BURNS

Tissue injury caused by thermal, chemical, electrical, or radiation energy.

Causes

• Thermal, e.g., hot fluids, flame, steam, hot solids, sun
• Chemical, e.g., acids, alkalis, and other caustic chemicals
• Electrical, e.g., domestic (low voltage) transmission lines (high voltage), lightening
• Radiation, e.g., exposure to excess radiotherapy or radioactive materials

Clinical features

• Pain, swelling
• Skin changes (hyperaemia, blisters, singed hairs)
• Skin loss (eschar formation, charring)
• Reduced ability to use the affected part
• Systemic effects in severe/extensive burns include shock, low urine output, generalised swelling, respiratory insufficiency, deteriorated mental state
• Breathing difficulty, hoarse voice and cough in smoke inhalation injury – medical emergency

Criteria for classification of the severity of burns

The following criteria are used to classify burns:

LEVEL

CRITERIA
Depth of the burn (a factor of temperature, of agent, and of duration of contact with the skin)	1st Degree burns Superficial epidermal injury with no blisters. Main sign is redness of the skin, tenderness, or hyper sensitivity with intact two-point discrimination. Healing in 7 days. 2nd Degree burns or Partial thickness burns It is a dermal injury that is sub-classified as superficial and deep 2nd degree burns. In superficial 2nd degree burns, blisters result, the pink moist wound is painful. A thin eschar is formed. Heals in 10-14 days. In deep 2nd degree burns, blisters are lacking, the wound is pale, moderately painful, a thick escar is formed. Heals in >1 month, requiring surgical debridement 3rd Degree burns Full thickness skin destruction, leatherlike rigid eschar. Painless on palpation or pinprick. Requires skin graft 4th Degree burns Full thickness skin and fascia, muscles, or bone destruction. Lifeless body part
Percentage of total body surface area (TBSA)	Small areas are estimated using the open palm of the patient to represent 1% TBSA. Large areas estimated using the “rules of nines” or a Lund-Browder chart. Count all areas except the ones with erythema only
The body parts injured	Face, neck, hands, feet, perineum and major joints burns are considered severe
Age/general condition	In general, children and the elderly fare worse than young adults and need more care. A person who is sick or debilitated at the time of the burn will be more affected than one who is healthy

Categorisation of severity of burns

Using the above criteria, a burn patient may be categorised as follows:

Minor/mild burn

• Adult with <15% TBSA affected or
• Child/elderly with <10% TBSA affected
• or
• Full thickness burn with <2% TBSA affected and no serious threat to
  function

SEVERITY	CRITERIA
Moderate (intermediate) burn	Adult with partial thickness burn 15- 25% TBSA or Child/elderly with partial thickness burn 10-20% TBSA All above with no serious threat to function and no cosmetic impairment of eyes, ears, hands, feet or perineum
Major (severe) burn	Adult with Partial thickness burn >25% TBSA or Full thickness burn >10% TBSA Child/elderly with Partial thickness burn >20% TBSA or full thickness burn of >5% TBSA affected Irrespective of age Any burns of the face and eyes, neck, ears, hand, feet, perineum and major joints with cosmetic or functional impairment risks, circumferential burns Chemical, high voltage, inhalation burns Any burn with associated major trauma

Management

Mild/moderate burns – First aid

• Stop the burning process and move the patient to  safety
• Roll on the ground if clothing is on fire
• Switch off electricity
• Cool the burn by pouring or showering or soaking the affected area with cold water for 30 minutes, especially in the first hour after the burn (this may
  reduce the depth of injury if started immediately),
• Remove soaked clothes, wash off chemicals, remove any constrictive clothing/rings
• Clean the wound with clean water
• Cover the wound with a clean dry cloth and keep the patient warm

At health facility

• Give oral or IV analgesics as required
• If TBSA <10% and patient able to drink, give oral fluids otherwise consider IV
• Give TT if not fully immunised
• Leave small blisters alone, drain large blisters and dress if closed dressing method is being used
• Dress with silver sulphadiazine cream 1%, add saline moistened gauze or paraffin gauze and dry gauze on top to prevent seepage
• Small superficial 2nd degree burns can be dressed
  directly with paraffin gauze dressing
• Change after 1-3 days then prn
• Patient may be exposed in a bed cradle if there are extensive burns
• Saline bath should be done before wound dressing
• If wound infected dress more frequenly with  silver sulphadiazine cream until infection is controlled

Severe burns

• First aid and wound management as above PLUS
• Give IV fluid replacement in a total volume per 24 hours according to the calculation in the box below (use crystalloids, i.e., Ringer’s lactate, or
  normal saline)
• If patient in shock, run the IV fluids fast until BP improves
• Manage pain as necessary
• Refer for admission
• Monitor vital signs and urine output
• Use antibiotics if there are systemic signs of infection: benzylpenicillin 3 MU every 6 hours +/- gentamicin 5-7 mg/kg IV or IM once a day
• Blood transfusion may be necessary
• If signs/symptoms of inhalation injury, give oxygen and refer for advanced life support

Surgery

• Escharotomy and fasciotomy for circumferential finger, hand, limb or torso burns
• Escharectomy to excise dead skin
• Skin grafting to cover clean deep burn wounds

Eye injury

• Irrigate with abundant sterile saline
• Place eye pad over eye ointment and refer

Additional care

• Nutritional support
• Physiotherapy of affected limb
• Counselling and psychosocial support
• Health education on prevention (e.g. epilepsy control)

Caution

• Silver sulphadiazine contraindicated in pregnancy, breastfeeding and premature babies

Fluid replacement in burns

• The objective is to maintain normal physiology as shown by urine output, vital signs and mental status
• Fluid is lost from the circulation into the tissues surrounding the burns and some is lost through the wounds, especially in 18-30 hours after the burns
• Low intravascular volume results in tissue circulatory insufficiency (shock) with results such as kidney failure and deepening of the burns
• The fluid requirements are often very high and so should be given as necessary to ensure adequate urine output

TREATMENT

• Give oral fluids (ORS or others) and/or IV fluids e.g. normal saline or Ringer’s Lactate depending on the degree of loss of intravascular fluid
• The total volume of IV solution required in the first 24 hours of the burns is:
  4 ml x weight (kg) x % TBSA burned plus the normal daily fluid requirement
• Give 50% of fluid replacement in the first 8 hours and 50% in the next 16 hours. The fluid input is balanced against the urine output. The normal
  urine output is: Children (<30 kg) 1-2 ml/kg/hour and adults 0.5 ml/kg/hour (30-50 ml /hour)

Prevention

• Public awareness of burn risks and first aid water use in cooling burnt skin
• Construction of raised cooking fire places as safety measure
• Ensure safe handling of hot water and food, keep well out of the reach of children
• Particular care of high risk persons near fires e.g. children, epileptic patients, alcohol or drug abusers
• Encourage people to use closed flames e.g. hurricane lamps. Avoid candles.
• Be ware of possible cases of child abuse