Burns

Published on 14/03/2015 by admin

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Chapter 20 Burns

Linda Dann

Skin is the largest organ in the body, approximating 15% of body weight and 4.9 square metres in an adult. It has a number of functions, which correspond to the rationale of management and the potential complications of burns:

• protection from the environment (infection)
• temperature control (hypothermia)
• fluid control (dehydration and fluid replacement)
• energy control (need for increased caloric intake in larger burns).

The majority of burns occur in the home and affect mainly young men and those at the extremes of age.

TYPES OF BURNS

• Thermal (including scalds)
• Chemical
• Electrical
• Radiation

Specific other factors

• Eyes: chemicals, flash burns, molten metal
• Extremes of age (< 5 or > 65 years)
• Airway/lung injury—blast injury may be fatal if untreated
• Hands/feet/perineum
• Circumferential burns of limbs or torso
• Burns crossing joints (especially flexor surfaces)
• Deliberate abuse

ASSESSMENT OF THE BURNS PATIENT

• History of the patient, including any chronic conditions that may affect wound healing such as steroid use, diabetes etc. Check tetanus status.
• History of the events surrounding the injury, including:

• time of injury (fluid requirements assessed from this time)
• location of event (in open air, in closed room etc) to give an indication of concomitant injury including carbon monoxide or toxic fume inhalation, blast injury, trauma from fall etc.

• Full examination to exclude other injury.
• Assessment of the depth and extent of the burn injury using standard protocols such as Wallace’s Rule of Nines or the Lund and Browder chart (Figure 20.1).
image

Figure 20.1 Lund and Browder chart: estimation of extent of burn

ASSESSMENT OF DEPTH AND EXTENT OF BURN

Extent of burn

There are two methods of assessment of the extent of burns:

1. Wallace’s Rule of Nines chart—varies with age, good for quick assessment
2. Lund and Browder chart—allows for age variation, more accurate.

Depth of burn

The utilisation of terms such as first-, second- and third-degree has been largely replaced by:

• Superficial. Refers to epidermal reddening, e.g. sunburn. Extremely painful, no blistering, skin is red and heals spontaneously without scarring, usually within a week.

Note: Superficial burns are not counted in assessing the extent of burn injury.

• Partial thickness. Subdivided into superficial and deep:

• Superficial partial thickness—red or pink with mild blistering as involves dermis. Extremely painful but heals spontaneously within 1–2 weeks.
• Deep partial thickness—may be initially red then white. Harder to assess. Involves deep layers of dermis and is extremely painful. May require skin grafting to prevent infection and scarring.

• Full thickness. Involves all layers of skin including blood vessels, nerve endings, hair follicles and the dermis. As a result, they are insensate, dry, white, translucent or even charred. All but the smallest (< 1 cm) will require skin grafting.

GENERAL MANAGEMENT

• Remove the victim from the source of injury.
• Provide supplemental oxygen if there is any possibility of blast injury, smoke or toxic fume inhalations, stridor, hoarseness of the voice, burns to the face or any evidence of soot around the mouth or nose.
• Any burned patient removed from an enclosed space may be assumed to have airway injuries even when no burns are evident.
• Adherent material should not be removed at this stage.
• Antibiotics are not required prophylactically—only if specific infection demonstrated.

Analgesia

Superficial and partial thickness burns are extremely painful.

In minor or localised burns, application of cold water (for at least 30 minutes) and dressings alleviate pain.

Simple oral analgesia may be required at home.

Inability to control pain is an indication for admission, particularly in children.

In more severe cases, initial management includes narcotic analgesia. Narcotics should be given intravenously and liberally, e.g. morphine 0.1 mg/kg initially, then titrated to response. Large doses are often required.

Other factors

Airway/lung injury/inhalation injury

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