Burns

What You Will Learn

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Depth of burns

The depth of injury should be assessed by the clinical appearance.

First-degree burns are red, painful, and dry. These burns are superficial, with damage limited to the epidermis. They are commonly seen with sun exposure or with mild, hot solid or scald injuries. They heal in 3 to 6 days without scarring. First-degree burns are not included in burn surface area calculations.
Second-degree, or partial-thickness, burns may be superficial (red, painful, mottled, blistered) and heal in 10 to 21 days with little or no scarring or deep dermal (pale, painful, and yellow), taking 3 weeks to heal and possibly resulting in scarring. They may result from immersion or flames.
Third-degree burns are full thickness and require grafts if they are more than 1 cm in diameter. They are avascular and are characterized by coagulation necrosis.
Fourth-degree burns involve underlying fascia, muscle, or bone.

Percent of body surface area involved

A severe burn includes:

Greater than 15% of the body surface area
Involves the face or perineum.
Second-degree and third-degree burns of the hands or feet
Circumferential burns of the extremities
Inhalation injuries resulting in bronchospasm and impaired pulmonary function also must be considered severe burns.

The location of the burn

The location of the burn is important in assessing the risk for disability.
The risk is greatest when the face, eyes, ears, feet, perineum, or hands are involved.
With partial-thickness burns, generally no disability results; however, full-thickness burns usually result in permanent impairment.
Inhalation injuries not only cause respiratory compromise, but also may result in difficulty in eating and drinking.
Inhalation injuries also may be associated with burns of the face and neck.

History

A careful history is extremely important.

Review of the history usually reveals a common pattern:

scald burn to the side of face, neck, and arm if liquid is pulled from a table or stove;
a pant leg area burn if clothing ignites;
splash areas from cooking; and
palm of hand contact with a hot stove.
"glove or stocking" burns of hands and feet, single-area deep burns on the trunk, buttocks, or back, and small-area, full-thickness burns (cigarette burns) in young children should raise the suspicion of child abuse.

Indications for Hospitalization for Burns

Infants with burns over greater than 10% BSA, children with burns over greater than 15% BSA,
High-tension wire electrical burns
Inhalation injury regardless of the size of body surface area burn
Inadequate home situation
Suspected child abuse or neglect
Burns to hands, feet, genitals

Laboratory and Imaging Studies

Most burn patients do not require immediate routine laboratory testing or imaging.
EU, Cr
Pcv
Blood culture
Blood grouping and crossmatch
Swab m/c/s

Treatment

First aid
Fluid resuscitation
Supply energy requirements
Pain control
Prevention of infection-early excision and grafting
Control of bacterial wound flora
Biologic and synthetic dressings to close wound

The triage decision is based on

Extent of the burn,
Body surface area involved,
Type of burn,
Associated injuries,
Any complicating medical or social problems, and
Availability of ambulatory management

Estimation of Body Surface Area of Burn.

The variable growth rate of the head and extremities throughout childhood makes it necessary to use surface area charts, such as that modified by Lund and Brower
The "rule of nines" used in adults may be used only in children older than age 14 years or as a very rough estimate to institute therapy before transfer to a burn center.
In small burns under 10% of BSA, the "rule of palm" may be used, especially in outpatient settings. The area from the wrist crease to finger crease (the palm) in the child equals 1% of the child's BSA.
The most accurate yet time-consuming method of determining skin involvement is with the Lund and Browder chart.

The goal of initial treatment is to
Stop the burning process; this includes

Removing the patient from the site of injury,
Cleansing away any chemical or injurious contactants, and
Removing the clothing.

The next priority is airway management
Few signs of injury may be present initially, although facial burns, singed nasal hairs or eyebrows, and acute inflammation of the oropharynx suggest inhalation injury.
Smoke inhalation may be associated with carbon monoxide toxicity; 100% humidified oxygen should be given if hypoxia or inhalation is suspected. Hoarseness on vocalization also is consistent with a supraglottic injury. Some children with inhalation burns require endoscopy, an artificial airway, and mechanical ventilation.

Fluid resuscitation

The systemic capillary leak that occurs after a serious burn makes initial fluid and electrolyte support of a burned child crucial.
The first priority is to support the circulating blood volume, via IV fluids to provide maintenance fluid and electrolyte requirements and to replace ongoing burn-related losses.
The resuscitation formula for fluid therapy must provide replacement fluid and maintenance fluid and is determined by the percent of body surface burned.
Amount of IV fluid in first 24 hours = weight in kg X 4 mL X % BSA burned
Administer one half of the calculated fluid during the first 8 hours and one half of the calculated fluid in the subsequent 16 hours.
The starting time is considered to be the time at which the burn occurred and not the time at which medical care is initiated.
Children aged 6 months to 5 years should receive the fluid recommended by calculations using the Parkland formula plus maintenance during the first 24 hours.
Urine output is the criterion standard for gauging appropriate intravascular volume and hydration status.
During the second 24 hours, dextrose in 0.25 normal saline is substituted for this regimen.
Colloid therapy may be needed for burns covering more than 30% of body surface area and may be provided after 24 hours of successful resuscitation with crystalloids

Provision of energy requirements

Children with significant burns require immediate nutritional support.
Enteral feeding may be resumed on day 2 or 3 of therapy
Children with critical burn injury may require parenteral nutrition if unable to tolerate full enteral feeds.

Pain control

Effective management of anxiety and pain (with sedation and analgesia) and
The prevention of hypothermia by maintenance of a neutral thermal environment.

Wound care

Initial management includes-

Relief of any pressure on peripheral circulation caused by eschar and débridement
Evaluate the wound for surface area and depth of injury
Place gauze dressings on a clean wound devoid of devitalized tissue.
Coverage with topical agents aids pain control and decreases insensible losses.
Burns generally are covered with silver sulfadiazine (1%) applied to fine-mesh gauze or, if the burn is shallow, with polymyxin B/bacitracin/neomycin (Neosporin) ointment.
When an extremity is involved, instruct the patient and family regarding immobility and as much elevation as possible
Tetanus toxoid should be provided for patients with incomplete immunization status; immune globulin

Surgical Care

Clean burned areas using isotonic sodium chloride solution or mild soap and water, taking care to maintain thermal homeostasis.
Remove ruptured blisters and devitalized epidermis with forceps and scissors or, more efficiently, by rubbing with gauze soaked in isotonic sodium chloride solution after an adequate level of analgesia is obtained.
Leave intact blisters alone.
Apply a topical antimicrobial (silver sulfadiazine, bacitracin) followed by a sterile dressing after the burn has been cleaned and debrided.
Dressings should be changed and wounds cleaned daily in outpatients.
Incision of burned skin (escharotomy) is the treatment for compartment syndrome.
For full-thickness burns, skin autografting and artificial skin substitutes are required for eventual closure.

Most children who sustain burns recover without significant disability.
Mortality is primarily associated with burn severity (extent of body surface area and depth), although the presence of inhalation injury and young age also predict mortality.
Physical scarring and emotional impact of disfiguring burns are long-term consequences of burn injuries.

More than 600,000 children sustain burns each year; 92% occur in the home.
Prevention is possible by using smoke and fire alarms, having identifiable escape routes and a fire extinguisher, and reducing hot water temperature to 49°C (120°F).
Immersion full-thickness burns develop after 1 second at 70°C (158°F), after 5 seconds at 60°C (140°F), after 30 seconds at 54.5°C (130°F), after 60 seconds at 53°C (127°F), after 5 minutes at 50°C (122°F), and after 10 minutes at 49°C (120°F).

Education on burns prevention

This includes

Making children and parents realize the danger of careless handling of fire and fire-causing materials like matches
Cooking should be at a higher level where the children cannot easily reach, and the position of the fire should not be easily overturned.
Cooking should be done with utensils that can be easily handled and-not with "handless" pots. The handles must be made of materials that are poor conductors of heat. The pots should have good covers
Houses should be better designed, well-planned and ventilated and overcrowding must not be allowed.
Epileptics, children and the infirm must not be left alone near open fire.
Care must be taken in the storage and use of kerosene and gas.
Hot cooking stoves must be cool before refilling.
Petrol should not be stored in the house and no open flames should be present when petrol and such inflammable fluids are exposed.
Candles must be put out before sleeping
Knowledge of how to prevent burns should take place as part of health education programmes on radio and television.
Formation of society groups on burns prevention.
Fire drills at various places

Practice Questions

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