Guideline and Treatment Algorithm for Burn Injuries
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REVIEW Guideline and treatment algorithm for burn injuries Ahmet Çınar Yastı, M.D.,1,2 Emrah Şenel, M.D.,3 Mutlu Saydam, M.D.,4 Geylani Özok, M.D.,5 Atilla Çoruh, M.D.,6 Kaya Yorgancı, M.D.7 1Department of General Surgery, Hitit University Faculty of Medicine, Çorum; 2Ankara Numune Training and Research Hospital, Burn Treatment Center, Ankara; 3Department of Pediatric Surgery, Yıldırım Beyazıt University Faculty of Medicine, Ankara; 4Department of Esthetic, Plastic and Reconstructive Surgery and Burns Unit, Yunus Emre Governmental Hospital, Eskişehir; 5Department of Pediatric Surgery, Ege University Faculty of Medicine, İzmir; 6Department of Esthetic, Plastic and Reconstructive Surgery, Erciyes University Faculty of Medicine, Kayseri; 7Department of General Surgery, Hacettepe University Faculty of Medicine, Ankara ABSTRACT As in many other countries, burn injuries are a challenging healthcare problem in Turkey. Initial management of burn patients is very important for future morbidity and mortality. Therefore, the Turkish Ministry of Health prepared “National Burns Treatment Algo- rithm” aided by the Scientific Burns Council. The basic aim of this algorithm is to guide physicians in the treatment of burn victims until they reach an experienced burns center. The content of this algorithm is first aid, initial management, resuscitation, and transfer policy. The Council started to work on this algorithm in 2011. Various consultants, including general surgeons, pediatric surgeons, aesthetic, plastic and reconstructive surgeons, anesthesiologists, and intensive care physicians, revised the first draft and it was sent to eight education and research hospitals of the Ministry of Health, four universities, and seven non-governmental organizations. In the last quarter of 2012, the algorithm was finalized and approved by the Scientific Council, after which, it was approved by the Ministry of Health and published. Key words: Algorithm; burn; guideline; treatment. Determining Burn Severity and On-Site Medical 2. Depth of the Burn: Burns are classified as superficial and Attention deep dermal in clinical practice. Determining Burn Severity In superficial burns, there is no or minimal dermal injury. Determining burn severity depends on the burned surface These are first degree and superficial second degree burns, area, depth of burn and the involved body area. and usually heal in 3 weeks without any sequelae. 1. Burned Surface Area: The ‘rule of nines’ can roughly The dermis is partially or completely injured in deep dermal estimate adult burns (Fig. 1a). However, more accurate dia- burns. They are classified as deep second, third and fourth grams are available for adults (Fig. 1b) and children (see Lund degree regarding dermal injury and underlying deep tissues. Browder’s diagram), and a brief form of the diagram is shown These will usually heal in more than three weeks and usually in Fig. 2. For practical calculation, the outstretched palm with require surgical intervention. fingers together can be accepted as 1% of the body surface area for an individual (Fig. 3). First Degree: Epidermis is intact, there is erythema, e.g.: sunburn Address for correspondence: Ahmet Çınar Yastı, M.D. Second Degree: Epidermal integrity is damaged. If the injury Vakif İş Hani, Çankırı Cad., No: 67/2, Dışkapı 06030 Ankara, Turkey is limited to the upper layers of dermis, it is Tel: +90 312 - 324 57 97 E-mail: [email protected] superficial second degree; however, involve- ment of the deeper (reticular) layers leads to Qucik Response Code Ulus Travma Acil Cerrahi Derg deep second degree burn. While superficial 2015;21(2):79-89 doi: 10.5505/tjtes.2015.88261 is much more painful, there is less pain and a blunt pressure feeling in deep burns. Copyright 2015 TJTES Third Degree: All layers of the dermis are involved. The skin is hard, dark, dry, painless, thromboses Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2 79 Yastı et al. Guideline and Treatment Algorithm for Burn Injuries (a) (b) 3.5% 3.5% 9% 1% 1% 18% 2% 2% 2% 13% 2% 13% 9% 9% 1.5% 1.5% 1.5% 1.5% 2.5% 2.5% 1% 1% 1% 1% 1% 1% 4.5% 4.5% 4.5% 4.5% 18% 18% 4.% 4.% 4.% 4.% 1.5% 1.5% 1.5% 1.5% Figure 1. (a) The rule of nines diagram. (b) Schema for estimation of body surface area in adults. inside the vessels, and there is typical burn child eschar. d. Inhalation injury Fourth Degree: All layers of the skin, subcutaneous fat tissue e. Electrical burns and deeper tissues (muscles, tendons) are f. Burns with concomitant additional trauma (such as involved, and there is a carbonized appear- head trauma, intra-abdominal injury, fractures) ance. g. Burns during pregnancy h. Co-morbidities adding significant risk to burns (such as 3. Burned Body Site: Burns of the eye, ear, face, hands, Diabetes Mellitus, corticosteroid use, immune suppres- feet, and genitalia are ‘special area burns’ and should be treat- sion) ed at an experienced burns unit/center. i. Burns of the eye, ear, face, hand, foot, major joint and genitalia. Classification Burn Severity Minor burns can be treated as an outpatient or in a burns 1. Minor Burns room. Moderate and severe burns must be hospitalized and a. Second degree adult burns less than 15% TBSA treated in a burns unit/center. b. Second degree child burns less than 10% TBSA c. Third degree child or adult burns less than 2% TBSA On-Site Medical Attention 2. Moderate Burns 1. Airway, breathing and circulation should be assessed. In a. Second degree adult burns involving 15 to 25% TBSA a multiple trauma patient, the ‘forget the burn’ principle b. Second degree child burns involving 10 to 20% TBSA is valid and the management of life threatening injury has c. Third degree child or adult burns involving 2 to 10% priority. TBSA 2. Rescuing the victim from the burning premises and extin- 3. Major Burn guishing the fire have priority. a. In adults, second degree burns greater than 25% TBSA 3. In minor burns, the burned area should be kept under b. In children, second degree burns greater than 20% running tap water for 20 minutes within the first 15 min- TBSA utes, and further burning should be stopped. c. Third degree burns greater than 10% in an adult or a 4. Hot liquid burns 80 Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2 Yastı et al. Guideline and Treatment Algorithm for Burn Injuries I II 1% 1% 2% 2% 2% 13% 2% 13% 1.5% 1.5% 1.5% 1.5% 2.5% 2.5% 1% 1% 1% 1% 1% II II II II III III III III 1.5% 1.5% 1.5% 1.5% Age 0 1 5 10 15 Adult Front or back half (%) (%) (%) (%) (%) (%) I (Head) 9½ 8½ 6½ 5½ 4½ 3½ II (Thigh) 2¾ 3¼ 4 4¼ 4½ 4¾ III (Leg) 2½ 2½ 2¾ 3 3¼ 3½ Figure 2. Lund-Browder schema. • All wet clothes are removed be rinsed with running water until the pain is relieved 5. Flame burns (this could take 60 minutes) • The patient is removed from the heat source and • Neutralizing agents are not recommended (contra- in- moved from the scene to open-air; however, if not pos- dication as may cause further heat) sible, the fire is extinguished. • Carbon monoxide or smoke intoxication is checked A large intravenous line insertion is required for every major and the patient is administered 100% oxygen. burn case and Ringer’s lactate solution should be the choice • Requirement for endotracheal intubation is evaluated. of fluid resuscitation. Circulation, respiration, and urinary out- 6. Electrical Burns put are observed if necessary. Detailed information regarding • Health care provider should be aware that the patient the event and the patient’s medical is likely to be injured in three different ways: real elec- history should be obtained, and the trical injury via electric current, arc burns, and flame emergency physician or burns sur- burns as a consequence of the electric current ignition. geon where the patient is to be trans- • The electricity is turned off and/or the patient should ferred should be informed of the burn severity and relevant medical history. be removed from the source, 1% • Requirement for immediate cardiopulmonary resuscita- Due to the expected edema forma- tion is evaluated (especially in low voltage injuries) tion in large burns, jewelry, including • Sign or symptoms of multiple trauma, blunt or pene- bracelets, rings and necklaces should trating trauma must be checked, be removed. 7. Chemical Burns Burn wounds should not be covered Figure 3. Practical es- • Dry chemicals are firstly brushed off, and then, should with medicaments or substances on- timation using palm. Ulus Travma Acil Cerrahi Derg, March 2015, Vol. 21, No. 2 81 Yastı et al. Guideline and Treatment Algorithm for Burn Injuries • One or two effective peripheral venous line may pro- vide sufficient venous access for children. However, for large burns requiring close monitoring, central cathe- terization is the optimum. • If central catheterization is not possible in children younger than 6 years of age, a 16-18 gauge needle (spi- nal needle is compatible) can be inserted from the dis- tal femoral or proximal tibial bone marrow (attention to the epiphysis plaque) under local anesthesia, and 100 ml/hour fluid can be delivered. Meanwhile, other intra- venous routes can be tried. • Temperature of the fluids should be close to the body temperature in order to avoid systemic hypothermia. 3. Associated traumas should be investigated and appro- priately managed if present. If a multi-trauma patient has concomitant burns, the relevant department of the vital injury follows up the patient. In these patients, the par- Figure 4. Escharotomy and/or fasciotomy sites.