Burns

Introduction

Burns is a common form of trauma in our environment. It involves coagulative necrosis of tissue cells following varied insults including:

The various types occur with varying
frequencies in various segments of the
population.

For example scalds occur with great
frequency in children while flame burns occur commonly in young adults.

Extensive skin loss with dehydration
Airway burns leading to dyspnoea,
tachypnoea, stridor, hypoxia, hypercarbia, airway obstruction and death
Breathing difficulties from circumferential chest burns
Acute respiratory distress syndrome, acute lung injury and pulmonary oedema
Massive fluid losses from evaporation and interstitial fluid shifts leading to hypovolaemic shock
Acute renal failure from pre renal failure, acute tubular necrosis, and the crush syndrome
Electrolyte abnormalities: hyper or hypokalaemia with cardiac dysrhythmias and/or arrest
Anaemia from destruction of red cells.
Also nutritional anaemia
Hypothermia
Immune dysfunction
Burns wound sepsis and septicaemia
Tetanus
Acute gastric dilatation
Stress ulcerations in the gastrointestinal system
Limb compartment syndrome
Crush syndrome
Deep vein thrombosis
Systemic Inflammatory Response Syndrome (SIRS)
Multiple Organ Dysfunction Syndrome (MODS)

At the scene: to stop the burning process or remove victim from the burn situation
Transfer the patient to hospital as soon as possible
In the hospital identify life threatening injuries and treat
Perform a detailed survey
Restore patient’s physiology as much as possible
Promote wound healing
Prevent complications
Rehabilitation

Copiously irrigate the wound with cold water (not ice cold) for 10-15 minutes
Avoid hypothermia and the use of agents such as raw eggs and palm oil. They are not useful and may promote wound sepsis
In hospital perform a quick primary survey. Check:
- Airway
- Breathing
- Circulation
- Disability
- Exposure
Correct problems identified
Give patient 100% oxygen
Pass an endotracheal tube if there is risk of airway obstruction
Obtain specimens for investigations as detailed above
Determine percentage total body surface area (TBSA) burned
- Wallace rule of nines is recommended in adults
- In children there are several charts e. g Lund and Browder charts
Calculate the total fluid requirement the first 24 hours using appropriate formulae
- Parkland’s formula recommended.
Determine burn depth
Apply burns dressing
Pass all relevant tubes and gadgets
- Nasogastric tube, urethral catheter, etc
Perform a detailed secondary survey (especially if combined with other trauma)
Obtain the AMPLE history
- Allergies,
- Medications,
- Past medical history, pregnancy,
- Last meal
- Environment (including details of the incident)
Administer tetanus prophylaxis depending on immune status
Apply relevant splintage
Commence prophylaxis against deep venous thrombosis
Physiotherapy
Decide whether patient should go to a burns unit or burns centre following standard criteria

Oxygen
Tetanus toxoid
Anti tetanus serum, antitetanus globulin as appropriate
Narcotic analgesics e. g. morphine, pethidine, tramadol
Nonsteroidal anti inflammatory analgesics e.g. diclofenac
H, receptor antagonists e.g. ranitidine
Prophylactic antibiotics e.g. cephalosporins
Topical wound dressing agents e. g with zinc oxide based creams, antibiotic-containing dressings