Treatment for Burns cases
Burns is a type of injury to flesh or skin caused by heat, electricity,chemicals, friction, or radiation. Burns that affect only the superficial skin are known as superficial or first-degree burns. When damage penetrates into some of the underlying layers, it is a partial-thickness or second-degree burn. In a full-thickness or third-degree burn, the injury extends to all layers of the skin. A fourth-degree burn additionally involves injury to deeper tissues, such as muscle or bone.
Burns are caused by-
In the United States, fire and hot liquids are the most common causes of burns. Of house fires that result in death, smoking causes 25% and heating devices cause 22%.Almost half of injuries are due to efforts to fight a fire.] Scalding is caused by hot liquids or gases and most commonly occurs from exposure to hot drinks, high temperature tap water in baths or showers, hot cooking oil, or steam. Scald injuries are most common in children under the age of five] and, in the United States and Australia, this population makes up about two-thirds of all burns. Contact with hot objects is the cause of about 20-30% of burns in children. Generally, scalds are first or second degree burns, but third degree burns may also result, especially with prolonged contact. Fireworks are a common cause of burns during holiday seasons in many countries. This is a particular risk for adolescent males.
Chemicals cause from 2 to 11% of all burns and contribute to as many as 30% of burn-related deaths.] Chemical burns can be caused by over 25,000 substances, most of which are either a strong base (55%) or a strong acid (26%).Most chemical burn deaths are secondary to ingestion. Common agents include: sulfuric acid as found in toilet cleaners,sodium hypochlorite as found in bleach, and halogenated hydrocarbons as found in paint remover, among others] Hydrofluoric acid can cause particularly deep burns which may not become symptomatic until some time after exposure.] Formic acid may cause the breakdown of significant numbers of red blood cells.
Electrical burns or injuries are classified as high voltage (greater than or equal to 1000 volts), low voltage (less than 1000 volts), or as flash burns secondary to an electric arc. The most common causes of electrical burns in children are electrical cords (60%) followed by electrical outlets (14%).] Lightning may also result in electrical burns] Risk factors for being struck include involvement in outdoor activities such as mountain climbing, golf and field sports, and working outside.] Mortality from a lightning strike is about 10%.While electrical injuries primarily result in burns, they may also cause fractures or dislocations secondary to blunt force trauma or muscle contractions. In high voltage injuries, most damage may occur internally and thus the extent of the injury cannot be judged by examination of the skin alone. Contact with either low voltage or high voltage may produce cardiac arrhythmias or cardiac arrest.
Radiation burns may be caused by protracted exposure to ultraviolet light (such as from the sun, tanning booths or arc welding) or from ionizing radiation (such as from radiation therapy, X-rays or radioactive fallout).] Sun exposure is the most common cause of radiation burns and the most common cause of superficial burns overall. There is significant variation in how easily people sunburn based on their skin type.] Skin effects from ionizing radiation depend on the amount of exposure to the area, with hair loss seen after 3 Gy, redness seen after 10 Gy, wet skin peeling after 20 Gy, and necrosis after 30 Gy. Redness, if it occurs, may not appear until some time after exposure. Radiation burns are treated the same as other burns. Microwave burns occur via thermal heating caused by the microwaves.] While exposures as short as two seconds may cause injury, overall this is an uncommon occurrence.
In those hospitalized from scalds or fire burns, 3–10% are from assault.] Reasons include: child abuse, personal disputes, spousal abuse, elder abuse, and business disputes.] An immersion injury or immersion scald may indicate child abuse.] It is created when an extremity or the lower body (buttock or perineum) is held under the surface of hot water.[ It typically produces a sharp upper border and is often symmetrical. Other high-risk signs of potential abuse include: circumferential burns, the absence of splash marks, a burn of uniform depth, and association with other signs of neglect or abuse. Bride burning, a form of domestic violence, occurs in some cultures such as India where a woman is burned due to what the husband or his family consider to be an inadequate dowry. In Pakistan, acid burns represent 13% of intentional burns, and are frequently related to domestic violence. Self-immolation (setting oneself on fire as a form of protest) is also relatively common among Indian women.
Burns can be classified by depth, mechanism of injury, extent, and associated injuries. The most commonly used classification is based on the depth of injury. The depth of a burn is usually determined via examination, although a biopsy may also be used.] It may be difficult to accurately determine the depth of a burn on a single examination and repeated examinations over a few days may be necessary.] In those who have aheadache or are dizzy and have a fire-related burn, carbon monoxide poisoning should be considered. Cyanide poisoning should also be considered.
The size of a burn is measured as a percentage of total body surface area(TBSA) affected by partial thickness or full thickness burns.] First-degree burns that are only red in color and are not blistering are not included in this estimation.] Most burns (70%) involve less than 10% of the TBSA.[ There are a number of methods to determine the TBSA, including the "rule of nines", Lund and Browder charts, and estimations based on a person's palm size.] The rule of nines is easy to remember but only accurate in people over 16 years of age. More accurate estimates can be made using Lund and Browder charts, which take into account the different proportions of body parts in adults and children. The size of a person's handprint (including the palm and fingers) is approximately 1% of their TBSA.
In order to determine the need for referral to a specialized burn unit, the American Burn Association devised a classification system. Under this system, burns can be classified as major, moderate and minor. This is assessed based on a number of factors, including total body surface area affected, the involvement of specific anatomical zones, the age of the person, and associated injuries. Minor burns can typically be managed at home, moderate burns are often managed in hospital, and major burns are managed by a burn center.
Historically, about half of all burns were deemed to be preventable. Burn prevention programs have significantly decreased rates of serious burns. Preventative measures include: limiting hot water temperatures, smoke alarms, sprinkler systems, proper construction of buildings, and fire-resistant clothing. Experts recommend setting water heaters below 48.8 °C (119.8 °F). Other measures to prevent scalds include using a thermometer to measure bath water temperatures, and splash guards on stoves. While the effect of the regulation of fireworks is unclear, there is tentative evidence of benefit with recommendations including the limitation of the sale of fireworks to children.
Resuscitation begins with the assessment and stabilization of the person's airway, breathing and circulation.] If inhalation injury is suspected, early intubation may be required.] This is followed by care of the burn wound itself. People with extensive burns may be wrapped in clean sheets until they arrive at a hospital. As burn wounds are prone to infection, a tetanus booster shot should be given if an individual has not been immunized within the last five years.] In the United States, 95% of burns that present to the emergency department are treated and discharged; 5% require hospital admission.] With major burns, early feeding is important Hyperbaric oxygenation may be useful in addition to traditional treatments.
In those with poor tissue perfusion, boluses of isotonic crystalloid solution should be given. In children with more than 10-20% TBSA burns, and adults with more than 15% TBSA burns, formal fluid resuscitation and monitoring should follow. This should be begun pre-hospital if possible in those with burns greater than 25% TBSA. The Parkland formula can help determine the volume of intravenous fluids required over the first 24 hours. The formula is based on the affected individual's TBSA and weight. Half of the fluid is to be administered over the first 8 hours, and the remainder given over the following 16 hours. The time frame is calculated from the time at which the burn occurred, and not from the time at which fluid resuscitation was begun. Children require additional maintenance fluid that includes glucose. Additionally, those with inhalation injuries require more fluid. While inadequate fluid resuscitation may cause problems, over-resuscitation can also be detrimental. The formulas are only a guide, with infusions ideally tailored to a urinary output of >30 mL/h in adults or >1mL/kg in children and mean arterial pressure greater than 60 mmHg. While lactated Ringer's solution is often used, there is no evidence that it is superior to normal saline Crystalloid fluidsappear just as good as colloid fluids, and as colloids are more expensive they are not recommended. Blood transfusionsare rarely required They are typically only recommended when the hemoglobin level falls below 60-80 g/L (6-8 g/dL)due to the associated risk of complications. Intravenous catheters may be placed through burned skin if needed orintraosseous infusions may be used.
Early cooling (within 30 minutes of the burn) reduces burn depth and pain, but care must be taken as over-cooling can result in hypothermia. It should be performed with cool water 10–25 °C (50.0–77.0 °F) and not ice water as the latter can cause further injury. Chemical burns may require extensive irrigation. Cleaning with soap and water, removal of dead tissue, and application of dressings are important aspects of wound care. If intact blisters are present, it is not clear what should be done with them. Some tentative evidence supports leaving them intact. Second degree burns should be re-evaluated after two days.[ In the management of first and second degree burns, little quality evidence exists to determine which type of dressing should be used. It is reasonable to manage first degree burns without dressings. While topical antibiotics are often recommended, there is little evidence to support their use.] Silver sulfadiazine (a type of antibiotic) is not recommended as it potentially prolongs healing time There is insufficient evidence to support the use of dressings containing silver or negative-pressure wound therapy
Burns can be very painful and a number of different options may be used for pain management. These include simple analgesics (such as ibuprofen and acetaminophen) and opioids such as morphine. Benzodiazepines may be used in addition to analgesics to help with anxiety. During the healing process, antihistamines, massage, or transcutaneous nerve stimulation may be used to aid with itching.] Antihistamines, however, are only effective for this purpose in 20% of people. There is tentative evidence supporting the use of gabapentin and its use may be reasonable in those who do not improve with antihistamines Intravenous antibiotics are recommended before surgery for those with extensive burns (>60% TBSA). As of 2008, guidelines do not recommend their general use due to concerns regarding antibiotic resistance and the increased risk offungal infections.] Tentative evidence, however, shows that they may improve survival rates in those with large and severe burns. Erythropoietin has not been found to be effective to prevent or treat anemia in people with burns.] In burns caused by hydrofluoric acid, calcium gluconate is a specific antidote and may be used intravenously and/or topically.
Wounds requiring surgical closure with skin grafts or flaps (typically anything more than a small full thickness burn) should be dealt with as early as possible. Circumferential burns of the limbs or chest may need urgent surgical release of the skin, known as an escharotomy. This is done to treat or prevent problems with distal circulation, or ventilation.] It is uncertain if it is useful for neck or digit burns.] Fasciotomies may be required for electrical burns.
Honey has been used since ancient times to aid wound healing and may be beneficial in first and second degree burns. The evidence for aloe vera is of poor quality. While it might be beneficial in reducing pain, and a review from 2007 found tentative evidence of improved healing times] a subsequent review from 2012 did not find improved healing over silver sulfadiazine. There is little evidence that vitamin E helps with keloids or scarring. Butter is not recommended. In low income countries, burns are treated up to one-third of the time with traditional medicine, which may include applications of eggs, mud, leaves or cow dung. Surgical management is limited in some cases due to insufficient financial resources and availability. There are a number of other methods that may be used in addition to medications to reduce procedural pain and anxiety including: virtual reality therapy, hypnosis, and behavioral approaches such as distraction techniques.
The prognosis is worse in those with larger burns, those who are older, and those who are females. The presence of a smoke inhalation injury, other significant injuries such as long bone fractures, and serious co-morbidities (e.g. heart disease, diabetes, psychiatric illness, and suicidal intent) also influence prognosis.] On average, of those admitted to United States burn centers, 4% die, with the outcome for individuals dependent on the extent of the burn injury. For example, admittees with burn areas less than 10% TBSA had a mortality rate of less than 1%, while admittees with over 90% TBSA had a mortality rate of 85%. In Afghanistan, people with more than 60% TBSA burns rarely survive. The Baux score has historically been used to determine prognosis of major burns; however, with improved care, it is no longer very accurate. The score is determined by adding the size of the burn (% TBSA) to the age of the person which used to more or less equal the risk of death
A number of complications may occur, with infections being the most common. In order of frequency, potential complications include: pneumonia, cellulitis, urinary tract infections and respiratory failure. Risk factors for infection include: burns of more than 30% TBSA, full-thickness burns, extremes of age (young or old), or burns involving the legs or perineum. Pneumonia occurs particularly commonly in those with inhalation injuries.[ Anemia secondary to full thickness burns of greater than 10% TBSA is common.] Electrical burns may lead tocompartment syndrome or rhabdomyolysis due to muscle breakdown. Blood clotting in the veins of the legs is estimated to occur in 6 to 25% of people. The hypermetabolic state that may persist for years after a major burn can result in a decrease in bone density and a loss of muscle mass.] Keloids may form subsequent to a burn, particularly in those who are young and dark skinned. Following a burn, children may have significant psychological trauma and experience post-traumatic stress disorder. Scarring may also result in a disturbance in body image. In the developing world, significant burns may result in social isolation, extreme poverty and in children abandonment.