The Hip: Preservation, Replacement and Revision

Management of Burns

- 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:

              - 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
                         present (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.
         - 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.
                      - Silver sulphadiazine, plus chlorhexidine and mafenide for antibacterial effect in infected full skin thickness rat burns.
                      - 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:
                      - 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 agents for 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 Herndon DN, 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
    - 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
            - 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.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, June 17, 2016 1:46 pm