Majority of burns that occurs are mostly treated in


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Majority of burns that occurs are mostly treated in

  1. 1. Majority of burns that occurs are mostly treated in emergency departments and later followed on an outpatient basis. Burns are usually accompanied with other minor injuries which are also treated inemergency departments. If the patient does not have any complications or he /she has burns of limited severity he can be seen on outpatient setting. Most of the burns that are experienced and seen inemergency departments are minor burns but it has been noted that; most of the individuals caring for these patients don’t have maximum skills required to approach the burnt patient. In today’s healthcare it is important for burn care management team to develop educational and clinical relationships with their referral emergency departments to deliver quality treatment and follow ups to their patients. There are three major types of burns that are mostly experienced: first degree, second degree and third degree burns. Each of these is treated differently and healing process takes different time period for recovery. Some of the significant burns are treated in burn care centers as they usually need thorough follow up and special care treatment. Burns are caused by anything that tend to inflame the outer skin (epidermis) or that causes injury to inner skin (dermis). Burns that occur to children are usually contact burns but they heal without any complications. Parents need to be educated on how to protect their children as most of these cases of burns are preventable (Swaminatha V Mahadevan, 1994) Setting an emergency room. Emergency rooms that receive burn victims are usually occupied with physicians and mostly there are no burn specialists. As soon as the victim arrives in an emergency room it is necessary to follow the following procedure: Check whether the burning process has stopped. It has been noted that patients who sometimes arrives at emergency departments comes smoldering in fire because the first aiders may not have fully stopped the burning on the victims body. At this point it is always necessary to determine the cause of burn on the victim’s body as different procedures are followed on different causes of burns. It is important not to try supplementing oxygen on someone who is still on fire as this can cause further explosion. If the victim is still on fire, you can try to put out the fire by using a blanket and by removing his /her clothes that are on fire. For injuries that have been caused by scalds cool water should be poured to the affected area within first thirty minutes. After thirty minutes it is of no help to the patient, therefore it is necessary to act expediently and fast as soon as the patient arrives in emergency room. (Pollack &Jonathan, 2008) For chemical burns, pour a lot of water to the victim as little water can cause further reaction of the chemical. Plentiful amount of water will help to dilute the effects of the chemical. After the victim has been administered, it is necessary to examine the type of chemical injury that has been caused and
  2. 2. apply appropriate neutralizer. It is worth to note that chemical injuries can make someone lose his/her sight and it is therefore important to flush the victims eyes with a lot of water immediately the accident happens even before taking him to emergency department or it may be too late. Tar, melted plastics and asphalts are treated differently as removing them is always very painful. These materials can retain heat for a very long time and it is necessary to first cool off the patient. They are later removed by use of chemicals but it is necessary to first give the victim an adequate airway. Electrical burns that are caused by low voltage current are most serious as the current enter the body through a very small opening and then exits through a small opening. This normally causes shock, unconsciousness, convulsion or loss of memory. A counter shock or a few minutes of CPR can help to restart the heart as most of this people are resusitatable. Inhalation injuries also cause death through carbon monoxide poisoning. The primary concern should therefore be to supplement the victim with plenty of oxygen and remove the patient from congested environment. After an emergency treatment has been given it is necessary now to treat the patient in case of any other complication apart from burn. Assess Airway, Breathing and Circulation Airway-Intubation is necessary as edema occurs within the first few hours with all burn victims. This is usually a breathtaking challenge that takes place within a very short period of time but it is necessary especially when the victim is suffering from burn on the face, tongue and hard palate. Definite intubation is required where the victim suffers from epiglottis, vocal cords, respiratory depression, hoarseness and posterior pharynx burns. It should be presumed that any victim whoa has been burned in a closed area suffers from inhalation injury until proved otherwise. There are three major types of airway injuries which are: Inhalation injury above the glottis. Carbon monoxide poisoning Inhalation below the glottis. Carbon monoxide poisoning is the most common type of airway injury as it is caused by incomplete burning of fuels. Carbon monoxide which has high affinity than oxygen takes hemoglobin and forms carboxy haemoglobin, this can make the patient to develop myocardial and cerebral hypoxia. It inhibits hemoglobin found in red blood cells from taking oxygen and takes carbon monoxide instead since it has high affinity. Common signs are central nervous systems complications: loss of memory, headache and confusion. The victim should be treated by immediate application of high flow oxygen.
  3. 3. Inhalation injuries above the glottis are caused by nasopharynxes which dissipate heat to the nose, mouth and throat. This may cause edema which can be experienced for a few hours and it can result to airway obstruction. The victims should immediately be intubated to protect the airway. Inhalation below the glottis normally affects the lungs and it is asymptomatic for the first 48 hours and the patient may have normal arterial lood gas levels. The victim should be intubated and at the same time be treated for respiratory distress. Breathing –whether the patient is suffering from external or internal injury it is necessary to allow enough airflow. For external injury, IV sedation may be required to help in incisions which start from axillaly lines. This process is normally not painful. For internal injury initial ventilation and intubation is normally required. Lavage can always be performed later if the physician find it necessary to the patient; Bronchodilating aerosols may be beneficial in this case. Circulation- fluid replacement is always necessary as it enables the victim to have frequent outflow of urine. Circulation sometimes may be restricted due to circumferential burns and Escharotomies should be performed if blood flow cannot be exhibited. Before performing peripheral escharotomies it is necessary to have good urine output that reflects adequate core volume.(Michael Brennan) Evaluate the extent and depth of the burn Burns are treated according to extreme at which they have affected the skin First degree burns are simple to heal as they only involves the upper layer of the skin and the very obvious example of this kind of a burn is the sunburn. The victim experiences tenderness and redness of the skin and they don’t make you very sick. Many people resuscitate themselves with oral fluids and they don’t need to be hospitalized. The wounds normally heal on their own and it takes about four to five days for recovery. The most important thing in first degree burns is to treat the symptoms and special care be given to avoid dehydration and loss of fluids. A second burn degree involves the epidermis and part of the dermis layer of the skin. You can detect whether a person suffers from second degree burn by observing the burn site. It usually appears red, blistered and it may be swollen and the victim may be experiencing some pain. Second degree burn may be as a result of scald injuries, flames or direct contact with hot object. Symptoms of a second degree burn are blisters, deep redness, painful touch, wetness and shininess of the skin and sometimes the victim may have a burn that is white and discolored in an irregular pattern.
  4. 4. Healing process of a second burn degree may take about three weeks to heal as long as the wound is treated and cleaned regularly. Sometimes if the victim has deep burn, it may take long than three weeks but this does not mean that the patient will not fully recover. A burn that does not extend to 10 percent of the skin surface can be treated on outpatient basis. Treatments may include administration of antibiotic ointments, dressing changes, cleaning of the wound depending on the severity of the burn and systemic antibiotics. A pain reliever like may be needed when dressing the wound since it is normally painful. Third degree burns are referred to as full thickness burn as it destroys the outer layer of the skin and the entire layer beneath. Third degree burns can be caused by a scalding liquid, flames from fire, electrical source or a chemical source. Most common symptoms of third degree burn are: swelling, dry leathery skin, black, white or yellow skin and the victim may be suffering from nerve failure. Healing process takes long as epidermis and hair follicles are destroyed and therefore no new skin will grow. Thorough medical attention should be followed but specific treatment is determined by extent of the burn, location of the burn, cause of the burn and severity of the burn. Treatment of the third burn includes: removal of the dead skin and tissue from the burned area, administration of intravenous (IV) containing electrolytes, antibiotics by mouth or intravenous, antibiotic ointment or creams, pain medications, warm humid environment for the burn and sometimes graft can be required to achieve closure of the wounded area. In case of very serious scars that are left after healing, functional and cosmetic reconstruction is necessary if the victim is okay with it. During the process of healing the patient should be supplemented with all type of nutrients and administration of high supply of proteins. Assess the criteria for referral to a burn center After administration of proper procedures the wound it is necessary to refer the patient to a burn centre where the follow up is necessary. Here the patient can be released to go home and be seen by the physician as an out patient. It all depends with the seriousness of the burn and the treatment required by the victim. Patients who experience serious burn injuries should be referred to a burn centre for special treatment. Observe and treat burn and associated injuries In case the patient is admitted in burn care centre related burn injuries. It is necessary to mote that patients may have a very large burn but they can survive and at the same time die because of other injuries that requires major attention. At burn centre the victim can be treated by experienced physicians who are experienced and have the know how to treat different types of burns. After the
  5. 5. cause and depth of burn has been noted, the burn should be covered with silver sulfadiazine and dry sterile dressings. Fluid replacement is the first initial burn treatment that is given to the patient. Once the person gets burnt, their capillaries began to leak and endothelial cells separate and become very porous and blood inside the vessel cannot be contained. Fluids in large amounts fluids therefore flow out into the tissue. Large burns are always accompanied by fluid that accumulates everywhere in the body and these patients can develop a significant amount of edema at the expense of vascular volume. As the consequence the blood volume goes down and the patient can develop what we call hypovolemic shock. ( Monafo WW,2001) Patients who have received burn greater than 10% require resuscitation but this depends on age and health of the victim. When resuscitating a patient who is twenty years old and is healthy, they can do the same for themselves by use of oral fluids but they should be given close observation. Victims who mostly suffer from electrical injury and inhalation injury always get s fluid resuscitation. This should be done within the first 24 hours. The main goal of resuscitating a patient is to make sure that he /she maintains his volume during the period of hypovolemia. Most of the burn centers have a formula that they use when performing resuscitation, it normally has two advantages i.e. calls for large amount of fluid and it is easy to remember. Urine volume is appropriate indicator of whether fluid resuscitation is adequate for the patient. Lactated lingers are also necessary if given to patients because they are most like extracellular fluid. Saline is not well recommended as it contains huge amount of chloride which may cause metabolic acidosis. Kidneys on the other hand are supposed to be perfumed adequately to help the patient make enough urine, lack of enough fluid can be indicated by patient making very little amount of urine but all the same diuretics should not be given to the patient. Electrical injuries patients or those with very deep tissue damage may have myoglobin in their urine. In a case like this these patients may require double the flash of urine to remove myoglobin from the kidney. It is very difficult to access the amount of fluid required in the patient’s body as this cannot be determined by the extent of burn on their bodies. It has been noted that edema get worse as resuscitation continues, this is most likely where there is a major burn of extremity that swells very quick. The burns in third degree are very hard and rigid and elasticity is always compromised. As fluid is continuously administered to these patients, the burn becomes tighter and tighter and circulation also become compromised. The patient may be seen to lose peripheral pulses, nerve function or motor function and these may lead to cyanotic. At this point the patient may start complaining about deep throbbing pain but this is always very difficult to evaluate in the field (.Königová R, 2004).
  6. 6. Escharotomy is a treatment that is given to patients to restore pulses; it involves cutting of the burned tissue with a scalpel medially and laterally. This makes the skin to spread apart as a result of tension and tightness caused by the swelling and this may cause complications related with edema. Edema also affects the chest and this can complicate breathing but through incision the chest can be put back in normal. Edema can also cause the swelling f the airway and it is therefore necessary to intubate the patient immediately as swellings can even occur inside affecting pharyngeal tissues and this can lead to death. Intubation is necessary even if the patient does not need it but it is of great help because it does not have any side effect to the same patient. ( Papini RP,1999) Treatment of minor burns (first burn degree) Minor burns are frequently experienced but they are not very difficult to treat as they get better on their own. Dressings and use of antibiotics are not a must but the most important thing is to keep the wound clean and make the patient feel comfortable. All blisters and devitalized tissues should be removed because if not removed, they can cause infection because of the fluid that collects within a blister. Nonadhearant gauze should be applied as it is more comfortable for the patient. It is necessary at the same time to apply ointment as it makes the patient more comfortable and it facilitates washing and to remove the old ointment. Washing of a minor burn has been recommended to fasten the healing of a minor burn. (Barbara Ravage, 2005) Burns of lower extremities may require a patient to be ace wrapped to make him/her feel more comfortable. The following procedure should be followed for special treatment of a wound: Clean the wound with plenty of water and soap. Remove the devitalized tissue. Make sure you have removed all the blisters All the hairs that are adjacent to the wound should be shaved. Regularly apply bland ointment. You can leave the wound open or wrap it lightly with gauze. Repeat ointment and cleanse the wound regularly through out the day. Never do the following to treat a minor burn: Soak the wound in ice water-this can make the burn to be more extensive and frostbite injury over a burn is great. Wrap in occlusive dressing. Treatment of second burn degree The main goal for treating second degree burns is normally to reduce pain and prevent infection. The following should be followed to treat a victim who has second degree burns:
  7. 7. Remove the victim’s clothes or any other sort of thing that is in direct contact with the body. Holds the burnt area with a moist cloth for around 10 minutes to stop the burning.NB don’t use cold ice water since this will just worsen the situation. Blisters should not be broken openly as these can cause a greater risk of infection. If blisters are open it is worth to note that running water should be avoided as this can increase the risk of shock. Place dry sterile gauze over the burn but any bandages with adhesive should be avoided. Drape a clean sheet over the wound but it should be loose to allow air in the wound. Butter oils and burn ointments should be avoided as this make the burn to take long to heal. Replace fluids through intravenous (IV) line through a tube that is placed into a vein. Give the patient antibiotics to protect the burned area from infection Sometimes a tetanus booster is needed if the patient’s immune system is down In case of scarring a skin graft can be done where a healthy skin is taken from an unburned area and be transplanted to the burned area. This is referred to as autograft. Treatment of third burn degrees. Minor third degree burns sometimes can be treated in a doctor’s office but other serious injuries can only be treated under special care as medical emergency. The following should be followed in treatment of a third degree burn victim: Get the person to an emergency room as soon as possible as the patient requires urgent treatment. Remove the victim’s clothes or any other sort of thing that is in direct contact with the body. Holds the burnt area with a moist cloth for around 10 minutes to stop the burning.NB don’t use cold ice water since this will just worsen the situation. Hospitalize the patient for further treatment. Administer in a constant mode a lot of fluids as the patient becomes dehydrated very first. Give the patient antibiotics to protect the wound from further infection. If the patient has severe burn he/she is put in a special room that is normally filled with pure oxygen under high pressure, this room is referred to as hyperbaric chamber and the patient is attended within the first 24 hours. Clean the wound and cover it with antibiotic cream and sterile bandages. Closely monitor the burned area to avoid any infection. It is necessary to change the bandage frequently. In some cases the patient may need a cover in his burned area through grafting. In a case where a human skin cannot be used, plastic surgeon can use animal skin and this is called xenograft or use a skin of another human and this is referred to as allograft. Both xenograft and allograft are temporary and they facilitate the healing of the skin.
  8. 8. Skin graft is usually performed after the removal of dead skin and tissue and after a graft procedure has been done the donor site normally looks like a skinned knee. Third degree burns may take weeks or months to heal and the patient require continuous physical therapy which helps restoration of burned areas and minimization of scars that occurs after healing. ( Carsin H,2000) Expected clinical outcome after treatment of burns After the patient has been treated from burns, he /she can fully recover or require some other medications to improve the status of the skin damaged. Pediatric burn injuries are one of the hazardous injuries that are experienced during childhood. Most of these injuries are very severe and they require multiple surgeries in order to heal the damaged skin. Cultured skin substitutes are required for healing massive burn wounds, and grafting is also necessary. Cultured skin grafts which are made from patient’s skin cells are combined with the fabric which stimulates the development of epidermal barrier or the outermost protective layer of the skin. After cultured skin grafts have been made they are taken to the operation room where they are applied to the patients wound. Cultured skin grafts are mostly applied to patients who have received second or third degree burns over more than 50% total body surface area. The healed skin of a patient who has undergone cultured skin process can be determined by softness, color, and shape and blood flow of the healed skin. Cultured skin results in faster recovery and improved outcome in the treatment of bums of more than 90 percent of the part of the body burned. (Carsin H& Aiinaud P,2004). Patients with burns can improve the likelihood of survival with implementation of treatments, supportive therapy, nutrition and advances in the control of sepsis. The superficial appearance of scars can be improved through a procedure known as dermabrasion. All larger areas around the neck and hands shows great improvement after the patient have been treated.( Glenn D.&Warden ,M.D,2001). Hyperpigmented Scars differs with different patients where some patients may have black powder like tattoos and some can have smaller dark spots or freckle-like lesions. Erbiurn YAG laser is a valuable tool that is used for reconstructive burn surgery. The YAG laser can effectively improve the fine irregularities and some hyperpigmentations and dotted tattoos which might have been caused from burn trauma. Normal skins after dermabrasion will reeepithelialize quickly from dermal glands and hair follicles Aboriginal and non- aboriginal burn victims responds differently from epithelial auto graft, ventilation and early skin repair. Aboriginal people are faced with inequities in access to health services which affects them greatly. (Wood FM, 1994)
  9. 9. As burned skin heals a thick scabbed surface called eschar develops and these can prevent blood from flowing to the injured area. Escharotomy procedure is applied in this case and the eschar is cut to enable the health tissue underneath to receive the blood flow required. ( Königová R,2004). Tips to remember when attending any burn victim For chemical burns water as the antidote should be used and one is supposed to first remember the causative agents before administering any antidote. Suspect carbon monoxide poisoning in all thermal and inhalation injuries. Hyperbaric oxygen is not required in these cases. Never transport an unstable patient as these will make it difficult for him to produce adequate urine. Don't forget about Td and allergy status For electrical burns which poses the victim to high risk of renal failure that is caused by methemoglobinuria due to underlying muscle necrosis, urine output of about 1 cc/kg/hr is necessary. Antibiotics should not be given prophylactically and steroids should not be indicated in burn management Dosages of IV Morphine as a standard pain relief should be titrated to patients with great care to avoid respiratory depression. An NG tube is indicated for burns >15% due to anticipated ileus.( Bras, Marijana; Loncar, Zoran,2005)