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Burns manual 2nd [autosaved]

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S
ShubhraDas2

Burn care

Healthcare
1 of 129
1Introduction 21 1 INTRODUCTION Somefacts •aburnmaybelifethreateningespecially inthevery youngandveryold •aburnisverypainful‘ithurtslike hell’ •regularsleepisverydifficult •aburnisunique,nootherconditionisso painfulfor solonganddebilitating •burnsarepreventable,yettheykeepoccurring •estimated mortality rates of fire-related burns in 2002 worldwide were322 000; 40 000 of themoccurred in sub-Saharan Africa(WHO) •more people suffer from disabilities and disfigurement causedbyburns •thisresultsinpersonalandeconomicaleffects on both the victim and family ultimately culminating in social stigma and restriction inparticipationinsociety
22BurnsManual local&generalresponsetotheburninjury What youshouldknow •localresponse experimental work by Jackson has shown that a burn wound consistsof3zones Jackson’sBurnWoundModel Zoneof coagulation Zoneof stasis Zoneof hyperaemia zoneof coagulation Cell death and immediate coagulation ofcellularproteins. Damage in microcirculation resulting in compromised circulation,untreated it will leadto necrosis Damage causing production of inflam- matory mediators leading todilatation ofbloodvessels zoneofstasis zoneof hyperaemia
1Introduction 23 • generalresponse - skinisthelargestorganin thebodyandisolateschemically, thermally, biologicallyandmechanicallytheinsidefromtheoutside - aburndestroysthesefunctions - aburnisthreedimensional,itopensupasurfaceandleadsto: 1. lossofwater,electrolytes,proteinsandheatduetovascular permeability, whichresultsintheformationofoedema 2. inburns>20%TBSA,effectsonthewholebodyare: a. hypovolaemia(=shockphase=first48hours) b. immunosuppressionleadingtoinfection c. impairment of barrier function of the gut leading to translocationofbacteria(itisthereforeimportantto startenteral feedingearly) d. systemicinflammatoryresponsepostburnaffectsthe lungsresulting in Adult Respiratory Distress Syndrome (ARDS), even in the absenceofinhalationinjury What to do • administrationoffirstaid • correctionofhypovolaemiaislifesavinginthefirsthourspostburn • appropriatemanagementofinfection • earlyenteralfeeding Keypoints for clinicalpractice ɶlocaleffectofburncauses3zonesofinjury ɶ normal capillary exchange is disturbed leading to oedemaandlossof albuminfromthecirculation ɶ general effects occur in circulation, metabolism, temperaturecontrol,immune competenceandfunctionof gut&lungs
24BurnsManual Epidemiology andcauses What youshouldknow • some burns are genuine accidents, but most do occur due to carelessness, inattention, pre-existing medical conditions or alcoholabuse • as long as cooking takes place at ground level and very young childrenarelookedafterbytheirslightlyoldersiblingsthis willbe themaincontributingfactortotheincidenceofburnsinchildren • lack of safety precautions by adults e.g. topping up paraffin lampswhilestillburningandhot • themostfrequentlyencounteredpre-existingmedicalcondi- tionis poorlycontrolledepilepsy,commonlyleadingtoburns • themajorityofburnstakeplaceathome • inmorethan50%ofthecaseschildrenyoungerthan10years are affected • main causes of burns are hot liquids and fire (>80%), each of whichcountsforapproximately40% • a number of burns especially in girls are caused by the combinationoffireandnylon(acrylic)dresses What todo • at community level safety measures must be taught with the emphasisonachange -incookinghabitsand -inthecarefortheveryyoungbythesomewhatolderbut not yetresponsiblesibling • treat and monitor pre-existing medical conditions e.g. epilepsy carefullyandinstructpatientsaboutthedangersof not taking the prescribedmedication
1Introduction 25 Keypoints for clinical practice ɶburnsarefrequentlycausedbycarelessnessandinattention ɶpre-existingmedicalconditionssuchaspoorlycontrolledepilepsy contribute totheburdenoftheburninjuryanditssequelae ɶthemajorityofburnsoccurinoraroundthehome ɶthemostaffectedgrouparechildrenbelowtheageof10years Theteamconceptofburncare BurnsUnit Improvementsinresuscitation,nutrition,theintroductionoftopical antimicrobials andtheintroductionofmanagementprotocolshave shownthatspeciallytrained staffisabletooperatemoreeffectively withinaburnsunit. BurnTeam This is a multidisciplinary group in which individual skills complementeachother. Membersare • clinicians • nurses,whoprovidethedaytodaycontinuityofcareandare thebackbone oftheteam • physiotherapists&occupationaltherapists,whoplayan indispensablerole intherehabilitationprocessfromthetime ofadmission • dietitians;tocounteracttheextremecatabolicresponse, optimalnutrition isparamountinthecareofburnpatients • socialworkersforreintegrationinthecommunity
2Emergencyexamination&management 27 2 EMERGENCY EXAMINATION&MANAGEMENT Prevention What youshouldknow • 90%ofburnsin childrencanbepreventedusingcommon senseand basichouseholdsafetymeasures • 60%ofburnsinchildrenoccurintheagegroupbelow3 years • mosthouseholdsstillcookatgroundlevelandtheveryyoung arelooked afterbytheslightlyoldersibling • inflammableclothingsuchasacrylicdressescancausesevereburns • carefulandcontinuousmanagementandfollowupofpre- existingmedical conditionssuchasepilepsycanpreventburns • alcoholabuseisindirectlyresponsibleforburns • beawareofthepossibilityof(child)abuse What to do • educatepeopleaboutsafetyandachieveitsimplementationin andaround thehomeaswellasatwork • teachandtrytoachieveachangeinlifestyleathomei.e.no cookingatground levelanddon’tletyoungchildrenbelookedafterbyotheryoungones
28BurnsManual firstaid What youshouldknow • themanagementofaburnstartsatthesceneofthe accident • quickactioncanreducetheareaandthedepthoftheburn • theprinciplesoffirstaidare - tostoptheburningprocess - tocooltheburnwound • coolingthesurfaceoftheburnisalsoaneffectiveanalgesic • coolingtheburnwoundwillonlybeeffectiveifcommencedwithin3hours oftheinjury • insmallchildrenprolongedcoolingmayleadto hypothermia • donotuseiceoricewater,itwilldeepenthetissueinjuryand increasestherisk ofhypothermia What todo • firstandforemostremovethepatientfromthecauseofburn, ifthepatients clothesareburningwraphim/herinablanketanddousewithwaterorrollon theground • inascald(hotwaterburn)removeclothingrapidly,becausesoakedclothing actsasareservoirofheat • leaveadherentclothinginplaceandcutaroundittoremovethenon adherentclothing • usecoldrunning(tap)waterfor10-20minutestostoptheburning process;theidealtemperatureis15-18°C(rangefrom8°till25°C) • sprayingorspongingisalsoeffective • preventhypothermiabycheckingthetemperature,keeping theambient temperatureat30°Cormoreandkeepingtherestofachildwellwrapped • notethetimeoftheinjury
2Emergencyexamination&management 29 Keypoints for clinicalpractice ɶthetreatmentofaburnstartsatthesceneoftheaccident ɶstoptheburningprocess ɶcooltheburnwound ɶpreventhypothermiaespeciallyinsmallchildren ɶnotetimeofinjury PrimarySurvey What to do A. Airwaymaintenance • openandcleartheairway;incaseofasuspectedinjurytothecervicalspine keepmovementofthenecktoaminimumandneverhyperflexor hyperextendtheheadandneck.Stabilizetheneckwithahardcollarorin between2sandbags • ifsmokeinhalationissuspectedintubatebeforeoedemamakesthisdifficultor evenimpossible B. Breathing&ventilation • exposethechestandmakesurethatchestexpansionisadequate • alwaysprovideO2insevereburnsorwheninhalationinjuryis suspectedgive 4-8L/minute • bewareofarespiratoryrateofmorethan20perminute • performescharotomy(decompression)infullthicknesscircumferential burnsofthechest(see Ch14,page97,103)
30BurnsManual C Circulationandhaemorrhagecontrol • checkpulse if theradialpulseispalpablethesystolicBPis100ormore if theradial pulseisnotfeltfeelforthefemoralpulse ifthefemoralpulseisfeltthesystolicBPis80ormore ifthefemoral pulseisnotfelt,feelforthecarotidpulse ifthecarotidpulseisfeltthe systolicBPis60ormore if thecarotidpulseisnotfeltimmediately startCPR • stopbleedingwithdirectpressure • checkcapillaryrefill,if>2secitmeanshypovolaemiaortheneedfor escharotomyonthatlimb;checktheotherlimbto compare • palloroccurswith≥30%lossofbloodvolume • insevereburns(>20%TBSA)insert2largeboreperipheralIVlines d disability-neurologicalstatus • checkthelevelofconsciousness(LOC) - A=Alert - V =responsetoVocalstimuli - P=responsetoPainfulstimuli - U =Unresponsive • examinethepupilsforlightreaction • hypoxiacancausereducedLOC e exposurewithenvironmentalcontrol • keeppatientwarm • keepenvironmentwarm • checkforanyadherentclothing,cutaroundit, when removingclothing
2Emergencyexamination&management f fluidresuscitation 31 • estimateTBSA,usetheLund&Browderchartorusethepalmarsurface ofthepatientsownhand=1% (see Ch13,page87, 88) • weighthepatient,ifnotpossibleusethefollowingformula:2x(ageinyears +4)=… kg,useonlyinchildren<12years • giveIV fluidsinburns>10%TBSAinchildrenand>15% TBSAinadults • useRinger’sLactateorsodiumchloride0.9%(NS) • formulatobeusedis4ccxwtinkgx%TBSAburn(see Ch3, page40) • givehalfofthecalculateddeficitinthefirst8hoursstartingfromthetimeof burnandnotfromthetimetheIV driphasbeencommenced • monitoradequacyofresuscitationbymeasuringtheurineoutput,children1 cc/kg/hr,adults(from30-40kgbodywt) 0.5cc/kg/hr~30-50cc/hr,accuratemeasurementisonly possiblewithanindwellingcatheter • insertaNGT inburns>20%TBSAinchildrenand>30% TBSAinadults • giveadequateanalgesia,preferablymorphine(notinneonates)orpethidine (see Ch3,page43)
32BurnsManual SecondarySurvey Thisisacomprehensivehistoryandheadtotoeexaminationafterlife- threatening conditionshavebeendiagnosedandtreated. • mechanismofinjury how when where Allergies medications Pastmedicalhistory lastmealevents/Environment relatedtoinjury (e.g.wasshe/heinaclosedroom) • AMPLE • headtotoephysicalexamination Burnwoundassessmentestimation oftheareaburnedWhat you shouldknow Theriskofdyingfromaburninjuryisrelatedtotheageofthepatientandthe percentageofthetotalbodysurfacearea(TBSA) burned.Intheveryyoungand oldyouwillfindthatthegreatertheareainjuredthehigherthemortalityrateis. Thatpartofthebodywhichisonlysuperficiallyburned(thereis onlyrednessbut noblisters,socalledepidermalburns)shouldnot beincorporatedintheestimation ofTBSA. Palpationoftheburnedarea(usegloves)willrevealblistersandwillhelpto excludeareasofonlyepidermalburns.
2Emergencyexamination&management 33 What to do • theruleofninesdividesthebodyinareasof9%ormultiplesof9%,thisruleis relativelyaccurateinadults,butinaccurateinchildren.Inchildrenuseasruleof thethumbthefollowing: uptotheageof1yeartheheadis18%andeachleg 14%,for eachfollowingyear - subtractfromthehead1% and - addtoeachleg0.5% (see Ch13,page89) • estimatetheareaburnedinsmallburnsbyusingtheareaofthepalmar surfaceofthehand(fromfingertipstowrist), whichisapproximately1%oftheTBSA(see Ch13,page88) • theLundandBrowderchartisthemostaccurateandtakesintoaccount theageofthepatient(see Ch13,page87) depthoftheburn Skinstructure Sebaceous gland Hair follicle Epidermis Dermis Sweat gland Subdermal fat
34BurnsManual Depthburnwound Superficial burn Middermal level Deep burn What youshouldknow Superficialburns Thesewillhealspontaneouslybyepithelialisationandcanbedividedin • epidermalburns,theyaffectonlytheepidermis,examplesareminorflash injuriesandsunburn. Hyperaemiaoccursduetotheproductionofinflammatorymediators, theyarepainfulandhealwithin7days • superficialdermalburns(=partialthicknesssuperficial),theyaffectthe epidermisandthesuperficialpartofthedermis.Here - theblisteristhemostimportantfeature - theexposeddermisispinktowhite - thesensorynervesareexposedandthewoundisthereforeextremely painful - theyhealwithin14days
2Emergencyexamination&management 35 deepburns Thesearemoresevereandwillonlyhealafteraprolongedperiodoftimeandwith significantscarring • deepdermalburns(=partialthicknessdeep),theremaybesomeblistering buthere - theappearanceofblotchyreddiscolorationischaracteristic - animportantfeatureistheabsenceofcapillaryrefill - thedermalnerveendingsaredestroyedresultinginlossof sensationto pinprick • fullthicknessburns,bothlayers(epidermisanddermis)aredestroyedandthe burnmaypenetrateunderlyingstructures.Here - theburnwoundhasawhite,waxyorcharredappearance - animportantfeatureistheleatheryappearancewhichis calledan eschar - thereisnopainsensation What to do diagnosisofburndepth Depth epiDermal superficial Dermal Deep Dermal full thicKness colour Red PalePink BlotchyRed White Blisters No Present +/- No capillary refill Present Present Absent Absent sensation Present Painful Absent Absent healing Yes Yes No No
36BurnsManual Ingeneralasuperficialdermal(=partialthicknesssuperficial) burn • hasamoistsurface • hasapositivecapillaryrefilland • ispainful Assessmentonday3-5postburnwillhelpdefinethedepthofthetotalareaburned emergencyburnwoundcare • beforehospitaladmissioncoverwithacleansheet • inhospitaleitherexposeordresswithoneoftheavailabletopicalagents • avoidtheuseoftightdressingsinlimbswithcompromisedcirculation Admissioncriteria • age neonates babies(<1year) children adults head&neck hands&feet groin&axilla perineum always(oftendeepburns) TBSA>5% TBSA>8% TBSA>15% • site circumferentialburnsofchestandlimbsfull thicknessburnsTBSA>5% electrical,chemical, inhalationburnssocialindication • depth • special • other Whenindoubtadmitovernightandreassessthenextday.
2Emergencyexamination&management 37 laboratory • takebloodforFBCorPCV (=haematocrit) • ifavailableurea,creatinine&electrolytes • inchildrenregularlycheckbloodglucosetodetect hypoglycaemia • incaseoffevercheckbloodformalariaparasites Keypoints for clinicalpractice ɶcheckairway&breathing,giveO2inchildwith>20%andadultwith>30%TBSA burned,give4-8litrehumidifiedO2/ minute ɶcheckpulseandcapillaryrefill ɶcheckneurologicalstatus,useAVPU ɶweighpatient[or2x(age+4)=kg],measureextent(TBSA),notetimeofburn ɶburns>10%inchildrenand>15%inadultsstartIV resuscitation ɶgiveRL/NS4ccxwtxTBSA% ɶgive½infirst8hours;calculatefromtimeofburn ɶmonitorurineoutput,inchildren>1cc/kg/hr,inadults>0.5cc/kg/hr, iflessincreasedrip rate ɶperformescharotomyand/orfasciotomy(decompression)iflimbcirculation iscompromisedor chestexpansionisdiminished ɶreasses4hourly:breathing,circulationandneurologicalstatus
38BurnsManual
3Hospitaltreatment 39 3 hoSPiTAlTreATmeNT fluidresuscitation What youshould know Oralfluids • inallburns<10%TBSAgiveoralfluids,useoralrehydration solution(ORS) • between10and15%TBSAgiveORS,butmonitortheintakeasinIV resuscitation • inburnsupto20%inchildrenand30%inadultsifnoIV orintraosseous accesscanbeachievedinsertanasogastrictubeandrehydratewithORS,use formulaasinIVresuscitation IVfluids • inmajorburns(>20-30%TBSA)thereisincreasedvascularpermeability duetoreleaseofinflammatorymediators(see Ch1,page23);thisleads tothedevelopmentofgeneralizedoedema • oedemaformationstopsafter18-30hours • fromapracticalpointofviewRinger’sLactate(Hartmann’ssolution)isthe internationallyacceptedchoiceofIV fluidfor theinitialresuscitation • childrenhavelimitedphysiologicalreserveandgreatersurfaceareatomassratio comparedtoadults • thethresholdtostartIV fluidsislower(10%)inchildrenandtheyneeda highervolumeperkg;inadditiontothevolumedeficittheyshouldbegiven maintenancefluidsaswell
40 BurnsManual What todo estimation/calculationoffluiddeficit • Adults 4ccRLxwtinkgx%TBSAburn=deficitfor the1st 24hrs nomaintenance • Children (< 30kg) 4ccRLxwtinkgx%TBSAburn=deficitfor the1st 24hrs plus maintenancewithDW 5%andNS* 2x… kg+10=… cc/hr or 100cc/kg<10kg+50cc/kg11-20kg+ 20cc/kg>20kgper24hrs e.g.a35kgchildwill need 2x35+10=80cc/hr or - 100cc/ kgforthefirst10kg=1000cc - 50cc/kgforthenext 10kg= 500cc - 20cc/kgforthelast 15kg= 300cc - thisgivesatotalof1000+500+300cc=1800cc/24hrs - whichisthesameas75cc/hr(1800÷24) *bewareofhyponatraemiaandhypoglycaemiainchildren
3Hospitaltreatment 41 howtogive • givehalfofthecalculateddeficitinthefirst8hoursstartingfromthetimeofthe burn(tob).Atthesametimeinchildrenstartmaintenance(fromthetimeof insertionoftheIVdrip) • givetheotherhalfofthedeficitoverthenext16hoursandin children continuetogivemaintenancefluids • forthesecond24hourperiodaftertheburnbothadultsandchildren mustbegivenmaintenancefluids(adults2500- 3000cc/24hrs) | 8hrs | 8hrs | 8hrs | 24hrs | tob ½deficit ¼deficit addmaintenanceinchildren ¼deficit maintenance bothchildren& adults monitoringadequacyoffluidresuscitation • thebestandmostreliablemethodisbymonitoringtheurine output • adults0.5cc/kg/hr~30-50cc/hr • children1.0cc/kg/hr • iftheurineoutputisbelowthislevelgiveextrafluids, eitherbygiving IV bolusesof5-10 cc/kg orbyincreasingthefluidintakeoverthenexthourto150%of theplanned volume • whentheurineoutputneedstobemonitoredcloselyanindwellingurinary catheterisnecessary.Makesurethecatheterisremovedafter48hours,itwill causeinfectionifleftintoo long • restlessness,confusionandanxietyaresignsofhypovolaemia (shock)and thefirstresponseistoassesstheadequacyofthefluidresuscitation • in childrenit is important to look forhypoglycaemia,to preventthis early enteralfeedingwithcarbohydratesisuseful • if possible check electrolytes, children are also prone to hyponatraemia
42BurnsManual Problemswithresuscitation • oliguria(urineoutput<20cc/hror<0.5cc/kg/hr)meansinsufficientfluid resuscitation,donotgivediureticstocorrectthis,giveextrafluidinstead • extrafluidresuscitationmaybenecessaryin - children - inhalationinjury - electricalinjury - delayedresuscitation Keypoints for clinicalpractice ɶfluidresuscitationisessentialforsurvival ɶIVresuscitation in children >10%TBSAburned adults >15%TBSAburned ɶthedeficitiscalculatedasfollows: child(<30kg) 4ccxwtinkgx%TBSAburnplusmaintenanceadult 4ccxwtinkgx%TBSAburn ½ofdeficitinthefirst8hours(fromthetimeoftheburn), ½overthenext16hours ɶchildrenneedcarbohydratesearly ɶuseRinger’sLactateinthe1st 24hours ɶforthe1st 48hoursinsertaurinarycatheterinburns>20%TBSA ɶmeasurePCV/Hb,bloodglucoseandelectrolytes ɶconstantreassessmentandappropriatereadjustmentofthefluidregimenarevitalmeasures tobetaken
3Hospitaltreatment 43 Painrelief What youshouldknow • aburnhurtslike hell • regularsleepisimpossible What to do • atregularintervals(4-6hourly)giveopiatesIVorIM • usemorphine(notinneonates),give0.1mg/kg/dose,donot useitmore frequentlythanevery2hours • ifmorphineisnotavailableusepethidineinstead,1-1.5mg/ kg/dosetobe given4-6 hourly • forchangeofdressingsuseketamine,2mg/kg/doseIMis recommended • after48hoursuseParacetamol,give15mg/kg/dose(maximum doseper24hours=4gin adults) Keypoints for clinicalpractice ɶuseopiatesinthefirst48hours ɶgiveatregularintervalsandnot PRN ɶuseketamine(2mg/kg/IM)forchangeofdressings
44 BurnsManual Nutrition What youshouldknow • earlyfeedingisimportantbecausethepassageoffoodthroughtheintestines - protectsthesmallbowelmucosafromdamagethatoccursafterstarvation andtraumaandso - preventstranslocationofbacteriathroughthebowelwall, whichmayleadto gram-negativesepsis.Thisisoftenfatalin severeburns • duetoariseinthemetabolicrateinsevereburnsprovisionof approximately2 to3xtheusualamountofenergyis required • thebodytemperaturerises(upto39°)andanyskincoolingwillcausea furtherriseinmetabolicrate • attheburnsite,wherethebloodflowmayincreasetenfold, theO2concentrationremainslowandthewoundtissuesuseanaerobic glycolyticpathways;inotherwordslargeamountsof glucoseareconsumed • thereisanincreasedbreakdownofproteinwith80to90%of thenitrogenlost intheurineasurea;thereisaconcomitantlossofleanbodymass.Aburnof 40%TBSAcancauseweightlossof30%withinafewweeks • in ourenvironmentpatientsareoftenundernourished.They arefromthe startwhenaburnissustained,nutritionallyatadisadvantage • there is also loss of vitamins and minerals due to skin loss and muscle breakdown
3Hospitaltreatment 45 What to do • keeptheambienttemperaturehigh • giveextrafeedshighin caloriesandproteins,suchasLikuni phala,high energymilk,Plumpy’nutandcommercialfeeds likeProNutro(see Ch 19,page129) • supplementwithVitaminsAandC,IronandZinc • useaggressivenutritionaltreatmentforburns>20% TBSA • inthisgroup(>20%TBSA)preferablystartnaso-entericfeeds 24hourspost burn • usethefollowingformulas - adultsproteins1g/kg+ 3g/%burn calories20kcal/kg+ 70 kcal/%burn - childrenproteins3g/kg+ 1g/%burn calories60kcal/kg+ 35 kcal/% burn • giveextrafeedstwicedailyinburnsupto20%;increasethefrequencywhen TBSAis>20%(see Ch19,page129) • preferablyfeedbymouth,ifthisisnotpossiblefeedbythesmallest possiblenasogastrictube • weighpatientsatleastonceaweek Keypoints for clinicalpractice ɶearlyfeedingisimportant ɶaddVitaminA&C,IronandZinc ɶinpatientswithburns>20%TBSAaggressiveearlyfeedingisessential ɶgiveinburnsupto20%TBSA2xdailyextrafeeds ɶinpatientswithburns>20%TBSAgiveextrafeedsaccordingtotable (see Ch19,page 129) ɶpreferablyfeedbymouth ɶweighpatientsatleastonceaweek
46BurnsManual Burnwoundcare What youshouldknow • awoundisadisruptionoftissuearchitectureandcellularprocesses • thethermalinsult(heatorcold),electricityorchemicalactioncause denaturationofproteinsandadisruptionofcellularstructures • aburnwoundinterfereswith - temperatureregulation - sensoryfunction - immuneresponse - protectionfrombacterialinvasion - protectionfromfluid loss • aburnwoundisheterogenousi.e.notallareasoftheburnareequally deep • aimofthetreatmentistominimizethedisruptionoffunction locallyaswellas systemically • thereforeanasearlyaspossiblehealedwoundisvitally important
3Hospitaltreatment 47 What to do • firstaid(see Ch2,page28) • cleantheburnwound - byhandheldshoweringtoremovedirt,dressingetc. - cleanfurtherbyusingHibicet® (Savlon® )ornormalsaline - opentheblistersandremoveloosetissue • earlyactivedebridementandSSg,considerthistreatment5dayspostburn inallpatientswithfullthicknessordeepdermal(=partialthicknessdeep) burnsofthehands. Thismaynotbepossibledueto - thegeneralconditionofthepatient - superimposedillnessortrauma - anaemia - inhalationinjury • delayedconservativemanagement,therearebasicallytwo approaches exposureoftheburnwoundisonlypossibleinacleananddryenvironment; after3-4daysadryandadherentslough(=eschar/crust)develops,whichactsasa barrieragainstinfection.Thisisachievedby - cleaningthewoundwithnormalsalineorHibicet®(Savlon®) - removingloosetissueandderoof blisters - allowingtheburnwoundtodryandtoformacrust(3-4days) - fromthenonthewoundcanbecleanedpreferablytwicedailywithnormal salineorHibicet®(patdryaftercleaning)andthepatientcanbebathed;after 10-14daystheburnhashealedorthesloughwillseparategraduallyleaving agranulatingwoundsurfacewhichcanbegrafted Beaware,thatinawarmandmoistenvironmenttheescharactsasaculture medium. Nursethepatientunderabedcradle(see figure)andunder mosquito netting.
48BurnsManual Closedwoundtreatmentinwhichdressingsareused. Thedressingisthebarriertoinfection,tobeeffectiveananti- bacterialtopical agenthastobeaddedotherwiseitwillcreateawarmandmoistenvironment whichactsasaculturemediumforbacteria. Examplesoftopicalagentsare - aceticacid0.5%,actsagainstPseudomonas,analternativeisdiluted vinegar - eusolinparaffin(EP)isusedtoremovesloughandtoinducegranulation tissueformation.IfnoEPisavailablesoakVaselinegauzeinEusol,applya layerofgauzesoakedinEusoloverit andcoverthesewithdrydressingsand abandage.IfawaterysolutionofEusolisusedthenthebandagedriesvery quickly - honeymixedwithghee,vegetableoil,glycerineorwateris activeagainst Staphylococcusaureus - papaya,alsohasantibacterialpropertiesandreducestheformationof hypergranulation - povidone- iodine(Betadine®)ointment,isactiveagainst Staphylococcusaureus - silversulphadiazine(Flamazine®),isactiveagainst StaphylococcusaureusandPseudomonasaeruginosa - silvernitratesolution(AgNO30.5%),asabove
3Hospitaltreatment 49 - tannins,madefromteaoritsbyproducts,willleadto improvedwound healingandreducedscartissueformation (fewerhypertrophicscars) - zincoxidecreamhasanantibacterialactionandpossiblyreducesthe formationofhypergranulation (see Ch17howtoprepareandtoadminister,page121) differencesbetweenthetwotreatmentoptions open closeD costs Low High infection Pseudomonasrare Pseudomonascommon laBour intensiVe Low High pain Painful Lesspainful eVaporation High Low heat loss High Low THEREISNO DIFFERENCEINSURVIVAL RATE
50BurnsManual Generalremarksondressingtechniques • preferablyuseafreshdressingpackforeachpatient • ideallydresstheburnwoundoncedaily.Withtheuseof honeyandzinc oxide,thedressingcanbeleftundisturbedfor2-3 days • removedressingsgently,otherwisenewlyformedtissuewillbedestroyed.Soak thedressingsinabathwhentheyareadherenttothewound • askthepatienttoparticipateinthetreatment,e.g.removalof dressings • batheorwashthepatientafterremovalofthe dressing • preferablytreatchildrenintheirroomorwardasthatisasafeenvironmentfor them • begenerouswithketamineespeciallyinchildren(see Ch 16,page118) • beeconomicwithgauzesanddressings,theyareexpensive
3Hospitaltreatment 51 Physiotherapy What youshouldknow • maintaining movement and appropriate position of all joints is essential becauseofthetendencyofcontractureformation indeepburns • preventionofcontractureshastostartrightfromthebeginningin thefirstfewdaysafteraburninjury • burnpatientstendtokeeptheirjointsinthe‘positionofcom- fort’andthiswill leadtocontractureformation • duetopainanddiscomfortburnpatientsdon’tmoveandmay developpressuresores What to do • topreventcontractureskeep - theneckinextension - theaxillainabduction - theelbowsinextension - thewristsneutralorin extension - themetacarpophalangealjointsinflexion - theinterphalangealjointsinextension - thekneesinextensionand - theanklesin90˚dorsiflexion • takeverygoodcareofpressuresoreareassuchasoccipital, sacraland calcanealareasandturnpatientsevery2hours24hoursadaytopreventthe developmentofpressuresores • mobilizepatientsasearlyaspossible • involvephysio-andoccupationaltherapistsatanearlystage(see Ch4, page59)
52BurnsManual Bacteriaandinfection What youshould know • infectionismainlyspreadbythehandsofthehealthcareworker • mostburnwoundswillbecolonizedwithbacteriaasearlyas3daysafterthe burn • whereitisnotpossibletoperformwoundcultureslookatthewoundandthe dressings,e.g.withPseudomonasinfections thedressingslookbluegreenand withStreptococcusinfection thewoundisoftenbrightred • microorganismsmostcommonlyseeninburnsare - Staphylococcusaureus - Pseudomonasaeruginosa - ßhaemolyticstreptococcus - Escheriacoli - Proteusmirabilis - Klebsiellapneumoniae - Candidaalbicans • intheearlystagesofaburn(first5days)theburnwoundiscolonized primarilywithgram-positivebacteriasuchasStaphylococcusaureus, laterfollowedbygram-negativebacteriasuchasPseudomonas • sepsis is adocumented infection with systemic inflammatory response syndrome(SIRS), whichis presentwhen2ormore ofthefollowingare found - temperature - heartrate - respiratoryrate - WBC > 38°Cor<36°C > 90beatsperminute > 20breathsperminute > 12000cellsor<4000cells/mm3
3Hospitaltreatment 53 • septicshockisasabovetogetherwithasystolicBP<90mmHgoradropinBP of>30mmHgdespiteadequatefluid resuscitation • beawareofotherpossibleinfectionssuchasmalaria,pneumonia, urinarytractinfectionsetc. What to do • usealcoholichandrub(AHR)inbetweenpatientsandwashhandswhen theyhavebeensoiled(see Ch16,page118) • takewoundswabswhenawoundinfectionissuspected • becautiouswiththeuseofurinarycathetersandiftheyarenecessary removethemassoonaspossible • incaseofsepsisstartwithacombinationofbroadspectrumantibioticse.g. chloramphenicolandgentamicine,takeimme- diatelyawoundswab&blood forbloodcultureandwhentheresultsareoutchangetothemostappropriate antibiotics • useantibioticsinshortcourses(notmorethan5days),usetheappropriate dose;itisbesttouseashighaspossibleadosefor theshortestpossibletime • givetheantibioticsintravenouslyuntilthefeverisdown,thenadministerorally • usetheappropriatetopicalagentse.g.silvernitrateoraceticacidfor Pseudomonas What not to do • donotgiveantibioticsprophylactically • donottreataninfectedwoundwithsystemicantibiotics unlessthereare signsofsystemicinfection
54BurnsManual Keypoints for clinicalpractice ɶcleantheburnwoundwithsalineorHibicet® (Savlon® ),deroofblistersandremoveloosetissue ɶtreateitherbyexposureorwithdressingswithantibacterialtopicalagents ɶalternatedifferenttopicalagents ɶtreatdeepburnsofthehandpreferablywithearlydebridementandskingraft (after5days) ɶbegenerouswiththeuseofketamineasananalgesicespeciallyinchildren ɶpreventcrossinfectionbyusingalcoholichandrubinbetweenpatients ɶwhenapatientisconfusedand/orirritablewithalowbodytemperaturethinkofsepsis ɶwithsuspectedsepsisuseacombinationofbroadspectrumantibiotics,giveshortsharpIV courses ɶdonotusesystemicantibioticsprophylacticallyorininfectedwoundswithoutsignsofsepsis,treat theinfectedwoundwithtopicalagentsinstead Closureoftheburnwound What youshouldknow • superficialdermalburnswillhealwithin10-14days • deepdermalburnswillhealwithin21-28days • anyburnnothealedafter21to28daysandlargerthan3cmindiametermay benefitfromaskingraft • aHbof12g%(minimumof8g%)oraPCVof40% (minimumof 24%)andagoodnutritionalstateareessentialforoptimalwoundclosure • fullthicknessburnsalwaysrequiresurgicalclosure(SSG, fullthickness graft,pinchgraftorflaps) • deepburnswillneeddesloughingeitherbydressingswith Eusolorby surgicaldebridement • allburnsrequiringskincovershouldbegraftedassoonaspossible,this reducesthechanceofinfection&anaemiaandletthepatientreturntoa positivenitrogenbalance
3Hospitaltreatment 55 • beforeasplitskingraftisappliedthewoundshouldbeclean,hashealthyflat granulationsandpreferablynobacteria(oralowcount,<105 or≤2+) • therearethreekindsoffreeskingraft - SSg(splitskingraft),takeswell,thethinnerthegraftthebetterthetake,is cosmeticallylesssatisfactory,shrinksin timeupto50%,ismostcommonly usedandcancoverlargeareasespeciallywhenmeshed - fullthicknessgraft,takeswithmoredifficulty,iscosmeticallybetterandwill shrinkupto20% - pinchgraft,iseasytodo,thecentreisfullthickness,thesidespartialthickness, resistspressureandinfectionwellandis recommendedforsmalldifficult areassuchasbackoflowerlegovertheAchillestendon • graftfailureisdueto - infection(takeawoundswabif possible) - bleeding(graftisliftedofits bed) - anaemia - movement(makesurethegraftisfixedwell) - unhealthygranulations,hypergranulationsornogranulationsatall • bestdonorareasare - foraSSG,thighs,upperarmsandflexoraspectoftheforearm - forafullthicknessgraft,postauricularskin,supraclavicularskinandthe groin - forapinchgraft,thethighs
56BurnsManual What & how to do • consideraskingraft - indefectslargerthan3cmindiameter - whenthewoundhasn’thealedafter21days • graftearlyinhandandfacialburns • howtotakeaSSG(see Ch14,page106) • theyaresutureddirectlyorsometimeswitha‘tie-over’suture(see Ch14, page110);whenappliedtoanarmoralegtheycanbefixedwithawell appliedbandage • shouldoverlapattheedges • maybemeshed(see Ch15,the‘Pizzacutter’,page111) • areplacedoverflexureswhicharemaximallystretched(andsplinted) • aredressedwithvaselinegauzepreferablysoakedinsilvernitratesolution 0.5%orwithSSD • areinspectedafter5daysunlessthewoundsmellsverybadlyearlieron,then inspectimmediately • whenthegrafthastakendressagainwithVaselinegauzeandbandage,after 10-14daysnodressingotherthanaprotectivebandageforanother2weeksis necessary.ApplyVaselineoroilycream(e.g.coconutoil,thereissome evidencethatit reducesthechanceofthedevelopmentofahypertrophicscar) tokeepthegraftedareasupple • applyonthedonorareaimmediatelyaftertakingtheskingraftgauzessoakedin ‘junglejuice’(see Ch16,page117)duringtheoperationandafterfinishing theoperationapplyVaselinegauzesoakedinsilvernitrateorSSDandleave undisturbed for10days.If,whenchangingthedressing,thegauzesarestill stucktothe donorareadonotremove,butinsteadapplyafreshbandageontopofthem
3Hospitaltreatment 57 do notapplyaskingraftif • thewoundiscolonizedwith - Streptococci(ßhaemolytic),seenonaGramstainorwhentheburn woundlooksbrightredandbleedseasily - Pseudomonasaeruginosa(bluegreenpus) • thereisaheavygrowthofbacteria>105or>2+ • hypergranulationispresent,treatwithzincoxideorpapayadressingsor scrapeawaybeforeapplyingthegraft • thewoundbedisfibrouswithoutgranulations • thepatientisotherwiseunwell Keypoints for clinicalpractice ɶconsideraSSGwhenthewoundhasnothealedafter21daysandis>3cmin diameter ɶgraftonlywhenaburnwoundhashealthygranulations, theHbis>_8g%orPCV>_24%&thepatientiswellnourished ɶfixgraftsecurely ɶinspectagraft5dayspostoperatively ɶleavethedonorareaundisturbeduntilithashealed ɶagraftremainsfragilefor3weeks ɶkeepsupplewithVaselineoroilycreamandbandagetoprotect
58BurnsManual
4Rehabilitation&reconstruction 59 4 rehABiliTATioN&reCoNSTrUCTioN What youshouldknow • maintainingmovementofalljointswiththehelpofphysio- and occupationaltherapistsisessential • burnsthattakelongerthan2weekstohealmaydevelophypertrophic scarring,physio-andoccupationaltherapymightberequiredtodeal withthisusingelasticbandagesandpressuregarments • pressuregarmentsareusedinthetreatmentofhypertrophicscars • managementofkeloidsismoredifficult • contracturesarepreventable • aburnpatientmaysufferpsychologicallyasaresultofpostburncosmetic disability(bodyimage)andmayneedhelpfromfamily,professionalsand friendsafterheorshehasbeendischargedfromhospital KeloiDs&hypertrophicscars Bothoccurasaresultofanexaggeratedwoundhealingresponse,butthecauseis unknown ɶkeloidsarefloridlesions,aregrosslyelevated,spreadandinvolvethenormalsurroundingskin, aretendertotouchandfeelitchy&hot ɶhypertrophicscarsareraised,initiallyred,donotinvolvethesurroundingnormalskinand eventuallyregress Thesedescriptionsaretheextremesandassucheasilyrecognizedbutinrealitytherearesimilarities andalsogradationfromonetotheother.Becausethetreatmentisoftensimilarthenameis thereforeoflessimportance,butkeloidsarenotoriouslydifficulttotreat
60 BurnsManual What todo • physicalscarringisbestpreventedbymaintainingcleannon-infected woundsandprovidingearlyskincover • hypertrophicscarsneedtobetreatedvigorouslybyphysio- and occupationaltherapistswithcustomfittedpressuregarmentsforaslongas 6-12monthsoruntilrednessanditchinesshavedisappearedandthescar hasflattened • keloidsaremoredifficulttodealwith,insmallkeloids (<2cm)intralesionalinjectionswithcorticosteroids(e.g. 0.5-1ccmethylprednisolone/ triamcinolone)every4-6weeksuntilflattening hasocccurredcanbehelpful,alargerkeloid canbeexcisedwithinits boundariesfollowedoneweeklaterbyintralesionalinjectionswithsteroids (weeklyintervalsx3, then6weekintervalsx3) • forbothhypertrophicscarsandkeloidstheuseoftopical siliconegel sheetshasbeenintroducedwithgoodresults. Itdecreasesthepain&itchingandresultsinflatteningof thescar.Themodeofactionisunclear.Itisparticularlyusefulinchildren.The sheetscanbewashedandreused • contracturescanbepreventedorreducedby - movementsofalljointsseveraltimesaday - passiveaswellasactivestretchingofjointsaffectedbyaburn - activitiesandgamestoachievethis - splintsandskintraction - pressuregarments - earlyclosureoftheburnwound • whenthisfailssurgicalreleaseofthecontracturemaybecarriedout whenithassoftened,6-12monthslateron • basicprinciplesforcontracturereleaseare, - transversereleasingincisions,ratherthanZ-plasties - serialreleasesandSSGforseverecontractures - occasionaluseoffullthicknessgrafts - theuseofflaps(random,axial,fascio-cutaneous)forthe moredifficultcontractures
4Rehabilitation&reconstruction 61 • giveseverelyburnedpatientsmaximumsupport,theyhavetodealwitha changeinbodyimage,lossofmoraleandsubsequentdeformities • givethemloveandshowcompassion;theyoftenneedsocio- economic support(extrafood,specialappliances,clothing) Keypoints for clinicalpractice ɶfrequentactiveandpassiveexerciseofalljointsis essential ɶcontracturesarepreventedbyexercises,splintingandtraction ɶtreathypertrophicscarswithpressuregarments ɶtreatmentofkeloidsisdifficult ɶaburnpatientwillneedpsychologicalsupportfromprofessionalstaff aswellasfrom relatives,friendsandcolleagues
62BurnsManual
5Burnsinchildren 63 5 BUrNSiNChildreN What youshouldknow Epidemiology • inyoungchildrentherearemorehotwaterburns(scalds),whileinolder childrenflameburnsaremorecommon Anaccuratehistoryisimportant,particularattentionshouldbegiventothenon- accidentalburn(childabuse) Bodysize&proportions • achilddiffersfromanadultinoverallsurfaceareatobodyweightratio leadingto - highermetabolicrate - greaterevaporation(waterlossthroughburnedarea) - greaterheatloss • alsoinachildtheheadandneckarecomparativelylargerthaninanadultand thelegsarecomparativelysmaller • inachildupto1yearoldtheheadandneckare18%oftheTBSA, whereaseachlegis14% • foreveryyearoflife>1yeartheheaddecreasesby1%, whereaseach leggains0.5% • byusingthismodificationoftheruleofninesitcanbeseenthattheadult proportionsarereachedattheageof10years Depthoftheburn • theskininchildrenismuchthinnerthaninadultsresulting indeeperburns, forexamplewaterof60˚Cwillcauseafull thicknessburn - inlessthan1secondinaninfant - in5secondsinanolderchild - after20secondsinanadult • burndepthassessmentismoredifficultthaninanadult, andcan remainsoupto7-10dayspostburn
64BurnsManual Fluidmanagement • differencesbetweenchildren&adults - inachildahigherproportionofbodywaterisextracellular,bloodvolumeis 80cc/kg(neonatesandbabies90cc/kg) comparedto60-70cc/kgin adults - renaltubularconcentratingcapacityisless,thismayleadto morerapidand greaterfluidloss - fluidoverloadontheotherhandmayquicklyleadtocerebraloedema, especiallyincombinationwithhyponatraemia. Thisriskcanbereducedbytheuseofcolloidsafterthe first12hours postburnandbythehead-uppositionin thefirst24hours • assessmentoffluidstatus - achildhasgoodcompensatorymechanisms,thusthecirculationis seeminglywellmaintainedinthefaceofafluid deficit,alsosignssuchas anxietyandagitation,whichareusefulsignsofshockinadultsarelesshelpful inchildren,becausetheymayoccurforotherreasons - subtlesignsofhypovolaemiaare - generalappearanceofthechild - skincolour& temperature - venousfilling • urineoutput - themostreliablewaytoassessfluidresuscitationisthemeasurement oftheurineoutput(1cc/kg/hr,range0.5-2cc/kg/hr),duetotheuse offinetubesforcathe- terisation,mechanicalobstructionofcathetersdoesoccur - whenurineoutputisinadequatecheckthereforefirstthepatencyofthe catheter,ifthisisfine,extrafluidbolusesshouldbegiven • intravenousaccess - can be difficult, cannulate larger veins (e.g. femoral vein) only if expertiseis available,cannulation through burned skin is acceptable althoughmoredifficult,intraosseous accessisrelativelysafeforashortperiodoftime(8-12 hours)
5Burnsinchildren 65 • maintenancefluids - arenecessaryin childrenandshouldcontain glucose,hypo- glycaemia especiallyinassociationwithhypothermiaoccursveryrapidly Airway • occultupperairwayobstructioniscommoninchildren, enlargementof adenoidsandtonsilsmayexistbeforetheburninjury • thelowerairwayisnarrow,thereforeswellingofthemucosaand accumulationofsecretionsinterfereswithoxygenation • breathingbydiaphragmaticmovementismoreimportantin children,this meansthatabdominalwallrigiditymayinterferewithoxygenation,considerin burnsoftheanteriorchestandupperhalfoftheabdomenescharotomies (see Ch20,page103) Gut • childrenaremorepronetogastricdilatationandtheytendto swallowairwhen crying,anasogastrictubecouldthereforebehelpfulinburns>20%TBSAfor thefirst48hours • becauseoftheirhighmetabolicrateandnutritionalneedsfor growth,children shouldbegivenearlyfeeds(after24hours)enterally;thisalsopreventslossof gutfunction (see Ch3,page45) Non-accidentalinjury • suspicionmayberaisedby - vagueorinconsistenthistory - historynotcompatiblewithpatternof burn/injury - presenceofothersignsoftrauma - certainpatternsofinjurysuchascigaretteburnmarksorsharp demarcationsasin‘bilateralshoe&sockscalds’ • notethatfalseaccusationisverydamagingtotherelatives,unusualand bizarrepatternscanbecausedbyaccidentalinjury
66BurnsManual Temperature • childrenoftenrunhightemperaturesinthefirstfewdays,unlessitexceeds 39°C,itwillneednotreatment.Beawareofmalaria,checkincaseoffever alwaysbloodformalariaparasites(MP’s) What to do • estimateTBSAburned(see Ch13,page87) calculate andgivethedeficitplusmaintenance(see Ch13,page 90, 92) - after12hoursreplacecrystalloidswithifpossiblealbumen 4.5%inaliquots eachaliquotis0.5xwtinkgxburn%TBSA giveeach aliquotover6,6and12hourscontinuemaintenance withcrystalloids • monitortheadequacyofthefluidresuscitationbymeasuringtheurineoutput (see Ch13,page90) • assessthefluidstatusbylookingatthegeneralcondition (irritable, restless),skincolour&temperatureandvenousfilling • giveadequateanalgesia(see Ch3,page43) • lookattherespiratoryrate,giveoxygen • consideraNGT inburns>20%TBSA • keepthechildwarmandtheambienttemperaturehigh • nurseinhead-uppositionintheshockphasetopreventcerebral oedema • preventhypoglycaemiaandhyponatraemia,checkblood glucosewith dextrostixandcheckelectrolytes.Ifthisisnot possibleuseasmaintenance fluidhalfDW 5-10%andhalf NSwith20mmolKCLperlitre • startenteralfeedingasearlyaspossible(after24hours)
5Burnsinchildren 67 Exampleoftheadministrationofalbumenafter12hoursinachildof10kgwithaburnof30% TBSA deficitforcrystalloidsis4x10x30=1,200cc600ccgiven in1st8hrs 150ccgiveninnext4hrs thengivealiquotsofalbumencalculatedasfollows: 0.5x10x30=150cc 150ccinnext6hrs150ccin next6hrsand150ccinnext12 hrs thatmeansthatafter36hoursthischildwillhavereceivedatotalof 750cccrystalloids plus450cccolloids=1,200ccIVinfusion giveatthesametimemaintenancewithcrystalloidsandcontinuethisforanother12hours(i.e.until48 hoursafterthestartofIVresuscitation) Keypoints for clinicalpractice ɶgreatermetabolicrate,heatlossandevaporation ɶsmallerrenaltubularconcentratingcapacity ɶhigherextracellularproportionofbodywater ɶaddtocalculateddeficitmaintenancefluids ɶwithsodiumandglucose ɶurineoutputtoassessthefluid resuscitation ɶintraosseousaccessissafeforashortperiodoftime(8-12hours,max.24hours) ɶearly(after24hours)enteralfeedinghighincaloriesandprotein (2-3xhigherthan thenormal)is essential All3leadtoamore rapid&greaterfluid loss
68BurnsManual
6Inhalationinjury 69 6 iNhAlATioN iNJUrY What youshouldknow Thereare3typesofinhalationinjuries • airwayinjuryabovethelarynx,thisisaburnduetoinhalation ofhotgases, mostcommonlyoccurringinanenclosedspace.Theyproducethesame changesasinathermalinjuryoftheskinresultinginoedemaleadingtoairway obstruction. Thisoftendevelopsatthetimeofmaximalwoundoedema(12-36hours postburn).Thistypeofinjuryisrelativelyuncommon • airwayinjurybelowthelarynx,isproducedbyinhalation oftheproducts of combustion • systemicintoxicationinjurybycarbonmonoxide(CO) from exhaustfumes& heatersandbycyanidefromburningplastics. CO hasamuchgreateraffinitytotheHbmoleculethanO2, thisleadsto tissueanoxia.Cyanideisrapidlyabsorbedbythe lungsandmaycauseloss ofconsciousnessandconvulsions Diagnosisofinhalation injury Inhalationinjuryispotentiallyfatal,thereforelookinallcasesof severeburnsfor • increasingrespiratoryobstructionoccurringoverseveralhours (thisisseenin injuriesabovethelarynx) • abnormalitiesinoxygenationasshownbyrestlessnessand confusion( thisisseenininjuriesbelowthelarynxandin systemicintoxication) Clinicalfindingssuggestiveofinhalationinjury are singednasalhairs productivecoughcroup- likebreathingrespiratory problems • burnstomouth,nose • sputumwithsoot • changeofvoice • inspiratorystridor What todo
70BurnsManual Abovethelarynx • closeobservation,ifstridorandrespiratorydistressoccurproceedto endotrachealintubation Belowthelarynxgiverespiratorysupport • humidifiedO2, 8litresperminutepreferablybyfacemask(non- rebreathingtype) • intubateifhigherO2concentrationsarerequiredorif bronchialtoilet isnecessarytoremovesecretions Insystemicintoxication • giverespiratorysupportwithhumidifiedO2(graduallyCO andcyanideare removedfromthebody,althoughforcyanideitdoesnotoccuraseffectively asforCO) • placetheunconsciouspatientinleftlateralcomaposition Keypoints for clinicalpractice ɶinhalationinjuriesarepotentiallyfatal ɶthediagnosisdependsstronglyonclinicalsuspicion ɶemergencytreatmentreliesonadministeringrespiratorysupportwith oxygenandpossibleendotrachealintubation ɶmortalityincreasesby30-50%
7Burnsofthehand 71 7 BUrNSof ThehANd What youshouldknow • thedorsumofthehandhasathinskinandthepalmathick skin • thefunctionofthehandandfingersisjeopardizedinsevereburnsifno promptandpropertreatmentisgiven • thedepthisdifficulttoassess • earlyskincoverisessential(ifafter5-7daysthereisnosignofhealing considerdebridement&grafting) • electricalburnsarealmostalwaysfullthicknessburns • beawareofthedevelopmentofacompartmentsyndrome What to do Intheacutestage(1-7days) • removedirtandadherentmaterialexcepttar • washcopiously,tapwatermaybeused • leaveblisters,whichdon’tinterferewithmovementorcirculation, undisturbed • applySSDandeitherputthehandinaplasticbagordressthefingers separatelytoavoid webbing • elevatethehandsonpillowsorwithasling • changedressingsdailytoassessthedepth • earlymovementoffingersandwristjointsareessential • insevereburnsgiveavolarsplintwiththehandinthepositionofrest(wristin 20˚extension,MCPjointsflexed70˚andfingers[IPjoints]straight) • performescharotomiesandfasciotomieswhendeemednecessary (see Ch14,page97etseq.) Intheintermediatestage(1-3weeks) • continuewithmobilization(activeandpassivemovements)&splinting • applyskingraftstobareareas
72BurnsManual Inthelongterm(after3weeks) • treathypertrophicscarswithpressuregarmentsfor 6-12months • contracturescanbemultipleandsevere,preventthemfrom occurringby goodearlytreatment • whencontractureshavedevelopedtheyhavetobereleasedsurgically Keypoints for clinicalpractice ɶearlyandappropriatetreatmentwillpreventcomplications ɶdebrideandperformskingraftsrelativelyearly ɶbeawareofcompartmentsyndromeandtreataccordingly ɶtreathypertrophicscarswithpressuregarments ɶestablishedcontracturesneedtobereleasedsurgically
8Facialandperinealburns 73 8 fACiAl ANd PeriNeAlBUrNS What youshouldknow • arecausedbyhotwater,fireorexplosions(paraffinlamps) • areoftendeepburns,butbecauseofagoodbloodsupplyfacialburnshealvery well • eyesmaybeinjuredbyexplosionsorchemicalsubstances • severelyburnedeyelidsmaycauseexposureofthecornea,ectropion andscarring • theskinofthetipofthenoseandearsisthinthereforecartilageoftenisalso burnedand/ orexposed(especiallythehelicalrim) • mouthandlipsareinjuredbyinhalationorchemicalingestion • inburnsoftheperineumandgenitalia,retentionofurinemayoccurduetothe developmentofoedema What to do General • cleanthoroughly • applytopicalagentsdaily • graftearlyandpreferablydonotusemeshgraftsinfacial burns,theywill givepoorcosmeticresults • infacialburnsnursein(semi)uprightpositionandwatchforsignsof inhalation(see Ch6,page69) Eyes • firstaid,washcopiouslywithwater(inchemicalburnsatleastfor1 hour)andcoverwithsterilepad • inhospital,evertthelidandremovesolid particles • applychloramphenicol1%ointmenttdsfor15days • insevereoedemajustcleanandwaituntiltheoedemahassubsided • ifthecorneaisexposeddoatarsorrhaphy • consulttheopthalmologistearly
74BurnsManual Eyelids • indeepburnsoftheuppereyelidsearlygrafting(between3and5days)is important • ectropionbecauseoflidretractionwillneedareleasefollowed byafull thicknessgraft Ears • exposedcartilageshouldberemoved • repeatedcleaningshouldbecarriedout • earlygraftingisbest Mouthandlips • copiouslavageinchemicalburns • earlyandselectivedebridement • applyplainVaselinetolips • topreventbleedingdonotremovecrusts Perineum&genitalia • insertacatheterandorobserveurinaryoutputcarefully • leaveburnsexposedpreferablyuntilhealed,thisareagetseasilysoiledwhen dressed,especiallyinsmallchildren • ifadressingisrequireduseVaselinegauze,changefrequently • observebowelmovements Keypoints for clinicalpractice ɶ washthoroughly ɶ cleanthoroughly ɶearlydebridementandskincoverage ɶconsultopthalmologistinanearlystage ɶbeawareofretentionofurineinperinealburns
9Electricalburns 75 9 eleCTriCAl BUrNS What youshouldknow • electricalburnsaredividedinto - lowvoltage(<1000volts),householdsupply - highvoltage(>1000volts),powersupply(e.g.ESCOM) - lightning,extremelyhighvoltage,shortduration,peculiarinjurypattern • tissue damage is caused by the generation of heat and depends on the resistanceofthetissues;skinandbonehaveahighand bodyfluidshavealow resistance • ahighconcentrationofcurrentandahighresistancecauseintenseheat • lowvoltagecurrentwillcauselocalcontactwoundsbutno deeptissue damage;itmaycausecardiacarrest • highvoltagecurrentcausesinjuryin2ways: - flashburn,thecurrentdoesn’tpassthroughthevictim,but theflashignites forexampletheclothes - transmissionofcurrentresultsinskinanddeeptissuedamage,thisisalwaysfull thickness;swellingwithinthelimbsmayproducesignsofacrushinjuryanda fasciotomymaybenecessary.Alsorenalfailureduetohaemolysisand myoglobinreleasefromthemuscleinjurymaydevelop • lightningcausesahighmortalitywhenthevictimisstruckdirectly,incaseofa sideflash(whenlightningstrikesatreeandthecurrentisthendeflected throughavictimonitswaytotheground)itcancauseavarietyofburn wounds,partial andorfullthickness
76 BurnsManual What todo • removethevictimfromthepowersource,beaware,thathighvoltageelectricity willdischargethroughair;40000voltswill jump13cm,ifyoucan’tturnoffthe poweruseapieceof woodtoseparatethevictimfromthepowersource, preferablystandonapieceofrubberorwearrubberboots • onceclearstartwithprimarysurveyasinanyburninjury • duetomuscleinjury(whichcanbeconcealed)thefluid requirementsare greaterthaninapureskinburn,aimfor aurineoutputof75-100cc/hror inchildren1.5cc/kg/hr especiallywhenthecolouroftheurineisdarkred • incaseofacardiacarrestadministerCPR • assesstheperipheralcirculationhourly,lookat/for - skincolour - oedema - capillaryrefill - peripheralpulses - sensorychanges • whenthefollowingsignsandsymptomsarepresent - apalpablytenselimb - painonstretchingmuscles - paraesthesia - a(not)palpablepulse - abriskcapillaryrefill acompartmentsyndromehasdeveloped,thisrequiresanurgent fasciotomy(see Ch14,page99etseq.)
9Electricalburns 77 Keypoints for clinicalpractice ɶavoidinjurytothosegivingfirstaid ɶtreatcardiacandrespiratoryarrestpromptly ɶmonitortheheartforatleast24hours ɶstandardburnsresuscitationformulaemaybeinsufficientduetothemuscleinjury ɶwatchformyoglobinuria(darkredurine),inthatcaseincreasethedriprateandaimforanhourly urineoutputof75-100cc(inchildren1.5cc/kg/hr)until theurineisclear ɶwhenacompartmentsyndromeissuspectedperformanurgentfasciotomy
78BurnsManual
10Chemicalburns 79 10ChemiCAlBUrNS What youshouldknow • morethan25000productswhichcancausechemicalburnsareavailablefor useinagriculture,household,industryandmilitaryforces • handsandupperlimbsaremostlyaffectedduetohandlingofthese substances • commonlyusedchemicalscapableofproducingburnsare: - household - industrial -military bleach,disinfectants,toiletbowlcleanersalkalissuch aspaintremovers,causticsoda,lime,washing powders acidssuchashydrochloricacid phosphorus • achemicalagentproducesprogressivedamageuntilitis inactivatedby aneutralizingagentordilutedwith water • estimationofdepthmaybedifficultinthefirstfewdays • somechemicalsproducesystemictoxicity(e.g.petrol) • accidentalingestion(e.g.batteryacid)ismorecommonin children • onethird of all patientswithintraoral burnseventuallyhave oesophageal injuries,endoscopyisnecessarytoseetheextentoftheinjury • strictureformationoftheoesophagusiscommonifburned bychemical substances • chemicalburnsoftheeyeareoftenseriousandmayleadto lossofeyesight
80 BurnsManual What todo • thefirstandforemostimportantactiontobetakenwithin 10minutesof theinjuryisapplicationofaconstantflowofwater • inanacidburnirrigatewithwaterandtreatfurtherasathermalburn • inanalkaliburnthereislessimmediatedamagethaninanacidburn, irrigateatleastfor1hour • phosphorusburnsareextinguishedbywater,particlesembeddedinthe skincontinuetoburn,thereforeremovethevisibleparticles • incaseofeyeinjuriestreatwithcopiousirrigationofwater,applytopical antibiotics(e.g.chloramphenicoleyeointment) topreventsecondary infection(see TheSurgicalHandBook Ed.EJ vanHasselt,2008,page 83,84) Keypoints for clinicalpractice ɶagentscausingchemicalburnsarewidelypresentinsociety ɶallchemicalburnsneedcopiousirrigationwithwater ɶsystemictoxicitymayoccur,especiallywithpetrol ɶchemicalinjuriestotheeyewillneedcopiousirrigationwithwaterforatleastone hourandthenreferraltoanophthalmologist
11Outpatientmanagement 81 11oUTPATieNTmANAgemeNT What youshouldknow • onlypatientswithsuperficialdermalburns/ deepdermalburns(partial thicknessburns)<10%TBSAshouldbetreatedasoutpatientswithexception oftheveryyoung&oldandthosewithburnsinspecialareasasdiscussedinthe admissioncriteria(see Ch2,page36) • scaldsarelesslikelytobedeepexceptinchildren • inhandburnsinvolvephysiotherapistsatanearlystage • everyhandburnthattakeslongerthan2weekstohealmaydevelop hypertrophicscarring • itchingmaydevelopinarecentlyhealedburn,moisturizingcreams, massageandpressureallhelp What to do • estimatetheextentoftheburnwiththepalmarsurfaceofthepatientshand (fromthefingertipstothewrist),itisapproxi- mately1%oftheTBSA(see Ch13,page88) • lookatthecolouroftheburn • notethepresenceorabsenceofblisters • applydigitalpressureandobservethecapillaryrefill • giveoralanalgesics • cleananddressthewound(see Ch3,page46etseq.)
82BurnsManual How to do it • followaseptictechnique • cleanwoundwithHibicet® (Savlon® )ornormalsaline • punctureblistersandremovealldeadandlooseskin • shaveallvisiblehairsaroundthewound • coverthewoundwithanyoftheavailabletopicalagents(see Ch17, page121) • apply1layerofVaselinegauzefollowedbydrysterilegauzesthenbandage,if noVaselinegauzeavailableapplythetopical agentonadrysterilegauzeand proceedasbefore • changethedressingsatleasttwiceweeklyormorefrequently whensoiled untilthewoundhashealed • advisepatientstoelevatebandagedlimbsinthefirstweekpostburn • whenthewoundhasn’thealedcompletelyafter3weeksrefertothenextlevel (e.g.districthospital/ burnsunit) • forminorburnsofthehandsorburnsinvolvingthejoints physiotherapy maybenecessary • afterthewoundhashealeditisoftenstillvulnerableanditchy, creams(e.g.aloe vera,coconutoil)and‘crepe’bandagescanbehelpful Keypoints for clinicalpractice ɶ meticulouscareoftheburnwoundis essential ɶ prescribeanalgesicsandgivethecorrectdose ɶwhentheburnwoundhasnothealedcompletelyafter3weeksrefer ɶaftertheburnwoundhashealedapplyoilycreamforoneweektokeepthescar supple ɶwhenhypertrophicscarringhasoccurredreferthepatient
12Criteriaandproceduresforreferral 83 12CriTeriA ANd ProCedUreS for referrAl fromhealthcentrestodistricthospital • refer - childrenwithburns>5%TBSA and - adultswithburns >10%TBSA - allneonatesirrespectivetheareaburned - allfullthicknessburns - allcircumferentialburnsimmediately - allburnsofface,hands,feet,genitalia, perineumandmajorjoints - allinhalationburns - allelectricalandchemicalburns • proceduresbeforereferral - keepthepatientwarm - washwoundswithHibicet® (Savlon® )ornormalsalineandcoverwith acleansheet - providepainrelief,paracetamolormorphine/ pethidineifpossible - givetetanusprophylaxis • howsoonshouldapatientbetransferred - ifthenearesthospitaliswithin30minutestravel,referthepatientassoon aspossiblebutstartthetreatmentofshock - ifthehospitalisfurtherawaygetfirsttheshockunder controlas describedonpage85
84BurnsManual fromdistricthospitaltothenextlevel(e.g.central hospital/ burnsunit) • refer - burns>30%TBSAinadults > 20%TBSAin children > 10%TBSAfullthickness - electricalandchemicalburns - burnswithassociatedinhalationinjury - extremeagegroups - circumferentialburnsofextremitiesandorchest - severehandburns - allburnswithassociatedmajortrauma • donotreferwhen - TBSA>50%,butinstead - giveadequateIV fluidsandanalgesics(opiates) - counselthefamilyandinformthemthatthepatientisnot likelytosurvive - ifapatientisstillaliveafter48hoursandtheurineoutputis morethan1cc/kg perhourcontactburnsunitorsurgeononcallinreferralhospitalfor advice
12Criteriaandproceduresforreferral 85 whenreferringapatienttakeintoaccountthefollowing • resuscitateadequatelyandstartbeforereferral - 4cc/kg/%TBSARinger’sLactate,give½ofthedeficitin first8hours postburn,adequacyisdeterminedbyurineoutput(seeCh13,page 90),inchildrenaddmaintenance,calculateasfollows:2x…kg+10=… cc/hr • monitortheurineoutputcarefully • giveopiates(morphine0.1mg/kg/doseorpethidine1 mg/kg/doseIV/IM) • give100%O2byfacemaskornasalprongs,4-8litre/ minuteinadults,in childrengiveatthehighestflowrateavailable • inchildrenwithburns>20%andadults>30%TBSAitis advisableto insertanasogastrictubetokeepthestomachemptyandsominimizethe riskofvomitingandaspiration • incaseofcircumferentialdeepburnsperformescharotomy(see Ch14,page 97etseq.)beforereferral.Incisetheskininto thesubcutaneoustissues • washthewoundwithSavlon® ornormalsalineandcoverwith acleansheet • keeppatientwarm • checkiftetanusprophylaxishasbeengiven,ifnotadministerwhenindicated See forcontactaddressesandtelephonenumbersCh20,page133
86BurnsManual
13Chartsandformulas 87 13ChArTS ANdformUlAS lund&Browderadmissionchart Name: Age/dob: Dateofadmission: ..........................................................M/ F ................................................................... ................................................................... Date&timeofburn:................................................................... Weightinkg:What happened: ................................................................... ................................................................... ................................................................... ................................................................... Inhalationinjury:yes/ no Firstaid: Epileptic:yes / no =Partialthickness(PT) =Fullthickness(FT) IGNORESIMPLEERYTHEMA FT%REGION PT% Head Neck Ant.trunk Post.trunk Rightarm Leftarm Buttocks Genitalia RightlegLeft legTotal Burn A A 1 1 1 2 2 2 21313 1.5 1.5 1.51.5 1.5 1.5 1.51.5 2.52.5 B B CCCC B B 1.751.75 1.751.75 Relativepercentageofbodysurfaceareaaffectedbygrowth area age0 age1 age5 age10 age15 aDult a:halfofhead 9.5 8.5 6.5 5.5 4.5 3.5 B:halfofonethigh 2.75 3.25 4 4.5 4.5 4.75 c:halfofoneleg 2.5 2.5 2.75 3 3.25 3.5
88BurnsManual 1% insmallburnsestimatetheextentoftheburnwiththepalmarsurfaceofthepatients hand(fromthefingertipstothewrist),itis approximately1%oftheTBSA
13Chartsandformulas 89 ruleofnines 9% 18% 14% 14% 9% 9% 1% 18%18% 9% 9% Front18% Back18% Front18% Back18% Thepictureontherightsideshowsachildof1year;foreachyearolderthan1year subtract1%fromthetotalpercentageoftheheadandadd0.5%foreachleg. Notethatbythetimeachildhasreachedtheageof10yearsithastheproportionsof anadult.
90BurnsManual emergencymanagementofSevereBurns A. Airwaymaintenancewithcervicalspine control B. Breathingandventilation C. Circulationwithhaemorrhagecontrol D. Disability–neurologicalstatus Alert/voice/Pain/Unresposive=AvPU E. Exposureandenvironmentalcontrol F. Fluidresuscitation(IV)proportionaltoburnsize adults:>15% TBSAchildren:>10%TBSA giveRL/NS4cc/kg/%TBSA / 24hrs givehalfinfirst8hourspostburnandtheotherhalfin thenext16 hours inchildren addmaintenanceNSwithDW 5%or10%per24hrs100cc/kg <10kg+50cc/kg11-20kg+20cc/kg>20kgbodyweightor 2x…… kg+10=…… cc/hr Monitorurineoutput: adults children(<30kg) G. GetlabtestsdoneGive drugsanalgesics 0.5cc/kg/hr~30-50 cc/hr 1.0cc/kg/hr(range0.5-2.0cc/kg/hr) PCV, FBC,U&E’s Morphine 0.1mg/kg/dose (notinneonates) Pethidine 1-1.5mg/kg/doseor Paracetamol10-15mg/kg/doseA Allergies MMedications PPastmedicalhistory LLast meal EEventsrelatedtoinjury H. History Headtotoeexamination
13Chartsandformulas 91 woundmanagement • infullthicknesscircumferentialburnsconsiderescharotomy (decompression)immediately,wheninextremitiesthereis painon stretchingmuscles,pulselessness,paraesthesiaandparalysisandinchest burnswhenthepatienthasdifficulties inbreathing • covertheburnwoundwithsomethingclean • elevateburnedlimbs • infacialburnstransport/nurseinhalfsittingposition • avoidtightdressingsorbandages Burnresuscitationformula=deficit+maintenance Howtoadminister • givehalfofthevolumedeficitinthefirst8hours,startingfromthetimeofthe burn;atthesametimeinchildrenstartmaintenancefluids • givetheotherhalfofthedeficitinthenext16hours,continue inchildrenwith maintenance • continuewithmaintenanceforanother24hoursinboth children& adults • measureurineoutputfor48hours
92BurnsManual howtocalculate 1st 24hours • Deficitchildren(<30kg) 4ccxwtinkgxTBSA%=… cc Addmaintenance 2x… kg+10=… cc/hr Or 100cc/kg<10kg+50cc/kg11-20kg+20cc/kg>20kg =… cc/24hrs See Ch3page40foranexampleofthecalculationof maintenancefluids • Deficitadult(>30kg) 4ccxwtinkgxTBSA% =… cc Nomaintenance 2nd24hours Inchildrencontinuewithcalculatedmaintenanceandgiveadults2500- 3000 cc/24hrsmaintenancefluidsaswell.DiscontinuetheIV dripafter48hoursifwell resuscitatedasmeasuredbytheurine output Urineoutput in>30kg in<30kg 30- 50cc/hr(0.5cc/kg/hr) 1 cc/kg/hr=… cc/hr
13Chartsandformulas 93 Table Usethefollowingtabletowritedownthedeficitandmaintenancetobegiven Date …………… …………… 8hours 16hours 24hours timeof Burn actualtime ……………… ……………… ……………… ……………… fluiDVolumein cc ascalculateD ……………… ……………… ……………… weight Whenthereisnoscaleavailablecalculatetheweightin children<12 yearsusingthisformula 2x(ageinyears+4)=…kg maintenancefluidsinchildren Usesodiumchloride0.9%andDextrosewater5-10% Upto 10kg 4cc/kg/hr or 100cc/kg/24hrs From11- 20kg 2cc/kg/hr or 50cc/kg/24hrs From21- 30kg 1cc/kg/hr or 20cc/kg/24hrs Anotherformulausedis 2xweightinkg+10=… cc/hr
94BurnsManual Normalpaediatricvitalsigns age Minimu m heart rate (b/min) SystolicBP (mmHg) Respiratio ns Breaths/ min Minimu m Hb (g/dl) Minimum PCV/Ht(%) <2yrs 100-160 60 30-40 11.0 33.0 2-5yrs 80-140 70 20-30 11.0 33.0 6-12yrs 70-120 80 18-25 11.5 34.5 > 12yrs 60-110 90 16-20 12.0 36.0
14Procedures 95 14ProCedUreS intraosseouspuncture Onlyinchildren<2-3yearsofage.Useintraosseousfluids preferably8- 12hoursbutnotlongerthan24hours Anatomy Femur Femur Tibia Tibia ObliqueLateral insertneedle 1- 2cm distallyofcentre pointtoinsert needle A B Thearrowsindicatethedirectionofthepuncture,alwaysstartwiththetibialintraosseous puncture1-2cmdistaltothetuberosity,underanangleofapproximately45-60°
96BurnsManual technique ɶstabilizethelegwithonehand, ɶpushtheneedleontothetibiaandrotateclockwisewhilepushing ɶusea14-16Gneedle ɶafterperforationofthecortexaspiratemarrow ɶinjectsodiumchloride0.9%,ifthisgoeseasilythenstartthedrip ɶsplinttheleg 45-60˚tomedial surface complications ɶ osteomyelitis ɶperforationthroughtheposteriorcortex ɶextravasation ɶhaematoma ɶintra-articularplacementoftheneedle ɶinjurytotheepiphysis
14Procedures 97 escharotomy (see alsodecompressionpage102) technique ɶpreferredsitesforincisions ɶheavylinesemphasizetheimportanceofincisingtheescharoverthejoints ɶincisetheskinintothesubcutaneoustissue
98BurnsManual Cross-section A C B Neurovascular bundle importantpoints ɶkeeptheincisioninthearmanteriorofthemedialcondyleattheelbowto preventinjurytothe ulnarnerve ɶtotreatthefingersplacetheincisionpreferablyalongtheulnarsurfacesofthefingers,thiswill preventfutureproblemswithscarsensitivitywhengraspingobjects
14Procedures 99 fasciotomy (see alsodecompressionpage102) lowerleg Skinincisionlateral Skinincisionmedial
100BurnsManual Decompression forthecompartment syndrome A B Anterior compartment Lateral compartment Posterior compartmentDeepposterior compartment Skinrotated to expose peroneal muscles Bluntscissorsorclosed arteryforceps Scissorsthrustdeepto decompressthedeep Posterior tibialnerveandvessels posteriorcompartment technique ɶafterincisingtheskin ɶonthemedialsideincisethefasciaoftheposteriorcompartment ɶonthelateralsidefirstincisethefasciaoverthelateralcompartment ɶthenrotatetheskinforwardstoincisethefasciaoftheperonealmuscles ɶfinallythroughthemedialincisionjustbehindthetibiathrustblunttippedscissorsto decompressthedeepposteriorcompartment
14Procedures 101 forearm Theforearmhas3compartments • volar(flexor) • dorsal(extensor) • mobilewad(upperforearmmusclesontheradialside) Theyareallsomewhatinterconnected;openingthevolarcom- partmentmay relievethepressureintheother2compartments.Ifafterincisionthearmstillfeels tightanadditionalincision shouldbemadetoreleasethedorsalcompartment Markingsforanincisiontodecompressthevolarforearm Theincisionbeginsinthehandforfulldecompressionofthecarpaltunnel Markingsfortheincisionsneededtodecompressthedorsumofthehandandforearm
102 BurnsManual Technique • makeanincisionasaboveandmakesureyouincludetheunderlyingfascia;in thepalmyouwillreleasethecarpaltunnel • thedorsalcompartmentandmobilewadarereleasedbyastraightlongitudinal incisiononthedorsalsurfaceofthearm; thisincisiondoesnothavetocross theelboworwrist decompression • escharotomyisassociatedwiththeacutemanagementof burns • theprinciplesandpracticeofthisprocedurearebadlyunder-stood,taught andcarriedout • escharotomyoftenisseenasaprocedurewithabeginningandanend • itwouldbebettertoseeitasaprocess • thisprocessiscalleddecompression Decompressionhastobeconsideredforallbodycompartmentswherean increaseincompartmentalpressuremaycompromiseavitalfunction. Compartmentsinclude • intra-andextracranialhead&neck • chest • abdomen • limbs Decompressionofthecraniummaybeachievedbyusinghyperos-molarsolutions suchasMannitol®toreduceswellingofthebrain, bycraniotomiesorbyfluid restrictionandelevationoftheupperbody. Decompressionofthechestisofteninadequatelydone,mainlybecausethe classicalincision(see alsopage97)doesnotdissociatetheribsfromthe abdomen(see picturea).
14Procedures 103 Picturebshowsareleasebelowandparalleltothecostalmargin,whichwill effectivelyseparatethechestandabdomenandsoreducesresistanceto ventilation. a b Abdominalcompartmentsyndrome,whichrecentlyhasbeenappreciatedcanbe diagnosedbymeasuringtheintra-abdominal hypertensionbydirectmeasurement ofthepressureintheurinarybladder.Itmayberesolvedbyconservativemeasures suchassedationandtheadministrationofdiuretics,possiblyfollowedbysurgical proceduressuchasescharotomyandfinallylaparotomy.To reducetheintra- abdominalpressuretheabdomenisnotclosedbut insteada‘Bogotabag’issutured totheskinedges(see TheSurgicalHandBook,Ed.EJ vanHasselt,2008,page 265). Inthelimbsconventialthinkingisfocusedonperipheralperfusion,butofgreater concernshouldbearaisedinterstitialpressurein theclosedosteofascialcompartments,whichmayleadtomicro- vascular compromise,ultimatelyresultingininadequatetissueoxygenation.
104BurnsManual Thecompartmentalanatomyofthelimbsiswelldescribedwith • 2compartmentsintheupperarm • 3intheforearm • 10inthehand • 3inthethigh • 4inthelowerleg • 4inthefoot Themechanismofthecompartmentsyndromeinacuteburninjuryis • riseoftheinterstitialpressureleadingto • celldeath,whichresultsin • furtheroedemaand • furtherriseinpressureandcelldeath Earlyfindingsofacompartmentsyndromeinthelimbsare • apalpablytenselimb • stillpalpablepulses • painonstretchingmuscles • paraesthesiaand • abriskcapillaryrefill(thissignisfrequentlynot mentioned)
14Procedures 105 management Non-surgical • inaraisedlimbthemeanarterialpressureandtherebythecapillaryflow maybereduced • inadependentlimbswellingofthetissuesmayincreaseandso • keepingtheextremityattheleveloftheheartisprobablythebest compromise • thereforethelimbshouldrestonapillow • anyconstrictingbandageshouldberemoved • thehaemodynamicstatusshouldbemonitoredcloselyespeci-allywithregard tofluidoverload;inthisperspecyivetheuseof colloidsinthisperspectivein resuscitationshouldbeconsidered Surgical Inacutecompartmentsyndromeitisprobablybetterto decompress‘toooften tooearly’than‘notoftenenoughtoolate’.Thefollowingprinciplesshouldbe adheredto, • avoiddamagetocutaneousnerves • preservelongitudinalveins • avoidstraightlineincisionsacrossjoints • decompressmajornervesand/ orvesselsasindicated relevanceoffasciotomytoescharotomy Thefiguresontheinsideoftheflapatthebackshowinredtheclassicalincisionsfor anescharotomyandinblackthedottedlinesforafasciotomy. Lookingatthecrosssectionofthelowerlegitisclearthat,whentheescharotomy incisionswouldbedeepenedtoincludethedeepfascia,thiswillleavetheanterior anddeepposteriorcompartmentsunreleased. Thereforeitwouldbemorelogicaltoperformanescharotomythroughthe sameskinincisionsadvocatedforafasciotomy(althoughinburnsareleaseof thefascialcompartmentsisnot oftennecessary).
106BurnsManual insummary • decompressionisaprocesswhichrequiresassessment, measurementandmonitoring • importantmeasuresarepositioningoflimbsandquantitative fluid resuscitation • surgicalinterventionshouldbeperformedinatheatrewith strictadherence toaseptictechniques • depth,extentandplacementofincisionsshouldbebasedon anatomical considerationsthatallowforthesafeandeffectiveconversionofan escharotomyintoafasciotomy Keypoints for clinicalpractice ɶremoverings,tightbandagesandclothing ɶposition thelimbsattheleveloftheheart ɶconsidercolloidsin resuscitation ɶconsidersurgicaldecompressionincircumferentialfullthickness anddeepdermal(partialthickness)burnsirrespectiveofsymptoms&signs ɶinfullthicknessburnsalsoconsiderfasciotomy ɶplacetheskinincisionsforanescharotomyasforafasciotomy ɶassessagain,againandagain ɶoperateintheatreunderstrictasepticconditionsandwithanaseptictechnique
14Procedures 107 Skincoverage • consideranyskindefectlargerthan3cmindiameterandnot yethealedafter3 weeksfor grafting • takepreferablytheskinofthethighand/ortheinneraspectof theupperarmas yourdonorarea • lubricatetheskinandtheknifewithVaseline • toensuretheproperthicknessadjusttheopeningoftheblade sothatyoucan snuglyfitthebevelededgeofanumber10scalpelbladeintotheopening • holdtheHumby/ Watsonknifeatanangleofabout45°with regardtothe skin,pressitdownandmakeatoandfromotion overthetightskin,theknife willglideforwardbyitsownweight Traction Traction Thickness gauge or scalpelbladeno.10
108BurnsManual • athingraftissemi-transparent,athickgrafthasthetextureof anorangepeel withcurlingedges • meshthegraftwithaPizzacutter(see Ch15,page111)or placemultiple cutsinthegraft,thispreventsbloodandserumfromaccumulatingunderthe graft • removefromtherecipientsiteanyhypergranulationor unhealthy lookingtissue • decreasetheamountofcontaminationbygentlyscrapingthewoundwith theedgeofascalpel • stopthebleedingbyapplyingawetgauzeandpressureforafewminutes, haemostasisisimportant • placethegraftwiththedermisside(theshinierside)downandeithersutureit inplaceinareaswherenoproperpressurebandagecanbeappliedorfixthe graftwith‘pullout’tie-oversutures(see thisCh,page110) • aftertakingthegraftapplyimmediatelyonthedonorsitegauzessoakedin ‘junglejuice’,afterfinishingtheoperationdressthedonorsitewithVaseline gauzesoakedinsilvernitratesolutionorSSDandleaveinplacefor10-14 days,ifsoiledremoveonlytheouterlayerandreapplyanewbandage • dresstherecipientareawithVaselinegauzesoakedinsilvernitratesolution orSSDif available • inspectthegraftonday5postoperatively,ifitstartstosmellearlieron,then inspectimmediately,cleanitgentlyandapplyanantibacterialtopicalagent • thegraftwillremainfragileforabout3weeks,protectitwith abandageand keepsupplewithVaselineoranyoilycream • inaSSGshrinkagecanoccurupto50%
14Procedures 109 Apinchgraft(see picture)canbeusedforsmallanddifficultareas e.g.backofthelowerlegneartheheel technique ɶuselocalanaesthesia,infiltratelignocaine0.5-1%undertheareatobeusedas donorskin ɶpickupa‘tent’ofskinwiththepointofaneedle ɶcutoffthelittlepieceofskinunderneath;aknifebladeno.11isveryeffective ɶlayitonthegranulatingrecipientarea ɶproceedasinaSSG 1 2 3
110BurnsManual The‘pullout’tie-overdressing The‘tie-over’dressingisawellknownmethodtofixingskingrafts becauseitfulfills thefollowingessentialcriteriarequiredforasuccesfulgrafttake: • pressure • absorptionof exudate • splinting/ immobilisation Recentlythefollowingmodifiedtechniquehasbeendeveloped. technique ‘pull out’ tie-oVer ɶfirstfixthegraftwithacircumferentialperipheral5/0absorbablesuture(see fig.1) ɶ3or4monofilament3/0suturesareappliedacrossthedefectbypassingthemthroughtheskin,the graft,acrossthegraftandbackthroughthegraftandtheskin(see fig.1) ɶparaffingauzeisthenappliedoverthegraftandasterilefoamorwoolplacedontop ɶthemonofilamentsuturesaretiedindividuallyoverthefoam(see fig.2) ɶastripofparaffingauzeiswrappedaroundtheedgeofthefoamfollowedbyadressing(see fig. 2) ɶbycuttingthemonofilamentsuturesandslidingthemout,thedressingcanberemovedeasily figure1 figure2
15Equipment&maintenance 111 15eQUiPmeNT&mAiNTeNANCe ThePizzacutter Byusingaroundpatternfile,notches5mmdeeparemadeinthesharpenededge ofthepizzacutteratdistancesof0.5or1cm. Onaboardpreferablyofveryhardwood(e.gteak)orsyntheticmaterial(e.g.hard plasticorresin)theskincanbecutbyrolling thewheel.Stripsof0.5cminwidthcan becutandwillgiveanex- pansionof1-1.5times.Thedevicecanbesharpenedby usingfine gritabrasivefilm(sandpaper)ortheequipmentdescribedbelow. howtosharpenyourhumbyknife • takeamicroabrasivefilmpreferablywithathickMylarbackingwith whichthemicrofilmiseasiertohandle • thealternativeisamicrofilmwithanadhesivebacking,whichisplacedontop ofapieceofX-rayfilm,whichisnotwiderthanthewidthoftheknifeofa Humbydermatome • usea15micronfilm(tobeobtainedfromgoodhardwarestores),see picture • afterlooseningoftheguidebarthefilmisinsertedwiththeabrasiveagainstthe blade,closethebladeoftheHumbyknife downontothebar,andpullthe filmthrough • adownwardangleof30degreesorsoremovesmoremetalespeciallyif thebladeisdull(see picture)
112BurnsManual • theprocessisrepeated5or6timeswhichshouldbeenoughtoimprove evenaverydullblade • onesheetwoulddoatleast10sharpenings • sharpeningonesideonlyisusuallyenough • the15micronfilmisprobablythemostdurable.Astheparticlesfractureafiner edgeisproduced,sousinganewfilm, followedbyausedoneisagoodstrategy 15u15u 15u 15u Microfinishingfilm 468L 30˚ angle
15Equipment&maintenance 113 Sharpeningyourinstruments Scalpels,razors,skingraftblades • rubtheinstrumentagainsttheroughsideofacombination stone,always keepthesameanglebetweenthebladeandthestone • withabluntkniferubinsmallcirclestobeginwith,oilthesurfaceofthe stone,withasharperkniferubinastraightdirection,usuallytowardsthe sharpedge • thebladeisbeginningtogetsharpwhenthereisnoreflection oflightfromthe veryedgewhenyouholditupagainstthelight Sharp Blunt
114BurnsManual • sometimesa‘burr’develops,youcanfeelitbystrokingwith thefinger.Rubit awaybystrokingthebladeagainstthestoneevenmorelightly,alwaysatthe sameangle,anduseoilasbefore Rubbingoff theburr Feelingfor theburr • whenthebladeisreallysharp,stropit.Hangthestropbyits shoelaceand strokethebladefirmlybypullingitawayfrom itssharpedge Smooth side Acombination stone Rough side Extra Aleather strop Asmall grindstone
16Drugprotocols 115 16drUgProToColS Tetanusprophylaxis • neverimmunized ATS1500USC/IM+ 0.5cctetanustoxoidvaccine(TTV) SC/IM repeat TTV 0.5ccweek4andweek8 • fullyimmunized <10yearsago,noneedforTTV > 10yearsago,give1doseofTTV • partiallyimmunized<10yearsgive1doseofTTV >10yearsgive3dosesofTTV with amonthlyinterval Tetanustreatment Incubationperiodbetween7-10days,theshortertheinterval betweenthe injuryandsymptomsthemoreseverethedisease gradingofseverity • grade1(mild) moderatetrismus,nospasms,norespiratoryproblems, noorlittledysphagia moderatetrismus,markedrigidity, shortlastingspasms,tachypnea>30/min, mild dysphagia severetrismus,generalizedrigidity, prolonged spasms,respiratoryfailuretachypnea>40/min, severedysphagia • grade2(moderate) • grade3(severe) • grade4(verysevere)sameasingrade3plusautonomic disturbances,suchashypertension& tachycardiaalternatedwithepisodesof hypotension& bradycardia
116BurnsManual Allpatientsshouldreceiveonadmission • antiserumpreferablyhumantetanusimmunoglobulin 3000-5000U IV/IM, ifnotavailableequineantiserum10000byslowIV injection.Bewareofanaphylacticreaction/ shock(see boxbelow for treatment) • sensitivitytestisunreliable,itmaybebettertoexpectananaphylactic reaction • antibiotics,metronidazole500mgIV 6hourlyor1gIV 12hourlyfor7 days(benzylpenicillinisapooreralternative2MU8hourlyIV for8days) • vaccinationbeforedischarge • wounddebridement grade1&2canbetreatedinhospitalwithoutICUfacilities • controlspasmswith - diazepam0.05-0.2mg/kg/hrIVor - phenobarbitone1.0mg/kg/hrIV/IM, followed3hourslaterwith chlorpromazine0.5mg/kg/6hourlyIM • reduceexternalstimuli • keepairwaypatent • changeposition2hourlybutgently • feedthroughnasogastrictube2xthenormalamount/calories grade3&4willneedmechanicalventilationandICU admission
16Drugprotocols 117 management of anaphylaxis ɶstopadministeringantiserum ɶsecureairwayandgiveO2 ɶgiveepinephrine(adrenaline)0.5-1.0mg=0.5-1.0ccofa1:1000solution IM, repeatevery10 minutesuntilBP&pulseincrease ɶgiveanantihistamine, likepromethazinehydrochloride25-50mgIVslowlyorchlorpheniramine10- 20mgIV ɶgivehydrocortisone100-300mgIV ɶdeteriorationrequiresIVfluids,aminophylline250-500mgIV,nebulizedsalbutamoland possiblemechanicalventilation ‘Junglejuice’ • addto1litreofsodiumchloride0.9%50cclignocaine1%plus1ccof adrenaline(epinephrine)1:1000,thiswill provideyouwithalocalanaestheticsolutionof0.05%with 1:1000000 epinephrine Incaseyouhaveasolutionoflignocaine2%use25ccperlitre sodiumchloride 0.9% • itcanbeusedtostopbleedingfromforexamplethedonorareaaftertakinga skingraftortoinfiltratetheareausedfor takingaskingraft(thisiscalled tumescenttechnique,becauseitwillraisetheskin)
118BurnsManual Alcoholichandrub(Ahr) • shouldbeusedtocleanyourhandsinbetweenpatients,is easytoprepare andbyaddingglycerinetomethylatedspirit yourhandswillnotdryout. Youonlyhavetowash yourhandswithwaterandsoapwhentheyaresoiled. Apply afterwardsAHR • prepareasfollows - addto500ccofmethylatedspirit - 2.5ccofglycerine drugscommonlyusedinburnpatients Drugs <50Kg > 50Kg analgesics Morphine 0.1mg/kg/dose(not inneonates) 10mg Pethidine 1-1.5mg/kg/dose 50-100mg Paracetamol 10-15mg/kg/dose 750-1000mg (maximumdoseis4g/ 24 hrs) frequency4-6hourly frequency4-6hourly anaesthetics Ketamine(priorto changeofdressing) 2mg/kgIM asin<50kg Ketamine (asananaesthetic) 4-10mg/kgIM 1-2mg/kgIV asin<50kg
16Drugprotocols 119 Drugs <50Kg > 50Kg antiBiotics PenicillineV 25mg/kg/dosePO QIDfor3days 500mg POQIDfor3days X-pen 25mg/kg/dose 25000U/kg/dose IV/IMQID 1- 2g 1- 2MU IV/IMQID Cloxacillin 25mg/kg/dose IV/POQID 500mg IV/POQID Chloramphenicol 12.5-50mg/kg/dose IV/POQID 500mg IV/POQID Gentamicin 5-7.5mg/kg/24hrs IV/IMoncedailyasa singledose 240mg IV/IMoncedailyasa singledose Ceftriaxone 50-80mg/kg/24hrsIV asasingledose 1- 2g IVasasingledose Ciprofloxacin 7.5-15mg/kg/24hrsPO dividedin2doses 500-750mg POtwicedaily Metronidazole 7.5mg/kg/dosePO/IV 6or8hourly 500mg PO/IV6or8hourly antiepileptics Phenobarbitone 5-8mg/kg/24hrs POassingledosenocte 60-300mg POassingledosenocte Phenytoin 4-8mg/kg/24hrsPO assingledose 150-300mg POassingledose anxyolitica Diazepam 0.2-0.5mg/kg/24hrs PO/IM/IV 5- 20mg PO/IM/IV Midazolam 0.2mg/kg/24hrsRectal/PO assingledose 5mg IMassingledose
120BurnsManual
17Topicalagents 121 17ToPiCAlAgeNTS Aceticacid0.5% Thisisawaterysolution,whichyourpharmacyshouldbeableto make. Analternativeis‘Vinegar’,thisisasolutionof5%strength,byadding1partof vinegarto9partsofwateryouwillhaveasolutionof0.5%.Itisalsoactiveagainst Pseudomonasaeruginosa.The waterysolutiondriesquicklyandhastobeapplied severaltimes aday.WithVaselinegauzesoakedinthissolutiondressingsonly needtobe changedoncedaily. Betadine® ointment10% Isapovidone-iodineointmentandisespeciallyactiveagainst Staphylococcusaureusbacteria. eusol(edinburghUniversitysolutionoflime) Mixedwithliquidparaffinitactsasadesloughingagent,italsohasan antibacterialaction,butwillnotdestroyPseudomonas.Keeppreferablyinthe fridge. Changedressingsdaily. gentianvioletpaint(gv paint)0.5% Hasadisinfectantandantifungalaction.Itwilldrythewoundandisusedinsmall almosthealedburnwounds.
122BurnsManual hibicet® / Savlon® MixChlorhexidine1.5%andCetrimide15% • 1in100withwaterforskindisinfectionandwoundcleansingand • dilute1in30inalcohol70%forpreoperativeskinpreparation honey& ghee HasanantibacterialactionagainstStaphylococcusaureusandalsocontainsa proteolyticenzyme.Thishelpstobreakdownthedenaturatedproteinsandso digestsnecrotictissue.Theghee componentpromotesgranulationformation.Mix2partsofhoneywith1partof ghee,keepoutoflightorstoreindarkjars/bottles.Ifnogheeisavailableuseinstead glycerine,vegetableoilorwaterinthesameway. mercurochrome HasthesameactionandindicationasGV paint.Keepalsothis solutioninairtight darkbottles,toohighaconcentrationistoxic. Papaya Thepulpofthefruitcontainstheenzymepapain.Itcanbeusedtoremovethe sloughfromthewound,toremovethickcrustsandtoreducehypergranulation. Mashthepulpandapplyathicklayer. Changethedressingeverysecondday.Patientssometimescomplainof itching.
17Topicalagents 123 Silversulphadiazine(SSd) AlsoknownasFlamazine®,isactiveagainstPseudomonasaeruginosa.Itcanbe appliedonVaselinegauzeordirectontotheburnwound. Itisusedforfacialburns andisdirectlyappliedonthewound, whichisthenleftexposed. Inhandburnsitisappliedontheburnwoundandthenthehandiseitherputina plasticbag,whichisfixedtothewristwith adhesivetapeoritisdressed(makesurethatthefingersaredressedseparately,thisto avoidwebbing). Ideallyithastobeapplieddaily. ItisalsopossibletomakeSSDinyourownpharmacy,thepres-criptioncanbe foundinPrimarySurgery,EditorMKing,VolumeTwo,Traumaonpage81orin CareoftheCriticallyIll Patient, D AKWatterse.a.,page236. Silvernitrate0.5% solution HasthesameactionasSSD,thedisadvantageisthatitstainssheetsand clothingblack. Preparethissolutionasfollows • take5gsilvernitratecrystals • mixthiswith15ccdistilledwater • dissolvethissolutionin1litresterilewater(=boilwaterfor 10minutesand cool) • airtightclosureofthebottlesisessentialtopreventoxidation, whichresultsina blacksilveroxideresidue
124BurnsManual Silvernitratestick(causticpencil) Eachstickcontains0.17gofsilvernitrate.Itismainlyusedto burnawaysmallareas ofhypergranulation.Itisverypainfulsouseitonlyinsmallareas.Beforeuse moistenwithwater. Tannin Tanninsarefoundinvariousplants,oneofthemistheteaplant. Groundtea stalkscontainthesameconcentrationoftanninsastealeaves. Ithasanantibacterialactionandalsoreducestheincidenceof hypertrophic scars. Prepareasfollows • over10gofgroundteastalksorteadust(foundinteabags)ortealeaves • pour100ccboilingwater, • leavethisfor10minutesandfilter Soakdressingsinthissolutionandapplythemontothewound,youcanalsouse Vaselinegauzessoakedinthissolution,applytheseonthewoundandaddan extralayerofordinarygauzesalsosoakedinthesolutionontop. Toobtain1litreofthissolution,pour1litreofboilingwaterover100gofteaorits byproducts. Zincoxidecream(5-15%) Reduceshypergranulationandalsohasanantibacterialeffect,applyonVaseline gauze,redressafter4days,removepreviouslayerwithanoilysolution
18Drugsstocklistforaburnsunit 125 18drUgS SToCKliST for ABUrNSUNiT no/quantity Anaesthetics Atropine Epinephrine (Adrenaline) Halothane Ketamine Lidocaine injection1mgin1ccvial 1cc vial1:1000 inhalation injection50mg/ccin10ccvial injection1%,2%in vial Lidocaine+epinephrine1:200000in vial Midazolam Suxamethoniu m Thiopental Analgesics injection2mg/ccin vial injection50mg/ccin vial 0.5gpowderforinjection Codeine tablet 30mg Diclofenac Ibuprofen tablet 25,50,100mg suppository 50,25,12.5mg tablet 200,400mg Morphine Paraceta mol Pethidine injection 10mgin1ccvial tablet 10mg oralsolution 10mg/5cc suppository 10,20mg tablet 500mg suppository 100mg syrup 125mg/cc injection 50mg/cc Anaemia Ferro+Folicacid tablet 60mg+250µg
126BurnsManual no/quantity Antibiotics Cefotaxime Ceftriaxone Chloramphenicol powderforinjection1g powderforinjection1g capsule oralsolution 250mg 150mg/5cc powderforinjection1ginvial Ciprofloxacin tablet suspension injection 100,500mg 250mg/5cc 2mg/cc Cloxacillin capsule oralsolution powderforinjection500mginvial 50-100ccbottle 500 mg 125mg/5cc 400mg+80mgCotrimoxazol 200mg+40mg/5cc Gentamicin Metronidazole 40-80mgin2ccvial 200/400mg 500mg 200mg/5cc tablet oralsolution injectiontablet suppository oralsolution injection 500mg/100ccvial PenicillinG (Xpen) powderforinjection600 mg/vial PenicillineV Antiepileptics tablet 250mg Carbamazepine tablet 100mg Phenobarbital tablet 30mg Phenytoin tablet 100mg 25mg
18Drugsstocklistforaburnsunit 127 iv fluids no/quantity Albumin(isotonic) 250-500cc Dextrose50% ampoule DextroseWater 1L 5%/ 10% Haemacel 500cc Ringer’sLactate 1L SodiumChloride0.9% 1L (NS) Sedatives Chloralhydrate mixture 1gin10cc Diazepam tablet 5,10mg injection 10,20mg TopicalAgents Aceticacid solution0.5%(alternativeis Vinegar) Betadine® solution/ointment10% (povidone-iodine) EusolinParaffin(EP ) Gentianvioletpaint0.5% combinationofChlorhexidine1.5%and Cetrimide15% Hibicet® /Savlon® (in dilutedform)Honey &Ghee MercurochromeSilver nitrate 1-2%solution crystals Silversulphadiazinecream1% Zincoxide cream5-15%
128BurnsManual no/quantity vaccines Tetanustoxoid ATS injection 5ccvials preferablyHumanTetanusImmunoglobin orequineantiserum
19NUTRITION 129 19NUTriTioN • 3simplefeedingregimensaregivenplusthenumberofdaily feedsin relationtothepercentageoftheTBSAburns • theseformulasarebasedonhighenergy&highproteinfeedsandshould containatleast250kcal(=1000kilojoules)per200cc(dividedinfat8g, protein10.5gandcarbohydrates42g) • theyareinliquidorsemisolidform Examplesare • Likuniphalawithgroundnutflower • highenergymilk • Plumpy’nut(Chiponde) ToallofthemmicronutrientslikeCMV(complexmultivitamins) areadded Numberofglassesorportions(200cc)daily extra %tBsa Burn 11-15 16-20 21-25 26-30 31-35 36-40 6.00hours • 9.30hours • • • • • • 11.00hours • • • • 14.00hours • • • 15.30hours • • • • • • 19.30hours • • • • 20.30hours • • 21.30hours • • • • • 22.30hours • •
130BurnsManual • inliquidformtheycanbegivenorallybytheglassorbyNGT drip;adripcan continuethroughoutthenight • thedailynormalhigh-proteinhigh-caloriedietmustcontinue withthese supplements • manypatientsarealreadymalnourishedbeforetheirburn • itisverydifficulttooverfeedaseverelyburnedpatient,feedmorenotless recipestomakehighprotein-highenergyfeeds • highenergyLikuniphala(thisisa4:1maizesoyaflourmix) Likuniphala sugar oil addwaterto 140g 35g 7cc 200cc thiswillgive706kcalperfeedandcouldbegiven2-3xperdayalongwith highenergymilkandPlumpy’nut • highenergymilk - withdriedskimmedmilkexampleof300ccportion driedskimmedmilkpowderoil sugar addwatertototalvolume 110g 60cc 50g 300cc gives440kcalsperfeed - withfreshcow’smilkexampleof300ccportion wholemilk oil sugar 300cc 10cc 15g gives352kcalperfeed
19NUTRITION 131 Give150cc/kgperdayindividedportions. • Plumpy’nut peanutpasteoil fullcreammilkpowdericing sugar complexmultivitamins 1250g 750g 1500g 1400g 10scoops thiswillmakeapproximately5kilogramsandwilldeliver545kcals/ 100 gramandneedstobegivenbyspoon Theserecipesaregenerallynotsuitableforchildrenbelowsixmonthsof age.
132BurnsManual
20Contactaddresses 133 20CoNTACTAddreSSeS malawi • QueenElizabethCentralHospital, Blantyre +265(0)1 874333 Telephoneoperator 877333 874502 877552 extension: 3250 BurnsUnit 3243 SurgicalAnnex 3096 MainOperatingTheatre • CollegeofMedicine,Blantyre +265(0)1 874678 SecretaryDepartmentof Surgery • E-mailaddresses surgery@medcol.mw • Postaladdress P/Bag414 Chichiri Blantyre3 Malawi elsewhere • EJ vanHasselt ehasselt@gmail.com • NederlandseBrandwondenStichting(DutchBurnsFoundation) www.brandwonden.nl info@brandwonden.nl
134BurnsManual
21Index 135 21iNdeX Pagenumbersinboldfaceindicatewholechapters ABC’s 13,29,90 Aceticacid 48,53,121,127 Abdominalcompartmentsyndrome(ACS) 103 Abdominalwallrigidity 65 Admissioncriteria 36 AdultRespiratoryDistressSyndrome(ARDS) 23 Airway 29,37,65,69,90 AlcoholicHandRub (AHR) 53,118 AMPLE 32 Anaesthetics(dose) 118 Analgesics(dose) 118 Anaphylaxis/shock 117 Antibiotics(dose) 119 Antiepileptics(dose) 119 Anxiolytica(dose) 119 Assessmentburnwound 32 Bacteriaandinfection 52 Barrierfunctionofthegut 23 Betadine® 48,121,127 Bodycompartments 102 Bodysize&proportionsinchildren 63 Breathing 29,65,69 Burnwoundcare 46-50 Burnwoundcareemergency 36 Burnsinchildren 63-67 Calculationfluid deficit 40 Calculationnutritionalneeds 45 Capillaryrefill 30,35,76,81,104 Carotidpulse 30 Causticpencil 124
136 BurnsManual Cellularstructure 46 Cerebraloedema 64,66 Cervicalspine 29,90 Chemicalburns 73,79-80 Childabuse 27,63 Chloramphenicoleyeointment 80 Circulation 30,64,90 Circumferentialburnwoundchest 29,36 Cleantheburnwound 47 Clinicalsignsinhalationinjury 69 Closedtreatmentburnwound 48 Closureburnwound 54 Clothing 27,28,30 Coagulationzone 22 Compartmentsyndrome 71,76,100,103-106 Compartmentalanatomy 104 Complicationsintraosseouspuncture 96 Confusion 41,69 Contactaddresses 133 Contractures 51,59-61 Contraindicationsskingraft 57 Coolingburnwound,duration 28 Deepburns 35,51,73 Debridementearlyactive 47 Decompression 29,91,97,102 Decompressionofthechest 103 Depthofaburn 28,33 Dextrosewater5-10% 40,66,93 Dextrose50% 127 Differencechildversusadult 64 Disability 30,59,90 Donorareaskingraft 55-57,106,117 Donotrefer 84 Dressings 36,43,48,71,82 Dressingtechnique 50 Drugstocklist 125
21Index 137 Earlyfindingsofacompartmentsyndrome 104 Ears 73,74 Effectburnonbody 23 Electricalburns 75-77 Electrolytes 23,37,41,66 Emergencyburnwoundcare 36 Epidemiology 24,63 Epilepsy 24,27 Eschar 35 Escharotomy(technique) 97-106 Estimationareaburned 33,87-89 Eusol 121 Exposure,environment 30 Exposuretreatment 47 Exposedversusclosedtreatment,differences 49 Eyes 73 Eyelids 73,74 Facialburns 73-74 Fasciotomy 76 Fasciotomylowerleg(technique) 99-100 Fasciotomyforearm(technique) 101-102 Feedingearly 44 Feedingformulas 45 FeedingviaNGT 45 Femoralpulse 30 Fever 37,53,66 Firstaid 23,28,47,73 Flamazine® 48,123 Fluidlossinchildren 64,67 Fluidrequirementsinelectricalburns 76 Fluidresuscitation 39,41,64,66,90 Fluidstatusassessmentinchildren 64 Fullthicknessgraft 54,55,60,74
138 BurnsManual Generalresponsetoburninjury 23 Gentianvioletpaint 121,127 Graftfailure 55 Granulations 55,57 Gut 23,65 Gutbarrierfunction 23 Handburns 71-72 Healingtimeburnwound 54 Honey& ghee 48,122,127 Hyperaemiazone 22 Hypertrophicscars 49,59-61 Hypoglycaemia 37,40,41,65,66 Hyponatraemia 40,41,66 Hypothermia 28,65 Hypovolaemia 23,30,41,64 Hypoxia 30 Ice(water) 28 Infections,othercauses 53 Inhalationinjury 23,29,42,47,69-70 Intraoralburns 79 Intraosseouscannulationduration 95 Intraosseouspuncture 95-96 Intravenousfluids 127 Irrigationinchemicalburns 80 Jackson’sburnwoundmodel 22 Jointmovements 59 Junglejuice 56,108,117 Keloids 59,60 Ketamine 43,50,118,125 Laboratory 37 Levelofconsciousness(assessment) 30
21Index 139 Lifestyle 27 Localresponsetotheburninjury 22 Likuniphala 45,129,130 Lund&Browderchart 31,87 Maintenancefluids 39,41,65,91 Maintenancefluidscalculation 40 Mechanismofcompartmentsyndrome 104 Mercurochrome 122,127 Monitoringfluid resuscitation 41 Morphine 31,43,83,90,118,125 Mortality 21,32,75 Mouth&Lip burns 74 Myoglobinuria 77 Nasogastrictube 45,65,85,116 Non-surgicalmanagementofcompartmentsyndrome 105 NormalSaline 47,82 Nosetip 73 Nutrition 25,44,45,129-131 Oedema 23,39,64,69,73,76,104 Oesophagealstricture 79 Oralfluids 39 Oxygenadministering 37,66 Paediatricburns 63-67 Paediatricnormalvital signs 94 Painrelief 43,83 Pallor 30 Palpationofburnwound 32 Paracetamol 43,83,90,118,125 Papaya 48,57,122 Perinealburns 73-74 Peripheralcirculationassessment 76 Pethidine 31,43,83,90,118,125
140 BurnsManual Phosphorusburns 80 Physiotherapy 51,82 Pinchgraft(indication) 54,55 Pinchgraft(technique) 109 Pizzacutter 56,108,111 Plasticbag 71,123 Plumpy’nut 45,129-131 Positionofrest 71 Pressuregarment 59-61,72 Prevention 27,51 Primarysurvey 29,76 Protein(denaturation) 44,46 Pseudomonas 48,52,57,121,123 Psychologicalsuffering 59 ‘Pullout’tie-over(technique) 110 Pupils 30 Radialpulse 30 Referralcriteriaandprocedures 83-85 Rehabilitation& Reconstruction 59-61 Renalfailure 75 Respirations 94 Respiratoryobstruction 69 Restlessness 41,69 Retentionofurine 73 Ringer’sLactate 31,39,85,127 Ruleof nines 33,63,89 Savlon® 47,54,82,122,127 Secondarysurvey 32 Sepsis 52-53 SharpeningHumbyknifeblade 111-112 Sharpeninginstruments 113 Silvernitrate 48,53,56,108,123,127 Silvernitratestick 124 Silversulphadiazine 48,123,127
21Index 141 Skinfunctions 23 Skingrafttypes 55 Splints 60 Splitskingraft(technique) 106 Staphylococcusaureus 48,52,121 Streptococcus 52 Superficialburns 34 Systemicinflammatoryresponsesyndrome 52 Systemicintoxication/toxicity 69,79 Tannin 49,124 Tapwater 28,71 Temperaturewaterforcoolingburnwound 28 Teamconcept 25 Tetanusprophylaxis 115 Tetanustreatment 115 Tie-over(technique) 110 Timeofburninjury 31,87,93 Timingofskingraft 54 Topicalagents 121-124 Translocationof bacteria 23,44 Urinarycatheter 41,53 Urineoutput 31,41,64,66,76,84,90,92 Vinegar 48,121,127 Vitamins 44-45,129 Waterinchemicalburns 80 Weightloss 44 WHO 21 Wounddefinition 46 Woundswab 53,55 Zincoxide 124,127
142BurnsManual
22Notes 143 ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ......................................................................................................
Burns manual 2nd [autosaved]
Burns manual 2nd [autosaved]
Burns manual 2nd [autosaved]
Burns manual 2nd [autosaved]
Burns manual 2nd [autosaved]
Burns manual 2nd [autosaved]
Burns manual 2nd [autosaved]

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Burns manual 2nd [autosaved]

  • 1. 1Introduction 21 1 INTRODUCTION Somefacts •aburnmaybelifethreateningespecially inthevery youngandveryold •aburnisverypainful‘ithurtslike hell’ •regularsleepisverydifficult •aburnisunique,nootherconditionisso painfulfor solonganddebilitating •burnsarepreventable,yettheykeepoccurring •estimated mortality rates of fire-related burns in 2002 worldwide were322 000; 40 000 of themoccurred in sub-Saharan Africa(WHO) •more people suffer from disabilities and disfigurement causedbyburns •thisresultsinpersonalandeconomicaleffects on both the victim and family ultimately culminating in social stigma and restriction inparticipationinsociety
  • 2. 22BurnsManual local&generalresponsetotheburninjury What youshouldknow •localresponse experimental work by Jackson has shown that a burn wound consistsof3zones Jackson’sBurnWoundModel Zoneof coagulation Zoneof stasis Zoneof hyperaemia zoneof coagulation Cell death and immediate coagulation ofcellularproteins. Damage in microcirculation resulting in compromised circulation,untreated it will leadto necrosis Damage causing production of inflam- matory mediators leading todilatation ofbloodvessels zoneofstasis zoneof hyperaemia
  • 3. 1Introduction 23 • generalresponse - skinisthelargestorganin thebodyandisolateschemically, thermally, biologicallyandmechanicallytheinsidefromtheoutside - aburndestroysthesefunctions - aburnisthreedimensional,itopensupasurfaceandleadsto: 1. lossofwater,electrolytes,proteinsandheatduetovascular permeability, whichresultsintheformationofoedema 2. inburns>20%TBSA,effectsonthewholebodyare: a. hypovolaemia(=shockphase=first48hours) b. immunosuppressionleadingtoinfection c. impairment of barrier function of the gut leading to translocationofbacteria(itisthereforeimportantto startenteral feedingearly) d. systemicinflammatoryresponsepostburnaffectsthe lungsresulting in Adult Respiratory Distress Syndrome (ARDS), even in the absenceofinhalationinjury What to do • administrationoffirstaid • correctionofhypovolaemiaislifesavinginthefirsthourspostburn • appropriatemanagementofinfection • earlyenteralfeeding Keypoints for clinicalpractice ɶlocaleffectofburncauses3zonesofinjury ɶ normal capillary exchange is disturbed leading to oedemaandlossof albuminfromthecirculation ɶ general effects occur in circulation, metabolism, temperaturecontrol,immune competenceandfunctionof gut&lungs
  • 4. 24BurnsManual Epidemiology andcauses What youshouldknow • some burns are genuine accidents, but most do occur due to carelessness, inattention, pre-existing medical conditions or alcoholabuse • as long as cooking takes place at ground level and very young childrenarelookedafterbytheirslightlyoldersiblingsthis willbe themaincontributingfactortotheincidenceofburnsinchildren • lack of safety precautions by adults e.g. topping up paraffin lampswhilestillburningandhot • themostfrequentlyencounteredpre-existingmedicalcondi- tionis poorlycontrolledepilepsy,commonlyleadingtoburns • themajorityofburnstakeplaceathome • inmorethan50%ofthecaseschildrenyoungerthan10years are affected • main causes of burns are hot liquids and fire (>80%), each of whichcountsforapproximately40% • a number of burns especially in girls are caused by the combinationoffireandnylon(acrylic)dresses What todo • at community level safety measures must be taught with the emphasisonachange -incookinghabitsand -inthecarefortheveryyoungbythesomewhatolderbut not yetresponsiblesibling • treat and monitor pre-existing medical conditions e.g. epilepsy carefullyandinstructpatientsaboutthedangersof not taking the prescribedmedication
  • 5. 1Introduction 25 Keypoints for clinical practice ɶburnsarefrequentlycausedbycarelessnessandinattention ɶpre-existingmedicalconditionssuchaspoorlycontrolledepilepsy contribute totheburdenoftheburninjuryanditssequelae ɶthemajorityofburnsoccurinoraroundthehome ɶthemostaffectedgrouparechildrenbelowtheageof10years Theteamconceptofburncare BurnsUnit Improvementsinresuscitation,nutrition,theintroductionoftopical antimicrobials andtheintroductionofmanagementprotocolshave shownthatspeciallytrained staffisabletooperatemoreeffectively withinaburnsunit. BurnTeam This is a multidisciplinary group in which individual skills complementeachother. Membersare • clinicians • nurses,whoprovidethedaytodaycontinuityofcareandare thebackbone oftheteam • physiotherapists&occupationaltherapists,whoplayan indispensablerole intherehabilitationprocessfromthetime ofadmission • dietitians;tocounteracttheextremecatabolicresponse, optimalnutrition isparamountinthecareofburnpatients • socialworkersforreintegrationinthecommunity
  • 6. 2Emergencyexamination&management 27 2 EMERGENCY EXAMINATION&MANAGEMENT Prevention What youshouldknow • 90%ofburnsin childrencanbepreventedusingcommon senseand basichouseholdsafetymeasures • 60%ofburnsinchildrenoccurintheagegroupbelow3 years • mosthouseholdsstillcookatgroundlevelandtheveryyoung arelooked afterbytheslightlyoldersibling • inflammableclothingsuchasacrylicdressescancausesevereburns • carefulandcontinuousmanagementandfollowupofpre- existingmedical conditionssuchasepilepsycanpreventburns • alcoholabuseisindirectlyresponsibleforburns • beawareofthepossibilityof(child)abuse What to do • educatepeopleaboutsafetyandachieveitsimplementationin andaround thehomeaswellasatwork • teachandtrytoachieveachangeinlifestyleathomei.e.no cookingatground levelanddon’tletyoungchildrenbelookedafterbyotheryoungones
  • 7. 28BurnsManual firstaid What youshouldknow • themanagementofaburnstartsatthesceneofthe accident • quickactioncanreducetheareaandthedepthoftheburn • theprinciplesoffirstaidare - tostoptheburningprocess - tocooltheburnwound • coolingthesurfaceoftheburnisalsoaneffectiveanalgesic • coolingtheburnwoundwillonlybeeffectiveifcommencedwithin3hours oftheinjury • insmallchildrenprolongedcoolingmayleadto hypothermia • donotuseiceoricewater,itwilldeepenthetissueinjuryand increasestherisk ofhypothermia What todo • firstandforemostremovethepatientfromthecauseofburn, ifthepatients clothesareburningwraphim/herinablanketanddousewithwaterorrollon theground • inascald(hotwaterburn)removeclothingrapidly,becausesoakedclothing actsasareservoirofheat • leaveadherentclothinginplaceandcutaroundittoremovethenon adherentclothing • usecoldrunning(tap)waterfor10-20minutestostoptheburning process;theidealtemperatureis15-18°C(rangefrom8°till25°C) • sprayingorspongingisalsoeffective • preventhypothermiabycheckingthetemperature,keeping theambient temperatureat30°Cormoreandkeepingtherestofachildwellwrapped • notethetimeoftheinjury
  • 8. 2Emergencyexamination&management 29 Keypoints for clinicalpractice ɶthetreatmentofaburnstartsatthesceneoftheaccident ɶstoptheburningprocess ɶcooltheburnwound ɶpreventhypothermiaespeciallyinsmallchildren ɶnotetimeofinjury PrimarySurvey What to do A. Airwaymaintenance • openandcleartheairway;incaseofasuspectedinjurytothecervicalspine keepmovementofthenecktoaminimumandneverhyperflexor hyperextendtheheadandneck.Stabilizetheneckwithahardcollarorin between2sandbags • ifsmokeinhalationissuspectedintubatebeforeoedemamakesthisdifficultor evenimpossible B. Breathing&ventilation • exposethechestandmakesurethatchestexpansionisadequate • alwaysprovideO2insevereburnsorwheninhalationinjuryis suspectedgive 4-8L/minute • bewareofarespiratoryrateofmorethan20perminute • performescharotomy(decompression)infullthicknesscircumferential burnsofthechest(see Ch14,page97,103)
  • 9. 30BurnsManual C Circulationandhaemorrhagecontrol • checkpulse if theradialpulseispalpablethesystolicBPis100ormore if theradial pulseisnotfeltfeelforthefemoralpulse ifthefemoralpulseisfeltthesystolicBPis80ormore ifthefemoral pulseisnotfelt,feelforthecarotidpulse ifthecarotidpulseisfeltthe systolicBPis60ormore if thecarotidpulseisnotfeltimmediately startCPR • stopbleedingwithdirectpressure • checkcapillaryrefill,if>2secitmeanshypovolaemiaortheneedfor escharotomyonthatlimb;checktheotherlimbto compare • palloroccurswith≥30%lossofbloodvolume • insevereburns(>20%TBSA)insert2largeboreperipheralIVlines d disability-neurologicalstatus • checkthelevelofconsciousness(LOC) - A=Alert - V =responsetoVocalstimuli - P=responsetoPainfulstimuli - U =Unresponsive • examinethepupilsforlightreaction • hypoxiacancausereducedLOC e exposurewithenvironmentalcontrol • keeppatientwarm • keepenvironmentwarm • checkforanyadherentclothing,cutaroundit, when removingclothing
  • 10. 2Emergencyexamination&management f fluidresuscitation 31 • estimateTBSA,usetheLund&Browderchartorusethepalmarsurface ofthepatientsownhand=1% (see Ch13,page87, 88) • weighthepatient,ifnotpossibleusethefollowingformula:2x(ageinyears +4)=… kg,useonlyinchildren<12years • giveIV fluidsinburns>10%TBSAinchildrenand>15% TBSAinadults • useRinger’sLactateorsodiumchloride0.9%(NS) • formulatobeusedis4ccxwtinkgx%TBSAburn(see Ch3, page40) • givehalfofthecalculateddeficitinthefirst8hoursstartingfromthetimeof burnandnotfromthetimetheIV driphasbeencommenced • monitoradequacyofresuscitationbymeasuringtheurineoutput,children1 cc/kg/hr,adults(from30-40kgbodywt) 0.5cc/kg/hr~30-50cc/hr,accuratemeasurementisonly possiblewithanindwellingcatheter • insertaNGT inburns>20%TBSAinchildrenand>30% TBSAinadults • giveadequateanalgesia,preferablymorphine(notinneonates)orpethidine (see Ch3,page43)
  • 11. 32BurnsManual SecondarySurvey Thisisacomprehensivehistoryandheadtotoeexaminationafterlife- threatening conditionshavebeendiagnosedandtreated. • mechanismofinjury how when where Allergies medications Pastmedicalhistory lastmealevents/Environment relatedtoinjury (e.g.wasshe/heinaclosedroom) • AMPLE • headtotoephysicalexamination Burnwoundassessmentestimation oftheareaburnedWhat you shouldknow Theriskofdyingfromaburninjuryisrelatedtotheageofthepatientandthe percentageofthetotalbodysurfacearea(TBSA) burned.Intheveryyoungand oldyouwillfindthatthegreatertheareainjuredthehigherthemortalityrateis. Thatpartofthebodywhichisonlysuperficiallyburned(thereis onlyrednessbut noblisters,socalledepidermalburns)shouldnot beincorporatedintheestimation ofTBSA. Palpationoftheburnedarea(usegloves)willrevealblistersandwillhelpto excludeareasofonlyepidermalburns.
  • 12. 2Emergencyexamination&management 33 What to do • theruleofninesdividesthebodyinareasof9%ormultiplesof9%,thisruleis relativelyaccurateinadults,butinaccurateinchildren.Inchildrenuseasruleof thethumbthefollowing: uptotheageof1yeartheheadis18%andeachleg 14%,for eachfollowingyear - subtractfromthehead1% and - addtoeachleg0.5% (see Ch13,page89) • estimatetheareaburnedinsmallburnsbyusingtheareaofthepalmar surfaceofthehand(fromfingertipstowrist), whichisapproximately1%oftheTBSA(see Ch13,page88) • theLundandBrowderchartisthemostaccurateandtakesintoaccount theageofthepatient(see Ch13,page87) depthoftheburn Skinstructure Sebaceous gland Hair follicle Epidermis Dermis Sweat gland Subdermal fat
  • 13. 34BurnsManual Depthburnwound Superficial burn Middermal level Deep burn What youshouldknow Superficialburns Thesewillhealspontaneouslybyepithelialisationandcanbedividedin • epidermalburns,theyaffectonlytheepidermis,examplesareminorflash injuriesandsunburn. Hyperaemiaoccursduetotheproductionofinflammatorymediators, theyarepainfulandhealwithin7days • superficialdermalburns(=partialthicknesssuperficial),theyaffectthe epidermisandthesuperficialpartofthedermis.Here - theblisteristhemostimportantfeature - theexposeddermisispinktowhite - thesensorynervesareexposedandthewoundisthereforeextremely painful - theyhealwithin14days
  • 14. 2Emergencyexamination&management 35 deepburns Thesearemoresevereandwillonlyhealafteraprolongedperiodoftimeandwith significantscarring • deepdermalburns(=partialthicknessdeep),theremaybesomeblistering buthere - theappearanceofblotchyreddiscolorationischaracteristic - animportantfeatureistheabsenceofcapillaryrefill - thedermalnerveendingsaredestroyedresultinginlossof sensationto pinprick • fullthicknessburns,bothlayers(epidermisanddermis)aredestroyedandthe burnmaypenetrateunderlyingstructures.Here - theburnwoundhasawhite,waxyorcharredappearance - animportantfeatureistheleatheryappearancewhichis calledan eschar - thereisnopainsensation What to do diagnosisofburndepth Depth epiDermal superficial Dermal Deep Dermal full thicKness colour Red PalePink BlotchyRed White Blisters No Present +/- No capillary refill Present Present Absent Absent sensation Present Painful Absent Absent healing Yes Yes No No
  • 15. 36BurnsManual Ingeneralasuperficialdermal(=partialthicknesssuperficial) burn • hasamoistsurface • hasapositivecapillaryrefilland • ispainful Assessmentonday3-5postburnwillhelpdefinethedepthofthetotalareaburned emergencyburnwoundcare • beforehospitaladmissioncoverwithacleansheet • inhospitaleitherexposeordresswithoneoftheavailabletopicalagents • avoidtheuseoftightdressingsinlimbswithcompromisedcirculation Admissioncriteria • age neonates babies(<1year) children adults head&neck hands&feet groin&axilla perineum always(oftendeepburns) TBSA>5% TBSA>8% TBSA>15% • site circumferentialburnsofchestandlimbsfull thicknessburnsTBSA>5% electrical,chemical, inhalationburnssocialindication • depth • special • other Whenindoubtadmitovernightandreassessthenextday.
  • 16. 2Emergencyexamination&management 37 laboratory • takebloodforFBCorPCV (=haematocrit) • ifavailableurea,creatinine&electrolytes • inchildrenregularlycheckbloodglucosetodetect hypoglycaemia • incaseoffevercheckbloodformalariaparasites Keypoints for clinicalpractice ɶcheckairway&breathing,giveO2inchildwith>20%andadultwith>30%TBSA burned,give4-8litrehumidifiedO2/ minute ɶcheckpulseandcapillaryrefill ɶcheckneurologicalstatus,useAVPU ɶweighpatient[or2x(age+4)=kg],measureextent(TBSA),notetimeofburn ɶburns>10%inchildrenand>15%inadultsstartIV resuscitation ɶgiveRL/NS4ccxwtxTBSA% ɶgive½infirst8hours;calculatefromtimeofburn ɶmonitorurineoutput,inchildren>1cc/kg/hr,inadults>0.5cc/kg/hr, iflessincreasedrip rate ɶperformescharotomyand/orfasciotomy(decompression)iflimbcirculation iscompromisedor chestexpansionisdiminished ɶreasses4hourly:breathing,circulationandneurologicalstatus
  • 18. 3Hospitaltreatment 39 3 hoSPiTAlTreATmeNT fluidresuscitation What youshould know Oralfluids • inallburns<10%TBSAgiveoralfluids,useoralrehydration solution(ORS) • between10and15%TBSAgiveORS,butmonitortheintakeasinIV resuscitation • inburnsupto20%inchildrenand30%inadultsifnoIV orintraosseous accesscanbeachievedinsertanasogastrictubeandrehydratewithORS,use formulaasinIVresuscitation IVfluids • inmajorburns(>20-30%TBSA)thereisincreasedvascularpermeability duetoreleaseofinflammatorymediators(see Ch1,page23);thisleads tothedevelopmentofgeneralizedoedema • oedemaformationstopsafter18-30hours • fromapracticalpointofviewRinger’sLactate(Hartmann’ssolution)isthe internationallyacceptedchoiceofIV fluidfor theinitialresuscitation • childrenhavelimitedphysiologicalreserveandgreatersurfaceareatomassratio comparedtoadults • thethresholdtostartIV fluidsislower(10%)inchildrenandtheyneeda highervolumeperkg;inadditiontothevolumedeficittheyshouldbegiven maintenancefluidsaswell
  • 19. 40 BurnsManual What todo estimation/calculationoffluiddeficit • Adults 4ccRLxwtinkgx%TBSAburn=deficitfor the1st 24hrs nomaintenance • Children (< 30kg) 4ccRLxwtinkgx%TBSAburn=deficitfor the1st 24hrs plus maintenancewithDW 5%andNS* 2x… kg+10=… cc/hr or 100cc/kg<10kg+50cc/kg11-20kg+ 20cc/kg>20kgper24hrs e.g.a35kgchildwill need 2x35+10=80cc/hr or - 100cc/ kgforthefirst10kg=1000cc - 50cc/kgforthenext 10kg= 500cc - 20cc/kgforthelast 15kg= 300cc - thisgivesatotalof1000+500+300cc=1800cc/24hrs - whichisthesameas75cc/hr(1800÷24) *bewareofhyponatraemiaandhypoglycaemiainchildren
  • 20. 3Hospitaltreatment 41 howtogive • givehalfofthecalculateddeficitinthefirst8hoursstartingfromthetimeofthe burn(tob).Atthesametimeinchildrenstartmaintenance(fromthetimeof insertionoftheIVdrip) • givetheotherhalfofthedeficitoverthenext16hoursandin children continuetogivemaintenancefluids • forthesecond24hourperiodaftertheburnbothadultsandchildren mustbegivenmaintenancefluids(adults2500- 3000cc/24hrs) | 8hrs | 8hrs | 8hrs | 24hrs | tob ½deficit ¼deficit addmaintenanceinchildren ¼deficit maintenance bothchildren& adults monitoringadequacyoffluidresuscitation • thebestandmostreliablemethodisbymonitoringtheurine output • adults0.5cc/kg/hr~30-50cc/hr • children1.0cc/kg/hr • iftheurineoutputisbelowthislevelgiveextrafluids, eitherbygiving IV bolusesof5-10 cc/kg orbyincreasingthefluidintakeoverthenexthourto150%of theplanned volume • whentheurineoutputneedstobemonitoredcloselyanindwellingurinary catheterisnecessary.Makesurethecatheterisremovedafter48hours,itwill causeinfectionifleftintoo long • restlessness,confusionandanxietyaresignsofhypovolaemia (shock)and thefirstresponseistoassesstheadequacyofthefluidresuscitation • in childrenit is important to look forhypoglycaemia,to preventthis early enteralfeedingwithcarbohydratesisuseful • if possible check electrolytes, children are also prone to hyponatraemia
  • 21. 42BurnsManual Problemswithresuscitation • oliguria(urineoutput<20cc/hror<0.5cc/kg/hr)meansinsufficientfluid resuscitation,donotgivediureticstocorrectthis,giveextrafluidinstead • extrafluidresuscitationmaybenecessaryin - children - inhalationinjury - electricalinjury - delayedresuscitation Keypoints for clinicalpractice ɶfluidresuscitationisessentialforsurvival ɶIVresuscitation in children >10%TBSAburned adults >15%TBSAburned ɶthedeficitiscalculatedasfollows: child(<30kg) 4ccxwtinkgx%TBSAburnplusmaintenanceadult 4ccxwtinkgx%TBSAburn ½ofdeficitinthefirst8hours(fromthetimeoftheburn), ½overthenext16hours ɶchildrenneedcarbohydratesearly ɶuseRinger’sLactateinthe1st 24hours ɶforthe1st 48hoursinsertaurinarycatheterinburns>20%TBSA ɶmeasurePCV/Hb,bloodglucoseandelectrolytes ɶconstantreassessmentandappropriatereadjustmentofthefluidregimenarevitalmeasures tobetaken
  • 22. 3Hospitaltreatment 43 Painrelief What youshouldknow • aburnhurtslike hell • regularsleepisimpossible What to do • atregularintervals(4-6hourly)giveopiatesIVorIM • usemorphine(notinneonates),give0.1mg/kg/dose,donot useitmore frequentlythanevery2hours • ifmorphineisnotavailableusepethidineinstead,1-1.5mg/ kg/dosetobe given4-6 hourly • forchangeofdressingsuseketamine,2mg/kg/doseIMis recommended • after48hoursuseParacetamol,give15mg/kg/dose(maximum doseper24hours=4gin adults) Keypoints for clinicalpractice ɶuseopiatesinthefirst48hours ɶgiveatregularintervalsandnot PRN ɶuseketamine(2mg/kg/IM)forchangeofdressings
  • 23. 44 BurnsManual Nutrition What youshouldknow • earlyfeedingisimportantbecausethepassageoffoodthroughtheintestines - protectsthesmallbowelmucosafromdamagethatoccursafterstarvation andtraumaandso - preventstranslocationofbacteriathroughthebowelwall, whichmayleadto gram-negativesepsis.Thisisoftenfatalin severeburns • duetoariseinthemetabolicrateinsevereburnsprovisionof approximately2 to3xtheusualamountofenergyis required • thebodytemperaturerises(upto39°)andanyskincoolingwillcausea furtherriseinmetabolicrate • attheburnsite,wherethebloodflowmayincreasetenfold, theO2concentrationremainslowandthewoundtissuesuseanaerobic glycolyticpathways;inotherwordslargeamountsof glucoseareconsumed • thereisanincreasedbreakdownofproteinwith80to90%of thenitrogenlost intheurineasurea;thereisaconcomitantlossofleanbodymass.Aburnof 40%TBSAcancauseweightlossof30%withinafewweeks • in ourenvironmentpatientsareoftenundernourished.They arefromthe startwhenaburnissustained,nutritionallyatadisadvantage • there is also loss of vitamins and minerals due to skin loss and muscle breakdown
  • 24. 3Hospitaltreatment 45 What to do • keeptheambienttemperaturehigh • giveextrafeedshighin caloriesandproteins,suchasLikuni phala,high energymilk,Plumpy’nutandcommercialfeeds likeProNutro(see Ch 19,page129) • supplementwithVitaminsAandC,IronandZinc • useaggressivenutritionaltreatmentforburns>20% TBSA • inthisgroup(>20%TBSA)preferablystartnaso-entericfeeds 24hourspost burn • usethefollowingformulas - adultsproteins1g/kg+ 3g/%burn calories20kcal/kg+ 70 kcal/%burn - childrenproteins3g/kg+ 1g/%burn calories60kcal/kg+ 35 kcal/% burn • giveextrafeedstwicedailyinburnsupto20%;increasethefrequencywhen TBSAis>20%(see Ch19,page129) • preferablyfeedbymouth,ifthisisnotpossiblefeedbythesmallest possiblenasogastrictube • weighpatientsatleastonceaweek Keypoints for clinicalpractice ɶearlyfeedingisimportant ɶaddVitaminA&C,IronandZinc ɶinpatientswithburns>20%TBSAaggressiveearlyfeedingisessential ɶgiveinburnsupto20%TBSA2xdailyextrafeeds ɶinpatientswithburns>20%TBSAgiveextrafeedsaccordingtotable (see Ch19,page 129) ɶpreferablyfeedbymouth ɶweighpatientsatleastonceaweek
  • 25. 46BurnsManual Burnwoundcare What youshouldknow • awoundisadisruptionoftissuearchitectureandcellularprocesses • thethermalinsult(heatorcold),electricityorchemicalactioncause denaturationofproteinsandadisruptionofcellularstructures • aburnwoundinterfereswith - temperatureregulation - sensoryfunction - immuneresponse - protectionfrombacterialinvasion - protectionfromfluid loss • aburnwoundisheterogenousi.e.notallareasoftheburnareequally deep • aimofthetreatmentistominimizethedisruptionoffunction locallyaswellas systemically • thereforeanasearlyaspossiblehealedwoundisvitally important
  • 26. 3Hospitaltreatment 47 What to do • firstaid(see Ch2,page28) • cleantheburnwound - byhandheldshoweringtoremovedirt,dressingetc. - cleanfurtherbyusingHibicet® (Savlon® )ornormalsaline - opentheblistersandremoveloosetissue • earlyactivedebridementandSSg,considerthistreatment5dayspostburn inallpatientswithfullthicknessordeepdermal(=partialthicknessdeep) burnsofthehands. Thismaynotbepossibledueto - thegeneralconditionofthepatient - superimposedillnessortrauma - anaemia - inhalationinjury • delayedconservativemanagement,therearebasicallytwo approaches exposureoftheburnwoundisonlypossibleinacleananddryenvironment; after3-4daysadryandadherentslough(=eschar/crust)develops,whichactsasa barrieragainstinfection.Thisisachievedby - cleaningthewoundwithnormalsalineorHibicet®(Savlon®) - removingloosetissueandderoof blisters - allowingtheburnwoundtodryandtoformacrust(3-4days) - fromthenonthewoundcanbecleanedpreferablytwicedailywithnormal salineorHibicet®(patdryaftercleaning)andthepatientcanbebathed;after 10-14daystheburnhashealedorthesloughwillseparategraduallyleaving agranulatingwoundsurfacewhichcanbegrafted Beaware,thatinawarmandmoistenvironmenttheescharactsasaculture medium. Nursethepatientunderabedcradle(see figure)andunder mosquito netting.
  • 27. 48BurnsManual Closedwoundtreatmentinwhichdressingsareused. Thedressingisthebarriertoinfection,tobeeffectiveananti- bacterialtopical agenthastobeaddedotherwiseitwillcreateawarmandmoistenvironment whichactsasaculturemediumforbacteria. Examplesoftopicalagentsare - aceticacid0.5%,actsagainstPseudomonas,analternativeisdiluted vinegar - eusolinparaffin(EP)isusedtoremovesloughandtoinducegranulation tissueformation.IfnoEPisavailablesoakVaselinegauzeinEusol,applya layerofgauzesoakedinEusoloverit andcoverthesewithdrydressingsand abandage.IfawaterysolutionofEusolisusedthenthebandagedriesvery quickly - honeymixedwithghee,vegetableoil,glycerineorwateris activeagainst Staphylococcusaureus - papaya,alsohasantibacterialpropertiesandreducestheformationof hypergranulation - povidone- iodine(Betadine®)ointment,isactiveagainst Staphylococcusaureus - silversulphadiazine(Flamazine®),isactiveagainst StaphylococcusaureusandPseudomonasaeruginosa - silvernitratesolution(AgNO30.5%),asabove
  • 28. 3Hospitaltreatment 49 - tannins,madefromteaoritsbyproducts,willleadto improvedwound healingandreducedscartissueformation (fewerhypertrophicscars) - zincoxidecreamhasanantibacterialactionandpossiblyreducesthe formationofhypergranulation (see Ch17howtoprepareandtoadminister,page121) differencesbetweenthetwotreatmentoptions open closeD costs Low High infection Pseudomonasrare Pseudomonascommon laBour intensiVe Low High pain Painful Lesspainful eVaporation High Low heat loss High Low THEREISNO DIFFERENCEINSURVIVAL RATE
  • 29. 50BurnsManual Generalremarksondressingtechniques • preferablyuseafreshdressingpackforeachpatient • ideallydresstheburnwoundoncedaily.Withtheuseof honeyandzinc oxide,thedressingcanbeleftundisturbedfor2-3 days • removedressingsgently,otherwisenewlyformedtissuewillbedestroyed.Soak thedressingsinabathwhentheyareadherenttothewound • askthepatienttoparticipateinthetreatment,e.g.removalof dressings • batheorwashthepatientafterremovalofthe dressing • preferablytreatchildrenintheirroomorwardasthatisasafeenvironmentfor them • begenerouswithketamineespeciallyinchildren(see Ch 16,page118) • beeconomicwithgauzesanddressings,theyareexpensive
  • 30. 3Hospitaltreatment 51 Physiotherapy What youshouldknow • maintaining movement and appropriate position of all joints is essential becauseofthetendencyofcontractureformation indeepburns • preventionofcontractureshastostartrightfromthebeginningin thefirstfewdaysafteraburninjury • burnpatientstendtokeeptheirjointsinthe‘positionofcom- fort’andthiswill leadtocontractureformation • duetopainanddiscomfortburnpatientsdon’tmoveandmay developpressuresores What to do • topreventcontractureskeep - theneckinextension - theaxillainabduction - theelbowsinextension - thewristsneutralorin extension - themetacarpophalangealjointsinflexion - theinterphalangealjointsinextension - thekneesinextensionand - theanklesin90˚dorsiflexion • takeverygoodcareofpressuresoreareassuchasoccipital, sacraland calcanealareasandturnpatientsevery2hours24hoursadaytopreventthe developmentofpressuresores • mobilizepatientsasearlyaspossible • involvephysio-andoccupationaltherapistsatanearlystage(see Ch4, page59)
  • 31. 52BurnsManual Bacteriaandinfection What youshould know • infectionismainlyspreadbythehandsofthehealthcareworker • mostburnwoundswillbecolonizedwithbacteriaasearlyas3daysafterthe burn • whereitisnotpossibletoperformwoundcultureslookatthewoundandthe dressings,e.g.withPseudomonasinfections thedressingslookbluegreenand withStreptococcusinfection thewoundisoftenbrightred • microorganismsmostcommonlyseeninburnsare - Staphylococcusaureus - Pseudomonasaeruginosa - ßhaemolyticstreptococcus - Escheriacoli - Proteusmirabilis - Klebsiellapneumoniae - Candidaalbicans • intheearlystagesofaburn(first5days)theburnwoundiscolonized primarilywithgram-positivebacteriasuchasStaphylococcusaureus, laterfollowedbygram-negativebacteriasuchasPseudomonas • sepsis is adocumented infection with systemic inflammatory response syndrome(SIRS), whichis presentwhen2ormore ofthefollowingare found - temperature - heartrate - respiratoryrate - WBC > 38°Cor<36°C > 90beatsperminute > 20breathsperminute > 12000cellsor<4000cells/mm3
  • 32. 3Hospitaltreatment 53 • septicshockisasabovetogetherwithasystolicBP<90mmHgoradropinBP of>30mmHgdespiteadequatefluid resuscitation • beawareofotherpossibleinfectionssuchasmalaria,pneumonia, urinarytractinfectionsetc. What to do • usealcoholichandrub(AHR)inbetweenpatientsandwashhandswhen theyhavebeensoiled(see Ch16,page118) • takewoundswabswhenawoundinfectionissuspected • becautiouswiththeuseofurinarycathetersandiftheyarenecessary removethemassoonaspossible • incaseofsepsisstartwithacombinationofbroadspectrumantibioticse.g. chloramphenicolandgentamicine,takeimme- diatelyawoundswab&blood forbloodcultureandwhentheresultsareoutchangetothemostappropriate antibiotics • useantibioticsinshortcourses(notmorethan5days),usetheappropriate dose;itisbesttouseashighaspossibleadosefor theshortestpossibletime • givetheantibioticsintravenouslyuntilthefeverisdown,thenadministerorally • usetheappropriatetopicalagentse.g.silvernitrateoraceticacidfor Pseudomonas What not to do • donotgiveantibioticsprophylactically • donottreataninfectedwoundwithsystemicantibiotics unlessthereare signsofsystemicinfection
  • 33. 54BurnsManual Keypoints for clinicalpractice ɶcleantheburnwoundwithsalineorHibicet® (Savlon® ),deroofblistersandremoveloosetissue ɶtreateitherbyexposureorwithdressingswithantibacterialtopicalagents ɶalternatedifferenttopicalagents ɶtreatdeepburnsofthehandpreferablywithearlydebridementandskingraft (after5days) ɶbegenerouswiththeuseofketamineasananalgesicespeciallyinchildren ɶpreventcrossinfectionbyusingalcoholichandrubinbetweenpatients ɶwhenapatientisconfusedand/orirritablewithalowbodytemperaturethinkofsepsis ɶwithsuspectedsepsisuseacombinationofbroadspectrumantibiotics,giveshortsharpIV courses ɶdonotusesystemicantibioticsprophylacticallyorininfectedwoundswithoutsignsofsepsis,treat theinfectedwoundwithtopicalagentsinstead Closureoftheburnwound What youshouldknow • superficialdermalburnswillhealwithin10-14days • deepdermalburnswillhealwithin21-28days • anyburnnothealedafter21to28daysandlargerthan3cmindiametermay benefitfromaskingraft • aHbof12g%(minimumof8g%)oraPCVof40% (minimumof 24%)andagoodnutritionalstateareessentialforoptimalwoundclosure • fullthicknessburnsalwaysrequiresurgicalclosure(SSG, fullthickness graft,pinchgraftorflaps) • deepburnswillneeddesloughingeitherbydressingswith Eusolorby surgicaldebridement • allburnsrequiringskincovershouldbegraftedassoonaspossible,this reducesthechanceofinfection&anaemiaandletthepatientreturntoa positivenitrogenbalance
  • 34. 3Hospitaltreatment 55 • beforeasplitskingraftisappliedthewoundshouldbeclean,hashealthyflat granulationsandpreferablynobacteria(oralowcount,<105 or≤2+) • therearethreekindsoffreeskingraft - SSg(splitskingraft),takeswell,thethinnerthegraftthebetterthetake,is cosmeticallylesssatisfactory,shrinksin timeupto50%,ismostcommonly usedandcancoverlargeareasespeciallywhenmeshed - fullthicknessgraft,takeswithmoredifficulty,iscosmeticallybetterandwill shrinkupto20% - pinchgraft,iseasytodo,thecentreisfullthickness,thesidespartialthickness, resistspressureandinfectionwellandis recommendedforsmalldifficult areassuchasbackoflowerlegovertheAchillestendon • graftfailureisdueto - infection(takeawoundswabif possible) - bleeding(graftisliftedofits bed) - anaemia - movement(makesurethegraftisfixedwell) - unhealthygranulations,hypergranulationsornogranulationsatall • bestdonorareasare - foraSSG,thighs,upperarmsandflexoraspectoftheforearm - forafullthicknessgraft,postauricularskin,supraclavicularskinandthe groin - forapinchgraft,thethighs
  • 35. 56BurnsManual What & how to do • consideraskingraft - indefectslargerthan3cmindiameter - whenthewoundhasn’thealedafter21days • graftearlyinhandandfacialburns • howtotakeaSSG(see Ch14,page106) • theyaresutureddirectlyorsometimeswitha‘tie-over’suture(see Ch14, page110);whenappliedtoanarmoralegtheycanbefixedwithawell appliedbandage • shouldoverlapattheedges • maybemeshed(see Ch15,the‘Pizzacutter’,page111) • areplacedoverflexureswhicharemaximallystretched(andsplinted) • aredressedwithvaselinegauzepreferablysoakedinsilvernitratesolution 0.5%orwithSSD • areinspectedafter5daysunlessthewoundsmellsverybadlyearlieron,then inspectimmediately • whenthegrafthastakendressagainwithVaselinegauzeandbandage,after 10-14daysnodressingotherthanaprotectivebandageforanother2weeksis necessary.ApplyVaselineoroilycream(e.g.coconutoil,thereissome evidencethatit reducesthechanceofthedevelopmentofahypertrophicscar) tokeepthegraftedareasupple • applyonthedonorareaimmediatelyaftertakingtheskingraftgauzessoakedin ‘junglejuice’(see Ch16,page117)duringtheoperationandafterfinishing theoperationapplyVaselinegauzesoakedinsilvernitrateorSSDandleave undisturbed for10days.If,whenchangingthedressing,thegauzesarestill stucktothe donorareadonotremove,butinsteadapplyafreshbandageontopofthem
  • 36. 3Hospitaltreatment 57 do notapplyaskingraftif • thewoundiscolonizedwith - Streptococci(ßhaemolytic),seenonaGramstainorwhentheburn woundlooksbrightredandbleedseasily - Pseudomonasaeruginosa(bluegreenpus) • thereisaheavygrowthofbacteria>105or>2+ • hypergranulationispresent,treatwithzincoxideorpapayadressingsor scrapeawaybeforeapplyingthegraft • thewoundbedisfibrouswithoutgranulations • thepatientisotherwiseunwell Keypoints for clinicalpractice ɶconsideraSSGwhenthewoundhasnothealedafter21daysandis>3cmin diameter ɶgraftonlywhenaburnwoundhashealthygranulations, theHbis>_8g%orPCV>_24%&thepatientiswellnourished ɶfixgraftsecurely ɶinspectagraft5dayspostoperatively ɶleavethedonorareaundisturbeduntilithashealed ɶagraftremainsfragilefor3weeks ɶkeepsupplewithVaselineoroilycreamandbandagetoprotect
  • 38. 4Rehabilitation&reconstruction 59 4 rehABiliTATioN&reCoNSTrUCTioN What youshouldknow • maintainingmovementofalljointswiththehelpofphysio- and occupationaltherapistsisessential • burnsthattakelongerthan2weekstohealmaydevelophypertrophic scarring,physio-andoccupationaltherapymightberequiredtodeal withthisusingelasticbandagesandpressuregarments • pressuregarmentsareusedinthetreatmentofhypertrophicscars • managementofkeloidsismoredifficult • contracturesarepreventable • aburnpatientmaysufferpsychologicallyasaresultofpostburncosmetic disability(bodyimage)andmayneedhelpfromfamily,professionalsand friendsafterheorshehasbeendischargedfromhospital KeloiDs&hypertrophicscars Bothoccurasaresultofanexaggeratedwoundhealingresponse,butthecauseis unknown ɶkeloidsarefloridlesions,aregrosslyelevated,spreadandinvolvethenormalsurroundingskin, aretendertotouchandfeelitchy&hot ɶhypertrophicscarsareraised,initiallyred,donotinvolvethesurroundingnormalskinand eventuallyregress Thesedescriptionsaretheextremesandassucheasilyrecognizedbutinrealitytherearesimilarities andalsogradationfromonetotheother.Becausethetreatmentisoftensimilarthenameis thereforeoflessimportance,butkeloidsarenotoriouslydifficulttotreat
  • 39. 60 BurnsManual What todo • physicalscarringisbestpreventedbymaintainingcleannon-infected woundsandprovidingearlyskincover • hypertrophicscarsneedtobetreatedvigorouslybyphysio- and occupationaltherapistswithcustomfittedpressuregarmentsforaslongas 6-12monthsoruntilrednessanditchinesshavedisappearedandthescar hasflattened • keloidsaremoredifficulttodealwith,insmallkeloids (<2cm)intralesionalinjectionswithcorticosteroids(e.g. 0.5-1ccmethylprednisolone/ triamcinolone)every4-6weeksuntilflattening hasocccurredcanbehelpful,alargerkeloid canbeexcisedwithinits boundariesfollowedoneweeklaterbyintralesionalinjectionswithsteroids (weeklyintervalsx3, then6weekintervalsx3) • forbothhypertrophicscarsandkeloidstheuseoftopical siliconegel sheetshasbeenintroducedwithgoodresults. Itdecreasesthepain&itchingandresultsinflatteningof thescar.Themodeofactionisunclear.Itisparticularlyusefulinchildren.The sheetscanbewashedandreused • contracturescanbepreventedorreducedby - movementsofalljointsseveraltimesaday - passiveaswellasactivestretchingofjointsaffectedbyaburn - activitiesandgamestoachievethis - splintsandskintraction - pressuregarments - earlyclosureoftheburnwound • whenthisfailssurgicalreleaseofthecontracturemaybecarriedout whenithassoftened,6-12monthslateron • basicprinciplesforcontracturereleaseare, - transversereleasingincisions,ratherthanZ-plasties - serialreleasesandSSGforseverecontractures - occasionaluseoffullthicknessgrafts - theuseofflaps(random,axial,fascio-cutaneous)forthe moredifficultcontractures
  • 40. 4Rehabilitation&reconstruction 61 • giveseverelyburnedpatientsmaximumsupport,theyhavetodealwitha changeinbodyimage,lossofmoraleandsubsequentdeformities • givethemloveandshowcompassion;theyoftenneedsocio- economic support(extrafood,specialappliances,clothing) Keypoints for clinicalpractice ɶfrequentactiveandpassiveexerciseofalljointsis essential ɶcontracturesarepreventedbyexercises,splintingandtraction ɶtreathypertrophicscarswithpressuregarments ɶtreatmentofkeloidsisdifficult ɶaburnpatientwillneedpsychologicalsupportfromprofessionalstaff aswellasfrom relatives,friendsandcolleagues
  • 42. 5Burnsinchildren 63 5 BUrNSiNChildreN What youshouldknow Epidemiology • inyoungchildrentherearemorehotwaterburns(scalds),whileinolder childrenflameburnsaremorecommon Anaccuratehistoryisimportant,particularattentionshouldbegiventothenon- accidentalburn(childabuse) Bodysize&proportions • achilddiffersfromanadultinoverallsurfaceareatobodyweightratio leadingto - highermetabolicrate - greaterevaporation(waterlossthroughburnedarea) - greaterheatloss • alsoinachildtheheadandneckarecomparativelylargerthaninanadultand thelegsarecomparativelysmaller • inachildupto1yearoldtheheadandneckare18%oftheTBSA, whereaseachlegis14% • foreveryyearoflife>1yeartheheaddecreasesby1%, whereaseach leggains0.5% • byusingthismodificationoftheruleofninesitcanbeseenthattheadult proportionsarereachedattheageof10years Depthoftheburn • theskininchildrenismuchthinnerthaninadultsresulting indeeperburns, forexamplewaterof60˚Cwillcauseafull thicknessburn - inlessthan1secondinaninfant - in5secondsinanolderchild - after20secondsinanadult • burndepthassessmentismoredifficultthaninanadult, andcan remainsoupto7-10dayspostburn
  • 43. 64BurnsManual Fluidmanagement • differencesbetweenchildren&adults - inachildahigherproportionofbodywaterisextracellular,bloodvolumeis 80cc/kg(neonatesandbabies90cc/kg) comparedto60-70cc/kgin adults - renaltubularconcentratingcapacityisless,thismayleadto morerapidand greaterfluidloss - fluidoverloadontheotherhandmayquicklyleadtocerebraloedema, especiallyincombinationwithhyponatraemia. Thisriskcanbereducedbytheuseofcolloidsafterthe first12hours postburnandbythehead-uppositionin thefirst24hours • assessmentoffluidstatus - achildhasgoodcompensatorymechanisms,thusthecirculationis seeminglywellmaintainedinthefaceofafluid deficit,alsosignssuchas anxietyandagitation,whichareusefulsignsofshockinadultsarelesshelpful inchildren,becausetheymayoccurforotherreasons - subtlesignsofhypovolaemiaare - generalappearanceofthechild - skincolour& temperature - venousfilling • urineoutput - themostreliablewaytoassessfluidresuscitationisthemeasurement oftheurineoutput(1cc/kg/hr,range0.5-2cc/kg/hr),duetotheuse offinetubesforcathe- terisation,mechanicalobstructionofcathetersdoesoccur - whenurineoutputisinadequatecheckthereforefirstthepatencyofthe catheter,ifthisisfine,extrafluidbolusesshouldbegiven • intravenousaccess - can be difficult, cannulate larger veins (e.g. femoral vein) only if expertiseis available,cannulation through burned skin is acceptable althoughmoredifficult,intraosseous accessisrelativelysafeforashortperiodoftime(8-12 hours)
  • 44. 5Burnsinchildren 65 • maintenancefluids - arenecessaryin childrenandshouldcontain glucose,hypo- glycaemia especiallyinassociationwithhypothermiaoccursveryrapidly Airway • occultupperairwayobstructioniscommoninchildren, enlargementof adenoidsandtonsilsmayexistbeforetheburninjury • thelowerairwayisnarrow,thereforeswellingofthemucosaand accumulationofsecretionsinterfereswithoxygenation • breathingbydiaphragmaticmovementismoreimportantin children,this meansthatabdominalwallrigiditymayinterferewithoxygenation,considerin burnsoftheanteriorchestandupperhalfoftheabdomenescharotomies (see Ch20,page103) Gut • childrenaremorepronetogastricdilatationandtheytendto swallowairwhen crying,anasogastrictubecouldthereforebehelpfulinburns>20%TBSAfor thefirst48hours • becauseoftheirhighmetabolicrateandnutritionalneedsfor growth,children shouldbegivenearlyfeeds(after24hours)enterally;thisalsopreventslossof gutfunction (see Ch3,page45) Non-accidentalinjury • suspicionmayberaisedby - vagueorinconsistenthistory - historynotcompatiblewithpatternof burn/injury - presenceofothersignsoftrauma - certainpatternsofinjurysuchascigaretteburnmarksorsharp demarcationsasin‘bilateralshoe&sockscalds’ • notethatfalseaccusationisverydamagingtotherelatives,unusualand bizarrepatternscanbecausedbyaccidentalinjury
  • 45. 66BurnsManual Temperature • childrenoftenrunhightemperaturesinthefirstfewdays,unlessitexceeds 39°C,itwillneednotreatment.Beawareofmalaria,checkincaseoffever alwaysbloodformalariaparasites(MP’s) What to do • estimateTBSAburned(see Ch13,page87) calculate andgivethedeficitplusmaintenance(see Ch13,page 90, 92) - after12hoursreplacecrystalloidswithifpossiblealbumen 4.5%inaliquots eachaliquotis0.5xwtinkgxburn%TBSA giveeach aliquotover6,6and12hourscontinuemaintenance withcrystalloids • monitortheadequacyofthefluidresuscitationbymeasuringtheurineoutput (see Ch13,page90) • assessthefluidstatusbylookingatthegeneralcondition (irritable, restless),skincolour&temperatureandvenousfilling • giveadequateanalgesia(see Ch3,page43) • lookattherespiratoryrate,giveoxygen • consideraNGT inburns>20%TBSA • keepthechildwarmandtheambienttemperaturehigh • nurseinhead-uppositionintheshockphasetopreventcerebral oedema • preventhypoglycaemiaandhyponatraemia,checkblood glucosewith dextrostixandcheckelectrolytes.Ifthisisnot possibleuseasmaintenance fluidhalfDW 5-10%andhalf NSwith20mmolKCLperlitre • startenteralfeedingasearlyaspossible(after24hours)
  • 46. 5Burnsinchildren 67 Exampleoftheadministrationofalbumenafter12hoursinachildof10kgwithaburnof30% TBSA deficitforcrystalloidsis4x10x30=1,200cc600ccgiven in1st8hrs 150ccgiveninnext4hrs thengivealiquotsofalbumencalculatedasfollows: 0.5x10x30=150cc 150ccinnext6hrs150ccin next6hrsand150ccinnext12 hrs thatmeansthatafter36hoursthischildwillhavereceivedatotalof 750cccrystalloids plus450cccolloids=1,200ccIVinfusion giveatthesametimemaintenancewithcrystalloidsandcontinuethisforanother12hours(i.e.until48 hoursafterthestartofIVresuscitation) Keypoints for clinicalpractice ɶgreatermetabolicrate,heatlossandevaporation ɶsmallerrenaltubularconcentratingcapacity ɶhigherextracellularproportionofbodywater ɶaddtocalculateddeficitmaintenancefluids ɶwithsodiumandglucose ɶurineoutputtoassessthefluid resuscitation ɶintraosseousaccessissafeforashortperiodoftime(8-12hours,max.24hours) ɶearly(after24hours)enteralfeedinghighincaloriesandprotein (2-3xhigherthan thenormal)is essential All3leadtoamore rapid&greaterfluid loss
  • 48. 6Inhalationinjury 69 6 iNhAlATioN iNJUrY What youshouldknow Thereare3typesofinhalationinjuries • airwayinjuryabovethelarynx,thisisaburnduetoinhalation ofhotgases, mostcommonlyoccurringinanenclosedspace.Theyproducethesame changesasinathermalinjuryoftheskinresultinginoedemaleadingtoairway obstruction. Thisoftendevelopsatthetimeofmaximalwoundoedema(12-36hours postburn).Thistypeofinjuryisrelativelyuncommon • airwayinjurybelowthelarynx,isproducedbyinhalation oftheproducts of combustion • systemicintoxicationinjurybycarbonmonoxide(CO) from exhaustfumes& heatersandbycyanidefromburningplastics. CO hasamuchgreateraffinitytotheHbmoleculethanO2, thisleadsto tissueanoxia.Cyanideisrapidlyabsorbedbythe lungsandmaycauseloss ofconsciousnessandconvulsions Diagnosisofinhalation injury Inhalationinjuryispotentiallyfatal,thereforelookinallcasesof severeburnsfor • increasingrespiratoryobstructionoccurringoverseveralhours (thisisseenin injuriesabovethelarynx) • abnormalitiesinoxygenationasshownbyrestlessnessand confusion( thisisseenininjuriesbelowthelarynxandin systemicintoxication) Clinicalfindingssuggestiveofinhalationinjury are singednasalhairs productivecoughcroup- likebreathingrespiratory problems • burnstomouth,nose • sputumwithsoot • changeofvoice • inspiratorystridor What todo
  • 49. 70BurnsManual Abovethelarynx • closeobservation,ifstridorandrespiratorydistressoccurproceedto endotrachealintubation Belowthelarynxgiverespiratorysupport • humidifiedO2, 8litresperminutepreferablybyfacemask(non- rebreathingtype) • intubateifhigherO2concentrationsarerequiredorif bronchialtoilet isnecessarytoremovesecretions Insystemicintoxication • giverespiratorysupportwithhumidifiedO2(graduallyCO andcyanideare removedfromthebody,althoughforcyanideitdoesnotoccuraseffectively asforCO) • placetheunconsciouspatientinleftlateralcomaposition Keypoints for clinicalpractice ɶinhalationinjuriesarepotentiallyfatal ɶthediagnosisdependsstronglyonclinicalsuspicion ɶemergencytreatmentreliesonadministeringrespiratorysupportwith oxygenandpossibleendotrachealintubation ɶmortalityincreasesby30-50%
  • 50. 7Burnsofthehand 71 7 BUrNSof ThehANd What youshouldknow • thedorsumofthehandhasathinskinandthepalmathick skin • thefunctionofthehandandfingersisjeopardizedinsevereburnsifno promptandpropertreatmentisgiven • thedepthisdifficulttoassess • earlyskincoverisessential(ifafter5-7daysthereisnosignofhealing considerdebridement&grafting) • electricalburnsarealmostalwaysfullthicknessburns • beawareofthedevelopmentofacompartmentsyndrome What to do Intheacutestage(1-7days) • removedirtandadherentmaterialexcepttar • washcopiously,tapwatermaybeused • leaveblisters,whichdon’tinterferewithmovementorcirculation, undisturbed • applySSDandeitherputthehandinaplasticbagordressthefingers separatelytoavoid webbing • elevatethehandsonpillowsorwithasling • changedressingsdailytoassessthedepth • earlymovementoffingersandwristjointsareessential • insevereburnsgiveavolarsplintwiththehandinthepositionofrest(wristin 20˚extension,MCPjointsflexed70˚andfingers[IPjoints]straight) • performescharotomiesandfasciotomieswhendeemednecessary (see Ch14,page97etseq.) Intheintermediatestage(1-3weeks) • continuewithmobilization(activeandpassivemovements)&splinting • applyskingraftstobareareas
  • 51. 72BurnsManual Inthelongterm(after3weeks) • treathypertrophicscarswithpressuregarmentsfor 6-12months • contracturescanbemultipleandsevere,preventthemfrom occurringby goodearlytreatment • whencontractureshavedevelopedtheyhavetobereleasedsurgically Keypoints for clinicalpractice ɶearlyandappropriatetreatmentwillpreventcomplications ɶdebrideandperformskingraftsrelativelyearly ɶbeawareofcompartmentsyndromeandtreataccordingly ɶtreathypertrophicscarswithpressuregarments ɶestablishedcontracturesneedtobereleasedsurgically
  • 52. 8Facialandperinealburns 73 8 fACiAl ANd PeriNeAlBUrNS What youshouldknow • arecausedbyhotwater,fireorexplosions(paraffinlamps) • areoftendeepburns,butbecauseofagoodbloodsupplyfacialburnshealvery well • eyesmaybeinjuredbyexplosionsorchemicalsubstances • severelyburnedeyelidsmaycauseexposureofthecornea,ectropion andscarring • theskinofthetipofthenoseandearsisthinthereforecartilageoftenisalso burnedand/ orexposed(especiallythehelicalrim) • mouthandlipsareinjuredbyinhalationorchemicalingestion • inburnsoftheperineumandgenitalia,retentionofurinemayoccurduetothe developmentofoedema What to do General • cleanthoroughly • applytopicalagentsdaily • graftearlyandpreferablydonotusemeshgraftsinfacial burns,theywill givepoorcosmeticresults • infacialburnsnursein(semi)uprightpositionandwatchforsignsof inhalation(see Ch6,page69) Eyes • firstaid,washcopiouslywithwater(inchemicalburnsatleastfor1 hour)andcoverwithsterilepad • inhospital,evertthelidandremovesolid particles • applychloramphenicol1%ointmenttdsfor15days • insevereoedemajustcleanandwaituntiltheoedemahassubsided • ifthecorneaisexposeddoatarsorrhaphy • consulttheopthalmologistearly
  • 53. 74BurnsManual Eyelids • indeepburnsoftheuppereyelidsearlygrafting(between3and5days)is important • ectropionbecauseoflidretractionwillneedareleasefollowed byafull thicknessgraft Ears • exposedcartilageshouldberemoved • repeatedcleaningshouldbecarriedout • earlygraftingisbest Mouthandlips • copiouslavageinchemicalburns • earlyandselectivedebridement • applyplainVaselinetolips • topreventbleedingdonotremovecrusts Perineum&genitalia • insertacatheterandorobserveurinaryoutputcarefully • leaveburnsexposedpreferablyuntilhealed,thisareagetseasilysoiledwhen dressed,especiallyinsmallchildren • ifadressingisrequireduseVaselinegauze,changefrequently • observebowelmovements Keypoints for clinicalpractice ɶ washthoroughly ɶ cleanthoroughly ɶearlydebridementandskincoverage ɶconsultopthalmologistinanearlystage ɶbeawareofretentionofurineinperinealburns
  • 54. 9Electricalburns 75 9 eleCTriCAl BUrNS What youshouldknow • electricalburnsaredividedinto - lowvoltage(<1000volts),householdsupply - highvoltage(>1000volts),powersupply(e.g.ESCOM) - lightning,extremelyhighvoltage,shortduration,peculiarinjurypattern • tissue damage is caused by the generation of heat and depends on the resistanceofthetissues;skinandbonehaveahighand bodyfluidshavealow resistance • ahighconcentrationofcurrentandahighresistancecauseintenseheat • lowvoltagecurrentwillcauselocalcontactwoundsbutno deeptissue damage;itmaycausecardiacarrest • highvoltagecurrentcausesinjuryin2ways: - flashburn,thecurrentdoesn’tpassthroughthevictim,but theflashignites forexampletheclothes - transmissionofcurrentresultsinskinanddeeptissuedamage,thisisalwaysfull thickness;swellingwithinthelimbsmayproducesignsofacrushinjuryanda fasciotomymaybenecessary.Alsorenalfailureduetohaemolysisand myoglobinreleasefromthemuscleinjurymaydevelop • lightningcausesahighmortalitywhenthevictimisstruckdirectly,incaseofa sideflash(whenlightningstrikesatreeandthecurrentisthendeflected throughavictimonitswaytotheground)itcancauseavarietyofburn wounds,partial andorfullthickness
  • 55. 76 BurnsManual What todo • removethevictimfromthepowersource,beaware,thathighvoltageelectricity willdischargethroughair;40000voltswill jump13cm,ifyoucan’tturnoffthe poweruseapieceof woodtoseparatethevictimfromthepowersource, preferablystandonapieceofrubberorwearrubberboots • onceclearstartwithprimarysurveyasinanyburninjury • duetomuscleinjury(whichcanbeconcealed)thefluid requirementsare greaterthaninapureskinburn,aimfor aurineoutputof75-100cc/hror inchildren1.5cc/kg/hr especiallywhenthecolouroftheurineisdarkred • incaseofacardiacarrestadministerCPR • assesstheperipheralcirculationhourly,lookat/for - skincolour - oedema - capillaryrefill - peripheralpulses - sensorychanges • whenthefollowingsignsandsymptomsarepresent - apalpablytenselimb - painonstretchingmuscles - paraesthesia - a(not)palpablepulse - abriskcapillaryrefill acompartmentsyndromehasdeveloped,thisrequiresanurgent fasciotomy(see Ch14,page99etseq.)
  • 56. 9Electricalburns 77 Keypoints for clinicalpractice ɶavoidinjurytothosegivingfirstaid ɶtreatcardiacandrespiratoryarrestpromptly ɶmonitortheheartforatleast24hours ɶstandardburnsresuscitationformulaemaybeinsufficientduetothemuscleinjury ɶwatchformyoglobinuria(darkredurine),inthatcaseincreasethedriprateandaimforanhourly urineoutputof75-100cc(inchildren1.5cc/kg/hr)until theurineisclear ɶwhenacompartmentsyndromeissuspectedperformanurgentfasciotomy
  • 58. 10Chemicalburns 79 10ChemiCAlBUrNS What youshouldknow • morethan25000productswhichcancausechemicalburnsareavailablefor useinagriculture,household,industryandmilitaryforces • handsandupperlimbsaremostlyaffectedduetohandlingofthese substances • commonlyusedchemicalscapableofproducingburnsare: - household - industrial -military bleach,disinfectants,toiletbowlcleanersalkalissuch aspaintremovers,causticsoda,lime,washing powders acidssuchashydrochloricacid phosphorus • achemicalagentproducesprogressivedamageuntilitis inactivatedby aneutralizingagentordilutedwith water • estimationofdepthmaybedifficultinthefirstfewdays • somechemicalsproducesystemictoxicity(e.g.petrol) • accidentalingestion(e.g.batteryacid)ismorecommonin children • onethird of all patientswithintraoral burnseventuallyhave oesophageal injuries,endoscopyisnecessarytoseetheextentoftheinjury • strictureformationoftheoesophagusiscommonifburned bychemical substances • chemicalburnsoftheeyeareoftenseriousandmayleadto lossofeyesight
  • 59. 80 BurnsManual What todo • thefirstandforemostimportantactiontobetakenwithin 10minutesof theinjuryisapplicationofaconstantflowofwater • inanacidburnirrigatewithwaterandtreatfurtherasathermalburn • inanalkaliburnthereislessimmediatedamagethaninanacidburn, irrigateatleastfor1hour • phosphorusburnsareextinguishedbywater,particlesembeddedinthe skincontinuetoburn,thereforeremovethevisibleparticles • incaseofeyeinjuriestreatwithcopiousirrigationofwater,applytopical antibiotics(e.g.chloramphenicoleyeointment) topreventsecondary infection(see TheSurgicalHandBook Ed.EJ vanHasselt,2008,page 83,84) Keypoints for clinicalpractice ɶagentscausingchemicalburnsarewidelypresentinsociety ɶallchemicalburnsneedcopiousirrigationwithwater ɶsystemictoxicitymayoccur,especiallywithpetrol ɶchemicalinjuriestotheeyewillneedcopiousirrigationwithwaterforatleastone hourandthenreferraltoanophthalmologist
  • 60. 11Outpatientmanagement 81 11oUTPATieNTmANAgemeNT What youshouldknow • onlypatientswithsuperficialdermalburns/ deepdermalburns(partial thicknessburns)<10%TBSAshouldbetreatedasoutpatientswithexception oftheveryyoung&oldandthosewithburnsinspecialareasasdiscussedinthe admissioncriteria(see Ch2,page36) • scaldsarelesslikelytobedeepexceptinchildren • inhandburnsinvolvephysiotherapistsatanearlystage • everyhandburnthattakeslongerthan2weekstohealmaydevelop hypertrophicscarring • itchingmaydevelopinarecentlyhealedburn,moisturizingcreams, massageandpressureallhelp What to do • estimatetheextentoftheburnwiththepalmarsurfaceofthepatientshand (fromthefingertipstothewrist),itisapproxi- mately1%oftheTBSA(see Ch13,page88) • lookatthecolouroftheburn • notethepresenceorabsenceofblisters • applydigitalpressureandobservethecapillaryrefill • giveoralanalgesics • cleananddressthewound(see Ch3,page46etseq.)
  • 61. 82BurnsManual How to do it • followaseptictechnique • cleanwoundwithHibicet® (Savlon® )ornormalsaline • punctureblistersandremovealldeadandlooseskin • shaveallvisiblehairsaroundthewound • coverthewoundwithanyoftheavailabletopicalagents(see Ch17, page121) • apply1layerofVaselinegauzefollowedbydrysterilegauzesthenbandage,if noVaselinegauzeavailableapplythetopical agentonadrysterilegauzeand proceedasbefore • changethedressingsatleasttwiceweeklyormorefrequently whensoiled untilthewoundhashealed • advisepatientstoelevatebandagedlimbsinthefirstweekpostburn • whenthewoundhasn’thealedcompletelyafter3weeksrefertothenextlevel (e.g.districthospital/ burnsunit) • forminorburnsofthehandsorburnsinvolvingthejoints physiotherapy maybenecessary • afterthewoundhashealeditisoftenstillvulnerableanditchy, creams(e.g.aloe vera,coconutoil)and‘crepe’bandagescanbehelpful Keypoints for clinicalpractice ɶ meticulouscareoftheburnwoundis essential ɶ prescribeanalgesicsandgivethecorrectdose ɶwhentheburnwoundhasnothealedcompletelyafter3weeksrefer ɶaftertheburnwoundhashealedapplyoilycreamforoneweektokeepthescar supple ɶwhenhypertrophicscarringhasoccurredreferthepatient
  • 62. 12Criteriaandproceduresforreferral 83 12CriTeriA ANd ProCedUreS for referrAl fromhealthcentrestodistricthospital • refer - childrenwithburns>5%TBSA and - adultswithburns >10%TBSA - allneonatesirrespectivetheareaburned - allfullthicknessburns - allcircumferentialburnsimmediately - allburnsofface,hands,feet,genitalia, perineumandmajorjoints - allinhalationburns - allelectricalandchemicalburns • proceduresbeforereferral - keepthepatientwarm - washwoundswithHibicet® (Savlon® )ornormalsalineandcoverwith acleansheet - providepainrelief,paracetamolormorphine/ pethidineifpossible - givetetanusprophylaxis • howsoonshouldapatientbetransferred - ifthenearesthospitaliswithin30minutestravel,referthepatientassoon aspossiblebutstartthetreatmentofshock - ifthehospitalisfurtherawaygetfirsttheshockunder controlas describedonpage85
  • 63. 84BurnsManual fromdistricthospitaltothenextlevel(e.g.central hospital/ burnsunit) • refer - burns>30%TBSAinadults > 20%TBSAin children > 10%TBSAfullthickness - electricalandchemicalburns - burnswithassociatedinhalationinjury - extremeagegroups - circumferentialburnsofextremitiesandorchest - severehandburns - allburnswithassociatedmajortrauma • donotreferwhen - TBSA>50%,butinstead - giveadequateIV fluidsandanalgesics(opiates) - counselthefamilyandinformthemthatthepatientisnot likelytosurvive - ifapatientisstillaliveafter48hoursandtheurineoutputis morethan1cc/kg perhourcontactburnsunitorsurgeononcallinreferralhospitalfor advice
  • 64. 12Criteriaandproceduresforreferral 85 whenreferringapatienttakeintoaccountthefollowing • resuscitateadequatelyandstartbeforereferral - 4cc/kg/%TBSARinger’sLactate,give½ofthedeficitin first8hours postburn,adequacyisdeterminedbyurineoutput(seeCh13,page 90),inchildrenaddmaintenance,calculateasfollows:2x…kg+10=… cc/hr • monitortheurineoutputcarefully • giveopiates(morphine0.1mg/kg/doseorpethidine1 mg/kg/doseIV/IM) • give100%O2byfacemaskornasalprongs,4-8litre/ minuteinadults,in childrengiveatthehighestflowrateavailable • inchildrenwithburns>20%andadults>30%TBSAitis advisableto insertanasogastrictubetokeepthestomachemptyandsominimizethe riskofvomitingandaspiration • incaseofcircumferentialdeepburnsperformescharotomy(see Ch14,page 97etseq.)beforereferral.Incisetheskininto thesubcutaneoustissues • washthewoundwithSavlon® ornormalsalineandcoverwith acleansheet • keeppatientwarm • checkiftetanusprophylaxishasbeengiven,ifnotadministerwhenindicated See forcontactaddressesandtelephonenumbersCh20,page133
  • 66. 13Chartsandformulas 87 13ChArTS ANdformUlAS lund&Browderadmissionchart Name: Age/dob: Dateofadmission: ..........................................................M/ F ................................................................... ................................................................... Date&timeofburn:................................................................... Weightinkg:What happened: ................................................................... ................................................................... ................................................................... ................................................................... Inhalationinjury:yes/ no Firstaid: Epileptic:yes / no =Partialthickness(PT) =Fullthickness(FT) IGNORESIMPLEERYTHEMA FT%REGION PT% Head Neck Ant.trunk Post.trunk Rightarm Leftarm Buttocks Genitalia RightlegLeft legTotal Burn A A 1 1 1 2 2 2 21313 1.5 1.5 1.51.5 1.5 1.5 1.51.5 2.52.5 B B CCCC B B 1.751.75 1.751.75 Relativepercentageofbodysurfaceareaaffectedbygrowth area age0 age1 age5 age10 age15 aDult a:halfofhead 9.5 8.5 6.5 5.5 4.5 3.5 B:halfofonethigh 2.75 3.25 4 4.5 4.5 4.75 c:halfofoneleg 2.5 2.5 2.75 3 3.25 3.5
  • 68. 13Chartsandformulas 89 ruleofnines 9% 18% 14% 14% 9% 9% 1% 18%18% 9% 9% Front18% Back18% Front18% Back18% Thepictureontherightsideshowsachildof1year;foreachyearolderthan1year subtract1%fromthetotalpercentageoftheheadandadd0.5%foreachleg. Notethatbythetimeachildhasreachedtheageof10yearsithastheproportionsof anadult.
  • 69. 90BurnsManual emergencymanagementofSevereBurns A. Airwaymaintenancewithcervicalspine control B. Breathingandventilation C. Circulationwithhaemorrhagecontrol D. Disability–neurologicalstatus Alert/voice/Pain/Unresposive=AvPU E. Exposureandenvironmentalcontrol F. Fluidresuscitation(IV)proportionaltoburnsize adults:>15% TBSAchildren:>10%TBSA giveRL/NS4cc/kg/%TBSA / 24hrs givehalfinfirst8hourspostburnandtheotherhalfin thenext16 hours inchildren addmaintenanceNSwithDW 5%or10%per24hrs100cc/kg <10kg+50cc/kg11-20kg+20cc/kg>20kgbodyweightor 2x…… kg+10=…… cc/hr Monitorurineoutput: adults children(<30kg) G. GetlabtestsdoneGive drugsanalgesics 0.5cc/kg/hr~30-50 cc/hr 1.0cc/kg/hr(range0.5-2.0cc/kg/hr) PCV, FBC,U&E’s Morphine 0.1mg/kg/dose (notinneonates) Pethidine 1-1.5mg/kg/doseor Paracetamol10-15mg/kg/doseA Allergies MMedications PPastmedicalhistory LLast meal EEventsrelatedtoinjury H. History Headtotoeexamination
  • 70. 13Chartsandformulas 91 woundmanagement • infullthicknesscircumferentialburnsconsiderescharotomy (decompression)immediately,wheninextremitiesthereis painon stretchingmuscles,pulselessness,paraesthesiaandparalysisandinchest burnswhenthepatienthasdifficulties inbreathing • covertheburnwoundwithsomethingclean • elevateburnedlimbs • infacialburnstransport/nurseinhalfsittingposition • avoidtightdressingsorbandages Burnresuscitationformula=deficit+maintenance Howtoadminister • givehalfofthevolumedeficitinthefirst8hours,startingfromthetimeofthe burn;atthesametimeinchildrenstartmaintenancefluids • givetheotherhalfofthedeficitinthenext16hours,continue inchildrenwith maintenance • continuewithmaintenanceforanother24hoursinboth children& adults • measureurineoutputfor48hours
  • 71. 92BurnsManual howtocalculate 1st 24hours • Deficitchildren(<30kg) 4ccxwtinkgxTBSA%=… cc Addmaintenance 2x… kg+10=… cc/hr Or 100cc/kg<10kg+50cc/kg11-20kg+20cc/kg>20kg =… cc/24hrs See Ch3page40foranexampleofthecalculationof maintenancefluids • Deficitadult(>30kg) 4ccxwtinkgxTBSA% =… cc Nomaintenance 2nd24hours Inchildrencontinuewithcalculatedmaintenanceandgiveadults2500- 3000 cc/24hrsmaintenancefluidsaswell.DiscontinuetheIV dripafter48hoursifwell resuscitatedasmeasuredbytheurine output Urineoutput in>30kg in<30kg 30- 50cc/hr(0.5cc/kg/hr) 1 cc/kg/hr=… cc/hr
  • 72. 13Chartsandformulas 93 Table Usethefollowingtabletowritedownthedeficitandmaintenancetobegiven Date …………… …………… 8hours 16hours 24hours timeof Burn actualtime ……………… ……………… ……………… ……………… fluiDVolumein cc ascalculateD ……………… ……………… ……………… weight Whenthereisnoscaleavailablecalculatetheweightin children<12 yearsusingthisformula 2x(ageinyears+4)=…kg maintenancefluidsinchildren Usesodiumchloride0.9%andDextrosewater5-10% Upto 10kg 4cc/kg/hr or 100cc/kg/24hrs From11- 20kg 2cc/kg/hr or 50cc/kg/24hrs From21- 30kg 1cc/kg/hr or 20cc/kg/24hrs Anotherformulausedis 2xweightinkg+10=… cc/hr
  • 73. 94BurnsManual Normalpaediatricvitalsigns age Minimu m heart rate (b/min) SystolicBP (mmHg) Respiratio ns Breaths/ min Minimu m Hb (g/dl) Minimum PCV/Ht(%) <2yrs 100-160 60 30-40 11.0 33.0 2-5yrs 80-140 70 20-30 11.0 33.0 6-12yrs 70-120 80 18-25 11.5 34.5 > 12yrs 60-110 90 16-20 12.0 36.0
  • 74. 14Procedures 95 14ProCedUreS intraosseouspuncture Onlyinchildren<2-3yearsofage.Useintraosseousfluids preferably8- 12hoursbutnotlongerthan24hours Anatomy Femur Femur Tibia Tibia ObliqueLateral insertneedle 1- 2cm distallyofcentre pointtoinsert needle A B Thearrowsindicatethedirectionofthepuncture,alwaysstartwiththetibialintraosseous puncture1-2cmdistaltothetuberosity,underanangleofapproximately45-60°
  • 79. 100BurnsManual Decompression forthecompartment syndrome A B Anterior compartment Lateral compartment Posterior compartmentDeepposterior compartment Skinrotated to expose peroneal muscles Bluntscissorsorclosed arteryforceps Scissorsthrustdeepto decompressthedeep Posterior tibialnerveandvessels posteriorcompartment technique ɶafterincisingtheskin ɶonthemedialsideincisethefasciaoftheposteriorcompartment ɶonthelateralsidefirstincisethefasciaoverthelateralcompartment ɶthenrotatetheskinforwardstoincisethefasciaoftheperonealmuscles ɶfinallythroughthemedialincisionjustbehindthetibiathrustblunttippedscissorsto decompressthedeepposteriorcompartment
  • 80. 14Procedures 101 forearm Theforearmhas3compartments • volar(flexor) • dorsal(extensor) • mobilewad(upperforearmmusclesontheradialside) Theyareallsomewhatinterconnected;openingthevolarcom- partmentmay relievethepressureintheother2compartments.Ifafterincisionthearmstillfeels tightanadditionalincision shouldbemadetoreleasethedorsalcompartment Markingsforanincisiontodecompressthevolarforearm Theincisionbeginsinthehandforfulldecompressionofthecarpaltunnel Markingsfortheincisionsneededtodecompressthedorsumofthehandandforearm
  • 81. 102 BurnsManual Technique • makeanincisionasaboveandmakesureyouincludetheunderlyingfascia;in thepalmyouwillreleasethecarpaltunnel • thedorsalcompartmentandmobilewadarereleasedbyastraightlongitudinal incisiononthedorsalsurfaceofthearm; thisincisiondoesnothavetocross theelboworwrist decompression • escharotomyisassociatedwiththeacutemanagementof burns • theprinciplesandpracticeofthisprocedurearebadlyunder-stood,taught andcarriedout • escharotomyoftenisseenasaprocedurewithabeginningandanend • itwouldbebettertoseeitasaprocess • thisprocessiscalleddecompression Decompressionhastobeconsideredforallbodycompartmentswherean increaseincompartmentalpressuremaycompromiseavitalfunction. Compartmentsinclude • intra-andextracranialhead&neck • chest • abdomen • limbs Decompressionofthecraniummaybeachievedbyusinghyperos-molarsolutions suchasMannitol®toreduceswellingofthebrain, bycraniotomiesorbyfluid restrictionandelevationoftheupperbody. Decompressionofthechestisofteninadequatelydone,mainlybecausethe classicalincision(see alsopage97)doesnotdissociatetheribsfromthe abdomen(see picturea).
  • 82. 14Procedures 103 Picturebshowsareleasebelowandparalleltothecostalmargin,whichwill effectivelyseparatethechestandabdomenandsoreducesresistanceto ventilation. a b Abdominalcompartmentsyndrome,whichrecentlyhasbeenappreciatedcanbe diagnosedbymeasuringtheintra-abdominal hypertensionbydirectmeasurement ofthepressureintheurinarybladder.Itmayberesolvedbyconservativemeasures suchassedationandtheadministrationofdiuretics,possiblyfollowedbysurgical proceduressuchasescharotomyandfinallylaparotomy.To reducetheintra- abdominalpressuretheabdomenisnotclosedbut insteada‘Bogotabag’issutured totheskinedges(see TheSurgicalHandBook,Ed.EJ vanHasselt,2008,page 265). Inthelimbsconventialthinkingisfocusedonperipheralperfusion,butofgreater concernshouldbearaisedinterstitialpressurein theclosedosteofascialcompartments,whichmayleadtomicro- vascular compromise,ultimatelyresultingininadequatetissueoxygenation.
  • 83. 104BurnsManual Thecompartmentalanatomyofthelimbsiswelldescribedwith • 2compartmentsintheupperarm • 3intheforearm • 10inthehand • 3inthethigh • 4inthelowerleg • 4inthefoot Themechanismofthecompartmentsyndromeinacuteburninjuryis • riseoftheinterstitialpressureleadingto • celldeath,whichresultsin • furtheroedemaand • furtherriseinpressureandcelldeath Earlyfindingsofacompartmentsyndromeinthelimbsare • apalpablytenselimb • stillpalpablepulses • painonstretchingmuscles • paraesthesiaand • abriskcapillaryrefill(thissignisfrequentlynot mentioned)
  • 84. 14Procedures 105 management Non-surgical • inaraisedlimbthemeanarterialpressureandtherebythecapillaryflow maybereduced • inadependentlimbswellingofthetissuesmayincreaseandso • keepingtheextremityattheleveloftheheartisprobablythebest compromise • thereforethelimbshouldrestonapillow • anyconstrictingbandageshouldberemoved • thehaemodynamicstatusshouldbemonitoredcloselyespeci-allywithregard tofluidoverload;inthisperspecyivetheuseof colloidsinthisperspectivein resuscitationshouldbeconsidered Surgical Inacutecompartmentsyndromeitisprobablybetterto decompress‘toooften tooearly’than‘notoftenenoughtoolate’.Thefollowingprinciplesshouldbe adheredto, • avoiddamagetocutaneousnerves • preservelongitudinalveins • avoidstraightlineincisionsacrossjoints • decompressmajornervesand/ orvesselsasindicated relevanceoffasciotomytoescharotomy Thefiguresontheinsideoftheflapatthebackshowinredtheclassicalincisionsfor anescharotomyandinblackthedottedlinesforafasciotomy. Lookingatthecrosssectionofthelowerlegitisclearthat,whentheescharotomy incisionswouldbedeepenedtoincludethedeepfascia,thiswillleavetheanterior anddeepposteriorcompartmentsunreleased. Thereforeitwouldbemorelogicaltoperformanescharotomythroughthe sameskinincisionsadvocatedforafasciotomy(althoughinburnsareleaseof thefascialcompartmentsisnot oftennecessary).
  • 85. 106BurnsManual insummary • decompressionisaprocesswhichrequiresassessment, measurementandmonitoring • importantmeasuresarepositioningoflimbsandquantitative fluid resuscitation • surgicalinterventionshouldbeperformedinatheatrewith strictadherence toaseptictechniques • depth,extentandplacementofincisionsshouldbebasedon anatomical considerationsthatallowforthesafeandeffectiveconversionofan escharotomyintoafasciotomy Keypoints for clinicalpractice ɶremoverings,tightbandagesandclothing ɶposition thelimbsattheleveloftheheart ɶconsidercolloidsin resuscitation ɶconsidersurgicaldecompressionincircumferentialfullthickness anddeepdermal(partialthickness)burnsirrespectiveofsymptoms&signs ɶinfullthicknessburnsalsoconsiderfasciotomy ɶplacetheskinincisionsforanescharotomyasforafasciotomy ɶassessagain,againandagain ɶoperateintheatreunderstrictasepticconditionsandwithanaseptictechnique
  • 86. 14Procedures 107 Skincoverage • consideranyskindefectlargerthan3cmindiameterandnot yethealedafter3 weeksfor grafting • takepreferablytheskinofthethighand/ortheinneraspectof theupperarmas yourdonorarea • lubricatetheskinandtheknifewithVaseline • toensuretheproperthicknessadjusttheopeningoftheblade sothatyoucan snuglyfitthebevelededgeofanumber10scalpelbladeintotheopening • holdtheHumby/ Watsonknifeatanangleofabout45°with regardtothe skin,pressitdownandmakeatoandfromotion overthetightskin,theknife willglideforwardbyitsownweight Traction Traction Thickness gauge or scalpelbladeno.10
  • 87. 108BurnsManual • athingraftissemi-transparent,athickgrafthasthetextureof anorangepeel withcurlingedges • meshthegraftwithaPizzacutter(see Ch15,page111)or placemultiple cutsinthegraft,thispreventsbloodandserumfromaccumulatingunderthe graft • removefromtherecipientsiteanyhypergranulationor unhealthy lookingtissue • decreasetheamountofcontaminationbygentlyscrapingthewoundwith theedgeofascalpel • stopthebleedingbyapplyingawetgauzeandpressureforafewminutes, haemostasisisimportant • placethegraftwiththedermisside(theshinierside)downandeithersutureit inplaceinareaswherenoproperpressurebandagecanbeappliedorfixthe graftwith‘pullout’tie-oversutures(see thisCh,page110) • aftertakingthegraftapplyimmediatelyonthedonorsitegauzessoakedin ‘junglejuice’,afterfinishingtheoperationdressthedonorsitewithVaseline gauzesoakedinsilvernitratesolutionorSSDandleaveinplacefor10-14 days,ifsoiledremoveonlytheouterlayerandreapplyanewbandage • dresstherecipientareawithVaselinegauzesoakedinsilvernitratesolution orSSDif available • inspectthegraftonday5postoperatively,ifitstartstosmellearlieron,then inspectimmediately,cleanitgentlyandapplyanantibacterialtopicalagent • thegraftwillremainfragileforabout3weeks,protectitwith abandageand keepsupplewithVaselineoranyoilycream • inaSSGshrinkagecanoccurupto50%
  • 89. 110BurnsManual The‘pullout’tie-overdressing The‘tie-over’dressingisawellknownmethodtofixingskingrafts becauseitfulfills thefollowingessentialcriteriarequiredforasuccesfulgrafttake: • pressure • absorptionof exudate • splinting/ immobilisation Recentlythefollowingmodifiedtechniquehasbeendeveloped. technique ‘pull out’ tie-oVer ɶfirstfixthegraftwithacircumferentialperipheral5/0absorbablesuture(see fig.1) ɶ3or4monofilament3/0suturesareappliedacrossthedefectbypassingthemthroughtheskin,the graft,acrossthegraftandbackthroughthegraftandtheskin(see fig.1) ɶparaffingauzeisthenappliedoverthegraftandasterilefoamorwoolplacedontop ɶthemonofilamentsuturesaretiedindividuallyoverthefoam(see fig.2) ɶastripofparaffingauzeiswrappedaroundtheedgeofthefoamfollowedbyadressing(see fig. 2) ɶbycuttingthemonofilamentsuturesandslidingthemout,thedressingcanberemovedeasily figure1 figure2
  • 90. 15Equipment&maintenance 111 15eQUiPmeNT&mAiNTeNANCe ThePizzacutter Byusingaroundpatternfile,notches5mmdeeparemadeinthesharpenededge ofthepizzacutteratdistancesof0.5or1cm. Onaboardpreferablyofveryhardwood(e.gteak)orsyntheticmaterial(e.g.hard plasticorresin)theskincanbecutbyrolling thewheel.Stripsof0.5cminwidthcan becutandwillgiveanex- pansionof1-1.5times.Thedevicecanbesharpenedby usingfine gritabrasivefilm(sandpaper)ortheequipmentdescribedbelow. howtosharpenyourhumbyknife • takeamicroabrasivefilmpreferablywithathickMylarbackingwith whichthemicrofilmiseasiertohandle • thealternativeisamicrofilmwithanadhesivebacking,whichisplacedontop ofapieceofX-rayfilm,whichisnotwiderthanthewidthoftheknifeofa Humbydermatome • usea15micronfilm(tobeobtainedfromgoodhardwarestores),see picture • afterlooseningoftheguidebarthefilmisinsertedwiththeabrasiveagainstthe blade,closethebladeoftheHumbyknife downontothebar,andpullthe filmthrough • adownwardangleof30degreesorsoremovesmoremetalespeciallyif thebladeisdull(see picture)
  • 91. 112BurnsManual • theprocessisrepeated5or6timeswhichshouldbeenoughtoimprove evenaverydullblade • onesheetwoulddoatleast10sharpenings • sharpeningonesideonlyisusuallyenough • the15micronfilmisprobablythemostdurable.Astheparticlesfractureafiner edgeisproduced,sousinganewfilm, followedbyausedoneisagoodstrategy 15u15u 15u 15u Microfinishingfilm 468L 30˚ angle
  • 92. 15Equipment&maintenance 113 Sharpeningyourinstruments Scalpels,razors,skingraftblades • rubtheinstrumentagainsttheroughsideofacombination stone,always keepthesameanglebetweenthebladeandthestone • withabluntkniferubinsmallcirclestobeginwith,oilthesurfaceofthe stone,withasharperkniferubinastraightdirection,usuallytowardsthe sharpedge • thebladeisbeginningtogetsharpwhenthereisnoreflection oflightfromthe veryedgewhenyouholditupagainstthelight Sharp Blunt
  • 93. 114BurnsManual • sometimesa‘burr’develops,youcanfeelitbystrokingwith thefinger.Rubit awaybystrokingthebladeagainstthestoneevenmorelightly,alwaysatthe sameangle,anduseoilasbefore Rubbingoff theburr Feelingfor theburr • whenthebladeisreallysharp,stropit.Hangthestropbyits shoelaceand strokethebladefirmlybypullingitawayfrom itssharpedge Smooth side Acombination stone Rough side Extra Aleather strop Asmall grindstone
  • 94. 16Drugprotocols 115 16drUgProToColS Tetanusprophylaxis • neverimmunized ATS1500USC/IM+ 0.5cctetanustoxoidvaccine(TTV) SC/IM repeat TTV 0.5ccweek4andweek8 • fullyimmunized <10yearsago,noneedforTTV > 10yearsago,give1doseofTTV • partiallyimmunized<10yearsgive1doseofTTV >10yearsgive3dosesofTTV with amonthlyinterval Tetanustreatment Incubationperiodbetween7-10days,theshortertheinterval betweenthe injuryandsymptomsthemoreseverethedisease gradingofseverity • grade1(mild) moderatetrismus,nospasms,norespiratoryproblems, noorlittledysphagia moderatetrismus,markedrigidity, shortlastingspasms,tachypnea>30/min, mild dysphagia severetrismus,generalizedrigidity, prolonged spasms,respiratoryfailuretachypnea>40/min, severedysphagia • grade2(moderate) • grade3(severe) • grade4(verysevere)sameasingrade3plusautonomic disturbances,suchashypertension& tachycardiaalternatedwithepisodesof hypotension& bradycardia
  • 95. 116BurnsManual Allpatientsshouldreceiveonadmission • antiserumpreferablyhumantetanusimmunoglobulin 3000-5000U IV/IM, ifnotavailableequineantiserum10000byslowIV injection.Bewareofanaphylacticreaction/ shock(see boxbelow for treatment) • sensitivitytestisunreliable,itmaybebettertoexpectananaphylactic reaction • antibiotics,metronidazole500mgIV 6hourlyor1gIV 12hourlyfor7 days(benzylpenicillinisapooreralternative2MU8hourlyIV for8days) • vaccinationbeforedischarge • wounddebridement grade1&2canbetreatedinhospitalwithoutICUfacilities • controlspasmswith - diazepam0.05-0.2mg/kg/hrIVor - phenobarbitone1.0mg/kg/hrIV/IM, followed3hourslaterwith chlorpromazine0.5mg/kg/6hourlyIM • reduceexternalstimuli • keepairwaypatent • changeposition2hourlybutgently • feedthroughnasogastrictube2xthenormalamount/calories grade3&4willneedmechanicalventilationandICU admission
  • 96. 16Drugprotocols 117 management of anaphylaxis ɶstopadministeringantiserum ɶsecureairwayandgiveO2 ɶgiveepinephrine(adrenaline)0.5-1.0mg=0.5-1.0ccofa1:1000solution IM, repeatevery10 minutesuntilBP&pulseincrease ɶgiveanantihistamine, likepromethazinehydrochloride25-50mgIVslowlyorchlorpheniramine10- 20mgIV ɶgivehydrocortisone100-300mgIV ɶdeteriorationrequiresIVfluids,aminophylline250-500mgIV,nebulizedsalbutamoland possiblemechanicalventilation ‘Junglejuice’ • addto1litreofsodiumchloride0.9%50cclignocaine1%plus1ccof adrenaline(epinephrine)1:1000,thiswill provideyouwithalocalanaestheticsolutionof0.05%with 1:1000000 epinephrine Incaseyouhaveasolutionoflignocaine2%use25ccperlitre sodiumchloride 0.9% • itcanbeusedtostopbleedingfromforexamplethedonorareaaftertakinga skingraftortoinfiltratetheareausedfor takingaskingraft(thisiscalled tumescenttechnique,becauseitwillraisetheskin)
  • 97. 118BurnsManual Alcoholichandrub(Ahr) • shouldbeusedtocleanyourhandsinbetweenpatients,is easytoprepare andbyaddingglycerinetomethylatedspirit yourhandswillnotdryout. Youonlyhavetowash yourhandswithwaterandsoapwhentheyaresoiled. Apply afterwardsAHR • prepareasfollows - addto500ccofmethylatedspirit - 2.5ccofglycerine drugscommonlyusedinburnpatients Drugs <50Kg > 50Kg analgesics Morphine 0.1mg/kg/dose(not inneonates) 10mg Pethidine 1-1.5mg/kg/dose 50-100mg Paracetamol 10-15mg/kg/dose 750-1000mg (maximumdoseis4g/ 24 hrs) frequency4-6hourly frequency4-6hourly anaesthetics Ketamine(priorto changeofdressing) 2mg/kgIM asin<50kg Ketamine (asananaesthetic) 4-10mg/kgIM 1-2mg/kgIV asin<50kg
  • 98. 16Drugprotocols 119 Drugs <50Kg > 50Kg antiBiotics PenicillineV 25mg/kg/dosePO QIDfor3days 500mg POQIDfor3days X-pen 25mg/kg/dose 25000U/kg/dose IV/IMQID 1- 2g 1- 2MU IV/IMQID Cloxacillin 25mg/kg/dose IV/POQID 500mg IV/POQID Chloramphenicol 12.5-50mg/kg/dose IV/POQID 500mg IV/POQID Gentamicin 5-7.5mg/kg/24hrs IV/IMoncedailyasa singledose 240mg IV/IMoncedailyasa singledose Ceftriaxone 50-80mg/kg/24hrsIV asasingledose 1- 2g IVasasingledose Ciprofloxacin 7.5-15mg/kg/24hrsPO dividedin2doses 500-750mg POtwicedaily Metronidazole 7.5mg/kg/dosePO/IV 6or8hourly 500mg PO/IV6or8hourly antiepileptics Phenobarbitone 5-8mg/kg/24hrs POassingledosenocte 60-300mg POassingledosenocte Phenytoin 4-8mg/kg/24hrsPO assingledose 150-300mg POassingledose anxyolitica Diazepam 0.2-0.5mg/kg/24hrs PO/IM/IV 5- 20mg PO/IM/IV Midazolam 0.2mg/kg/24hrsRectal/PO assingledose 5mg IMassingledose
  • 100. 17Topicalagents 121 17ToPiCAlAgeNTS Aceticacid0.5% Thisisawaterysolution,whichyourpharmacyshouldbeableto make. Analternativeis‘Vinegar’,thisisasolutionof5%strength,byadding1partof vinegarto9partsofwateryouwillhaveasolutionof0.5%.Itisalsoactiveagainst Pseudomonasaeruginosa.The waterysolutiondriesquicklyandhastobeapplied severaltimes aday.WithVaselinegauzesoakedinthissolutiondressingsonly needtobe changedoncedaily. Betadine® ointment10% Isapovidone-iodineointmentandisespeciallyactiveagainst Staphylococcusaureusbacteria. eusol(edinburghUniversitysolutionoflime) Mixedwithliquidparaffinitactsasadesloughingagent,italsohasan antibacterialaction,butwillnotdestroyPseudomonas.Keeppreferablyinthe fridge. Changedressingsdaily. gentianvioletpaint(gv paint)0.5% Hasadisinfectantandantifungalaction.Itwilldrythewoundandisusedinsmall almosthealedburnwounds.
  • 101. 122BurnsManual hibicet® / Savlon® MixChlorhexidine1.5%andCetrimide15% • 1in100withwaterforskindisinfectionandwoundcleansingand • dilute1in30inalcohol70%forpreoperativeskinpreparation honey& ghee HasanantibacterialactionagainstStaphylococcusaureusandalsocontainsa proteolyticenzyme.Thishelpstobreakdownthedenaturatedproteinsandso digestsnecrotictissue.Theghee componentpromotesgranulationformation.Mix2partsofhoneywith1partof ghee,keepoutoflightorstoreindarkjars/bottles.Ifnogheeisavailableuseinstead glycerine,vegetableoilorwaterinthesameway. mercurochrome HasthesameactionandindicationasGV paint.Keepalsothis solutioninairtight darkbottles,toohighaconcentrationistoxic. Papaya Thepulpofthefruitcontainstheenzymepapain.Itcanbeusedtoremovethe sloughfromthewound,toremovethickcrustsandtoreducehypergranulation. Mashthepulpandapplyathicklayer. Changethedressingeverysecondday.Patientssometimescomplainof itching.
  • 102. 17Topicalagents 123 Silversulphadiazine(SSd) AlsoknownasFlamazine®,isactiveagainstPseudomonasaeruginosa.Itcanbe appliedonVaselinegauzeordirectontotheburnwound. Itisusedforfacialburns andisdirectlyappliedonthewound, whichisthenleftexposed. Inhandburnsitisappliedontheburnwoundandthenthehandiseitherputina plasticbag,whichisfixedtothewristwith adhesivetapeoritisdressed(makesurethatthefingersaredressedseparately,thisto avoidwebbing). Ideallyithastobeapplieddaily. ItisalsopossibletomakeSSDinyourownpharmacy,thepres-criptioncanbe foundinPrimarySurgery,EditorMKing,VolumeTwo,Traumaonpage81orin CareoftheCriticallyIll Patient, D AKWatterse.a.,page236. Silvernitrate0.5% solution HasthesameactionasSSD,thedisadvantageisthatitstainssheetsand clothingblack. Preparethissolutionasfollows • take5gsilvernitratecrystals • mixthiswith15ccdistilledwater • dissolvethissolutionin1litresterilewater(=boilwaterfor 10minutesand cool) • airtightclosureofthebottlesisessentialtopreventoxidation, whichresultsina blacksilveroxideresidue
  • 103. 124BurnsManual Silvernitratestick(causticpencil) Eachstickcontains0.17gofsilvernitrate.Itismainlyusedto burnawaysmallareas ofhypergranulation.Itisverypainfulsouseitonlyinsmallareas.Beforeuse moistenwithwater. Tannin Tanninsarefoundinvariousplants,oneofthemistheteaplant. Groundtea stalkscontainthesameconcentrationoftanninsastealeaves. Ithasanantibacterialactionandalsoreducestheincidenceof hypertrophic scars. Prepareasfollows • over10gofgroundteastalksorteadust(foundinteabags)ortealeaves • pour100ccboilingwater, • leavethisfor10minutesandfilter Soakdressingsinthissolutionandapplythemontothewound,youcanalsouse Vaselinegauzessoakedinthissolution,applytheseonthewoundandaddan extralayerofordinarygauzesalsosoakedinthesolutionontop. Toobtain1litreofthissolution,pour1litreofboilingwaterover100gofteaorits byproducts. Zincoxidecream(5-15%) Reduceshypergranulationandalsohasanantibacterialeffect,applyonVaseline gauze,redressafter4days,removepreviouslayerwithanoilysolution
  • 104. 18Drugsstocklistforaburnsunit 125 18drUgS SToCKliST for ABUrNSUNiT no/quantity Anaesthetics Atropine Epinephrine (Adrenaline) Halothane Ketamine Lidocaine injection1mgin1ccvial 1cc vial1:1000 inhalation injection50mg/ccin10ccvial injection1%,2%in vial Lidocaine+epinephrine1:200000in vial Midazolam Suxamethoniu m Thiopental Analgesics injection2mg/ccin vial injection50mg/ccin vial 0.5gpowderforinjection Codeine tablet 30mg Diclofenac Ibuprofen tablet 25,50,100mg suppository 50,25,12.5mg tablet 200,400mg Morphine Paraceta mol Pethidine injection 10mgin1ccvial tablet 10mg oralsolution 10mg/5cc suppository 10,20mg tablet 500mg suppository 100mg syrup 125mg/cc injection 50mg/cc Anaemia Ferro+Folicacid tablet 60mg+250µg
  • 105. 126BurnsManual no/quantity Antibiotics Cefotaxime Ceftriaxone Chloramphenicol powderforinjection1g powderforinjection1g capsule oralsolution 250mg 150mg/5cc powderforinjection1ginvial Ciprofloxacin tablet suspension injection 100,500mg 250mg/5cc 2mg/cc Cloxacillin capsule oralsolution powderforinjection500mginvial 50-100ccbottle 500 mg 125mg/5cc 400mg+80mgCotrimoxazol 200mg+40mg/5cc Gentamicin Metronidazole 40-80mgin2ccvial 200/400mg 500mg 200mg/5cc tablet oralsolution injectiontablet suppository oralsolution injection 500mg/100ccvial PenicillinG (Xpen) powderforinjection600 mg/vial PenicillineV Antiepileptics tablet 250mg Carbamazepine tablet 100mg Phenobarbital tablet 30mg Phenytoin tablet 100mg 25mg
  • 106. 18Drugsstocklistforaburnsunit 127 iv fluids no/quantity Albumin(isotonic) 250-500cc Dextrose50% ampoule DextroseWater 1L 5%/ 10% Haemacel 500cc Ringer’sLactate 1L SodiumChloride0.9% 1L (NS) Sedatives Chloralhydrate mixture 1gin10cc Diazepam tablet 5,10mg injection 10,20mg TopicalAgents Aceticacid solution0.5%(alternativeis Vinegar) Betadine® solution/ointment10% (povidone-iodine) EusolinParaffin(EP ) Gentianvioletpaint0.5% combinationofChlorhexidine1.5%and Cetrimide15% Hibicet® /Savlon® (in dilutedform)Honey &Ghee MercurochromeSilver nitrate 1-2%solution crystals Silversulphadiazinecream1% Zincoxide cream5-15%
  • 108. 19NUTRITION 129 19NUTriTioN • 3simplefeedingregimensaregivenplusthenumberofdaily feedsin relationtothepercentageoftheTBSAburns • theseformulasarebasedonhighenergy&highproteinfeedsandshould containatleast250kcal(=1000kilojoules)per200cc(dividedinfat8g, protein10.5gandcarbohydrates42g) • theyareinliquidorsemisolidform Examplesare • Likuniphalawithgroundnutflower • highenergymilk • Plumpy’nut(Chiponde) ToallofthemmicronutrientslikeCMV(complexmultivitamins) areadded Numberofglassesorportions(200cc)daily extra %tBsa Burn 11-15 16-20 21-25 26-30 31-35 36-40 6.00hours • 9.30hours • • • • • • 11.00hours • • • • 14.00hours • • • 15.30hours • • • • • • 19.30hours • • • • 20.30hours • • 21.30hours • • • • • 22.30hours • •
  • 109. 130BurnsManual • inliquidformtheycanbegivenorallybytheglassorbyNGT drip;adripcan continuethroughoutthenight • thedailynormalhigh-proteinhigh-caloriedietmustcontinue withthese supplements • manypatientsarealreadymalnourishedbeforetheirburn • itisverydifficulttooverfeedaseverelyburnedpatient,feedmorenotless recipestomakehighprotein-highenergyfeeds • highenergyLikuniphala(thisisa4:1maizesoyaflourmix) Likuniphala sugar oil addwaterto 140g 35g 7cc 200cc thiswillgive706kcalperfeedandcouldbegiven2-3xperdayalongwith highenergymilkandPlumpy’nut • highenergymilk - withdriedskimmedmilkexampleof300ccportion driedskimmedmilkpowderoil sugar addwatertototalvolume 110g 60cc 50g 300cc gives440kcalsperfeed - withfreshcow’smilkexampleof300ccportion wholemilk oil sugar 300cc 10cc 15g gives352kcalperfeed
  • 112. 20Contactaddresses 133 20CoNTACTAddreSSeS malawi • QueenElizabethCentralHospital, Blantyre +265(0)1 874333 Telephoneoperator 877333 874502 877552 extension: 3250 BurnsUnit 3243 SurgicalAnnex 3096 MainOperatingTheatre • CollegeofMedicine,Blantyre +265(0)1 874678 SecretaryDepartmentof Surgery • E-mailaddresses surgery@medcol.mw • Postaladdress P/Bag414 Chichiri Blantyre3 Malawi elsewhere • EJ vanHasselt ehasselt@gmail.com • NederlandseBrandwondenStichting(DutchBurnsFoundation) www.brandwonden.nl info@brandwonden.nl
  • 114. 21Index 135 21iNdeX Pagenumbersinboldfaceindicatewholechapters ABC’s 13,29,90 Aceticacid 48,53,121,127 Abdominalcompartmentsyndrome(ACS) 103 Abdominalwallrigidity 65 Admissioncriteria 36 AdultRespiratoryDistressSyndrome(ARDS) 23 Airway 29,37,65,69,90 AlcoholicHandRub (AHR) 53,118 AMPLE 32 Anaesthetics(dose) 118 Analgesics(dose) 118 Anaphylaxis/shock 117 Antibiotics(dose) 119 Antiepileptics(dose) 119 Anxiolytica(dose) 119 Assessmentburnwound 32 Bacteriaandinfection 52 Barrierfunctionofthegut 23 Betadine® 48,121,127 Bodycompartments 102 Bodysize&proportionsinchildren 63 Breathing 29,65,69 Burnwoundcare 46-50 Burnwoundcareemergency 36 Burnsinchildren 63-67 Calculationfluid deficit 40 Calculationnutritionalneeds 45 Capillaryrefill 30,35,76,81,104 Carotidpulse 30 Causticpencil 124
  • 115. 136 BurnsManual Cellularstructure 46 Cerebraloedema 64,66 Cervicalspine 29,90 Chemicalburns 73,79-80 Childabuse 27,63 Chloramphenicoleyeointment 80 Circulation 30,64,90 Circumferentialburnwoundchest 29,36 Cleantheburnwound 47 Clinicalsignsinhalationinjury 69 Closedtreatmentburnwound 48 Closureburnwound 54 Clothing 27,28,30 Coagulationzone 22 Compartmentsyndrome 71,76,100,103-106 Compartmentalanatomy 104 Complicationsintraosseouspuncture 96 Confusion 41,69 Contactaddresses 133 Contractures 51,59-61 Contraindicationsskingraft 57 Coolingburnwound,duration 28 Deepburns 35,51,73 Debridementearlyactive 47 Decompression 29,91,97,102 Decompressionofthechest 103 Depthofaburn 28,33 Dextrosewater5-10% 40,66,93 Dextrose50% 127 Differencechildversusadult 64 Disability 30,59,90 Donorareaskingraft 55-57,106,117 Donotrefer 84 Dressings 36,43,48,71,82 Dressingtechnique 50 Drugstocklist 125
  • 116. 21Index 137 Earlyfindingsofacompartmentsyndrome 104 Ears 73,74 Effectburnonbody 23 Electricalburns 75-77 Electrolytes 23,37,41,66 Emergencyburnwoundcare 36 Epidemiology 24,63 Epilepsy 24,27 Eschar 35 Escharotomy(technique) 97-106 Estimationareaburned 33,87-89 Eusol 121 Exposure,environment 30 Exposuretreatment 47 Exposedversusclosedtreatment,differences 49 Eyes 73 Eyelids 73,74 Facialburns 73-74 Fasciotomy 76 Fasciotomylowerleg(technique) 99-100 Fasciotomyforearm(technique) 101-102 Feedingearly 44 Feedingformulas 45 FeedingviaNGT 45 Femoralpulse 30 Fever 37,53,66 Firstaid 23,28,47,73 Flamazine® 48,123 Fluidlossinchildren 64,67 Fluidrequirementsinelectricalburns 76 Fluidresuscitation 39,41,64,66,90 Fluidstatusassessmentinchildren 64 Fullthicknessgraft 54,55,60,74
  • 117. 138 BurnsManual Generalresponsetoburninjury 23 Gentianvioletpaint 121,127 Graftfailure 55 Granulations 55,57 Gut 23,65 Gutbarrierfunction 23 Handburns 71-72 Healingtimeburnwound 54 Honey& ghee 48,122,127 Hyperaemiazone 22 Hypertrophicscars 49,59-61 Hypoglycaemia 37,40,41,65,66 Hyponatraemia 40,41,66 Hypothermia 28,65 Hypovolaemia 23,30,41,64 Hypoxia 30 Ice(water) 28 Infections,othercauses 53 Inhalationinjury 23,29,42,47,69-70 Intraoralburns 79 Intraosseouscannulationduration 95 Intraosseouspuncture 95-96 Intravenousfluids 127 Irrigationinchemicalburns 80 Jackson’sburnwoundmodel 22 Jointmovements 59 Junglejuice 56,108,117 Keloids 59,60 Ketamine 43,50,118,125 Laboratory 37 Levelofconsciousness(assessment) 30
  • 118. 21Index 139 Lifestyle 27 Localresponsetotheburninjury 22 Likuniphala 45,129,130 Lund&Browderchart 31,87 Maintenancefluids 39,41,65,91 Maintenancefluidscalculation 40 Mechanismofcompartmentsyndrome 104 Mercurochrome 122,127 Monitoringfluid resuscitation 41 Morphine 31,43,83,90,118,125 Mortality 21,32,75 Mouth&Lip burns 74 Myoglobinuria 77 Nasogastrictube 45,65,85,116 Non-surgicalmanagementofcompartmentsyndrome 105 NormalSaline 47,82 Nosetip 73 Nutrition 25,44,45,129-131 Oedema 23,39,64,69,73,76,104 Oesophagealstricture 79 Oralfluids 39 Oxygenadministering 37,66 Paediatricburns 63-67 Paediatricnormalvital signs 94 Painrelief 43,83 Pallor 30 Palpationofburnwound 32 Paracetamol 43,83,90,118,125 Papaya 48,57,122 Perinealburns 73-74 Peripheralcirculationassessment 76 Pethidine 31,43,83,90,118,125
  • 119. 140 BurnsManual Phosphorusburns 80 Physiotherapy 51,82 Pinchgraft(indication) 54,55 Pinchgraft(technique) 109 Pizzacutter 56,108,111 Plasticbag 71,123 Plumpy’nut 45,129-131 Positionofrest 71 Pressuregarment 59-61,72 Prevention 27,51 Primarysurvey 29,76 Protein(denaturation) 44,46 Pseudomonas 48,52,57,121,123 Psychologicalsuffering 59 ‘Pullout’tie-over(technique) 110 Pupils 30 Radialpulse 30 Referralcriteriaandprocedures 83-85 Rehabilitation& Reconstruction 59-61 Renalfailure 75 Respirations 94 Respiratoryobstruction 69 Restlessness 41,69 Retentionofurine 73 Ringer’sLactate 31,39,85,127 Ruleof nines 33,63,89 Savlon® 47,54,82,122,127 Secondarysurvey 32 Sepsis 52-53 SharpeningHumbyknifeblade 111-112 Sharpeninginstruments 113 Silvernitrate 48,53,56,108,123,127 Silvernitratestick 124 Silversulphadiazine 48,123,127
  • 120. 21Index 141 Skinfunctions 23 Skingrafttypes 55 Splints 60 Splitskingraft(technique) 106 Staphylococcusaureus 48,52,121 Streptococcus 52 Superficialburns 34 Systemicinflammatoryresponsesyndrome 52 Systemicintoxication/toxicity 69,79 Tannin 49,124 Tapwater 28,71 Temperaturewaterforcoolingburnwound 28 Teamconcept 25 Tetanusprophylaxis 115 Tetanustreatment 115 Tie-over(technique) 110 Timeofburninjury 31,87,93 Timingofskingraft 54 Topicalagents 121-124 Translocationof bacteria 23,44 Urinarycatheter 41,53 Urineoutput 31,41,64,66,76,84,90,92 Vinegar 48,121,127 Vitamins 44-45,129 Waterinchemicalburns 80 Weightloss 44 WHO 21 Wounddefinition 46 Woundswab 53,55 Zincoxide 124,127
  • 122. 22Notes 143 ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ......................................................................................................