- See:
-
Burns of the Hand:
-
Chemical Burns:
-
Electrical Burns:
-
Frost Bite:
- Initial Management:
-
trauma management:
- patients require a generalized trauma assessment w/ all clothing removed;
- determine nature of the burn (flame,
chemical,
electrical);
-
medical management:
- tetanus prophylaxis:
- fluid management:
- burn patients may have substantially higher fluid requirements than other trauma patients depending on the surface area involved;
- fluid needs to be titrated to maintain adequate output, and special care needs to be taken when myoglobinuria is prsent (see
reperfusion injury);
-
estimate burn depth:
-
first degree:
- typical "sun burn" injury;
- injury is limited to the dermis, do not blister, and appear erythematous;
- these injuries will often heal within a week;
- consider
indomethacin to limit inflammation and pain;
- the affected extremity should be submerged in cold water for 30 min inorder to limit tissue damage;
-
partial thickness burns:
-
full thickness burns:
-
4th degree:
- dermis + deep tissue (muscle, tendon, bone, nerve)
- treatment
amputation or
flap coverage and lateral reconstruction;
- consider
external fixation;
- Surgical Considerations:
-
initial debridement:
-
compartment syndrome: (pts w/
electrical burns are at high risk);
- escharotomy:
- indicated for full thickness circumferential burns;
- as full thickness injuries are insensate, anesthesia requirements are minimal;
- references:
-
The adequacy of limb escharotomies-fasciotomies after referral to a major burn center.
-
Intramuscular pressure in the burned arm: measurement and response to escharotomy.
-
wound management:
- wounds are washed once daily;
-
wound dressings:
- occlusive dressing using bland petrolatum impregnated gauze under dry sterile gauze, will absorb any serous exudaate, yet provide the patient comfort and protect the wound;
- references:
-
Polyurethane film (Opsite) vs. impregnated gauze (Jelonet) in the treatment of outpatient burns: a prospective, randomized study.
-
The use of Biobrane for coverage of the pediatric donor site.
-
Burn wound closure with cultured autologous keratinocytes and fibroblasts attached to a collagen-glycosaminoglycan substrate.
-
topical antibiotics: (choices)
-
mafenide acetate apply burn cream following early morning daily cleansing;
-
silver sulfadiazine burn cream is applied for the nocturnal 12 hours;
-
mafenide acetate alternate w/
silver sulfadiazine topical;
- references:
-
Therapeutic efficacy of timentin and augmentin versus silvadene in burn wound infections.
-
Failure of topical prostaglandin inhibitors to improve wound healing following deep partial-thickness burns.
-
Comparison of silver sulphadiazine 1 per cent, silver sulphadiazine 1 per cent plus chlorhexidine digluconate 0.2 per cent and mafenide acetate 8.5 per cent for topical antibacterial effect in infected full skin thickness rat burn wounds.
-
Silver sulphadiazine and the healing of partial thickness burns: a prospective clinical trial.
-
soft tissue coverage:
-
soft tissue coverage for the hand
-
split thickness skin grafts
- in the STSG dressing, consider the addition of
mafenide solution into the postoperative dressing inorder to decrease the incidence of infection;
-
full thickness skin grafts
- references:
-
A comparison of full-thickness versus split-thickness autografts for the coverage of deep palm burns in the very young pediatric patient.
-
Proceedings of the NIH Conference: Advances in Understanding Trauma and Burn Injury: Session IV: Wound Healing: Current Status of Skin Replacements for Coverage of Extensive Burn Wounds.
-
Selection of topical antimicrobial agents for cultured skin for burns by combined assessment of cellular cytotoxicity and antimicrobial activity.
-
Treatment of severe burns with widely meshed skin autograft and meshed skin allograft overlay.
-
Early adipofascial flap coverage of deep electrical burn wounds of upper extremities.
-
Early free-flap coverage of electrical and thermal burns.
- Management of Specific Injuries:
-
hand burns:
- foot burns:
- references:
-
Early ambulation and discharge in 100 patients with burns of the foot treated by grafts.
-
Reconstruction of foot burn contractures in children.
- fracture management:
-
The management of fractures in thermally injured patients.
- Complications of Burns:
-
infection:
- risk of infection is directly proportional to the surface area of the burn;
- common organisms:
-
staph aureus,
enterobacteriaceae, serratia sp,
providencia sp,
pseudomonas sp,
candida;
-
antibiotics: (for systemic infections);
-
vancomycin +
amikacin +
antipsuedomonas agents;
- references:
-
Therapeutic efficacy of timentin and augmentin versus silvadene in burn wound infections.
-
The changing epidemiology of infection in burn patients.
-
Increased burn patient survival with individualized dosages of gentamicin.
-
catabolism:
-
nutrition:
-
beta blockers
- in the report by David N. Herndon M.D et al, 25 children with acute and severe burns (more than 40 percent of total body-surface area) were
studied in a randomized trial;
- 13 received oral propranolol for at least two weeks, and 12 served as untreated controls;
- dose of propranolol was adjusted to decrease the resting HR by 20 percent from each patient's base-line value.
- beta-blockade decreased the heart rates and resting energy expenditure in the propranolol group, both as compared
with the base-line values and as compared w/ values in the control group;
- net muscle-protein balance increased by 82 % over base-line values in the propranolol group, whereas it decreased
by 27 percent in the control group;
- in children with burns, treatment with propranolol during hospitalization attenuates hypermetabolism
and reverses muscle-protein catabolism;
- references:
-
Beneficial effects of aggressive protein feeding in severely burned children.
-
Proceedings of the NIH Conference: Advances in Understanding Trauma and Burn Injury: Session I: Nutrition and Metabolism:
Antibiotics and the Postburn Hypermetabolic Response.
-
Plasma norepinephrine, epinephrine, and thyroid hormone interactions in severely burned patients.
- Reversal of Catabolism by Beta-Blockade after Severe Burns
David N. Herndon M.D. NEJM. Volume 345:1223-1229 Oct 25, 2001 No 17
-
contracture:
- skin contracture:
- muscle contracture (fibrosis):
- joint contracture:
- unlike tendon adhesions, joint contracture will limit passive motion;
- tendon adherence to bone:
- tendon adherence to bone is also common following fractures;
- passive motion may be present but active motion is diminished;
- FDS most often will adhere to the proximal phalanx (limiting PIP motion);
- FDP most often will adhere to the middle phalanx (limiting DIP motion);
- FDP adherence to the proximal phalanx will cause limitation of motion in both the DIP and PIP joints;
- references:
-
Prevention and treatment of postburn scars and contracture.
-
Reconstruction of foot burn contractures in children.
- Outside Links:
-
GMO Manual
-
First Aid Manual
-
Iowa Family Practice Handbook - 1
-
Iowa Family Practice Handbook - 2
-
Merck Manual
-
chemical exposure
-
GMO Manual
-
GMO Manual
-
First Aid Manual
-
Iowa Family Practice Handbook
-
Merck Manual
-
flash injury
-
GMO Manual
Evaluation of protocol change in burn-care management using the Cox proportional hazards model with time-dependent covariates.
