Burn Injury

 Introduction:

        Damage to the body tissue is caused by heat, chemicals, electricity, sunlight or radiation os called burn injury.

      Burn injury results in destruction of the layers of the skin and depletion of fluids and electrolytes.

Classification of burns based on the depth of the tissue involved,

1. First degree burn : Superficial burn which causes local inflammation of the skin involves injury to the upper third of the dermis. Eg. Sunburn
2. Second degree burn : Deeper burn and in addition to pain, redness and inflammation, there is blistering of the skin.
3. Third degree burn : Involves all the three layers of the skin caused death of that area of skin. This is relatively painless because the nerves are damaged.

Extent of Burn Injury:

    Burns are measured as a percentage of total body area affected. Method used is the " Rule of Nine".

   If  more than 15% -20% of the body is involved then, significant fluid may be lost.

Park Land Formula :

  Fluid requirement calculated as 4cc * weight in kg *% of burn= Initial fluid required in the first 24 hours

      Half of this given in first 8 hrs

Management of Burns:

1. First aid:

• Minor Burn(First degree or second degree of burn involving a small area): 

1. Gently clean the wound with lukewarm water.
2. Remove any rings or bracelets or any other constricting articles(inflammation occuring may cause edema ).

Burn may be dressed with topical antibiotic ointment like Neosporin or Bacitracin

1. Tetanus Toxoid immunization should be given.

• Major Burn ( second degree and third degree ):

1. Remove the patient from the burning area.
2. Remove any burning material from the body.
3. Check for breathing and circulation (pulse). Once safe , keep the patient warm and take the patient to the emergency.
4. Never use cold water on the patient as this may lead to hypothermia.

2.Emergency Room:

  Major Burn:

•  Evaluate the degree and extent of the burn
• Cover the burnt area with sterile gauze
• Ensure that the airway is patent and administer 100% of oxygen as prescribed
• Monitor for respiratory distress and assess the need for intubation
• Monitor arterial blood gases and carboxy hemoglobin level
• In case of an inhalational injury, administer 100 % of oxygen via a tight fitting non rebreather face mask as prescribed untill the carboxy hemoglobin level falls below 15%
• Initiate an intravenous line or prepare for central venous line as prescribed
• Administer IV fluid to maintain fluid balance
• Monitor vital signs closely
• Monitor intake and output. Place s Foley catheter as prescribed
• Insert a naso gastric tube as prescribed to remove gastric secretions and prevent aspiration
• Administer TT, pain medication and antibiotics as prescribed by the IV route
• Prepare the patient for an Escharotomy , or fasciotomy as prescribed.

Escharotomy:

What is an escharotomy?

       An escharotomy is a surgical procedure performed to allow greater circulation to that part of the body.

Why is it performed?

       A severe injury, such as a very deep burn, can cause tissue to swell so much that blood no longer flows past the injury easily. The skin acts as a tight bandage, preventing the site of injury from expanding to accommodate the swelling, resulting in compression of the blood vessels, nerves, muscle and tissue below. This problem is often referred to as compartment syndrome.

        When compartment syndrome develops it is a surgical emergency. The treatment is to cut into the skin and the tissues underneath to allow them to spread open, relieving the pressure building in the affected area.

Who performs the escharotomy?

       The escharotomy will be performed by a senior member of the Burns Medical team.

Are the escharotomy lines closed afterwards?

      Unlike a typical surgical incision, these incisions are not closed as the operated area requires continuous assessment and monitoring.

      It is normal to be able to see the tissues and structures under the open incisions. Any open wound has a risk of infection so the area will be covered by sterile dressings and bandages.

      As swelling reduces, the surgical incisions will begin to close and when the edges of the incision are close enough, the patient will return to theatre to have the wounds closed, or occasionally skin grafted.

Will there be a scar?

Escharotomy can result in abnormal scarring that can present as thick, hypertrophic, retracting and painful scars. Scar therapists will be involved in managing the escharotomy scars from the day of the surgery to try and minimise these. 

Fasciotomy – A cut made in the fascia to relieve pressure and increase blood flow. This type of operation is often used to treat severe circumferential burns and compartment syndrome.

Release – A surgical procedure which releases the scar tissue and allows for better range of motion and function. A release may require the addition of a skin graft. 

Tracheostomy – A cut made by a surgeon into the neck that allows a tube to be placed into the lungs which will help the patient breathe.

Amputation — In some extreme cases a patient may need amputation or the removal of a body part. Your burn care team will work closely with you through this process if necessary. Amputees can lead healthy, fulfilling lives.

FLAP RECONSTRUCTION:

Flaps are a full thickness section of skin that is surgically removed from one part of the body and transferred to another part of the body. 

SKIN GRAFTS FOR BURNS:

A graft is skin that is surgically placed on a deeply burned area or to cover an open wound. Types of grafts include:

Allograft – A skin graft taken from the skin bank (cadaver skin) and placed on a patient’s burn to help it heal. This is not a permanent graft.

Autograft – A thin layer of donor skin taken from an unburned part of the patient’s body and placed on the burned part of the body. This is a permanent graft. 

Mesh Graft – A skin graft that is meshed by putting it through a special machine. This meshing allows the skin graft to be stretched in order to cover a larger area.

Split Thickness Auto Graft (STAG) – A thin layer of donor skin from an unburned part of the body that is meshed (stretched) to cover a larger area. The meshing creates a pattern of small slits in the skin, which creates a better bond to the burned skin.

Sheet Grafts – A thin layer of donor skin that is not meshed and does not have the pattern that meshed donors have. These grafts produce a smooth appearance and are typically placed on hands and faces. Sheet grafts take longer to heal and require the patient to have restricted movement and activity during the healing process.

BURN SURGERY TEAM

The burn surgery team consists of a:

• burn surgeon,
• general surgery resident,
• burn APC (advanced practice clinician,

anesthesia,

• OR (operating room) scrub tech,
• OR nurse, and an
• OR HCA (health care assistant).

PREPARING FOR SURGERY

      If the provider decides a patient needs surgery, they will explain the procedure to you. They will also need written consent from you to perform surgery.

Before Surgery:

      Patients will not be allowed to have anything to eat or drink after midnight on the day of surgery. Before surgery, the anesthesiologist and the operating room nurse will talk to the patient and family to answer questions and review the procedure. The patient will then be taken to the operating room. A child life specialist is often available to escort pediatric patients to the operating room. The length of surgery depends on the extent of the burn injury and the surgical plan.

    Family can wait in the burn center waiting room.

After Surgery:

    After surgery, the care team will take the patient back to the burn unit or recovery area. The nurse will assess when visitors are allowed into the patient room. Patients often experience pain after surgery. Your care team will work together to manage your pain. 

    Your dressings are not typically changed for three to five days after surgery. The dressings may be bulky and often splinted to protect the new graft. You may be required to keep the grafted body part still for several days. This may mean you will be on bed rest, however, your medical team will work with you to determine an appropriate level of activity after surgery.

Staples holding the graft in place are removed within a week of the procedure. Wound care and activity level will be adjusted based on your individual needs.

Resuscitation phase:

• Begins with the initiation of IV fluids and ends when the capillary integrity returns to near normal level.
• The amount of fluid administered is based on patient's weight and extent of injury.
• The aim is to prevent shock by maintaining adequate circulating blood volume and maintaining organ perfusion.
• Successful fluid resuscitation is evaluated by stable vital signs, adequate urine output, palpable peripheral pulses and clear sensorium.

Acute Phase:

1. Acute phase usually begins 48-72hrs after the time of injury when the patient is hemodynamically stable. Capillary permeability is restored and diuresis has begun.
2. The goal is to control infection, wound care, wound closure, nutritional support, pain management and physical therapy.

Rehabilitation phase:

• This is the last phase 9f burn care; the aim is to make the patient achieve maximum function and independence by;

1. Promoting wound healing
2. Increasing strength and function
3. Minimizing deformities
4. Giving emotional support 

Care of the Graft sight :

• Graft sight is immobilized and elevated
• Avoid pressure on the graft
• Roll cotton tipped applicator  over the graft to remove exudates because exudates can lead to infection and prevent graft adherence
• Monitor for any foul smelling discharge, increased temperature, increased white blood cells and fluid accumulation
• Instruct the patient to lubricate the healing skin with prescribed agent
• Instruct the patient to protect the affected area from sunlight

Care of the donor site:

1. Method of care varies depending on the physician
2. Moist gauze dressing is applied at the time of the surgery to maintain pressure and stop oozing
3. Keep the donor site clean, dry, and free from pressure 
4. Instruct the patient not to scratch the donor site
5. Apply lubricating lotion to soften the area and reduce the itching after the site has healed ( with proper care, the donor site may heal within 7-14 days)

Physical therapy:

• Splinting, positioning, ambulation and activities of daily living are implemented early in the acute phase of recovery to maximize functional and cosmetic outcome 

Formulas for Fluid Replacement in Burn victim