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BURN FIRST AID

  • Stop burning process by removing clothing, irrigating burns
  • Use cool running water to reduce temperature of burn
  • Extinguish flames by allowing patient to roll on ground, by applying a blanket, by using water or other fire-extinguishing liquids
  • In chemical burns, remove or dilute chemical agent by irrigating with large volumes of water
  • Wrap patient in clean cloth or sheet, transport to nearest appropriate medical facility
  • Do not start first aid before ensuring your own safety (switch off electricity, wear gloves for chemicals, etc.)
  • Do not apply paste, oil, turmeric or raw cotton to burn
  • Do not apply ice, may deepen injury
  • Avoid prolonged cooling with water, will lead to hypothermia
  • Do not open blisters until topical antimicrobials can be applied at health care facility
  • Avoid application of topical medication until patient has been placed under appropriate medical care

ACUTE BURN MANAGEMENT

  • Stop the burning
  • ABCDE's
  • Determine percentage area of burn
  • Good IV access, early fluid replacement
  • Adequate pain control essential
  • Severity of burn determined by:
    • - Burned surface area
    • - Depth of burn
    • - Other considerations

ACUTE BURNS

  • 1st degree: superficial
    • epidermis and upper dermis
  • 2nd degree: partial thickness
    • Superficial partial thickness (S)
    • Deep partial thickness (P)
      • - Penetrates deep in dermis
      • - Skin grafting recommended
  • 3rd degree: full-thickness
    • Destroy all epidermal and dermal elements
    • Always use skin grafts
  • Most are mixed depth
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ACUTE BURN MANAGEMENT

Airway: beware of inhalation, rapid airway compromise

Breathing

Circulation: fluid replacement

Disability: compartment syndrome

Exposure: percentage area of burn

Morbidity and mortality rises with increased burn surface area or with increased age; even small burns may be fatal in elderly

ACUTE BURNS

Depth of Burn Characteristics Cause
First degree
  • Erythema
  • Pain
  • Absence of blisters
  • Sunburn
Second degree
  • superficial partial thickness
  • Red or mottled
  • Flash burns
  • Blisters
  • painful
  • Contact with hot liquids
Second degree
  • deep partial thickness
  • Pale
  • Reduced sensation
  • With or without blisters
 
Third degree
  • full thickness
  • Dark and leathery
  • Dry
  • Fire
  • Electricity or lightning
  • Prolonged exposure to hot liquids/objects

ESTIMATION OF BURN AREA: Rule of 9's

  • Count non-superficial burns (2nd degree and 3rd degree)
  • The patient’s hand is approximately 1% of body surface area.
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ESTIMATION OF BURN AREA: CHILDREN

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Area By Age in Years
  0 1 5 10
Head (A/D) 10% 9% 7% 6%
Thigh (B/E) 3% 3% 4% 5%
Leg (C/F) 2% 3% 3% 3%

FLUID RESUSCITATION

Necessary for burns

  • >15% of total body surface area (TBSA) in adults
  • >10% of total body surface in children
  • Use Ringer’s lactate or normal saline

The fluid requirement for the first 24h can be calculated
2 - 4 ml x body weight in kg x %TBSA

  • Give half in the first 8h and remainder in the next 16h
  • Children also need maintenance fluids with glucose
  • Monitor urine output and adjust iv fluids

ACUTE BURN MANAGEMENT

  • Focus care on rapid healing, infection prevention
    • If small area: immerse in cold water 30 minutes to reduce oedema, tissue damage
  • Tetanus toxoid
  • Remove broken, tense or infected blisters
  • Excise adherent necrotic tissue
  • Gently cleanse burn with 0.25% (2.5 g/l) chlorhexidine solution, 0.1% (1 g/l) cetrimide solution, or another mild water-based antiseptic
  • Maintain good nutrition: very high metabolic demands due to burns
  • Change burn dressing daily or as often as necessary to prevent seepage through dressing
  • On each dressing change, remove any loose tissue
  • Inspect wounds: discoloration, hemorrhage may indicate developing infection.
  • Cellulitis in surrounding tissue is an indicator of infection
  • Fever is not a useful sign; may persist until burn healed
  • Administer topical antibiotic chemotherapy daily: Silver nitrate (0.5% aqueous) cheapest, apply with occlusive dressings, does not penetrate eschar
  • Use silver sulfadiazine (1% miscible ointment) with single layer dressing; has limited eschar penetration, may cause neutropenia
  • Mafenide acetate (11% miscible ointment) used without dressings; penetrates eschar but causes acidosis
  • Alternating these agents is an appropriate strategy

Serious burn requiring hospitalization:

  • Greater than 15% burns in adult
  • Greater than 10% burns in child
  • Any burn in very young, elderly, infirm
  • Full thickness burns
  • Burns of special regions: face, hands, feet, perineum
  • Circumferential burns
  • Inhalation injury
  • Associated trauma or significant pre-burn illness: e.g. diabetes
  • Treat burned hands with special care to preserve function
  • Cover hands with silver sulfadiazine, place in loose polythene gloves or bags secured at wrist
  • Elevate hands first 48 hours, then start hand exercises
  • At least once a day, remove gloves, bathe hands, inspect burn, reapply silver sulfadiazine, gloves
  • If skin grafting necessary, consider treatment by specialist after healthy granulation tissue appears

ACUTE BURN MANAGEMENT: Healing phase

  • Burn depth and surface involved influence duration of healing phase
  • Without infection, superficial burns heal rapidly
  • Apply split thickness skin grafts to full-thickness burns after wound excision or appearance of healthy granulation tissue
  • Plan to provide long term care to patient
  • Burn scars undergo maturation
    • First red, raised, uncomfortable
    • Frequently become hypertrophic, form keloids,
    • Although soften, fade with time; can take up to two years

ACUTE BURN MANAGEMENT: Nutrition

  • Energy, protein requirements extremely high due to the catabolism of trauma, heat loss, infection, demands of tissue regeneration
  • If necessary, feed patient through nasogastric tube to ensure adequate energy intake
  • Anemia and malnutrition prevent burn wound healing, result in failure of skin grafts
  • Eggs, peanut oil are good, locally available supplements

ACUTE BURN MANAGEMENT IN CHILDREN

  • ABCDE – consider respiratory injury
  • Use ringer's lactate or normal saline for resuscitation
  • Add maintenance fluids, glucose to avoid hypoglycemia
  • Admit all children
    • with burns >10% of body and
    • those involving face, hands, feet, perineum
    • circumferential
  • Prevent infections with topical antibiotics.
  • Prevent contractures by passive mobilization and splinting
  • Scars cannot expand to keep pace with growth, may lead to contractures
  • Arrange for early surgical release of contractures before interfere with growth
  • Burn scars on face lead to cosmetic deformity, ectropion, contractures about lips
  • Ectropion can lead to exposure keratitis, blindness; lip deformity restricts eating, mouth care
  • Consider specialized care (referral) as skin grafting insufficient to correct facial deformity
  • Pain control, especially during procedures
  • Tetanus vaccination
  • Nutrition
    • Begin feeding as soon as practical
    • Need high caloric diet
  • Burn contractures
    • - Prevent by splinting flexor surfaces, passive mobilization of involved areas
  • Physiotherapy and rehabilitation
    • Begin early, continue throughout burn care
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