Tawfeeq Irshad Mir
Injuries that result from direct contact with or exposure to any thermal, chemical, electrical, or radiation source are termed burns. Burn injuries occur when energy from a heat source is transferred to the tissues of the body. The depth of injury is related to the temperature and the duration of exposure or contact. Burn care has improved in recent decades, resulting in a lower mortality for victims of burn injuries. Dedicated burn centers have been established in which multi disciplinary burn team members work together to care for the burn client and family. Advances in pre-hospital and inpatient care have contributed to survival. However, despite these advances, many people are still injured and die each year from burns. In kashmir, it is estimated that 20,000 people are treated every year for a burn injury. Of these approximately 15,000 will require hospitalisation. After traversing a lot of literature on burns, seeking guidelines from world health organisation, after surfing thousands of research papers on burn management, here I have come up with an improvised model of health care for burn patients.
Wound care :
First aid :
• If the patient arrives at the health facility without first aid having been given, drench the burn thoroughly with cool water to prevent further damage and remove all burned clothing.
• If the burn area is limited, immerse the site in cold water for 30 minutes to
reduce pain and oedema and to minimize tissue damage.
• If the area of the burn is large, after it has been doused with cool water, apply
clean wraps about the burned area (or the whole patient) to prevent systemic
heat loss and hypothermia.
• Hypothermia is a particular risk in young children.
• First 6 hours following injury are critical; transport the patient with severe burns
to a hospital as soon as possible.
Initial treatment
• Initially, burns are sterile. Focus the treatment on speedy healing and
prevention of infection.
• In all cases, administer tetanus prophylaxis.
• Except in very small burns, debride all bullae. Excise adherent necrotic (dead)
tissue initially and debride all necrotic tissue over the first several days.
• After debridement, gently cleanse the burn with 0.25% (2.5 g/litre)
chlorhexidine solution, 0.1% (1 g/litre) cetrimide solution, or another mild water- based antiseptic.
• Do not use alcohol-based solutions.
• Gentle scrubbing will remove the loose necrotic tissue. Apply a thin layer of
antibiotic cream (silver sulfadiazine).
• Dress the burn with petroleum gauze and dry gauze thick enough to prevent
seepage to the outer layers.
Daily treatment
• Change the dressing daily (twice daily if possible) or as often as necessary to
prevent seepage through the dressing. On each dressing change, remove any
loose tissue.
• Inspect the wounds for discoloration or haemorrhage, which indicate
developing infection.
• Fever is not a useful sign as it may persist until the burn wound is closed.
• Cellulitis in the surrounding tissue is a better indicator of infection.
• Give systemic antibiotics in cases of haemolytic streptococcal wound infection or septicaemia.
• Pseudomonas aeruginosa infection often results in septicaemia and death.
Treat with systemic aminoglycosides.
• Administer topical antibiotic chemotherapy daily. Silver nitrate (0.5% aqueous) is the cheapest, is applied with occlusive dressings but does not penetrate eschar. It depletes electrolytes and stains the local environment.
• Use silver sulfadiazine (1% miscible ointment) with a single layer dressing. It has limited eschar penetration and may cause neutropenia.
• Mafenide acetate (11% in a miscible ointment) is used without dressings. It
penetrates eschar but causes acidosis. Alternating these agents is an
appropriate strategy.
• Treat burned hands with special care to preserve function.
− Cover the hands with silver sulfadiazine and place them in loose polythene gloves or bags secured at the wrist with a crepe bandage;
− Elevate the hands for the first 48 hours, and then start hand exercises;
− At least once a day, remove the gloves, bathe the hands, inspect the burn
and then reapply silver sulfadiazine and the gloves;
− If skin grafting is necessary, consider treatment by a specialist after healthy
granulation tissue appears.
Healing phase
• The depth of the burn and the surface involved influence the duration of the
healing phase. Without infection, superficial burns heal rapidly.
• Apply split thickness skin grafts to full-thickness burns after wound excision or the appearance of healthy granulation tissue.
• Plan to provide long term care to the patient.
• Burn scars undergo maturation, at first being red, raised and uncomfortable.
They frequently become hypertrophic and form keloids. They flatten, soften
and fade with time, but the process is unpredictable and can take up to two
years.
• In children
– The scars cannot expand to keep pace with the growth of the child and may
lead to contractures.
– Arrange for early surgical release of contractures before they interfere with
growth.
• Burn scars on the face lead to cosmetic deformity, ectropion and contractures
about the lips. Ectropion can lead to exposure keratitis and blindness and lip
deformity restricts eating and mouth care.
• Consider specialized care for these patients as skin grafting is often not
sufficient to correct facial deformity.
Nutrition :
• Patient’s energy and protein requirements will be extremely high due to the
catabolism of trauma, heat loss, infection and demands of tissue regeneration.
If necessary, feed the patient through a nasogastric tube to ensure an
adequate energy intake (up to 6000 kcal a day).
• Anaemia and malnutrition prevent burn wound healing and result in failure of
skin grafts. Eggs and peanut oil and locally available supplements are good.
( The author is a student of B Sc Hons Nursing at GMC SRINAGAR . Views are his own [email protected] )
