Burns

The majority of burns are caused by heat, which may be open flame, contact heat, and hot liquids (scalds). Others are chemical, electric, friction, sunburns,and irradiation.NB: Extreme cold can cause tissue injuries(i.e frostbite).

 

Initial Management of Burn Cases

FIRST AID MEASURES

If not acted upon at lower level, initiate the following management plan:

1. Airway: Ensure patient has a clear airway for example by suction of oral airway, endotracheal intubation and tracheostomy.
2. Breathing: Ensure the patient is breathing and receiving oxygen by mask if need be.
3. Circulation: Ensure adequate intravenous access and availability of intravenous crystalloids;group and cross match blood.
4. Give tetanus toxoid and analgesics.

QUICK ASSESSMENT OF THE EXTENT OF BURNS

Degree of burn:

• First degree: Epidermis only involved.
• Second Degree: Epidermis and portions of dermis involved.
• Third degree: All skin layers, including the subcutaneous tissue are involved.

1. Special sites of injury(note facial, perineal, hand, and feet).
2. Look out for circumferential burns on extremities.
3. The Wallace Rule of Nines (Described) is used to estimate the extent of burns
4. Admit if it meets admission criteria.

Initiate fluid management schedule.

CRITERIA FOR ADMISSION

1. Extent of burns: Are>10%body surface area. If the extent is >25% of body surface area, transfer to a special burns unit.
2. Burns to the following burn areas:

• Hand and feet
• Face and neck
• Perineum
• Joints and other associated injuries

1. Inhalation burns
2. Chemical and electrical burns
3. In the presence of other known pre-existing disease, e.g diabetes mellitus

REFERRAL PROCEDURES.

1. Ensure adequate documentation at the first contact with the patient. During referral it is important for resuscitation to continue and to provide an appropriate escort during transportation. The following needs to be observed during referral of the patient:
2. The patient is covered with a dry sheet.
3. The patient is kept warm.
4. The patient received appropriate analgesics.

At the receiving facility:

1. Reconfirm the examination findings as the earlier facility if referred.
2. Re-evaluate the extent of the burns using the Wallace rules of nine for adults.(Check burns images)
3. Prepare for correctional surgery and grafting(Plastic surgery).

Fluid Therapy

Fluid administration is the mainstay of burn treatment and is life saving.Quick vascular access is mandatory. IMPORTANT: Do not waste time on collapsed peripheral veins;urgently perform a cut-down to facilitate fluid therapy. (See Fluid Management schedule) .

Re-evaluate the extent of the burns using the Wallace rules of nine for adults to guide the administration of fluid.

BODY SURFACE AREA ESTIMATION IN ADULTS

“Rules of nines” is used for estimating the extent of a burn surface area in adults.By adding the affected areas together the percentage of the total body surface burnt can be calculated quickly.

BODY SURFACE AREA ESTIMATION IN CHILDREN

Note that the body surface area distribution in children is different to adult and is continuously changing with growth. (See images) which will assist in body surface area estimation for the different age groups in children.

Did you know?: IMPORTANT: It is safer to overestimate body surface area than to underestimate it. A useful rough guide is to estimate the palm of the hand excluding the fingers as being approximately 1%. The total body are is critical to the fluid management of the burn patient.

AMOUNT OF FLUIDS TO BE ADMINISTERED

Calculation Using the Parklands Formula

1. 4*Total body surface area burnt*weight in Kg=ml of fluids to be administered within the 24hours from the time of the burns.
2. The total fluids calculated should be administered as indicated below:

• First 8 hours from the time of burns=½ total calculated fluid.
• Next 8 hours=¼ total calculated fluid.
• Next 8 hours=¼ total calculated fluid

1. As an example, for a 80kg man with 20% burn, total fluid {80kg*20%*4}ml=6400ml. Administer as follows:

• 3,200ml within the first 8 hours.
• 1,600ml in the next 8 hours.
• 1,600 over the next 8 hours.

Nota Bene: Other Fluid Management Considerations.

For management of a person with burns, the following is necessary:

1. Types of fluids to use;these should either be normal saline or Hartman’s solution.
2. Monitoring should be carried out for vital signs, urine output(NB:maintain at least 1-2ml/kg/hr) and packed cell volume.
3. Care of the burn surface includes the following:

• Cleaning with clean water, antiseptics or normal saline
• Applying antiseptic cream like silver sulphadiazine and nursing wounds exposed and using a cradle.
• Using a moist plastic bag for burns of the hand and feet after antiseptic cream application.
• Early surgical debriding of dead, burned tissue and skin grafting for extensive burns.

1. Pregnant females are more prone to the effects of burns than non pregnant females. For pregnant women with burns observe the following:

• Prompt and aggressive fluid management is essential.
• Pregnancy is associated with a 50% increase in intravascular volume as well as a 43% increase in cardiac output.

IMPORTANT:These factors in addition to others make pregnant women more prone to fluid loss associated with burns. As a result, a pregnant woman will not likely conform to the Parklands fluid replacement formula and may need up to twice the volume. In fluid resuscitation for these patients variables like urine output, heart rate, central venous pressure, and mean arterial pressure are more reliable indicators of successful resuscitation.

1. Types of fluids used for treating burns include the following:

• Crystalloids
• Normal saline
• Ringer’s lactate solution(nb:use with cation in patients who have associated metabolic acidosis following burns)

1. The type of monitoring required for patients with burns include the following:

• Vital signs
• Urine output(maintain at least 1-2ml/kg/hr)
• Urea and electrolytes
• Packed cell volume.

Special Burn

TYPES OF BURNS

1. Circumferential burns: If this leads to compartment syndrome, an escharotomy should be performed.
2. Inhalational burns: Should be suspected if there are burned lips and/or burned nostrils, especially in cases of open fires and smoke. Give humidified air and oxygen, bronchodilators, and appropriate antibiotics. Intubation may be necessary.

 

NB:For pregnant females with burns, early intubation and mechanical ventilatory support is strongly recommended if inhalation burn injury is suspected due to risk of tracheal oedema. Both the functional residual capacity ventilatory support is particularly important.

1. Electrical burns: These are deep burns, and require specialized care.
2. Chemical burns: To manage these types of burns, irrigate with plenty of water and soap.

MANAGEMENT OF ELECTRICAL BURNS

 

Low voltage electrical injury tends to be associated with electrocution(cardiac arrest), while high voltage burns are associated with extensive tissue destruction rather than electrocution. The body tissues mostly vulnerable to electrical injury are peripheral nerves and skeletal muscles.

1. Injury from electrical burns occurs through two main avenues:

• Electric shock resulting in cardiac arrhythmias and muscle spasm.
• Thermal injury resulting in muscle destruction.

1. Diagnosis of electrical burn can be made on the basis of:

• History of contact6
• Presence of 2 contact injury points on skin.
• Presence of cardiac arrhythmias and respiratory disturbances.
• Presence of ske;etal fractures secondary to muscle spasms.

1. Management at level 4 to 5

• Resuscitate as appropriate
• Maintain a fluid balance and urine output.
• Initiate or continue analgesia. For severe burns, give morphine 10 mg IV 6 hourly.
• If more specialized treatment is needed refer to the burns unit.

1. At level 6  (burns unit):

• Cardiovert if needed. Cardioversion may be electrical or chemical.
• Maintain adequate urine output, more than 50ml/hr, but raise to more than 100ml/hr to avoid renal failure secondary to myoglobinea.
• Give antiarrhythmic drugs if needed.
• Administer tetanus toxoid as in all burns
• Look out for compartment syndrome.

1. The rest of the treatment plan will follow in a similar fashion to other burns.
2. Skin grafting shortens the duration of hospital stay and should be performed early when necessary.
3. Start physiotherapy and occupational therapy early.

Mortality Risk From Burns

Improvements in wound care and the sue of antibiotics have had an influence on the survival following burns. However, the risk of mortality is directly related to the body surface area that is burned. Other relevant independent factors influencing mortality are the HIV status of the patient and the presence of respiratory burns.