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

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.

ESTIMATION OF BURN AREA: CHILDREN

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