kcal
D.3000 kcal
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