Present concepts concerning the care of the burned patient

PRESENT CONCEPTS CONCERNING THE CARE OF THE BURNED PATIENT* WILLIAM E. ABBOTT, M.D.~ DETROIT, MICHIGAN

AND

B

ECAUSE significant changes have occurred in the treatment of therma injuries over the past five years, it seemed desirabIe to review brieAy some of the more recent trends and outIine a method of treating burns which has been found to be satisfactory. The treatment of patients with burns can be divided into the foIIowing four main categories: I. The earIy therapy consisting of the reIief of pain and treatment of shock; 2. the immediate care of the IocaI wound and the contro1 of infection; 3. the nutritiona and metaboIic problems of the burned patient and 4. skin grafting and the prevention of scars and contractures. EARLY TREATMENT Immediate treatment of burns shouId consist of instituting shock therapy as soon as possibIe and genera1 anesthesia shouId be avoided. Experimenta studies by EIman’ demonstrated that the mortality rate is definiteIy increased foIIowing the administration of barbiturates and morphine whiIe cIinica1 experience has shown that such compounds should be empIoyed cautiousIy and onIy when necessary. Since rehef of pain heIps aIIeviate shock some medication for this purpose shouId be beneficia1. Because the circuIation is frequentIy impaired foIIowing a burn or injury, morphine given subcutaneousIy or intramuscuIarIy is often not absorbed and therefore does not reIieve pain.2 Repeated injections may Iater be absorbed when the circuIation has been restored to norma with a resuIting morphine poisoning.3 Because of this, Beecher2v3 advises giving morphine suIphate, grains 34 intravenousIy to aduIts

JOHN WINSLOW HIRSHPELD, M.D. ITHACA, NEW YORK

and repeating every haIf hour or so if necessary. The intravenous administration of o. I to 0.2 per cent procaine has been empIoyed for the reIief of pain and whiIe there has been IittIe experience with this method, it may offer a suitabIe way of reIieving the discomfort whiIe shock therapy is being carried out. Gordan4 advises injecting I Gm. of novocain crystaIs in 500 to I000 cc. of an isotonic saIt soIution over a period of one to one and one-haIf hours. During the past ten years the treatment of shock in burned patients has been IargeIy accompIished by the use of pIasma. In the past few years it has been noted both experimentaIIy5,” and cIinicaIIy’-lo that the use of a sodium containing eIectroIyte soIution and bIood is just as effective as pIasma and in some respects is preferabIe. PIasma was advocated primariIy because of the osmotic effect of the’protein moIecuIe and aIso because it reduces the existing hemoconcentration. However, it has been demonstrated that there is some reduction in the red ceI1 mass foIIowing a burn”v12 and that hemoconcentration can be overcome and an adequate circuIating bIood voIume maintained if eIectroIyte soIutions are empIoyed.5-7 PIasma proteins have been shown to be Iost from the vascuIar system at a rate comparabIe to that of sodium folIowing a burn. l3 Thus, the more recent trend has been toward suppIying bIood which contains both red ceI1 and protein eIements and to maintain the circuIation by increasing tissue tension by the administration of an eIectroIyte soIution. In a series of patients treated with Iarge amounts of pIasma the edema in the burned

* Presented in the Forum on Fundamental SurgicaI ProbIems before the Thirty-second the American CoIIege of Surgeons, CIeveIand, Ohio, December 16-20, 1946. t Research Division, Harper Hospital, Detroit, Mich. 296

CIinicaI Congress of

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Abbott, HirshfeId-Treatment

areas remained for Ionger periods of time than it did in those patients treated with an eIectroIyte soIution and bIood. Th’is probably occurred because of the presence of reIativeIy large amounts of protein in the extravascular spaces of the traumatized area in the pIasma treated patients. Various solutions have been demonstrated to be effective in combating shock”,‘, ‘J*10,14,‘zbut we prefer a soIution which contains inorganic eIectroIytes in amounts similar to that found in the extracellular ffuid. Since additiona water shouId be provided so that good kidney fuhction will occur, such a solution has been administered after diIuting it to two-thirds the origina strength. Hartman’s solution (Ringer-Iactate) can be used or one containing 6 Gm. of sodium chIoride and 2:~ Gm. of sodium bicarbonate per Iiter. In order to make the Iatter two soIutions hypotonic, 500 cc. of water shouId be added to 1,000 cc. of an isotonic soIution. In many instances the patient wiI1 be abIe to drink this mixture but if it cannot be taken orally due to nausea or vomiting or if it seems that the burn is suffIcientIy seliere so that vomiting might occur, it is wise to administer the solution intravenousIy until the patient’s condition improves. Since the hematocrit and various other chemical constituents often faiI to indicate the amount and type of treatment necessary,‘,l”J7 the latter shouId be governed by the severity of the burn and the size of the individua1 patient. The extent of the body surface area burned can be determined from the charts advocated by Lund and Browder.ls The amounts of hypotonic electroIyte soIution and blood which have been found to be effective are shown in TabIe I. No hard and fast ruIe shouId be used in prescribing therapy but the amounts of the various solutions shouId be aItered to fit the patient’s individua1 requirements and his response to treatment. The authors,5 as we11 as others9 have found that the urinary output provides a vaIuabIe guide as to the state of the patient and the effec-

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tiveness of therapy. In order that frequent checks can be made it is often desirabIe to insert a FoIey catheter into the bIadder of patients with a moderate or severe burn. The urine is then coIIected into a Iarge graduated cyIinder so that the per minute TABLE THE

AMOljNT

SOLUTION

AND

COMBATING

15

15 to

35

WHOLE

SHOCK

BLOOD

RESlJLTlNG

Amount eaual to 6 to 8% of paI tient’s body weight

i

,

to 14% of body weight

12

ELECTROL\TB

TO

BE

FROM

USED

IN

A BCRS

Amount of Blood Given

1during First Twenty-four I lours

25 to 50 cc. for every per cent the body is burned or an amount equal to z to 6% of body weight; (the larger quantities to

8toIz%ofbody

: weight , 35 to 100

I

PHYSIOLOGICAL.

1 i

I

5 to

0.6

The Amount of Hypotonic EIectroIyte S oIution Given in the First Twenty-four Hours

1

Per Cent of Body Surface Burned

OF

I be given to patients with third degree burns)

rate of urinary flow can be frequentIy and easiIy caIcuIated. When the inhaIation of smoke and fumes has occurred it wouId seem wise to inject an isotonic eIectroIyte soIution into the burned area as advocated by Berman and his co-workers.16~1g By such a method, tissue tension is increased with a preservation of a norma bIood pressure and pulmonary edema is Iess IikeIy to occur. The amount of whoIe bIood employed should vary somewhat depending on the age of the person, the extent and depth of the burn and the patient’s cardiovascuIar status. SmaIIer amounts of blood shouId be given to patients with first and second degree burns and somewhat Iarger quantities empIoyed when third degree burns are present, since more red ceIIs are destroyed or Iost in patients with third degree burns. The red ceIIs are not onIy destroyed initiaIIy with heat but are subsequently trapped in the capiIIaries in the injured area. Because

298

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of a persistent negative nitrogen baIance, the presence of infection, the oozing of bIood from granuIating surfaces and the opening up of new capilIaries during heaIing the patient with a third degree burn requires Iarge amounts of bIood initiaIIy and often again after the first two to four weeks. It is we11 to give smaIIer amounts of morphine, bIood and eIectroIyte soIution when treating smaI1 individuaIs or infants and the quantities empIoyed shouId be governed by the patient’s size and the severity of the injury. LOCAL

WOUND

THERAPY

Many of the oIder and more wideIy empIoyed methods of caring for burned areas have certain disadvantages. Bettman20 recentIy reported a 3.1 per cent mortaIity rate in over 700 patients on whom tannic acid and siIver nitrate were used. It was aIso evident from this study that Iiver necrosis did not cause death in any of the patients who succumbed; however, it has been shown both cIinicaIIy 21*22and experimentaIIy23 that the use of tannic acid and other chemica1 eschar producing substances causes IocaI injury to tissues. Thus, when such methods are used it is conceivabIe that a deep, second degree area might be converted into a third degree burn or that harmfu1 systemic changes may occur. In most instances death due to Iiver necrosis occurred foIIowing a burn when tannic acid jeIIy was empIoyed or when the patient was put in a bath containing a tannic acid soIution.24,2j However, SaItonstaI1, WaIker, Rhoads and Leez6 demonstrated by Iiver function tests that the chemica1 eschar producing substances usuaIIy cause some impairment to Iiver function, aIthough in many instances it was not severe enough to cause death. Since more recent studies27-2g have provided methods which have a11 the advantages of the chemica1 eschar methods without their IocaI and systemic III effects, the use of tannic acid is contraindicated in the treatment of therma injuries. It has aIso been emphasized that toxic systemic

of Burns

effects may occur in patients who have had boric acid appIied to the burned area or a crystalline suIfonamide compound used as a dusting powder or used in a water soIubIe ointment base. Since there is IittIe evidence to indicate that the suIfonamides are advantageous when appIied IocaIIy they are best avoided. The ora administration of the various suIfonamide compounds shouId not be instituted unti1 an adequate voIume of urine is being excreted. PeniciIIin can be injected safeIy and shouId be empIoyed when infection is IikeIy to occur. In 1942, AIIen and Koch2’ described the use of the occIusive or pressure dressing technic. If such dressings are used, vaseIine or carbowax is pIaced over the burned area, foIIowed by Iayers of steriIe gauze dressings, mechanic’s waste and an eIastic ace bandage or Aanne cut on the bias. AIthough this method had some advantages over the oIder forms of treatment and has been empIoyed wideIy during the past few years, it is not entireIy satisfactory. First, it is obvious that effective pressure cannot be employed on the head, neck, tho;rax, or abdomen and thus in these regions the dressings act mereIy as a steriIe covering. When they are appIied to the head and neck contamination often occurs due to vomiting or excessive saIivation and when they are used on the chest interference with pulmonary ventiIation may resuIt. SecondIy, application of pressure dressings are often very time-consuming and cumbersome and the patient experiences a certain amount of discomfort when the dressings are changed. Protein, saIts and fIuid continue to seep into the dressing, not onIy causing a Ioss of these constituents but aIso providing desirabIe media for bacteria as we11 as a rather unpIeasant odor. In some patients an unexpIained fever necessitates remova of the dressing so that the wound can be inspected and the presence or absence of infection determined. Chase2s has devised a protein extract from the beef aorta which when appIied to the burned area produces an eschar which has no apparent IocaI or systemic

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HirshfeId-Treatment

this injurious effects. He has empIoyed technic in several hundred ambulatory patients and more recently ZyIa and WeIler3O have used it in more than 400 seriousIy burned patients and have found it to be quite satisfactory. This protein extract can be applied in ointment form directly to the burned area or it can be put on fine mesh gauze which is then laid over the injured region. Experience obtained during the war indicated that extensive washing and’ debridement of the burned area was not necessary. Chase28 as weII as ZyIa and WelIer”O have employed a germicida1 detergent which is first sprayed over the burned area and fohowed by a normal saline soIution. These workers advocated using the protein extract either in the so-caIIed open method or cIosed method. In the open method the protein extract is apphed to the burned area and the patient is placed on a Bradford frame under a heat tent. SubsequentIy, if the eschar cracks, more ointment can be appIied. In the closed method the ointment is covered by a fine mesh gauze and the region wrapped with a sterile dressing. If infection occurs, the eschar which is produced Iiquifies. The wound can be frequentIy inspected when either the open or cIosed methods are empIoyed without fear of introducing further infection. More recentIy, Howes and Ackermann2g reported a technic for treating the IocaI wound which appears to be sound and especiaIIy advantageous in patients with third degree burns. It is efficient, simpIe, nontoxic and apparentIy acceIerates the separation of the dead tissue resuIting from a third degree burn. NUTRITIONAL THE

AND METABOLIC BURNED

PROBLEMS

OF

PATIENT

The nutritiona problem of the burned patient has been discussed eIsewhere.31 Briefly, the patient shouId receive a diet equal to 1.6 times his basa1 caIoric requirement. Twenty per cent of the tota caIoric intake shouId be derived from protein.

of Burns

299 AmericanJournalof Sllr&.cry

Burned and injured patients should be given a vitamin intake ranging from five to ten times their normaI daiIy requirement.32 This is especiaIIy true of vitamin C and B compIex. In patients with mild burns, food can be taken on the day of injury but in those patients with moderate or severe burns it is best to start the oral intake of food on the second or third day. After five to fifteen days the total calorrc intake and the amount of protein can be gradually increased as the patient toIerates the food. During the convalescence period the patient by choice drinks large quantities of fluid.’ Experimenta studies33 and the aforementioned cIinica1 observations indicate that fairIy Iarge amounts of water are retained by the body. Thus, after three days the low plasma or serum eIectroIyte vaIues which are often encountered usuaIIy do not indicate a deficiency of these products if adequate shock therapy has been given but resuIt from the retention of abnorma1 amounts of water. After the first or second day, the intake of Iarge amounts of sodium-containing soIutions is best avoided. We have empIoyed a concentrated plasma or albumin solution or a small amount of hypertonic eIectroIyte soIution to promote diuresis and overcome the existing dihrtion. In extensive third degree burns, it is desirabIe to increase the oral intake of saIt and protein when the necrotic tissue begins to separate and administer bIood to prevent or combat anemia and hypoproteinemia. SKIN

GRAFTING AND

AND

PREVENTION

OF SCARS

CONTRACTURES

Grafting of third degree burned areas shouId be carried out as soon as possibIe. The dermatone method described by Padgett 34 has been found to be satisfactory by most workers. Many of the metaboIic changes that occur can be avoided or the duration of these aIterations shortened if grafting is carried out promptly. The hazard of infection is aIso minimized when the unheaIed areas are reduced in size. The remova of dead tissue by the appIication of

300

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HirshfeId-Treatment

pyruvic acid paste as advocated by Connor and Harvey3”‘36 or the more recent method of Howes and Ackermannt2g shouId contribute greatIy in reducing the time required for a seriously burned patient to recover and thus minimize infection, metabohc changes, contractures, etc. OccasionaIIy the earIy excision and grafting of third degree areas is a heIpfuI way of handling these patients.37 SUMMARY

The treatment of patients with thermal burns can be divided into four main categories and the essentia1 points can be outlined as fohows. I. The treatment of shock shouId be instituted as earIy as possibIe and accomphshed by the judicious use of whoIe bIood and an eIectroIyte solution. The rehef of pain in such subjects is best a&ompIished by the intravenous administration of morphine suIphate, grains g to 46. 2. The immediate care of the IocaI wound is best carried out in the folIowing Extensive debridement is not manner: necessary, however, in most patients it is felt that a simpIe, non-traumatizing irrigation of the area provides some benefit. FoIIowing this, either the protein extract advocated by Chase28 or the ointment advocated by Howes and Ackermann2g shouId be apphed to the burned area. The systemic administration of penicihin is frequentIy advantageous for combating infection. 3. The nutritiona and metabohc probIems can be best summarized as fohows: (I ) Food is usuahy omitted (except in those patients with mild burns) for twenty-four to forty-eight hours; (2) a diet containing 1.6 times the patient’s basal caIoric requirements is then given. Twenty per cent of this diet should consist of a nutritionally adequate protein; (3) after five to fifteen days the diet is graduaIIy increased as it is toIerated so that it wiII provide adult patients with around 3,000 caIories and from 120 to 300 Gm. of protein daily; (4) patients with moderate or severe burns

of Burns

SEPTEMRF.R, ,047

should be given approximately ten times the daiIy requirements of the water-soluble vitamins and an adequate amount of vitamins A..and D for at Ieast two weeks; (5) since water retention occurs, especiaIIy between the second and fourteenth day folIowing a burn, and leads to a hemodiIution, this is best corrected by restricting the tota daiIy fluid intake to 2,000 to 4,000 cc. and administering a concentrated steriIe sohrtion of aIbumin or pIasma intravenously and repeating if necessary. The administration of 250 cc. of a hypertonic eIectroIyte solution (2 to 5 per cent) can also be administered between the third and twelfth days; (6) during the convaIescent period whoIe bIood shouId be given to correct or preferabIy to prevent anemia or hypoproteinemia (if the hemoglobin is over 16 Gm. per IOO cc. albumin or pIasma may be empIoyed). 4. Since the successfu1 care of such patients is dependent on the early healing of wounds, the remova of sIoughing tissue and the grafting of skin should be accompIished at the earhest possible date. If adequate therapy is given as soon as possibIe, preferably in an attempt to prevent shock, maInutrition, infection and a proIonged convaIescence from open wounds instead of overcoming these conditions once they exist, the mortahty and morbidity rates show continued improvement. REFERENCES I. ELMAN, R. Influence of ether, morphine and nembutal on mortality in experimental burns.

Ann. Surg.,

120: 211-213,

1944.

H. K. Delayed morphine poisoning in battle casuahies. J. A. M. A., 124: 1,193-1,194,

2. BEECHER,

* 944. 3. BEECHER, H. K. Symposium on management of Cocoanut Grove burns at Mass. General Hospita1; resuscitation and sedation of patients with burns which include airway; some problems of immediate therapy. Ann. Surg., I 17: 825-833, 1943. 4. GORDAN, R. A. Intravenous novocaine for analgesia in burns. Canad. M. A. .I., 49: 478-481, 1943. r;. MOYER. C. A.. COLLER. F. A.. IOB. V., VAUGHAN, H. II. and ‘MARTY, ‘D. A ‘study of the interrelationship of saIt solutions, serum and defibrinated bIood in the treatment of severely scalded, anesthetized dogs. Ann. Surg., 120: 367-376, 1944.

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0. ABBOTT, W. E., MEYER, F. L., HIRSHFELD, J. W. and GRIFFIN, G. E. MetaboIic aIterations following thermal burns, 1v; the effect of treatment with whole bIood and eIectroIyte solution or with pLasma following an experimenta burn. Surgery, 17: 794-804, 1945. 7. ABBOTT, W. E., PILLING, M. A., GRIFFIN, G. E., ~HIRSHFELD,J. W. and MEYER, F. L. MetaboIic alterations foIIowing therma burns, v; the use of whoIe blood and an eIectroIyte solution in the treatment of burned patients. Ann. Surg., 122: 678-692, 1945. 8. EVANS, E. I. and BIGGER, I. A. The rationaIe of whole bIood therapy in severe burns. Ann. Surg., 122: 693-705, 1945. 9. LANGE, H. J., CAMPBELL, K. N. and COLLER, F. A. Present policies in the treatment of the severeIy burned patient; an outline of treatment incIuding the use of whoIe bIood transfusions. J. Michigan M. Sot., 45: 619-633, 1946. 10. MCDONALD, J. J., CADMAN, E. F. and &UDDER, J. The importance of whoIe blood transfusions in the management of severe burns. Ann. Surg., 124: 332-353, 1946. I I. SHEN, S. C., HAM, T. H. and FLEMING, E. M. Studies on destruction of red bIood ceIIs; mechanism and complications of hemoglobinuria in patients with thermal burns; spherocytosis and increased osmotic fragility of red blood cells. New England J. Med., 229: 701-713, 1943. 12. MOORE, F. D., PEACOCK, W. C., BLAKELY, E. and COPE, 0. The anemia of thermal burns. Ann. Surg., 124: 811-839, 1946. 13. COPE, 0. and MOORE, F. D. Study of capiIIary permeability in experimental burns and burn shock using radioactive dyes in bIood and Iymph. J. Ch. InVeStigatiOn, 23: 241-257, 1944. 14. Fox, C. L., JR. Oral sodium Iactate in the treatment of burn shock. J. A. M. A., 124: 207-212, 1944. 15. BERMAN, J. K., PETERSON, L. and BUTLER, J. The treatment of burn shock with continuous hypodermocIysis of physiological saline soIution into the burned area; experimental study. Surg., Gynec. +Y Obst., 78: 337-345, 1944. 16. ABBOTT, W. E. A review of the present concepts on fluid balance. Am. J. M. SC., 2 I I : 232-239, 1946. 17. ABBOTT, W. E. FIuid eIectroIyte and nutritional probIems in surgery. S. Clin. Nortb America, 26: 1,330-1.360, 1946. 18. LUND, C. C. and BROWDER, N. C. Estimation of areas of burns. Surg., Gynec. @ Obst., 79: 352-358, 1944. 19. BERMAN, J. K., PIERCE, G. S. and BEST, M. M. Burn shock; its treatment with continuous hypodermocIysis of isotonic solution of sodium chloride into the burned areas; clinical studies in two cases. Arch. Surg., 53: 577-587, 1946. 20. BETTMAN, A. G. Causes of death in burned patients; a report of 23 deaths in 744 burned 1 _^ patients. Am. J. >uTg., 71: 2b-35, 1940.

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30 I

21. CANNON, B. and COPE, 0. Rate of epithelial regeneration; a clinical method of measurement, and the effect of various agents recommended in treatment of burns. Ann. Surg., I 17: 8592, 1943. 22. HIRSHFELD, J. W., PILLING, M. A. and MAUN, M. E. A comparison of the effects of tanning agents and of Vaseline gauze on fresh wounds of man. Surg., Gynec. u Obst., 76: 556561, 1943. 23. MAUN, M. E., SCHNEIDER, R. C., PILLING, M. A. and HIRSHFELD, J. W. Tissue reactions to medicaments used in the IocaI treatment of burns. Surgery, 14: 229-238, 1943. 24. RAE, S. L. and WILKINSON, A. W. Liver function after burns in chiIdhood, changes in Iaevulose tolerance. hlCet, I : 332-334, 1944. 25. MCCLURE, R. D., LAM, C. R. and ROMENCE, H. Tannic acid and the treatment of burns; an obsequy. Ann. Surg., 120: 387-398, 1944. 26. SALTONSTALL,H., WALKER, J., JR., RHOADS, J. E. and LEE, W. E. The influence of IocaI treatment of burns on Iiver function. Ann. Surg., 121: 291-300, 1945. 27. ALLEN, H. S. and KOCH, S. L. The treatment of patients with severe burns. Surg., Gynec. @ Obst., 74: 914924, 1942. 28. CHASE, C. H. A new eschar technique for the IocaI treatment of burns. Surgery, (to be pubIished). 29. HOWES, E. L. and ACKERMANN, W. The physioIogical approach to the local treatment of burns. Bull. Am. Coil. Surgeons, 32: 93, 1947. 30. ZYLA, E. L. and WELLER, C. N. (Unpublished data.) 31. ABBOTT, W. E., HIRSHFELD, J. W., WILLIAMS, H. H., PILLING, M. A. and MEYER, F. L. Metabolic alterations folIowing thermal burns, VI; the effect of aItering the nitrogen and caIoric intake or of administering testosterone propionate on the nitrogen balance. Surgery, 20: 284-294, 1946. 32. LEVENSON,S. M., GREEN, R. W., TAYLOR, F. H. L., ROBINSON, P., PAGE, R. C., JOHNSON, R. E. and LUND, C. C. Ascorbic acid, riboflavin, thiamin, and nicotinic acid in relation to severe injury, hemorrhage, and infection in the human. Ann. Surg., 124: 840-856, 1946. 33. ABBOTT, W. E., HIRSHFELD,J. W. and MEYER, F. L. Metabolic aIterations following thermal burns, II; changes in the pIasma voIume and pIasma protein in the convalescent phase. Surg., Gynec. @‘RObst., 81: 25-30, 1945. 34. PADGETT, E. C. Skin Grafting. SpringfieId, III., 1942. CharIes C. Thomas. 35. CONNOH, G. J. and HARVEY, S. C. The heaIing of deep therma burns; preliminary report. Ann. Surg., 120: 362-366, 1944. 36. CONNOR, G. J. and HARVEY, S. C. The pyruvic acid method in deep clinica burns. Ann. Surg., 124: 799-810. 1946. 37. COPE, 0.. LANGOHR, J. L., MOORE, F. D. and WEBSTER, R. C., JR. Expeditious care of fuIIthickness burn wounds by surgical excision and grafting. Ann. Surg., 125: 1-22, 1947.