Burns

Major burns should be dealt with in a specialised unit. Only the principles of management of a severe burn will be addressed.

Pathophysiology:

• Loss of integument and direct tissue injury lead to a generalised fluid leak into the burn area
• This results in fluid loss and oedema formation
• Secondary problems include myocardial depression (which usually recovers within 24 hours)
• There is also a degree of immunosuppression, with the major late problem of infection

Assessment:

• The area of burn should be determined
• The method used is to assess the percentage of the total body surface area which has been damaged and the depth of the injury
• There are graphical charts available for this

Problems associated with a large burn:

• Fluid loss
• Myocardial depression
• Oedema formation:
• Airway obstruction
• Compartment syndromes
• Airway burn – hypoxia
• Tissue damage – myoglobinuria
• Immunosuppression – infection

Management:

• The rules of ABC (airway, breathing and circulation) apply
• The airway must be assessed and, if necessary, protected by intubation
• Indications for endotracheal intubation include:
• Lung injury with hypoxia from inhalational burns
• Oedema (in the case of head and neck burns – can develop rapidly and occlude the airway)

• There are massive fluid losses post-burn injury due to the formation of oedema and loss of the cutaneous barrier
• Various formulae have been produced to guide fluid management in the resuscitation, an example of which is the Parkland formula using Ringer’s lactate solution:

Volume (mL)/24h = 4 x weight (kg) x percentage of total body surface area burnt

• These formulae are rough guides and resuscitation should be more accurately guided by clinical assessment using:
• Tissue perfusion
• Blood pressure
• Urine output

• The other important aspect of management is the control of pain and anxiety
• Pain may be very severe initially but anxiety becomes a growing problem as the patient becomes aware of the predicament

Specific treatment:

• Do NOT apply cold water to extensive burns – this may intensify shock
• Do NOT burst blisters
• Covering extensive partial thickness burns with sterile linen prior to transfer to a burns unit will deflect air currents and relieve pain
• Use morphine in 1-2mg aliquots IV
• Suitable dressings (which should be changed every 1-2 days) include:
• Vaseline gauze
• Silver sulfadiazine under absorbent gauze

• Ensure tetanus immunity
• Give 50ml whole blood for every 1% full-thickness burn, half in the second 4h of IV therapy and half after 24h