Burns

exp date isn't null, but text field is

Tissue injury caused by thermal, chemical, electrical, or radiation energy.

Causes

• Thermal, e.g., hot fluids, flame, steam, hot solids, sun
• Chemical, e.g., acids, alkalis, and other caustic chemicals
• Electrical, e.g., domestic (low voltage) transmission lines (high voltage), lightening
• Radiation, e.g., exposure to excess radiotherapy or radioactive materials

Signs and symptoms

• Pain, swelling
• Skin changes (hyperaemia, blisters, singed hairs)
• Skin loss (eschar formation, charring)
• Reduced ability to use the affected part
• Systemic effects in severe/extensive burns include shock, low urine output, generalized swelling, respiratory insufficiency, deteriorated mental state
• Breathing difficulty, hoarse voice and cough (smoke inhalation injury) – medical emergency

Depth of Burn

1st Degree burns- Superficial epidermal injury with no blisters. Main sign is redness of the skin, tenderness, or hypersensitivity with intact two-point discrimination. Healing in 7 days

2nd Degree burns or Partial thickness burns It is a dermal injury that is sub-classified as superficial and deep 2nd degree burns. In superficial 2nd degree burns, blisters result, the pink moist wound is painful. A thin eschar is formed. Heals in 10-14 days. In deep 2nd degree burns, blisters are lacking, the wound is pale, moderately painful, a thick eshcar is formed. Heals in >1 month, requiring surgical debridement

3rd Degree burns Full-thickness skin destruction, leather-like rigid eschar. Painless on palpation or pinprick. Requires skin graft

4th Degree burns Full-thickness skin and fascia, muscles, or bone destruction. Lifeless body part

Complications

• Shock
• Severe skin infection
• Contractures
• Airway obstruction

Investigations

• Full blood count
• Kidney function tests - to assess loss of electrolytes
• Blood glucose test- to determine glycaemic level

Treatment Objectives

• Promote wound healing and prevent secondary micro-organism infections
• Prevent airway obstruction
• Secure body fluid circulation to prevent kidney damage
• Alleviate pain
• Prevent complications

Non-pharmacological Treatment

Assess:

• - Airway
• - Breathing: beware of inhalation and rapid airway compromise
• - Circulation: fluid replacement
• - Disability: compartment syndrome
• - Exposure: percentage area of burn.

Essential management points:

• - Stop the burning
• - ABCDE
• - Determine the percentage area of burn (Rule of 9’s)
• - Good IV access and early fluid replacement

First Aid

Burns Caused by Heat

• Immediate cooling by immersion in clean water for 30 minutes, then apply simple dry and clean dressing.
• Remove clothing if not adherent to the skin and wrap in clean cloth.

Chemical Burns

• Brush off any dry chemicals and copiously irrigate the area with clean running water for about 30 minutes.
• Do not apply ice or ice slush
• Remove contaminated clothing
• Avoid contaminating skin that has not been in contact with the chemical

Electrical Burns

• Cool burns as above. A patient unconscious from electrical burns will need urgent cardiac assessment and resuscitation

General Measures

• Ensure room is warm since exposed burn patients lose heat rapidly.
• Monitor pulse, temperature regularly
• Give high protein, high energy diet
• Give vitamin supplementation, high dose vitamin C

Pharmacological Treatment

Mild/moderate burns

Pain control

• Make sure that pain control is adequate, including before procedures such as changing dressings.
• Give oral or IV analgesics as required

Paracetamol oral

Adult:

500 mg to 1 g 6-8 every hours as required

Child: 

6-12 years: 250-500 mg every 6-8 hours or when necessary

3-5 years: 250 mg every 6-8 hours or when necessary

Up to 3 years: 125 mg every 6-8 hours or when necessary

OR

Narcotic analgesics

Morphine sulphate IV

0.05–0.1 mg/kg IV every 4 hours if pain is severe

Note Total Body Surface Area (TBSA) is <10% and the patient is able to drink, give oral fluids; otherwise consider IV as stated below

Check tetanus vaccination status.

• If not immunized, give tetanus immune globulin.
• If immunized, give tetanus toxoid booster, 0.5mL IM, if this is due
• Leave small blisters alone, drain large blisters and dress if closed dressing method is being used
• Dress with silver nitrate (0.5% aqueous) OR silver sulphadiazine cream 1%, add saline moistened gauze or paraffin gauze and dry gauze on top to prevent seepage.

Note:

• Silver sulphadiazine is contraindicated in pregnancy, breastfeeding and premature babies
• Small superficial 2nd degree burns can be dressed directly with paraffin gauze dressing
• Change after 1-3 days, then when necessary
• Patient may be exposed in a bed cradle if there are extensive burns
• Saline baths should be done before wound dressing; avoid alcohol based solutions
• If wound is infected, dress more frequently with silver sulphadiazine cream until infection is controlled

Severe burns

• First aid and wound management as above
• Plus IV fluid replacement in a total volume per 24 hours according to the calculation below (use crystalloids, e.g. Ringer’s lactate, or normal saline)
• If patient is in shock, give IV fluids fast until BP improves
• Manage pain as necessary
• Refer for admission
• Monitor vital signs and urine output

Treat secondary infection if present.

• If there is evidence of local infection (pus, foul odour or presence of cellulitis), treat with

Amoxicillin oral

Adult:

500 mg every 8 hours for 7-14 days

Child:

15 mg/kg orally three times a day

PLUS

Cloxacillin oral

25 mg/kg

 

If septicaemia is suspected give

Gentamicin IM or IV

7.5 mg/kg once a day

PLUS

Cloxacillin IM or IV

25–50 mg/kg four times a day

Note: If infection is suspected beneath an eschar, remove the eschar.

Blood transfusion may be necessary

• If signs/symptoms of inhalation injury, give oxygen and refer for advanced life support (refer to specialist)

Fluid replacement in Burns

• Give oral fluids (ORS or others) and/or IV fluids e.g. 0.9% saline or Ringer’s lactate depending on the degree of loss of intravascular fluid
• The total volume of IV solution required in the first 24 hours of the burns is: 4 mL x weight (kg) x % TBSA burned plus the normal daily fluid requirement
• Give 50% of fluid replacement in the first 8 hours and 50% in the next 16 hours. The fluid input is balanced against the urine output. The normal urine output is:

Adult:

0.5 mL/kg/hour (30-50 mL/hour)

Child:

 (<30 kg) 1-2 mL/kg/hour

Fluid replacement calculation

• Fluid resuscitation is required for burns covering > 10% total body surface. Use Ringer’s lactate or 0.9% saline with 5% glucose; for maintenance, use Ringer’s lactate with 5% glucose or half-normal (0.45%) saline with 5% glucose.
• First 24 hours: Calculate fluid requirements by adding maintenance fluid requirements to the additional emergency fluid requirements (volume equal to 4 mL/kg for every 1% of surface burnt).
• Administer half of total fluid in first 8 h, and remaining fluid in next 16 h.
• Example: 20 kg child with a 25% burn:
• Total fluid in first 24 h = (60 ml/h x 24 h) + 4 ml x 20 kg x 25% burn = 1440 ml + 2000 ml = 3440 ml (1720 ml over first 8 h)
• Second 24 h: give half to three quarters of fluid required during the first day.

Additional Care

• Nutritional support
• Physiotherapy of affected limb

Prevention

• Public awareness of burn risks and first aid water use in cooling burnt skin
• Construction of raised cooking fire places as safety measure
• Ensure safe handling of hot water and food; keep well out of the reach of children.
• Particular care of high-risk persons near fires e.g. children, epileptic patients, alcohol or drug abusers.
• Encourage people to use closed flames e.g. hurricane lamps. Avoid candles.
• Beware of possible cases of child abuse

Referral

• If a superficial burn has not healed in 7-10 days, it has either become infected or is deeper than anticipated, if in doubt consult the surgeons.