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:
- Name and phone number of referring physician.
- Name and age of patient.
- Mechanism, extent, and circumstances of bum: - time of
injury - associated injuries - pre-existing health.
- Advise the referring physician concerning: - fluid therapy
- foley catheter - intubation, etc.
- 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.
- No prophylactic antibiotics or steroids should be given.
- 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:
- History of rheumatic fever in the past, or
- 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.
- 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.
- 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.
- 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.
- 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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