The Burn PDF - A Guide to Burns - Treatment & Management

The burn/ Dr. Yousif Al-Jubori THE BURN CAUSES 1. Thermal burn (most common): It occurs due to direct contact with flame, and hot object, or indirect exposure to heat, as; sunburn. 2. Chemical burn, such as; burn from acids and alkali. 3. Electrical burn: Severity of the burn depends on...

The burn/ Dr. Yousif Al-Jubori THE BURN CAUSES 1. Thermal burn (most common): It occurs due to direct contact with flame, and hot object, or indirect exposure to heat, as; sunburn. 2. Chemical burn, such as; burn from acids and alkali. 3. Electrical burn: Severity of the burn depends on the strength of current and the duration of contact. 4. Radiation burn, such as; local erythema that may follow radiotherapy. SEVERITY OF BURN The severity of a burn is assessed based on the depth of burn, and the size of burn. 1. Depth of burn: Burns may be classified into partial thickness and full thickness, depending on whether or not the germinal epithelial layer of the skin is intact or destroyed. a. Partial thickness burn (superficial burn): The germinal epithelium is partially intact, but the dermis, and its appendages, as; sweat glands and hair follicles remain largely preserved. There is capillary dilation and transudation of plasma, and the patient develops erythema and areas of blistering. Sensation is present. Complete healing takes place. b. Full thickness burn (deep burn): The germinal epithelium, dermis and its appendages are destroyed. Sensation is absent. Healing is much slower than partial thickness, and is incomplete and associated with scarring, and contractures. 2. Size of burn: The size of the burn area can be roughly assessed using the rule of nines. The surface area of body is divided into zones of nine and its multiplications, taking into account the differences in the body surface area with age. For example, infant’s head has proportionately greater surface area than adult’s head. Rule of nines: Head and neck 9. Each arm 9. Each leg 2 × 9 = 18. Front of the trunk 2 × 9 = 18. Back of the trunk 2 × 9 = 18. Perineum 1. As a rough rule, the patient’s hand is approximately 1% of the body surface area. 1  The burn/ Dr. Yousif Al-Jubori MANAGEMENT 1. Hospitalization: Hospital admission is required, if the burn area is over 15% in adults, or 10% in a children. Minor burns could be managed in outpatient clinic. 2. Airway control and ventilation: Smoke inhalation produces thermal injury of the respiratory tract. Laryngeal oedema produces respiratory obstruction, and alveolar damage produces acute lung injury (ARDS). These are managed by intubation or tracheostomy. 3. Pain: Relieve pain with intravenous opiates (e.g., morphine). 4. Treatment of shock: Hypovolaemic shock is a direct result of fluid loss through the damaged capillaries and tissues. It is mainly occurred in the first 24 hours after burning. Fluid loss is proportional to the size of the burn and NOT to its depth. a. Amount of fluid replacement: Fluid replacement in first 24 h (mL) = 4 × weight (kg) × burn area (%). This does not include the daily maintenance of fluids (3 litres in adult), which must be added to the total fluid replacement. b. Rate of fluid replacement: Half the volume should be given in the first (8) hours, and the remainder over the next (16) hours. c. Type of fluid replacement: Lactated Ringer’s (Hartmann’s) solution is the crystalloid of choice for the first 24 h. Shocked patients, should receive colloid infusion, such as; haemaccel, albumin, or fresh frozen plasma. Anaemia results from destruction of red cells in the affected area, should be treated by blood transfusion. 5. Observation: Careful clinical assessment of the patient should include monitoring of the pulse rate, blood pressure, central venous pressure, body temperature, haematocrit estimation, and hourly urinary output. 6. Sepsis: Burn infection usually occurs with Streptococcus pyogenes or Pseudomonas aeruginosa. Systemic administration of broad-spectrum antimicrobial treatment is indicated; (e.g., Amoxicillin, gentamycin, and metronidazole). 7. Nutrition: The patient’s nutrition should be maintained, especially when burns are extensive. If enteral nutrition is not possible, parenteral feeding should be started early to avoid catabolism. 8. Muscle exercises: These must be applied in bed ridden patient with severe burn to prevent pulmonary embolism from prolonged immobility. 2  The burn/ Dr. Yousif Al-Jubori 9. Anti-ulcer treatment: Omeprazole is indicated to prevent Curling’s ulcer (stress peptic ulcer). 10.Local treatment of burn: a. Dressing: Non-adherent dressings with a topical antibiotic such as silver sulfadiazine cream (Flamazine) is applied to the burn, and changed daily. b. Wound excision: Any necrotic tissue will be a focus of infection, which requires total excision of the burn wound. c. Escharotomy: Circumferential full thickness burns, which are affecting the chest or limb contract and restrict breathing and impair blood flow to the limbs. Such contractions need emergent longitudinal incisions to help breathing and save the limb (= escharotomy). d. Skin graft: Large burn area, keloid, and contracture require application of skin grafts. PROGNOSIS Early death usually occurs from hypovolaemic shock, while late death after 1 week usually occurs from septicaemia. The prognosis depends on: 1. Depth of the burn: More deep burn carries higher mortality than superficial burn. 2. Size of the burn: Large percentage of the burn area carries high mortality. 3. Age of the patient: Young infants and the elderly carry a higher mortality than young adults. 4. Infection: Infected burn has high mortality. MCQ. 1. Deep thickness burn: a. The germinal epithelium and dermis are mostly intact. b. There are local signs of inflammation, as redness and blistering. c. Pain sensation is absent. 2. Regarding the rule of nines in burn: a. Head and neck are approximately 18%. b. Each leg is approximately 18%. c. Front and back of the trunk are approximately 18%. 3  The burn/ Dr. Yousif Al-Jubori 3. Hospitalization to a burned patient occurs when: a. 15% burn in adults. b. 10% burn in child. c. All of the above. 4. Fluid requirement for 70 kg patient with a 30% burn in 24 hours is approximately: a. 25% of the fluid should be given in the first 8 h and the other 75% in the next 16 h. b. 5000 ml of ringer lactate. c. 8500 ml of ringer lactate. 4