Collection of Practical Guides for Wounds of the Servizo Galego de Saúde
Practical Guide for Burn Injuries. Practical Guide No 5
Collection of Practical Guides for Wounds of the Servizo Galego de Saúde Practical guide for burn injuries Practical Guide No. 5
Xunta de Galicia Consellería de Sanidad Servicio Gallego de Salud Dirección General de Asistencia Sanitaria 2016 Publisher: Xunta de Galicia Consellería de Sanidade Servizo Galego de Saúde Dirección Xeral de Asistencia Sanitaria Graphic design and layout: Versal Comunicación, S.L. Year: 2016
Licence: Creative Commons Attribution-ShareAlike 4.0 International Licence (CC BY-SA 4.0) http://creativecommons.org/licenses/by-sa/4.0/ 01 Collection of Practical Guides for Wounds of the SERVIZO GALEGO DE SAÚDE
— Nº 1 Pressure Ulcers — Nº 2 Ulcers of the Lower Limb — Nº 3 Diabetic Foot — Nº 4 Neoplastic Skin Lesions — Nº 5 Burn Injuries — Nº 6 Acute Surgical Wound — Nº 7 Moisture Associated Skin Damages — Nº 8 Trauma Wounds
Úlceras Fóra Programme. Servizo Galego de Saúde (Sergas), 2016
evidence toachieveanimprovementinthepatient’s qualityofcareandsafety. by ulcersandwounds,oratriskofsuffering them, in ordertoincorporatethebestavailable to patientsaffectedapproach practice inthecareandcomprehensive improve theirclinical Saúde, describestheeffort(doctors andnurses)to of manyprofessionals andenthusiasm That is why thisCollection of Practical Guides for Wounds from the in theclinicalvariabilityforthistypeoflesions. reduction ofcriteriaandacorresponding etc.) which allowustomovetowardsthestandardisation establish preventivemeasures,treatments, use of products, monitoring,registration, objectives proposedwastosetcommoncarecriteria(toidentifytherisk,assesslesions, strategic lines inthe approach of everything relatedto ulcers andwounds,oneof the basic Through the and systematisethecareactivityarisingfromthisprocess. to been working improve the structure, resources andconditionsrequired,to try to normalise have years we so forseveral treatment ofthistypelesions; and of theprevention management impact ofaproper and of theimportance there isanawareness Department, Integration Directorate for Care ManagementandOrganisational Sub- from theGeneral intensively more and (Sergas), de Saúde Galego Servizo From the professionals. also bytheworkloadandclinicalvariabilitythattheircarerepresentsforhealthcare carers, and and families to theimpactthatithasontheir in patients,due of life the lossofquality magnitude due to the extra financial cost it means for sustainability of the health system, due to of great a healthproblem to ulcersandwoundsimplies Everyone knowsthattheapproach PRESENT Úlceras Fóra Programme A TION the reference frameworkto develop and establish GeneralDirectoroftheHealth Innovation throughthe Servizo Galegodeaúde Assistance Department Servizo Galego de Jorge Aboal Health Care V iñas
7 PRACTICAL GUIDE FOR BURN INJURIES PREFACE
This Practice Guide was developed with the participation of health professionals in primary care and hospital care of the Servizo Galego de Saúde (Sergas) and reviewed by expert professionals and scientific institutions at national level, under the coordination of the General Sub-Directorate for Care Management and Organisational Innovation and Direction of Sanitary Assistance of Sergas.
The recommendations for clinical practice based on evidence that are included in this guide are of a general nature and therefore do not define a single course of conduct to be followed in a procedure or treatment for the integral care that is intended to be carried out. Any amendment or variation of the recommendations set forth herein, shall be based on clinical judgement (internal evidence) of the health care professional who applies them and the best clinical practices of the time; as well as the specific needs and preferences of each patient in particular; the resources available at the time of the sanitary attention and in the regulations established by the institution or health centre where they are intended to be applied. G UI D E FOR BURN INJURIE S P R AC TI CA L
8 AND IMPLEMENT and disseminationontheInternetthroughofficialwebsiteofSergas. SergasHealthcare in the institutions all public Network, the dissemination in of an official statement to the presentation media, its official disclosure in scientific the events Galicia, de Xunta The diffusionof de Sanidadethe processentailsaceremonialpresentationat the Consellería Innovation, ofSergas. Department, of the General Sub-Directorate Generalfor Care ManagementandOrganisational Management of the Úlceras Collection of Practical GuidesonWounds of Sergas, shallbeco-ordinatedthroughthe strategy ofthispracticalguide;aswellas,theentire andimplementation The dissemination DISSEMINA Fora Programme;that is to say, by theHealthCareIntegration TION A TION T echnical
9 PRACTICAL GUIDE FOR BURN INJURIES VALIDITY AND UPDATE
The guide should be reviewed after 3 years from the date of its publication. Its updating can be performed before the end of this period if any of the recommendations of evidence modify its categorisation which may lead to a clinical risk of safety for the patient and / or affect the quality of care. G UI D E FOR BURN INJURIE S P R AC TI CA L
10 INDEPENC OF technical managementandthecoordinatorsofworkinggroup. regarding the (Sergas) declarethatdecisionstakenbythe there iseditorialindependence of PracticalGuidesforWoundsThe editorsoftheCollection de Saúde of theServizo Galego expressed, whichincludesevidenceandrecommendations. and itsdevelopment. stage preparation the during influenced contents or been results not the change have could that they interest of that conflicts state by and date, to up and complete is herein contained to havemadeaneffortdeclare The authorsofthispracticalguide that theinformation toensure
DeclaraTION OFCONFLITS INTEREST ikewise, the authors of the guide assume responsibility for thecontent assume responsibility theauthorsof guide Likewise, AND EDITORIAL
11 PRACTICAL GUIDE FOR BURN INJURIES
ASSESSMENT AND CLASSIFICATION of THE EVIDENCE
The scientific evidence and recommendations set forth in this Practical Guide were the result of the assessment and analysis of the sources of information consulted as bibliographic reference (clinical practice guides, guides based on the best evidence, other documents based on evidence, systematic reviews and original articles); the critical reading method and consensus by nominal group between authors and panel of experts was used to prepare it.
The classification of the level of evidence and grading of the recommendations hasbeen maintained while respecting the original source consulted and the scale of evidence that has been used. The method that CENETEC (National Centre of Technological Excellence in Health) of Mexico in the development of their clinical practice guidelines (GPC) has been used for this: • Classify with the symbol [E] that evidence which is published in any GPC, followed by its alphanumeric classification (quality of the study, if it is referenced) and bibliographic citation. • Categorise with the symbol [R] those recommendations identified by any GPC, followed by their strength of recommendation (by A-B-C-D levels, in descending order according to clinical importance, or by their grading in high-moderate-low evidence). • Identify with the symbol [GP] those actions and / or activities considered as good practices, which are not referenced or supported by any GPC, but that appear in other documents based on the evidence (guides to good clinical practice, clinical pathways, protocols based on evidence, etc. ) and whose evidence has been obtained through systematic reviews, meta-analyses, clinical trials, etc.
The scales on the level of evidence and degree of recommendations that are described in the contents of this practical guide can be consulted through the bibliographic sources referenced in the summary table of recommendations / evidence. G UI D E FOR BURN INJURIE S P R AC TI CA L
12 PRACTICAL GUIDE FOR BURN INJURIES PRACTICAL GUIDE No 5
Collection of Practical Guides for Wounds of the Servizo Galego de Saúde
INDEX
01. LIST OF AUTHORS, COORDINATORS AND REVIEWERS | 16 |
02. INTRODUCTION | 18 | 2.1. Justification | 18 | 2.2. Scope and Objectives | 18 | 2.3. Questions to be Answered by this Practical Guide | 19 |
03. DEFINITION | 20 |
04. EPIDEMIOLOGY | 21 |
05. CLASSIFICATION | 22 | 5.1. According to depth | 22 | 5.2. According to aetiology | 25 | 5.3. According to extension | 25 |
06. ETIOPATHOGENESIS. PREDISPOSING FACTORS. DIAGNOSIS | 29 |
07. GENERAL GUIDELINES FOR TREATMENT. | 31 | EVIDENCE AND RECOMMENDATIONS 7.1. Pre-hospital care | 31 | 7.2. hospital care | 38 |
08. SPECIAL BURNS. TREATMENT CONSIDERATIONS | 46 | 8.1. electrical burns | 46 | 8.2. Chemical burns | 47 | 8.3. injuries due to contrast extravasation or cytostatic agents | 50 |
09. GENERAL PREVENTION GUIDELINES | 54 | evidenCE AND RECOMMENDATIONS
10. SUMMARY OF EVIDENCE RECOMMENDATIONS | 56 |
11. LITERATURE | 59 |
12. ANNEX | 62 | G UI D E FOR BURN INJURIE S P R AC TI CA L
15 01 LIST OF AUTHORS, COORDINATORS AND REVIEWERS
TECHNICAL MANAGEMENT
Úlceras Fóra Programme Health Care Integration Department. General Sub-Directorate for Care Management and Organisational Innovation. Directorate General of Health Care. Servizo Galego de Saúde (Sergas) [email protected]
WORKING GROUP
AUTHORS OF THE GUIDE María Pilar Casteleiro Roca Specialist Doctor in the Plastic Surgery, Reconstruction and Burns Department at the University Hospital Complex of A Coruña. Organisational Structure of Integrated Management of A Coruña. Javier Castro Prado Primary Care Nurse “Plaza de Ferrol” Outpatient Health Centre, Lugo. Organisational Structure of Inte-grated Management of Lugo, Cervo and Monforte de Lemos.
COORDINATORS OF THE COLLECTION OF GUIDES José María Rumbo Prieto Supervisor for Care, Research and Innovation. University Hospital Complex of Ferrol Organisational Structure of Integrated Management of Ferrol. Camilo Daniel Raña Lama Nurse Labañou Health Centre Organisational Structure of Integrated Management of A Coruña. María Blanca Cimadevila Álvarez Head of the Health Care Integration Department General Sub-Directorate for Care Management and Organisational Innovation. Directorate General of Health Care. Servizo Galego de Saúde (Sergas). Ana Isabel Calvo Pérez Technician of the Health Care Integration Department General Sub-Directorate for Care Management and Organisational Innovation. Directorate General of Health Care. Servizo Galego de Saúde (Sergas). Josefa Fernández Segade Technician of the Health Care Integration Department General Sub-Directorate for Care Management and Organisational Innovation. Directorate General of Health Care. Servizo Galego de Saúde (Sergas). G UI D E FOR BURN INJURIE S P R AC TI CA L
16 Servizo GalegodeSaúde;2016. de Saúde.SantiagoCompostela(A Coruña): Xunta de Galicia. Consellería de Sanidade. Fernández-Segade No 5]. M. P.,Casteleiro-Roca Castro-Prado HOW TO QUOTETHEDOCUMENT REVIEWERS Panel ofexperts Scientific InstitutionsandSocieties NacionaldeEnfermería • Asociación • Federación Gallega deCirugía Plástica,ReparadorayEstética(SGCPRE) • Sociedad EspañoladeHeridas(SEHER) • Sociedad Españolade • Asociación Gallega deHeridas (SGH) • Sociedad Outón Dosil • Carmen • Teresa SegoviaGómez PedroGarcíaFernández • Francisco ofTrainers• Group andGuidesinWounds fortheÚlcerasForáProgrammeofSergas • Grupo Oficial deEnfermeríaPontevedra • Colegio Oficial deEnfermeríaOurense • Colegio Oficial deEnfermería • Colegio Oficial deEnfermeríaLugo • Colegio deEnfermeríaGalicia • Academia EspañoladeMédicos GeneralesydeFamilia (SEMG) • Sociedad GallegadeMedicina FamiliaryComunitaria(AGAMFEC) • Asociación Crónicas (GNEAUPP) la IntegridadCutánea(ANEDIDIC) Management of A Coruña. niversity Nurse. University “Puerta deHierro”UniversityospitalMadrid. Nurse. In charge of the Multidisciplinary Nurse CoordinatoroftheCareStrategyUnitHospitalComplexJaén. (FAECAP) In: Rumbo-Prieto J. M., Nacional de ., editors. Collection of PracticalGuides forWoundsJ., editors. Collection oftheServizoGalego para Asociaciones ospital Complex of Hospital A Structure of Coruña Organisational el Raña-Lama C. D., M. Cimadevila-Álvarez Estudio EnfermeríaVascular yHeridas(AEEVH) J. PracticalGuideforBurnInjuries.[Practical de y A Asesoramiento Coruña Enfermería Dermatológica Unit for Pressure UlcersandChronicWounds. Comunitaria en e InvestigacióndelDeterioro Úlceras por y B., Calvo-Pérez A. Atención Presión y Integrated Primaria Heridas de I.,
17 PRACTICAL GUIDE FOR BURN INJURIES 18
PRACTICAL GUIDE FOR BURN INJURIES on themostcurrentevidence. practices availableforthecareofadultswithaburninjury;accordingtoclinicalpracticebased This guide is therefore meant as a synthesis of the best interventions and preventive or therapeutic service ofpatients. care levels. care and safety of patients that shall allow for greater efficiency of the process between the different recommendations ofpractice basedonevidenceand;toattainafewquality careindicatorsforthe economic resourcesavailable fromtheGalicianhealthandsocio-healthcare systembasedonthe health probleminsociety, aswellachievegreateroptimisation inthemanagementofhumanand variability oftreatmentsand professionaluncertainty, reduce theprevalenceandincidenceofthis burn injuriesposeasahealthproblem. which treatment, and referral detection, prevention, of actions specific perform factors, risk identify The aim of the Guide is to provide guidelines and/or standardised criteria to serve as a reference to care levelsintheCommunityofGalicia:PrimaryH ealth Care,HospitalCareandSocio-Care. with directorindirectresponsibilityfortheintegralapproach ofburninjuries,inanythethreehealth The scopeof 2.2. SCOPE for the Collection isalignedinlinewithstrategyNo.10(ImprovingClinicalPractice),oftheQualityPlan General Sub-DirectorateforCareManagementandOrganisationalInnovation.nturn,sucha strategies and lines of action promoted through the Úlceras Practical Guides of Wounds of the Servizo Galego de Saúde (Sergas); in accordance with the This clinical andpathology. same problemorpatientandeveninaprofessionalrelationtopatientswiththe techniques, tests,anddiagnosticskills,clinicaljudgementdecision-makingwhenfacingthe person who decides. causes aconsiderablevariabilityofdecisionsbasedonthetime,informationavailableand turn in which etc.) guides, protocols, evidence, scientific patient, the of preferences experience, into accountseveralalternativesfromavarietyofinformationsources(clinicaldata,professional healthcare professionals. to take on thepreventionandcaring), and also by the workload thattheircare represents for in life of quality of loss the to patients, dueto the impactthatithasontheirfamiliesandcarers (which in many cases have due systems, health the for means it cost financial extra the to The approachtochroniculcersandwoundsimpliesahealthproblemofgreatmagnitudedue 2.1. JUSTIFICATION 02 INTRODUCTION o. 5) is integrated into the Collection of Practical GuidetoBurnInjuries(PracticalNo.5)isintegratedintotheCollectionof National The Guideisaddressedtopeopleaffected, informalcarersandallhealthprofessionals Health System 2010, as well as, with Sergas Strategy 2014: Public health at the AND OBJECTIVES This gives rise to a great disparity in the performance of the professionals in herefore, the decision-making regarding its approach requires taking Therefore, thedecision-makingregardingitsapproachrequirestaking he aim is to contribute to the welfare of people, reduce the The aimistocontributethewelfareofpeople,reduce the ora Programme coordinated by the Fora Programme coordinated by the 2.3. QUESTIONSTO BE • • • • • • • • • • • professionals followtofacilitatetheircare? and carers informal patients, should education health and guidelines therapeutic What What treatmentrecommendationsarebest? What preventionrecommendationsarethemostindicated? What complicationscanoccur? What treatmentsand/ortherapeuticmeasuresaremostappropriate? What measuresmustbeimplementedforaproperhealing? How todiagnoseaburninjury? What arethemostfrequentlocations? What typearetheyandhowclassified? andpathogenesis? What istheirepidemiology howaretheydefined? What areburninjuriesand ANSWERED BY THISPRACTIAL GUIDE
19 PRACTICAL GUIDE FOR BURN INJURIES 20
PRACTICAL GUIDE FOR BURN INJURIES of dermalandsubdermalstructures. (caustic) and cold,chemicals from asimpleerythematothetotal destruction products; thatcausechangesranging biological current, electric radiation, objects, hot liquids, flames, agents: of differentto theaction tissues, due in living produced that are Burns arelesions physical 03 DEFINITION 1 04 EPIDMIOLOGY substances. InGaliciathistypeofinjuryinchildrenrepresents4.8%. of caustic accidents arecausedbyingestion inourcountry 5% ofhousehold For example, are oldageandinfancy.of burnsareproduced the greatestnumber The stagesofthelifewhere hot liquids(scalding),especiallybywaterandoil,followedsolids(iron,stove). by burns. Withindomesticburnsthemostfrequentarethoseproduced and chemical electrical by followed mechanisms, main the being flames and explosion with environment, work the in 10% and15% Between 60%and80%oftheburnsoccurindomesticspherebetween hospital care.Mortalitydataarearound200peopleayear, includingpatientsofallages. suffer individuals About 120,000 and only5%need each yearinSpain fromsometypeofburn 2, 3
21 PRACTICAL GUIDE FOR BURN INJURIES 22
PRACTICAL GUIDE FOR BURN INJURIES not synonymouswithseriousness. tissues affected,and othersubcutaneous of aburn. the degree itindicates 5.1. AG TOCCORDIN DEPTH 05 CLASSIFICA and intheinteriorofglandsfolliclestofacilitate re-epithelialisation. follicles. root ofthepilosebaceous dermis. Doesnotaffect thepapillary layers, reaching epidermic dermis orthe thereticular 5.1.2. 5.1.1. Epidermalburn(1 • Noexudate. • Hotanddryskin. • Nophlyctenae. • Erythema. • Tracción del pelo negativo. • Muyexudativa. rojo intensoorosado. color herida la de Lecho • • Flictenas. Figure 1 Superficial SIGNS SIGNS Dermal st :
degree) the depth of the lesion refers to the various layers of theskin layers refers tothevarious of thelesion the depth Burn stinging/burning. • Sensationofitching, • Hypersensitivity. • Pain:frommildtosevere. especially whenhandling. • Tend tobeverypainful, • Hyperaesthesia. TION slets of epithelial cells remain in the epidermal ridges in the epidermal remain cells Islets ofepithelial (2 : theinjurypartiallyaffects theepidermis. SYMPTOMS SYMPTOMS nd
degree Courtesy ofJosepPetit Photo 1. 4, 5,6 1stdegreeburn superficial) complications. • Withoutscar, except week. • Healinginlessthana temporary dyschromia. • Justleaveslight days. • Healing:between7to14 : the injury affects all PROGNOSIS PROGNOSIS he degree alone is alone The degree (Photo 2) . Courtesy ofJosepPetit Photo 1. 1stdegreeburn superficial sensitiveterminationsaredestroyed. follicles. andthepilosebaceous cellsthatarepartofthesweatglands epidermal viable reaching the reticular dermis.Doesnot affect the subcutaneous tissue. 5.1.3. DeepermalBurn(2 • Positivehairtraction. and exudative. red orwhite,smooth,shiny pale wound the of Surface • • There maybephlyctenae. Figure 3 Figure 2 SIGNS dermal lesions. than superficial examination • Lesspainfulon • Pain. SYMPTOMS nd degree) Courtesy ofJosepPetit Photo 2. Courtesy ofJosepPetit Photo 3. (Photo 3) 2nddegreesuperficialburn : theinjuryaffectslayers, allepidermic Deep2nddegree burn . and skinautograft. • Treatment: debridement surgery. within 15days,referfor If theydonotepithelialise • • Significantsequelae. 15 daysand3months. • Epithelialisationbetween PROGNOSIS There areonlysome The
23 PRACTICAL GUIDE FOR BURN INJURIES 24
PRACTICAL GUIDE FOR BURN INJURIES years It is very important to note that the assessment of burns in children, especially in children under four children. of seconddegree)andthetypicalwhitelesionsorparchmentthey arealmostneverseen. Figure 4 (Photo 4) periosteum). the skin,affects tissueandotherstructures(fascia,muscle,tendon,vessels, subdermal 5.1.4. Subdermal Burn(3rddegree) dark browntoblack. • Colour:frompearlywhite, burned tissue). • Eschar(mummificationof of age, Upon admission,third-degreeburnshaveinchildrenan intenseredcolor(forwhatcould seem differs . SIGNS The nerveendingsandthe annexed skinaredestroyed(follicles,glands,etc). significantly from Photo 5. that of adjacenttissues. planes andduetoirritation compression ofunderlying • Sometimespaindueto sensitivity. • Anaesthesia, without of Hairsign IMPORTANT adults. SYMPTOMS Photo 4. : complete destructionoftheentirethickness Thus, 3 rd superficial degreeburns appearance psychological damage. amputations, retractions), (keloids, dyschromia, • Importantsequelae treatment withautografts. • Mostrequiresurgical lesions. possible onlyinverysmall • Spontaneoushealingis PROGNOSIS burns are in deeper severe burnsshouldbetreatedinahospital. of the severity of a burn.On this shalldependthe referralto a specialistcentre.Moderateand 5.2. ACCORDING 5.3. during thefirstactions,inurgencyandemergency. ACCORDING the totalbodysurfaceareathatisburned(TBSA)orbymultiplesof9. in apatient. extension vasoconstriction and solidification of water from inside the cells, which produces tissue which cells, necrosis. The injuriesmainlyaffect acralareas(fingers,earsandnose). the inside from water of solidification and vasoconstriction specialist centre. substance andits concentration andthe time of contact. that alters thepHoftissues. proportional totheamountofwateritcontains. the tissues. passing through when heat generated 5.3.1. Wallace ruleof nines 5.2.6. Burnsdue to cold 5.2.5 Radioactiveburns: 5.2.4. Chemical Burns 5.2.3. Burns due to 5.2.2. 5.2.1. Thermalburns flash. Itstreatmentdiffers fromtheburnproducedbyelectriccurrent. radiation, etc. such as radiation solar radiation, ultraviolet,laser,and non-ionizing microwave, infrared • High • Low ofRiskcardiacarrest. tissues. voltage(<1.000V),produceslittledestruction • • • • Cardiac monitoringshouldbeperformedandreferraltoaburnunit. syndrome. andcompartmental arrest, alterationofrhythm,fractures,rhabdomyolysis bones. to thepathoflong structuresclose in theinternal surface. another with of theskin friction by thesudden is caused Due tofriction:theburn ishotsolids. Contact: themechanism burns. dirtier are They fire. a of flames the with contact direct to due produced are Flames: Scalds: duetohotliquids. Tend butextensive. tobeclean,superficial, Electrical Burns voltage TO TO (>1.000 THE THE AETIOLOGY Electrical Flash his involves dividing the body surface in areas equivalent to 9%of the bodysurfaceinareasequivalent dividing This involves : producedbytheactionofheat. : produced by acidic or base substances and corrosive substances EXTENSION : theyareproducedbythedirectactionofanelectriccurrentor V), presentsgreattissuedestructionatthecontactpointsand : the effect of theextremecoldontissuesproduces produced by ionizing radiation (X-rays, gamma rays, etc). (X-rays, gamma radiation by ionizing produced : this isamethodthat is usedtocalculatetheburnedskin The severityof the burnwilldependon natureof the : this is the first thing to consider in the assessment : a shortcircuitisusuallyproducedbecauseofthe : the aetiology of the burn is especially important is especially of theburn : theaetiology T end to be limited anddeep. end tobelimited They canbe: he resistance of eachtissueisinversely The resistance They should allbereferredto a They cancausecardiac
25 PRACTICAL GUIDE FOR BURN INJURIES 26
PRACTICAL GUIDE FOR BURN INJURIES calculate the% 5.3.3. Land&BrowderT 5.3.2. Ruleofone(PalmtheHand) limbs muchsmaller. differentmuch biggerandthe their growth,withheadbeing anatomicareasduring of thepatient. of TBSA 1% is way this in covered be can that surface the extended), and together (fingers This isusefulforsmallareasandasacomplementarytooltotheWallace rule. TBSA that isburned. Source: https://es.wikipedia.org/wiki/Quemadura Figure 5. Photo 6.Ruleofone. Wallace rule able : in children the proportions of the% the proportions : inchildren The palm ofthepatient’s handis taken asareference RuleofPalmtheHand : this is a rapid assessment tool to this isarapidassessmenttoolto : TBSA varyinthe T able 1.Land&BrowT T Genitals Left foot Right foot Left leg Right leg left thigh right thigh Left hand Right hand Left forearm Right forearm Left arm Right arm Buttocks rear trunk Anterior trunk Neck Head otal urned area burned the lowerlimbsis27%plusage. percentage extensionof the head inchildrenunder10yearoldis 18% lessageandthat of In a morepracticalwayof assessing a burn extensioninchildrenit is assumedthat the CHUAC’s own compilation Figure 6. Percentageextensionofthe head able years 0 to 1 100 % 3,5 % 3,5 % 5,5 % 5,5 % 2,5 % 2,5 % 13 % 13 % 19 % 1 % 5 % 5 % 3 % 3 % 4 % 4 % 5 % 2 % years 1 TO 5 100 % 3,5 % 3,5 % 6,5 % 6,5 % 2,5 % 2,5 % (Figure 6). 13 % 13 % 17 % 1 % 5 % 5 % 3 % 3 % 4 % 4 % 5 % 2 % years 5 TO 9 100 % 3,5 % 3,5 % 5,5 % 5,5 % 2,5 % 2,5 % 13 % 13 % 13 % 1 % 8 % 8 % 3 % 3 % 4 % 4 % 5 % 2 % 9 TO 14 years 100 % 3,5 % 3,5 % 8,5 % 8,5 % 2,5 % 2,5 % 13 % 13 % 11 % 11 1 % 6 % 6 % 3 % 3 % 4 % 4 % 5 % 2 % ADULTS 100 % 3,5 % 3,5 % 9,5 % 9,5 % 2,5 % 2,5 % 13 % 13 % 2 % 7 % 1 % 7 % 7 % 3 % 3 % 4 % 4 % 5 %
27 PRACTICAL GUIDE FOR BURN INJURIES 28
PRACTICAL GUIDE FOR BURN INJURIES 5.3.4. Serious burn Uncompliated moderate burn Minor burn • Burnsinpeopleathighrisk:diabetes,lungdisease,cardiovascular • Burnsinpregnantwomen • Burnswithtrauma • All inhalationlesions • Chemicalburnsinriskareas • Electricalburns • Burnsaffecting eyes,ears, face,feet,perineumandjoints • Third-degree burnsgreaterthanorequalto10%of TBSA • Second-degreeburnsof25% TBSA inadultsor20%children with patients and injuries concurrent inhalation, to due lesions, electrical Excludes • • TBSAin of 20% to 10% or adults TBSAin of 25% to 15% of burn Second-degree • with patients and injuries concurrent inhalation, to due lesions, electrical Excludes • • Third degree burn less than 2% of TBSA without affecting special areas (eyes, ears, TBSAof 10% than less or adults TBSAin of 15% than less burn, Second-degree •
Classification compromising, cancer, AIDS, etc. high risk special of attention areas affect not does that TBSA of 10% than less burn degree Third children high risk face, feet,perineumandjoints) in children Classification ofburnsextension of an Burn Association)(American the Extension of the American Burn Association, , immuno- adapted conductance of thetissue. conductance and of exposure, are theintensityofheat,duration the lesion The factorsthatdetermine 6.1. ETIOP f 06 A the capillaryintegrity, butitisalsoduetothefactors: oedema. But the largeoedemathat occurs dueto the burnsisnotonlydueto the loss of formation of compartment towardtheinterstice,withconsequent from theintravascular fluid of extravasation the causes which integrity, capillary of loss produces turn in which after the first few days post-burn. This is due to the alteration of the mechanical barrier of barrier mechanical the of alteration the to due is This post-burn. days few first the after with neutrophilia)andplatelets (thrombocytopeniaandthrombocytosis). 6.1.7. 6.1.6. 6.1.5. 6.1.4. META6.1.3. BOLIC 6.1.2. 6.1.1. SKINLESION irritants (smoke)orthedirectburn. trachea, bronchiandlungparenchyma)dueto the effects of constriction andoedemaof failure. is respiratory after theburn tract canbeaffectedof therespiratory All levels (larynx, hours or days (due to flow deficit), and renal type from the second week (usually due to sepsis, nephrotoxicity, due etc). (usually week second the from type renal and deficit), flow first to the (due days in or type hours prerenal a is Diuresis patient. burned the in failure renal acute of cause in the body that produce significant increase of metabolic expenditure and increase of andincrease expenditure of metabolic nutritional requirements. increase significant produce that body the in permeability andvasodilation. of heat,redness,pain,functionalimpotenceandoedema. • • • • increase intheperipheralvascularresistance-andadecreasedcardiacoutput. Haemodynamic instability: due to notable and early reduction of plasma volume and an sodium fromtheplasmacompartment,whichgenerateshyponatremia. of extravasation the to due Mainly tissue: burned the in pressure osmotic of Increase Change ofthecellularmembrane. the systemichypovolemiadelaysextravasationoffluid. injury,burns thisoccurslater, inthecaseoflarge between18and 24hours,because formed inasmallburnreachesitsmaximumlevelbetween8and12hoursafterthe from theplasmatowardsintersticeandalsoofproteins.Generally, theoedema Alteration in the integrity of the microcirculation: as a result of the extravasation of fluid IMMUNOLO GICAL HAEMATOLOGICAL RENAL HAEMODYNAIC ALTERATIONS RESPIRATOR THOGENESIS. PREDSPOIN ACTORS. DIAGNOS ATHOGENESIS ALTERATIONS he burn produces the following produces The burn ALTERATIONS : Y ALTERATIONS the burn produces inflammation, which manifests itself in the form the in itself manifests which inflammation, produces burn the ALTERATIONS ALTERATIONS :
the burn produces hypo-renal perfusion, being the main being perfusion, hypo-renal produces the burn : the burn produces a series of hormonal changes : the burnproducesaseriesofhormonal : the first cause of death in the first fewdays first the in of death cause first the : : infection remains the leading cause of death cause the leading remains : infection : the burn producesa loss of skin integrity, : alterationofthewhiteseries (leucocytosis physiopathological mechanisms There isanincreaseofvascular
:
29 PRACTICAL GUIDE FOR BURN INJURIES 30
PRACTICAL GUIDE FOR BURN INJURIES clinical historyshouldincludethefollowingdata: clinical. It is fundamentally 6.3. DIAGNOSIS the basalmetabolism,sothattheirheatproductionisless. system. With regardstotheelderly,having animmaturethermoregulation there isadecreasein is easier andquicker, in additionto not having defence mechanisms to slow downthe cold by of heat),sothatthelossheat surface area(lossofheat)andtotalbodymass(production In the caseof children, theyoungertheyareinage,greaterproportionbetweenbody It should beborneinmind that there arespecialpopulations,suchaschildrenandtheelderly. 6.2. PREDISOSINGFACTORS • • • • • • • • body’s defencesystems(humoralandcellular). of the and alteration the lossofprotein, the humanbody(skinandmucousmembranes), First aidreceived. Place wheretheaccidentoccurred. Anatomic locationoftheburn. Degree oftheburns. Percentage of TBSA (Ruleofthe9orpalmhand 1%). Causal agent. Date andtimeoftheburn. Personal medicalhistory. he correct initial assessment ofaburnisveryimportant. The correctinitial A proper 7.1.2. URGENT circulatory function,airwayandrespiratoryfunction(seeCPRalgorithm). the to CABin changed been American resuscitation of theso-called intheimplementation is standardised this has ABC (since2013 the lifeofpatient. that couldcompromise discard theproblems and is toidentify thing first injury.the of So type another have may that accident an of result a is burn the sometimes trauma patient.Giventhat as apotentialmultiple All burnedpatientmustbeconsidered 7.1.1. URGENT or arechildrenundertheageof15yearsolderadultsover60old. development clinical can bereferrediftheyareassociatedwithacomplex environment) hospital the we cantreatoutside (which burns referred. Minor are generally burns severe and All moderate reference. transfer totheBurnsUnitof their until the hospital or in transport of theaccident,during place of interventions outside the hospital to ensure properattentionof the burned patientat the patient isthespeedinstartingsuitabletreatment. burned the of mortality and morbidity of reduction the in influence most that factors the of One 7.1. PRE-HOSITAL for 07 GENERAL
• • • • • • • • • • except inburns withachemicalaetiology. centre), health (hospital, place appropriate an reaching until phlyctenae the debride Not clean water. or solution saline with soaked towels or gauze dressings, gel water with injury the Cover Use non-conductivematerial. patient. the touching before current this disconnect current, electrical to due victim a is it If If itisaburnduetochemicalagentcontinuewith irrigationuntilreachingthehospitalcentre. (this wouldbeideal). Avoid possiblehypothermia. Cooling of the burns with whatever is at hand, water, saline solution or water gel dressings Assessment oftheburns.EstimateBSA (ruleof9,rule1). Remove clothing,rings,watches,belts. ambulance, etc). from the place of the event and in a safe place with clean possible air.as away If necessary far request as help area (fire, safe a in place and rescue their ensure victims, the Identify Detain thecombustionprocess. account. into taken be must rescuer the to danger potential precautions. The universal take Always AND RECOMMENDA PREHOSPIT PREHOSPIT TREA CARE GUIDELINES TMENT (4, 5) AL AL Heart cardio adequate an ensuring guides); Association CLINICAL TREA TMENT That iswhyitnecessarytosetupaprotocol EVIDENC
TREA TIONS CONSIDERA TMENT (annex 1). TIONS (3, 4,5,6) This
31 PRACTICAL GUIDE FOR BURN INJURIES 32
PRACTICAL GUIDE FOR BURN INJURIES 7.1.3. LOCAL from the bacterial flora itself present in the skin appendages. If it is not debrided and the and debrided not is it If appendages. skin the in present itself flora bacterial the from contaminated they can become mustalwaysbedebrided because The phlyctenae washing theareamustbe driedwithoutrubbingtopreventdamagethe viabletissues. betaineto at0.1%)indicated. plus undecilenamidopropil Always atroomtemperature. After 0.1% solution 1 or2%,polyhexanide (chlorhexidine water orabroadspectrum antiseptic with soapand risk ofinfection(majorburns),iscleaning dirt orhigh where thereisvisible between washingtheburnwithpotablewater,serum. Only water withsoaporphysiological Regarding 2 • 1 • dehydration producedbytheburn. Apply several timesadaytoavoidskindryness. The hydration of the skin using creams, oils or gels, is the best way to recover the skin’s pain quickly, donotadhereand alsopreventhypothermia,duetotheirdivingsuiteffect. are thebestoptioninburnsofthermalorigin,unlikerestdressingstheycalm area orbyplacingasoakedcleangauzeclothsovertheaffected area.Water geldressings should beused(ambienttemperature). deepening ofthelesion,aswellanincreasedriskhypothermia. A temperatureof18-20º The use of cold water or saline solution produces vasoconstriction and accelerates the mediators. heat action, dilute and drag the chemicals), relieve pain; decrease the release of inflammatory The objectives of cooling are: to neutralise the action of the causal agent (slow down the 3 Do notapplyverycoldwater. If anantisepticisnecessary, usechlorhexidinedigluconate. If anantisepticisnecessary, usechlorhexidinedigluconate. Dry thelesionwithoutrubbingarea. Do notuseverycoldwater. Rinse withpotablewaterorsalinesolution. Protection fromthesunduring15-30days. Moisturise theskin. ST RD ND DEGREE(SUBDERMAL): DEGREESUPERFICIAL-DEE (DERMAL)and DEGREE (EPIDERMAL): CARE OFTHEWOUNDS , current evidence indicates that there are no significant differences significant no are there that indicates evidence current cleaning,
TREA CARE 8, 9 TMENT OF 7 WOUNDS THE 7 OFBURNS The areashouldbeirrigatedorimmersetheaffected 5 11 Low. Low. Low. 10 (4, 5) EVIDENCE LEVEL 5, 12,13 5, 14 Low. Moderate. Low. Low. Moderate. EVIDENCE LEVEL There isnosingleorspecificproduct,butitshalldependonseveralfactors: sulphadiazine at1%,maybeagoodoption. such assilver of ointments the application material), of thearea,lacksuitable (orography (MHE). However,environment of amoisthealing with dressings covering incertaincircumstances, of infectionwhen lower costandaincidence Recent studiesshowabetterevolution, PREHOSPIT 7.1.4. necessary toapplytopicalantimicrobials. In second-degreeburnswithoutriskofinfectionit isnot exudate insuperficial burns. Hydrocolloid dressingsare suitableforthemanagementof Use dressingswithlowand adaptableadherence. over another. ontheeffectivenessThere isnotenoughevidence of a dressing • • • • • shall beproperlyassessedandwillcoveredwiththebestdressingforthatmoment. Once thecleaninganddebridementof the denaturedtissuehasbeencompleted,burn Burns shouldnotberubbedorbrushedbecause: it isnecessarytousesurgicalmaterial,sincetheepidermismuchthicker. of thefeet, soles and of thehands it breaks.Onthepalms towards theedgeuntil epidermis bed. wound to actinthe not beable route, theywill via topical antimicrobials applying when epidermis, the burn cancontinueto deepen. If we leavethe phlyctenae andwedonot debride the dead and bed wound the on pressure exert can phlyctena the in is that fluid the hand, other the epidermis isnotremoved,acorrectassessmentoftheburncannotbemade.On denatured that exertamoredurableandeffective effect thanusualointments. cadexomer,with iodized attraction, dressings intra molecular etc. silver, silvernanocrystalline. with ionic dressings with riskpatients,wehave exudate, etc),orwearedealing purulent smell, cellulite, (bad or infection colonisation of critical or signs If thereisariskofinfection • Availability ofmaterial. Non-traumatic whenremoved. Easy toadapt. Evolutionary stageoftheburn. Amount ofexudatefromtheburn. Characteristics oftheburn(extension,depth,ethology, location). • • h val eihla cls r dsryd hc ae on t b o hl fr faster a for help of be to reepithelialisation andforbetteraestheticquality. going are which destroyed are cells epithelial viable The andgermsarespread. isproduced, Pain, bleeding 11 T o debride the phlyctenae we can do this with tweezers and pull the devitalised pull and we candothiswithtweezers the phlyctenae o debride RECOMMENDATIONS AL TOPICAL 13, 18 ther dressings available havehoney,available Other dressings by on adsorption based TREA 15 TMENT 17 (4, 5) Moderate. Moderate. High. Moderate. These areoftendressings EVIDENCE LEVEL
33 PRACTICAL GUIDE FOR BURN INJURIES 34
PRACTICAL GUIDE FOR BURN INJURIES deep burns.Ithasthecapacityofpenetrationineschar. Adverse effects areveryscarce. be effective forupto24h, althoughitisrecommendedtochangeevery12hoursinextensive healing; agenerouslayerofthepreparationsilversulphadiazinecreamwithceriumnitratecan sulphadiazine eliminatestheresistors.Itsactivityisshortinexposedhealing,occlusive being afungicideagainstCandida.Resistorscanbeseen. action ofsulphonamidesandsilver. Itiseffective againstgrampositiveandnegative, SIL either hydrocellularorhydrocolloid,ahydrogelsheet,shallgivegoodcoverage. to cover superficial burns in the most exudative stage (2-5 days). Afterwards a thinner dressing, coverage adequate bed provides with thewound adhesion andlittleaggressive with selective to beusedindeepburns. are notrecommended dressings Hydrocolloid Adressing hydrocellular 7.1.5. OTHERPREHOSPIT create resistance. and can thatitimprovestheprognosis burn (eveninelectrical),giventhatthereisnoevidence The useofSYSTEMIC ANTIBIOTHERAPY aspreventionisNOT frequency ofdressings. a lower and requiring in children,sincetheyoftencooperateverylittle,duetoconvenience toxicity,spectrum action,low safe, ithasabroad rare. Itisoftenused are andhypersensitivities load oftheinjury.Silver dressingsareanoptioninthetreatmentofbacterial Silverisquite Do notusesystemicantibioticspreventivelyinminorburns. the dressings. Silver dressings,comparedwithsulphadiazine,reducepainin average hospitalstay. Silver dressingscanhelpreducetheneedforand cerium nitrate. In third-degreeburnssulphadiazineshouldbeappliedwith burns, issilversulphadiazine. The topicalantibioticoffirstchoiceinsecond-andthird-degree epithelialised skin. Dressings withsiliconeprotecttheperilesionaland Use sunscreenproducts. hydrocolloid ones. Hydrocellular dressingshavehigherabsorptioncapacitythat Moisturise theskin. VER SULPHADIAZINEisthemostusedtopicalagentinburnsunits.tcombines 27 13, 21,22,23 19 20 5, 8,9,29 16 SKIN CARE 5, 8,9,29 10, 21,22 AL CARE The additionofceriumnitrateto 28 Moderate. Moderate. recommended in anytypeof recommended Very low. Moderate. Moderate. Moderate. Moderate. Moderate. Low. EVIDENCE LEVEL 3 Chlorhexidine is the antimicrobial of choice to prevent infection in the oral cavity.in theoral to preventinfection of choice is theantimicrobial Chlorhexidine ophthalmology. it mustbereferredto or otherpathology If theeyepresentstoomuchpain,exudate,ulceration should beavoided. protected fromthesunforayearandhalfhealing. radiation. ultraviolet all filter can that product protection sun no The producttoapplyshouldbeeffectivetype againstultravioletradiation A andB. areas toavoiddyschromia. epithelialised in already The useofsunscreenproductsisrequired high or very high protection. high orveryprotection. A protectionfactorof50isrecommended. barrier productsformafilminthemucosabyrelievingpainstatesofinflammation. to besufficient. paracetamol and/orNSAIDSevery8hoursor4andalternatingmedicationstend of pain. in themanagement level national at consensus no is There painful. most the usually are burns dermal Superficial at differentand at thebeginning can besevere The pain process. the healing during levels the mucosa. Use barrierproductsofthemucosaandprotectiveagents A glucose intakeisrecommended. Enteral nutritionshouldbe administeredearly. The preferentialuseofenteral nutritionisrecommended. Burned patientswillreceiveahighproteinintake. 200% oftheestimatedenergyexpenditure. not exceed intake does that thecaloric It isrecommended Use chlorhexidine0.12%asantiseptic. Clean eyesseveraltimesaday. until healed. continuously and individually the stateofnutrition Evaluate 35, 36 34 31 NUTRITIONAL MOUTH CARE EY CARE ts management will depend on theteamresponsible. depend will Its management 22 CARE 36, 37 P AIN MANAGEENT 32, 33,34 36 38, 39 36 36, 37,38 T imes whenthesunismostpowerful Very low. Moderate. Very low. High. Moderate. High. High. High. High. 29
Ideal productsarethose of EVIDENCE LEVEL EVIDENCE LEVEL EVIDENCE LEVEL 30 Injuredareasmustbe 33 In general Mucosal There is
35 PRACTICAL GUIDE FOR BURN INJURIES 36
PRACTICAL GUIDE FOR BURN INJURIES neoglucogenesis andcurbtheproteincatabolism,preservingpartofleanmusclemass. the intensityof support maydecrease in thenutritional The glucoseadministered cannot eat,bymouth,75%ofthecaloricandproteinneeds,shouldbeadministeredfeedingtube. About 20%to25%ofthecaloricintakeshouldbeprovidedinformprotein.Inpatientswho demands ofthepatient,affect thebodycompositionandcauseseriousnutritionaldisorders. trigger Systemic Inflammatory Response Syndrome. These events cause an increase in metabolic microcirculation of these structures, causes immunosuppression and organic insufficiency, and can underlying tissuesandevenorgansfarawayfromtheprimaryinjury;itaffects thenutrient Thermal aggressionaltersthehistology, physiology, biochemistryandimmunologyoftheskin, their useinburnsbyfamilies: In ourcommunitywehave acataloguewith32varietiesofMHEdressingswearegoing tosee 7.1.6.1. Moisthealin g environmentdressins(MHE) to CAREFORBURNS This canmainlydivided in: 7.1.6. RECOMMENDEMA capillaries intheformationprocess(neoangiogenesis). is theincreaseofoedemabygravitydripandorthostaticpressurebloodin In thecaseofburns,walkingtoactivatecirculatedisnotsuitable.Herewhatharmful In theinitialstage,burnedareamustberestedandraised. Check thestatusoftetanusimmunisation. (pressotherapy) andsiliconemasks,whicharemade tomeasure. When hypertrophicanddisablingscarsremain,elasticgarmentscanbeapplied starting towalk,avoidthevascularstasisinscarringarea. When itaffects thelowerlimbs,compressionbandages orstockingsshouldbewornwhen kept inhyperextension. If theinjuryaffects joints,inthesynthesisstage(3-5days), thelimbconcernedshouldbe deepening oftheinjury. Cotton edgedbandagesshrinkwithmoistureandputpressureonthelesion,causing The idealiselastictubularmesh. Elastic orcohesivebandageswillbeusedtoallowtheexpansionofphysiologicaloedema. Low Evidence Fingers mustbedressedindividually, toavoidtheadhesionbetweenthem. . 4, 5 3, 5 CARE OFTHEBANDAGES 3, 5 TERIAL OTHER CARE
5 4, 5 4, 5 3, 22 36 37 39 Sunscreen products : toprotectepithelialized areasandavoid discolorations. itching. Moisturizers: moisturizing productswillserveto restore andmaintaintheskin,to prevent enhance itsaction. Collagenase: removes devitalizedtissue. If there’s no exudate, hydrogel must be providedto the slough.Curesevery 24hours Silver sulfadiazine with burns.Ceriumallows agreatinsightinto cerium nitrate: third-degree dressing shouldbeevery12hours. every 8or12hours.Withocclusive cure apply it. Inexpository of theburnrequires orography Silver sulfadiazine:burns, in secondandthird degree whentherearenoothermaterialsorthe 7.1.6.2. Ointments and creams PRODUCT modula met Ma Algina Hydrogels Pol Hydrocolloids with hydrofibre Hydrocolloids Antimicrobial Interf With ionicharge trix alloproteinases yurethanes tes ace mshe
tors (MMP)
Stimulate healing. CHARATERISTIS Recovers thehealingactivity. MMP. Modulates theactionof Haemostatic. High absorptioncapacity autolytic debridement. Improves enzymaticand Water content. adherence. The siliconeonesarelow- and non-adhesives. Semi-permeable adhesives retention. Exudate absorptionand Absorbent gelformers. Gel former. High absorptioncapacity. releasing. Silver releasingandnon- Wide spectrumbactericides. newly formedtissue. Protect thewoundbedand They arehydrophobic. Bioactive withZn + , Mn + andCa + . epithelialisation stage. Lesions inthegranulationand INDICATIONS significant delayinhealing. and infectedtissue,presenta Burns thatarefreeofnecrotic Requires secondaryfastening. burns. Very exudative2nddegree In A&A itcoolsandrelievespain. granulation tissue. apply onlesionswithgood already epithelialisedtissue, The siliconeonesrespectthe 2nd degreeburns. stages ofepithelialisation. The superfineisidealinfinal 2nd degreesuperficialburns. dressing. Requires anotherretaining Exudative 2nddegreeburns. signs ofinfection. 2nd degreeburnswithriskor tissue. Deeper burnswithgranulation gauze thisissufficient Sometimes withameshand Superficial burns.
37 PRACTICAL GUIDE FOR BURN INJURIES 38
PRACTICAL GUIDE FOR BURN INJURIES life, applyingtheso-calledresuscitation ABC: injury. So the first thing is to identify and discard the problems that could compromise the patient’s type of trauma patient,takingintoaccountthattheremaybeanother a multiple is potentially As has already been specified throughout this subject, we must consider that any burned patient 7.2.1. Urgent Hospit 7.2. HOSPITAL Antiseptics • • • • intubationmust an orotracheal becarriedout when thereis suspicion of upper • Airway: resuscitation are: Resuscitation/P intravascular spacetowardtheinterstitialspace. as “shockbyburn”. affectingCirculation: theburns >20%BSAknown changes producecardiovascular Spinal cord injury: at between50%-100%.Inallothercasesadministeroxygen28%-35%. oxygen at 35%. If there was exposure to gases and smoke, administer humidified oxygen, Respiratory function hoarseness andstridor. mucosa, productivecoughing, of nasalwhiskers,burnsonthelipsorinoropharynx effectthermal local andbyoedema. burns. extensive with patients or in obstruction airway the oralcavity. in severeburns.Moreover,burns, even infection of in burns of choice itistheantiseptic side effectsskin absorption.It is usedindirtyoratriskof arerareduetotheirnegligible active againstgram+, gram -andspores.Its activity israpidandhasalastingaction.Its Chlorhexidine • • • • • • • replenishment ofthedailylossfluids thatoccursthroughth e burn. between 24 and 48hoursafterthe burn. We cannot forget,fromthatmoment, the occurs usually which ceases, formation oedema the when ends resuscitation The suitable foruseinresuscitation, aslongtheyareprovidedintheright amount. In general the fluids that contain salt at least in isotonic quantities with the plasma are glycogen depositsarevery scarceandrequireanextracontributionofcarbohydrates. their totalexcessiveandharmfulcontribution. An exceptionissmallchildren,whose Avoid solutions containing dextrose the in adults and towards older children, this since that would of imply passage burned tissueandtheintracellularspace. the by produced losses, plasma sodium Replenish of theorgans(thefluidaccentuatesoedema). perfusion adequate maintain to necessary volume fluid of amount least the Provide the healthy tissue. in extent, lesser a to and, tissue burned the in seized fluid of loss the Restore Maintain the perfusion of vital organs and prevent the development of multiple organ failure. CARE : the antiseptic of choice because of its broad antimicrobial spectrum, being antimicrobial of itsbroad because of choice : theantiseptic ACU: tries to avoid the shock by burn. In general, the objectives of
cervical and back immobilisation until the non-existence of injury is proven. heir initial pathophysiology is duetothelossofplasmafrom pathophysiology Their initial : saturation>98%mustbeensured.Inextensiveburnsadminister al ClinicCare he signs that indicate thermal injury are theburning that indicatethermalinjury The signs he upper airway is affectedairway The upper bythe • prophylaxis:dependingonthepatient’s• Anti-tetanus historyofimmunisation. • • • • necessary to putinanasogastrictube (seenutritionalcare). staff.by specialist assessed until absolute be always Diet: should it is occasions Onmany are opioids(morphine). the mostcommonlyusedmedications route. Ingeneral or subcutaneous intramuscular Pain Control: intravenous must be usedpreferably, avoiding administrationusingan history, basal lifeandthecharacteristicsofthermaltraumathattheyhavesuffered. system, in addition to identifying associated trauma, researching the patient’s previous clinical Secondary Assessment the GlasgowOutcomeScaleandthroughpupilassessment. Neurological function require initialmonitoringof: Physiological: hospitaladmission in generalburnedpatientsrequiring measurements • • • • • • • • • •
Body temperature-tryingtomaintainanormaltemperature. monitoring. Electrocardiography ofinputsandoutputsliquids. Proper balance flow isareflectionofsystemicperfusionduringtheearlystageburn. blood renal the - ml/kg/h 0.5 Objective - diuresis hourly with catheterisation Urinary Heart rate (the presence of tachycardia > 130 bpm usually indicates need of fluids). pressure-tryMAPBlood (meanarterialpressure)of70mmHg. oximeter. usingpulse Oxygenation gases arethearterialroutemustbeattemptedbyinsertingthroughhealthyskin. because thelimbswerebeburned,oriffrequentextractionsarerequiredforblood if itisnotpossibletoobtainbloodpressuremeasurementsusingasphygmomanometer worst option a central vein in burned area. area, followedbycentralveininanon-burnedperipheralburnedareaoras TypeVascularof non-burned the in vein peripheral a be should option first the Access, smoke inhalation,delayintheresuscitationorhypovolemia). adjusted subsequently in the light of the diuresis (needs can be higher in the case of in the half theother and 8 hours, following 16 hours. first the in administered be should half - hours 24 first the in BSA % / kg / ml 4 = RL infusion: fluid the start to used is FORMULA burn iselectric)and1ml/kg/hinchildren(forunder30kg). when it reaches a minimum of 0.5-1 ml/kg/h in adults (more than 1 ml/kg/h if the acceptable considered is which diuresis, the is organs of perfusion the reflects best adequate perfusionoftheorgansmustbegiven. Calculation of the amount of fluid, the least amount of fluid volume required to maintain routine basis.Colloidsarenoteffective inthefirst8hoursafterburn. incidence ofacuterenalfailureandtohighermortalityshouldnotbeusedona children). Fluidslikehypertonicsalinesolutionhavebeenassociatedwithincreased to bicarbonateintheliver. Formulaswithglucoseshouldbeavoided(exceptinyoung similar to that of extracellular fluid, and lactate is a source base due to its conversion is composition LACTATE, its RINGER because is fluid replenishing used most The : assessment and reassessment of the level of awareness using of awareness reassessment ofthelevel and assessment : This calculated volume is only indicative to start the infusion, a physicalexaminationshallbecarriedoutusing system-by- f the patient is haemodynamically unstable, or If the patient is haemodynamically unstable, or he non-invasive parameter that The non-invasiveparameterthat The PA RKLAND
39 PRACTICAL GUIDE FOR BURN INJURIES 40
PRACTICAL GUIDE FOR BURN INJURIES manner, withburnsonthefaceandperineumbeing anexception. patients’In general must becarriedoutinanocclusive admission hospital thatrequire dressings conditions. then the patientmustbesedated. required sterile out under be carried should All burndressings started to remove remainsof cream, detritusandnon-viabletissues.If is a strongerdebridement together with serial debridement of the burns. As for the first time, the washing of the lesion butIn the successive dressingof the burned patientwashesof the same type shall becarriedout be dressing iscompleted,whichmaybeocclusiveorexpositorydependingonthetypeofinjury. orsterilewater,solution saline and the remains aredebrided and epithelial thephlyctenae affectedwashing the surfacesarerinsedwith soap. Subsequently surfaceswithmildantiseptic subsequently used), be can water 0cold BSA 10% than less extension of burns superficial (in water by drag-outwithlukewarm bathtub,carryingoutwashing is performedinanappropriate The first care of the burns consists in washing the patient. If patient conditions permit the dressing rgent Hospital7.2.2. U Treatment ofBurns The mainagentsusedare: of theburn. andthelocalconditions on thetypeofpreparation of thedressingsvariesdepending the burn. of on thecondition depending action isperformed for local of acertainpreparation The choice are applieddirectlyontheskin. than theuseofantiseptics. in theepithelialisation practice. The rationale of this practice is, in isnot trying to agents avoid infections that cause a chemotherapeutic significant delay oftopical use necessary, in caseofburnsthat require hospitaladmission,theuseofantisepticsisusual the burns superficial of case the in Although • • • • • Complementary tests in burns. Their use is restricted to superficial burns to control the inflammatory phenomena used creamsareoneofthe fewtopicalnonantiseptic preparations Corticoids: corticosteroid cutaneous produce can inhibition; hypersensitivity andhyperthyroidism. fibroblastic to due delayed be can Healing eschar. in the gram andspores, fungi,viruses,cystsandprotozoa.Poorpenetration negative Povidone iodine: the germicide action of iodine is important andincludespositive effects arescarceduetothevirtuallyzeroabsorptionthroughskin. of gram, inhibitsgerminationthespores,rapid action andsustainableactivity. Adverse Chlorhexidine: effectivebroad spectrum antimicrobial, against positivegramandnegative is recommendedtochangeevery12hoursinextensive deepburns. nitrate canbeeffectivecerium cream with sulphadiazine of silver it to 24h,although forup layer ofthepreparation a generous dressings, dressings, inocclusive short inexpositive against grampositiveand negative, beinga fungicide against Candida.Its activity is Silver sulphadiazine: The rotationofthesetopicalantisepticsisessentialtoavoidresistance. • • • • • Others. Analytics: bloodtests,biochemistryandcoagulation. ECG. Chest x-ray. withcarboxyhaemoglobindetermination. gasanalysis Arterial blood : those which must be carried outare: : those whichmustbecarried This isthemost used topicalagentinburnsunits.It is effective hese agents are spread on compresses that on compresses These agentsarespread (Photo 6) . The frequency Photo 8. (Photo 8and9) Urgent surgeryconsistsof escharotomies inthe carrying out affecteddecompression areas. sheets, etc). of burns (pressotherapy,treatments usedwhentherehasbeenanepithelialisation silicone causes alterations. which scarring of pathological the possibility and by secondintention healing minimise treatment will surgical On theotherhand,anadequate etc. shrink scars,synachiae, position, reduce contractures duetoanimproper to reducejoint service, isessential with therehabilitation and splints,collaboration treatment withbandages treatment of burned patientsanattemptshouldbemadefrom When performingdressings the start of the with urgentsurgicalinterventionbeingcarriedoutifnecessary. (Photo7) even causing musclenecrosisintheaffected limb.Specialattentionshouldbepaidtotheseburns, bloodcirculation, compromising syndrome, compartment cause may superficial) (even burns onlimbs,neckorchest. to thepresenceofcircular When theinitialassessmentof a burned patientiscarriedoutspecialattentionshouldbegiven 7.2.3. UrgentSurical Treatment ofBurns • : gentamycin, nitrofurazone, neomycin,bacitracin,etc. Others: gentamycin,nitrofurazone, to reducethishypergranulationtakingadvantageoftheirlocalvasoconstrictoreffect. tissue, whereitisused growth ofgranulation areas withluxuriant and pain,orinthebloody Deepcircumferential burnofbothlowerlimbs, whichrequiresurgent surgery TO PREVENT . , carrying out actions designed to reduce them. Postural to reduce out actionsdesigned SEQUELA,carrying Photo 7. Expositivedressing.Occlusivedressing he presence of circular burns inlimbs of circular The presence inally we haveadjunctive Finally .
41 PRACTICAL GUIDE FOR BURN INJURIES 42
PRACTICAL GUIDE FOR BURN INJURIES Photo 9. than 25%-35% oftheBSA. 10% ofbody surfaceareatohavean excision). the excessivebloodloss thatwouldoccur(2-3redcellconcentratepackages arerequiredper of theburned areainextensiveburns,amongotherfactors; perform completeexcision due to to tissue. Itisnotpossible of theburned excision complete consists in debridement Surgical after theburn. stability ofthepatientbeforeperformingit. early,be done should of theburn debridement Surgical the haemodynamic but wemustensure wounds. the of coverage final a out carry to and tissue damaged irreversibly the remove to is objective is thetreatmentofchoicefordeepburns.Its surgery in thepatientwithburninjuries Scheduled heduled 7.2.4. Sc the affected limbmaybeneeded. of amputation trauma) anurgent to electrical due burns in (especially burns In thecaseofdeep to perform themonthechest or neckwhentheairwayventilationofpatientiscompromised. are performedintheextremities,itmayalsobenecessary surgeries most oftheurgent Although Deepcircumferentialdermalburninbothupperlimbs,whichrequiresurgentsurgery Photo 10. Surgical TreatPatientment intheBurned Decompressionescharotomiesinupperlimbs This isusuallyachievedbetweenthe3rdand5thday xcisions are not usually carried out onmore Excisions are notusually DEFINITIVE, althoughnoneofthemisideal: We haveSEVERAL intensely burnedpatientisnottheeliminationoftissuethatviable,butitscoverage of thepatientpermitsit. condition that thehaemodynamic The debridementandcoverageof an intensely burnedpatientisperformedserially, provided The debridementofburnedtissuecanbebasicallytwotypes: out, soareastobeintervenedmustprioritised: In massivedeepburns(>60%)thecompleteexcisionofaffected tissuecannotbecarried • • • • • • • BIOSYNTHETIC OVERAGE: SYNTHETIC OVERAGE:withdressings(hydrocolloid,silver, hydrofibre,etc). avoid desiccationofthetissues.Itisperformedonlyinspecialcases. requires immediatecoverageto should notbedoneonthefaceorperineum sequelae, aesthetic routes, higher drainage interrupts venousandlymphatic plane. Disadvantages: Advantages: morestraightforwardtechnically,of the and betterviability lessbleeding FASCIAL and coverageofthedebridedtissue. of vessels, stops withpressure,electrocoagulation which bleeding, capillary Produces tissue isreached. healthy the underlying until or hydroscalpel, or electric) (manual TANGENTIAL Each patientrequiresanindividualassessmentandprioritisationofareastooperate. burn of percentage highest the possible, startingwithanyarea. of excision the is priority the that argue authors Other followed bythechestandabdomen,finallyback,palmssoles. next, be then would limbs lower The confirmed. is lesion the of depth the that provided of joints, especially theupperlimb. and hands the to priority giving areas, functional with first dealing favour authors Some • • would beindicated infull-thicknessskin losses.Itspriceisvery high. coverage This cultures. keratinocyte autologous or autograft fine a by replaced is formation of a neodermis after about threeweeksinthe recipient bed;the outer layer COMPLETE: synthetic dressingwhich due to its facilitates the composition sheet. (Photo11). silicone external an with together intersected is origin porcine of collagen purified up fromanylonmeshinwhich used, made BIORANE: isthemostuniversally : removal of burned tissue until the fasciaisreached. tissue until of burned DEBRIDEMENT:removal DEBRIDEMENT:removalofburnedtissueusingdermatome tangential METHODS Photo 11. CoveragewithBiobrane FOR CUT Then faceandneck(for its aesthetic importance) ANEOUS COVERAGE, he challenge in thetreatmentof The challenge TEMPORAR Y OR
43 PRACTICAL GUIDE FOR BURN INJURIES 44
PRACTICAL GUIDE FOR BURN INJURIES Photo 12. • • coverage thatmajorburnspose. BIOLOGICAL AUTOGRAFTS: this is the best final coverage when the patient has sufficient donor areas: Skingraftwithoutmeshing.Partialmeshedskin • • • • • • • • • • • •
price ishigh. way. Their definitive a in skin the of components two the offers that substitute only currently creatingthemost expectations, their fundamentaladvantagebeingthe keratinocytes fromabiopsy ofthepatientsthemselves. coverage being researched, it is a complete skin that is created from fibroblasts and latest the is - grafts) compounds and (cultivated Autologous Allogenic Skin Artificial of keratinocytesorafineautograftwouldsubsequently needtobeimplemented. Cultivation of Allogeneic Keratinocytes - would act as a neodermis on which a culture as describedforthetreatmentofpatientswhodonot havesufficientdonorareas. coverage definitive first the is skin. This patient’shealthy the of biopsy a from grown are Cultivation of Autologous Keratinocytes - large sheets of keratinocytes are obtained which ALLODERM: anotherformofskinsubstitute. Has ahighantigenicpower, thereforeitislostinafewdays. used. very - glycerol in preserved and/or Cryopreserved allografts or Homografts in rejection produces that approximately 72hours. capacity antigenic high use, limited (pig): Xenografts burns intheelderlyandchildren. joints wherethatofincreasedthicknessispreferable,usingthinneronesinmassive and hands neck, face, of coverage for except mm, 0.20-0.25 is thickness ideal The The graftisobtainedusingadermatome. Any unburnedskinarea(exceptthefaceandhands)canbeusedasdonorarea. neovascularisation fromthebed. capillary definitive a is there day fifth and third the between and graft, the of system is collagen and produced. In24-48hours,theplasmaofreceptorbedshallnourishcapillary fibrin by adhesion an graft the of application after hours first the In They are applied during the same operation in which the burn debridement takes place. and theydonotactasabarrieruntiltheepithelialisationoccurs).(Photo12). a greatersurfaceareaandlessbruising,butpresentsworseaestheticappearance, result butincreasedfrequencyofhaematoma,themeshgraftpresentscapacitytocover Grafts can be applied as a sheet or meshed (the sheet graft presents a better aesthetic retraction ofit,butgreaterdifficultythatittakes.
SUBSTITUTES: inskinbanksto solve theproblemsof developed cutaneous There are: he greater the thickness of the autograft, the less The greaterthethicknessofautograft,less These aretheonesthat aureus, Staphylococcusepidermidis Staphylococcus are the tissueswithburns in frequency with greater isolated The germsthatare cultures areavailablethatallowustoperformspecifictreatmentforeachinfection. shall bestarteduntiltheresultsof the microbiological intravenous systemicantibiotherapy empirical spectrum of sepsis,broad by signs is accompanied infection In theeventthatlocal use ofbroadspectrumantiseptics,increaseinthefrequencydressings… treatment: antiseptic empirical topical starting amoreaggressive The treatmentisthenperformed skin biopsy(donotcarryoutcultivationthroughswabsgiventheirzeroeffectiveness). culture througha by microbiologic of localinfection mustbeaccompanied suspicion The clinical Antibiotic prophylaxisisneveradministeredintheburnedpatientexceptelectricalinjuries. lesions coveringthebloodysurfacesearly. of thermal surgical burns: correctlyusingtopicalantiseptics,settingouttheelimination The most effective action to prevent infectionsinburnedpatientsis the of correct handling the 7.2.5. Local InfectionoftheBurn andPseudomonasaeruginosa .
45 PRACTICAL GUIDE FOR BURN INJURIES 46
PRACTICAL GUIDE FOR BURN INJURIES The different typesofelectricaltraumareferto: of thecontact,resistanceatcontactpointandindividualsusceptibility. (amperage), the type of current (continuous or alternate), the flow path of the current, the duration parameters: voltage,current on several theelectriccurrentcausesdepends The damage Unit. children inthe domestic sphere. speak of electrical trauma. associated with another type of traumatic injuriesinadditionto the burn, whichiswhyweusually It should beborneinmind 15% of that approximately patients whosuffer an electricburnare of allthermallesionsinrelationtotheirsize,affecting normallytheskinanddeepertissues. a cytotoxicreaction. resistance, producing becomes anaccidental by averyhighintensityheatwhenthevictim’sElectrical burnsarethermalproduced body 8.1. Electrial Burns higher haemodynamicandfunctionalalterationsthanotherburns. different moredestructive sincethattheygenerate potentially fromotherburns,being behaviour There is a group of burns that we canconsiderspecialdueto their actionmechanism, andtheir treA 08 SPECIAL • • ELECTRIAL • INDIRECT • quickly, aggressivelyand mustbemaintainedfor quitesometime). effective resuscitationisespecially arrest, in whichthecardiopulmonary whenit is started of hivesanderythema). to areaction (similar fades quickly dendritic, or that looks like a fern on the skin that appears in the first hour after the injurypattern, erythematosus tree-like dendritic, is abranched, by lightning a traumacaused and ELECTRIAL like thewrist,elbows,armpitorpoplitealgap. flexing of areas in another,especially to body the of part one from current the of re-entry DIRECT ELETRIAL • • organs. Itisatraumathatsimilartoproducedby crushing. that areassociatedwithintensedestructionofdeeptissues affect multiple degrees several of skin the to burns are - V) (>1000 trauma electrical voltage High the mouthandhands. all sphere. of 80% approximately constitute - electrical injuries. V) (<1000 trauma electrical voltage Low ELECTRICAL he burn is usually locatedintheareaclosetoinjury,The burnisusually whichtendtobe TRAUMA FLASH: A flash burn is produce that should be managed like a flame burn. TMENT lectrical trauma usually affectsElectrical traumausually mainly youngmalesat work, and TRAUMA hey are especially frequent in the child population in thedomestic frequent inthechildpopulation They are especially BURNS. CAUSEDBY LIGHTNIN G: thetypicalskinmanifestation of
TRAUMA They are the most frequent causeof amputations inthe They cancauseseverearrhythmia. CONSIDERA : there is passage of electrical current throughthebody: of electrical : thereispassage
OR VOLTAIC ARC: aretheresultofexitand There canbecardiorespiratory They arethemostdevastating TIONS Burns The topicaltreatmentofelectricaltraumaburnsis thesameasthatofanythermaltrauma. formula, butanIVpatternshouldbemaintainedwith Lactate Ringerfordiuresis1ml/kg/h. the Parkland trauma doesnotfollow inthepatientwithelectrical replacement Hydro-electrolytic The mainclinicalmanifestationsofelectricaltraumaare: Most chemicalburnsare littleextensivebutdeep. 8.2. Chemical Burns syndromes mayappearinthefirst48hoursaftertrauma. outside (Icebergeffect). towards the most, onecansaythatthedamageduetoelectricaltraumaisfrominside bythe offered Theresistance heat. on the tissues varies tissue type depending (table 3). As it is the bone that accumulates the generates tissues the through flows that electricity The • • • • • • • • • • • • necrosis orliver, kidneydamage,ocularalterations,etc. perforation, pancreatic organs, abdominal canoccurintheintraabdominal Other: injuries Bone: fracturesoccurinupto10%ofcasesduemuscletetanisation. consciousness, headache,seizures… damage (2-5%),lossof (29%), medullary neuropathy seen asacuteorlateperipheral and canbe variable are highly manifestations clinical Neurological: theneurological in the produces cardiacarrhythmiasearly.and changes Highvoltage:producessinustachycardia foratleast24hours. Low voltage: Cardiac: cardiac monitoringshouldbeperformed V The increaseofthemyoglobincanresultinkidneydamagethatmustbecontrolled. to treatment. and inthecontrolofresponse of muscledamage is usefulinthediagnosis potassium. and myoglobin) (CPK and increase crush syndrome.It produces oedemaandmusclenecrosisthat produces anenzymatic Muscular: of the behaviour electricaltraumain relationto the musclesissimilarto a current). made toidentifytheentryburn(inelectriccurrent)andexit(of Cutaneous: burns of varying degrees(dermalandsubdermal). An attempt should be Action mechanism ortoxicityof thechemical agent. Tissue penetration. Exposure time orcontactwiththeskin. Quantity ofproductthat causes theburn. Concentration ofthechemical agent. : electrical trauma produces thrombosisofthevessels. ascular: electricaltraumaproduces T wave. The muscletissuedevelopsoedemaandnecrosis,compartmental + GREATER RESISTANCE - LESSERRESISTANCE TENDONS VESSELS MUSCLE NER BONE SKIN F AT VES The intensityofachemical burnwilldependon: he monitoring of the increase of theCPK of theincrease The monitoring
47 PRACTICAL GUIDE FOR BURN INJURIES 48
PRACTICAL GUIDE FOR BURN INJURIES with thefollowingspecialconsiderations: The initialmanagementof a chemicalburn isexactlythesameasthat of any thermaltrauma The mainactionmechanismsofchemicalsubstancesare: The maintypesofchemicalagentsare: product. the to exposure the since elapsed time the to according varies and difficult is depth burn the of agentand not cease until the tissues or medical treatment neutralises the product, therefore,the estimate thecausative of the characteristics to of thetissueinjury.to themechanism according does damage burns, thetissue thermal Unlike according classified are burns Chemical • • • • • • • • • • • • • • • and electrolyte analysismust be carried out on a basis to regular ensure metabolicstability. gases blood arterial that so complication, systemic largest the is pH the of alteration The close aspossibletothe body temperature. as and thetemperatureofirrigation if possible, place oftheaccidentbetween 28and31ºC attempt should bemadeto avoid this complication maintaining the temperature of the saline. An physiological or water with irrigation continuous the to due hypothermia Avoid chemical agents(lithium,sodium,magnesiumand potassium). can aggravatethe injury by producing heatgeneratingchemicalreactionswithsome saline withthe exception of physiological a few cases. or water with irrigation continuous than better be to shown not have and obtain to difficult are agents neutralising the cases of majority the in agents, neutralising of use the Avoid and theexposuretimetobeableaddress treatmentaccurately. burn the of agent causative the of identification the to given be should attention Special shown toreducetheseverityofburnandhospitalstay. with waterhasbeen period shouldbeatleast30minutes.Copiousirrigation irrigation centre. the hospital on reaching must berepeated of theaccidentandwhich place the in immersion) (never solution saline physiological or water with irrigation Abundant Blistering orthatformblisters:(Spanishflies,Nitrogenmustards,etc). Dehydrating: substancesthatextractwaterfromtheaffected tissues(sulphuricacid). hydrofluoric). acid and (oxalic mechanisms homeostasis membranes, orinterferewiththecellular Cellular orprotoplasmicpoisons Corrosion hydrochloric acidandnitricderivatives). Reduction halogenated substances(chromicacid,bleaches,potassium)intotheproteinmolecule. Oxidation also produceanexothermicreaction,whichcontributestotissuedamage. Inorganic solutions cellular proteinstructure. Organic solutions: act by membraneof dissolving the the cellsandaltering lipid pH greaterthan11.5 produceseriousdamagebycausingnecrosisliquefaction. Bases: theyareprotonacceptorsubstances,thepHcanvaryfrom7to14. Burns byacidsaremorefrequentandlessseverethanburnsbases. from 7 to 0. by clottingoncontactwiththeskin. Acids withapHlessthan2causenecrosis ionsandcanlowerthepH hydrogen Acids: theyareprotondonorsubstances,releasing : protein denaturation is produced by inserting oxygen ions, sulphur or oxygen ions,sulphur by inserting : proteindenaturationisproduced : cause direct and massive proteindenaturation(cement,sodiumhydroxide). andmassive : causedirect : the reduction of the amino links leads to protein denaturation (mercurial, oftheaminolinksleadstoproteindenaturation : the reduction : damage the skin by direct contact and the formationofsalts. the skinbydirectcontactand : damage : produce formation of esters from fatty acids of cell formation ofestersfromfattyacids : produce In addition, the use of neutralisers Those witha They The subcutaneous injection of calcium gluconate at 10%(0,5ml/cm of calciumgluconate injection subcutaneous with waterfollowedby the of abundant washing/irrigation application a calcium gluconategelor may appear.levels ofcalcium,becausearrhythmiasandhypocalcaemia monitoringandto monitor theserum is requiredfor electrocardiographic 50% hospitalisation this affects more than5%of the BSA ormorethan1%ofBSA ifitsconcentrationishigherthan tohydrofluoric The exposure vomiting mustNOT that the person does not present convulsions, difficult airway or decreased consciousness), and dressings. Intheeventofingestion the personmustbegivenaglassofmilkorwater (provided with skingraftortemporary of thedeepburnsmustbeperformedand covered excision tangential it, a layersoftheburn,inthesecases,andifstatus patientallows from thedeeper hours withperiodsofrest4hours).Waterproduct the chemical maynoteliminate irrigation (at least2 saline with waterorphysiological irrigation The treatmentconsistsincontinuous and perforation).(Photo13). opacification corneal scars, cause can (it penetration corneal rapid the of because serious effects can occur due to the absorption of the chemical. causing tissuedestructionthatisperpetuatedinthetimeafterinitialexposure.Systemic extensive burns.Causticsodahastheabilitytopenetratedeeplyintoskinandtissues environments burns are generally small in size,but industrial environments there canbe burns arefrequentduetooralingestionofsodainthecontextsuicideattempts.Inhome Exposure tocausticsoda(sodiumhydroxide),verycommonincleaningproduct.Chemical must becarriedoutintheBurnsUnit. of thelesion excision surgical treatment immediate tothe medical pain. Ifthereisnoresponse • • • sulphadiazine), initialdebridementandcutaneouscoverageinnon-viabletissues. as inanythermalinjury.(silver antimicrobials out withtopical be carried should Dressings The principles of treatment of the wound-burn produced by chemical agents are the same mechanical ventilationwithpositivepressureattheendofexpiration. by injury an like treated be - protecttheairway,inhalation and intubation oxygen therapyandifnecessaryorotracheal should it suspected is tract respiratory the of affectation If since aminimumamountofchemicalmayproducesignificantdamage. and foralongtime(30-60minutes), is begunwithwater assoonpossible irrigation that recommended is It burns. ocular of case in OPHTHALMOLOGY BY ASSESSMENT beprovoked. Photo 13. generates an intenseheatand importanttissuedamage.If acid generates Burnduetocausticsoda Ocular affectation is particularly 2 ) with the aim of relieving the ) withtheaimofrelieving Its treatment includes
49 PRACTICAL GUIDE FOR BURN INJURIES 50
PRACTICAL GUIDE FOR BURN INJURIES Usually the twomechanisms interact toproduce theskin failure. be inthecaseofchemicalburns),butthatisexplained assecondarytothetwomechanisms: fact thattheeffect necrosisisnotdue toskincontactwiththissubstance(asitwould ofcellular necrosis that achemicalburnassuch, is but not considered that is a separateentity, due to the The extravasationof a cytostatic agent orof a contrastagentscancause asecondaryskin and non-antineoplastic: The agents that produce skinalterationsdueto extravasation aresortedsimplyintoantineoplastic 8.3.2. ETIOPA The mostimportantriskfactorsfortheoccurrenceofextravasationsubstancesare: consideration becausetheycanproduceskinfailureofsimilarcharacteristicstoaburn. years arereferredto the Plastic Surgeondueto an extravasation,theymust be takeninto in 15 patients of everyhundred 0.01 patients 0.1 and that around (it isestimated infrequent as thoseofcontrast,are both ofcytostaticagentsaswell injuries, extravasation Although 8.3.1. EPIDMIOLOGY LESIONDUE type andquantityofextravasatedagent,aswellthereactionpatient’s skin. Their treatmentwillbesimilartothatofaburn,butwithcertainconsiderationsdependingonthe they can cause an acute skin failure similar to a burn, which is why we include them in this section. Injuries caused by the extravasation of an agent cannot be considered as burns as such,however, 8.3. Injuriesdueto contrastextravasation • • • • • • • • • • or ischemia and absenceofsurgicaltreatment ofcompartment syndromeassociatedwith it. is increased. planes muscular compartmentgenerates suffering andskinischemiaasthevolume ofthedeep or subcutaneous the in effect mass the through which substance, the of action Indirect or tissue cellular subcutaneous subdermis, incontactwith theskin,inducingcytotoxicityandnecrosis. the in located is which substance, the of action Direct or radiology conventional in used interventionist studies. agents contrast mainly are agents Non-neoplastic orcytostaticagentsaredividedintoirritantandblistering. The antineoplastic Obesity. dermatitis…) Extensive skindiseases(psoriasis, the injectionsite. stroke, or paralysis (prior state drowsiness, cognitiveimpairment),whichpreventthepatienttodetectearlyalterationsin mental the or patient the of alterations sensitive Local involuntary or (voluntary injection the of time movements…) the at patient the of collaboration Poor of history of accesstoveinstheotherlimbthatisnotaffected. lymphedema, with patients in example, lymphadenectomy, For only haveavailability we would limb, because oramputationofanupper veins. weak or small Fragile, Numerous priorvenepunctures. cytostatic agents THOGENESI LEIONDUE n this case, skin necrosis would be secondary to prolonged skin to prolonged secondary be would necrosis In thiscase,skin TO EXTRAVASA TO EXTRAVASA TION TION extravasated, buttheclinicalassessment. clinical situation. the severityof extravasated toguide type ofagentextravasatedandestimatevolume special attentiontothe history (thesameasinanytypeofburn),paying a precisemedical require of thecasescontrastorcytostaticextravasationgenerally The clinicalevaluation 8.3.4. EXPLORA The clinicalmanifestationsdependonthetypeofchemicalagentextravasated: 8.3.3. CLINICAL • • toxicity. NON-NEOPLASTIC mediastinum andpleura. affectation,to theskin addition routes, in in peripheral occur affectation canpresent of those that at centralvenouscatheterlevel,unlike that takeplace The extravasations may alsocausetheappearanceofcompartmentalsyndrome. tissuesbytheextravasatedagent intheskinandadjacent This localreactionproduced generating secondaryischemia. of thetissues, direct compression and agents) (hyperosmolar of osmolarity alteration is the action exert their they usually by which CONTRAST AGENTS:themechanism • • burning, and cutaneous tightness. cutaneous and burning, the vein,itching, point oralong in theinjection with phlebitis and hypersensitivity) Irritants: they generate a local inflammatory reaction (local oedema, erythema, heat frequent than with the irritants. The most significant vesicant group is anthracyclines. manner,are more in weeksormonths.Long-termsequelae becauseitcanappear a staggered in develop could necrosis at 2or3daysand blistering and skin peeling loss oftotalskinthickness. Blistering agents: they generatetissuenecrosisand scaling, sometimes resulting in symptoms usuallylastforhours,andproducelong-termsequelae. T wo typesofsubstancesaregenerallydifferentiated: However, what determinesthe type of treatment is not the quantity of agent PRACTICEOFLESIONDUE TION LESIONDUE Photo 14. AGENTS: the mechanismby which theiractionis exerted iscell Extravasationofcontrastagent The symptomsstarts with localskinburning,followedby here is no necrosis or peeling of theskin. There isnonecrosisorpeeling TO EXTRAVASA TO EXTRAVASA TION TION The
51 PRACTICAL GUIDE FOR BURN INJURIES 52
PRACTICAL GUIDE FOR BURN INJURIES There arealsosomegeneralguidelinesformanagement ofextravasations: where thesetypesofagentsareperfused. in theunits that areavailable ontheextravasatedagents,guides depending there areguides Although there are no random clinical trials for the specific treatment of each extravasated agent, 8.3.6. There areafewbasicguidelineswhichmustbefollowedinordertoavoidextravasations: 8.3.5. PREVENTIONOFLESIONDUE examination shallbefocusedon: limb. the upper in place takes generally of substances The extravasation • • • • • • • • • • • • • • which itisrecommended toapplyheat. in etoposide, the or (vincristine) alkaloids vinca the of case the in except cold, local Apply the metacarpophalangeal joints,mobilisingthewristandalsoelbow. as well as joints, interphalangeal distal and proximal the mobilising by fingers close and open separately: limb upper the of joints the mobilise patient the that recommended is It compartment syndrome. of risk the and swelling the decrease and return venous improve to raised, limb the Keep extravasated agent,andfortheadministrationof thepossibleantidote. The catheter must not be immediately withdrawn, but is maintained to suck up the excess stopped be immediately.must or theroutebewashed. that localpressurebeapplied Itisnotrecommended infusion the agent, an of extravasation of suspicion clinical is there If in thecaseofcentralcatheters. such as local pain or paraesthesia in the infusion area, or chest pain or shortness of breath symptoms, any has patient the if reviewed patient the and stopped be should infusion The The cannula should be secured through the application of a plaster that holds the peripheral pathway. well aslimbswithlymphedemaorhypoperfusion. as avoided, be should areas radiated previously or thrombosis, or sclerosis scars, with Areas be first must saline of ml perfused toverifythattherouteispermeable. 10 5 and Between confirmed. be must blood of backflow good A we shallselectforearm,backofhand,wristandantecubitalfossa. preferably not be used for the infusion of cytostatic or contrast agents. The peripheral pathway must be channelled before the start of the infusion; the old route should measurement ofthepressureincompartment. of the treatment regardless surgical of urgent is anindication of compartmentsyndrome In clinical practice, it is usually not necessary to resort to this measure, since the symptoms compartmental syndrome. confirms this Hg, mm 25 than greater is it If pressure. intracompartimental the measuring and puncture needle through out carried is syndrome compartment of confirmation The distal paresthesia,localhardtouchintheextravasationareaorcompartment. the hands, in coldness of distal be theemergence would data warning presented: it being Touch: the existence of data for compartment syndrome must be assessed or of the risk of as erythema,oedema,phlyctenae,blistersornecrosis. such suffering, skin of signs of emergence the to given be should Observation: Attention TREA TMENT OFLESIONDUE TO EXTRAVASA TO EXTRAVASA TION y order of preference, By order of preference, TION The technical symptoms whichrequiredsurgicaltreatment Photo 15. • • • • •
treatment isthesameincasesofcompartmentsyndromeproducedbyburns. and musclenecrosisor of the soft it. tissues surrounding fasciotomies, toavoidischemia of decompressive treatment willbecarriedoutconsisting increased to due syndrome withdataofskinsuffering,pressure or extracompartimental intracompartimental surgical compartment of suspicion clinical with cases, extreme In except inthecaseofextravasationsoxaliplatin. to reduce the formation of oedema and local inflammation. Corticosteroids are not indicated, The administration of non-steroidal anti-inflammatory drugs intravenously is recommended, Dimethylsulphoxide, HyaluronidaseorDexrazoxane,butstudiesareunderway. such as of antidotes the application about trials inhumans clinical are norandomised There antidotes. specific of administration the about disagreement still is there Currently require surgicaltreatment,consistinginthecarryingoutdelayeddebridementandgrafting. In theeventthatareasofskinfailuredonothealwithconservativetreatmenttheymay initially is treatment failure producedbyaburn. conservative failure, skin with areas performed withlocaldressings,usingthesamecriteriaasintreatmentofanacuteskin being there of event the In Extravasation of contrast agent in the back of the hand of a new-born. Compartment syndrome The clinical suspicionandthe
53 PRACTICAL GUIDE FOR BURN INJURIES 54
PRACTICAL GUIDE FOR BURN INJURIES In theKitchen: In thebathroom: The maingeneralrulesofpreventionreferto: flames andcorrosivesubstances. substances, electricity,the riskfactorsthatproduceburns:hotsolidsandliquid at avoiding aimed campaigns educational them, through to avoid to follow rules suggest the riskfactorsand Adults: injury.to thermal sensitive extremely as theyare in children, prevention on is essentially Most literatureonthissubject 09 GENERAL • • • • • • • • • • • • • • • • • • • • • • •
Do nothavehotdrinkswhileyouachildonyourlap. walkersinthekitchen. Do notallowchildrentouse thatarenotbeingused. Disconnect allelectricalappliances totestthetemperature. Introduce theelbow(adult), When fillingthebathstartwithcoldwaterandendwater. of 54ºmayscaldachildintwoorthreeseconds. Water thermostats in bathrooms allow you to adjust the water temperature. Temperatures Place screensinfrontofchimneys. Place the TV andmusicequipmentagainstthewall. Smoke alarmsathomearerecommended. Fitting plugprotectors. Keeping matches,lighters,chemicals,andlitcandlesawayfromchildren. Not usingfireworksorsimilar. powersockets. Not overloading andmuchlesssoinbed. insidethehome Not smoking Here some of therules previously seen and aboveall a lot of common sensemustprevail. happen. Finally, accidents also accidents occur during leisure: motorcycle exhausts, barbecues, sunburn, etc. such where scenario next the Occupational safetystandards mustbefollowedandstrengthened. is work home, the after adults For Meals andhotdrinksmustbeoutofthereach children. Keep thehandlesofpotsandpansawayfromreachchildren. Do notheatbaby’s bottlesinthemicrowave. armswhilecooking. Do notholdachildinyour liquids. the review to installation of important gas, electricity,is electrical appliances it and storage so of flammableoccur, and corrosive accidents the of majority the where is home The Prevention mustbeassociatedwiththestrengtheningofsafetystandards. same risks,butincreasedbythelossofreflexes associatedwithage. the have People society. modern to inherent dangers the to associated are burns Adult AND RECOMMENDA GUIDELINES. EVIENC 40 40 t is therefore important to teach the general population to identify population to teachthegeneral important Itistherefore PREVENTION 40 TIONS 40 40
RECOMMENDATIONS microwave. of foodinthe the preparation during An increaseofburnshasbeenobserved The kitchenandbathroomarethesiteswhereburnsmostoftenhappen. The mostseriousdamageisbyimmersioninhotliquidsandfire. Mortality isincreasedinchildrenunderthreeyearsofage. Children underfiveyearsoldhaveanincreasedriskofburns. Increase thedisseminationofaculturepreventioninburns. Be carefulwiththehandlingofhotliquidsinpresencechildren. Store causticsubstancesinsafeplaces,awayfromthereachofchildren. Avoid theunsupervisedpresenceofchildreninkitchensandbathrooms. 40, 41,42 Very low. Very low. Very low. Very low. Very low. Very low. Very low. Very low. Very low.
55 PRACTICAL GUIDE FOR BURN INJURIES 56
PRACTICAL GUIDE FOR BURN INJURIES eVIDENCEREOMMDA 10 SUMMAR [R] [R] [R] [R] [R] [R] [R] [R] [GP] [R] [R] [R] [R] that hydrocolloid ones. dressings havehigherabsorption capacity Hydrocellular exudate insuperficialburns. of for themanagement are suitable dressings Hydrocolloid adherence. adaptable and low with dressings Use healing dressinginhumidenvironmentoveranother. There isnot enough evidenceontheeffectiveness of a necessary toapplytopicalantimicrobials. In second-degree burnswithoutriskof infection it is not Debride blistersorphlyctenae. If anantisepticisnecessary, use chlorhexidinedigluconate. Rinse withpotablewaterorsalinesolution. Protect fromthesun(during15-30days). areas. Use sunscreenprotectionproducts(FPS>15)inepithelialised Moisturise theskintorestoremoisture. Do notapplyverycoldorfrozenwater(<15ºC). Dry thelesionwithoutrubbinginjuredarea. Evidence []/Rommendation [R]/ Good Practie[GP] Y OF
TIONS (GPC SAS,2011). (GPC SAS, 2011). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011) (GPC SAS,2011). Level /Grade (GPC SAS,2011). MODERATE MODERATE MODERATE MODERATE MODERATE MODERATE HIGH LOW LOW LOW LOW LOW LOW 5 5 5 5 5 5 5 5 5 5 5 5 5 . [GP] [R] [GP] [R] [GP] [R] [R] [R] [R] [R] [R] [R] [R] [R] [R] [R] A glucoseintakeisrecommended. Enteral nutritionshouldbeadministeredearly. The preferentialuseofenteralnutritionisrecommended. Burned patientswillreceiveahighproteinintake. 200% oftheestimatedenergyexpenditure. It is recommendedthatthecaloricintakedoesnotexceed until healed. and continuously Evaluate thestate of nutritionindividually agents ofthemucosa. Use barrierproductsofthemucosaandprotective Clean eyesseveraltimesaday. hospital stay. reducedressingsandaverage canhelp Silver dressings Do notusesystemicantibioticspreventivelyinminorburns. during dressings. pain reduce sulphadiazine, with compared dressings, Silver Silver dressingscanhelpreducedressingsandaveragehospitalstay. cerium nitrate. with shall beapplied burnssulphadiazine In third-degree andthird- degree burns,issilversulphadiazine. in second- choice first of antibiotic topical The Dressings withsiliconeprotecttheperilesionalandepithelialisedskin. Use chlorhexidine0.12%asamouthantiseptic. 34
HIGH(GPC SAS,2011). (NUT (NUT (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011) (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). (JPEN, 2002). MODERATE MODERATE MODERATE MODERATE MODERATE MODERATE MODERATE VER VER VER VER VER VER VER HOPS,2005). HOPS,2005). HIGH Y LOW Y LO W Y LOW Y LOW Y LOW Y LOW Y LOW 37 5 5 5 5 5 5 5 5 5 5 5 5 5 . 36 36 5
57 PRACTICAL GUIDE FOR BURN INJURIES 58
PRACTICAL GUIDE FOR BURN INJURIES [GP] [GP] [GP] [GP] [E] [E] [E] [GP] [R] often happen arethesiteswhereburnsmost The kitchenandbathroom by fire and in hotliquids is byimmersion The mostseriousdamage Mortality isincreasedinchildrenunderthreeyearsofage in burns ofacultureprevention Increase thedissemination children of in thepresence ofhotliquids Be carefulwiththehandling reach ofchildren Store causticsubstancesinsafeplaces,awayfromthe bathrooms Avoidin kitchensand presence ofchildren theunsupervised tubular mesh3,5 oedema. of physiological expansion the be usedtoallow will bandages Elastic orcohesive to avoidtheadhesionbetweenthem one, by one out carried be shall fingers the of dressing The The idealiselastic (Cochrane, 2004). (Cochrane, 2004). (Cochrane, 2004). (Cochrane, 2004). (Cochrane, 2004). (Cochrane, 2004). (GPC SAS,2011). (GPC SAS,2011). (GPC SAS,2011). VER VER VER VER VER VER VER VER LOW Y LOW Y LOW Y LOW Y LOW Y LOW Y LOW Y LOW Y LOW 5 5 5 40 40 40 40 40 40 13 Burns andScaldsinPrimaryCare. of Group.Management newZeelandGuidelines 12 7 Protocolo de tratamiento de las quemaduras en formaciónMédicaContinuada.Protocolodetratamientolasquemaduras Atención 4 11 6 14 3 17 1 11 5 8 9 16 10 15 2
Evidence -BasedestPractiqueGuidelineSummary;2007. Servicio Andaluz deSalud.DistritoSanitarioMálaga;2005.p.22-5. por presión cutánea: úlceras de laintegridad el manejo de prácticaclínicapara R Barcelona: MargeMédicaooks;2009. Primaria Andaluz deSalud;2011. que sufrenquemaduras de personas práctica clínicaparaelcuidado P A C W G B S P M mayo de2013]. Available on:http://www.index-f.com/evidentia/n6/r143articulo.php. C. J. G F R H P P C., en laemergenciayurgencia sulfadiazine treatment:aprospectiverandomized trial with standard patients incomparison paediatric time inburned reduces healing dressing 2006. quemado en lainfancia.Trascendencia socialalaspuertasdel2000 Humectantes. OFF two foamdressings (1): 36-48. sistemática conmetaanalisis las úlcerasporpresión: una revisión kq/groups/23009980/1464829695/name/quemaduras+protocolos+aps.pdf. Review quemado 130-59. Máster en Dermofarmacia y Cosmetología (5ªed.). LITERA ábregas érez bad alu etit ugmann argent érez hávez odríguez udspith odriguez arcí arcí orilla oo T
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PRACTICAL GUIDE FOR BURN INJURIES 21 28 20 27 22 35 29 33 32 26 24 19 23 18 31 30 25 34 I Rehabilitation. 1998;19(4):279-83. & Care of Burn scalds. Journal partial-thickness with on children the ef_cacyofMepitel T un hospitalterciario al pacientequemado: nutricionales Auditoría deprocesosen unServiciodeQuemados 2005; 26(4):344-7. method islesspainful? thickness burns:which trial of randomized prospective, in thetreatmentofpartial Acticoat versussilversulfadiazine Manage. 1999;45(6):39-44,46-7. dressing inthemanagementofpressureulcers. dressing to a hydrocolloid (2): 198-201. treated asinpatientswithsilversulfadiazine applied sized burnstreatedasoutpatientswithin-hospital Acticoat(tm) tothosechildren quemados. [monografía deinternet].2005.[AccessMai2016]. Availableon: http://www.indexer.net/ 2002; 24:456-7. patients with oral lesion: preliminary findings from an open pilotSymp. Manag. study.JPain saliva decuatrocolutoriosconclorhexidina G D K B M H S O V P G D G S K adulta quemada enetapaaguda quemada adulta lc0029.php. 1. [AccessMai2016]. 2005; Availableon: http://www.index-f.com/lascasas/documentos/ doc/58870830/17/T Minsal; 2007.[Guía [Acceso mayode2016]. online]. Availableon: http://es.scribd.com/ Odontológica Urgencia GuíaClínica deSalud. Ministerio Ambulatoria 47. McGraw- Hill;1993. recomendacion_pSolares_sept06.pdf. [Accesomayo 39-43. 265,(26/09/2006): nºL de 2016]. Availableon: http://www.aemps.gob.es/cosmeticos Higiene/cosmeticos/docs/ Europea, la Unión de Oficial Diario CE). sobrelosmismos. alasdeclaraciones y de laComisión Recomendación solar deprotección productos los de Eficacia Wound Care.2005;18(3):323-32. nnocenti ratamiento delascicatrices.(1ºEd.)Madrid:lsevier España; 2007.p.123-32. a endli eeley a hear aras eters e errera e otschall sborn ómez arner iquet v v S anagh anagh los anti
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61 PRACTICAL GUIDE FOR BURN INJURIES 62
PRACTICAL GUIDE FOR BURN INJURIES Guides 2010for cardiopulmonaryresuscitation oftheEuropeanResuscitationCouncil. Sanitarias deGalicia- 061 Source: Adaptation oftheManualadvancedlifesupportinpre-hospital emergencies.FundaciónPúblicaUrxencias Basic lifesupport algorithm of adults AnNex 1 12 ANNEX If available 30:2 2 ventilations 30 chestcompressions Call 112 NO Breathes normally? Ask forhelp Open airway Not responding? According torecommendationsoftheEuropean2010ResuscitationCouncil Basic LifeSupport You canavoidaprematuredeath 30:2 Recover YES AUTOMa DESFIBRILLATION Basic lifesupport algorithm of adults AnNex 1 12 ANNEXTRNSL tic (DEA) y position
1. 3. Followtheinstructionsofitsmessages 2. Placethedefibrillationpatches T urn onDEA TION
63 PRACTICAL GUIDE FOR BURN INJURIES Index of photos and images
• Photo 1: courtesy of Josep Petit. • Photo 2: courtesy of Josep Petit. • Photo 3: own source. • Photo 4: own source. • Photo 5: own source. • Photo 6: own source. • Photo 7: own source. • Photo 8: own source. • Photo 9: own source. • Photo 10: own source. • Photo 11: own source. • Photo 12: own source. • Photo 13: own source. • Photo 14: own source. • Figures 1, 2, 3 y 4: extraídas de la cita bibliográfica nº 4. • Figure 5: extraída de la dirección electrónica: https://es.wikipedia.org/wiki/Quemadura. • Figure 6: own source. CHUAC. • Rule 1 (the palm of the hand): own source. G UI D E FOR BURN INJURIE S P R AC TI CA L
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