Management of Patients with Burns

Overview of Burn Injuries

• Burn injuries are painful, costly, disfiguring, and require intensive rehabilitation therapy.
• They can lead to long-term disability and affect individuals of all ages and socioeconomic statuses.
• Annual estimates:
  • 486,000 people treated for burns in the U.S.
  • 40,000 hospitalized
• Predominant causes of burns: thermal injuries (due to heat).

Severity and Classification of Burns

• Burns are classified by depth:
  • First-degree burns (superficial):
  • Damage limited to the outermost skin layer (epidermis).
  • Symptoms: Pain, redness/erythema, intact epidermis.
  • Nikolsky’s sign negative: Burned tissue does not separate from underlying dermis.
  • Second-degree burns (partial-thickness):
  • Involves entire epidermis and part of the dermis.
  • Symptoms: Very painful, blisters, moist wound bed due to serous leakage.
  • Healing time: Generally 2-3 weeks.
  • Third-degree burns (full-thickness):
  • Complete destruction of epidermis, dermis, and possibly underlying tissue.
  • Symptoms: Leathery, dry texture, lack of sensation due to damaged nerve fibers.
  • Fourth-degree burns (deep burn necrosis):
  • Extends into muscle or bone, critical for assessing severity.

Determining Burn Depth and TBSA

• Assessment factors include injury mechanism, agent, temperature, duration, and skin thickness.
• Methods to estimate TBSA affected by burns:
  • Rule of Nines: Quick estimation by anatomic regions (each region ~9% TBSA).
  • E.g., half an arm = 4.5% TBSA if burnt.
  • Lund and Browder Method: More accurate, adjustable for age, divides body into small areas.
  • Palmer Method: Hand size about 1% of TBSA, useful for scattered burns or large burns with minimal sparing.

Risk Factors and Complications

• Increased mortality predictors:
  • Higher percent of TBSA burned
  • Presence of inhalation injury
  • Increased age
• Specific locations of burns can lead to:
  • Respiratory obstruction: Face, neck, chest burns.
  • Difficulty in self-care and function: Hands, feet, joints.
  • Increased infection risk: Ears, nose, perineum burns.
  • Circulatory compromise from circumferential burns in extremities.
• Patients with preexisting cardiovascular or renal issues have poorer prognoses.

Pathophysiology of Burns

• Physiological changes include local necrosis in burn center and viable tissue at periphery:
  • Zones in burn injuries:
  • Zone of coagulation: Central area with necrosis.
  • Zone of stasis: Injured cells that can become necrotic if ischemic.
  • Zone of hyperemia: Minimally injured area that may recover.
• Severity correlates with temperature of agent and duration of contact:
  • At 54°C (130°F) for 30 secs: Burn injury
  • At 60°C (140°F): Full-thickness burn in 5 secs
  • At 71°C (160°F): Immediate full-thickness burn.

Initial Management of Burns

• Emergent phase: From injury to completion of resuscitation.
  • Remove patient from burning source.
  • Primary survey: Airway, breathing, circulation, disability, expose and examine (ABCDE).
  • Immediate therapy includes:
  • Establish airway and provide 100% humidified oxygen.
  • Establish IV access for fluids (large-bore)
  • Cover burn with clean, dry cloth.
  • For chemical burns, irrigation begins immediately.
• Fluid resuscitation:
  • Important for TBSA >20% to restore circulation and prevent shock.
  • Use of Lactated Ringer's (LR):
  • 2 mL LR x body weight (kg) x %TBSA for thermal burns.
  • 4 mL LR x body weight (kg) x %TBSA for electrical burns.
  • Administer half volume in first 8 hours, other half over 16 hours.

Ongoing Care and Fluid Management

• Monitor:
  • Vital signs,
  • Fluid intake/output, relieved shock symptoms.
  • Prevent fluid overload and complications (pulmonary edema, heart failure).
• Urinary output is key to assessing resuscitation success:
  • 0.5-1 mL/kg/hr for thermal injuries,
  • 75-100 mL/hr for electrical injuries.

Nutritional Support

• Essential for combating hypermetabolism and promoting healing.
• Early nutritional support recommended, often via enteral feedings.
• Ensure adequate caloric intake to maintain nitrogen balance and minimize muscle catabolism.

Psychological and Emotional Support

• Address grief, loss, and coping strategies during rehabilitation.
• PTSD is common due to trauma; seek appropriate counseling and support systems.
• Family involvement in care and rehabilitation planning enhances recovery outcomes.

Rehabilitation Phase

• Ongoing evaluations of physical and psychosocial progress.
• Early mobilization and participation in therapy critical to prevent complications like contractures and scarring.
• Patients educated and involved in their care plans.

Infection Control and Prevention

• Regular monitoring for infection and proper wound care techniques.
• Importance of hydration and nutrition to boost immune function and recovery.
• Surveillance cultures at admission; provide timely interventions based on individual needs.

Conclusion

• Management of burn patients requires a comprehensive, multidisciplinary approach for optimal outcomes. Continuous assessment, preventive measures, and tailored therapies must be maintained throughout recovery phases.