Bailey & Love 28ed

Chapter 46: Burns

Learning Objectives

  • Assess the area and depth of burns in adults and children.

  • Understand the pathophysiology of burn injuries and their systemic effects.

  • Calculate the rate and quantity of fluids required.

  • Recognize the need for transfer to a specialist burn unit.

  • Learn principal techniques for treating burns.

  • Understand the pathophysiology of electrical and chemical burns.

Introduction

  • Significant advancements in reducing morbidity and mortality from burns over the last 50 years.

  • The future involves a better understanding of physiological control, reconstruction, rehabilitation, and new technologies.

  • Large burn injuries have considerable effects on patients and their families, stressing the importance of multidisciplinary care.

Incidence and Mechanism of Burn Injury

  • Incidence: In the UK, about 175,000 visits to emergency departments are due to burns; approximately 13,000 require admission.

    • 1,000 severe burns require fluid resuscitation.

    • Half of all burn victims are children under 16.

  • Mechanism by Age:

    • Children: Primarily caused by scalds from kettles, pans, hot drinks; screening for non-accidental injury is crucial.

    • Adolescents: Burns typically result from experimentation with matches and flammable liquids.

    • Adults: Flame burns are common, with scalds and contact burns becoming more frequent with age.

    • Screening for non-accidental injuries is also essential among the elderly.

  • Other noteworthy factors include the link between mental health issues (e.g., drug abuse) and burn injuries.

Burn Prevention

  • Regulatory measures and public education have significantly reduced burn incidences.

  • Important measures include:

    • Legislation for flame-retardant clothing and furniture.

    • Promotion of smoke alarms and safe designs for cookers and gas fires.

    • Education on setting hot water thermostats and being aware of dangers (e.g., hair straighteners).

Pathophysiology of Burn Injury

  • Skin Function: Essential for protection, thermoregulation, immune response, vitamin D production, and sensation.

  • Airway and Lung Injury: Inhalation of hot air can lead to upper and lower airway injuries and metabolic poisoning.

    • Warning Signs: Burns on face/neck, blistering, hoarse voice, singed nasal hair, history of being trapped in fire.

  • Metabolic Poisoning: Carbon monoxide is an immediate cause of death from fire; treatment involves high-flow oxygen therapy.

  • Inflammation and Circulatory Changes: Burns provoke an inflammatory response, increasing vascular permeability and leading to significant fluid loss.

    • Shock occurs when fluid loss exceeds a certain threshold of TBSA burned.

Immediate Care of the Burn Patient

  • Prehospital Care Principles:

    • Ensure rescuer safety, stop the burning process, check for other injuries, cool the burn, provide oxygen, elevate affected areas, and administer analgesia.

  • Hospital Care: Follow trauma management principles (Airway, Breathing, Circulation, Disability, Exposure, Fluid Resuscitation).

    • Determinate severity based on TBSA percentage burned, presence of inhalation injury, burn depth, and patient’s age/comorbidities.

    • Admission criteria to burn units include suspected respiratory injury, fluid resuscitation needs, and burns on sensitive areas (face, hands, etc.).

Assessment of the Burn Wound

  • Assessing Size: Use methods like the "Rule of Nines" to estimate burn size (i.e., each limb or body part assigned a percentage).

    • Lund and Browder chart is more accurate for children and larger burns.

  • Assessing Depth: Based on history (e.g., temperature, burn cause) and clinical examination (e.g., capillary refill, sensation).

    • Different depths include superficial partial-thickness, deep partial-thickness, and full-thickness burns with varying healing and treatment processes.

Fluid Resuscitation

  • Intravenous resuscitation for burns greater than 15% TBSA in adults and 10% in children.

  • Different resuscitation fluids (crystalloids like Hartmann's solution, colloids like albumin) used based on patient needs.

  • Monitoring: Monitor urine output to adjust fluid rates; complications of over-resuscitation should be avoided.

Treating the Burn Wound

  • Group A Burns (Superficial Dermal Partial-Thickness): Focus on preventing infection and managing pain during dressing changes.

    • Options range from simple dressings to advanced biological dressings.

  • Group B Burns (Full-Thickness and Deep Dermal Burns): Requires cleaning, assessment, and potentially escharotomy.

    • Surgical excision may be necessary, particularly for circumferential burns.

Additional Considerations

  • Pain Management: Important for acute (intravenous opiates) and chronic (oral medications) phases.

  • Nutritional Needs: Increased caloric needs in patients with burns over 15% TBSA; enteral feeding initiated early can prevent gut issues.

  • Infection Control: Patients become immunocompromised; proper wound care and antibiotics are essential.

  • Psychological Support: Critical due to the trauma of burn injuries; strategies should be developed for coping and support.

Non-Thermal Burn Injuries

  • Electrical Injuries: Differentiated into low and high voltage, with varying severity of tissue damage.

  • Chemical Injuries: Management involves identifying chemicals and addressing systemic poisoning risks, with specific protocols for acids and alkalis.

  • Radiation Injuries: Conservative management for localized damage; systemic effects may require supportive care.

  • Cold Injuries: Divided into acute (industrial accidents) and frostbite; treatment involves gradual rewarming and conservative monitoring.

Recent Advances

  • Innovations include advanced dressings, cultured skin grafts, and 3D printing technologies for skin substitutes.