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MANAGEMENT OF �BURN WOUND�

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

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Content

  1. Introduction

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  • Management of the Burn Wound

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INTRODUCTION

Burn injury

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  • Is a surgical emergency, which requires prompt and aggressive treatment.
  • The management of burns requires a multi-disciplinary approach in order to obtain the best aesthetic and functional outcome.

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  • The aim of modern burn management after the initial resuscitation is to achieve early wound closure and prevent burn sepsis.
  • Early tangential excision and skin grafting is very important to prevent the occurrence of hypertrophic scarring and the resultant disabling contractures which are often difficult to treat and time consuming.

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Causes of burn:

  1. Thermal (flame)
  2. Hot liquids (scalds)
  3. Chemical (acids,alkalis,corrosives)
  4. Electrical and lightning
  5. Radiation
  6. Inhalation
  7. Friction (abrasion)

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Depth of Burn Injury

  • Depending upon the depth of tissue damage, burns may be classified as either superficial or deep.
  • In practice, all burns are a mixture of areas of different depth.

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Epidermal

(1st degree)

Partial thickness (2nd degree)

Full thickness

(3rd degree)

Superficial dermal

Deep dermal

Colour

Hyperemia

Pale pink

Blotchy red

White leathery

Blisters

None

Present

None

Capillary refill

Present

Present

Absent

Absent

Sensation

Very painful

Very painful

Absent

Absent

Spontaneous healing

Yes

Yes

No

No

Physical Appearance

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Table: Diagnosis of Burn Depth

* Patients with deep dermal and full thickness (3rd degree) burn require immediate referral to specialist hospital

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MANAGEMENT OF THE BURN WOUND

  1. Burn injury is a medical emergency.

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  • After immediate first aid has been given, the principles of primary and secondary survey and simultaneous resuscitation should be followed as per ATLS principles (Airway, Breathing, Circulation, Disability, Exposure, and Fluid Resuscitation).

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  1. The burn areas are assessed using the Lund and Browder chart.
  2. This will help to identify patients that need to be referred to a specialized medical facility (see Table 8a-2) and to start fluid resuscitation as per Parkland Formula.

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Note: areas of erythema are not included

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Criteria for Injuries Requiring Referral to Specialist Hospital

  1. Full thickness burns greater than 5% TBSA in any age group;
  2. Partial thickness burns > 10% TBSA in patients in paediatric age groups and adult > 50 years of age;
  3. Partial thickness burns > 15% TBSA in all groups;
  4. Burns involving the face, hands, feet, genitalia, perineum and over joints;
  5. Electrical burns, including lightning injury;
  6. Chemical burns with serious functional and cosmetic impairment;
  7. Suspicion of inhalational injury
  8. Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery or increase the mortality rate;
  9. Any burn patient with concomitant trauma (e.g. fractures or intra-abdominal injuries);
  10. Burn injury in patients who require special social, emotional, and/or long-term rehabilitative support, including cases of suspected child abuse, substance abuse, etc.

Table 8a-2

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  1. In extensive burns, the appropriate treatment is to cover the wound with a clean sheet or plastic cling wrap before transfer. Do not cover the burns with Silver Sulfadiazine (SSD) as it may mask the depth of burns. Remember to keep the patient warm.

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  • Cover minor burns with dressings such as paraffin gauze moistened with sterile normal saline or 0.1% aqueous chlorhexidine solution.

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  • Do not constrict limb circulation with tight dressings. It is important to elevate the involved extremities.

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  1. Since burn injury is a wound, local protocol for tetanus mustbe followed.

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  • Adequate pain relief must be provided (refer to chapter on pain management).

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  • If the burns appear to be epidermal or superficial partial thickness, continue with either topical antimicrobial dressings (SSD), paraffin gauze or any available modern wound dressings until the wound heals (please refer to the chapter on wound dressing material).

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  1. If the burns are full thickness, or deep partial thickness which are unlikely to heal within 3 weeks, you may want to refer to a specialist hospital where patient may require tangential excision and split-thickness skin grafting.

Tangential excision of partial thickness burn wound until viable tissue.

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  1. There is no need for prophylactic antibiotics unless there is evidence of infection.

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  • Remember the importance of splinting the affected joints to prevent contractures. Patient must continue with rehabilitation upon discharge.

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  • The use of pressure garments may continue for up to one year or two depending on the severity of the hypertrophic scarring.

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  • All patients must be followed up for at least six months to one year to detect any developing contractures and hypertrophic scars which warrants a referral to a plastic surgeon.

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Indications for Referral to Specialist Hospital After Failure of Conservative Management

  1. No progress of healing after 3 weeks of treatment.
  2. Presence of slough, necrotic patch or infection.
  3. Occurrence of hypertrophic scarring and early contractures.

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TAKE HOME MESSAGES

  • Know how to assess severity of burn injury.
  • Know when to refer to Specialist Hospital.

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REFERENCES

  • Rajiv Sood, Bruce M Achauer. Achauer and Sood’s Burn Surgery: Reconstruction and Rehabilitation: Elsevier: 50-76; 2006.
  •  John L Hunt, Gary F Purdue, Ross I S Zbar. Burns: Acute Burns, Burn Surgery, And Postburn Reconstruction. Selected Readings in Plastic Surgery 9(12), 2000.o
  •  Jeffrey J Roth, William B Hughes. The Essential Burn Unit Handbook: Quality Medical Publishing; 2004.
  •  Greenfield LJ, Mulholland M, Oldham KT, Zelenock GB, Lillemoe KD. Surgery, Scientific Principles and Practice , 2nd ed. Philadelphia: Lippincott-Raven, 1997.

 

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THANK YOU

Wound Care Training Module - National Wound Care Committee