Major Burns

Advances in critical care, aggressive nutritional support and early wound excision have contributed to increased survival of burns victims in developing countries. We face the major problem of wound sepsis and wound cover.

Emergency Phase (0-72 hour) Initial Assessment

History : History related to burns:— When? — Where? — How long is the period of contact?

What caused it?

• General History: Pre-existing illnesses.

Examination

• General examination for inhalation injuries, associated injuries
• Assessment of burns area [(TBSA) total body surface area]
• Rule of nine: For adults (Fig)
• Lund: Browder chart for children.
• Depth of wound
• Pinprick test, Blisters, Erythema (Superficial)
• Parchment like skin with pattern of thrombosed vessels (Deep)
• Unburnt area should be mapped.

Initial Management in Emergency Room

The burn wound itself is not of major importance in the first few hours of injury.

• Secure airway
• Assess vital signs
• Remove patient’s clothing and obtain body weight
• Start large bore IV line
• Estimate the area of 2nd and 3rd degree burns
• Calculate fluid requirement
• Insert a Foley catheter
• Insert nasogastric tube for TBSA burns over 20%
• Sedate by IV medication
• Immunize against tetanus
• Cover with clean sheet.

Criteria for Admission

• Adults with burns over 15% TBSA
• Children with burns over 10% TBSA
• Full thickness burns over 2% TBSA
• Inhalation injury
• All electrical burns
• High risk (65 yr). Pre-existing medical illness.

Fluid Resuscitation

Parkland formula is convenient to remember

Crystalloids are used 4 ml/kg × % of TBSA burns

First 24 hours: Rate of Infusion 50% in 1st 8 hr, 25% in 2nd 8 hr , 25% in 3rd 8 hr

Second 24 hours Maintenance fluid for evaporation water loss. Crystalloids and colloids can be used in second 24 hours.

Monitoring

• Vital signs
• Urine output record, ideal: — 1-2 ml/hr in adults — 0.5-1 ml/hr in children
• CVP line if feasible
• Packed cell volume (PCV) estimation
• Blood chemistry

In inhalation injury :

• Blood gas analysis if feasible
• 100% oxygen inhalation till blood gases return to normal
• Intubation in upper airway problems
• Avoid steroids and prophylactic antibiotics.

Wound Care

Initial care

• Clean the wound with soap and water
• Blisters can be left intact if they are smaller than 1-2 cm
• Shave scalp, axilla, pubic regions
• Elevate burnt extremities to reduce oedema
• Escharotomy: In encircling full thickness burn of trunk and limbs

Topical application

Silver sulphadiazine, Bacitracin, Mupirocin

• Ideal to have isolation special wards which control temperature and humidity.
• Ancillary Care
• Antibiotics—according to the infecting organism
• Nutritional support
• Physiotherapy—earlier the better
• Wound care with strict asepsis. Special problems of wounds are better dealt by concerned specialists.