|Year : 2012 | Volume
| Issue : 1 | Page : 7-10
Ten commandments of burn management
Department of Burns, Plastic and Maxillofacial Surgery, Safdarjung Hospital, New Delhi, India
|Date of Web Publication||13-May-2013|
J L Gupta
B-90, Swasthya Vihar, Vikas Marg, Delhi - 110 092
Source of Support: None, Conflict of Interest: None
In our vast country, with poor communication and transport facilities, there is no "Burn Program" or facilities for the treatment of burn injuries. Acute burn care requires meticulous planning and attention to details. I propose them as "The Ten Commandments" of burn care. These are - maintain circulation and blood pressure (shock management), maintain airway, increase body resistance, avoid bacterial toxemia, avoid auto-toxemia, watch for renal complications and multiple organ dysfunctions, maintain nutrition, abide by principles of biomechanical physiotherapy and rehabilitation and analyze factors for reducing mortality. Adherence to these principles can help us decrease the morbidity and mortality in this unfortunate set of patients.
Keywords: Burn management, mortality, reducing burn morbidity
|How to cite this article:|
Gupta J L. Ten commandments of burn management. Indian J Burns 2012;20:7-10
| Introduction|| |
In our vast country, with poor communication and transport facilities, there is no "Burn Program" or facilities for the treatment of burn injuries. It therefore poses a great challenge. On a rough estimate seven million persons get burnt every year and about 0.7 million persons are hospitalized for treatments. Four out of five involved are women and children. Most accidents occur at home.
Acute burn care requires meticulous planning and attention to details. Often, small things escape attention and result in avoidable mortality and morbidity. I believe that care can be significantly improved if certain principles are adhered to. I propose them as "The Ten Commandments" of burn care. I hope that these commandments will help and guide the young surgeon treating burns in far and remote corners of this vast continent.
Management of shock
- Maintain circulation and blood pressure (shock management)
- Maintain airway
- Increase body resistance
- Avoid bacterial toxemia
- Avoid auto-toxemia
- Watch for renal complications and multiple organ dysfunctions
- Maintain nutrition
- Abide by principles of biomechanical physiotherapy and rehabilitation
- Attend to psychological, emotional aspects and counseling
- Analyze factors for reducing mortality.
Maintenance of circulation and blood pressure is vital. The management should be done in the intensive care unit. Burn management is labor intensive and hence attention to equipping it with more number of doctors and nurses is important. It is not merely equipped with intensive care gadgets; rather the quality of personnel involved in burn care makes all the difference.
The estimation of surface area burnt is now well understood and practiced. The depth is determined by history, clinical impression and pinprick test. The controversy and clash between crystalloids and colloid during the resuscitation period continues to interest researchers and clinicians alike. It has been my experience that as our patients belong to a poor socioeconomic strata, due to prior malnutrition their hemoglobin and serum proteins are at lower levels from before the burn accident therefore they need replacement of plasma during some stage of resuscitation to bring their hemoglobin and serum proteins to normal range.
The good old method of hourly urinary output, monitoring pulse (volume and tension), blood pressure, CVP, improvement in impression of dehydration, thirst, restlessness and general well being appear to be excellent guides and satisfactory in almost all cases. Total body surface area (TBSA) burns as small as 15-20% in a healthy adult, and 6-8% in a child may develop burn shock. It is suggested that all patients with such burn should be resuscitated for shock immaterial of its depth.
The maximum loss of fluid from the intravascular compartment is in the first 8 h, the loss is continuous but not that high in the next 24 h. The loss of fluid consists of water, salt (electrolyte), plasma proteins and blood. The quantity loss depends upon the depth of burns, surface area and is aggravated by the high fragility of heat exposed RBC, sledging of RBCs and the pre-injury nutritional status of patients.
Many formulas for quantity and quality of fluid replacement have been suggested. There is no general agreement among the specialists. Accepted ingredients are water and salt but the spectrum varies from high molecular weight to isometric and hypertonic salt solution. Commonly used solutions are ringer lactate solution, isotonic saline, human plasma, albumin, plasma expanders, etc.
Special problems of burns in infants and children are that the temperature regulating mechanism is very labile. The skin is soft and thin and there is tubuloglomerular immaturity. This makes them susceptible to overloading and dehydration. Additionally, there is poor compensation in shock with a labile mechanism, narrow margins and reserves in pulmonary gas exchange and ventilation as also high energy requirements.
Maintenance of airway
Key to maintaining airway is maintenance of a good posture, good oro-pharyngeal and tracheo-bronchial-pulmonary toilet (endoscopy). A smoke injury complex leads to hypoxia and hence retention of carbon dioxide. Accumulation of additional poisonous gases leads to further cytotoxicity. Maintaining a good patent airway by endotracheal tubes or tracheotomy and application of positive pressure ventilation is vital. Involvement of a chest physician, anesthetist and intensive care physicians should begin early.
Inhalation of hot air fumes, resulting in thermal injury, hypoxia due to low oxygen intake appears to be common-sense knowledge but the poisoning caused by the incomplete products of combustion such as carbon monoxide, burning of plastic and other synthetic material results in complications. These excretions and the allergic response followed by blood poisoning results in pulmonary edema and death. Understanding of this complicated process is the need of the hour which will result in significant improvement in therapy. It is a big challenge for any chest/pulmonary endoscopists and anesthetists to reverse the process. Therefore:
Resuscitation, ICU area and burns ward should have control of temperature for extremes of hot/cold climate and humidity. The area should have enforcement of standards of aseptic technology.
- Make sure there is clean airway
- Setup a reliable drip
- Provide analgesic
- Ascertain safe airway
- Take blood sample
- Catheterize bladder
- Estimate the size of burn and fluid loss
- Calculate expected plasma requirement and colloid deficit.
Increase body resistance
Fresh blood transfusion and use of adjunct therapy like immunoglobulin/pentaglobulin and vaccines should be considered early. Literature since many decades now suggests that the key to restoring good body resistance is early wound closure. Diet and nutrition should be maintained at an adequate level. High protein and high calorie diet should be used to avoid negative nitrogen balance.
Every burn patient needs lot of blood as the patient loses blood during the process of burn injury during frequent change of dressing and during operations for early wound closures. Therefore, there is necessity of a good blood bank for treatment of burns.
There is reduction of serum levels of IgA complements c3 and c4 in immediate post burn period indicating a degree of immune suppression. Total serum protein and albumin ratio also indicates degree of immune suppression. Return of immune globulins to normal level indicates favorable progress. Therefore, administration of specific immune globulins or pentaglobulins for prevention and treatment of septic shock and improving resistance are recommended.
Avoid bacterial toxemia
The primary source of infection is the burn wound itself. Hence, the wound should be kept dry-and infection free. Dressing room precautions to avoid cross infection should be kept in mind. Specific antibiotics, parenteral and topical should be used as indicated. One should always look for tight eschar and always check distal circulation.
A burn wound is absolutely sterile to start with, it becomes septic later on after being handled inappropriately. The burn dressing should be done only in sterile atmosphere. The dressing of burn wound takes as much time as a simple operation and is done by the best of surgical aseptic methods. No amount of antibiotics can correct improper handling of the wound.
Early wound closure and use of skin covers and substitute should be considered to avoid auto toxemia. Early closure of burn wound has the most important development in burn therapy. The limitation is high loss of blood and availability of skin cover (homo graft, auto graft). For cropping a large area of auto graft from different unconventional donor sites, different shapes and sizes of skin grafting instruments/dermatomes have been invented and designed. Donor sites are made to heal quickly to render subsequent crop of skin graft. In still larger areas mesh graft and micro skin graft can alternate with homograft/auto graft to achieve the total coverage. As a homograft is a temporary cover the areas have to be covered by auto graft after homograft is rejected.
Watch and detect complications
Renal complications should be monitored. Urine should be monitored for presence of hemoglobinuria, myohemoglobinuria, oliguria, low specific gravity with large amount of urine and anuria. Though its use is controversial, use of hypertonic polysaccharide solutions (10-20% Mannitol) can be considered on a case to case basis. Acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS) need to be identified early to prevent mortality.
Maintain nutrition (avoid negative nitrogen balance)
Very high metabolic response to burn infection is well established and recognized. Inflammation alone can produce a substantial increase in the metabolic rate. Similarly it would appear that the hyper metabolic response could be minimized by early wound closure (excision and grafting) and subsequent control of inflammation and infection. This can be achieved definitely by auto graft. It can be reduced significantly by use of other substitutes temporarily. Enteral feeding was recommended for the control of curling ulcer and was latter followed/replaced with antacid and histamine receptor antagonist, but needless to say that enteral nutritional support of the burn victim has an overriding advantage over medicines and parenteral therapy. It should be started as soon as bowel movement appears and gradually increased in quantity and quality to achieve the desired caloric intake. It has a great advantage of avoiding damage to mucosa (mucosal atrophy) of the gut and reducing the bacterial absorption. The contents of enteral feeding should include high protein and essential amino acid and vitamins to combat the negative nitrogen balance and immune response.
Abide by principles of biomechanical physiotherapy and rehabilitation
Physiotherapy should be started early. Rehabilitation starts from day one and disability and deformity is better prevented than treated. It is important of keep burn patients active and mobilized as much as possible after admission to the hospital. In case of extensive burns movement of patients into different position at intervals will be necessary to prevent:
Active, passive and assisted movements of the body and breathing exercises play a very important role in preventing contractures, deformities, and disabilities. Physical rehabilitation of burn patients begins on admission. Maintenance of function and mobility is best accomplished by promoting judicial positioning, application of splints and promoting functional independence.
- Chest complications
- Pressure sores
- Deep veins thrombosis
- Pulmonary emboli
Psychological/emotional priorities and counseling
Psychological disturbance may range from mild depression to psychosis. Counseling of patient and his/her relatives goes a long way in minimizing these problems. Psychotherapy should also start early and is an important adjunct to burn management.
Emotional problems arising, from mild depression to overt psychosis are common occurrence among burn patients. Fear, hostility, lack of cooperation, lack of motivation are common and require a dedicated team. At the time of discharge the patients along with the attendants are motivated and properly advised regarding regular care of wound, raw areas, sun baths, managing clothing and psychotherapy.
Over a period of time they develop scars/hyper trophic scars and keloids, disfigurement, deformities and disabilities. In this process of rehabilitation the entire family has to be included and incorporated. They should be given printed instructions in the regional language along with the hospital discharge slip and reviewed regularly in the outpatient department to assess the improvement.
Instant death is due to extensive charring and fatal inhalation injury. In immediate post burn period, hypovolemic shock and severe metabolic derangement may also lead to mortality due to multiple organ failure and toxemia. Factors affecting mortality in burn are:
- Extremes of age
- Burn depth
- Burn etiology
- Poor socio economic strata
- Inhalation injury
- Associated medical diseases
- Timing of wound closure
| Conclusions|| |
Adherence to these principles and commandments can help us decrease the morbidity and mortality in this unfortunate set of patients.