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The Treatment of Acute Burns
The Treatment of Acute Burns MARY M. MARTIN, M.D. * EVERETT IDRIS EVANS, M.D., PH.D., F.A.C.S.**
THE methods of treatment of the acute burn in daily practice in this Burn Unit are delineated in the following paper. The basis for development of these methods is the experience gained from 450 severely burned patients admitted to the Burn Unit during the past three year period. These methods of treatment have achieved a low mortality rate; for example, the past year only 1 patient has died with a burn of less than 50 per cent of the body surface. However, practically all patients die who have extensive third degree burns of more than 50 per cent despite alleviation of shock and despite successful combating of infection. Any child with a burn of 20 per cent or over, or any adult with a burn of 30 per cent or over, should be put on the critical list and the family advised of the difficulties and complications which may arise. IMMEDIATE STEPS, INCLUDING ALLEVIATION OF PAIN
The problems attendant upon the treatment of an acute burn may be manifold. The logical and methodical way to treat a serious burn is to meet each successive problem as it occurs during the post-burn course. After alleviation of pain, the first major issue to be met is the shock which occurs one-half hour or so after burning, and which deepens with each successive hour which passes before treatment is begun. Attention to the local treatment of the burn must be deferred until the shock is prevented by prompt therapy or until shock which has already been present is successfully treated. From the Department of Surgery, Medical College of Virginia, Richmond, Virginia. These observations were made during a study conducted under Contract Number DA-l,.9-007-MD-99 between the Medical Research and Development Board, Department of the Army, and the Medical College of Virginia, Richmond, Virginia.
* Chief Resident,
Burn Unit, Medical College of Virginia.
** Professor of Surgery and Director, Surgical Research Laboratories, Medical College of Virginia. 1119
1120
Mary M. Martin, Everett I. Evans
The treatment of the acute burn, then, begins immediately after the burn is incurred. It is important to leave the burn surface alone, other than to remove any burned or wet clothing, and cover the burns with clean or sterile sheets if they are available. No ointment or any other surface medication should be applied. Any attempt at debridement or cleansing of the burn should be deferred until the definitive dressing is applied. It is of importance to give any indicated narcotic intravenously if possible, since there is ordinarily delayed and erratic absorption of narcotic medication until the patient begins to respond to resuscitation therapy. The additive effect of several large doses of narcotic may result in a marked narcosis in the patient twelve to twenty-four hours after the time of burning. The patient may be kept quite comfortable on frequent small intravenous doses of a narcotic and spaced intravenous doses of anyone of the long-acting barbiturates. Patients who have relatively small burns may be given relatively large doses of narcotic. The larger and deeper the burn, the more caution is necessary in choosing the narcotic dosage. FLUID REPLACEMENT
When the patient reaches the dressing room or operating room where the definitive treatment is begun, he is weighed, or a recent weight is ascertained from the patient. While this is being done, resuscitation of the patient from shock or to prevent shock is begun. Either a cut-down with insertion of an intravenous plastic cannula, or a needle to which has been welded a plastic cannula (the withdrawal of the stylet of which leaves a plastic cannula in the vein) is inserted. The infusion of a plasma substitute (in this unit we use Dextran) or plasma-not saline or glucose in water-is immediately begun. An estimate of the extent of surface area burned is made. This is done according to the chart reproduced in Figure 149. This gives the percentage of the body surface area of each portion of the body for all ages including babies to adults. From this estimate, the amount of intravenous fluid to be given is calculated. The formula in use in this Burn Unit is 1 ml. of plasma or plasma substitute per kilogram of body weight for each percentage point of body surface burned, up to 50 per cent, and a like amount of saline during the first twenty-four hour period.! Any burn of an extent greater than 50 per cent is considered only as 50 per cent, since the amount of fluid lost does not increase in burns of larger extent. 2 For instance, if a patient weighs 20 kilograms (44 pounds) and has a 50 per cent burn, he will require 1000 ml. of plasma or plasma substitute. He will also require the same amount of normal saline, intravenously during the first twenty-four hour period. If a patient weighing 10 kilo-
Treatment of Acute Burns
1121
INFANT :AND YOUNG CHILD Relative Percentages of Areas Affected by 9rowth (After Lund) Area A. B C
z
0
Age
= 1/2 = i /2
of head of one thigh 1/2 of one leg
9-1/1. 2-3/4 2-1/2
1 8-1/Z 3 ... 1/4 2-1/Z
5
6-1/2 4 1.-3/4
OLDER CHILD AND ADULT Relative Percentages of Areas Affected by Growth (After .Lund) Area
Age
A= 1/2 of head B :=: 1/2 of one thigh C = 1/2 of one leg
10 5-1/2 4-1/4 3
15 4-1/Z 4-1/Z 3-1/4
Adult
3-1/2. .-3/4 3-1/2.
Fig. 149. Per cent burn by areas at different stages of growth.
Mary M. Martin, Everett 1. Evans
1122
grams has a 30 per cent burn he will require 300 ml. of plasma or plasma substitute and 300 ml. of normal saline intravenously during the first twenty-four hour period. The total amount of intravenous fluid given is halved for the second twenty-four hour period. The water requirement is figured as 2000 ml. daily for adults or enough, after the calculated intravenous fluid replacement has been made, to keen the urine output between 25 and 50 ml. If the burn is third degree (fire or boiling water), or one which appears deep and possibly third degree, or if it is very extensive, half of the plasma substitute is given as whole blood. The hematocrit, hemoglobin and red blood cell count are followed for the first two days as a guide, along with the hourly urine output, to the succession of fluids and their rate of administration. The saline requirement which has been calculated for the burn (especially in a patient ,vho has had a pulmonary burn or an elderly patient with the cardiovascular-renal status in doubt) can be given part or all as halfTable 1 FLUID INTAKE AND NORMAL DAILY AND HOURLY URINARY EXCRETION FLUID INTAKE, AGE
o to 12 months. . . . . . . . .. 1 to 4 years 4 to 7 years 7 to 10 years 10 to 12 years
Adult
24
HOURS
.
. . . . . .
200 500 575 650 725 1500
to to to to to to
500 ml. 575 ml. 650 m!. 725 m!. 800 ml. 2000 ml.
URINARY EXCRETION PER HOUR
8 20 24 28 30 50
to 20 to 24 to 28 to 30 to 33 ml.
m!. ml. ml. 1nl. ml.
normal saline by mouth. This saline must be iced in order to be tolerated. It must then be remembered that twice as much solution must be given by mouth since it must be half-normal saline if given orally, and that part of the water requirement then must be considered as given, since half of the half-normal saline is water. As soon as the intravenous fluid is started, blood for hemoglobin, red blood cell count, hematocrit, and type and cross matching should be drawn. A femoral puncture is usually necessary in a large burn or in the patient already in severe shock. The next procedure is to insert a self-retaining Foley catheter in the bladder. The bladder is emptied at the time of insertion, using manual compression if necessary. In a patient, especially a male, whose genitalia are badly burned, it may be somewhat difficult to insert the catheter and in some instances a dorsal slit will be necessary. The urine is collected hourly and the rate of fluid and the type of fluid administered depend upon the hourly output of urine coupled with the information gleaned from red count, henloglobin and hematocrit. As mentioned, we endeavor to keep the urine output between 25 and 50 ml. per hour in the adult, and correspondingly lower in the child. Table 1 summarizes the fluid intake and normal excretion rates at various ages.
Treatment of Acute Burns
1123
LOCAL TREATMENT
The next step is the debridement or cleansing of the wound. In this unit, only very loose pieces of skin are debrided and any dirt present is removed with gentle swabbing with Phisoderm. Dry dressings are used in the first dressing, to aid in keeping the burn surface dry, free from maceration and subsequent bacterial growth. These dressings consist of a fine mesh gauze next to the burn vvound, next a layer of absorbent cotton and a subsequent layer of ,vater-repellent cellulose with a Mass-
Fig. 150. X-ray photograph of a properly applied splint to the hands.
linn backing which has all been sewn together to make a prefabricated dressing. The dressing is pinned together with sterile safety pins, and then secured with some type of elastic or stretchable bandage. The bandage must not be applied too tightly, and must be applied evenly so that there is no swelling between constricted areas. Tight bandages should be avoided, especially in hand dressings, in dressings of the lower extremities or across the upper abdomen. A syndrome somewhat like the cast. syndrome may occur if the bandages across the upper abdomen aretoo tight. Gastric dilatation can occur, which may be fatal to the patient. If it does occur, it is alleviated only, if at all, by constant gastric suction and positioning the patient on the right side.
1124
Mary M. Martin, Everett I. Evans
When dressing hands, a somewhat different procedure is carried out. A very lightly impregnated petrolatum gauze is applied to the hand. Each finger is dressed separately. The hand must be dressed in proper position of function. It is desirable to apply splints to badly burned hands in order to keep them in proper position. An x-ray photograph of a properly applied splint is shown in Figure 150. The hands must be encompassed in a fairly voluminous dressing. Over the fine-mesh gauze (which is scarcely impregnated with petrolatum) several compresses are applied to each finger and to the front and back of the hand. The splint is applied, as well as several large absorbable cotton pads. All are held in place with an Ace bandage. EXPOSURE TREATMENT
The exposure treatment may be used in some instances and may be the best type of treatment for certain burns. For instance, in babies who have only buttock burns, or back burns, the exposure treatment (when all four extremities are securely restrained) works very well. The exposure treatment, however, calls for more adequate nursing care, and if the patient is not under the most expert care, and wriggles free from restraint, he scratches at the newlyJormed crust, with resulting infection. In our experience, the exposure treatment will not work when the burn is circumferential, inw~ich case it only leads to wet, macerated, infected burns. In babies withfac<1 burns, utmost care must be taken to restrain the hands in order to keep the infant from scratching his face. When treating burns of the buttocks or back by the exposure method, a cradle over the bed with a sheet over the cradle but with air able to circulate through the head and foot of the cradle will allow drying of the crust and still protect the patient from chilliness. Face burns are not dressed. Petrolatum is not applied to a burn of the face. A small amount of mineral oil or petrolatum may be applied to the lips. The eyes may be irrigated carefully daily with boric acid solution, taking care to insure that none of the solution runs down on the burned portion of the face. No other medication or treatment is applied to the face and a firm crust is allowed to form. ANTIBIOTICS
Some type of antibiotic must be administered. It is best for the first few days in a burn of moderate to severe extent to administer the antibiotic either intramuscularly or intravenously in order to be sure that the patient who may not tolerate oral fluids receives and absorbs adequate antibjotic therapy. Crysticillin, aureomycin and Chloromycetin have been used in this unit and all three equally well serve the purpose of keeping down any septicemia or bacteremia in the first days after the burn. The patient who has incurred a third degree burn, an extensive
Treatment of Acute Burns
1125
burn of any sort, or a very dirty burn is best given either toxoid or tetanus antitoxin depending upon whether or not he ha~ had any previous antitetanus treatment. POSITIONING
The position of the patient in bed after dressing is important. If it is a burn of the face, the head must be elevated. Burns of the hands, upper extremities and lower extremities must also be elevated in order to lessen the swelling which inevitably occurs. The amount of pain in the extremity will be lessened with elevation. Sling supports from an orthopedic bed may be conveniently used to support the hands. If the patient will in all probability be in bed one month or more, footboards must be put at the bottom of the bed, and the patient on his back kept with his feet at a right angle against the board in order to prevent footdrop. When the patient lies face downward, the feet must hang over the edge of the mattress in order to allow them to hang at a right angle. PULMONARY BURNS
If the patient has had a respiratory burn, a tracheotomy set must be by the bedside and, at the first sign of pulmonary edema, intravenous saline should be deleted from the intravenous fluid replacement and an effort made to give this calculated requirement by mouth. Intravenous aminophylline and/or aminophylline suppositories sometimes alleviate the pulmonary edema. Oxygen, either by nasal catheter or by tent, in the very young may help in cases of pulmonary burns. CORTICOSTEROID THERAPY
No ACTH or cortisone is given. In this unit, it has been found consistently that eosinophil counts taken daily for two weeks after a burn was received have varied from 0 to 10, whether the patients were babies or elderly adults of 85. This would indicate that the patient liberates enough ACTH of his own under this severe stress, and certainly needs no added hormone. DIET
A very important part of the treatment of the burned patient is the diet. For the first t,venty-four hours, nothing is given by mouth except half-normal iced saline (or if the patient is nauseated, a few ice chips). During the second twenty-four hours, if the patient seems to be tolerating the half-normal saline well, judicious amounts of skim milk (e.g. 25 ml.) are given every half hour during a twenty-four hour period. It is better to give small amounts and bother the patient at frequent intervals during the night than to fill the stomach with large amounts every four
1126
Mary M. Martin, Everett I. Evans
or six hours. If the patient tolerates this skim milk for a period of six to eight hours, at the end of the forty-eight hour period a type of formula is instituted which is calculated to conform with the National Research Council specifications for the daily caloric, protein, carbohydrate, fat and vitamin requirements. It may be administered by a nasogastric tube if necessary. It will make up into a form which will not clog a very small sized plastic tube. LATER CARE
No effort is made to change the plenary dressing until approximately ten days after its application unless some evidence of infection or gross soiling of the dressing is manifested. At the second dressing, ordinarily, the burn is gently cleansed ,vith Phisoderm and the same antibiotic which has been administered parenterally is sprinkled upon the burn surface. At this time decision is made as to whether grafting is to be immediate, delayed, or will not be necessary and heavy absorptive dressings are again applied over a fine mesh gauze, this time impregnated with a water soluble, nonmacerating base. Blood studies necessary throughout the course of the first days after burning include first the blood urea nitrogen and nonprotein nitrogen determinations as a measure of the amount of protein breakdown and renal function. Sodium, potassium, carbon dioxide and chloride determinations are made daily in case of severe burn. These become most important during the period of diuresis which begins three to four days after the burn occurs, since the most marked shift of fluid back to the cardiovascular system takes place at this time. At this time fluid intake is mainly oral, and the intravenous cannula is kept open with a very slow drip of glucose in water. When the urine output becomes more than the intake and when the formula is tolerated well and intake is adequate by mouth, the drip is shut down and if all goes well, discontinued. PRIMARY EXCISION AND GRAFTING
Some burns may be treated by the method of primary excision if the operating room and anesthesia facilities are always available. In small burns which are incontrovertibly third degree, perhaps the best treatment is to excise the burn and apply a split thickness graft immediately. In large burns, in which the life of the patient is in question, and the availability of skin is scarce, primary excision would perhaps make the amount of available skin for grafting even less, and a period of watchful waiting is to be desired. In some patients there will be little area from which to take skin. If such areas as the forearms or legs must serve as donor sites six or seven times, very thin split thickness grafts must be taken in order to be able
Treatment of Acute Burns
1127
to reuse the sites every ten days. The instrument which seems best for this purpose in our hands is the electric dermatome. M~ch thinner grafts may be taken successfully with this instrument time and time again than with other instruments available to us at this time. COMPLICATIONS
Some conditions which occur in patients who are burned may be pregnancy, sickle cell anemia (especially in Negro children), Curling's ulcer, central nervous system lesions, arteriosclerosis, kidney disease, prostatism with long-standing cystitis or urinary retention, and the like. Patients, pregnant when burned, often miscarry. Great care should be taken to keep burned pregnant patients flat in bed. They should be given progesterone and enough sedation to prevent restlessness. In many children who otherwise would not be adversely affected by a fairly small burn, if a sickle cell anemia or even a nutritional anemia is present, profound shock may result. Any patient ,vith a large burn who is overloaded with oral fluids or food early after the time of burning, or given water to drink as he desires, may build up a tremendous gastric dilatation or hemorrhagic gastritis. In some instances, if the central nervous system is involved, a Curling's ulcer with massive hematemesis may result. In patients with a markedly elevated blood urea nitrogen, anuria usually eventuates and the patient dies in a uremic coma. Patients with extensive signs of central nervous system involvement, such as mental aberration with gradual deterioration into a comatose state, may die in three or four weeks with an extreme hyperpyrexia of 106° to 108°F without any evidence of blood stream or local infection, despite normal electrolyte and renal chemistries and with adequate nutrition and no weight loss. Others in this group may develop a severe hypopyrexia as low as 95°F. Burn patients may develop pseudodiabetes, possibly as a result of the presence of a large amount of circulating hormone due to the stress to which they have been subjected. If, on a high calorie formula, the patient complains of excessive thirst and has an excessive output of urine, it is well to test the urine for sugar and ascertain the fasting blood sugar two or three days in succession. This complication may be successfully treated by lowering the caloric intake or adjusting the proportion of fat, protein and carbohydrate. Rarely, very small amounts of insulin are necessary. The patient with the pulmonary burn or the cardiac or elderly patient may die in pulmonary edema, either from congestive failure due to poor cardiac reserve or intrinsic pulmonary edema from irritation of the finer bronchioles and alveoli by smoke or heat, or both. Even in a very small burn, the latter complication is almost without exception fatal.
1128
Mary M. Martin, Everett I. Evans SUMMARY
Prompt replacement of fluid losses in the burned patient, and anticipation of each crisis a,s it arises throughout the post-burn course, will enable the general practitioner to bring patients with moderate and severe burns safely through the shock phase. If the burns are not extensive (i.e. if they are not third degree burns of 50 per cent or more of the body surface) there is a good chance, if the treatment encompassed in the foregoing is employed, that they may be tided over the first critical two weeks and eventually reach grafting and be healed. REFERENCES 1. Evans, E. I., Purnell) O. J., Robinett, P. W., Batchelor, A. D. R. and Martin,
M. M.: Fluid and Electrolyte Requirements in Severe Burns. Ann. Surg. 135: 804 (June) 1952. 2. Cope, O. and Moore, F. D.: The Redistribution of Body Water and The Fluid Therapy of the Burned Patient. Ann. Surg. 126: 1010 (Dec.) 1947.
THE methods of treatment of the acute burn in daily practice in this Burn Unit are delineated in the following paper. The basis for development of these methods is the experience gained from 450 severely burned patients admitted to the Burn Unit during the past three year period. These methods of treatment have achieved a low mortality rate; for example, the past year only 1 patient has died with a burn of less than 50 per cent of the body surface. However, practically all patients die who have extensive third degree burns of more than 50 per cent despite alleviation of shock and despite successful combating of infection. Any child with a burn of 20 per cent or over, or any adult with a burn of 30 per cent or over, should be put on the critical list and the family advised of the difficulties and complications which may arise. IMMEDIATE STEPS, INCLUDING ALLEVIATION OF PAIN
The problems attendant upon the treatment of an acute burn may be manifold. The logical and methodical way to treat a serious burn is to meet each successive problem as it occurs during the post-burn course. After alleviation of pain, the first major issue to be met is the shock which occurs one-half hour or so after burning, and which deepens with each successive hour which passes before treatment is begun. Attention to the local treatment of the burn must be deferred until the shock is prevented by prompt therapy or until shock which has already been present is successfully treated. From the Department of Surgery, Medical College of Virginia, Richmond, Virginia. These observations were made during a study conducted under Contract Number DA-l,.9-007-MD-99 between the Medical Research and Development Board, Department of the Army, and the Medical College of Virginia, Richmond, Virginia.
* Chief Resident,
Burn Unit, Medical College of Virginia.
** Professor of Surgery and Director, Surgical Research Laboratories, Medical College of Virginia. 1119
1120
Mary M. Martin, Everett I. Evans
The treatment of the acute burn, then, begins immediately after the burn is incurred. It is important to leave the burn surface alone, other than to remove any burned or wet clothing, and cover the burns with clean or sterile sheets if they are available. No ointment or any other surface medication should be applied. Any attempt at debridement or cleansing of the burn should be deferred until the definitive dressing is applied. It is of importance to give any indicated narcotic intravenously if possible, since there is ordinarily delayed and erratic absorption of narcotic medication until the patient begins to respond to resuscitation therapy. The additive effect of several large doses of narcotic may result in a marked narcosis in the patient twelve to twenty-four hours after the time of burning. The patient may be kept quite comfortable on frequent small intravenous doses of a narcotic and spaced intravenous doses of anyone of the long-acting barbiturates. Patients who have relatively small burns may be given relatively large doses of narcotic. The larger and deeper the burn, the more caution is necessary in choosing the narcotic dosage. FLUID REPLACEMENT
When the patient reaches the dressing room or operating room where the definitive treatment is begun, he is weighed, or a recent weight is ascertained from the patient. While this is being done, resuscitation of the patient from shock or to prevent shock is begun. Either a cut-down with insertion of an intravenous plastic cannula, or a needle to which has been welded a plastic cannula (the withdrawal of the stylet of which leaves a plastic cannula in the vein) is inserted. The infusion of a plasma substitute (in this unit we use Dextran) or plasma-not saline or glucose in water-is immediately begun. An estimate of the extent of surface area burned is made. This is done according to the chart reproduced in Figure 149. This gives the percentage of the body surface area of each portion of the body for all ages including babies to adults. From this estimate, the amount of intravenous fluid to be given is calculated. The formula in use in this Burn Unit is 1 ml. of plasma or plasma substitute per kilogram of body weight for each percentage point of body surface burned, up to 50 per cent, and a like amount of saline during the first twenty-four hour period.! Any burn of an extent greater than 50 per cent is considered only as 50 per cent, since the amount of fluid lost does not increase in burns of larger extent. 2 For instance, if a patient weighs 20 kilograms (44 pounds) and has a 50 per cent burn, he will require 1000 ml. of plasma or plasma substitute. He will also require the same amount of normal saline, intravenously during the first twenty-four hour period. If a patient weighing 10 kilo-
Treatment of Acute Burns
1121
INFANT :AND YOUNG CHILD Relative Percentages of Areas Affected by 9rowth (After Lund) Area A. B C
z
0
Age
= 1/2 = i /2
of head of one thigh 1/2 of one leg
9-1/1. 2-3/4 2-1/2
1 8-1/Z 3 ... 1/4 2-1/Z
5
6-1/2 4 1.-3/4
OLDER CHILD AND ADULT Relative Percentages of Areas Affected by Growth (After .Lund) Area
Age
A= 1/2 of head B :=: 1/2 of one thigh C = 1/2 of one leg
10 5-1/2 4-1/4 3
15 4-1/Z 4-1/Z 3-1/4
Adult
3-1/2. .-3/4 3-1/2.
Fig. 149. Per cent burn by areas at different stages of growth.
Mary M. Martin, Everett 1. Evans
1122
grams has a 30 per cent burn he will require 300 ml. of plasma or plasma substitute and 300 ml. of normal saline intravenously during the first twenty-four hour period. The total amount of intravenous fluid given is halved for the second twenty-four hour period. The water requirement is figured as 2000 ml. daily for adults or enough, after the calculated intravenous fluid replacement has been made, to keen the urine output between 25 and 50 ml. If the burn is third degree (fire or boiling water), or one which appears deep and possibly third degree, or if it is very extensive, half of the plasma substitute is given as whole blood. The hematocrit, hemoglobin and red blood cell count are followed for the first two days as a guide, along with the hourly urine output, to the succession of fluids and their rate of administration. The saline requirement which has been calculated for the burn (especially in a patient ,vho has had a pulmonary burn or an elderly patient with the cardiovascular-renal status in doubt) can be given part or all as halfTable 1 FLUID INTAKE AND NORMAL DAILY AND HOURLY URINARY EXCRETION FLUID INTAKE, AGE
o to 12 months. . . . . . . . .. 1 to 4 years 4 to 7 years 7 to 10 years 10 to 12 years
Adult
24
HOURS
.
. . . . . .
200 500 575 650 725 1500
to to to to to to
500 ml. 575 ml. 650 m!. 725 m!. 800 ml. 2000 ml.
URINARY EXCRETION PER HOUR
8 20 24 28 30 50
to 20 to 24 to 28 to 30 to 33 ml.
m!. ml. ml. 1nl. ml.
normal saline by mouth. This saline must be iced in order to be tolerated. It must then be remembered that twice as much solution must be given by mouth since it must be half-normal saline if given orally, and that part of the water requirement then must be considered as given, since half of the half-normal saline is water. As soon as the intravenous fluid is started, blood for hemoglobin, red blood cell count, hematocrit, and type and cross matching should be drawn. A femoral puncture is usually necessary in a large burn or in the patient already in severe shock. The next procedure is to insert a self-retaining Foley catheter in the bladder. The bladder is emptied at the time of insertion, using manual compression if necessary. In a patient, especially a male, whose genitalia are badly burned, it may be somewhat difficult to insert the catheter and in some instances a dorsal slit will be necessary. The urine is collected hourly and the rate of fluid and the type of fluid administered depend upon the hourly output of urine coupled with the information gleaned from red count, henloglobin and hematocrit. As mentioned, we endeavor to keep the urine output between 25 and 50 ml. per hour in the adult, and correspondingly lower in the child. Table 1 summarizes the fluid intake and normal excretion rates at various ages.
Treatment of Acute Burns
1123
LOCAL TREATMENT
The next step is the debridement or cleansing of the wound. In this unit, only very loose pieces of skin are debrided and any dirt present is removed with gentle swabbing with Phisoderm. Dry dressings are used in the first dressing, to aid in keeping the burn surface dry, free from maceration and subsequent bacterial growth. These dressings consist of a fine mesh gauze next to the burn vvound, next a layer of absorbent cotton and a subsequent layer of ,vater-repellent cellulose with a Mass-
Fig. 150. X-ray photograph of a properly applied splint to the hands.
linn backing which has all been sewn together to make a prefabricated dressing. The dressing is pinned together with sterile safety pins, and then secured with some type of elastic or stretchable bandage. The bandage must not be applied too tightly, and must be applied evenly so that there is no swelling between constricted areas. Tight bandages should be avoided, especially in hand dressings, in dressings of the lower extremities or across the upper abdomen. A syndrome somewhat like the cast. syndrome may occur if the bandages across the upper abdomen aretoo tight. Gastric dilatation can occur, which may be fatal to the patient. If it does occur, it is alleviated only, if at all, by constant gastric suction and positioning the patient on the right side.
1124
Mary M. Martin, Everett I. Evans
When dressing hands, a somewhat different procedure is carried out. A very lightly impregnated petrolatum gauze is applied to the hand. Each finger is dressed separately. The hand must be dressed in proper position of function. It is desirable to apply splints to badly burned hands in order to keep them in proper position. An x-ray photograph of a properly applied splint is shown in Figure 150. The hands must be encompassed in a fairly voluminous dressing. Over the fine-mesh gauze (which is scarcely impregnated with petrolatum) several compresses are applied to each finger and to the front and back of the hand. The splint is applied, as well as several large absorbable cotton pads. All are held in place with an Ace bandage. EXPOSURE TREATMENT
The exposure treatment may be used in some instances and may be the best type of treatment for certain burns. For instance, in babies who have only buttock burns, or back burns, the exposure treatment (when all four extremities are securely restrained) works very well. The exposure treatment, however, calls for more adequate nursing care, and if the patient is not under the most expert care, and wriggles free from restraint, he scratches at the newlyJormed crust, with resulting infection. In our experience, the exposure treatment will not work when the burn is circumferential, inw~ich case it only leads to wet, macerated, infected burns. In babies withfac<1 burns, utmost care must be taken to restrain the hands in order to keep the infant from scratching his face. When treating burns of the buttocks or back by the exposure method, a cradle over the bed with a sheet over the cradle but with air able to circulate through the head and foot of the cradle will allow drying of the crust and still protect the patient from chilliness. Face burns are not dressed. Petrolatum is not applied to a burn of the face. A small amount of mineral oil or petrolatum may be applied to the lips. The eyes may be irrigated carefully daily with boric acid solution, taking care to insure that none of the solution runs down on the burned portion of the face. No other medication or treatment is applied to the face and a firm crust is allowed to form. ANTIBIOTICS
Some type of antibiotic must be administered. It is best for the first few days in a burn of moderate to severe extent to administer the antibiotic either intramuscularly or intravenously in order to be sure that the patient who may not tolerate oral fluids receives and absorbs adequate antibjotic therapy. Crysticillin, aureomycin and Chloromycetin have been used in this unit and all three equally well serve the purpose of keeping down any septicemia or bacteremia in the first days after the burn. The patient who has incurred a third degree burn, an extensive
Treatment of Acute Burns
1125
burn of any sort, or a very dirty burn is best given either toxoid or tetanus antitoxin depending upon whether or not he ha~ had any previous antitetanus treatment. POSITIONING
The position of the patient in bed after dressing is important. If it is a burn of the face, the head must be elevated. Burns of the hands, upper extremities and lower extremities must also be elevated in order to lessen the swelling which inevitably occurs. The amount of pain in the extremity will be lessened with elevation. Sling supports from an orthopedic bed may be conveniently used to support the hands. If the patient will in all probability be in bed one month or more, footboards must be put at the bottom of the bed, and the patient on his back kept with his feet at a right angle against the board in order to prevent footdrop. When the patient lies face downward, the feet must hang over the edge of the mattress in order to allow them to hang at a right angle. PULMONARY BURNS
If the patient has had a respiratory burn, a tracheotomy set must be by the bedside and, at the first sign of pulmonary edema, intravenous saline should be deleted from the intravenous fluid replacement and an effort made to give this calculated requirement by mouth. Intravenous aminophylline and/or aminophylline suppositories sometimes alleviate the pulmonary edema. Oxygen, either by nasal catheter or by tent, in the very young may help in cases of pulmonary burns. CORTICOSTEROID THERAPY
No ACTH or cortisone is given. In this unit, it has been found consistently that eosinophil counts taken daily for two weeks after a burn was received have varied from 0 to 10, whether the patients were babies or elderly adults of 85. This would indicate that the patient liberates enough ACTH of his own under this severe stress, and certainly needs no added hormone. DIET
A very important part of the treatment of the burned patient is the diet. For the first t,venty-four hours, nothing is given by mouth except half-normal iced saline (or if the patient is nauseated, a few ice chips). During the second twenty-four hours, if the patient seems to be tolerating the half-normal saline well, judicious amounts of skim milk (e.g. 25 ml.) are given every half hour during a twenty-four hour period. It is better to give small amounts and bother the patient at frequent intervals during the night than to fill the stomach with large amounts every four
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Mary M. Martin, Everett I. Evans
or six hours. If the patient tolerates this skim milk for a period of six to eight hours, at the end of the forty-eight hour period a type of formula is instituted which is calculated to conform with the National Research Council specifications for the daily caloric, protein, carbohydrate, fat and vitamin requirements. It may be administered by a nasogastric tube if necessary. It will make up into a form which will not clog a very small sized plastic tube. LATER CARE
No effort is made to change the plenary dressing until approximately ten days after its application unless some evidence of infection or gross soiling of the dressing is manifested. At the second dressing, ordinarily, the burn is gently cleansed ,vith Phisoderm and the same antibiotic which has been administered parenterally is sprinkled upon the burn surface. At this time decision is made as to whether grafting is to be immediate, delayed, or will not be necessary and heavy absorptive dressings are again applied over a fine mesh gauze, this time impregnated with a water soluble, nonmacerating base. Blood studies necessary throughout the course of the first days after burning include first the blood urea nitrogen and nonprotein nitrogen determinations as a measure of the amount of protein breakdown and renal function. Sodium, potassium, carbon dioxide and chloride determinations are made daily in case of severe burn. These become most important during the period of diuresis which begins three to four days after the burn occurs, since the most marked shift of fluid back to the cardiovascular system takes place at this time. At this time fluid intake is mainly oral, and the intravenous cannula is kept open with a very slow drip of glucose in water. When the urine output becomes more than the intake and when the formula is tolerated well and intake is adequate by mouth, the drip is shut down and if all goes well, discontinued. PRIMARY EXCISION AND GRAFTING
Some burns may be treated by the method of primary excision if the operating room and anesthesia facilities are always available. In small burns which are incontrovertibly third degree, perhaps the best treatment is to excise the burn and apply a split thickness graft immediately. In large burns, in which the life of the patient is in question, and the availability of skin is scarce, primary excision would perhaps make the amount of available skin for grafting even less, and a period of watchful waiting is to be desired. In some patients there will be little area from which to take skin. If such areas as the forearms or legs must serve as donor sites six or seven times, very thin split thickness grafts must be taken in order to be able
Treatment of Acute Burns
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to reuse the sites every ten days. The instrument which seems best for this purpose in our hands is the electric dermatome. M~ch thinner grafts may be taken successfully with this instrument time and time again than with other instruments available to us at this time. COMPLICATIONS
Some conditions which occur in patients who are burned may be pregnancy, sickle cell anemia (especially in Negro children), Curling's ulcer, central nervous system lesions, arteriosclerosis, kidney disease, prostatism with long-standing cystitis or urinary retention, and the like. Patients, pregnant when burned, often miscarry. Great care should be taken to keep burned pregnant patients flat in bed. They should be given progesterone and enough sedation to prevent restlessness. In many children who otherwise would not be adversely affected by a fairly small burn, if a sickle cell anemia or even a nutritional anemia is present, profound shock may result. Any patient ,vith a large burn who is overloaded with oral fluids or food early after the time of burning, or given water to drink as he desires, may build up a tremendous gastric dilatation or hemorrhagic gastritis. In some instances, if the central nervous system is involved, a Curling's ulcer with massive hematemesis may result. In patients with a markedly elevated blood urea nitrogen, anuria usually eventuates and the patient dies in a uremic coma. Patients with extensive signs of central nervous system involvement, such as mental aberration with gradual deterioration into a comatose state, may die in three or four weeks with an extreme hyperpyrexia of 106° to 108°F without any evidence of blood stream or local infection, despite normal electrolyte and renal chemistries and with adequate nutrition and no weight loss. Others in this group may develop a severe hypopyrexia as low as 95°F. Burn patients may develop pseudodiabetes, possibly as a result of the presence of a large amount of circulating hormone due to the stress to which they have been subjected. If, on a high calorie formula, the patient complains of excessive thirst and has an excessive output of urine, it is well to test the urine for sugar and ascertain the fasting blood sugar two or three days in succession. This complication may be successfully treated by lowering the caloric intake or adjusting the proportion of fat, protein and carbohydrate. Rarely, very small amounts of insulin are necessary. The patient with the pulmonary burn or the cardiac or elderly patient may die in pulmonary edema, either from congestive failure due to poor cardiac reserve or intrinsic pulmonary edema from irritation of the finer bronchioles and alveoli by smoke or heat, or both. Even in a very small burn, the latter complication is almost without exception fatal.
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Mary M. Martin, Everett I. Evans SUMMARY
Prompt replacement of fluid losses in the burned patient, and anticipation of each crisis a,s it arises throughout the post-burn course, will enable the general practitioner to bring patients with moderate and severe burns safely through the shock phase. If the burns are not extensive (i.e. if they are not third degree burns of 50 per cent or more of the body surface) there is a good chance, if the treatment encompassed in the foregoing is employed, that they may be tided over the first critical two weeks and eventually reach grafting and be healed. REFERENCES 1. Evans, E. I., Purnell) O. J., Robinett, P. W., Batchelor, A. D. R. and Martin,
M. M.: Fluid and Electrolyte Requirements in Severe Burns. Ann. Surg. 135: 804 (June) 1952. 2. Cope, O. and Moore, F. D.: The Redistribution of Body Water and The Fluid Therapy of the Burned Patient. Ann. Surg. 126: 1010 (Dec.) 1947.