Management of Burn Injuries

Fig. 11.1

Escharotomies. The lines indicate the location for escharotomies. Note that it is important that the cut is deep enough to accomplish a tissue release. This needs to be specifically addressed at the areas marked, as it is more difficult to assess the right tissue depth at these locations, i.e., close to the major joints

C. Circulation

The circulatory status of the patient should be examined. It includes assessing the skin color, sensitivity, peripheral pulses, and capillary refill. Heart rate and blood pressure should also be included to confirm adequate organ perfusion. Be aware that heart rate effects need to be judged cautiously as it may also be affected by other reasons than hypovolemia, such as anxiety and/or pain. Blood pressure monitoring when done may be difficult, be aware of the risk for faulty or compromised measurements by, e.g., deep circumferential burns. In cases the peripheral circulation in the extremities is compromised, consider early escharotomies and invasive blood pressure measurements (See Fig. 11.1).

D. Disability

The burn injured patient during “normal” conditions in the acute phase should not have an altered level of consciousness (LOC) even in cases of very severe burns. The LOC should be assessed, e.g., by the Glasgow Coma Scale (GCS). If the level of consciousness (LOC) is altered, suspect other underlying processes such as other trauma, carbon monoxide and/or cyanide intoxication, hypoxia, e.g., especially in a closed space and where fire is fierce, or other medical conditions such as stroke or diabetes.

E. Expose and Examine

The patient should be thoroughly examined and in order to do this removal of the clothing is necessary. Be aware of the risk for hypothermia. Jewelry, especially such as rings, should be removed due to the risk of compromising extremity (finger) blood flow as tissue edema develops. At this occasion, the important assessment of the burn injuries may be performed and evaluated. Important for the outcome is to initiate the fluid therapy early, which may be done at this point and when the extent of the burn injury becomes evident. A simplified fluid starting strategy has been suggested by the ABA for the very early burn care where a significant burn (>30%) is encountered. See Table 11.1 below.

Table 11.1

Patients with >30% TBSA obtain two large bore, indwelling venous catheters and a suggested simplified prehospital fluid management plan may be as is presented in this Table (11.1)

A simplified fluid management plan
≤5 years	125 mL LR/h
6–13 years	250 mL LR/h
≥14 years	500 mL LR/h

11.2.2.2 Secondary Assessment

The complementary second assessment is undertaken rapidly after the first assessment and it is aimed at examining the patient thoroughly from head to toe, mainly in order to rule out other more important injuries that may pose a danger to the patient. One important point is that this examination needs to be undertaken in detail as the burn injury often is the most prominent injury and it may lead to that other injuries may be overlooked. If the assessment is done at larger facilities and there is a suspicion of other concomitant trauma, a regular trauma assessment algorithm may be undertaken and involving, e.g., ultrasound scan abdomen and/or (complementary) whole body CT scan.

Other issues to address at this point are to get a good medical history. This is important from mainly two aspects, firstly, the circumstances around the burn injury as it may help in determining the prognosis and may indicate the future burn treatment needs. Secondly, to assess the patients’ present co-morbidities and ongoing medical treatments.

1.

Circumstances of the burn. Where and when did it happen—what were the injury mechanisms (scald, flame, chemical, or electrical). Especially the factors, heat level (degrees) and exposure time (seconds) may signal the risk for deep injuries. Indoor accident and risk for inhalation injuries. Are other injury mechanisms present and relevant?
2.

Medical history. Previous or associated illnesses (diabetes; hypertension; other heart, lung, or kidney disease)— Ongoing medical treatment, alcohol use or other (abuse), allergies. Time for last oral fluid or food intake. The tetanus immunization status—need for complementary injections?

11.2.2.3 Fluid Treatment

A cornerstone in the treatment of the burn injury is the fluid treatment. Usually i.v. fluid is provided to injuries larger than 15% total burn surface area % (TBSA%) [24, 25]. In order to provide fluid treatment intravenously, i.v. lines are needed. These are most commonly applied in the extremities in non-injured tissue, but in cases of massive burns also burned areas may be used. In larger burns, getting vascular access may prove difficult and central i.v. lines may be mandatory as may an intraosseous cannula, or vein cutdown strategies in children. The fluid treatment may be initiated early at the scene of the accident, but should not significantly delay transportation. If transport is planned for more than 1 h, starting the i.v. fluid is most often recommended (see also Table 11.1). The background for the fluid needs for the burn patients is the rapid fluid loss to the injured tissue that is caused by the negative imbibition pressure, developing in the injured tissues secondary to the thermal injury and that “pulls” the fluid from the vascular space into the surrounding tissues. This effect is at its maximum after approximately 2 h, therefore the urgent time frame. Also a generalized permeability increase in the vascular tree is developing in parallel and that is due to the generalized inflammatory reaction that develops in the body after the burn injury. This effect is added to the effect by the imbibition pressure and they constitute the reason for the fluid needs of the burn injured [26]. The permeability change is claimed to subside at 8 h and most of it is undertaken within 24 h if the care is not complicated by sepsis and it is therefore most often recommended that the fluid provided is based on crystalloids until this time point [23, 27, 28]. In the USA fluids are based on lactated Ringer solutions, whereas many countries elsewhere do use acetated Ringer. In cases of refractory situations despite extensive fluid volume provided, the addition of colloids and/or vasoactive drugs may be relevant and needed [29, 30]. For most injuries, this is however uncommon. There are several fluid protocols in use worldwide today (Table 11.2) and the most commonly used is the one first presented by Dr. Baxter in the 1960s, called the Parkland formula as it was used initially at the Parkland Memorial Hospital in Dallas (Table 11.3) [32]. This scheme recommends in adults 2–4 mL/kg/TBSA% of crystalloids (Ringer’s solution—lactate/acetate) for the first 24 h, 50% provided during the first 8 h, and 50% during the following 16 h. In children the corresponding fluid volume need is larger, that is 3–4 mL/kg/TBSA% and to this the normal 24 h fluid needs are added (Table 11.3). It is important to stress that the fluid volume suggested is to be closely adjusted according to endpoints—that is mainly urine output. In order to maintain perfusion of internal organs, the endpoint goal is for a urine output of 30 mL/h (or 0.5 mL/kg/h) in adults and 1 mL/kg/h in children. If insufficient urine output, a 30% increase in the fluid volume per hour provided is recommended. Alternatively, if urine output is too large a corresponding decrease is suggested.

Table 11.2

Alternative fluid protocols (Modified from [31])

Crystalloid-based protocols
Parkland	Ringer’s lactate/acetate 2–4 mL/kg/TBSA%; half of the fluid during first 8 h
	Children: Ringer’s lactate/acetate 3–4 mL/kg/TBSA%
Modified Brooke	Ringer’s lactate/acetate 2 mL/kg/TBSA%
Colloid-based protocols
Evans	NACl 1 mL/kg/TBSA%+ colloid 1 mL/kg/TBSA%+ 2000 mL glucose solution (5%)
Brooke	Ringer’s lactate/acetate 1.5 mL/kg/TBSA%+ colloid 0.5 mL/kg %+ 2000 mL glucose solution (5%)
Slater	Ringer’s lactate/acetate 2000 mL/24 + fresh frozen plasma 75 mL/kg/24 h
Dextran-based protocols
Demling	Dextran 40 in NaCl (2 mL/kg/h in 8 h) + Ringer’s lactate/acetate in sufficient amounts to induce a urine volume of 30 mL/h + fresh frozen plasma (0.5 mL/kg/h from 8 to 26 h post burn)
Hypertonic protocols
Monafo	250 mEq Na/L. Amounts provided to induce a urine output of 30 mL/h
Warden	Ringer’s lactate + 50 mEq sodium bicarbonate (total 180 mEq) during the first 8 h to induce a urine output of 30–50 mL/h. Thereafter Ringer’s lactate with the same urinary output goal

Table 11.3

The Parkland protocol

Adults

Ringer’s lactate/acetate 2–4 mL/kg/TBSA%. 50% provided during the first 8 h. The remaining fluid during the following 16 h

Children

Ringer’s lactate/acetate 3–4 mL/kg/TBSA%. 50% provided during the first 8 h. The remaining fluid during the following 16 h. Normal 24 h fluid needs are added to this as glucose solution

It is important to stress that neither too little fluid nor too large fluid volumes in relation to the needs should be provided as it will lead to less successful results [33]. The needs vary largely between injuries and patients underlining the need for close surveillance and follow-up. In general and presently, in cases of less successful fluid resuscitations most often too large fluid volumes have been provided [30]. Too large fluid volumes will lead to deepening of the burn wound and secondary complications from other body compartments such as generalized large edema including cerebral, pulmonary edema and compartment situations, most importantly abdominal compartment syndrome [33]. Especially if using central circulatory endpoints rather than urine output during the first 12–18 h, such risk is higher [34]. Using the parkland formula, the patients appear “hypovolemic” as examined by central circulation techniques, e.g., echocardiography in the very early part of the resuscitation period [35, 36].

There are situations where larger fluid needs may be present. In general it has been claimed especially for inhalation or electrical injuries and in cases of a delayed start of fluid treatment. In the case of inhalation injuries the data supporting larger fluid needs are older and in newer investigations smaller effects of inhalation injury on the fluid needs have been seen [30]. In electrical injuries, the total tissue damage may be larger despite that the skin burn is less extensive. Other instances where larger fluid volumes are called for are in cases of high voltage electrical injuries or crush injures or when myo- och hemoglobinemia is present. Under these circumstances, an increased diuresis and alkalinization of the urine is recommended. The diuresis should reach 1–2 mL/kg/h (adults) and the pH of the urine should be kept alkaline preferably around or above 7. This is accomplished by adding sodium bicarbonate solution to the resuscitation fluids. This strategy should be continued as long as the pigments are present in the urine.

11.2.2.4 Burn Wound Evaluation

Most often the first burn wound evaluation is made under the heading “exposure” in the primary survey, at, e.g., the accident. A more thorough examination is then be made after the second survey. In evaluating the wound, it is important to have it adequately exposed and cleaned from debris and blisters, the latter situation calls for good analgesia or is done during general anesthesia. The risk of hypothermia should always be addressed. The wound evaluation is done mainly in two aspects, to determine, the depth and total percent body surface area injured (TBSA%). The depth is mainly important as it affects the treatment (surgical excision or not) and the TBSA% is important for the prognosis. TBSA% (including depth) is together with the age of the patient and the prevalence of inhalation injury, the most important prognostic factors for the injury. This will govern prognosis and also the fluid treatment.

Burn Wound Depth

How deep into the skin the injury progresses is dependent on several factors. Firstly, it depends on the thermal energy transferred to the tissue. This depends on the temperature and the exposure time; high temperature and longer exposure times increase the risk for significant injuries. The energy transfer process is further affected by the type of transfer, e.g., convection transfers more energy, and this is counteracted by the ability of the tissue to withstand the temperature (thicker skin—better resistance) or dissipate the heat (higher blood flow reduces the injury). In practice, this is exemplified by the lower risk for injuries on the back, in palms and soles with their thicker nature and the higher risk in elderly and children with their generally thinner skin.

Burn wound depth (see Fig. 11.2) has traditionally been divided into three levels according to anatomy, first degree—epidermal injury, second degree—dermal and third degree—subdermal burns. Today a two-level nomenclature is used which focuses more on treatment strategies: partial thickness burns (including epidermal and superficial dermal injuries first and superficial second degree burn; old nomenclature) and full thickness burns (including deep second degree and subdermal burns; old nomenclature). Modern care for partial thickness is conservative treatment, whereas full thickness burns are surgically excised and transplanted.

../images/188491_2_En_11_Chapter/188491_2_En_11_Fig2_HTML.jpg — Fig. 11.2

Burn wound. Skin anatomy in relation to burn wound depth terminology

A burn involving the epidermis is usually erythematous and very painful but does not contain blisters. It is exemplified by a sunburn. The dead epidermis sloughs off and is replaced by regenerating keratinocytes within 2–3 days. A partial thickness burn wound is a superficial dermal burn and extends down to the papillary dermis and usually forms blisters. When the blisters are removed, the wound is pink, wet, and highly sensitive. Blanching is present. These wounds heal within 2 weeks (Fig. 11.3a; Photo). Deep dermal wounds extend down to the reticular dermis and usually take more than 3 weeks to heal. These wounds also show blistering but the wound underneath has a mottled and white appearance. Blanching if at all present is slow. Sensitivity to pinprick is reduced and pain is described as discomfort rather than pain. See Fig. 11.3b (Photo). Full thickness wounds involve the entire dermis and extend to the underlying tissue. Appearance is described as charred, leathery, and firm. The wound is insensitive to touch and pinprick. See Fig. 11.3c (Photo). Deep dermal and full thickness wounds are surgically excised and autologous transplanted.