Burn(EMERGENCY EXAMINATION AND TREATMENT)

The order of priorities in the management of a major burn injury is

A)                Airway maintainance

B)                  Breathing and ventilation

C)                 Circulation

D)                Disability

E)                 Exposure and envirnmental control

F)                 Fluid resus

In severe facial & neck burns early endotracheal intubation or tracheostomy should be considered . Early escharotomy may be needed in circumferential chest or limb burns where respiratory or circulatory disturbance is observed .

Fluid resuscitation

It is important at an early stage to secure  large bore  intra venous line . Samples are taken for haemoglobin , urea, and electrolytes  and blood cross matching  . Having estimated the percentage burned surface area and measured the body weight , initial fluid resuscitation can be planned .

The simplest formula –3-4 ml /kg body weight /% burn /in first 24 hours .

 Half of this volume is given in the first  8 hours and the rest in the next 16 hours . Timing begins from  the time of  the burn , not the start of  resuscitation . Hartmann solution is prefered  but other isotonic solution may be used . Metabolic fluid requirment are also needed . A urinary  catheter is essential . Urine output is best  guide to adequate tissue perfusion in an adult. One should aimed for 30-40 ml /hour .

FURTHER  MANAGEMENT 

A detailed history , physical examination and examination of burned area is carried out  . Adequate pain relief must be provided , usually by means of  intra venous morphine . Good notes and drawing of burn area is needed . Patient with major burns should ideally be treated in a specialised  burn unit .

Indication for refferal include –

 Burn requiring fluid resuscitation

Burn of special area ( face , hands feets ,perineum ,genitalia ) .

Full thickness burn > 5% of body surface area .

Circumferential limb or chest burns .

Electric burn

Chemical burn

Burn of children or elderly

Where non accidental injury is suspected in the  case of  a child

Associated medical condition or pregnancy .

 Associated other trauma .

Adequate assesment , resuscitation and fluid administration should be  secured before transfer of the patient . The burn unit provides facilities for immediate physiotherapy and occupational therapy to minimise  limb stiffness . Nutritional support is available . Early establishment of normal feeding appear to protect the small bowel mucosa and prevent translocation of gram negative bacteria .Inhalation injury often requires  ventilation and monitoring  by blood gasses and bronchoscopy .

DRESSINGS 

Epidermal burn with erythema and no blisters do not need dressings .Analgesia and moisturising  cream are used . Burns of the face are generally treated by exposure , largely because of the difficulty of dressing . Where is much crusting it may be necessary to apply an petroleum jelly arround the eyes and frequent toilet of the eyes and orifices may be needed .Burns of the trunks and limbs are usually dressed . Superficial dermal burns with blistering are usually dressed to absorb exudate , prevent desiccation , provide pain relief , encourage epithelialization and prevent infection .Appropriate dressings are plastic films, hydrocolliods , preserved cadaver or pig skin , alginates or paraffin gauze . Partial thickness skin injuries heal within  2-3 weeks . Any wound that remains unhealed or granulating at  3 weeks will not heal satisfactorily without surgical intervention  . Where deep burns are being managed with dressing a tropical anti microbial agent such as silver sulphadiazine cream is used.