Burns

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A burn is basically destruction of the skin. In certain situations deeper tissues such as subcutaneous tissue, muscle and bone may be involved. The burn may be superficial or deep depending on the extent of  the injury. This condition, which can have devastating effects on affected people, can be prevented most of the time. It affects young and fit people in most cases and they must be managed properly so that they can return to their normal life.

Cause

  • Dry heat (fire)
  • Wet heat (scalds) from hot liquids, steam, soups etc.
  • Electrical (low or high voltage)
  • Chemical (acids and alkalis)

Symptoms

  • Pain (very severe in superficial type and less in deeper burns)
  • Swelling 
  • Difficulty in breathing 
  • Blisters 

Signs

  • Shock 
  • Inhalational injury (burnt nasal hairs, soot in the throat, hoarseness of the voice and black particles in sputum)
  • Swelling 
  • Blister formation  
  • Charring of tissue (deep burns)
  • ECG changes (electrical burns)

Investigations

  • FBC and sickling
  • BUE and Creatinine 
  • Wound swab
  • Blood gases
  • Chest X-ray 

TreatmentTreatment Objectives

  • Prevent further injury from burns
  • Relieve pain 
  • Replace lost fluid
  • Prevent infection of burn wound 
  • Aid healing of the burn wound  
  • Avoid complications

Non-pharmacological treatment

  • Remove clothing from affected part
  • Put affected part under running water if available till pain goes away or it is reduced
  • If chemical is in powder form brush it off the affected part and put under running water 
  • Secure airway
  • Leave intact blisters alone
  • Do not apply any creams or ointment
  • Affected limbs should be elevated
  • Good nutrition 
  • Psychological therapy
  • Physiotherapy
  • Reassure patient 

Pharmacological treatment 

See sections below

Referral Criteria

  • Refer all cases of burns with the following characteristics to a specialist. 
  • Partial-thickness burns more than 10% of TBSA 
  • Deep burns of any percentage.
  • Burns involving face, hands, feet, genitalia, perineum, or major joints
  • Chemical burns 
  • Electrical burns 
  • Any burn with concomitant trauma in which burn poses greatest risk to patient 
  • Inhalation injury 
  • Infected burns 
  • Burns with pre-existing diabetes, renal failure etc

For burns with Total Body Surface Area (TBSA) of less than 10% in children and 15% in adults

  • Update tetanus prophylaxis
  • Liberal oral fluids
  • Dress burns with Silver Sulphadiazine
  • Give oral analgesia and oral antibiotic

Oral antibiotic

  • Flucloxacillin, oral, 

Adults

500 mg 6 hourly for 2 weeks

Children 

5-12 years; 250 mg 6 hourly for 2 weeks

1-5 years; 125 mg 6 hourly for 2 weeks

< 1 year; 62.5 mg 6 hourly for 2 weeks 

If the Patient has burns (TBSA) of more than 10% in children and 15% in adults

  • Admit
  • Update tetanus prophylaxis (See section on ‘tetanus prophylaxis’)
  • Resuscitate by calculating IV fluids requirement using Parkland’s formula (4 xTBSA x Weight of Patient) given in the form of crystalloids
  • In adults give half of calculated total fluid in first 8 hours from the time of injury and the other half in 16 hours as Ringers lactate
  • In children add daily fluid requirement to the calculated fluid for resuscitation and administer as above as Ringers lactate and 4.3% dextrose in ⅕ saline
  • Dress burns with silver sulphadiazine
  • Give opioid analgesia and antibiotic

 

Antibiotic

  • Cloxacillin, IV, 

Adults

500 mg 6 hourly for 7 days

Children 

5-12 years; 250 mg 6 hourly for 7 days

1-5 years; 125 mg 6 hourly for 7 days

< 1 year; 62.5 mg 6 hourly for 7 days 

If allergic to penicillins

  • Clindamycin, IV, (if patient is allergic to penicillin)

Adults

300-600 mg 6 hourly for 7 days

Children

3-6 mg/kg 6 hourly for 7 days

And 

  • Metronidazole, IV,

Adults

500 mg 8 hourly for 7 days

Children

7.5 mg/kg 8 hourly for 7 days

If the Patient has burns (TBSA) of more than 20% in children and 30% in adults (considered as severe burns)

  • Admit
  • Update tetanus prophylaxis (See section on ‘tetanus prophylaxis’)
  • Resuscitate by calculating IV fluids requirement using Parkland’s formula (4 x TBSA x Weight of Patient) given in the form of crystalloids
  • In adults give half of calculated total fluid in first 8 hours from the time of injury and the other half in 16 hours as Ringers lactate
  • In children add daily fluid requirement to the calculated fluid for resuscitation and administer as above as Ringers lactate and 4.3% dextrose in 1/5 saline
  • Dress burns with silver sulphadiazine

Pharmacological treatment: 

  • Cefuroxime, IV,

Adults

750 mg-1.5 g 8 hourly for 7 days

Children

25 mg/kg 8 hourly for 7 days

And

  • Metronidazole, IV,

Adults

500 mg 8 hourly for 7 days

Children

7.5 mg/kg 6 hourly for 7 days

 

 

If a burn is clinically infected 

  • Admit
  • Update tetanus prophylaxis (See section on ‘tetanus prophylaxis’)
  • Take wound swabs and blood for culture and sensitivity testing
  • Give IV Fluids
  • Give IV Analgesics
  • Start IV Antibiotics

1st Line Treatment 

  • Gentamicin, IV,

Adults

40-80 mg 8 hourly for 14 days

Children

1-12 years; 2.5 mg/kg 8 hourly for 14 days

< 1 year; 2.5 mg/kg 12 hourly for 14 days

Or 

  • Ceftazidime, IV, 

Adults 

1-2 g 8 hourly 

Children 

1 month-18 years; 25 mg/kg 8 hourly  

Neonates

21-28 days; 25 mg/kg 8 hourly 

7-21 days; 25 mg/kg 12 hourly 

< 7 days; 25 mg/kg daily 

And

  • Metronidazole, IV, 

Adults

500 mg 8 hourly for 7 days

Children

7.5 mg/kg 8 hourly for 7 days

And

  • Cloxacillin, IV

Adults

500 mg 6 hourly for 7 days

Children 

5-12 years; 250 mg 6 hourly for 7 days

1-5 years; 125 mg 6 hourly for 7 days

< 1 year; 62.5 mg 6 hourly for 7 days 

2nd Line Treatment

  • Meropenem, IV,

Adults

0.5-1 g 8 hourly

Children

12-18 years; 0.5-1 g 8 hourly 

1 month-12 years (> 50 kg); 0.5-1 g 8 hourly

1 month-12 years (< 50 kg); 10-20 mg/kg 8 hourly

Neonate

> 7 days; 20 mg/kg 8 hourly 

< 7 days; 20 mg/kg 12 hourly                     

Or 

  • Amikacin, slow IV over 3-5 minutes, (monitor serum Amikacin levels)

Adults 

7.5 mg/kg 12 hourly (max. 1.5 g daily and 15 g per course)

Children  

12-18 years; 7.5 mg/kg every 12 hours (max. 500 mg 8 hourly, and 15 g per course)