Burns

Introduction

Burns is a common form of trauma in our environment. It involves coagulative necrosis of tissue cells following varied insults including:

  • Flames
  • Chemicals
  • Electricity
  • Friction
  • Cold or hot fluids

The various types occur with varying
frequencies in various segments of the
population
For example scalds occur with great
frequency in children while flame burnsĀ  occur commonly in young adults.

Clinical features (and complications)

  • Extensive skin loss with dehydration
  • Airway burns leading to dyspnoea,
    tachypnoea, stridor, hypoxia, hypercarbia, airway obstruction and death
  • Breathing difficulties from circumferential chest burns
  • Acute respiratory distress syndrome, acute lung injury and pulmonary oedema
  • Massive fluid losses from evaporation and interstitial fluid shifts leading to hypovolaemic shock
  • Acute renal failure from pre renal failure, acute tubular necrosis, and the crush syndrome
  • Electrolyte abnormalities: hyper or hypokalaemia with cardiac dysrhythmias and/or arrest
  • Anaemia from destruction of red cells.
  • Also nutritional anaemia
  • Hypothermia
  • Immune dysfunction
  • Burns wound sepsis and septicaemia
  • Tetanus
  • Acute gastric dilatation
  • Stress ulcerations in the gastrointestinal system
  • Limb compartment syndrome
  • Crush syndrome
  • Deep vein thrombosis
  • Systemic Inflammatory Response Syndrome (SIRS)
  • Multiple Organ Dysfunction Syndrome (MODS)

Investigations

  • Full Blood Count
  • Electrolytes and Urea
  • Grouping and cross matching
  • Arterial blood gases
  • Chest radiograph
  • Electrocardiogram
  • Wound swab for microscopy, culture and sensitivity
  • Blood culture
  • Intracompartmental pressure monitoring

Treatment objectives

  • At the scene: to stop the burning process or remove victim from the burn situation
  • Transfer the patient to hospital as soon as possible
  • In the hospital identify life threatening injuries and treat
  • Perform a detailed survey
  • Restore patient’s physiology as much as possible
  • Promote wound healing
  • Prevent complications
  • Rehabilitation

Treatment

  • Copiously irrigate the wound with cold water (not ice cold) for 10-15 minutes
  • Avoid hypothermia and the use of agents such as raw eggs and palm oil. They are not useful and may promote wound sepsis
  • In hospital perform a quick primary survey. Check:
    • Airway
    • Breathing
    • Circulation
    • Disability
    • Exposure
  • Correct problems identified
  • Give patient 100% oxygen
  • Pass an endotracheal tube if there is risk of airway obstruction
  • Obtain specimens for investigations as detailed above
  • Determine percentage total body surface area (TBSA) burned
    • Wallace rule of nines is recommended in adults
    • In children there are several charts e. g Lund and Browder charts
  • Calculate the total fluid requirement the first 24 hours using appropriate formulae
    • Parkland’s formula recommended.
  • Determine burn depth
  • Apply burns dressing
  • Pass all relevant tubes and gadgets
    • Nasogastric tube, urethral catheter, etc
  • Perform a detailed secondary survey (especially if combined with other trauma)
  • Obtain the AMPLE history
    • Allergies,
    • Medications,
    • Past medical history, pregnancy,
    • Last meal
    • Environment (including details of the incident)
  • Administer tetanus prophylaxis depending on immune status
  • Apply relevant splintage
  • Commence prophylaxis against deep venous thrombosis
  • Physiotherapy
  • Decide whether patient should go to a burns unit or burns centre following standard criteria

Drug treatment

  • Oxygen
  • Tetanus toxoid
  • Anti tetanus serum, antitetanus globulin as appropriate
  • Narcotic analgesics e. g. morphine, pethidine, tramadol
  • Nonsteroidal anti inflammatory analgesics e.g. diclofenac
  • H, receptor antagonists e.g. ranitidine
  • Prophylactic antibiotics e.g. cephalosporins
  • Topical wound dressing agents e. g with zinc oxide based creams, antibiotic-containing dressings

Prevention

  • Health education to promote healthy lifestyle and avoidance of risky behaviour
  • Installation of fire warning systems such as smoke detectors in buildings
  • Control of petroleum products
  • An efficient fire service.
  • Fire protocols in all establishments