EMERGENCY AND LOCAL THERAPY

Dayoub A., Barakat 0.

Faculty of Medicine - Burns Section, University of Aleppo, Syria

SUMMARY. After burn injury, all patients are in pain, the degree of which varies, and they are irritable and restless. So measures for the relief of pain should be taken. The wound surface should be covered with sheets or clean clothes. When transportation of the patient is deemed necessary, it should be carried out as quickly as possible under the prerequisite of safety. During transportation, the patient should be laid crosswise if possible, or in a position with the feet toward the direction of travel.

When the patient is carried up or down stairs, the head should be kept lower than the feet.
Early care of burns denotes the emergency diagnosis and treatment of the bum patient at the receiving unit or hospital after resuscitation of' the patient at the spot where the burn was sustained and/or after transportation. The condition of the burn patient must be rapidly and concretely analysed, with particular attention being paid to life-threatening factors. Emergency management should then proceed rapidly and in orderly fashion according to the degree of urgency.
The procedures followed for local therapy are as follows:

1. Maintaining the patency of the respiratory tract
2. Ascertaining concomitant traumas and poisonings
3. Establishment of intravenous lines
4. Use of analgesics
5. Use of urinary retention catheter
6. Debridement: the management of the local wound must wait until shock has become stable and the patient has quietened down. The incision should reach the deep fascia, otherwise the object of decompression cannot be realized.

The wound surface following incision may be protected with iodoform gauze or silver sulphadiazine cream. 7) Prevention of tetanus and haemolytic Streptococcus infection.

Emergency care & transportation

1. Rapid eradication of the cause of bum
2. Taking effective measures for initial care
3. Preparing the patient for transportation

Taking effective measures for initial care

1. Resuscitation of critically ill patients
2. Relief of pain
3. Protection of the wound surface

The procedures followed for local therapy

1. Early care of burns
2. Maintaining the patency of the respiratory tract
3. Ascertainingconcomitant traumas & poisonings
4. Establishment of intravenous lines
5. Use of analgesics
6. Use of urinary retention catheter
7. Debridement
8. Prevention of tetanus & haemolytic Streptococcus infection.

Emergency Care and Transportation
Priorities in the emergency care of burn patients are:

1. rapid eradication of the cause of burn and
2. taking effective measures for initial care giving necessary emergency treatment or preparing the patient for transportation.

Eradication of the Cause of Burn
When the clothing is on fire, the victim should immediately lie down and put out the fire by rolling slowly on the ground. Alternatively the clothing should be taken off right away or sprayed with large quantities of water, or the fire should be smothered with heavy clothing, blankets, or other suitable means at hand. The patient should never be allowed to run around. If the patient is burned by jellied gasoline the body should be covered with many layers of wet cloth.
Limbs with small or medium sized burns may be immersed in cold water in order to decrease pain as well as to lessen injury.
Again, when the clothing is wetted by acids, alkali, or other caustic chemicals, it must be removed right away. The wound should then be irrigated with large quantities of tap water for a long time. When the bum is caused by dry lime the particles should be removed first and the wound cleansed with water. It is important to note that a copious amount of water must be used.
Particular attention should be paid to whether the eyes are burned or not. If they are, they should be irrigated first using a suitable amount of tap water.
When the burn is caused by phosphorus, the wound should immediately be covered with well-wetted cloth or immersed in water, in order to prevent the flare-up of the phosphorus by its contact with air.
Oily dressings are contraindicated because phosphorus may be dissolved in oil and large quantities of phosphorus may be absorbed resulting in phosphorus poisoning.
In high tension electric injuries, the electric current must be cut off immediately. Flames caused by electric sparks should be extinguished and necessary first aid given.

If respiratory and cardiac arrest occur in critically ill patients, cardiopulmonary resuscitation should be carried out immediately. When the respiratory tract is severely burned and is accompanied by obstruction of the air-passage, tracheotomy should be performed immediately. When the burn trauma is complicated by haemorrhage, haemostasis should be achieved at once. If fractures are a complication, immobilization with simple means should be implemented.

After burn injuries, all patients are in pain, the degree of which varies, and they are irritable and restless. Measures for the relief of pain should be taken.

The wound surface should be covered with sheets or clothes.

When their condition permits, burn patients may be treated on the spot. When transportation of the patient is deemed necessary it should be carried out as quickly as possible under the prerequisite of safety.
It is best to get the severely burned patient to the hospital within 2-3 hours after injury. Other-wise it is safer to wait until he has passed the shock stage. Transportation of the patient at the peak of the shock stage should never be allowed.
If transportation requires more than one hour physiological saline solution should be given by intravenous infusion before and during the journey in order to prevent shock. Injection of large amounts of glucose solution or intake of water orally should be prohibited, because it will not prevent shock and may have serious consequences, such as oedema of the brain. If shock has already appeared, the blood volume should first be replenished, and the patient may be transported after the shock has become stable.
During transportation the patient should be kept warm and rocking should be avoided.
For old people and infants with light or medium burns, or adults whose condition is complicated by other traumas, precautions against the occurrence of shock should be taken if the journey is long.
As obstruction of the air passage may Occur in patients with burns of the respiratory tract during the course of transportation, measures for tracheotomy should be kept in readiness. During transportation the patient should be laid crosswise if possible, or in a position with the feet toward the direction of travel. When the patient is carried up or down stairs, the head should be kept lower than the feet.

Early care of burns: early care of burns denotes the emergency diagnosis and treatment of the burn patient at the receiving unit or hospital after resuscitation of patient at the spot where the burn was sustained and/or after transportation; the condition of the burn patient must be rapidly and concretely analysed, with particular attention being paid to life -threatening factors. Emergency management should then proceed rapidly and in orderly fashion according to the degree of urgency.

If the patient has remained for a long time in a closed environment full of smoke and his oral mucous membrane appears pale and oedematous with accompanying hoarseness and respiratory distress, or if there are deep burns of the head, face and neck, especially around the mouth and nose, with signs of obstruction of the air passage, then tracheotomy should be performed as soon as possible.

Careful and meticulous examination should be made to ascertain whether there are concomitant intracranial injuries, thoracic and abdominal trauma, rupture and perforation of viscera, internal haemorrhage, fracture of limbs and spinal column and carbon monoxide poisoning. With the exception of fracture of the limbs and spinal column, if there are severe traumatic complications such as rupture of the liver and spleen, massive internal haemorrhage, tension, pneumothorax and extradural haematoma, then an emergency operation should be performed. It is imperative that attention should not be paid only to the management of the wound, while measures to treat traumas or poisoning threatening the life of the patient are neglected. Of course if there are absorbable poisonous substances on the wound surface, they should be eradicated in the period of early care.

At the same time as the above-mentioned examinations are being conducted, lines for intravenous replacement of fluids should be established and crystalloid and colloid solutions should be given to those patients who are liable to shock. Generally venipuncture is employed. If the patient is already in shock and peripheral veins are empty, of if the patient is very irritable and restless, venipuncture and fixation of the needle are difficult. If the veins of the limbs are destroyed or if rapid replacement of fluids is necessary in severe burns, then fluids may be replaced by catheterization of the superior vena cava by way of (a) the cephalic vein or (b) the internal or external jugular vein. Assessment of the bum surface area and budgeting of the replacement of fluids are done simultaneously with the above procedure.

After the venous inlet has been established, diluted analgesics should be given intravenously.

When the patient's hourly output of urine needs to be observed (in adults with burns to more than 40 percent of the 13SA or third degree bums to more than 20 percent of the BSA), a urinary retention catheter should be used.

At the time of primary debridement, blood volume deficit must be constantly kept in mind, i.e. the management of the local wound must wait until shock has become stable and the patient has quietened down.
The incision should reach the deep fascia; otherwise the object of decompression cannot be realized. The wound surface following incision may be protected with iodoform gauze or silver sulphadiazine cream.
Circular constrictive eschars of the limbs may affect circulation of the distal extremities, while circular eschars of the chest and abdomen may affect respiratory movement. All constrictive eschars should be decompressed immediately for sites of decompression incisions.

Tetanus antitoxin should be injected intramuscularly (3,000) units for adults and (1,500) units for children. If the patient has electric burns or large pieces of muscle have been destroyed by burn, tetanus toxoids should be injected.

RÉSUMÉ. A la suite de la brûlure, tous les patients souffrent de douleur de degré variable et ils sont irritables et agités. Il faut donc prendre des mesures pour soulager la douleur. On doit couvrir la surface de la brûlure avec des draps ou des vêtements propres. S'il apparaît nécessaire de transporter le patient, il faut agir le plus tôt possible tout en respectant les mesures pour protéger le patient. Pendant le transport le patient doit être mis de travers, s'il est possible, autrement en position avec les pieds en avant dans le sens du voyage. Quand il faut transporter le patient par l'escalier, ou en haut ou en bas, il faut que la tête soit plus en bas des pieds. Les soins précoces des brûlures dénotent le diagnostic d'urgence et le traitement du brûlé au Centre des Brûlures ou à l'Hôpital, après la réanimation du patient sur le champ et/ou après le transport. On doit faire une analyse rapide et concrète des conditions du brûlé, en faisant attention particulière aux facteurs capables de menacer la vie. A ce point on peut passer rapidement et avec ordre à la gestion du cas selon le degré d'urgence. Les procédures suivies pour la thérapie locale sont:

1. Maintenir ouvertes les voies respiratoires.
2. Vérifier la présence concomitante de traumatismes et d'empoisonnement.
3. Etablir des lignes intraveineuses.
4. L'emploi des analgésiques.
5. L'emploi du cathéter en cas de rétention d'urine.
6. Le débridement: ce traitement de la blessure locale doit attendre jusqu'à ce qui le choc se soit stabilisé et que le patient soit tranquille. L'incision doit atteindre le faisceau profond, autrement on ne peut pas réaliser le but de la décompression.

La surface de la blessure après l'incision peut être protégée avec la gaze iodoforme ou la crème sulfidiazine argentée. 7) La prévention de tétanos et l'infection streptococcique hémolytique.