Burns are skin trauma, produced by thermal agents, electrical, chemical or radiation. They still cause significant pain and can sometimes be life-threatening and / or functional.
Classification of burns:
Severe burns: one or more of the following:
– Body surface area burned (SCB) greater than 10% in children and 15% in adults
– Injuries by inhalation (fumes, hot air, particles, toxic gases, etc.)
– Major trauma associated (fracture, decay, head trauma, etc.)
– Location: face, hands, neck, perineum, joints (put into play the functional prognosis)
– Electrical or chemical burns or from explosion
– Age <3 years or> 60 years or underlying pathology (eg epilepsy, malnutrition..)
Minor burns: SCB less than 10% in children and 15% in adults, in the absence of other risk factors
This table allows to accurately estimate the% of SCB age: p. ex. burns of the face, anterior chest, left arm and circular inner side of the left forearm in a child 2 years: 8.5 + 13 + 4 + 1.5 = 27% of SCB.
Apart burns 1st degree (painful erythema without blistering) and very deep burns (third degree, carbonization) it is impossible to arrival to determine the depth of the burns. Differentiation is possible after J8-J10.
Looking for smoke inhalation signs:
Dyspnea with drawing, bronchospasm, soot in the mouth / nostrils, cough, black sputum, hoarseness, etc.
Treatment of severe burns (in hospital):
I- Immediate Care:
At the arrival :
– Ensure airway; O2 high speed, even if the SpO2 is normal.
– Peripheral venous route, preferably in safe area (intraosseous if not possible venous access).
– Ringer’s lactate (RL): 20 ml / kg the first time, even if the patient is stable.
– Morphine SC: 0.2 mg / kg (the level 1 and 2 of analgesics are ineffective).
– In case of chemical burns: abundant water wash for 15 to 30 minutes, without diffusing the product to healthy skin; do not attempt to neutralize the product.
Once the patient is stabilized:
– Remove clothing if they are not stuck to the burn.
– Taking of the burn mechanism, causal agent, time, etc.
– Assess burns: scope, depth, carbonization; eye burns or functional areas; circularity burns members, chest and neck.Wear a mask and sterile gloves during the examination.
– Look for associated injuries (fractures, etc.).
– To protect and warm the patient: sterile drape / clean, survival blanket.
– Ask a urinary catheter if SCB> 15%, electrification, perineum burns.
– Ask a nasogastric tube if SCB> 20% (the block at dressing).
– Calculate and start and electrolyte intake for the first 24 hours.
– Intensive surveillance: awareness, pulse, blood pressure, SpO2, respiratory rate (RR) every hour; temperature and diuresis every 4 hours.
– Investigations: hemoglobin, blood, urine dipstick.
– Prepare the patient for the first dressing in the operating room.
– At the initial stage the burn is not bleeding: Find bleeding if hemoglobin is normal or low.
– The burn itself does not alter consciousness. In case of impaired consciousness, think of a head injury, poisoning, epileptic postictal confusion.
– Clinical manifestations of electrical burns are highly variable depending on the current. Look for complications (arrhythmia, rhabdomyolysis, neurological disorders).
II- General care in the first 48 hours:
fluid replacement to correct hypovolemia:
* Basic inputs: RL and 5% glucose alternately, 4 ml / kg / h for the first 10 kg + 2 ml / kg / h for the following 10 kg + 1 ml / kg / h for each kg remaining (at -Dessus 20 kg and below 30 kg)
Note: increase the contribution of 50% (3 ml / kg x% SCB the first 8 hours) if inhaled or electric shock. In case of burns> 50% BSA, limit the calculation to 50% CBS.
This protocol is to be adapted according to systolic blood pressure (SBP) and diuresis. Do not cause a volume overload. Reduce inputs if urine output exceeds the upper limit.
If oliguria despite expansion volemic well conducted:
Dopamine IV: 5 to 15 mcg / kg / min by syringe pump or epinephrine IV: 0.1 to 0.5 mcg / kg / min by syringe pump
Beyond 48 hours, if the basic fluid intake is sufficient orally or by nasogastric tube lane, stop the infusion.
All cases: prolonged humidified oxygen therapy, respiratory physiotherapy.
emergency surgical procedures if needed (tracheostomy, thorax releasing incisions).
Do not administer corticosteroids (no effect on edema, promote infection).
No specific treatment direct bronchopulmonary lesions.
See care of the pain.
Initiate nutrition very early, as soon H8:
– Daily requirement in adults: • Energy: 25 kcal / kg + 40 kcal / SCB%
• protein: 1.5 to 2 g / kg
– High-calorie products (NRG5, Plumpy’nut, F100) are essential if CBS is> 20% (natural foods are insufficient).
– Dietary intakes are split as follows: 50% carbohydrate, 30% fat, 20% protein.
– Increase of 5-10 times the recommended daily allowance of vitamins and trace elements.
– Prioritise oral or tube feeding (if necessary SCB> 20%).
– Start with small amounts at J1, increasing gradually to the recommended energy needs in 3 days.
– Systematically evaluate the nutritional status (weight 2 times / week).
– Reduce energy costs: occlusive dressings, hot (28-33 ° C), early skin coverage; management of pain, insomnia and depression.
Patients at risk of rhabdomyolysis (severe burns and extensive, electrical injuries, trauma of member overwrite)
Monitor for myoglobinuria: dark urine and urine strips. If myoglobinuria, alkaline forced diuresis for 48 hours (20 ml of8.4% sodium bicarbonate per liter of RL) for diuresis of 1 to 2 ml / kg / h. Do not administer dopamine or furosemide.
Fight against infection:
The fight against infection is a constant concern to healing.
Infection is one of the most common and most serious complications:
– Respect the hygiene measures (eg gloves for skin contact..).
– Strict management of the burn (dressing changes, early excision).
– Separate the recently burned patients (<7 days) older (³ 7 days).
– No systemic antibiotics in the absence of systemic infection.
The infection is defined by the presence of at least 2 of the 4 following signs: temperature> 38.5 ° C or <36 ° C, tachycardia, tachypnea, increased white blood cell count of more than 100% (or significant decrease in blood cells white).
– In the event of systemic infection, start empirical antibiotic therapy:
Children> 1 month:
cefazolin IV: 75 mg / kg / day in 3 injections + ciprofloxacin PO: 30 mg / kg / day in 2 divided doses
Adult: cefazolin IV: 6 g / day in 3 injections + ciprofloxacin PO: 1.5 g / day in 3 doses
– A local infection without evidence of systemic infection requires a local treatment with silver sulfadiazine.
– Omeprazole IV from D1:
Children: 1 mg / kg / once daily
Adult: 40 mg / once daily
– Prophylaxis / tetanus vaccine (tetanus see).
– Prophylaxis: SC nadroparin to begin 48 to 72 hours after the burn. Dose adapted to high risk if SCB> 50% and / or electrifying high voltage; moderate risk if SCB 20 to 50% and / or burns of the lower limbs.
– Physiotherapy from J1 (prevention of contractures), analgesia required.
– Intentional Burns (attempted suicide, aggression): special psychological support.
III- Local care:
The regular dressing changes 1 prevents infection, reduces heat and fluid losses, limit energy expenditure and relieves the patient. Dressings should be occlusive, analgesics, enable the mobilization and to prevent contractures.
– General principles
• Adhere strictly aseptic technique.
• The dressings require the use of morphine in burn not anesthetized.
• The first dressing is done under general anesthesia block, the following block under general anesthesia or morphine room.
• At the first dressing, shaving hairy areas (armpits, groin, pubis) if burns affecting neighboring tissues; scalp (earlier in case of burning of the face, around the skull when burning). Cut nails.
• Clean the burn with a foam solution of povidone-iodine (PVI 1 volume of 7.5% + 4 volumes of sodium chloride 0.9% or sterile water). Scrub gently with compresses, avoid bleeding.
* 1 The open technique “burned patient naked under mosquito net” and the spa are outdated technologies and must not be used.
• Complete removal of blisters with forceps and scissors.
• Rinse with sodium chloride 0.9% or sterile water.
• Dry the skin by dabbing with sterile gauze.
• Apply silver sulfadiazine directly by hand (wear sterile gloves) on all burned surfaces, uniform layer of 3-5 mm (except eyelids and lips).
• Apply a layer of gauze impregnated fats (Jelonet® or tulle gras) using a technique of back and forth (not circular).
• Cover with sterile gauze, folded in “sail”. Never encircle a limb with a single compress.
• Cover all by unretracted crepe bandages.
• Elevate members to prevent edema; immobilization in extension.
– Frequency: every 48 hours systematically; every day in the presence of secondary infection or certain locations (p. ex. perineum).
• The distal ischemia burnt member is the main complication in the first 48 hours. ischemia signs to look for: cyanosis or pallor of the extremities, dysesthesia, hyperalgesia, disappearance of capillary pulse.
• Daily monitoring: pain, bleeding, and infection evolution.
IV- Surgical care:
– Emergency Surgical Procedures:
• discharge Incisions circular burns limbs and fingers to prevent ischemia; chest or neck when breathing.
• Tracheotomy in case of airway obstruction by a compressive edema (p. Ex. Deep head and neck burns).Tracheotomy is possible in burned area.
• Tarsoraphie in case of eye burns or deep burns of the eyelids.
• Surgery associated injuries (fractures, visceral lesions, etc.).
– Surgery of the burn:
• Excision-graft deep burns, anesthesia under the block between J5 and J6: excise the necrotic skin structures (bedsores) and cover at the same time by thin skin autografts. high bleeding potential intervention does not exceed 15% of SCB in the same operation.
• If early excision-graft is not feasible, use the sequence debridement-budding-healing. Debridement is spontaneously under the action dressings sulfadiazine / tulle gras and, if necessary, mechanically by surgical removal of necrotic tissue. It is followed by a granulation which may require surgical scraping in case of hypertrophic buds.
The risk of infection is high and the long time (> 1 month).
V- Management of Pain:
All burns require analgesic treatment. The intensity of the pain is not always predictable and regular evaluation is essential: using a verbal rating scale (VRS) in children> 5 years and adults and NFCS or FLACC scales in children <5 years (see pain).
Morphine is the treatment of choice for moderate and severe pain. The development of tolerance is common in burned and require increased doses.
Adjuvant treatments can complement the drug analgesia (p. Ex. Massage, psychotherapy).
Continuous pain (felt at rest):
– Moderate pain:
paracetamol PO: 60 mg / kg / day in 4 divided doses
+ Tramadol PO: 4 to 8 mg / kg / day in 4 divided doses
– Moderate to severe pain:
paracetamol PO: 60 mg / kg / day in 4 divided doses + slow-release morphine PO: 1 to 2 mg / kg / day in 2 divided doses every 12 hours. Patients with severe burns, gastrointestinal absorption is random the first 48 hours. Morphine is administered subcutaneously 0.2 mg / kg every 4 hours.
Acute pain related to care:
Analgesics are administered in addition to treating aches.
– Important Gestures and extensive burns: general anesthesia in surgery.
– Non-surgical and limited Gestures (dressing, painful physiotherapy):
• low to moderate pain, 60 to 90 minutes before treatment:
Codeine PO 0.6 mg / kg or tramadol PO: 2 mg / kg rarely possible to achieve the task in good conditions. If that fails, use morphine.
• moderate to severe pain, 60 to 90 minutes before treatment:
immediate release morphine PO: initial dose of 0.5 to 1 mg / kg. The effective dosage is usually around 1 mg / kg, no maximum dose.
or morphine SC: initial dose of 0.2 to 0.5 mg / kg. The effective dosage is usually around 0.5 mg / kg, no maximum dose.
Note: These doses correspond to those of adults.
For acetaminophen, the dose is the same in children.
For tramadol and codeine, the dosages are identical for children> 6 months.
For morphine, the dosages are identical in children> 1 year, to be divided by 2 before the age of one year, by 4 before the age of 3 months.
– The management of pain during dressing in bed with morphine requires:
• A trained nurse team.
• The availability of oral morphine immediate release and naloxone.
• Close supervision: awareness, FR, heart rate, SpO2, every 15 minutes during the first hour of the dressing and regular monitoring.
• Evaluation of pain and sedation during the gesture and one hour after.
• Equipment to mask ventilation and manual aspiration.
• Soft gestures during any contact with the patient.
– Adaptation of morphine doses for dressings
• If the pain intensity (EVS) is 0 or 1: continue with the same dosage.
• If EVS ≥ 2: increase the dosage by 25 to 50%. If analgesia is insufficient, the dressing will be done under anesthetic block.
– Take advantage of residual analgesia after dressing for physiotherapy.
– As a last resort (no morphine and not achievable general anesthesia) in a secure context (trained staff, resuscitation equipment, surveillance room), adding ketamine IM at analgesic doses (0.5 to 1 mg / kg ) strengthens the paracetamol + tramadol before a bandage.
Chronic pain (during rehabilitation)
– Treatment is guided by regular self-assessment of pain. He appealed to paracetamol and tramadol. Neuropathic pain can occur.
– All other associated pain (physical therapy, mobilization) should be treated as acute pain.
Minor burns (outpatient):
– Local Care dressings to sulfadiazine or tulle gras (except superficial first degree burns).
– Pain: paracetamol associations ± tramadol usually enough.