burns%20-%20initial%20management
BURNS - INITIAL MANAGEMENT
Thermal burns are burns due to external heat sources that raises skin and tissue temperature causing tissue cell death or charring. Flame is the most common type of burn. Inhalation injury is found in 30% of victims of major flame burns.
Chemical burns are due to strong acids, alkalis, detergents or solvents coming into contact with the skin. Tissues are damaged by protein coagulation or liquefaction rather than hyperthermic activity.
Electrical burns are due to electrical current or lightning coming in contact with the body.
First degree burns or superficial burns appears similar to sunburn that is painful, dry, swollen, erythematous without blisters and involves only the epidermis.
Second degree burns or partial-thickness burns has appearance of moist blebs, formation of vesicle and blister; underlying tissue is mottled pink and white with good capillary refill; this involves the entire epidermis and a variable portion of the dermal layer.
Third degree burns or full-thickness burns appears dry, leathery eschar, mixed white waxy, khaki, mahogany and soot stained. It involves the entire epidermis and dermis, leaving no residual epidermis cells, may include fat, subcutaneous tissue, fascia, muscle and bone.

Pharmacotherapy

Analgesics

  • Pain control in children is done with the use of Paracetamol for out-patient & opioid analgesics (Morphine) for admitted patients
    • Opioid are still the analgesic of choice for moderate to severe pain in pediatric patients
    • Non-opioid analgesics (Paracetamol & Ibuprofen) are used for pediatric patients for minor pains or as an adjunct to opioid analgesics for severe pain

Emollients & Skin Protectives

  • Superficial burns may be effectively treated with lotion & creams
    • The lipid contents of these treatments help accelerate repair of damaged skin

Surgical Dressings

  • Dressings (eg silver coated, hydrocolloid, moisture-retentive) absorbs drainage, increase healing time, decreases pain, & helps control bacterial growth in burns
    • They also provide protection & isolation of wounds from the environment
  • Application of dressings directly to large blisters is beneficial
  •  Burn wounds heal best in moist environment, which can be provided by application of dressings
    • Closed dressing is recommended for raw areas, deep partial thickness, & full thickness burns

Biologic dressing

  • Eg allogenic amnion
  • Uses amniotic fetal membranes as wound dressing
  • Has shown to be an effective protective dressing in partial-thickness burn wounds

Synthetic dressing

  • Eg hydrocolloid dressings, Collagen/Silicone-coated nylon threads
  • Has shown to be an effective protective dressing in superficial partial-thickness burn wounds
  • Studies show that use of synthetic dressing causes less pain, increases healing time, has better patient compliance, & is cheaper as compared to other types of dressings
  • Hydrocolloid dressings are recommended for small-area partial thickness burns & in the final stages of healing of small burn wounds

Skin Antiseptics

  • Eg Povidone Iodine solution, Chlorhexidine
  • Disinfectants may be used to prevent colonization of bacteria within wound beds but further studies are needed
  • Scrubbing of burn wounds with antiseptics is not recommended

Topical Antibiotics

  • Topical antibiotics are effective against most burn pathogen
  • Prophylactic parenteral antibiotics are not indicated in the initial management of burn wounds

Sulfonamides

  • Eg Silver sulfadiazine, Sulfathiazole silver
  • Silver sulfadiazine is the recommended topical antibiotic for burn wounds
  • Not to be used on infants <2 months of age
  • Bacteriostatic, broad spectrum antibiotic
  • Action: Interferes with the folic acid synthesis of susceptible organisms

Vaccine

  • Eg Tetanus toxoid
    • Recommended for patients with more than 1st-degree burn
    • Should be considered for patients who received tetanus toxoid and immunoglobulin >10 years ago and those whose immune status is uncertain

Non-Pharmacological Therapy

Initial Therapy

  • Wash burned skin with cool running water for 20 minutes
  • Make sure to remove any debris, clothing, jewelry, etc from the affected area
  • Keep the patient warm to avoid hypothermia: wrap the patient in clean sheets

Blisters

  • Leave small blisters (<6 mm) intact in partial-thickness burns
  • Remove thin walls of large blisters (>6 mm) especially near joints & those more likely to rupture spontaneously
    • Removing the extra wall will allow direct application of moist wet dressings & the affected area

Maintenance Treatments

  • Lipid-rich topical treatments (eg lotion, moisturizers, aloe vera) are also recommended for healing lesions
    • Helps accelerate repair of damaged skin
  • Oral rehydration schemes may be considered in patients whose access for fluid resuscitation is only orally
    • Salt-containing fluids (eg rice water w/ salt, Oral Rehydration Solution, Lassi) may be given in small amounts so that the equivalent amounts to 10% BSA

Wound Care & Skin Grafts

Wound Care

  • Appropriate dressing depends upon burn degree, location, & wound exudate
  • Occlusion dressing is preferred for patients with superficial partial thickness burns & donor sites of split-thickness skin grafts
  • For burns with minimal to moderate exudate, polyurethane, hydrocolloids & hydrogels are recommended
  • Foams & alginates are preferred for partial thickness burns with moderate-high exudate
  • Biologic dressing is an option for burns with intact vesicles when modern dressing options cannot be applied
    • Snip-open technique coated with topical antibiotic and covered with bulky dressing is recommended

Skin Grafts

  • Management option for coverage of second- or third-degree burns
  • Split-thickness grafts are preferred for burns with large affected areas & less donor skin or donor sites
    • Self-regenerating ability allows this type of graft to be re-harvested once healing is complete
  • Full-thickness grafts are better aesthetically but with limited availability of donor site & vascularity
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