Burn Introduction Management Of Minor And Major Burn Prevention

Introduction:

A burn is an injury caused by thermal, chemical, electrical, or radiation energy. A scald is a burn caused by contact with a hot liquid or steam but the term 'burn' is often used to include scalds.Most burns heal without any problems but complete healing in terms of cosmetic outcome is often dependent on appropriate care, especially within the first few days after the burn. Most simple burns can be managed in primary care but complex burns and all major burns want a specialist and skilled multidisciplinary approach. 

Management of minor burn:

• Clean burns with soap and water, or a dilute water-based disinfectant to remove loose skin.
• All blisters should be deroofed to help assess depth of burn .
• Nonadhesive dressing, with gauze padding is usually effective, but biological dressings are better, especially for children.
• Dressings should be examined at 48 hours to reassess the burn, including depth.
• Dressings on superficial partial thickness burns can be changed after 3-5 days in the absence of infection.
• If infection occurs, daily wound inspection and dressing change is required

Management of major burn:

Prompt irrigation with running cool tap water for 20 minutes provides appropriate cooling. Very cold water should be avoided (causes vasoconstriction and worsens tissue ischaemia and local oedema). Chemical burns may need longer periods of irrigation.

• Dressings help relieve pain and keep the area clean but avoid circumferential wrapping as can cause constriction.
• All patients with facial burns or burns in an enclosed environment should be assessed by an anaesthetist for early intubation.
• For full thickness circumferential burns, escharotomy may be required to avoid respiratory distress or reduced circulation to the limbs as a result of constriction.
• Transfer to a burns centre or other appropriate care centre as indicated.

Immediate management of Burn:

Airway:
The airway above the glottis is very susceptible to obstruction because of exposure to heat. The clinical presentation of inhalation injury may be subtle and often does not appear in the first 24 hours.

Clinical indications of inhalation injury include:

• Singeing of the eyebrows and around the nose.
• Carbon deposits and acute inflammatory changes in the oropharynx.
• Carbon-particles seen in sputum.
• Hoarseness.
• History of impaired awareness, e.g. alcohol or head injury, and/or confinement in a burning environment.
• Explosion, with burns to head and torso.
• Carboxyhaemoglobin level greater than 10% if the patient is involved in a fire.

Management of acute inhalation injury:

• Early management may require endotracheal intubation and mechanical ventilation.
• Transfer to a burn centre.
• Stridor is an indication for immediate endotracheal intubation.
• Circumferential burns of the neck may lead to swelling of the tissues around the airway and so require early intubation.

Stop the burning process:

• Remove all clothing - adherent synthetic clothing and tar should be actively cooled with water, and left for formal debridement.
• Dry chemical powders should be carefully brushed from the wound.
• Rinse the involved body surface areas with copious amounts of tap water. Cool the burn with tepid water for up to 20 minutes. Great care is required as cooling may cause hypothermia, especially in children and those with extensive burns - and may worsen shock.
• Remove constricting clothing and jewellery before covering the patient with warm, clean and dry linens to prevent hypothermia.

Breathing:

• Arterial blood gas determinations should be obtained as a baseline but arterial PO2 does not reliably predict CO poisoning. Therefore, baseline carboxyhaemoglobin levels should be obtained, and 100% oxygen should be administered.
• Elevation of the head and chest by 20 to 30 degrees reduces neck and chest wall oedema. If a full-thickness burn of the chest wall leads to severe restriction of the chest wall motion, chest wall escharotomy may be required.
• Carbon monoxide (CO) poisoning: has a much greater affinity than oxygen for haemoglobin and so displaces oxygen.
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• Higher CO levels may result in headache and nausea, confusion, coma and death.
• CO dissociates very slowly but this is increased by breathing high-flow oxygen via a non-rebreathing mask.

Intravenous access and fluid replacement:

• Large-calibre intravenous lines must be established immediately in a peripheral vein.
• Any adult with burns affecting more than 15% of the body surface area or a child with more than 10% of body surface area affected requires fluid resuscitation.
• Resuscitation fluids required in the first 24 hours from the time of injury 

Adults:

• 3-4 ml (3 ml in superficial or partial thickness burns, 4 ml in full thickness burns or those with associated inhalation injury) of Hartmann's solution/kg body weight/% total body surface area.
• Half of this calculated volume is given in the first eight hours and the other half is given over the following 16 hours.

Children:

• Resuscitation fluid as above plus maintenance (0.45% saline with 5% dextrose) which should be titrated against nasogastric feeds or oral intake:
• 100 ml/kg for first 10 kg body weight plus 50 ml/kg for the next 10 kg body weight plus 20 ml/kg for each extra kg.
• Ensure adequate analgesia: strong opiates should be used.
• Prevent hypothermia.

Complication :

• Respiratory distress from smoke inhalation or a severe chest burn
• Fluid loss, hypovolaemia and shock
• Infection
• Increased metabolic rate leading to acute weight loss
• Increased plasma viscosity and thrombosis
• Vascular insufficiency and distal ischaemia from a circumferential burn of limb or digit
• Muscle damage from an electrical burn may be severe even with minimal skin injury; rhabdomyolysis may cause renal failure
• Haemoglobinuria and renal damage

Prevention:

There are many important aspects of prevention of burns, including:

• Safety in the workplace.
• Safety in the home, including regularly checking smoke alarms.
• Good parenting to protect children.
• Care of the frail elderly and the socially isolated.
• Prevention of sunburn: appropriate duration and timing of sunbathing, sun protection creams, and regulation of tanning booths.