% vol = 15 number = 2 nextlink = 59 titolo = "BURN INJURIES - TREATMENT OF BURN PATIENTS PRIOR TO ADMISSION TO THE EMERGENCY DEPARTMENT" volromano = "XV" data_pubblicazione = "June 2002" header titolo %>
SUMMARY. When we speak of burns, we do not mean just superficial, localized injuries but also injuries involving all systems of the human body. The causes of burn injuries are thermal, chemical, electrical, and others. Burns can be divided into three categories: superficial burns (first-degree burns), partial-thickness burns (second-degree burns), and full-thickness burns (third-degree burns). The factors that determine the seriousness of a burn are: 1. depth; 2. extent; 3. localization; 4. age; 5. co-existing illnesses; 6. presence of inhalation burns; 7. co-existing injuries. With regard to the first-aid treatment of patients suffering from thermal or electrical burns, we hold the burned area under cold water in order to cool the affected tissues, unless the burns are extensive or third-degree. We never prick the blisters and we never remove clothing adhering to the wound. We place the patient on the ground if the clothing is on fire. The successive phases of burns treatment in the emergency department are described, as also immediate treatment.
Burns are the most serious injuries a person can suffer, and they are perhaps the only injuries that require specialist treatment by a team of medical and nursing personnel possessing a specific specialization, in our case in the treatment of burns. The main aim of this team is to prevent the patient’s death and then to proceed to rehabilitation.1,2
The treatment of burns, whether serious or mild, has always constituted a problem, and progress has only recently been achieved as regards treatment and full recovery.3
The burn is not a superficial and localized injury affecting only the skin: it is systemic, and involves all systems of the body. This point was clearly made by Ioannovich: a full-thickness burn in 20% of the total body surface area (TBSA) is as serious as a thigh-level amputation following a train accident.4
The burn is an injury consisting of the destruction of the skin and the underlying tissues, due to thermal, electrical, or chemical causes.5
The majority of burns are thermal, i.e. they are due to high temperature (scalding, 44.5%; fire, 24.2%; sunlight, 11.7%). Chemical burns due to caustic acids (sulphuric or hydrochloric acid) or to caustic bases (potassium hydroxide or sodium hydroxide) follow with 6.2%. Electrical burns account for 3.6% of cases, while the remaining 9.9% are due to various causes (radioactivity, etc.).6-8
The extent and the depth of the injury caused by heat depend on how long the heat affects the skin.9
Sudden exposure to heat above 51 °C causes immediate destruction of tissues, while exposure to heat above 71 °C, even for less than a second, causes full-thickness burns.10
In the past, burns were divided into seven degrees. These were then reduced to four degrees and now, with further developments in plastic surgery, the division of burns is reduced to three degrees.1,2,5
First-degree burns affect only the epidermis, causing reddening of the skin, pain, and oedema.
Second-degree burns affect not only the epidermis but also some of the dermis, causing reddening of the skin, acute pain, and the formation of blisters and oedema in and around the affected area.
Third-degree burns destroy the full thickness of the skin (epidermis, dermis, subcutaneous fat, muscle, and bones). The burned area is white and dry. Owing to the destruction of the nerve endings, pain is minor or non-existent.
Burns are thus divided into the following three categories:
There is another classification of burns:1,2
The gravity of the burn and the gravity of the patient’s condition depend on the following factors:
There are several ways of evaluating the extent of a burn. One very simple and relatively precise way is the “rule of nine”, devised by Wallace. According to this rule, the various parts of the body are divided into surfaces corresponding to 9% TBSA or its multiples, with the exception of the perineum, which is calculated as 1% TBSA. This rule does not apply to children under the age of 10 yr.1,5
Another simple rule for evaluating the extent of small-scale burns is based on the size of the patient’s palm, which according to Colson is reckoned to be 1.15% TBSA.1
Other rules also exist.
Precise evaluation of the extent of a burn is important because of the serious problem of the loss of large quantities of fluids and electrolytes from the burned area, as the skin is destroyed and can no longer prevent body fluids from evaporating. The blisters that form absorb fluids, depriving the body of them. As a result, large quantities of fluids and electrolytes are lost and intravenous fluid replacement is necessary. Otherwise, shock is inevitable and this may be fatal. The extent of the burn has to be known in order to estimate fluid replacement requirements.1,13
The seriousness of a burn depends to a large degree on the localization of the burn, i.e. the precise area injured. The areas that need most attention are the face, the neck, the limbs, and the perineum. Burns on the face and the neck may cause oedema in the upper respiratory passages. Problems may also arise with regard to the patient’s appearance, as also to functioning of the eyes, ears, nose, etc.
Burns in the limbs may leave scars causing mobility problems.
The risk of infection is high when the perineum is involved, since the skin is burned and can no longer protect the area from contamination from airborne bacteria.14
Burns, irrespective of their degree and extent, are more dangerous in children under 2 yr old and in the elderly. In children, the immune system is not mature enough to withstand such a complex situation, and the weakened organism of the elderly is also unable to handle the burn effectively.
Burns are very common in children and the elderly - children are often attracted by dangerous objects (matches, electric devices, chemical substances, lighters) in their ignorance of the possibly dangerous consequences, while the elderly may not be able to react effectively to an accident involving fire.5
Diabetes mellitus, heart disease, pneumonia, immunosuppression, cancer, and various other illnesses make the human organism less resistant to burns.
An injury to the respiratory system may be life-threatening. Injuries caused by inhalation of smoke are dangerous owing to the pernicious impact that combustion products have on the mucous membrane as also to the absorption of poisonous substances inhaled together with smoke by the mucous membrane. The most frequent form of poisoning involves carbon monoxide, which is a product of incomplete combustion.15,16
A burn creates a very serious problem for the human organism. When the burn is associated with other injuries occurring at the time of the accident or before the patient is taken to hospital, it becomes more serious and even life-threatening.
The complications and sequelae of burns depend on their gravity. Complications involving all systems of the body may develop.17 The most serious complications are the following:1,5
It has already been said that a severe problem facing the patient is the loss of fluids from the burned area. The more extensive the burn, the larger the quantity of fluids lost.
Since the continuity of the skin in the burned area has been destroyed, the burned area is more liable to contamination from airborne bacteria. This infection can easily turn into septicaemia, as the organism is already affected by a serious burn injury and is incapable of effective resistance.
The immediate danger after a burn injury is shock as a result of the loss of body fluids (oligaemic shock) or of septicaemia (septic shock). The acute pain due to the burn is one of the causes of shock.
The wrinkles and scars that form as the burn heals generate various aesthetic problems.
When the wrinkles and scars affect mobility and/or limit the patient’s movements, the burn is responsible for functional problems or disabilities.
A burn is an injury that in most cases leaves no disability, provided it is properly treated. On the contrary, if treated inadequately or not following standard rules and principles, a burn can seriously threaten not only the patient’s life but also his or her rehabilitation in society and at work because of malformations and disabilities.18
There are two ways of treating a burn patient. The first way is to provide first-aid treatment on the spot, i.e. where the accident took place, and to transfer the burn patient to hospital only if the burn is extensive. The second way is to move the patient to a specialist burns centre immediately in order to treat the burn injury systemically and topically, given the availability of the necessary equipment and specialist knowledge.19,20
The treatment of burns caused by heat or electricity starts with the application of cold water in order to cool destroyed tissues and to minimize damage to them.9,21,22
This treatment is not administered in extensive or third-degree burns, as cold water may aggravate the state of shock.
The respiratory passages must be checked to ensure that the patient is properly oxygenated. Close observation of the victim can prevent suffocation.25,26
A vein chosen for intravenous fluid replacement should be able to accept large quantities of fluids (15-20 l per 24 h in extensive burns). The drip inserted into the vein should not pass through the affected area; it is recommended that it should be placed in the neck (subclavicle), in the arm, or in the crural vein, in order to avoid thrombophlebitis.
Pulse, arterial pressure, temperature, and respiration frequency (danger of dyspnoea) should be carefully recorded in order to evaluate the patient’s general state.
The patient’s name and age are recorded, as well as the causes of the burn, including the conditions in which the accident took place, so that the patient can be properly treated. It is of the utmost importance for the physician to know if the patient is suffering from any disease (nephropathy, allergy, heart disease, diabetes mellitus), if first-aid treatment was given, and if the patient takes drugs, has ever suffered from allergies caused by a drug, or has suffered any other injury apart from the burn (e.g. a fracture).
It is necessary to know the quantity and the specific gravity of the urine excreted by the patient.
In modern practice, the rhinogastric tube is placed as soon as the patient is admitted to hospital in order to allow proper feeding. In the past, it was placed in order to divert gastric fluids.
To evaluate the quantity of the burned surface, all burned areas are added together, irrespective of their depth.
The depth of the burn cannot always be evaluated precisely when the patient is admitted to hospital. The depth of the burned area should therefore be re-assessed on the second or third day post-burn. Qualitative evaluation includes sensibility of the burned area, erythema, formation of blisters, and the extent of oedema.
This entails haematocrit, electrolytes, blood air, and urine specific gravity. During the first days after the accident, the tests should be repeated every 2-4 h. Urea, blood sugar, creatine, albumin, liver function, and blood group should be carefully recorded.
Thorax radiography is necessary.
Steps should be taken to limit the patient’s psychological and emotional reactions (e.g. pain, anxiety).28
The purpose of the clinical and laboratory check of the burn patient during the first two days after the accident is to evaluate the effectiveness of treatment and to diagnose complications as soon as possible.
When a burn patient is admitted to hospital, any watches, bracelets, etc. are removed from the burned area before it begins to swell. All clothing that constricts the body is removed, in order not to compress the burned area and to prevent it from adhering to the wound.21
The burned area is treated in aseptic conditions, with large quantities of cold sterile water, antiseptic solution (NaCl), iodide soap, or Betadin. The lather produced by the antiseptic solution is cleansed with physiological saline, the dead tissues are removed, and the blisters are emptied.22,23
In chemical burns, the burned area should be scrupulously cleaned and, depending on the particular caustic chemical that caused the accident, water or any other suitable solution should be used.29,30
We then check haematosis of the limbs, inspecting the arteries or using a Doppler. The vitality of the skin, as also of the perichondrium of the lobe and the nose are also checked. If haematosis is not considered to be satisfactory, or if there is extensive oedema, a section is recommended.
Once the method of treatment is selected (open, closed, or surgical), an antibacterial drug or a combination of various drugs is applied to the burned area. Before selecting the antibacterial drug, we consider the wound’s bacterial flora, its virulence and absorbency, and the drug’s reaction in the tissues.
The first purpose of systemic therapy is to prevent the patient’s death; healing of the wounds will follow.
In all cases of burn injury, antibiotic drugs are prescribed to protect the burned area from infection.14
Plastic surgery may be necessary to minimize scars and wrinkles, and generally to improve the appearance of the patient’s skin and limb mobility.
Daily physiotherapy, starting immediately after the accident, contributes greatly to the maintenance of limb function after burn injury.31
Therapy affects the recovery of burn injuries. The immediate application of appropriate therapy, plus proper nursing care, influences the final prognosis. Any delay in treatment may complicate the patient’s recovery. Delay reduces the possibilities of making a sound prognosis and increases the risk of death.
The therapy applied to burn patients depends on the extent, depth, and localization of the burn.
Burns affecting up to 15% TBSA in adults and 10% TBSA in children do not require hospital treatment, provided that the burn is not in the face, neck, limbs, or perineum. After cleaning of the affected area and the administration of injections for tetanus, it is recommended that the patient should be given analgesic drugs and fluids by mouth. The quantity of urine excreted should be recorded. Treatment is given in the out-patients’ department.1
Burns in more than 15% TBSA require treatment in the plastic surgery department. The sooner systematic treatment of the burned area begins, the fewer complications there will be and the greater the chances of recovery.
Complications may occur during the treatment of burn injuries, although they heal quickly. Burns constitute an injury to the skin, and the utmost attention is necessary when nursing a burn patient.2,32
It should be borne in mind that a burn is an accident and is therefore to a large degree preventable.5,33 Most burn accidents happen in the home and only occasionally at work (e.g. in factories).34
The following points should be taken into account:
RESUME. Quand on parle des brûlures, on indique non seulement les lésions superficielles localisées mais surtout les lésions qui intéressent tous les systèmes du corps. Les causes des brûlures sont thermales, chimiques, électriques et autres. On peut diviser les brûlures en trois catégories: brûlures superficielles (de premier degré), brûlures d’épaisseur partielle (de second degré), et brûlures à toute épaisseur (de troisième degré). Les facteurs qui déterminent la gravité de la brûlure sont: 1. profondeur; 2. étendue; 3. présence de lésions d’inhalation; 4. âge; 5. autres maladies; 6. présence de lésions d’inhalation; 7. lésions concomitantes. Pour ce qui concerne les premiers secours des patients atteints de brûlures thermales ou électriques, nous plaçons la partie du corps brûlée sous de l’eau froide pour refroidir les tissus lésés (mais non les brûlures étendues ou de troisième degré). Nous ne crevons pas les bulles et nous n’enlevons pas les vêtements qui adhérent à la lésion. Nous étendons le patient par terre si les vêtements sont en flammes. L’Auteur conclut en décrivant les phases successives du traitement des brûlures dans le service des urgences comme aussi les actions immédiates.