Burns

Table I.

Are there graphic representations to aid with determination of total body surface area burned?

Refer to Figure 1 (Infant Lund Browder chart) and Figure 2 (Rule of nines).

Figure 1

Figure 2

What other disease/condition shares some of these symptoms?

There are some medical diseases that can mimic thermal or chemical burns. These include Steven’s Johnson, Toxic epidermal necrolysis, epidermolysis bullosa, staphylococcal scalded skin syndrome, and erysipelas.

What caused this disease to develop at this time?

Because burns are typically related to exposure, there are not lab values, epidemiologic information, nutrition or genetic information that is helpful. Certainly exposure and questions related to household chemicals, profession, home safety, and fire safety are pertinent in determining how or why the patient was burned.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

• Although there are no laboratory studies that will help confirm a diagnosis of a burn in a patient, there are a few basic laboratory studies that may be useful as the patient is being followed.

  Complete Blood Count (CBC) that reveals an unexpectedly low hemoglobin or hematocrit should instigate an investigation into associated injuries leading to occult blood loss, or it may be low secondary to a dilutional effect of aggressive fluid resuscitation. Maintaining adequate oxygen carrying capacity is important when treating any patient, but specifically burned patients and so knowing the hemoglobin level is imperative.

  Basic metabolic panel which includes electrolyes, BUN and creatinine are helpful because of the significant fluid shifts and metabolic changes that occur in a burned patient.

  Carbon monoxide level may be indicated if the patient was in a fire.

  Total and ionized calcium are helpful in patients with chemical burns from hydrofluoric or hydrochloric acid.

  Other laboratory studies should be done based on the pattern of injury. For example, in a crush injury, a urinalysis for myoglobin is helpful.

  Blood, urine or cerebrospinal fluid cultures are not routinely done, especially early in diagnosis or management.

Would imaging studies be helpful? If so, which ones?

Imagine studies are indicated depending on the mechanism of injury. If the burn is fire related, then a chest x-ray and upper airway film may be indicated for suspected inhalational injury. If there is concern for other trauma, then the imaging studies should be based on the injury. Alternatively, in burns in which there is no concern for airway or breathing abnormalities then no routine imaging is necessary.

Confirming the diagnosis

The Journal of Burn Care and Rehabilitation (April 2001 pp17) published an algorithm for initial burn management that was developed through a collaborative task force supported by the ABA, the National Coalition of Burn Center Hospitals, and Paradigm Health Corporation, which reviewed the literature to develop practice guidelines. The guidelines and algorithm use Class II and Class III evidence.

See attached algorithm(Figure 3) of initial assessment of burn injury.

Figure 3.

If you are able to confirm that the patient has burns, what treatment should be initiated?

Initial and emergent management

The initial management of a child with either a thermal burn or a chemical burn begins with the ABC’s. Airway, breathing and circulation is assessed early and immediately, and supplying supplemental oxygen, especially if the burn was the result of a fire, is important. There are other priorities in the early management of these patients that should be done whether the burn is a chemical burn or a thermal burn. First, removing the patient from the environment and removing all clothing and jewelry will help stop the burning process. In the case of a chemical burn, brushing away any dry chemical from the patient will help decrease the exposure to the patient.

In patients with thermal burns, the burn can be covered with a clean sheet and pain medication should be provided. If there is concern for upper airway involvement the patient should be intubated immediately before the airway anatomy becomes distorted. Soot in the mouth or burns on the face or nose may be a better predictor of an inhalational injury than symptoms of hoarseness or stridor.

Early intubation is also indicated if the patient has a decreased level of consciousness, possibly secondary to carbon monoxide or cyanide which can interfere with ventilation. Circumferential burns can limit chest wall compliance and may lead to respiratory compromise as well and intubation should be considered in these patients. When intubating a burn patient, rapid sequence intubation should be performed. Etomidate and succinylcholine can be used if there is no risk for hyperkalemia. Preserving the blood pressure is important as these patients have significant shifts in fluid and blood pressure.

Children may present with signs of circulatory collapse and should be assessed carefully for other injuries. If these children have no other injuries and they are tachycardic with poor peripheral perfusion and hypotension they may be experiencing “burn shock”. Burn shock occurs in patients with large burns, usually >15-20% TBSA. Inflammatory mediators lead to increased capillary permeability and depressed myocardial function which can cause hypotension and shock.

Patients with moderate to severe burns with or without circulatory compromise require aggressive fluid resuscitation. If possible, a central venous catheter should be placed. If no other access is available, an intraosseous line is indicated.

The Parkland formula for fluid resuscitation is favored over other methods because of its simplicity. 4ml/kg per percent TBSA burned of resuscitation fluid is used for initial fluid management. Ringers lactate is used rather than normal saline. In patients younger than 5 years old, maintenance fluid is added to the resuscitation fluid and 5% dextrose is recommended to be added in these patients to prevent hypoglycemia. Half of the resuscitation fluid is given in the first 8 hours and the rest is given over the ensuing 16 hours.

It’s important to recognize that these fluid formulas provide only an estimated amount of fluid necessary. Following urine output and clinical status is essential. A urine output of 1-2ml/kg/hour is appropriate for children under 30 kilograms and 0.5-1ml/kg/hour is adequate for patients over 30 kg. An unusually high urine output can be deceiving and can indicate hyperglycemia which is common in burn patients and can provoke an osmotic diuresis. Checking the urine for glucose can help determine whether hyperglycemia is contributing to the urine output.

Early pain control is also important. Most burn centers use morphine, however fentanyl can be used in patients with unstable blood pressure.

Early wound management is limited to cleaning with a mild soap and warm water. Any debris in the wound bed should be removed. Debridement of the necrotic tissue can help decrease the risk of infection and can help determine the true depth of the burn. This early debridement can be done with sterile saline soaked gauze.

There is some controversy related to unroofing blisters. A large painful blister or one that is likely to rupture is generally removed. Smaller blisters that are not painful may be left alone. If the patient is to be transferred to a burn center quickly, simply cover the burn with a dry sterile dressing. No ointments should be applied because they can interfere with burn assessment at the burn center.

For any patient not being immediately transferred to a burn center, partial and full thickness burns should be dressed. The dressing should be moist and provide a barrier that reduces the risk for infection. The dressing should not adhere to the wound and topical antibiotics can be used to reduce the risk of infection. The dressing can be held in place by gauze wrap or a net tubular wrap. In partial thickness burns treated in an outpatient environment, topical antibiotic creams are not necessary.

If the patient has a partial or full thickness burn and has not been immunized to tetanus or the immunization status is unknown, tetanus immunoglobulin should be given. If the patient has not received a tetanus booster within 5 years then a tetanus booster should be administered.

For chemical burns, the initial management is the same. Remove the patient from the environment, remove clothing and jewelry to stop the burning process. Brush away any dry chemical from the patient to help decrease exposure. The use of copious irrigation is often important. There are some chemical exposures that can cause worsening of the burn if exposed to water. These will be discussed later.

Using warm water in high volumes but low pressure decreases the risk of hypothermia and scattering of the chemical. Irrigation should begin at the site of contamination and the eyes and face. Irrigation of the face prevents further inhalation or ingestion of the chemical. Guidelines for irrigation of chemical burns are not supported by good evidence.

For any chemical burn, continuous irrigation until the pH of the skin returns to normal is necessary. Re-checking the pH of the skin 15-20 minutes after irrigation is stopped can help determine whether there is any residual chemical. For eye exposures, irrigation for 15 minutes is typically sufficient for the eye pH to return to normal. Additionally, penetration into the cornea is unusual. Early ophthalmologic evaluation is recommended in these cases.

The treatment of burn wounds can be complex. Burn wound healing is a complicated process with three phases: inflammation, proliferation and tissue formation, and tissue remodeling. The tissue remodeling can take several weeks to months and the fibroblast is an important component to this remodeling.

Often, in partial and full thickness burns, the wound bed can become colonized with bacteria. This can delay the wound healing process. Several topical options have been used to decrease the bacterial load and promote healing. Silver sulfadiazine is one of the most common and most well known topical agents. The sulfadiazine has a bacteriostatic effect on the bacteria while the silver disrupts the endocellular structures of the bacteria.

There is no data, however, to support that silver sulfadiazine decreases bacterial wound infections despite it’s bacteriostatic activity. It has been combined with other agents to promote improved wound healing. The chart below shows some of the common agents used in the topical treatment of burns and includes the clinical indications and contraindications of each.

Longer term management and treatment

Further treatment depends upon the severity, size, and location of the burn. In circumferential partial or full thickness burns an escharotomy may be indicated if respiratory compromise or compartment syndrome is a problem. An escharotomy is done by making an incision through the depth of the burn eschar. This is done by a surgeon familiar with the care of burn patients, typically in a burn center.

Additionally, patients with severe burns are at high risk from infection. Careful monitoring of their temperature, vital signs, and clinical status is critical for early identification of a potentially deadly infection. Central lines must also be fastidiously attended to in order to prevent a deep vein thrombosis or line infection.

Burn patients are also susceptible to hyperglycemia. Tight glucose control has been linked with better outcomes in children with severe burns. Furthermore, aggressive nutritional support and dealing with the systemic inflammatory response help to improve outcomes in children with severe burns.

Physical therapy, occupational therapy and speech therapy may play a role in both the long term and short term treatment of patients with moderate to severe burns.

Skin grafting is also a potential long term treatment that any patient with moderate to severe burns may have to discuss with their doctor.

What are the adverse effects associated with each treatment option?

In the early treatment of a burned patient, fluid resuscitation is a major component of treatment. As with any aggressive fluid resuscitation effort, there is the potential to overload the patient with fluid that exceeds the ability of the heart to manage. This may lead to pulmonary edema. Careful clinical observation for signs of fluid overload or myocardial depression can help prevent this from occurring.

In chemical burns, aggressive irrigation may cause splaying of the chemical to other parts of the body. Therefore, careful, low pressure, but copious irrigation is the appropriate management of most chemical burns to prevent this from occurring.

Early wound debridement can cause bleeding and pain. Having the patient under good pain control is absolutely essential. Also, ensuring that the appropriate surgical subspecialist is available for debridement will decrease the risk of bleeding and infection during and after wound debridement.

The topical options for treatment all have some contraindications. They are listed In Table II. The adverse effects are primarily related to allergic type reactions the patient may develop from the topical treatment.