Last updated: August 2022 Show
Burns are cutaneous lesions caused by exposure to heat, electricity, chemicals or radiation. They cause significant pain and may threaten survival and/or compromise function. Classification of burnsSevere burns: one or more of the following parameters:
Minor burns: involving less than 10% of the BSA in children and 15% in adults, in the absence of other risk factors Evaluation of burnsExtent of burnsLund-Browder table – Percentage of body surface area according to age
This table helps to accurately calculate the % of BSA involved according to patient’s age: e.g. burn of the face, anterior trunk, inner surface of the lower arm and circumferential burn of left upper arm in a child 2 years of age: 8.5 + 13 + 1.5 + 4 = 27% BSA. Depth of burnsApart from first-degree burns (painful erythema of the skin and absence of blisters) and very deep burns (third-degree burns, carbonization), it is not possible, upon initial examination, to determine the depth of burns. Differentiation is possible after D8-D10.
Evaluation for the presence of inhalation injuryDyspnoea with chest wall indrawing, bronchospasm, soot in the nares or mouth, productive cough, carbonaceous sputum, hoarseness, etc. Treatment of severe burnsI. Initial managementOn admission
Once the patient is stabilized
II. General measures during the first 48 hoursResuscitative measuresIntravenous replacement fluid to correct hypovolaemia: Fluid and electrolyte requirements during the first 48 hours according to age
Note: increase replacement volumes by 50% (3 ml/kg x % BSA for the first 8 hours) in the event of inhalation injury or electrical burn. For burns > 50% BSA, limit the calculation to 50% BSA. This formula provides a guide only and should be adjusted according to systolic arterial pressure (SAP) and urine output. Avoid fluid overload. Reduce replacement fluid volumes if urine output exceeds the upper limit. Target endpoints for IV replacement fluids
In patients with oliguria despite adequate fluid replacement: Respiratory care
AnalgesiaSee Pain management NutritionStart feeding early, beginning at H8:
Patients at risk of rhabdomyolysisIn the event of deep and extensive burns, electrical burns, crush injuries to the extremities:
Infection controlPrecautions against infection are of paramount importance until healing is complete. Infection is one of the most frequent and serious complications of burns:
Other treatments
III. Local treatmentRegular dressing changes a prevent infection, decrease heat and fluid losses, reduce energy loss, and promote patient comfort. Dressings should be occlusive, assist in relieving pain, permit mobilisation, and prevent contractures. Basic principles
Technique
Frequency
Monitoring
IV. Surgical careEmergency surgical interventions
Burn surgery
V. Pain managementAll burns require analgesic treatment. Pain intensity is not always predictable and regular assessment is paramount: use a simple verbal scale (SVS) in children > 5 years and adults and NFCS or FLACC scales in children < 5 years (see Pain, Chapter 1). Morphine is the treatment of choice for moderate to severe pain. Development of tolerance is common in burn patients and requires dose augmentation. Adjuvant treatment may complement analgesic medication (e.g. massage therapy, psychotherapy). Continuous pain (experienced at rest)
Acute pain experienced during careAnalgesics are given in addition to those given for continuous pain.
Note: these doses of morphine are for adults, dosing is the same in children > 1 year, should be halved in children less than 1 year, and quartered in infants less than 3 months.
Chronic pain (during the rehabilitation period)
Minor burns
What are the signs and symptoms of the airway burn?Harsh cough; stridor; Burns to the face; head and neck swelling; inflamed oropharynx. Singed nasal hair, eyebrows or eyelashes; Soot in the saliva, sputum, nose or mouth.
What are the effects of burns on the respiratory system?The respiratory system can be damaged, with possible airway obstruction, respiratory failure and respiratory arrest. Since burns injure the skin, they impair the body's normal fluid/electrolyte balance, body temperature, body thermal regulation, joint function, manual dexterity, and physical appearance.
What would cause a lower airway burn?When smoke is inhaled, toxic products of combustion injure airway tissues and/or cause metabolic effects. Hot smoke usually burns only the pharynx because the incoming gas cools quickly. An exception is steam, which carries much more heat energy than smoke and thus can also burn the lower airways (below the glottis).
What are 4 clinical consequences that can occur as a result of a smoke inhalation injury?Symptoms may include cough, shortness of breath, hoarseness, headache, and acute mental status changes.
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