A. Primary Surgical Treatment.
I. General Considerations.
1. A high percentage of burns are received accidentallythrough carelessness and negligence. Efforts should be made to prevent burns byemphasizing the dangers associated with handling gasoline and other inflammablematerials, and instituting suitable safety measures.
2. In the early management of a burn casualty, the primaryconsiderations are:-
a. Prevention and control of shock.
b. Prevention of contamination of the burn surface duringtreatment and evacuation.II. Specific Considerations.
Initial care.
1. Control of pain by morphine administration. In extensiveburns, ? grain doses ofmorphine may be necessary. If anoxia is present, large doses of morphine aredangerous, and under such circumstances the dose should not exceed ? grain. Ifthe patient is in shock, absorption of subcutaneous or intramuscular morphinemay be delayed, in which case repeated doses of morphine should be given withcaution. Relief of shock and improvement in peripheral circulation may lead torapid absorption and over-dosage if morphine has been repeated in such cases.Careful administration of intravenous morphine has the advantage that pain ismore promptly and certainly controlled, and the danger of over-dosage fromrepeated subcutaneous or intramuscular administration is nullified. Doses of 1/6to ? grain,given slowly in 10 cc. of sterile distilled water or saline, and repeated asnecessary, is perhaps the safest method of intravenous morphine administration.
2. Early plasma replacement therapy should be instituted. Ifevacuation cannot be carried out quickly to a place for definite therapy, plasma should be started as part of the first aid measures. If one or twounits of plasma can be given early, even in the first half-hour, livesmay be saved. Quantities of plasma up to twelve units may be required in thefirst twenty-four hours for extensive burns. If the patient is in shock whenplasma is started, the first two or three units should be given rapidly.
3. From the first, efforts should be made to preventcontamination of the burn surface by nose and throat organisms. Those handlingthe patient should always be masked. If masks are not available, they can beimprovised. Aseptic technique, with gloves and instruments if possible, shouldbe used at all times.
4. Casualties with 15% or over of body surfaceburnedshould be treated as litter patients immediately.
5. Clothing need not be removed unless too dirty,charred, contaminated or soaked with oil or chemicals.
6. No cleansing or debridement should beattempted in thefield. This procedure should only be done in hospitals where completefacilities for definitive treatment are available.
7. Cover the wound with sterile dressings, triangularbandages, or clean sheets. Evacuate to hospital for definitive treatment ofthe burned area as quickly as possible. Boric acid ointment or Vaseline appliedto a grossly contaminated burn complicates the later cleansing of the burnsurface. If a local application is considered necessary, 5%
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sulfadiazine cream is preferred because of its bacteriostaticeffect and its relative ease of removal later if cleansing and debridement areconsidered necessary.
8. Application of sulfadiazine cream, boric acidointment or petrolatum to a grossly contaminated burn are not to be considered as definitive treatment.
9. Eyes should be gently irrigated with saline or boricsolution, and a mild ointment (4% boric acid ointment), or oil instilled. Do notapply sulfadiazine cream to the eyes or lids, since it is extremely irritatingto the conjunctiva. The lids should be closed with a pad of dampened gauze overthem and a dry one held with adhesive, if possible, as the best dressing for thecornea is the lid. Cocaine or other anesthetics should not be used, asanesthesia of the cornea might lead to damage. If there is evidence of cornealinjury, the case requires the attention of an ophthalmologist as early aspossible.
10. Severe burns of the hands, or of one hand alone, shouldbe considered as major burns and evacuated to a hospital for definitivetreatment.
11. Tetanus toxoid is indicated for all patients with secondor third degree burns.
12. Tannic acid, tannic acid jelly, triple dye,gentian-violet, gentian-violet jelly, and other membrane forming applications,should NOT be used.
13. RAPID EVACUATION TO DEFINITIVE TREATMENT SHOULD BEEFFECTED.
B. Definitive Surgical Treatment
I. General Considerations.
1. Each hospital should be prepared at all times with a burnteam and a plan for admission, sorting and treatment of multiple burncasualties.
2. In the very early stages the treatment of shock andhemoconcentration takes precedence over local treatment of the burn.
3. Definitive treatment of the burned area is given at thefirst opportunity presented by the condition of the patient and the presence ofadequate hospital facilities. It is aimed at obtaining and maintaining a woundfree of contamination and infection.
II. Specific Considerations.
1. Systemic Treatment
a. Plasma must be given to maintain blood volume. Asimplemethod of estimating the amount of plasma necessary is that of adding 100 cc.of plasma for every point the hematocrit determination exceeds the normal of 45.Another rough method is that of administering 500 cc. of plasma for each 10% ofthe body surface burned. The adequacy of plasma administration can be determinedby frequent red blood cell, hemoglobin, and hematocrit determinations. An effortshould be made to keep the red blood cell count at 5.5 million or below, thehematocrit reading below 50, and the hemoglobin down to 100%. The generalcondition of the patient, the pulse and blood pressure, are other invaluableguides.
Continued plasma therapy for three or four days may benecessary, and, following this, plasma should be given at intervals tomaintain the blood proteins at a normal level.
b. A standard method of estimating body surface burned isby use of the Berkow formula, as follows:
Head | 6% |
Upper Extremities: |
|
| Both arms and forearms | 13% |
| Both hands | 5% |
| Total | 18% |
Trunk and Neck: |
|
| Anterior surface | 20% |
| Posterior surface | 18% |
| Total | 38% |
Lower Extremities: |
|
| Both thighs | 19% |
| Both legs | 13% |
| Both feet | 6% |
| Total | 38% |
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c. The need for whole blood transfusion will develop insomecases as early as 2-3 days after the burn is incurred. Plasma is not asubstitute for whole blood if secondary anemia is present.
d. A urinary output of 1,000 cc. to 1,500 cc. dailymust be established as soon as possible. In the first 24 hours after anextensive burn, it is more important to effect adequate plasma replacement, thanto give parenteral crystalloids. During this period it is believed that the saltrequirements are met by the salt content of the plasma administered. Thedaily fluid intake should be maintained at 3,000 cc. to 4,000 cc., and, ifparenteral fluids are necessary to reach this level, chief reliance should beplaced on 5% glucose in distilled water. Saline should be given sparingly,usually only if there is vomiting or some other cause for salt depletion. As ageneral rule, not over 1,000 cc. of normal saline should be given over a 24-hour period.
e. During the critical phase (which may last up to 72 hoursor longer), the patient must be closely observed for the development ofpulmonary edema, shock, morphine overdosage, or the development of cerebralmanifestations. Oxygen therapy is often indicated during this period.
f. From the first, the importance ofmaintaining thenutritional state of the patient should be kept in mind. Every effort should bemade to give adequate food and liquids with a high content of carbohydrate,protein and vitamins.
g. A prophylactic dose of polyvalent gas bacillus antitoxinmay be given for deep burns at the discretion of the medical officer.
2. Cleansing andDebridement
a. No attempt will be made to clean or debride the burnsurface until shock is adequately controlled.
b. The wound will always be treated under standard operatingroom technique with patient and attendants fully masked.
c. Morphine sedation will be adequate to allow debridementand cleansing of the wound in the majority of cases. Intravenous morphine maybe indicated in some instances. If general anesthesia is necessary, firstconsideration should be given to light intravenous Pentothal sodium. Inhalationanesthesia is contra-indicated if an associated blast injury ispresent or suspected.
d. In some cases, if the patient is received a short timeafter the burn is incurred, and if the wound is free of gross contamination,cleansing and debridement may be considered unnecessary.
e. Those burns showing gross contamination should be cleansedwith neutral soap and water, and irrigated with saline. Lard, mineral oil orether, in small amounts, may be used for removal of grease and heavy oil. Thecleansing should be done gently with gauze or cotton swabs. Green soap and brusheswill not be used. The cleansing should include the skin surrounding theburn.
f. Removal of loose shreds of epidermis and large blistersshould be done after thorough cleansing. Small blisters may be left undisturbed,or removed, depending on the extent of the procedure necessary and the conditionof the patient.
g. Immediate excision and grafting of burns has such limitedapplication that it is not recommended.
h. Debridement should not include excision on loose skin fromthe eyelids, ears or fingers. Blisters in these areas may beincised after cleansing.
3. Dressing.
a. The burned area should be covered with single strips offine mesh gauze (44-mesh gauze bandage), impregnated with 5% sulfadiazinecream, boric acid ointment or
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petrolatum. Sulfadiazine cream is preferred because ofthe early high local concentration of the drug obtained. It does not standautoclaving and should be prepared at the operating table by spreading thinly on44-mesh gauze bandage. Sulfanilamide powder may be used with boric acidointment or petrolatum, but the total dose should not exceed 10 grams. Localsulfonamide therapy is only of value as a prophylactic against virulentinfection in the early stages. It is useless after pus has developed fromordinary pyogenic infection of the deeply burned areas. Ordinarily there willbe no indication for continuation of local sulfonamide therapy after thefirst dressing, which, in a favorable case, can be postponed tobetween seven and fourteen days.
b. The remainder of the dressing will consist of gauze,absorbent cotton, cotton waste, or cellulose. The dressing will be thicklyapplied over all the burn and will be bandaged on snugly with even pressurethroughout. Stockinette or some form of elastic bandage may be used, ifavailable, to maintain pressure. Care should be taken to prevent thepressure dressing from forming an area of constriction. In the case ofextremities, the pressure dressing should include the entire extremitydistal to the burn.
c. Immobilization of the part by plaster splints placed overthe dressing should be effected when possible. Skin-tight plaster castsshould not be used. If a complete plaster casing is applied, it should besplit to allow for swelling.
d. Burned hands should be carefully dressed with pressure to,and including, the tips of the fingers. The hand should be in the position offunction with fingers separated and flexed. Edema is further prevented byelevation, which is best accomplished by overhead suspension attached to plasterarm splints applied over the pressure dressings.
e. Pressure dressings are applied to the face as elsewhere,taking care to protect the eye, pad the ears, and leave an adequate respiratoryairway.
f. Genitalia should be covered with 5% sulfadiazine cream andsimple dressings. The dressings should be applied in such a manner that theycan be changed separately as necessary.
g. Dressings should be changed infrequently in the earlystages of a burn, and, if possible, the dressings should be done in theoperating room with standard aseptic technique.
h. In some instances it may be necessary to change thedressing at four to five days on a clean and uninfected case, because ofexternal soiling or soaking of the dressing by exudation of plasma. In suchcases, it is often satisfactory to change the bulky outer portion of thedressing and not disturb that immediately over the burn surface.
4. Sulfonamide Therapy
a. If a sulfonamide is used locally, oral or parenteraladministration of the drug should be postponed until adequate kidney function isdemonstrated by a daily urinary output of 1,500 cc., and the blood sulfonamidehas dropped to a low level. After this period, if evidence of sepsis develops,oral therapy should be instituted and continued as indicated.
b. All cases with moderate to severe burns, that have not hadlocal sulfonamides applied, will be started on oral chemotherapy. Sulfadiazineis the drug of choice for oral administration (sulfanilamide may be substituted). It should be given with caution in the early stage of a burn, andthe dose should not exceed 0.5 gram every four hours until the urinary outputhas reached a normal level. Frequent blood level determination should be done.
5. Further Care of Burned Surface
a. If virulent infection is prevented, healing of superficial burns will take place rapidly.
b. After a period of about two weeks, infection of deeply burned areas by ordinary pyogenic organisms will make frequent dressings necessary in order to maintain cleanliness and promote separation of slough.
c. Wet dressings using saline, boric, Dakin's or azochloramid solution for irrigation should be applied and changed daily.
d. Dressings should be wet before removal.
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RETURN TO TABLE OF CONTENTSe. If possible, saline baths should be used for ease of removal of dressings,for cleanliness and to promote active exercises.
f. Unhealed areas should be prepared for grafting, and grafts applied asearly as possible. It is often possible to begin grafting within three or fourweeks after the burn is incurred.
g. Active motion should be instituted in severe hand burns not later thanseven days following the injury. This can be facilitated by removing thedressing and placing the extremity in an arm basin filled with saline.
6. General Care
a. Whole blood transfusions may be necessary as early as three or four daysafter the burn, and at regular intervals thereafter until the case is healed orgrafted.
b. A diet high in calories, protein, carbohydrate and vitamins shouldbe maintained.
c. The blood protein level should be observed and kept at a normal level byplasma transfusions as necessary.
d. Careful and sympathetic nursing care is an absolute essential.
