Annals of the MBC - vol. 2 - n' 1 - March 1989

A SUGGESTED MEDITERRANEAN STANDARD BURN THERAPY MANUAL

Kaddoura 11.

Division of Plastic & Reconstructive Surgery, Faculty of Medicine, American University of Beirut - Beirut, Lebanon


SUMMARY. In order to standardize the basic treatment of the burn patient, it is mandatory to eliminate unnecessary variables such as techniques of fluid resuscitation, colloid administration, topical antibiotic therapy, hydrotherapy, antacid administration, hyperalimentation, etc.. For that reason a burn manual was designed at AUBMC. It is taken for granted that it might not be the ideal protocol and therefore it will be reevaluated every two years so that new scientific data may be integrated into it. The manual was intended to be simple and workable. Thus it starts with the means of referral to the bum,unit, the physical examination, the initial fluid resuscitation (Parkland Formula) and diagnosis of inhalation injury. The extent of burn diagram is filled, and wounds are cleaned in the hydrotherapy and dressed. No colloids are given until 8 hours post burn when capillary integrity is restored. Diuretics are avoided whenever possible and prophylactic antibiotics are not given until cultures show pathogenic organisms with high counts. In burns above 30% B.S.A. our patients receive cryoprecipitate 4 units per day to replace reduced levels of factors 1, V and VIII and fibronectin. They are also given heparin and persantin to moderate platelet consumption problems. The use of NG feeding or hyperalimentation and antacids is discussed. The indications for early excision are reviewed together with the use of biologic dressings. The manual concludes by reviewing the responsibilities of the bum team, the indications for consultation, guidelines for medical orders and Lund and Browder charts that are filled upon admission and refilled on a weekly basis to document the patient's burn wounds status.

Aims

Thermal trauma is probably the most complex of all forms of injury. The patient's response to his burn injury is extremely variable, and his response to treatment is similarly unpredictable. In order to optimally study the efficacy of treatment, it is mandatory to standardize much of the basic treatment of the burned patient, to eliminate unnecessary variables such as techniques of fluid resuscitation, colloid administration, topical antibiotic therapy, hydrotherapy, antacid administration, hyperalimentation etc. This will allow us to compare results and use a common language, especially in planning future research. The standard manual could be updated every two to three years.

Referral to the burn center

The optimal time for the referral of patients to the Burn Centre is directly after the injury, as soon as they have been evaluated and stabilized. All transfers should be arranged directly through the senior M.D. on call. Prior to transport, the airway and any associated injuries should be carefully assessed. Patients trapped in closed spaces breathing in smoke and patients with severe facial bums and/or patients with involvement of the upper airway or vocal cords with swelling oedema or carbonaceous material very probably require intubation.
Ensure that prior to transport the patient has two large gauge catheters inserted into peripheral veins. A Foley catheter should be inserted and urine output maintained at 30-5Occ per hour. Fluid resuscitation during the first 24 hours is given according to the Parkland formula of 4 cc per kg% bum, with half of that volume administered during the first 8 hours. Initiate pre-transfer fluid resuscitation and remember that fluid resuscitation is necessary from the time of the bum injury, and that the patient may be behind in fluids when he ultimately arrives at the initial hospital. It is important to realize that a fluid formula is only a guideline: the ultimate criteria for fluid replacement are maintenance of adequate circulation and urine output. Avoid use of diuretics and use an efficient common analgesic such as i.v. Morphine.

Transfer information

The following information should be obtained by the admitting housestaff prior to the patient's transfer from another hospital:

  1. Name and phone number of referring physician.
  2. Name and age of patient.
  3. Mechanism, extent, and circumstances of bum: - time of injury - associated injuries - pre-existing health.
  4. Advise the referring physician concerning: - fluid therapy - foley catheter - intubation, etc.
  5. Wound Care: wounds should generally be quickly covered with saline-moistened gauze or moistened sterile towels and a clean sheet. Time should not be spent on elaborate dressings or searching for often unavailable topical antibiotics.
  6. No prophylactic antibiotics or steroids should be given.
  7. No diuretics should be given.

Adwission to the burn centre

On arrival, the patient is evaluated in the hydrotherapy room after all his dressings are removed. The patient should have a full physical examination, his initial lab work and other baseline tests are obtained. The ~xExtent of bum~> diagram is drawn, showing all areas of partial and full thickness bum; areas of first degree bum are not recorded. Remember that circumferential bums to limbs may require early escharotomy with or without a further fasciotomy.
The bum wound is cleaned in the hydrotherapy room and wound cultures are taken. Topical antibiotic therapy is then initiated. Unless otherwise directed, silver sulphadiazine cream is applied as a topical agent in a layer 2-4 min thick, by the nursing staff with the help of the resident, directly over the bum wound. An occlusive normal saline and dry dressing is then applied over the silver sulphadiazine cream to prevent drying and further infection of the bum wound. Bums of the face are generally left open and treated with terramycin or fucidine ointment applied qid to prevent the wound from drying. Bums of the face and limbs require elevation.
Prophylactic systemic antibiotic therapy is almost never indicated. In fact, it is usually contraindicated. The only indications for systemic prophylactic antibiotics are:

  1. History of rheumatic fever in the past, or
  2. Severe high voltage electrical injury (over 1,000 volts).

Following thorough assessment and dressing, the patient's condition and prognosis is discussed with his relatives and O.R. consent is taken for any required procedure(s).

Initial resuscitation

All burns over 15% will generally require I.V. therapy. During the first 24 hours, fluids are administered according to the Parkland formula of 4ce of Ringer's lactate per kg % burn. Half of this volume is given over the first 8 hours and the remaining half over the subsequent 16 hours. Elderly or debilitated patients and patients with inhalation injury require considerably less volume. Patients with severe electrical burns require more.
All patients with burns over 25% B.S.A. are administered colloid during the first 24 hours. No colloid is given until 8 hours post-burn when capillary integrity is restored, at which time colloid is given exclusively as fresh frozen plasma at a volume of 0.33 cc per kg % burn. After one week, fresh frozen plasma is discontinued and stored plasma can be given as required.
Urine volume is maintained at 0.5 cc per kg per hour. Decreased urine output for a 2 hour period should generally be treated with a bolus of fluid if hypovolaemia is suspected. Diuretics should be avoided: burns involving > 50% B.S.A. have a high incidence of pulmonary dysfunction. They are usually intubated maintaining a PaO 2 of 1 -0.

Haematological factors

Bums involving 30% B.S.A. or more are more susceptible to haematological dysfunction. Specifically, they may have reduced levels of factors 1, V and VIII and fibronectin. They may also develop platelet consumption problems. These patients are therefore routinely administered cryoprecipitate, 4 units per day (for factors 1, V, and VIII and fibronectin). They are also given heparin and persantin to x~moderate>> platelet function. To 500 cc of i.v. solution, 125 ing of persantin and 2500 units of heparin are added. This volume is then given as a continuous infusion over each 24 hour period.

Daily progress

Upon admission to the hospital or surgical intensive care unit, the patient's weight is recorded daily. During the acute phases of his bum, certain lab tests are done daily. Fluid intake and output are recorded daily.
During the initial 24-48 hours post-bum, bowel sounds are generally absent in the patient with a bum over 25%. A paralytic ileus results from vascular shunting caused by hypovolaemia. Bowel sounds generally return between the second and third post-bum day. At this time, enteral feedings are begun and gastric secretions are, thereby, much more effectively neutralized.
During the early post-bum period, before feedings have begun, the most effective treatment to neutralize gastric secretions is with both antacids and concomitant H 2 blocker therapy i.e. Cimetidine. Antacids are given as Maalox TC 15 cc g/h, clamped for 40 minutes and then to intermittent suction for 20 minutes. Cimetidine is given at a dose of 300 mg i.v. q 6 hours. Gastric pH is maintained above 6.0 at all times.
Patients with burns over 25% generally require calories equal to twice their basal energy expenditure (2x B.E.E.). They require protein in amounts of about 1.5 gin per kg per day. Daily food intake and caloric counts will be monitored by the dietician and recorded daily on the Burn Data Sheet. Any significant delay in initiating enteral feedings, or in continuing them, should be circumvented by consideration of early central or peripheral hyperalimentation.

Early excision and skin grafting

Generally speaking, patients whose bums heal within three weeks of their injury require no skin grafting. As soon as a decision can be made that the patient will not heal his wounds within three weeks, early excision is usually indicated. (Because of early excision under general anaesthesia, daily debriding by nurses and the residents in the hydrotherapy is usually minimized, unless it can be done painlessly!) This excision is generally begun between the third and seventh post-burn days for known full-thickness burns, and may be done in stages with a larger burn. Early skin grafting is performed whenever possible, either at the time of the excision or later. Bleeding is often profuse during burn excision procedures. A 10% burn excision may require 6 units of packed cells. A 20% bum may require an exchange transfusion, and 16 units of platelets.
The resident is encouraged to be active in the formulation of the overall surgical plan for each patient, which should emerge 2 to 3 days post-burn for known full-thickness burns. If it is suspected that the burned areas could heal within three weeks, excision is generally not indicated, and the "watch and waiC policy is usually favoured.
In the treatment of the patient with a larger burn, the use of biological dressings may be indicated later in his treatment. It must be stressed that these agents are useful only as a temporary skin substitute and that they can be used only on wounds which are surgically clean and free from infection. 1 favour the use of Biobrane in these particular patients.

Invasive Monitoring

Invasive monitoring (C.V.P., Swan-Ganz) is generally not required in the immediate resuscitation phase. The insertion of these devices has significant morbidity - particularly with infection in the burn patient. Furthermore, the fluid volumes required to bring many of these parameters within normal levels in the acute phase are believed by many to result in over-resuscitation and subsequent pulmonary oedema.
Invasive monitoring may be necessary for particularly large burns refractory to initial r 1 esuscitation, in fragile elderly patients, or in burns with pre-existing cardiac disease. In these cases, lines should be rotated or changed over guide wires to new sites (as should peripheral lines) every 72 hours to minimize catheter sepsis.

Patient charts

Lab flow sheets must be brought up to date on a daily basis. This is the responsibility of the nursing staIT. In addition, extent of bum diagrams should be re-drawn on a weekly basis by the housestall (residents) and compared to pre-existing diagrams. Acute bum patients should have a daily progress note recorded on the chart. When a resident leaves on weekends, vacations etc., a more detailed note is expected. All final notes must be dictated prior to the patient's discharge from the unit so that they may accompany the patient.

Four important warnings

These particular warnings are so important that they must be carefully stressed.

  1. The most frequent single mistake made by inexperienced bum physicians is over-reaction to a decrease in haematocrit on the third to the sixth post-burn day. Some of this reduction in haematocrit is due to damage to red blood cells. However, some of the apparent reduction is also due to rapid absoffition of bum oedema fluid at this time. Therefore, excessive transfusion given at this time may be associated with a high incidence of pulmonary oedema.
  2. Upper airway obstruction secondary to oedema, following an inhalation injury, can be terrifying in its speed of onset. All facial bums in patients trapped in closed spaces with suspected inhalation injuries must be very closely examined and monitored. If there is any suspicion of inhalation injury, do not hesitate to consult respiratory medicine, who can provide bronchoscopic evaluation of the upper airways.
  3. Diagnosis of systemic sepsis is difficult in bum patients who frequently have high fevers and elevated white counts without sepsis. When sepsis develops, the downhill course can occur very precipitously.
  4. Typically, one generally waits for two signs of sepsis prior to starting parenteral antibiotics. If two of the following signs occur simultaneously, the Infectious Disease Service should be consulted immediately: ileus, confusion, leukopenia, marked reduction in platelets, high fever or glucose intolerance.

Electrical injuries pose special problems, particularly those involving high voltage, which may result in extensive underlying tissue destruction. They may therefore require much more fluid volume than estimated. Myoglobinuria and haeniaglobinuria may require flushing with mannitol. Bicarbonate may also be necessary to alkalinize the urine.

Consultations

The success of the management of our future burn care is going to be largely dependent upon the expertise and co-operation of the various members of the burn team. Appropriate consultations should therefore be requested early in the patient's course from the following services as indicated:

  • Infectious Disease: all burns
  • Physiotherapy and Occupational Therapy: most burns, deep bums to hands and other joints usually require splinting within 24 hours
  • Dietician: all burns
  • G.I. Medicine: burns over 20% B.S.A. - Haematology: burns over 30% B.S.A.
  • Anaesthesia: burns over 50% or with inhalation injury, or when indicated
  • Respiratory Medicine: for inhalation injuries and when indicated.

Appropriate consultations from other services should always be sought as soon as there is an indication for them.

Rehabilitation

Many burn patients require extensive physiotherapy and psychological assistance following discharge from the hospital. This should frequently be arranged at home or on an outpatient basis by our own outside therapists.

Guidelines for medical orders - Acute care (48 hours)

1. % BSA Burn
2. Weight kg
3. Diet - NPO
4. VS qlh
5. N-G tube to low suction
6. Foley catheter to straight drainage
7. Tetanus toxoid 0.5 cc IM
8. Morphine 2 to 6 mg IV q2h prn
9. Input and output qlh
10. On admission and daily - Class A lab tests
11. On admission and every Monday and Thursday - Class B lab tests.
12. Activity - bed rest
13. Cimetidine 300 mg IV qid
14. Maalox TC 15cc qlh - clamp tube for 20 minutes after given
15. Splint orders
16. Fluids - first 24 hours:
a) first 8 hours - RL _ cc per hour
b) second 8 hours - RL cc per hour
c) second 8 hours - FFP cc per hour
d) third 8 hours - RL _ cc per hour
e) third 8 hours - FFP - cc per hour
17. Fluids - second 24 hours:
a) 2/3 - 1/3 cc per hour
b) FFP cc per hour
18. Record gastric pH q2h
19. CXR
20. ABG
21. EKG
22. 02 orders
23. Wound swabs
24. Dressing orders

Scrum hepatoglobulin, free haemoglobin Urine haemoglobin, myoglobin Carbon monoxide - if indicated Request consultations Elevate burned parts On admission and every week - medical photographs In burns over 30% BSA, to 500 cc of IV solution, add 125 mg persantin and 2,500 units heparin and run continuously over each 24-hour period
In burns over 30% BSA, give cryoprecipitate - 4 units per day

Guidelines for medical orders - Intermediate care

1. % BSA Burn
2. Weight kg
3. Diet
4. VS qlh
5. Foley catheter
6. Morphine - 2 to 4 mg IV q2h prn
7. Input and output q8h
8. Daily - Class A lab tests
9. Every Monday and Thursday - Class B lab tests
10. Activity
11. Cimetidine 300 mg IV qid
12. Maalox TC 15 cc qlh
13. Nurse to record gastric pH q4h
14. IV fluids
15. Daily calorie count
16. Splint orders
17. Daily supplements:
- Multivitamins I tab bid
- Ascorbic acid 500 mg bid
- Zinc sulphate 220 mg bid
- Fe gluconate 300 mg tid
- Folate I ing O.D. 18. Dressing orders
19. Wound swabs every Monday and Thursday
20. CXR every Monday and Thursday, first 2 weeks
21. Request consultations
22. Medical photographs, weekly

RÉSUMÉ. Afin de standardiser le plus possible le traitement de base du patient brûlé, il est essentiel d'éliminer les variables non nécessaires comme pour exemple les techniques de réanimation liquide, l'administration des colloïdes, la thérapie antibiotique topicale, l'hydrothérapie, l'administration antiacide, l'hyperalimentation, etc.
Pour cette raison le Centre Médical de l'Université Américaine de Beirut a préparé un Manuel des Brûlures. Naturellement ce Manuel ne peut représenter le protocole idéal et pourtant il sera rééxaminé tous les deux ans pour permettre l'inclusion de nouvelles données scientifiques. Le but du Manuel est simple et pratique. Il commence en considérant les modalités de l'arrivée du patient dans le Centre des Brûlés, la visite médicale, la réanimation initiale (formule de Parkland) et le diagnostic de la lésion aux voies respiratoires.
On complète le diagramme de l'étendue de la brûlure, on déterge les blessures en hydrothérapie et on effectue le pansement.
On administre les colloïdes 8 heures après la lésion, quand l'intégrité capillaire est rétablie. On évite, si possible, les diurétiques et on administre les antibiotiques prophylactiques seulement quand les cultures indiquent des organismes pathogènes avec des taux élevés.
Pour les brûlures de plus de 30% BSA les patients reçoivent 4 unités au jour de cryoprécipité pour augmenter les niveaux réduits des'facteurs 1, V, VIII et de fibronectine. Ils reçoivent aussi l'héparine et le persantine pour moàérér les problèmes de consommation des plaquettes.
On discute de l'emploi de l'alimentation NG ou de l'hyperalimentation, et des antiacides. On considère les indications pour l'excision précoce ainsi que l'emploi des pansements biologiques.
Le Manuel se termine en considérant les responsabilités de l'équipe des brûlures, les indications pour la consultation, les directives pour les thérapies médicales, et les formulaires de Lund e Browder qui sont remplis au moment de l'hospitalisation et successivement toutes les semaines pour documenter l'évolution des brûlures.




 

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