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.