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• history of drug or alcohol ingestion MORE ABOUT • history of associated mechanism of .

It is important to identify inhalation ADELIN MUGANZA, MD, FRCSI, FCS (SA) injury at an early stage. Clinical indi- Specialist Surgeon: Chris Hani cations of inhalation injury include: Baragwanath Hospital and University of • facial burns the Witwatersrand, Johannesburg • singeing of the eyebrows and nasal vibrissae ELIAS DEGIANNIS, MD, PhD, FRCS (Glasg), FACS, FCS (SA) • carbon deposits and acute inflam- Principal Surgeon, Director of matory changes in the oropharynx Trauma and Associate Professor • carbonaceous sputum of Surgery: Chris Hani Baragwanath •hoarseness, rasping or cough Hospital and University of the • glottic oedema Fig. 1. Wallace ‘rule of nines’. Witwatersrand, Johannesburg • history of impaired mentation • confinement in a burning environ- The patient has the same priori- ment ties as all other trauma patients. • explosion with burns to head and torso A full assessment should include: • carboxyhaemoglobin level greater Airway than 10% in patient who is Breathing (beware of inhalation and involved in fire. rapid airway compromise) Circulation (fluid replacement) Pitfall Disability () A pulse oximeter will give a falsely Exposure (% burn). high reading for oxygen saturation in ESSENTIAL MANAGEMENT the presence of carboxyhaemoglobin, POINTS due to bound haemoglobin. Age in years 0 1 5 10 • Stop the burning. The symptom of stridor is an indication Head (A/D) 10 9 7 6 • ABCDE, then determine the percent- for immediate endotracheal intubation. Thigh (B/E) 3 3 4 5 age area of burn (rule of nines). Electrical burns are often more serious Leg (C/F) 2 3 3 3 • Good IV access and early fluid than they appear. Remember that dam- Fig. 2. Extent of burn in children. replacement. aged skin and muscle can result in acute renal failure. The events surrounding the burn 6, deduct 1% from each leg and add should be thoroughly elucidated, since EXTENT OF THE BURN it to the head. In scattered burns use this information will influence early the patient’s palm (1%) to assess The extent of a burn is estimated with diagnostic and therapeutic interven- extent. the ‘rule of nines’ (Fig. 1). Only tion. Specific attention should be given second-, third- and fourth-degree burns DEPTH OF THE BURN to: are taken into account (head 9%, • mechanism of injury The depth of a burn is most commonly anterior torso 18%, posterior torso • duration of and location of expo- estimated in terms of degree. 18%, arms 9% each, legs 18% each, sure • First-degree (superficial) burns dam- perineum 1%). For children below the • source of burn, e.g. fire, hot water, age the epidermis alone. There is age of 6 a modified ‘rule of nines’ is paraffin, kerosene, etc. erythema and pain. applied (Fig. 2). For each year below • type of combustible material

386 CME July 2004 Vol.22 No.7 MORE ABOUT

• Second-degree (partial thickness) ADJUNCTS Which patients are suitable burns damage the entire epidermis for rehabilitation? • Analgesia — adequate analgesia and a variable depth of the dermis. Patients with the following conditions (preferably morphine) should be They are characterised by a red or will benefit from rehabilitation: given intravenously. mottled appearance with associat- • cerebrovascular accidents (CVA) • Bladder catheterisation if burn ed swelling and formation. • (HI) > 20% The surface is wet and painfully • neurological disorders, e.g. • Nasogastric drainage hypersensitive, even to air currents. Guillain-Barré syndrome •Tetanus prophylaxis They will probably need skin graft- • burns • Antibiotics — there is no place for ing. • joint replacements routine systemic antibiotic prophy- • Third-degree (full thickness) burns • laxis cause complete destruction of the • amputations • Escharotomies may be required for epidermis and dermis. All the skin • (SCI). appendages, including hair folli- ventilation and prevention of com- cles, sweat and sebaceous glands partment syndrome. What makes a patient and sensory fibres are destroyed. unsuitable for This results in an initially painless, The local care of the burn rehabilitation? includes appliance of local antimicro- insensate dry surface that may • coma bial agents, early tangential excision appear either white and leathery or • Inability to co-operate and respond of the burn tissue and skin grafting. charred and cracked with exposure to therapy of underlying fat. ELECTRICAL BURNS • severe infection • Fourth-degree burns involve fascia, • respiratory distress. muscle and bone. Possible problems can include cardiac arrest or arrhythmias, extensive muscle Patients may benefit from a period in FLUID ADMINISTRATION damage (often the external injury is a ‘step down’ facility at this stage, Fluid is administered intravenously to minor), compartment syndrome, frac- and then be reassessed for rehabilita- all patients with > 20% body surface ture of long bones or spine, renal fail- tion suitability. area (BSA) burn. A 14G cannula ure due to myoglobin. ECG, cardiac What does rehabilitation should be placed, if necessary through enzymes and radiography for suspect- involve? the burn. The estimated crystalloid ed fractures are necessary investiga- requirement for the first 24 hours after tions. It is important to hydrate the • Initial assessment by a trained injury is calculated based on the patient and secure good diuresis to assessor to evaluate if the patient is patient’s weight and percentage BSA prevent renal failure, and to excise the suitable for rehabilitation. burn. Usually the Parklands formula is dead tissue and check viability of the •Full assessment on admission by the recommended. Ringer’s lactate is underlying muscle. multidisciplinary ‘team’, consisting used. of: • doctor Volume required = 4 ml x BSA (sec- REHABILITATION IN A • physiotherapist ond-, third- or fourth-degree burns • occupational therapist only) x body weight (kg). NUTSHELL • speech therapist • social worker. One half of the calculated volume is •Planning of treatment, length of given during the first 8 hours after stay and planning for discharge. injury, and the remaining volume is VIRGINIA WILSON, MB BS, DCH (UK) • Full involvement of family, with reg- infused over the next 16 hours. It General Practitioner: Netcare ular feedback at ‘family’ meetings. should be emphasised that the formula Rehabilitation Hospital, Johannesburg • Involvement of other professionals is only an estimate, and more or less as required, e.g. urologist, dieti- What is the aim of fluid may be required to maintain ade- cian, psychologist (including sexual rehabilitation? quate tissue perfusion as measured by counselling), psychiatrist. rate of urine output (1 - 2 ml/kg/h). It Physical rehabilitation aims to achieve • Full nursing support for all general is helpful to monitor the haematocrit maximum functional independence for care, particularly with bladder, (HCT). A normal level is about 40%. If the patient in all activities of daily liv- bowel and pressure area care. the haematocrit is rising, e.g. to 45% ing. These activities include dressing, What is the average length or 50%, this implies haemoconcentra- grooming, bathing, toileting, feeding of stay (excluding tion, and the rate of fluid infusion is and walking as well as functioning in complications)? increased. Conversely, if the HCT falls the work or family environment within below 40%, then the rate can be the restrictions of the disability. •CVA: 3 - 6 weeks reduced. •HI: up to 12 weeks

July 2004 Vol.22 No.7 CME 387