Further management
It is important to complete a detailed history of pre-existing problems
and of the burn injury. A detailed physical examination and examination of the
burned area is carried out. Adequate pain relief must be provided, usually by
means of intravenous morphine. Good notes and a drawing of the burn area are
needed. Smaller burns may be managed satisfactorily on an outpatient basis
with arrangements for further dressing either at a hospital follow-up clinic or
by the general practitioner. Patients with major burns should ideally be treated
in a specialised burns unit. Indications for referral include:
• burns of special areas (face, hands, feet, perineum, genitalia);
• full-thickness burns >5 per cent body surface area;
• circumferential limb or chest burns;
• electrical burns;
• chemical burns;
• burns in children or the elderly;
• where nonaccidental injury is suspected in the case of a child;
• associated medical conditions or pregnancy;
• associated other trauma.
Adequate
assessment, resuscitation and fluid administration should be secured before
transfer of the patient. The trend towards early surgical excision and closure
of the wound dictates that any patient with a wound which is unlikely to heal
spontaneously should have the benefit of a plastic or burns surgical opinion at
the earliest possible stage. A burns unit is often the most convenient place to
undertake regular dressings. Dressing changes in an appropriate area are likely
to minimise cross-infection, although formal isolation is rarely used unless a
patient is shown to have an antibiotic-resistant organism, such as methicillin-resistant
Staphylococcus aureus. The burns unit provides facilities for immediate
physiotherapy and occupational therapy to minimise limb stiffness. Nutritional
support is available. Early establishment of normal feeding appears to protect
the small bowel mucosa and prevent translocation of Gram-negative bacteria.
Inhalation injuries often require ventilation and monitoring by blood gases and
bronchoscopy. These are best managed in a respiratory intensive care unit with
appropriate surgical support for the management of the burn wound.
Dressings
Epidermal burns with erythema and no blisters do not need dressings.
Analgesia and moisturising cream are used. Burns the face are generally treated
by exposure, largely because the difficulty of dressing (Fig.
14.6). Where there
is much crusting it may be necessary to apply an ointment such as petroleum
jelly, particularly around the eyes, and frequent toilet of the eyes and
orifices may be needed. Burns of the trunk and limbs are usually dressed. Where
possible the burns should be inspected by an experienced doctor to check on the
assessment of area and depth before the application of dressings, as appearances
may subsequently be difficult to interpret. Superficial dermal burns with
blistering are usually dressed to absorb exudate, prevent desiccation, provide
pain relief, encourage epithelialisation and prevent infection. Appropriate
dressings are plastic films, hydrocolloids, preserved cadaver or pig skin,
alginates or paraffin gauze. A thick layer of gauze may then be placed on top to
allow transudation of any fluid and layers of wool or padding are applied
over this to act as a sump for exudate. Dressing changes are painful and should
not be performed more than necessary. Partial-thickness skin injuries heal
within 2—3 weeks. Any wound that remains unhealed or granulating at 3 weeks
will not heal satisfactorily without surgical intervention. Plastic surgical
advice should certainly be sought by 3 weeks or at an earlier stage if the wound
is extensive or showing evidence of considerable slough formation. Enzyme
preparations may be used to facilitate sloughing. Where deep burns are being
managed with dressings a topical antimicrobial agent such as silver
sulphadiazine cream is used.
There is controversy about the use of routine antibiotic administration.
It is almost inevitable that a burned surface will become colonised by
microorganisms. The administration of broad-spectrum antibiotics on a routine
basis is likely to encourage the emergence of resistant organisms. Children
suffering from burn wounds are often given routine antibiotics to limit the
possibility of metastatic infection. Almost any organism may colonise a wound.
Beta-haemolytic streptococci are likely to delay healing and should be
treated. Staphylococcus aureus is a frequent pathogen and Pseudomonas
particularly grows on raw surfaces. These organisms may be best treated by
local antiseptic preparations, although where there is any evidence of
cellulitis, antibiotics should be administered. Frequent wound swabs should be
cultured and where there is any rise in temperature, blood cultures should be
taken.
Whether
to administer an antibiotic before an organism is cultured from the blood is an
individual clinical decision that depends on the severity of the patient’s
condition.
Monitoring
for the onset or progress of infection should consist of:
• routine temperature measurement;
• frequent wound swab cultures;
• wound inspection by an experienced doctor or nurse at the time of
dressing change;
• blood cultures.
Toxic
shock syndrome
Toxic shock syndrome (TSS) is a life-threatening, exotoxin-mediated
disease caused by S. aureus. It can occur in children who often have
small body surface area burns. It presents with fever, a rash, myalgia,
diarrhoea and vomiting and can progress rapidly to hypotension and multiorgan
failure. Treatment is by dressing change, fluid resuscitation, antibiotics and
immunoglobulin. Mortality can be high, but prompt active intervention appears to
be effective. It is important to have a high index of suspicion regarding this
condition when treating burned children.
Surgical
treatment
Partial-thickness burns should heal without surgical intervention, but
full-thickness burns require surgical management. There are two alternative
policies for deep burns. One can await spontaneous desloughing and apply
split-skin grafts at 3 weeks. This policy has the advantage that early operation
can be avoided, but has the disadvantage of slow healing and greater scarring
that follows a granulating wound. Alternatively, early excision of the burn is
carried out with the application of skin cover, usually a skin graft, but
where indicated a flap. This has the advantage of obtaining rapid healing and
early restoration of function, and minimises the risk of adverse scarring. Where
facilities allow, a policy of early operation for deep burns is preferred. Early
tangential excision of skin grafting is a technique used for deep dermal
burns, usually performed within 48 hours. Successive layers of the burned tissue
are shaved with a split-skin grafting knife until a healthy bleeding dermal bed
is reached upon which the skin grafts are applied. The rationale of this
treatment is that deep dermal burns will heal slowly with considerable scarring.
The healing process can be expedited by this method. It is a technique that
requires considerable experience in the interpretation of the wound bed. Any
surgery of this type is associated with considerable blood loss and limbs should
be operated on with the assistance of a tourniquet. On the trunk it may be
necessary to use a dilute infusion of adrenaline subcutaneously. Following
excision of burned
Mobilisation and rehabilitation
The
move towards earlier excision and skin cover and early mobilisation of the
patient succeeds in reducing the incidence of complications such as infection
and deep vein thrombosis. Most burns units have an intensive programme of physiotherapy
and mobilisation without which limb oedema would progress to joint contractures.
Surgical reconstruction of the burn injury
The
major complication of burn injury is scarring (Fig.
14.11). Lumpy hypertrophic
or keloid scars can be limited by the