EMmedonline

Burns wound is classified into

1) First degree burns injury :

• Injury confined to the epidermis. These burns are painful erythematous & blanch to touch with an intact epidermal barrier.

• They are not life threatening and generally do not require intravenous fluid replacement because the epidermis remains intact.

2) Partial Thickness Burns (Second degree burns )

• They are characterised by a red or mottled appearance with associated swelling and blister formation.

• The surface have a weeping, wet appearance and is painfully hypersensitive, even to air current.

3) Full Thickness Burns (Third degree Burns )

• Skin may also appear translucent or waxy white.

• Surface is painless and generally dry; it may be red, but doesn't blanch with pressure.

• There is little swelling of the full thickness burned tissue, although the surrounding tissue may swell a significant amount.

Estimating the Burns Size

• Rule of 9

• In infants or young child's head represents a larger proportion of the surface area and lower extremities represent a smaller proportion than an adult.

• The percentage of total body surface area of an infant's head is twice that of the normal adult.



MANAGEMENT

Airway

• Early protection of the airway is important.

• Pharyngeal thermal injuries can produce marked upper airway edema and early protection of the airway is important.

Breathing

• Breathing concern arises from

1. Hypoxia : Due to inhalation injury, inadequate ventilation due to circumferential chest burns or traumatic thoracic injury unrelated to the thermal injury.

2. Carbon monoxide poisoning : Suspected in burns in enclosed space

3. Smoke inhalation injury

• Supplement oxygen .

• Early management of inhalation injury may require endotracheal intubation and mechanical ventilation.

Circulation

• Any patient with burns more than 20% of the body surface requires fluid resuscitation.

• Secure two large bore IV cannula.

• Upper extremities are preferred.

• If the extent of the burns precludes placement of the catheter through unburned skin, the IV should be placed through through the burned skin into the accessible vein.

• Fluid requirement

• Parkland Formula : LR 4 ml * weight * %BSA over 24 hrs. Initial half over first 8 hrs and rest of the fluid over next 16 hrs.

• Aim is to target a urine output of 1-2 ml/kg/hr. The rate of the fluid has to be adjusted based on urine output.

Documentation

Investigation

• ECG, Chest X-ray

• Electrolytes

• ABG

• HbCO levels

Gastric tube insertion

• Insert a gastric tube and attach it to a suction setup if patient experience nausea, vomiting or abdominal distension or if burns involve more than 20% of total BSA.

Narcotics, Analgesics & Sedatives

• Hypoxemia and fluid resuscitation should be carried before administering narcotics since they can mask signs of hypoxemia and hypovolemia.

Wound care

• Partial thickness burns are painful when air current pass over the burned surface.

• Gently cover the burns with clean sheet.

• Do not break blisters or apply antiseptic agents.

• Do not apply cold water to a patient with extensive burns >10% of BSA.

Tetanus Immunisation

Antibiotics

• No indication for prophylactic antibiotics. Reserved only for treatment of infection.

• Topical Antibiotics

• Silver sulfadiazine 1% : Apply with a thin layer of silver sulfadiazine cream to the burn and then cover it with gauze dressing.

• Alternatively triple antibiotic with neomycine, polymyxin-B and bacitran zinc can also be applied.

• Dressings are changed twice daily as long as they continue to weep and then once daily.

• Dressings with synthetic occlusive dressing heal better.

Monitor for compartment syndrome

Updated on 15/12/14

Reference

• Tintinalli

• ATLS Students Manual