Burns And Their Management

Burns and Their Management By CJ Lau 28 Oct 2009

What causes burns  Dry

heat (fire)  Wet heat (steam or hot liquids)  Radiation, heated objects, friction  Sun, chemicals, electricity - Thermal burns are the most common kind of burns - Occurs when flames, hot metals, scalding liquids, or steam come into contact with skin

Symptoms  Blisters  Pain

(the degree of pain is not related to the severity of the burns as most serious burns can be painless)  Peeling skin  Redness, swelling  Shock (symptoms include pale and clammy skin, weakness, bluish of lips and fingernails and drop in alertness )

Assessment   1. 2. 3. 4. 5.

Burns patient has the same priorities as all other trauma patients. Assess: Airway Breathing: beware of rapid airway compromise Circulation: fluid replacement Disability: compartment syndrome Exposure: percentage area of burn

Essential Management Points  

  1. 2.

Stop the burning Determine the percentage area of burn (Rule of 9’s) Good IV access and early fluid replacement Severity of burn is determined by: Burned surface area Depth of burn

Rule of 9’s      

Commonly used to estimate the burn surface area in adults The body is divided into anatomical region that represents 9% (or multiply of 9%) of the total surface body area The outstretched palm and fingers approximates to 1% of the body surface area If the burned area is small, assess how many time your hand covers the area Morbidity and mortality rises with increasing burned surface area Also rises with increasing age, so even small burns may be fatal in elderly people

Children  Rule

of 9’s is imprecise for estimating the burned surface area in infant and children  Infant or young child’s head and lower extremities represent different proportions of surface areas than in adults  Burns greater than 15% in an adult and greater than 10% in a child, or any burn occurring in the very young or elderly are serious.

Depth of burn 

It is important to estimate the depth of burn to assess its severity and to plan for future wound care. Burns can be divided into 3 types.

Depth of burns

Characteristics

Cause

Healing

First degree burn 1) superficial -involves only epidermis

Erythema

sunburn

Three

Second degree burn (partial thickness) -involves epidermis and superficial portions of dermis

Red

or mottled Flash burns Usually forms blisters

Contact

Third degree burn (full thickness) -extend through and destroy dermis - Considered serious

Dark

Fire

scarring

Pain Absence

to six days without

of blister

and leatherly Dry and inelastic painless

with hot liquids

7-21days Scarring

is unusual Pigment changes may occur

Scarring

is severe Electricity or lightning Spontaneous healing is not Prolonged exposure to hot possible liquids or objects

Superficial burn

Partial thickness burn

Full thickness burn

Serious burn requiring hospitalization  Greater

than 15% burns in adult  Greater than 10% burns in children  Any burn in the elderly or very young  Any full thickness burn  Burns of special regions: face, hands, feet, perineum  Circumferential burns  Inhalation injury  Associated trauma or significant pre-burn illness: eg.diabetes

Wound care/first aid 

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Drench the burn thoroughly with cool water (not ice) to prevent further damage and remove all burned clothing If the burn area is limited, immerse the site in cool water for 30 minutes to reduce pain and oedema If the area is large, after it has been doused with cool water, apply clean wraps about the burned area to prevent systemic heat loss and hypothermia Hypothermia is a particular risk in young children First 6 hours following injury are critical, transport the patient with severe burns to hospital as soon as possible.

Initial treatment  

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Consists mainly of cooling, simple cleansing and appropriate dressing Cleaning- burn wound should be cleaned, but use of disinfectant is discouraged as it can inhibit healing. Growing support for washing the wound using mild soap and water. Debridement- Sloughed or necrotic skin including ruptured blisters, is debrided. Extensive debridement is generally not required immediately and may be deferred until the initial follow up visit. Blisters- ruptured blisters should be removed, but management of clean intact blisters is controversial. Needle aspiration should never be performed, as it increases risk of infection.

Treatment 

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Pain management- for small burn injuries, paracetamol and NSAIDs, alone or in combination with opiods are often appropriate. Patients with sustained burns and significant pain should be treated with IV narcotics. Elevation of foot and hand burns above the level of the heart can reduce pain and swelling for several days following the injury Pruritus is common and can be treated with systemic antihistamines or moisturizing lotions Tetanus immune globulin should be given to patient who have not received a complete immunization, particularly for any burns deeper than than superficial thickness. Dressing- superficial burns do not require dressings. Partial and full thickness burns should be dressed.

Dressings Basic dressing  For emergency treatment, a basic gauze dressing provides good burn coverage.  It is placed after the application of topical antibiotic and consists of a first layer of nonadherent gauze placed over the burn, a second layer of fluffed dry gauze, and an outer layer of elastic gauze. Biologic and synthetic dressings  Generally not used in the emergency department  Should be applied within first 6 hours after injury  Can be used to treat partial thickness burns  May reduce pain, help prevent infection and promote healing  More difficult to apply, expensive, and not readily available

Dressings 

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Bismuth impregnated petroleum gauze & biosynthetic dressingappears advantageous for young children and adults with superficial partial thickness burn. Both are applied as a single layer over the burn and then covered with an external bulking dressing (to absorb wound exudate). Dressing change- range from twice weekly to weekly. Best to change dressings whenever they become soaked with excessive exudates or other fluids.

Management of Infection  All

suspected burn infections warrant aggressive management including admission and parenteral antibiotics  Burn infections can extend the depth and extent of a burn, converting a superficial partial-thickness into deep partial thickness or full thickness burn.  Many authors recommend full thickness skin biopsy for any hospitalized patient due to the risk of infection with resistant organisms.

Scarring 

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The depth of the burn and the surface involved influence the duration of healing phase. Without infection, superficial burn heals rapidly. Burns scars undergo maturation, at first being red & raised. They frequently become hypertrophic and form keloids. They soften, flattened and fade with time, but the process is unpredictable and takes time. Silicon can significantly reduce scar hypertrophy scars as late as twelve years after injury. Burn scars on the face lead to cosmetic deformity, ectropion and contractures about the lips. Consider specialized care for these patients as skin grafting is often not sufficient to correct facial deformity.

References  

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WHO Management of Burns Bethel, CA, and Krisanda, TJ. Burn care procedures. In: Clinical Procedures in Emergency Medicine. 4th ed, Roberts, JR, Hedges, JR (Eds), Saunders, Philadelphia 2004. p.749. Karyoute, SM, Badran, IZ. Tetanus following a burn injury. Burns Incl Therm Inj 1988; 14:241. Burn pain- A Unique Challenge, International Association for the study of pain, Vol IX, Issue 1, March 2001 Church, D, Elsayed, S, Reid, O et.al. Burn Wound Infections, Clinical Microbiology Reviews, Vol 9, No.2, April 2006, page 403434 Gang, RK, Bang, RL, Sanyal, SC, et al. Pseudomonas aeruginosa septicaemia in burns. Burns 1999; 25:611. Up to date