Year : 2020 | Volume
: 28 | Issue : 1 | Page : 4--6
Tips in the management of burns
Consultant, Professor & Head, Department of Burns Plastic & Maxillofacial Surgery, VMMC & Safdarjung Hospital, New Delhi, India
Dr. Shalabh Kumar
Consultant, Professor & Head, Department of Burns Plastic & Maxillofacial Surgery, VMMC & Safdarjung Hospital, New Delhi - 110029
Burns is a serious health problem in our country. Burn management is a complex and resource intensive process and requires a dedicated multidisciplinary team working in coordination in all the aspects of burn care simultaneously. Most burn patients get treated by the general practitioner primarily and then referred to higher centers. Specialized burn centers are few in number, and affordable care is hard to find other than government run institutions. A lot of research has been done in the fields of burn resuscitation, nutrition, synthetic and biologic dressings, and surgical management of burn wounds, etc., and several advances have been made, but most institutes managing burns are restricted by their availability of resources and high patient load and hence adopt their own protocols based on their patient characteristics, resources, and experience in treating burns. Here, I have shared a few tips and wisdom I have gained in the management of burns based on my experience of almost 30 years in treating burns at a government run tertiary burn care center. Despite all efforts, severe burns are still associated with very high morbidity and mortality and so a concerted effort needs to be made at the national as well as grass root level to raise the awareness and education regarding burns safety and prevention of burns.
|How to cite this article:|
Kumar S. Tips in the management of burns.Indian J Burns 2020;28:4-6
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Kumar S. Tips in the management of burns. Indian J Burns [serial online] 2020 [cited 2021 Nov 30 ];28:4-6
Available from: https://www.ijburns.com/text.asp?2020/28/1/4/316584
The estimated annual incidence of burns in India each year is around 7 million, and it is responsible for 1.4 lakhs deaths and 1.7 lakhs people with burns-related disabilities each year. Due to predominantly poor socioeconomic status, over population, illiteracy, and inaccessibility to advanced burn care in most parts of the country, the incidence and deaths and deformities have continued to rise.
Our department runs a 64-bedded burn center and treated over 6000 burns in the year 2019. Despite an increase in the number of burn centers in the country in the last few decades, the number of burn patients has steadily increased to two folds since the year 2000.
Management of burns requires dedicated centers with a multifaceted team that can provide comprehensive care to the burn patient. Acute burn is an emergency trauma and the ABC of trauma care applies to this as well. Fluid resuscitation, prevention and treatment of burn wound infection and physiotherapy, and rehabilitation form the cornerstones in the management of burns.
Fluid Resuscitation in Burns
A significant amount of research has been done since the 1960s to find the ideal resuscitation fluid (both crystalloids and colloids) and the most suitable regimen for burn resuscitation. Despite that there is no consensus.
Ringer lactate (RL) is still the most commonly used resuscitation fluid and Parkland formula and modified Brooke's formula the most commonly used fluid resuscitation regimens. All regimens are merely for guidance with the main goal of maintaining good tissue perfusion and the fluid therapy should be titrated accordingly. Several advances have been made in hemodynamic monitoring and use of biochemical markers to assess cellular perfusion in trauma and critically ill patients. However, the systemic effects of burns are not the same as other trauma/critically ill patients and none have yet been completely established as a guide for fluid therapy in burns. Hourly urine output and clinical parameters are still the most commonly used parameters to titrate fluid therapy in burns, including at ours.
Most fluid regimens use isotonic fluid RL in the first 48 h of burns. In a study done at our department, it was noted that the use of RL alone or dextrose solution as maintenance fluid in burn resuscitation was associated with hyponatremia. The use of DNS as maintenance fluid instead of RL reduced the chances of hyponatremia. The resuscitation formula that we follow at our institute (Safdarjung formula) is as follows:
Two ml/kg/%TBSA burns RL + 2500 ml DNS as maintenance fluid for 24 h from the time of burn injury-half of the fluid is given in the first 8 h and the next half in the following 16 h.
On the second day, i.e., next 24 h, the fluid is given as follows:-
One ml/kg/%TBSA burns RL + 2500 ml DNS as maintenance fluid.
Maintenance fluid is titrated as per urine output.
Burn Wound Management
The goal of treatment is early wound healing with functional restoration. While superficial burns heal spontaneously, deep burns often require surgical intervention. There are many options available for dressing materials and the selection of appropriate dressing material depends on depth of burns, location of wound, wound condition, desired moisture retention and drainage, desired frequency of dressing change, and cost.
First degree burns require emollient/moisturizer and pain alleviation.
Superficial partial thickness burns heal in a period of 10–14 days, and the aim is to maintain a moist environment and avoid contamination until the wound heals. For such wounds, we find collagen-based dressings ideal as they fulfil both the above needs and dry up and automatically separate from the wound, once healed.
Treatment of choice for deep full-thickness wounds is excision and skin grafting as they do not heal spontaneously.
The treatment of choice for deep partial thickness burns is early tangential excision and auto-grafting. However, this is often not possible if the patient presents late to us, is inadequately resuscitated or unstable, extensive burns, in extremes of age and severe comorbidities. Apart from these, in most institutes, there are logistical issues such as high patient load, unavailability of operation theaters, intensive care unit beds, inaccessibility to skin banks, etc., it may not be possible to do so in all patients. In such cases, a more conservative approach is suited wherein the wounds are managed with dressings for 3–4 weeks, frequency of dressings, and debridement as indicated. The depth of burn is variable across a wound and some areas may heal spontaneously while others require intervention. Several specialized dressing materials are available for the management of wounds during this time, and we find nano-crystalline silver-based dressing to be better among them. However, these dressing materials are expensive and availability may vary from institution to institution. After 3–4 weeks, the residual areas should be covered with autologous skin graft.
Prevention and Treatment of Burn Wound Infection
In the first 24 h after burns, the burn wound is usually sterile and gradually gets colonized by the nonpathogenic commensal bacteria in the skin, surrounding environment and from patient's gut flora due to transmigration of micro-organisms (if the patient remains in shock). When these micro-organisms start colonizing the burn wounds and the bio burden crosses the threshold of 105 colony-forming units per gram of tissue, there is a risk of deeper invasion of unburnt tissue and then frank sepsis.
Hence, the availability of quantitative culture reports is important to determine the diagnosis of burn wound sepsis/sepsis. Qualitative cultures merely indicate colonization and are neither reliable indicators to start the systemic antibiotic nor to the response to antibiotics.,
There is no role of prophylactic antibiotics in burns. Topical antibiotics and proper wound care therapy are effective in reducing the colonization in the burn wound and the use of systemic antibiotics is justified only when there is a deeper invasion of unburnt tissue or there are features of systemic sepsis. Unwarranted and rampant use of antibiotics is not only harmful for the patient but also encourages the development of resistance to antibiotics in the micro-organisms.
We do not start prophylactic antibiotics in burn patients at admission and it is started only if the patient shows features of burn wound sepsis or systemic signs of infection. In case of unavailability of a positive culture report, empiric broad-spectrum antibiotics should be started as per the local antibiogram. As per our department antibiogram, we start with piperacillin tazobactam and the antibiotics are changed according to subsequent culture sensitivity reports.
The duration of antibiotic use is confined to 5–7 days and if the patient does not respond to the antibiotics, fungal infection and other sources of infection should be sought and treated accordingly. The resolution of systemic signs of infection is a reliable indicator to de-escalate the antibiotics and prolonged use of antibiotics should be avoided.
Rehabilitation and Physiotherapy
This is often a neglected aspect in burn care. The general concept is that once the wounds heal and patient is discharged, the role of rehabilitation and physiotherapy begins. On the contrary, it should start from day one of burn injury.
Positioning, splintage, and physiotherapy are the main components of a good Burn Rehabilitation Program.
Due to edema in the wounds and adoption of position of comfort, the patient often develops joint stiffness and contracture in that position of comfort. Hence, all the patients must be instructed about the importance of positioning of limbs and neck and must do physical therapy in the form of range of motion exercises for all joints three to four times per day. For patients who are not able to maintain the required position, splintage must be done in the desired position. Hands particularly require splintage with wrist in 20°–30° degrees dorsiflexion, MCP joints in 70°–90° flexion, fingers fully extended and thumb in abduction and extension. Early ambulation and chest physiotherapy are also very important components of burn rehabilitation. Patients are encouraged to perform their activities of daily living as soon as possible. This not only reduces the burden of care on the caregivers of the patient but also helps boost the patients' morale.
Despite all measures burn-related scarring and deformities are often unavoidable and it is nearly impossible to completely restore a patient after burns, functionally and esthetically. Hence, the prevention is always better than cure, and a concerted effort is needed for the prevention of burns injuries.
Burns require multimodal, specialized, and comprehensive care. Early and adequate fluid resuscitation, appropriate wound management, proper use of antibiotics, and a good burn rehabilitation program are the main tenets of management of burns. In addition to building more burn centers to improve the outcome of burns in our country, efforts need to be made to prevent it.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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