Burn medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Eman Alademi, M.D.[2]
Medical Therapy
The American Burn Association recommends burn center referrals for patients with:
- partial thickness burns greater than 10% total body surface area or:[1][2]
- Partial-thickness burns <10 percent TBSA in patients 10 to 50 years old
- Partial-thickness burns <5 percent TBSA in patients under 10 or over 50 years old
- Full-thickness burns <2 percent TBSA in any patient without other injury
- full thickness burns
- burns of the face, hands, feet, genitalia, or major joints
- chemical burns, electrical, or lighting strike injuries
- significant inhalation injuries
- burns in patients with multiple medical disorders
- burns in patients with associated traumatic injuries
Patients being transferred to burn centers do not need extensive debridement or topical antibiotics before transfer. Whether transferring or referring to a burn center, you should contact them before
If burns classified as severe (> 20% TBSA), fluid resuscitation should be initiated to maintain urine output > 0.5 mL/kg/hour. One commonly used fluid resuscitation formula is the Parkland formula. The total amount of fluid to be given during the initial 24 hours = 4 ml of LR × patient’s weight (kg) × % TBSA. Half of the calculated amount is administered during the first eight hours beginning when the patient was initially burned. For example, if a 70 kg patient has a 30% TBSA partial thickness burn they will need 8400 mL Lactated Ringer solution in the first 24 hours with 4200 mL of that total in the first 8 hours [(4 mL) × (70 kg) × (30% TBSA) = 8,400 mL LR]. Remember that the fluid resuscitation formula for burns is only an estimate and the patient may need more or less fluid based on vital signs, urine output, other injuries or other medical conditions (see Burns, Resuscitation, and Management for discussion of the management of severely burned patients).
In patients with moderate to severe flame burns and with suspicion for inhalation injury, carboxyhemoglobin levels should be checked, and patients should be placed on high flow oxygen until carbon monoxide poisoning is ruled out. If carbon monoxide poisoning is confirmed, continue treatment with high-flow oxygen and consider hyperbaric oxygen in select cases (see Hyperbaric, Carbon Monoxide Toxicity chapter). Cyanide poisoning can also occur from smoke inhalation and can be treated with hydroxocobalamin (see Inhalation Injury chapter).[3][4]
A local anesthetic is usually sufficient in managing pain of minor first-degree and second-degree burns. However, systemic anti-inflammatory drugs such as naproxen may be effective in mitigating pain and swelling. Additionally, topical antibiotics such as Mycitracin are useful in preventing infection to the damaged area[5]. Lidocaine can be administered to the spot of injury and will generally negate most of the pain. Regardless of the cause, the first step in managing a person with a burn is to stop the burning process at the source. For instance, with dry powder burns, the powder should be brushed off first. With other burns, such as those caused by exposure to chemicals, the affected area should be rinsed throughly with a large amount of clean water to remove the caustic agent and any foreign bodies. Cold water should not be applied to a person with extensive burns, however, as it may compromise the burn victim's temperature status.
If the patient was involved in a fire accident, then it must be assumed that he or she has sustained inhalation injury until proven otherwise, and treatment should be managed accordingly. At this stage of management, it is also critical to assess the airway status. Any hint of burn injury to the lungs (e.g. through smoke inhalation) is considered a medical emergency. Survival and outcome of severe burn injuries is remarkably improved if the patient is treated in a specialized burn center/unit rather than a hospital. Serious burns, especially if they cover large areas of the body, can result in death.
Once the burning process has been stopped, the patient should be volume resuscitated according to the Parkland formula, since such injuries can disturb a person's osmotic balance. This formula dictates the amount of Lactated Ringer's solution to deliver in the first twenty four hours after time of injury. This formula excludes first and most second degree burns. Half of the fluid should be given in the first eight hours post injury and the rest in the subsequent sixteen hours. The formula is a guide only and infusions must be tailored to the urine output and central venous pressure. Inadequate fluid resuscitation causes renal failure and death.
Treatment of Low Grade Burns(minor thermal burns)
A local anesthetic is usually sufficient in managing pain of smaller first-degree and second-degree burns. Lidocaine can be administered to the spot of injury and will generally negate most pain.
Contraindicated medications
Severe burns with hyperkalemia is considered a relative contraindication to the use of the following medications:
The American Burn Association recommends burn center referrals for patients with:
- partial thickness burns greater than 10% total body surface area
- full thickness burns
- burns of the face, hands, feet, genitalia, or major joints
- chemical burns, electrical, or lighting strike injuries
- significant inhalation injuries
- burns in patients with multiple medical disorders
- burns in patients with associated traumatic injuries
Patients being transferred to burn centers do not need extensive debridement or topical antibiotics before transfer. Whether transferring or referring to a burn center, you should contact them before beginning extensive local burn care treatments.[12][13]
Minor burns which you plan to treat can be approached using the “C” of burn care:
- Cooling - Small areas of burn can be cooled with tap water or saline solution to prevent progression of burning and to reduce pain.
- Cleaning – Mild soap and water or mild antibacterial wash. Debate continues over the best treatment for blisters. However, large blisters are debrided while small blisters and blisters involving the palms or soles are left intact.
- Covering – Topical antibiotic ointments or cream with absorbent dressing or specialized burn dressing materials are commonly used.
- Comfort – Over-the-counter pain medications or prescription pain medications when needed. Splints can also provide support and comfort for certain burned areas.
Surgical and other procedures
You may need one or more of the following procedures:
- Breathing assistance. If you've been burned on the face or neck, your throat may swell shut. If that appears likely, your doctor may insert a tube down your windpipe (trachea) to keep oxygen supplied to your lungs.
- Feeding tube. People with extensive burns or who are undernourished may need nutritional support. Your doctor may thread a feeding tube through your nose to your stomach.
- Easing blood flow around the wound. If a burn scab (eschar) goes completely around a limb, it can tighten and cut off the blood circulation. An eschar that goes completely around the chest can make it difficult to breathe. Your doctor may cut the eschar to relieve this pressure.
- Skin grafts. A skin graft is a surgical procedure in which sections of your own healthy skin are used to replace the scar tissue caused by deep burns. Donor skin from deceased donors or pigs can be used as a temporary solution.
- Plastic surgery. Plastic surgery (reconstruction) can improve the appearance of burn scars and increase the flexibility of joints affected by scarring.
Lifestyle and home remedies
To treat minor burns, follow these steps:
- Cool the burn. apply a cool water (not cold) , wet compress until the pain eases. Don't use ice. Putting ice directly on a burn can cause further damage to the tissue[6].
- Remove rings or other tight items. Try to do this quickly and gently, before the burned area swells.
- Don't break blisters. Fluid-filled blisters protect against infection. If a blister breaks, clean the area with water (mild soap is optional). Apply an antibiotic ointment. But if a rash appears, stop using the ointment.
- Apply lotion. Once a burn is completely cooled, apply a lotion, such as one that contains aloe vera or a moisturizer. This helps prevent drying and provides relief.
- Bandage the burn. Cover the burn with a sterile gauze bandage (not fluffy cotton). Wrap it loosely to avoid putting pressure on burned skin. Bandaging keeps air off the area, reduces pain and protects blistered skin.
- Take a pain reliever. Over-the-counter medications, such as ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) or acetaminophen (Tylenol, others), can help relieve pain.
- Consider a tetanus shot. Make sure that your tetanus booster is up to date. Doctors recommend that people get a tetanus shot at least every 10 years.
Whether your burn was minor or serious, use sunscreen and moisturizer regularly once the wound is healed.[7]
References
- ↑ Mertens DM, Jenkins ME, Warden GD (1997). "Outpatient burn management". Nurs Clin North Am. 32 (2): 343–64. PMID 9115481.
- ↑ Baxter CR (1993). "Management of burn wounds". Dermatol Clin. 11 (4): 709–14. PMID 8222354.
- ↑ "StatPearls". 2020. PMID 30480960 PMID: 30480960 Check
|pmid=value (help). - ↑ Burn and Trauma Branch of Chinese Geriatrics Society. Ming J, Lei P, Duan JL, Tan JH, Lou HP | display-authors=etal (2018) [National experts consensus on tracheotomy and intubation for burn patients (2018 version).] Zhonghua Shao Shang Za Zhi 34 (11):E006. DOI:10.3760/cma.j.issn.1009-2587.2018.11.E006 PMID: 30440148 PMID: 30440148
- ↑ Minor Burns quickcare.org Accessed February 25, 2008
- ↑ Pushkar NS, Sandorminsky BP (1982). "Cold treatment of burns". Burns Incl Therm Inj. 9 (2): 101–10. doi:10.1016/0305-4179(82)90056-0. PMID 7150995.
- ↑ "Burns - Diagnosis and treatment - Mayo Clinic".