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The Planning of Patient Care in a Hospital Burn Unit
The Planning of Patient Care in a Hospital Burn Unit JOHN A. BOSWICK, JR., M.D.* NELSON H. STONE, M.D., Ph.D. **
The planning of patient care in a hospital bum unit is dependent upon several factors: the size of the unit, its administrative philosophy, and its approach to patient care. Such plans are also related to the size of the facility in relationship to the needs of the area it serves. A bum unit with a large number of beds in a community in which they would rarely be filled, could give long-term care and carry out clinical investigational projects without interfering with optimal patient care. The planning of patient care in a hospital bum unit is significantly related to the facilities in the unit, such as an operating room, areas for physical and occupational therapy, treatment rooms for dressing changes and wound care, and outpatient facilities. It also depends upon the relationship of the unit and its facilities to the other departments and areas of the hospital and to other hospitals and institutions in the community. In a large hospital, where all bum patients are admitted to the bum unit (if space is available), maximal staffing will be required to manage the acute care, surgical care, and day-to-day nursing and outpatient care. In this article, the Sumner L. Koch Burn Unit at the Cook County Hospital in Chicago will be described and its role within the hospital and community will be presented: its admission policy, staffing, and certain aspects of care and rehabilitation.
DESCRIPTION OF UNIT In the late 1930's and early 1940's, Dr. Sumner L. Koch and his associates pioneered in the treatment of bums at Cook County Hospital and 'Director, Sumner L. Koch Burn Unit, and Chief, Hand Surgical Service, Cook County Hospital; Associate Professor of Surgery, Northwestern University Medical School, Chicago, Illinois "Assistant Director, Hand and Burn Surgical Services, Cook County Hospital; Assistant Professor of Surgery, Northwestern University Medical School
Surgical Clinics of North America- Vol. 50, No.1, February, 1970
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276
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A.
BOSWICK, JR., NELSON
H.
STONE
established a service at that hospital for this purpose. It was initially a part of the Children's Surgical Service. During World War II, this service was converted into a separate facility for research and clinical purposes under the auspices of the National Research Council. This unit remained active until 1956. In July of 1961, a burn service was again formed at Cook County Hospital as part of the Pediatric Surgical Service. In January of 1962, for administrative and staffing purposes, the Pediatric Burn Service was converted into a Pediatric Burn Unit. The need for a similar unit for adults was recognized and established. The two units combined in September 1964, in the area that is now the Sumner L. Koch Burn Unit of the Cook County Hospital. It occupies most of the fifth floor of the Children's Hospital Building and has a capacity for approximately 35 patients (depending upon the ratio of children to adults). Within the unit there is a dressing room with three whirlpool baths and a shower, where wound care is rendered to the patient as frequently as indicated. The unit has its own operating room, where wound debridement, skin grafting, and reconstructive and other surgical procedures are performed. The unit also has an area set aside for occupational and physical therapy, as well as a play and recreational area. The offices of the director and the assistant director as well as most of the staff are in the unit, which facilitates patient care and administration. Patients are arranged in rooms according to the severity of their injury or by age or sex.
ADMISSION POLICY Patients who present themselves to Cook County Hospital with acute or reconstructive burn problems are admitted directly to the unit. On occasion, the bed capacity of the unit becomes filled and patients are admitted to other areas of the hospital under the supervision of the burn unit staff, to be transferred to the unit when a bed becomes available. Such patients represent slightly over 50 per cent of the burn unit adInissions. The remaining patients come as elective admissions from the outpatient clinic of the hospital or as transfers from other hospitals in the region. Patients referred from other hospitals constitute two groups: those who are seen in the emergency rooms of these institutions and are never admitted there but are referred directly, and those who have been adInitted for initial care and are transferred for intermediate and definitive therapy. Referrals of the latter two groups come mostly from the area of Cook County, but in the past few years, there have been referrals and adInissions from eight Midwestern states. When a bed exists, it is the policy of the unit to accept patients for transfer from other institutions with acute or reconstructive burn problems. The decision for transferring a patient is based on bed availability, the patient's needs (meaning the extent, depth, and location of the burns) and, on occasion, family situations.
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STAFFING The unit is directed by a full-time surgeon and a full-time assistant, whose offices are in the unit, but who have other surgical responsibilities within the hospital. Between five and seven residents from the Departments of General and Plastic Surgery are assigned to the unit, as are one or more surgical fellows pursuing special training in burn surgery or research. Interns are assigned to the unit upon their request as part of their surgical internships. Students from the city's five medical schools rotate through the unit as part of their clinical clerkships in surgery. The nursing staff consists of a chief nurse, who is responsible for all nursing activities of the unit, and a clinical supervisor, whose main responsibility is in the field of patient care. There are five head nurses who have responsibility in the area of patient care, operating room, and dressing rooms, and 14 other registered nurses working in these areas. Twelve licensed practical nurses work as a member of the nursing team in all areas of the unit. The 16 nursing attendants work in all of the clinical areas and perform essential jobs as members of the nursing team. A unit manager and three clerical workers are responsible for the clerical and some of the administrative work on the unit. The secretarial staff is a part of the office of the director and has as one of its main responsibilities the maintaining of patient records for on-going clinical research studies. The unit has its own full-time occupational therapist, who is responsible for the occupational and physical therapy needs of the patients. She works under the supervision of the physicians responsible for patient care and in consultation with the consulting physiatrist. A portion of her responsibility is the day-to-day care of patients and clinical investigation related to rehabilitation. Consultants in physical medicine, plastic and reconstructive surgery, and psychiatry meet regularly with the burn unit staff for consultation purposes and are available for emergencies or urgent problems. Outpatient facilities consist of a clinic for the care of acute burns, which meets 6 days a week and a contracture clinic, which meets once a week and sees patients with contractures from our unit or referred from other facilities.
INITIAL CARE The plan for initial care of serious burns at the Cook County Hospital Burn Unit can be adapted to any emergency facility or nonspecialized hospital, which should have the capability of providing interim or initial care of urgent burn problems, even if the patient will eventually be transferred to a specialized center. Prior to transfer, attention must often be directed to restoration or maintenance of vital functions and to the preservation of vital body parts. The necessary equipment should be
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available in every emergency receiving area, and the plan of care should be familiar to all responsible personnel.
Airway Burn patients should be immediately evaluated for the adequacy of ventilatory exchange and for the possibility of inhalation injury. Knowledge of the circumstances of the burn may alert the personnel to the risk of respiratory injury. Severe and extensive burns caused by indoor fires have the greatest risk of being associated with respiratory tract injury. Involvement of the face (regions of the mouth and nose) suggests the need for close observation. Patients showing dyspnea, stridor, hoarseness, or expectoration of sooty sputum are also suspect. If clinical signs of respiratory insufficiency are obvious, the patient is intubated with a cuffed endotracheal tube and ventilation is assisted with an Ambu bag, anesthesia gas machine, or mechanical ventilator. The decision to perform a tracheostomy and the procedure itself then cease to be urgent. The operation can be performed meticulously with proper tubes and under optimal circumstances: adequate light, instruments, and assistance. Soft plastic tracheostomy tubes with inflatable cuffs and connectors to fit standard respirators are used, since ventilatory assistance is usually necessary. Since tracheostomy incisions often are made through or near burned tissue, the incision is carefully dressed with an antibiotic cream. Patients being observed for possible respiratory insufficiency are treated with humidified oxygen and should have arterial blood gas determinations to assist in the evaluation. Arterial P0 2 values below 70 mm. Hg (with the patient breathing room air) strongly suggest the need for ventilatory assistance. Essential equipment which is available in the admitting area includes sterile set-up trays for intubation, tracheostomy, and suction.
Cutdown and Fluid Infusion Once the airway has been assured, a major vein must be cannulated for the administration of fluids and drugs and for the measurement of central venous pressure. A plastic cannula of the largest possible diameter is passed through a vein of the upper extremity (cephalic or basilic) or neck (external jugular) into an intrathoracic position so that it can be used both for infusions and CVP measurement. The sizes of polyethylene catheters which are most useful are PE-240, PE-190, and PE-50, in both 15 and 38 inch lengths. To avoid wasting time and injuring veins when they are collapsed, a surgical cutdown is usually preferred to percutaneous insertion. Infusion of lactated Ringer's solution is begun according to a rapid mental calculation (using the "rule of nines") until time permits a more precise calculation based upon one of the accepted formulas. The balanced salt solution is initially infused rapidly until a satisfactory urine output is achieved.
Pain Relief Small doses of narcotics are administered intravenously to patients complaining of pain, as soon as the venous cutdown has been performed
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and after it is ascertained that restlessness and anxiety are not caused by hypoxia. Since partial thickness burns are often hyperesthetic and full thickness burns hypesthetic or anesthetic, superficial burns are usually more painful than deep ones. Morphine provides cutaneous analgesia and sedation superior to meperidine.
Blood Sampling Blood samples are withdrawn from the cutdown catheter for determinations of complete blood count, hematocrit, serum electrolytes, BUN, blood sugar, and type and cross match. Appropriate containers for these specimens should be available.
Antibiotics Penicillin G in dosage of approximately 1.2 million units is recommended for the first 5 days, primarily to eradicate streptococci which colonize normal and burned skin. Erythromycin or lincomycin is substituted in 2 gm. per day dosage for patients allergic to penicillin. Other antibiotics are reserved for diagnosed or suspected bacterial complications.
Bladder Catheterization An indwelling urinary catheter is inserted, the bladder urine measured, and the hourly recording of output and specific gravity is begun. Expendable supplies for the insertion of a Foley catheter and sterile collection of urine should be available. Gastric Intubation Gastric intubation quickly eliminates the hazard of acute gastric dilation and effectively treats the early nausea and ileus that accompany serious burns. The tubes of adult patients are connected to thermotic or vacuum suction and those of infants and young children are connected to gravity drainage. Caution must be exercised in the gastric intubation of patients with respiratory injury in whom tracheostomy has' not been performed. Trauma to the vocal cords may induce spasm and cause acute respiratory insufficiency. Gastric tubes are removed as soon as the ileus and nausea subside. Pediatric and adult sizes of nasogastric tubes should be available for insertion into patients with burns exceeding 20 to 25 per cent.
Initial Wound Care After all emergent and urgent steps in initial care have been dispatched, attention can be directed to the burn wound itself. If the patient can be easily and readily moved, the wounds are washed either in a bathtub, whirlpool tank, or Hubbard tank. Otherwise, the bath is given on the litter or in bed. Sterile basins, gloves and sponges are used in the initial bath and debridement. Blisters are ruptured and devitalized burned tissue is gently removed. Sterile dressing instrument sets (thumb forceps, straight scissors, and Allis forceps) are packaged for use during debridements and dressing applications. Hair in the vicinity of the burn is shaved. Burned and unburned areas are thoroughly washed with a
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A.
BOSWICK, JR., NELSON
H.
STONE
hexachlorophene soap solution. Since deep burns contract and become rigid, circumferential burns of the extremities can cause ischemia of the hands and feet, and circumferential burns of the thorax can restrict ventilation. Incision of these eschars (escharotomy) to the level of the deep fascia may be urgently required. Since full thickness burns are insensitive and most of the superficial vessels are thrombosed, escharotomy can be performed without anesthesia, and few transected vessels will require ligation. Instruments ordinarily available for cutdowns or minor surgery are adequate.
DEFINITIVE WOUND CARE Following the phase of initial treatment of burn patients, care of the burn wounds becomes the most time-consuming activity for burn unit personnel. To hasten the healing of partial thickness burns and the eventual grafting of full thickness burns, while conserving the time of valuable personnel, most burn units develop integrated regimens for wound care: effective positioning and immobilization as indicated, daily bathing and debridement, the use of topical antibacterial agents, and the application of allografts and xenografts.
Positioning and Activity Meticulous attention to patient positioning and activity can avert the unfortunate stigmas of chronic bed care: decubitus ulcers, contractures, and compression neuropathy. Specific sequelae of inattention to positioning and activity in burn patients include. maceration of wounds, refractory edema, and soft tissue calcification. Maceration, which is most likely to occur in body creases and folds (groin, axilla, neck), may result in conversion of a partial thickness injury to a full thickness loss. Because edema is more readily prevented than treated, burned extremities, when not actively used, should be maintained in an elevated position. Calcification may occur in the soft tissue, leading to eventual ankylosis of joints (especially elbows), which have been subjected to prolonged immobilization. Circ-O-Lectric and electrically operated hospital beds facilitate proper patient positioning. Resilient heel protectors and silicone gel or foam rubber pads are useful adjuncts to diligent care by nursing personnel.
Bathing and Debridement Regular bathing and debridement of burn wounds are important contributions to the success of any regimen of wound care and require access to hydrotherapy tanks, which should, if possible, be located within the burn unit. Most wound treatments can be delegated to trained and experienced nursing personnel under the supervision of the responsible physician.
Topical Antibacterial Agents In recent years, a number of topical agents with a variety of chemical structures have been introduced for the suppression of the bacterial
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population within the burn wound to a level which can be managed by the patient's defenses. The use of topical agents (recently reviewed by MoncrieF) results in improved healing of deep second degree burns and improved survival statistics. In addition to 0.5 per cent silver nitrate solution and mafenide (Sulfamylon) acetate cream, which are readily available, several other topical agents are currently being evaluated: furazolium (Novofur), gentamicin (Garamycin), and silver sulfadiazine (CF-100). The controversy whether burn wounds should be treated "open" or "closed" has largely been dispelled by the widespread use of topical antibacterial agents, which, in many instances, dictate the technique of wound care. Silver nitrate in 0.5 per cent solution, which is bacteriostatic against the organisms commonly encountered in burn wounds, was introduced into modern burn therapy by Moyer and his associates. 4 Many layers of cut gauze soaked in AgN0 3 are applied directly to the wound surface and held in place with bias-cut stockinette. Dressings are moistened every 2 hours and are changed at least daily. The major disadvantages of therapy with AgN0 3 are the more demanding requirements for nursing care, the inevitable staining of all objects necessarily or inadvertently wet by the solution, and the electrolyte depletion which often results. Mafenide acetate (Sulfamylon) is available as a 10 per cent cream to be applied open (preferably) or in dressings. This sulfonamide penetrates the eschar and also is bacteriostatic against the usual organisms which colonize burn wounds. Mafenide is convenient to apply and moderate in cost. During the daily bath, the previously applied cream is easily washed off. Mafenide is then reapplied in a thin layer (lor 2 mm.) and supplemented during the day, as necessary, where it has been rubbed off or mechanically dislodged. In spite of the availability and use of topical antibacterial agents, sepsis originating in the burn wounds is a major cause of death in patients with severe burns. Hopefully, topical agents will be developed which are even more effective than those currently available. Allografts and Xenografts In conjunction with topical antibacterial therapy, the use of splitthickness allograft skin from cadaver donors as biological dressings has become an integral part of treatment of both partial thickness and full thickness burns. Allografts are used in partial thickness burns to hasten epithelialization once the crust has been separated and in full thickness burns to improve the quality of granulations and test the receptivity of recipient sites prior to grafting. Allografts used for these purposes are removed within 4 or 5 days after application, before they become vascularized and adherent. Because donors for allografts become available unpredictably, they are most conveniently harvested and processed under sterile conditions in the burn unit operating room. When the need for biological dressings exceeds the allograft supply, xenografts from either pigs or dogs are utilized. Allograft and xenograft biological dressings are packaged in petri dishes containing penicillin and streptomycin and are stored under refrigeration.
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SURGERY For the welfare of the burn patient, the safety of other hospital patients and the convenience of burn unit personnel, a private operating room should be located within or adjacent to the burn unit. Otherwise unreasonable delays might be encountered in the scheduling of burn cases in a "clean" operating room, burn patients are transported through "clean" areas of the hospital, and burn unit personnel are excessively diverted from the unit. Experience has demonstrated the advantages of having anesthesia administered by specific personnel familiar with the physiological derangements of burn patients. A private operating room also adds to the convenience of removing homografts from cadaver donors. Since skin grafting constitutes most of the surgical pr@cedures performed on acute burn patients, the variety of equipment and instruments required in the operating room is small compared to a general surgical room. Both hand-operated and power-driven dermatomes are advantageous in specific circumstances. The nitrogen-powered Brown dermatome is most useful for rapid removal of skin grafts when covering extensive burns. The Reese dermatome is especially valuable when grafts of precise thickness and shape are required and when contours and bony prominences make the operation of the Brown dermatome difficult. One of the important recent technical innovations in skin grafting has been the development of skin meshers. These fiat or rotary devices cut parallel rows of alternating slits in the skin which permit it to be stretched. In addition to increasing the coverage of a skin graft by as much as two-fold, meshed grafts easily cover irregularly contoured areas and permit the escape of exudate. Because the diamond pattern persists after healing has taken place, meshed grafts should not be used on the hands or face.
REHABILITATION With the marked expansion of this unit from 1962 to 1966, a very obvious need for improvement in rehabilitation of the burn patient was recognized to be one of the great needs of this service. In 1966, a formal affiliation between the Sumner L. Koch Burn Unit of Cook County Hospital and the Rehabilitation Institute of Chicago was established. This affiliation resulted in a physiatrist being assigned part-time to the burn unit. He would see patients in the acute phase and recommend early care in regard to prevention and treatment of rehabilitation problems. The physiatrist also meets with the surgical and plastic surgical staff and the occupational therapist in a weekly contracture rehabilitation clinic. When patients are ready for discharge from the burn unit with their burn wounds closed, many have the need for extensive rehabilitation. Such patients are referred to the Rehabilitation Institute of Chicago for both inpatient and outpatient therapy. They are seen there by members
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of the burn unit staff periodically and are re-evaluated in the contracture clinic at the burn unit when indicated. Many of these patients are returned to the burn unit for various reconstructive procedures.
SUMMARY The planning of patient care in a hospital burn unit is dependent upon many factors. Some of the most important are the size of the unit and the facilities available within the unit. Other important aspects are the administrative philosophy of the unit and its relationship to the institutions within the area it serves. One of the largest and most active independent burn units in the world is the Sumner L. Koch Burn Unit of Cook County Hospital. The development and operation of the unit is presented.
REFERENCES 1. Boswick, J. A., Jr.: Current concepts in the clinical management of the burn patient. SURG. CLIN. N. AMER., 47:49, 1967. 2. Boswick, J. A., Jr., and Stone, N. H.: Methods and materials in managing the severely burned patient. SURG. CLIN. N. AMER., 48:177, 1968. 3. Moncrief, J.' A.: The status of topical antibacterial therapy in the treatment of·burns. Surgery, 63:862-867,1968. 4. Moyer, C. A., Brentano, L., Gravens, D. L., Margraf, H. W., and Monafo, W. W., Jr.: Treatment of large human burns with 0.5 per cent silver nitrate solution. Arch. Surg., 90:812867,1965. 1825 W. Harrison Street Chicago, Illinois 60612
The planning of patient care in a hospital bum unit is dependent upon several factors: the size of the unit, its administrative philosophy, and its approach to patient care. Such plans are also related to the size of the facility in relationship to the needs of the area it serves. A bum unit with a large number of beds in a community in which they would rarely be filled, could give long-term care and carry out clinical investigational projects without interfering with optimal patient care. The planning of patient care in a hospital bum unit is significantly related to the facilities in the unit, such as an operating room, areas for physical and occupational therapy, treatment rooms for dressing changes and wound care, and outpatient facilities. It also depends upon the relationship of the unit and its facilities to the other departments and areas of the hospital and to other hospitals and institutions in the community. In a large hospital, where all bum patients are admitted to the bum unit (if space is available), maximal staffing will be required to manage the acute care, surgical care, and day-to-day nursing and outpatient care. In this article, the Sumner L. Koch Burn Unit at the Cook County Hospital in Chicago will be described and its role within the hospital and community will be presented: its admission policy, staffing, and certain aspects of care and rehabilitation.
DESCRIPTION OF UNIT In the late 1930's and early 1940's, Dr. Sumner L. Koch and his associates pioneered in the treatment of bums at Cook County Hospital and 'Director, Sumner L. Koch Burn Unit, and Chief, Hand Surgical Service, Cook County Hospital; Associate Professor of Surgery, Northwestern University Medical School, Chicago, Illinois "Assistant Director, Hand and Burn Surgical Services, Cook County Hospital; Assistant Professor of Surgery, Northwestern University Medical School
Surgical Clinics of North America- Vol. 50, No.1, February, 1970
275
276
JOHN
A.
BOSWICK, JR., NELSON
H.
STONE
established a service at that hospital for this purpose. It was initially a part of the Children's Surgical Service. During World War II, this service was converted into a separate facility for research and clinical purposes under the auspices of the National Research Council. This unit remained active until 1956. In July of 1961, a burn service was again formed at Cook County Hospital as part of the Pediatric Surgical Service. In January of 1962, for administrative and staffing purposes, the Pediatric Burn Service was converted into a Pediatric Burn Unit. The need for a similar unit for adults was recognized and established. The two units combined in September 1964, in the area that is now the Sumner L. Koch Burn Unit of the Cook County Hospital. It occupies most of the fifth floor of the Children's Hospital Building and has a capacity for approximately 35 patients (depending upon the ratio of children to adults). Within the unit there is a dressing room with three whirlpool baths and a shower, where wound care is rendered to the patient as frequently as indicated. The unit has its own operating room, where wound debridement, skin grafting, and reconstructive and other surgical procedures are performed. The unit also has an area set aside for occupational and physical therapy, as well as a play and recreational area. The offices of the director and the assistant director as well as most of the staff are in the unit, which facilitates patient care and administration. Patients are arranged in rooms according to the severity of their injury or by age or sex.
ADMISSION POLICY Patients who present themselves to Cook County Hospital with acute or reconstructive burn problems are admitted directly to the unit. On occasion, the bed capacity of the unit becomes filled and patients are admitted to other areas of the hospital under the supervision of the burn unit staff, to be transferred to the unit when a bed becomes available. Such patients represent slightly over 50 per cent of the burn unit adInissions. The remaining patients come as elective admissions from the outpatient clinic of the hospital or as transfers from other hospitals in the region. Patients referred from other hospitals constitute two groups: those who are seen in the emergency rooms of these institutions and are never admitted there but are referred directly, and those who have been adInitted for initial care and are transferred for intermediate and definitive therapy. Referrals of the latter two groups come mostly from the area of Cook County, but in the past few years, there have been referrals and adInissions from eight Midwestern states. When a bed exists, it is the policy of the unit to accept patients for transfer from other institutions with acute or reconstructive burn problems. The decision for transferring a patient is based on bed availability, the patient's needs (meaning the extent, depth, and location of the burns) and, on occasion, family situations.
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STAFFING The unit is directed by a full-time surgeon and a full-time assistant, whose offices are in the unit, but who have other surgical responsibilities within the hospital. Between five and seven residents from the Departments of General and Plastic Surgery are assigned to the unit, as are one or more surgical fellows pursuing special training in burn surgery or research. Interns are assigned to the unit upon their request as part of their surgical internships. Students from the city's five medical schools rotate through the unit as part of their clinical clerkships in surgery. The nursing staff consists of a chief nurse, who is responsible for all nursing activities of the unit, and a clinical supervisor, whose main responsibility is in the field of patient care. There are five head nurses who have responsibility in the area of patient care, operating room, and dressing rooms, and 14 other registered nurses working in these areas. Twelve licensed practical nurses work as a member of the nursing team in all areas of the unit. The 16 nursing attendants work in all of the clinical areas and perform essential jobs as members of the nursing team. A unit manager and three clerical workers are responsible for the clerical and some of the administrative work on the unit. The secretarial staff is a part of the office of the director and has as one of its main responsibilities the maintaining of patient records for on-going clinical research studies. The unit has its own full-time occupational therapist, who is responsible for the occupational and physical therapy needs of the patients. She works under the supervision of the physicians responsible for patient care and in consultation with the consulting physiatrist. A portion of her responsibility is the day-to-day care of patients and clinical investigation related to rehabilitation. Consultants in physical medicine, plastic and reconstructive surgery, and psychiatry meet regularly with the burn unit staff for consultation purposes and are available for emergencies or urgent problems. Outpatient facilities consist of a clinic for the care of acute burns, which meets 6 days a week and a contracture clinic, which meets once a week and sees patients with contractures from our unit or referred from other facilities.
INITIAL CARE The plan for initial care of serious burns at the Cook County Hospital Burn Unit can be adapted to any emergency facility or nonspecialized hospital, which should have the capability of providing interim or initial care of urgent burn problems, even if the patient will eventually be transferred to a specialized center. Prior to transfer, attention must often be directed to restoration or maintenance of vital functions and to the preservation of vital body parts. The necessary equipment should be
278
JOHN
A.
BOSWICK, JR., NELSON
H.
STONE
available in every emergency receiving area, and the plan of care should be familiar to all responsible personnel.
Airway Burn patients should be immediately evaluated for the adequacy of ventilatory exchange and for the possibility of inhalation injury. Knowledge of the circumstances of the burn may alert the personnel to the risk of respiratory injury. Severe and extensive burns caused by indoor fires have the greatest risk of being associated with respiratory tract injury. Involvement of the face (regions of the mouth and nose) suggests the need for close observation. Patients showing dyspnea, stridor, hoarseness, or expectoration of sooty sputum are also suspect. If clinical signs of respiratory insufficiency are obvious, the patient is intubated with a cuffed endotracheal tube and ventilation is assisted with an Ambu bag, anesthesia gas machine, or mechanical ventilator. The decision to perform a tracheostomy and the procedure itself then cease to be urgent. The operation can be performed meticulously with proper tubes and under optimal circumstances: adequate light, instruments, and assistance. Soft plastic tracheostomy tubes with inflatable cuffs and connectors to fit standard respirators are used, since ventilatory assistance is usually necessary. Since tracheostomy incisions often are made through or near burned tissue, the incision is carefully dressed with an antibiotic cream. Patients being observed for possible respiratory insufficiency are treated with humidified oxygen and should have arterial blood gas determinations to assist in the evaluation. Arterial P0 2 values below 70 mm. Hg (with the patient breathing room air) strongly suggest the need for ventilatory assistance. Essential equipment which is available in the admitting area includes sterile set-up trays for intubation, tracheostomy, and suction.
Cutdown and Fluid Infusion Once the airway has been assured, a major vein must be cannulated for the administration of fluids and drugs and for the measurement of central venous pressure. A plastic cannula of the largest possible diameter is passed through a vein of the upper extremity (cephalic or basilic) or neck (external jugular) into an intrathoracic position so that it can be used both for infusions and CVP measurement. The sizes of polyethylene catheters which are most useful are PE-240, PE-190, and PE-50, in both 15 and 38 inch lengths. To avoid wasting time and injuring veins when they are collapsed, a surgical cutdown is usually preferred to percutaneous insertion. Infusion of lactated Ringer's solution is begun according to a rapid mental calculation (using the "rule of nines") until time permits a more precise calculation based upon one of the accepted formulas. The balanced salt solution is initially infused rapidly until a satisfactory urine output is achieved.
Pain Relief Small doses of narcotics are administered intravenously to patients complaining of pain, as soon as the venous cutdown has been performed
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and after it is ascertained that restlessness and anxiety are not caused by hypoxia. Since partial thickness burns are often hyperesthetic and full thickness burns hypesthetic or anesthetic, superficial burns are usually more painful than deep ones. Morphine provides cutaneous analgesia and sedation superior to meperidine.
Blood Sampling Blood samples are withdrawn from the cutdown catheter for determinations of complete blood count, hematocrit, serum electrolytes, BUN, blood sugar, and type and cross match. Appropriate containers for these specimens should be available.
Antibiotics Penicillin G in dosage of approximately 1.2 million units is recommended for the first 5 days, primarily to eradicate streptococci which colonize normal and burned skin. Erythromycin or lincomycin is substituted in 2 gm. per day dosage for patients allergic to penicillin. Other antibiotics are reserved for diagnosed or suspected bacterial complications.
Bladder Catheterization An indwelling urinary catheter is inserted, the bladder urine measured, and the hourly recording of output and specific gravity is begun. Expendable supplies for the insertion of a Foley catheter and sterile collection of urine should be available. Gastric Intubation Gastric intubation quickly eliminates the hazard of acute gastric dilation and effectively treats the early nausea and ileus that accompany serious burns. The tubes of adult patients are connected to thermotic or vacuum suction and those of infants and young children are connected to gravity drainage. Caution must be exercised in the gastric intubation of patients with respiratory injury in whom tracheostomy has' not been performed. Trauma to the vocal cords may induce spasm and cause acute respiratory insufficiency. Gastric tubes are removed as soon as the ileus and nausea subside. Pediatric and adult sizes of nasogastric tubes should be available for insertion into patients with burns exceeding 20 to 25 per cent.
Initial Wound Care After all emergent and urgent steps in initial care have been dispatched, attention can be directed to the burn wound itself. If the patient can be easily and readily moved, the wounds are washed either in a bathtub, whirlpool tank, or Hubbard tank. Otherwise, the bath is given on the litter or in bed. Sterile basins, gloves and sponges are used in the initial bath and debridement. Blisters are ruptured and devitalized burned tissue is gently removed. Sterile dressing instrument sets (thumb forceps, straight scissors, and Allis forceps) are packaged for use during debridements and dressing applications. Hair in the vicinity of the burn is shaved. Burned and unburned areas are thoroughly washed with a
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JOHN
A.
BOSWICK, JR., NELSON
H.
STONE
hexachlorophene soap solution. Since deep burns contract and become rigid, circumferential burns of the extremities can cause ischemia of the hands and feet, and circumferential burns of the thorax can restrict ventilation. Incision of these eschars (escharotomy) to the level of the deep fascia may be urgently required. Since full thickness burns are insensitive and most of the superficial vessels are thrombosed, escharotomy can be performed without anesthesia, and few transected vessels will require ligation. Instruments ordinarily available for cutdowns or minor surgery are adequate.
DEFINITIVE WOUND CARE Following the phase of initial treatment of burn patients, care of the burn wounds becomes the most time-consuming activity for burn unit personnel. To hasten the healing of partial thickness burns and the eventual grafting of full thickness burns, while conserving the time of valuable personnel, most burn units develop integrated regimens for wound care: effective positioning and immobilization as indicated, daily bathing and debridement, the use of topical antibacterial agents, and the application of allografts and xenografts.
Positioning and Activity Meticulous attention to patient positioning and activity can avert the unfortunate stigmas of chronic bed care: decubitus ulcers, contractures, and compression neuropathy. Specific sequelae of inattention to positioning and activity in burn patients include. maceration of wounds, refractory edema, and soft tissue calcification. Maceration, which is most likely to occur in body creases and folds (groin, axilla, neck), may result in conversion of a partial thickness injury to a full thickness loss. Because edema is more readily prevented than treated, burned extremities, when not actively used, should be maintained in an elevated position. Calcification may occur in the soft tissue, leading to eventual ankylosis of joints (especially elbows), which have been subjected to prolonged immobilization. Circ-O-Lectric and electrically operated hospital beds facilitate proper patient positioning. Resilient heel protectors and silicone gel or foam rubber pads are useful adjuncts to diligent care by nursing personnel.
Bathing and Debridement Regular bathing and debridement of burn wounds are important contributions to the success of any regimen of wound care and require access to hydrotherapy tanks, which should, if possible, be located within the burn unit. Most wound treatments can be delegated to trained and experienced nursing personnel under the supervision of the responsible physician.
Topical Antibacterial Agents In recent years, a number of topical agents with a variety of chemical structures have been introduced for the suppression of the bacterial
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population within the burn wound to a level which can be managed by the patient's defenses. The use of topical agents (recently reviewed by MoncrieF) results in improved healing of deep second degree burns and improved survival statistics. In addition to 0.5 per cent silver nitrate solution and mafenide (Sulfamylon) acetate cream, which are readily available, several other topical agents are currently being evaluated: furazolium (Novofur), gentamicin (Garamycin), and silver sulfadiazine (CF-100). The controversy whether burn wounds should be treated "open" or "closed" has largely been dispelled by the widespread use of topical antibacterial agents, which, in many instances, dictate the technique of wound care. Silver nitrate in 0.5 per cent solution, which is bacteriostatic against the organisms commonly encountered in burn wounds, was introduced into modern burn therapy by Moyer and his associates. 4 Many layers of cut gauze soaked in AgN0 3 are applied directly to the wound surface and held in place with bias-cut stockinette. Dressings are moistened every 2 hours and are changed at least daily. The major disadvantages of therapy with AgN0 3 are the more demanding requirements for nursing care, the inevitable staining of all objects necessarily or inadvertently wet by the solution, and the electrolyte depletion which often results. Mafenide acetate (Sulfamylon) is available as a 10 per cent cream to be applied open (preferably) or in dressings. This sulfonamide penetrates the eschar and also is bacteriostatic against the usual organisms which colonize burn wounds. Mafenide is convenient to apply and moderate in cost. During the daily bath, the previously applied cream is easily washed off. Mafenide is then reapplied in a thin layer (lor 2 mm.) and supplemented during the day, as necessary, where it has been rubbed off or mechanically dislodged. In spite of the availability and use of topical antibacterial agents, sepsis originating in the burn wounds is a major cause of death in patients with severe burns. Hopefully, topical agents will be developed which are even more effective than those currently available. Allografts and Xenografts In conjunction with topical antibacterial therapy, the use of splitthickness allograft skin from cadaver donors as biological dressings has become an integral part of treatment of both partial thickness and full thickness burns. Allografts are used in partial thickness burns to hasten epithelialization once the crust has been separated and in full thickness burns to improve the quality of granulations and test the receptivity of recipient sites prior to grafting. Allografts used for these purposes are removed within 4 or 5 days after application, before they become vascularized and adherent. Because donors for allografts become available unpredictably, they are most conveniently harvested and processed under sterile conditions in the burn unit operating room. When the need for biological dressings exceeds the allograft supply, xenografts from either pigs or dogs are utilized. Allograft and xenograft biological dressings are packaged in petri dishes containing penicillin and streptomycin and are stored under refrigeration.
282
JOHN
A.
BOSWICK, JR., NELSON
H.
STONE
SURGERY For the welfare of the burn patient, the safety of other hospital patients and the convenience of burn unit personnel, a private operating room should be located within or adjacent to the burn unit. Otherwise unreasonable delays might be encountered in the scheduling of burn cases in a "clean" operating room, burn patients are transported through "clean" areas of the hospital, and burn unit personnel are excessively diverted from the unit. Experience has demonstrated the advantages of having anesthesia administered by specific personnel familiar with the physiological derangements of burn patients. A private operating room also adds to the convenience of removing homografts from cadaver donors. Since skin grafting constitutes most of the surgical pr@cedures performed on acute burn patients, the variety of equipment and instruments required in the operating room is small compared to a general surgical room. Both hand-operated and power-driven dermatomes are advantageous in specific circumstances. The nitrogen-powered Brown dermatome is most useful for rapid removal of skin grafts when covering extensive burns. The Reese dermatome is especially valuable when grafts of precise thickness and shape are required and when contours and bony prominences make the operation of the Brown dermatome difficult. One of the important recent technical innovations in skin grafting has been the development of skin meshers. These fiat or rotary devices cut parallel rows of alternating slits in the skin which permit it to be stretched. In addition to increasing the coverage of a skin graft by as much as two-fold, meshed grafts easily cover irregularly contoured areas and permit the escape of exudate. Because the diamond pattern persists after healing has taken place, meshed grafts should not be used on the hands or face.
REHABILITATION With the marked expansion of this unit from 1962 to 1966, a very obvious need for improvement in rehabilitation of the burn patient was recognized to be one of the great needs of this service. In 1966, a formal affiliation between the Sumner L. Koch Burn Unit of Cook County Hospital and the Rehabilitation Institute of Chicago was established. This affiliation resulted in a physiatrist being assigned part-time to the burn unit. He would see patients in the acute phase and recommend early care in regard to prevention and treatment of rehabilitation problems. The physiatrist also meets with the surgical and plastic surgical staff and the occupational therapist in a weekly contracture rehabilitation clinic. When patients are ready for discharge from the burn unit with their burn wounds closed, many have the need for extensive rehabilitation. Such patients are referred to the Rehabilitation Institute of Chicago for both inpatient and outpatient therapy. They are seen there by members
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of the burn unit staff periodically and are re-evaluated in the contracture clinic at the burn unit when indicated. Many of these patients are returned to the burn unit for various reconstructive procedures.
SUMMARY The planning of patient care in a hospital burn unit is dependent upon many factors. Some of the most important are the size of the unit and the facilities available within the unit. Other important aspects are the administrative philosophy of the unit and its relationship to the institutions within the area it serves. One of the largest and most active independent burn units in the world is the Sumner L. Koch Burn Unit of Cook County Hospital. The development and operation of the unit is presented.
REFERENCES 1. Boswick, J. A., Jr.: Current concepts in the clinical management of the burn patient. SURG. CLIN. N. AMER., 47:49, 1967. 2. Boswick, J. A., Jr., and Stone, N. H.: Methods and materials in managing the severely burned patient. SURG. CLIN. N. AMER., 48:177, 1968. 3. Moncrief, J.' A.: The status of topical antibacterial therapy in the treatment of·burns. Surgery, 63:862-867,1968. 4. Moyer, C. A., Brentano, L., Gravens, D. L., Margraf, H. W., and Monafo, W. W., Jr.: Treatment of large human burns with 0.5 per cent silver nitrate solution. Arch. Surg., 90:812867,1965. 1825 W. Harrison Street Chicago, Illinois 60612