- 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.