BURN

                                                                                                                   

Mechanism:

  1. Minimal  temperature needed for thermal injury: >50C.
     
  2. Thermal injury causes  fluid collection in the area as a consequence  of  inflammatory  mediators activation ,  ­ vascular permeability regional blood flow, proteolysis.
     
  3. Maximal edema formation is in the first 6-8 hrs. and continues for 24 hrs.

Classification:

  1. First degree = erythema, pain, +/- edema, limited to epidermis.
     
  2. Second degree  or Partial Thickness = involves epidermis and  dermis which contains hair follicles , nerves. If the burn is Superficial  Partial  Thickness then it presents with  redness, bullae, and heals in 2 wks with no scarring. If the burn  is Deep Partial Thickness  then it appears waxy-white indistinguishable  from 3° burn and heals with scarring. The distinction can not be made upon presentation but later, when healing takes place.
     
  3. Third degree burn  or  Full Thickness = dry , inelastic, insensitive, charred or pearly white skin. The only definite sign is visible thrombosed  veins.

History and Physical:

  1. Determine type and length  of exposure as contact burn, burning clothes, adherent liquids (grease) penetrate deeper than flash burns.
     
  2. Look for  mental status, airway compromise, singed nasal hair ,  stridor, hoarseness, carbonaceous  sputum
     
  3. Determine BSA by  "rules of nine" of pt's palm size.

Complications:

  1. Ophto - eye injury with corneal burn
     
  2. Vascular - local or systemic edema. Maximal effect in 8 hr. and stabilize in 24 hr.
     
  3. CV - hypovolemia,  ¯C.O.,­ PVR
     
  4. GU - hypoperfusion to kidney causes ATN
     
  5. Respiratory - burns produce # of pathologies : 1)CO poison  2) chemical injury
     with subsequent  tracheobronchitis  3) cyanide  toxicity  4) upper  airway edema  5) ARDS
  6. GI - ileus ,Curling ulcers
     
  7. Immune -  ¯neutrophil  chemostaxis leading to immune suppression
     
  8. Hematology -  ¯RBC mass (from lysis of thermally injured cells) ,¯ plt , leukopenia.

Prehospital Care:       

  1. Insert NG tube if evidence of distention / ileus and  aeromedical transportation is  anticipated  since pts suffer barotrauma and rupture.
     
  2. Wrap  burned area in clean dry gauze . Don't apply ice directly (causes hypothermia).
     
  3. If tar burn, cool it but do not remove it on scene.

Burn Classification:

  1. 1.    major burn :
     
    • partial thickness >25% BSA
       
    • full thickness >10% BSA
       
    • burn to face, eye, ears, hands
       
    • burn from caustic, electric injury (see Electrical injury)
       
    • burn with major trauma , inhalation

      these pts must be transferred to Burn center for treatment
       
  2. 2.   moderate burn:
     
    • partial thickness <25% BSA
       
    • full thickness <10% BSA

      these pts can treated in any  hospital
       
  3. 3.  minor burn:
     
    • <15% of 2 burn
       
    • <3% of 3 burn

      these pts can be treated as OPD.

Management:

  1. Airway/ Breathing - if compromise is suggested, perform bronchoscope and intubation.
     
  2. Circulation:      
    • IVF  by Parkland formula  is used only if >20% of BSA is involved via  2 or 3 burn.
       
    • LR most commonly advocated. The formula is   4ml x kg x BSA. The formula must be adjusted from the time of exposure to burn and   1/2  given  in first  8hrs. Another formula  of convenience in the ER is  (kg x BSA)/4   which
      gives an hourly rate .                                                              
      Note:   In addition to Parkland formula pt must receive maintenance fluids.
        
    • For proper monitor of adequate tissue perfusion the U.O. has to equal 0.5ml/kg/hr
       
    •  Hypertonic  saline is advocated for pt with limited cardiac function.
  3. NG , Foley , CO level determination.

     
  4. Td 0.5 mg IM , Anti-acids (Curling ulcers) , Sterile dry  gauze , Warm blankets to prevent hypothermia
     
  5. Evaluate eye with fluorescein stain for corneal abrasion.
     
  6. Escharatomy  - on chest is done like a "frame". On the extremities done on lateral and medial aspect with  Y shape towards digital webs. When doing the extremities, skip the joints.  The dissection is done until subcutaneous tissue is evident. The above procedures done if ventilation or circulation are  compromised.
     
  7. Avoid local irritants (iodine).
     
  8. Blisters - some authors recommend debridement.

OPD  Treatment:

  1. 1°burn = only a non-adherent  fine mesh gauze and change q3-5 days with-out any antibiotics.
     
  2. For 2° and 3° burn, topical antibiotics. Variety  of choices but  silver sulfadiazine (except the face) and Bacitracin are most commonly used . Apply BID.
     
  3. Other alternatives are synthetic dressings: Duoderm, Opsite, Epilock. Those are applied directly to fresh moist burn and left on  until the wound heals or dressing separates from wound spontaneously.

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