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The Management of Burns: With Particular Reference to the Open Treatment
The Management of Burns With Particular Reference to the Open Treatment THOMAS D. PEMRICK, M.D. * MERLE M. MUSSELMAN, M.D., F.A.C.S. **
THE treatment of the wound is but one of several important factors in the general management of the burned patient. There have been favorable reports on the use of the open treatment of the wound. 1 • 2 In our experience, the morbidity was less and the hospital stay shorter when this method was used. GENERAL MANAGEMENT
Successful treatment of the burned patient demands immediate initiation of an orderly pattern of management and close attention. A patent airway must be assured immediately. Tracheotomy is essential when laryngotracheal edema develops from the inhalation of flame. Shock Primary shock, immediately following the burn, is uncommon. Wilson found that only 2.5 per cent of 80 patients with fatal burns died of primary shock.3 We have not seen primary shock. Secondary shock develops insidiously from four to twenty-four hours after the burn. The most widely accepted explanation for this is that of Blalock' and Phemister. 6 The blood volume is reduced because of the loss of plasma-like fluid at the site of the burn. Sodium, protein and red blood cells are lost and intense hemoconcentration follows. l • 7 The mechanism of production and the extent of the loss of plasma-like fluid at the site of injury are hot yet clarified. The blood volume must be restored soon to prevent secondary shock. A formula is a helpful guide for calculating the amount and type of
* Resident in Sv-rgery, Wayne County General Hospital, Eloise, Michigan. ** Director of Surgery, Wayne County General Hospital, Eloise, Michigan,· structor in Surgery, University of Michigan, Ann Arbor.
11S'!
In-
1128
Thomas D. Pemrick, Merle M. Musselman
fluid for replacement, but may lead to excessive or inadequate replacement. We use a simple rule based on the severity and extent of the burn modified by the patient's clinical response. We give 2 to 5 per cent of body weight as whole blood and 8 to 15 per cent of the body weight as plasma and electrolyte solution in the first forty-eight hours.8. 9 The larger amounts are used for burns of 50 per cent or more of the body surface. One-third of the total amount is given the first twelve hours, one-third the second twelve hours and one-third the next twenty-four hours. We agree with Evans10 that great care should be taken in administering more than 10 per cent of the body weight as fluids in a twentyfour hour period. The amounts are modified by the patient's response as indicated by thirst, pulse, blood pressure and the urinary output. We strive for a urinary output of about 50 cc. per hour. The electrolyte is given orally as a hypotonic solution when possible. * Water alone causes water intoxication. In addition to the above fluid, it is necessary to provide 2000 cc. of water for insensible loss and urinary output. Vomiting may add to the fluid requirements. Evidence of hemolysis indicates a greater need for whole blood. We seldom use the total amount of fluid calculated for replacement. Wound Care
The aim of any method of wound care is to control wound infection, decrease fluid and protein loss, support skin regeneration and provide a satisfactory bed for early grafting. Tetanus antitoxin is given routinely and tetanus toxoid is given at the same time to develop an active immunity. Wide spectrum antibiotics are used. Sensitivities of the organisms in the wound are determined from time to time. Wounds should be grafted as soon after the acute phase as possible. Closure of the wound decreases sepsis, loss of protein and morbidity. Nutrition
After the shock phase, the maintenance of adequate nutrition is the most important part of the management. The need for protein may be increased to 600 grams per day in an extensive burn.? Fat and carbohydrate are necessary to provide calories and to spare protein. The daily caloric requirements may be increased to 6000. Larger amounts of thiamine and other vitamins are necessary because of the increased rate of metabolism from infection and fever. These various requirements are met by increased amounts of a balanced diet. The dietitian serves as an
* Hypotonic electrolyte solution is made up of 3 grams of sodium chloride and 1.5 grams of sodium bicarbonate, sodium lactate or sodium citrate per liter.
Management of Burns
1129
important member of the therapeutic team by catering to the patient's likes and calculating the amount of protein, fat, carbohydrate and calories ingested daily. Patients should be weighed daily for more accurate control of nutrition. Feedings by gastric tube may be necessary. When starting feeding by gavage, caloric intake should be increased slowly over a period of a few days. Concentrated formulas sometimes cause anorexia. Table 1 A COMPARISON OF THE CLOSED AND OPEN METHODS OF TREATMENT SURVIVORS Hospital Stay (Days) EXTENT OF BURN
NO. PTS. MORTALITY
No. Grafted
Grafted Pts.
Nongrafted Pts.
38 78 89 0
27 33 0 0
Av.64
Av.30
Closed Method-73 Patients 32 32 7 2
0-10% 10-30% 30-60% 60-100% Totals ............. 1
73
0 3 3 2 1
8 (11%)
11 (34%) 18 (56%) 4 (57%) 0 1
23 (46%)
1
Open Method-81 Patients 22 52 5 2
0-10% 10-30% 30-60% 60-100% Totals.
.....I
0 1 3 2
7 (32%) 25 (48%) 3 (60%) 0
35 39 74 0
----------81
I 6 (7.4%)
!
35 (43%) I
Av.13
13.5 20.5 0 0
----Av.17
THE OPEN METHOD OF WOUND TREATMENT
We have reviewed two groups of patients; one treated by the closed method, and the other by the open method of wound care. The number of patients, the age of the patients and the extent of the burns were comparable. As shown in Table 1, the hospital stay and morbidity were less in the group treated by the open method. Tn addition, the number of anesthetics for dressing changes and debridement were less and the operations for skin grafting were fewer. Similar experiences have been reported by Wallace,n Blocker2 and others.13 The mortality rate was not decreased significantly.
T 1130
Thomas D. Pemrick, Merle M. Musselman
Advantages
The following list includes advantages of open treatment which we found important: 1. Increases awareness of, evaluation of, and attention to the wound. 2. Reduces pulmonary complications-better ventilation. 3. Allows dissipation of b.ody heat. 4. Encourages mobilization. 5. Eliminates warm, moist environment for bacterial growth.
Fig. 316. Patients are placed in a bed dressed in this manner. Drafts are held to a minimum by the drapes and heat is supplied with lights. The overhead bar encourages patients to turn and aids mobilization.
•
6. Reduces invasive infection. 7 .. Reduces destruction of skin and permits earlier wound closure. 8. Simplifies care and saves material. 9. Eliminates the uncomfortable, fetid dressings. 10. Eliminates anesthetics for and laborious changes of dressings. Procedure
Our routines for open treatment are relatively simple. Fresh burns are cleaned or debrided only if they are very dirty. Sterile water and a mild soap are used. The patients are placed in a bed dressed with fresh linen in the manner illustrated in Figure 316. We use clean technique rather than sterile technique when handling the patients. We avoid
r Management of Burns
1131
gross contamination from talking or breathing over the wounds. Pain is not a problem. After a few hours very little sedation is necessary. The large amount of fluid lost from the wound surface and the edema may be readily appreciated. This loss of fluid and edema- cannot be pre-
Fig. 317. a, This thin eschar, retracting along the edges, covered an extensive area of second degree burn in an infant. Infection was not a problem and grafting was unnecessary. b, These were thick eschars over third degree burns. They were undermined by infection. The eschars were debrided surgically 9 days after the burn and grafted later. The patient was discharged in 37 days .. c, This is a white, avascular eschar over an area of third degree burn. It was d~brided surgically 3 days after the burn and grafted immediately.
1132
Thomas D. Pemrick, Merle M. Musselman
vented by any method. 12 With the open method the nurses and doctors are more aware of the importance of fluid loss and care of the wound. The location of the burn does not limit the use of open treatment. The patients are encouraged to change position frequently. Most of them are gotten out of bed on the third day. We have had good results treating hands by this method. The hands assume the position of function naturally and motion is started early. We have also treated constricting burns of the trunk and extremities without difficulty. By estimating areas of third degree burn, we have been able to excise them and start grafting as early as the fourth day. Differentiation between second and third degree burns is not easy and is difficult to describe. Usually, the wound is white, depressed, dry and painless in a third degree burn; and red, raised and moist in a second degree burn. After about two days, an eschar develops and seals the wound. In a third degree burn the eschar is thick; it wrinkles and the tissue under it becomes soft and loose. Closure of wounds before the patIents become debilitated is one of the more important advantages of the open method. When infection is evident, tub soaks and wet dressings are alternated with exposure of the wounds. Debridement is carried out on the ward, often in the tub, under sedation. A general anesthetic is seldom necessary. After debridement the wound is covered with thin mesh gauze until the surface is ready for grafting. If patients could be housed the open treatment would be an acceptable method of care in time of disasterP It would not be satisfactory for patients to be transported. CONCLUSIONS
Wound care is only one factor in the management of the burned patient. It is the integration of the several factors that will lead to more success. We have found the open method of treatment to have advantages over the closed method. The most important of these were reduction of morbidity, hospital stay and expense of care. The mortality was not reduced. REFERENCES 1. Wallace, A. B.: The Exposure Treatment of Burns. The Lancet 1: 501, 1951. 2. Blocker, T. G., Blocker, V., Lewis, S. R. and Snyder, C. S.: Experiences with the Exposure Method of Burn Therapy. Plast. & Reconstruct. Surg. 8: 87, 1951. 3. Wilson, E. J.: Treatment of Burns and Scalds by Tannic Acid. Brit. M. J. 2: 91, 1928. 4. Blalock, A.: Experimental Shock: Importance of Local Loss of Fluids in Production of Low Blood Pressure after Burns. Arch. Surg. 20: 959, 1930.
Management of Burns
1133
5. Parsons, E. and Phemister, D. B.: Hemorrhage and "Shock" in Traumatized Limbs; Experimental Study. Surg., Gynec. & Obst. 51: 196, 1930. 6. Fox, C. L. and Keston, A. S.: Mechanism of Shock from Burns and Trauma Traced with Radioactive Sodium. Surg., Gynec. & Obst. 80: 561, 1945. 7. Moore, F. D., Langohr, J. L., Ingebretsen, M. and Cope, 0.: The Role of the Exudate Losses in the Protein and Electrolyte Imbalance of Burned Patients. Ann. Surg. 132: 1, 1950. 8. Lange, H. J. and Campbell, K. N.: The Treatment of the Severely Burned . Patient. University Hospital Bulletin, University of Michigan, 11: 90, 1945. 9. Moyer, C. A., Coller, F. A., lob, V., Vaughan, H. H. and Davis, M.: A Study of Interrelationship of Salt Solutions, Serum and Defibrinated Blood in the Treatment of Severely Scalded Anesthetized Animals. Ann. Surg. 120: 367, 1944. 10. Evans, E. 1.: The Early Management of the Severely Burned Patient. Surg., Gynec. & Obst. 94: 273, 1952. 11. Wallace. A. B.: Treatment of Burns: A Return to Basic Principles. Brit. J. Plast. Surg. 1: 232, 1949. 12. Rhinelander, F. A., Langohr, J. L. and Cope, 0.: Exploration into Physiologic Basis for Therapeutic Use of Restrictive Bandages in Thermal Burns: Experimental Study. Arch. Surg. 59: 1056, 1949. 13. Pulaski, E. J., Artz, C. P., Reiss, E. and Davis, J. H.: Evaluation of the Exposure Method in Burns. Surgical Forum Clinical Congress of American College of Surgeons, Philadelphia, W. B. Saunders Company, 1952, p. 518.
THE treatment of the wound is but one of several important factors in the general management of the burned patient. There have been favorable reports on the use of the open treatment of the wound. 1 • 2 In our experience, the morbidity was less and the hospital stay shorter when this method was used. GENERAL MANAGEMENT
Successful treatment of the burned patient demands immediate initiation of an orderly pattern of management and close attention. A patent airway must be assured immediately. Tracheotomy is essential when laryngotracheal edema develops from the inhalation of flame. Shock Primary shock, immediately following the burn, is uncommon. Wilson found that only 2.5 per cent of 80 patients with fatal burns died of primary shock.3 We have not seen primary shock. Secondary shock develops insidiously from four to twenty-four hours after the burn. The most widely accepted explanation for this is that of Blalock' and Phemister. 6 The blood volume is reduced because of the loss of plasma-like fluid at the site of the burn. Sodium, protein and red blood cells are lost and intense hemoconcentration follows. l • 7 The mechanism of production and the extent of the loss of plasma-like fluid at the site of injury are hot yet clarified. The blood volume must be restored soon to prevent secondary shock. A formula is a helpful guide for calculating the amount and type of
* Resident in Sv-rgery, Wayne County General Hospital, Eloise, Michigan. ** Director of Surgery, Wayne County General Hospital, Eloise, Michigan,· structor in Surgery, University of Michigan, Ann Arbor.
11S'!
In-
1128
Thomas D. Pemrick, Merle M. Musselman
fluid for replacement, but may lead to excessive or inadequate replacement. We use a simple rule based on the severity and extent of the burn modified by the patient's clinical response. We give 2 to 5 per cent of body weight as whole blood and 8 to 15 per cent of the body weight as plasma and electrolyte solution in the first forty-eight hours.8. 9 The larger amounts are used for burns of 50 per cent or more of the body surface. One-third of the total amount is given the first twelve hours, one-third the second twelve hours and one-third the next twenty-four hours. We agree with Evans10 that great care should be taken in administering more than 10 per cent of the body weight as fluids in a twentyfour hour period. The amounts are modified by the patient's response as indicated by thirst, pulse, blood pressure and the urinary output. We strive for a urinary output of about 50 cc. per hour. The electrolyte is given orally as a hypotonic solution when possible. * Water alone causes water intoxication. In addition to the above fluid, it is necessary to provide 2000 cc. of water for insensible loss and urinary output. Vomiting may add to the fluid requirements. Evidence of hemolysis indicates a greater need for whole blood. We seldom use the total amount of fluid calculated for replacement. Wound Care
The aim of any method of wound care is to control wound infection, decrease fluid and protein loss, support skin regeneration and provide a satisfactory bed for early grafting. Tetanus antitoxin is given routinely and tetanus toxoid is given at the same time to develop an active immunity. Wide spectrum antibiotics are used. Sensitivities of the organisms in the wound are determined from time to time. Wounds should be grafted as soon after the acute phase as possible. Closure of the wound decreases sepsis, loss of protein and morbidity. Nutrition
After the shock phase, the maintenance of adequate nutrition is the most important part of the management. The need for protein may be increased to 600 grams per day in an extensive burn.? Fat and carbohydrate are necessary to provide calories and to spare protein. The daily caloric requirements may be increased to 6000. Larger amounts of thiamine and other vitamins are necessary because of the increased rate of metabolism from infection and fever. These various requirements are met by increased amounts of a balanced diet. The dietitian serves as an
* Hypotonic electrolyte solution is made up of 3 grams of sodium chloride and 1.5 grams of sodium bicarbonate, sodium lactate or sodium citrate per liter.
Management of Burns
1129
important member of the therapeutic team by catering to the patient's likes and calculating the amount of protein, fat, carbohydrate and calories ingested daily. Patients should be weighed daily for more accurate control of nutrition. Feedings by gastric tube may be necessary. When starting feeding by gavage, caloric intake should be increased slowly over a period of a few days. Concentrated formulas sometimes cause anorexia. Table 1 A COMPARISON OF THE CLOSED AND OPEN METHODS OF TREATMENT SURVIVORS Hospital Stay (Days) EXTENT OF BURN
NO. PTS. MORTALITY
No. Grafted
Grafted Pts.
Nongrafted Pts.
38 78 89 0
27 33 0 0
Av.64
Av.30
Closed Method-73 Patients 32 32 7 2
0-10% 10-30% 30-60% 60-100% Totals ............. 1
73
0 3 3 2 1
8 (11%)
11 (34%) 18 (56%) 4 (57%) 0 1
23 (46%)
1
Open Method-81 Patients 22 52 5 2
0-10% 10-30% 30-60% 60-100% Totals.
.....I
0 1 3 2
7 (32%) 25 (48%) 3 (60%) 0
35 39 74 0
----------81
I 6 (7.4%)
!
35 (43%) I
Av.13
13.5 20.5 0 0
----Av.17
THE OPEN METHOD OF WOUND TREATMENT
We have reviewed two groups of patients; one treated by the closed method, and the other by the open method of wound care. The number of patients, the age of the patients and the extent of the burns were comparable. As shown in Table 1, the hospital stay and morbidity were less in the group treated by the open method. Tn addition, the number of anesthetics for dressing changes and debridement were less and the operations for skin grafting were fewer. Similar experiences have been reported by Wallace,n Blocker2 and others.13 The mortality rate was not decreased significantly.
T 1130
Thomas D. Pemrick, Merle M. Musselman
Advantages
The following list includes advantages of open treatment which we found important: 1. Increases awareness of, evaluation of, and attention to the wound. 2. Reduces pulmonary complications-better ventilation. 3. Allows dissipation of b.ody heat. 4. Encourages mobilization. 5. Eliminates warm, moist environment for bacterial growth.
Fig. 316. Patients are placed in a bed dressed in this manner. Drafts are held to a minimum by the drapes and heat is supplied with lights. The overhead bar encourages patients to turn and aids mobilization.
•
6. Reduces invasive infection. 7 .. Reduces destruction of skin and permits earlier wound closure. 8. Simplifies care and saves material. 9. Eliminates the uncomfortable, fetid dressings. 10. Eliminates anesthetics for and laborious changes of dressings. Procedure
Our routines for open treatment are relatively simple. Fresh burns are cleaned or debrided only if they are very dirty. Sterile water and a mild soap are used. The patients are placed in a bed dressed with fresh linen in the manner illustrated in Figure 316. We use clean technique rather than sterile technique when handling the patients. We avoid
r Management of Burns
1131
gross contamination from talking or breathing over the wounds. Pain is not a problem. After a few hours very little sedation is necessary. The large amount of fluid lost from the wound surface and the edema may be readily appreciated. This loss of fluid and edema- cannot be pre-
Fig. 317. a, This thin eschar, retracting along the edges, covered an extensive area of second degree burn in an infant. Infection was not a problem and grafting was unnecessary. b, These were thick eschars over third degree burns. They were undermined by infection. The eschars were debrided surgically 9 days after the burn and grafted later. The patient was discharged in 37 days .. c, This is a white, avascular eschar over an area of third degree burn. It was d~brided surgically 3 days after the burn and grafted immediately.
1132
Thomas D. Pemrick, Merle M. Musselman
vented by any method. 12 With the open method the nurses and doctors are more aware of the importance of fluid loss and care of the wound. The location of the burn does not limit the use of open treatment. The patients are encouraged to change position frequently. Most of them are gotten out of bed on the third day. We have had good results treating hands by this method. The hands assume the position of function naturally and motion is started early. We have also treated constricting burns of the trunk and extremities without difficulty. By estimating areas of third degree burn, we have been able to excise them and start grafting as early as the fourth day. Differentiation between second and third degree burns is not easy and is difficult to describe. Usually, the wound is white, depressed, dry and painless in a third degree burn; and red, raised and moist in a second degree burn. After about two days, an eschar develops and seals the wound. In a third degree burn the eschar is thick; it wrinkles and the tissue under it becomes soft and loose. Closure of wounds before the patIents become debilitated is one of the more important advantages of the open method. When infection is evident, tub soaks and wet dressings are alternated with exposure of the wounds. Debridement is carried out on the ward, often in the tub, under sedation. A general anesthetic is seldom necessary. After debridement the wound is covered with thin mesh gauze until the surface is ready for grafting. If patients could be housed the open treatment would be an acceptable method of care in time of disasterP It would not be satisfactory for patients to be transported. CONCLUSIONS
Wound care is only one factor in the management of the burned patient. It is the integration of the several factors that will lead to more success. We have found the open method of treatment to have advantages over the closed method. The most important of these were reduction of morbidity, hospital stay and expense of care. The mortality was not reduced. REFERENCES 1. Wallace, A. B.: The Exposure Treatment of Burns. The Lancet 1: 501, 1951. 2. Blocker, T. G., Blocker, V., Lewis, S. R. and Snyder, C. S.: Experiences with the Exposure Method of Burn Therapy. Plast. & Reconstruct. Surg. 8: 87, 1951. 3. Wilson, E. J.: Treatment of Burns and Scalds by Tannic Acid. Brit. M. J. 2: 91, 1928. 4. Blalock, A.: Experimental Shock: Importance of Local Loss of Fluids in Production of Low Blood Pressure after Burns. Arch. Surg. 20: 959, 1930.
Management of Burns
1133
5. Parsons, E. and Phemister, D. B.: Hemorrhage and "Shock" in Traumatized Limbs; Experimental Study. Surg., Gynec. & Obst. 51: 196, 1930. 6. Fox, C. L. and Keston, A. S.: Mechanism of Shock from Burns and Trauma Traced with Radioactive Sodium. Surg., Gynec. & Obst. 80: 561, 1945. 7. Moore, F. D., Langohr, J. L., Ingebretsen, M. and Cope, 0.: The Role of the Exudate Losses in the Protein and Electrolyte Imbalance of Burned Patients. Ann. Surg. 132: 1, 1950. 8. Lange, H. J. and Campbell, K. N.: The Treatment of the Severely Burned . Patient. University Hospital Bulletin, University of Michigan, 11: 90, 1945. 9. Moyer, C. A., Coller, F. A., lob, V., Vaughan, H. H. and Davis, M.: A Study of Interrelationship of Salt Solutions, Serum and Defibrinated Blood in the Treatment of Severely Scalded Anesthetized Animals. Ann. Surg. 120: 367, 1944. 10. Evans, E. 1.: The Early Management of the Severely Burned Patient. Surg., Gynec. & Obst. 94: 273, 1952. 11. Wallace. A. B.: Treatment of Burns: A Return to Basic Principles. Brit. J. Plast. Surg. 1: 232, 1949. 12. Rhinelander, F. A., Langohr, J. L. and Cope, 0.: Exploration into Physiologic Basis for Therapeutic Use of Restrictive Bandages in Thermal Burns: Experimental Study. Arch. Surg. 59: 1056, 1949. 13. Pulaski, E. J., Artz, C. P., Reiss, E. and Davis, J. H.: Evaluation of the Exposure Method in Burns. Surgical Forum Clinical Congress of American College of Surgeons, Philadelphia, W. B. Saunders Company, 1952, p. 518.