Burn medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eman Alademi, M.D.[2]
Overview
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)
The majority are minor burn and can be managed on an outpatient basis without the need for burn specialist consultation.[6]
To be considered minor, burns must also generally meet the following criteria:
- Isolated injury (ie, no suspicion of inhalation or high-voltage injury)
- Does not involve face, hands, perineum, or feet
- Does not cross major joints
- Is not circumferential
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.
TREATMENT
- Dressings Basic dressing, dry, nonstick gauze only, Biologic and synthetic dressings
Oral burns :Minor oral mucosal burns typically require no specific treatment other than saline rinses and basic oral hygiene. Alcohol-based mouth rinses should be avoided as they can irritate wounds and increase pain.
Several case reports describe epiglottitis caused by thermal injury after an oral scald burn. Close attention should be paid to young children with oral scald burns as their airway structures are narrower and are more prone to obstruction with smaller degrees of inflammation and swelling. If there is any concern for airway compromise or about the extent of injury, the patient is best evaluated in the ED, where a more in-depth inspection of the epiglottis and airway can be performed[13][14][15][16][17][18].
Contraindicated medications
Severe burns with hyperkalemia is considered a relative contraindication to the use of the following medications:
Reference
- ↑ 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
- ↑ Brigham PA, McLoughlin E (1996). "Burn incidence and medical care use in the United States: estimates, trends, and data sources". J Burn Care Rehabil. 17 (2): 95–107. doi:10.1097/00004630-199603000-00003. PMID 8675512.
- ↑ Balin AK, Pratt L (2002). "Dilute povidone-iodine solutions inhibit human skin fibroblast growth". Dermatol Surg. 28 (3): 210–4. doi:10.1046/j.1524-4725.2002.01161.x. PMID 11896770.
- ↑ 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.
- ↑ Waitzman AA, Neligan PC (1993). "How to manage burns in primary care". Can Fam Physician. 39: 2394–400. PMC 2379923. PMID 8268745.
- ↑ Hill MG, Bowen CC (1996). "The treatment of minor burns in rural Alabama emergency departments". J Emerg Nurs. 22 (6): 570–6, quiz 576-8. doi:10.1016/s0099-1767(96)80214-5. PMID 9060321.
- ↑ Greenhalgh DG (1996). "The healing of burn wounds". Dermatol Nurs. 8 (1): 13–23, 66, quiz 24-5. PMID 8695324.
- ↑ Goldberg RM, Lee S, Line WS (1990). "Laryngeal burns secondary to the ingestion of microwave-heated food". J Emerg Med. 8 (3): 281–3. doi:10.1016/0736-4679(90)90006-h. PMID 2373837.
- ↑ Kannan S, Chandrasekaran B, Muthusamy S, Sidhu P, Suresh N (2014). "Thermal burn of palate in an elderly diabetic patient". Gerodontology. 31 (2): 149–52. doi:10.1111/ger.12010. PMID 24797620.
- ↑ Sheridan RL (1996). "Recognition and management of hot liquid aspiration in children". Ann Emerg Med. 27 (1): 89–91. doi:10.1016/s0196-0644(96)70302-5. PMID 8572457.
- ↑ Kudchadkar SR, Hamrick JT, Mai CL, Berkowitz I, Tunkel D (2014). "The heat is on... thermal epiglottitis as a late presentation of airway steam injury". J Emerg Med. 46 (2): e43–6. doi:10.1016/j.jemermed.2013.08.033. PMID 24113478.
- ↑ Go H, Yang HW, Jung SH, Park YA, Lee JY, Kim SH; et al. (2007). "Esophageal thermal injury by hot adlay tea". Korean J Intern Med. 22 (1): 59–62. doi:10.3904/kjim.2007.22.1.59. PMC 2687594. PMID 17427650.
- ↑ Watts AM, McCallum MI (1996). "Acute airway obstruction following facial scalding: differential diagnosis between a thermal and infective cause". Burns. 22 (7): 570–3. doi:10.1016/0305-4179(96)00032-0. PMID 8909764.