58. Burns
From Primary Surgery
58 Burns
58.1 Caring for a severe burn
(58-3 - 'tear out page' at the end of the book / not relevant) (58-4 “It is reproduced again on one of the end papers” / not relevant)
In many of the hospitals for which we write the problem of burns is a straightforward one-neglect, by both doctors and nurses! Burns may fill a third of your surgical beds. They are dirty, smelly cases, time consuming to treat properly and demoralizing for the patients, who are often full of complaints. It is so easy to pass a patient by with the thought, or the statement-'Just another burn!' So be sure to take a great interest in the detailed care of burns, and encourage the nurses to do so too. Although the emphasis of the early parts of this chapter is on the resuscitation of severe burns, they will only be a minority of your patients.
You should be able to: (1) Prevent infection turning a partial thickness burn into a full thickness one. This mostly means the correct early treatment. (2) Minimize the severity of all contractures, and prevent many of them completely. The important step is to graft full thickness burns early, usually between the 10th and 18th day. By doing this you will prevent a patient, especially a child, being unnecessarily disabled by what may be only a small burn. Tragedies, like those in Figure 58-1 are completely unnecessary. (3) Release and graft some of the contractures that you have not been able to prevent. If you have done your best to prevent contractures in the early stages, those that you will later need to release should not be too severe. Many
of the contractures that are still common in the developing world are the result of neglected early treatment, and would be the despair of plastic surgeons in the industrial world. (4) Prevent all deaths from shock in the first 48 hours, except in the most extensive burns. (5) Save the lives of most adults with 30 to 40% burns, and of most children with burns of 20 to 25%.
THE GENERAL METHOD FOR A SEVERE BURN
Only an occasional patient will require the full regime described here. Most patients have lesser burns.
IMMEDIATE FIRST AID Pouring cold water on a burn immediately after the accident, or putting a burnt limb in water during the first few seconds, cools the patient's burnt tissue. I t relieves his pain and can prevent superficial burns becoming deep, especially when the agent is hot fluid like porridge or syrup.
Cover the burn with the cleanest thing available, such as a recently washed sheet. Don't apply any ointments or local remedies.
PRIORITIES IN CARING FOR BURNS If a patient's eyelids or hands are burnt, make saving his sight and the use of his hands your priorities.
THE FIRST 24 HOURS AFTER A BURN
ADMISSION The indications for admission include: (1) All patients liable to shock (that is all burns over 10%). (2) Any patient who has burnt his face, eyes, hands, feet or perineum, whatever the size of his burn. ALWAYS admit a child with a burnt hand. (3) All patients who have inhaled smoke. If possible, refer all these patients.
SECURE THE PATIENT'S AIRWAY This is the first priority if a patient has burnt his face or inhaled smoke-see Section 58.27. Only do a tracheostomy if it is absolutely necessary and intubation fails (52.1). But, if it is necessary, do one. Asphyxia will kill a patient quicker than hypovolaemia or i nfection.
If his breathing is noisy, his airway is obstructed. Hoarseness and stridor occur late in the shock stage and are important signs of impending airway obstruction.
If there is a contracting eschar round his neck, you may have to do a tracheostomy to remove the obstruction and an escharotomy to relieve the constriction.
If his face is swollen, suspect oedema and obstruction of his nasopharynx.
If his respiratory tract might be burnt, look for burnt nasal vibrissae, soot in his nostrils, and burns on his tongue, oral mucosa, palate, and pharynx. Is there any soot in his sputum?
WHEN WAS THE PATIENT BURNT? Record the exact time of the burn-time your fluid replacement planffrom that moment and not from the time of admission.
HOW WAS HE BURNT? Question his relatives, or the ambulance men carefully. They will have been to the scene of the accident.
SETUP A GOOD DRIP Do this for all burns over 15% in adults and 10% in children under 3 years, taking careful aseptic precautions. Start with Ringer's lactate, or 0.9% saline-NOT 5% dextrose! Look for a good arm vein, and if necessary cut through burnt skin. If possible use the veins in a patient's forearm and avoid his long saphenous vein at his ankle. This vein usually goes into spasm, and is a bad one to use in shocked patients. If you can leave it intact, it may be very useful later.
Put in as big a cannula as you can, and fix it firmly. The best way to keep a drip running is to make sure it never stops. If the blood enters the cannula and clots there, his lifeline has gone. So make sure that nobody turns off the drip while waiting for a fresh bottle. As you put the cannula in, take blood for a haematocrit (or haemoglobin), and for grouping and cross matching.
MORPHINE AFTER A SEVERE BURN If a patient has been severely burnt, pain may not be very marked after 2 hours, especially if the surface of his burn has been cooled. He will often present later than this.
If he is restless, but not in great pain, he needs fluids, not morphine.
If he is in severe pain, and has not inhaled smoke, give him intravenous morphine in the doses advised in section A 8.7.
If there is any danger that he has burnt his lungs, avoid morphine and other opioids.
When you give morphine, give a small dilute dose intravenously slowly over several minutes. Observe his respiration and his relief from pain. Give him as much morphine as he needs and no more. You may be able to give it through a small vein on the back of his hand. It is most urgently needed in shallow burns and fatal ones.
WEIGH HIM If this is impractical, guess his weight. Weigh him at least once a week subsequently.
IF NECESSARY (58.4), CATHETERIZE THE PATIENT'S BLADDER. Pass an indwelling catheter. Use a small self-retaining catheter, empty his bladder, and start to measure his urine, every hour on the hour. Keep early urine specimens to compare with later ones. If he develops haemoglobinuria, you will know if this is getting worse or not. Start a fluid balance chart (A 15.5).
Try to measure the volume of urine actually produced by his kidneys during the previous hour. The urine bag should be small and it must have a short tube (not more than 10 cm), or urine will accumulate and make measurements inaccurate. If this is impractical, particularly in a child, collect it in a bedpan or urine bottle and measure it 4 hourly.
HOW BIG AND HOW DEEP IS HIS BURN? Use the chart in Fig. 58-4, or the rule of nines or sevens (58-3). For small or scattered burns, estimate how many times the area of his hand (1%) would fit on his burn. Draw the burn on a photocopy of Fig. 58-4, and sketch in the areas of each depth (58-9).
HOW MUCH FLUID AFTER A SEVERE BURN?
Calculate this from the formula in Fig. 58-5 as discussed in Section 58.4. Decide how much intravenous fluid to give him during the next hour and write down the appropriate infusion rate. If he has a burn of over 30%, he needs some of his fluid requirement as colloids, such as dextran or plasma, so prescribe them (58.7).
If he is thirsty and wants to drink, let him do so.
TETANUS PROPHYLAYIS Give all burns patients tetanus toxoid (54.11).
OTHER MEASURES If a patient's burn is large, give him penicillin for five days to prevent streptococcal infection (57.3) and assist in the prevention of tetanus. Prescribe the necessary sedatives.
If he has lost blood from other injuries, make as good an estimate as you can of this, based on Fig. 53-3. If possible measure his central venous pressure (A 19.2). Transfuse him as necessary and keep it between 4 and 8 cm of water. It must not exceed 15 cm.
LOOK FOR OTHER INJURIES Look especially for fractures of his pelvis (76.1), ribs (65.1), and spine (64.1). These are often missed.
LOOK FOR OTHER DISEASES Especially in children who are often burnt partly because they are ill and fretful with some other disease, such as diarrhoea or an upper respiratory infection.
CAUTION ! Don't apply splints, dressings, or casts too tightly over burnt tissue, because it is going to swell. Wait until the swelling has gone down.
Burns over a fracture may be an indication for traction rather than for an external splint.
ESCHAROTOMY If this is necessary (58.18), it will be necessary immediately.
X-RAYS If a patient might have inhaled smoke, X-ray his lungs.
NURSING A SEVERE BURN
Place the patient on a clean sheet under which is a layer of plastic to prevent the mattress being soiled. If possible don't let him lie on the burn. Keep the bed clothes off him with a cradle.
If he is conscious, lie him supine or prone (depending on the site of the burn) and raise his legs or the foot of his bed. Don't give him a pillow or let him sit up until shock is over.
If he is unconscious, lie him on his side, head down in the recovery position (51-2).
CAUTION ! Wash your hands before and after touching him. If possible use sterile disposable gloves. Try to make sure the nurses do so too.
Keep him mobilized as much as you can. If his burns are extensive, move him into different positions every two hours to prevent chest complications, bed sores, thrombosis, and embolism.
NASOGASTRIC TUBE If a patient's burn is very severe, or he is nauseated or vomits, or his abdomen is distended and his bowel sounds are scanty, pass a nasogastric tube. He may inhale his vomit at any time, particularly if he is weak or semiconscious. Intravenous chlorpromazine, 0.5 mg/kg 6 hourly, may ease his nausea.
MAKE A PLAN FOR HIM Where appropriate, tell the patient and his relatives what you expect to happen and when. Record it in his notes.
AFTER THE FIRST 8-HOUR PERIOD AND AFTER EACH SUBSEQUENT 8 HOUR PERIOD
Reassess the patient after the first hour and at the end of each of the 8 hour periods in Fig. 58-5. Is his urine volume adequate? Did he get the fluid he should have had during the previous eight hours? Give clear instructions to the nurses for the next 8 hours. For example, "If he will not drink, give. . ., If his urine volume is less than X ml for two hours or more, do..." etc.
NEXT DAY AFTER A SEVERE BURN
Reassess the extent of the patient's burn. Areas which showed only erythema yesterday may have blisters today and need to be included in the area of partial thickness skin loss.
LATER, WATCH FOR THE COMPLICATIONS OF BURNS
Anuria and oliguria are serious complications. Check the urine collected from the patient's catheter (58.10).
Haemoglobinuria is common in burns and contributes to renal failure.
Pulmonary oedema is due to too much fluid, perhaps combined with lung damage, so reduce the infusion rate; give him frusemide and perhaps steroids.
Anaemia Watch for this and treat it as necessaary (58.10).
Contractures and joint stiffness Anticipate the places where contractures will form and nurse him in the positions which will prevent them, as in Fig. 58-16. Splint his joints appropriately, and mobilize ;hem as soon as the skin over them has healed (58.24). Keep burnt hands in a plastic bag (58.29) and encourage full movements from the start.
THE FURTHER MANAGMENT OF A SEVERE BURN
Read on-to learn about prevention and physiology (58.2), to measure the extent of a patient's burn (58.3), to assess his fluid needs during shock (58.4), the kind of fluid he needs (58.5), whether you should allow him to drink or not (58.6), his need for colloids or blood (58.7), resuscitating him if he was admitted late (58.8), his fluid needs when shock is over (58.9), problems with fluid and blood replacment (58.10), feeding him (58.11), assessing the depth of his burn (58.12), choosing a method to treat his burn (58.13), the exposure method (58.14), the occlusive dressing method (58.15), the saline method (58.16), early excision of a burn (58.17), sloughs and eschars (58.18), grafting (58.19), preventing infection (58.20), antibiotics (58.21), topical agents (58.22), treating an infected burn (58.23), preventing contractures (58.24), relieving broad contractures (58.25), relieving narrow contractures with a Z-plasty (58.26), burnt lungs (58.27), burnt eyes (58.28), burnt hands and feet (58.29), burnt face and ears (58.30), burns of the trunk (58.31), burnt bones and joints (58.32).
THE FIRST DAY AFTER A SEVERE BURN IS CRITICAL
EXAMINE THE PATIENT OFTEN
58.2 Prevention and physiology
Many burnt patients are children who have pulled cooking pots over themselves, or fallen into the fire. Most are poor, and many are malnourished. Some are epileptics who have fallen into the fire during a fit. An increasing number come from factories where safety precautions are not observed. Enforcing such precau-
tion would prevent many burns, so would the improved control of epilepsy.
The skin is the largest structure in the body. It isolates a patient's inside from his outside, chemically, thermally, mechanically, and biologically. A burn destroys these functions, so that treatment is mainly an attempt to restore them. A severe burn is a three dimensional rather than a two dimensional lesion. It opens up a huge surface through which the body loses water, electrolytes, proteins, and heat, and across which bacteria and drugs can enter. The immediate result of a burn is severe shock which lasts about 48 hours. This is followed by 'a period of 2 or 3 weeks during which the slough over a deep burn separates, allowing you to graft it. During this period sepsis is the major problem.
The area of a burn determines the volume of fluid lost and the volume you must give a patient in the first few hours to replace it and prevent shock. The depth of his burn determines how you should treat it, and especially, if you need to graft it. Its position determines how you should nurse him and especially how you should prevent contractures. Between them the area, depth, and position of a patient's burn determine what will happen to him.
AREA, DEPTH AND POSITION DETERMINE THE OUTCOME OF A BURN
58.3 What percentage of a patient's body surface has been burnt?
The proportions of parts of the body differ in adults and children. Estimate them with the chart in Fig. 58-4, which is also included as a 'tear out page' at the end of the book. This table is difficult to remember, so memorize the rule of nines in adults and the rule of sevens in children, in Fig. 58-3. Remember that the area of a patient's hand (not yours!) is about 1% of the total area of his body. When you calculate the area of a burn, don't include the area of erythema in a white skin (it is not visible in a black one). Blisters may not appear for 24 hours, so revise your estimate if more appear after you have first examined a patient. Burns are easily underestimated in a black skin, and over-estimated in a white one.
There is an upper limit to the severity of a burn above which a patient is almost sure to die, and if he does live his life will only be a burden to him. In anything but the most sophisticated burns units a patient with a burn of 60% or more is so unlikely to live that compassionate palliation may be the only logical treatment for him. Morphine and a drip to prevent him suffering thirst will make his last days more comfortable. Scarce facilities are probably better kept for patients with a greater chance of life.
58.4 How much fluid does a shocked patient need?
A patient loses much fluid into tissues which have been burnt, but not actually killed-most of it is lost during the first 8 hours. He loses more fluid this way than by evaporation from the surface of his burns, or into blisters. The loss of this fluid sends him into shock and raises his haematocrit. At the same time he also loses water and electrolytes in his urine, and water through his lungs and his normal skin. Treat him by replacing all this fluid.
Severe injuries, as from a road accident, for example, cause shock immediately, but the shock following a burn develops more slowly. Half an hour after a severe burn a patient may look surprisingly well, but four hours later he will be deeply shocked. Try to prevent this and resuscitate him before he becomes shocked. If you delay, he may die.
A burn of over 15% in an adult, or 10% in a child, causes shock. Burns of this severity always need a drip, lesser ones may do, especially in children. Besides childhood, old age, malnutrition, and anaemia can also reduce a patient's ability to withstand a burn and increase his liability to shock.
Many formulae are used. Although some centres use plasma and colloids, there is no evidence that a patient does better. They are expensive, so only crystalloids are described here. Give an adult 1 ml of fluid for each 1 % of his body burnt, for each kilo of his weight. Thus a 60-kg man with a 20% burn needs 60 x 1 x 20 = 1,200 ml of fluid. Give a child under six years twice as much. Give him 2 ml of fluid for each 1 % of his body surface burnt for each kilo of his weight. Thus a 6-kg child with a 20% burn needs 6 x 2 x 20 = 240 ml of fluid. Both adults and children need these volumes of fluid once in the first eight hours following the burn, once in the next 16 hours, and once again in the following 24 hours.
This formula is designed for use with Ringer's lactate or 0.9% saline, or if necessary Darrow's solution, and is more generous than those designed for use with colloids.
After 48 hours you can usually take a patient's drip down, but only provided that his urine output is satisfactory and he is drinking well. There is a danger of overhydration if fluids are continued unnecessarily after 48 hours.
Calculate a patient's fluid needs from the time of the burn, not from the time of admission. If admission is delayed, you will need to give the fluid correspondingly faster (58.8).
CALCULATE A PATIENT'S FLUID NEEDS FROM THE MOMENT OF THE BURN
The formula above accounts only for the fluid loss from the burn itself, and not for a patient's ordinary daily fluid requirements (metabolic water needs), which vary with his size and the ambient temperature and are given in Scale E Fig. 58-6. So give him this volume of fluid in addition to the fluid you give him to treat the shock his burns have caused. Give him his daily fluid requirements (metabolic water needs) as 5% dextrose intravenously, or as water by mouth, as in the next section.
IMMEDIATE FLUID REPLACEMENT IN BURNS
DOES THE PATIENT NEED A CATHETER? All patients with burns of over 30% need a catheter to measure their urine output. Patients with burns of less than 10% never do. Patients with burns of between 10% and 30% only need one if their urinary output is poor. A patient also needs a catheter if his perineum has been burnt. Catheters have their risks, so observe this intermediate group of patients carefully. It is tragic for a patient with a minor burn to die later from a urinary infection.
First, align his height and weight with a ruler, this will cross Scale F, at a point which indicates his surface area. Then held the ruler vertically at this point (hold it parallel to the thick vertical lines) and read off his blood volume etc. For further instructions, see the next figure. Drawn at the suggestion of Peter Bewes using data from the Ciba-Geigy Scientific Tables.
IS HE GETTING ENOUGH FLUID? A patient's urine flow is the most reliable indication as to whether you have treated his shock adequately or not. But: (1) His bladder must be empty before collection starts. (2) The formula is a rough guide only, so adjust it according to how he responds. Watch his jugular venous pressure, and listen to the bases of his lungs. Adjust the rate of infusion and the volume of fluid you give him like this:-
If he is already shocked, give the initial transfusion fast over 10 or 15 minutes. A severely shocked patient may have lost a third of his blood volume, so be prepared to give him up to a third of his blood volume fast. You will need to know what his blood volume is, so consult Scale C, in Fig. 58-6. Thus a child with a blood volume of a litre may need up to 330 ml of fluid. As soon as he starts to recover, slow the drip.
If treatment starts late, give more fluid than the formula indicates.
For example, say he was 152 cm tall and weighed 20 kg. He would have a surface area of 1 square metre, a blood volume of 2.5 litres (scale C), and a plasma volume o£ about 1.6 litres (scale D). His fluid requirement would be about 2150 ml (scale E), and his minimum daily urine output about 600 ml (scale G). If you cannot weigh and measure him, estimate his approximate height and weight from his age. This will be much less accurate.
If shock is not controlled, give more fluid than the formula indicates. Here are the signs that shock is not controlled and that he needs more fluid: restlessness, cold hands or feet, a rising pulse rate, thirst, sweating, collapsed veins, or a falling blood pressure. A common error is to give morphine instead of fluid to relieve restlessness.
A patient should secrete between 0.5 to 1.0 ml/kg of urine an hour. For a 70 kg adult this is between 35 and 70 ml per hour. Scale G, in Fig. 58-6 is drawn at 0.5 ml per hour, so this is his minimum output. If he is secreting less urine than this, he usually needs more fluid, but he may need less if he has renal failure (58.10). The minimum volume of urine required to excrete the solutes produced by metabolism is about 300 ml in a normal person and 600 to 800 ml in a burns patient.
If you are not giving colloids, his urine flow is the best indication of adequate fluid replacement.
If you are giving him colloids, combine estimation of his urine output with: (1) inspection of his jugular venous pressure, (2) the filling of his peripheral veins, (3) the colour and temperature of his skin, and (4) the capillary filling of his nail beds.
If his jugular venous pressure rises and there are basal crepitations, you are over-infusing him (which is a less common error than under-infusion), so reduce his fluid intake drastically. As he loses fluid from the surface of his burn he should improve.
If you can measure his microhaematocrit, measure it 2 hourly for the first 8 hours, then 8 hourly thereafter. Fill two capillary tubes from a pin prick in his ear (in case one breaks), and plot the readings immediately on his fluid balance chart.
Provided he was not anaemic or polycythaemic before treatment began, changes in his haematocrit will be a useful guide to fluid replacement. A high haematocrit shows that he needs more fluid and vice versa. Don't be a slave to it, and consider it with other signs.
A PATIENT SHOULD EXCRETE 0.5 TO 1 ml/kg OF URINE PER HOUR
(35 to 70 ml per hour for adults)
58.5 What kinds of fluid does a severely burnt patient need?
A severely burnt patient needs fluid for two purposes, and for each of them the fluid must be different.
(1) A patient needs fluid to replace his fluid loss and treat shock. Besides losing water, he loses sodium from his extracellular fluid into the cells of the unburnt part of his body, so that his plasma sodium falls and must be replaced. If you replace this fluid with plain water, or 5% dextrose intravenously, he may become confused and die from water intoxication (58.10), especially if he is a child, due to excess water and not enough sodium. So, give him Ringer's lactate or 0.9% saline intravenously. If necessary, you can give him Darrow's solution.
When you replace a patient's fluid losses by mouth, give him saline or oral rehydration fluid, or milk not pain water or tea. This is especially important with young children. To make a suitable solution, add a teaspoonful of salt, and another one of sodium bicarbonate, to a litre of water. If you add fruit juice, and serve the mixture cold from the fridge, no child will refuse it.
(2) A patient needs fluids to fulfil his basal (metabolic) water loss. For this he needs water without sodium, so estimate this need from scale E, (his daily fluid requirements) in Figure 58-6. Give him the water he needs as 5% dextrose intravenously, or as water by mouth.
58.6 Should you let a burns patient drink?
Intravenous fluids are expensive and may be scarce, so it is convenient to let a patient take his fluids by mouth, if he can. This may be possible if his burns are not too extensive, but it can cause problems. He may drink too little or too much. Nausea, gastric dilatation, and ileus may occur in severe burns. Shock, on the other hand, makes him thirsty, and he may be tempted to drink too much. If he does, he may vomit severely, so manage him like this:
SHOULD A BURNS PATIENT DRINK? If he is thirsty and wants to drink, let him do so, even if he is being given intravenous fluids.
If his burn is under 10% let him take all his fluids by mouth as bicarbonate saline (58.5), or milk.
If his burn is between 10% and 15%, he is on the borderline. Treat him with supervised oral fluids, if you can.
If his burn is more than 15%, give him his calculated fluid needs intravenously. If intravenous fluids are very scarce and you want to try treating him orally, pass a nasogastric tube and empty his stomach hourly before giving test quantities of oral fluids.
If his stomach empties normally, give him up to 75% of his fluid requirements by mouth.
If his stomach does not empty normally, stop oral fluids and give him all his fluid requirements intravenously.
THE REPLACEMENT FLUID FOR SHOCK MUST CONTAIN ENOUGH SODIUM
58.7 Does a burns patient need blood?
If a deep burn is more than 10% in a child, or 20% in an adult, give the patient some blood, especially if his burn is full thickness. Give it on the second day at the end of the shock phase, and repeat it as necessary. Give him one per cent of his blood volume for each one per cent of a deep burn. Thus a 60 kg patient with a 30% burn needs 30% of 4.4 litres (this is his blood volume as read off from Scale C, in Fig. 58-6) or about 1300 ml of blood. A simpler way of estimating the blood that a severely burnt patient needs is to give him 25 ml/kg. Signs which suggest that blood is indicated are: (1) Evidence of blood loss such as haematemesis, melaena, or delayed haemoglobinuria (18 to 36 hours after burning). (2) A falling haematocrit, when plasma or crystalloid infusions have not been excessive.
58.8 If resuscitation starts late
Don't be deceived if a patient who arrives early looks quite well. His severe pain may have gone and the ill effects of hypovolaemia may not be manifest yet. If transport in your district is difficult, most of your patients will arrive late. If a patient with a severe burn takes more than three hours to reach you, he will arrive severely shocked. The longer the delay the worse his shock, and the more important it is for you to correct his fluid deficit quickly, and the more difficult this will be without overloading his circulation. Suppose that a 70 kg adult has a 40% burn, and is admitted four hours later. During the eight hour period following the burn he should have 40 x 70 = 2800 ml. Four hours of this period has already elapsed, so he needs this volume of fluid during the remaining 4 hours, or 700 ml an hour. Because his burn is over 40%, he will need some of this fluid as colloids. Here is some guidance for managing these difficult cases.
RESUSCITATION STARTS LATE Calculate a patient's fluid deficit as in Fig. 58-5. Start by giving him saline, until he becomes conscious, or his peripheral pulses return.
After an hour give him chlorpromazine 0.5 mg/kg and look for a fall in his jugular venous pressure. Chlorpromazine will reduce vasconstriction and enable you to proceed with giving him the rest of his calculated fluid requirements.
Monitor his urine volume carefully, and if possible, his central venous pressure also (A 19.2).
58.9 How much fluid does a burns patient need when shock is over?
If a patient has a comparatively minor burn, he will probably start to at and drink normally when shock is over. He will then be able to adjust his fluid and electrolytes himself without difficulty, so that you can take his drip down at about 48 hours, and start giving him a high protein diet about the third or fourth day. But, if his burn is extensive and he is not drinking for any reason, you will have to control his fluid and electrolyte intake for him. Two things are particularly important at this stagewater and sodium.
Water Although little plasma will leak from a patient's burn after 48 hours when shock is over, he will continue to lose fluid by evaporation from its wet surface. In a 30% burn he may lose 2 litres of fluid a day in addition to his loss by other routes. The result is that he can easily become dehydrated, hypernatraemic, wasted, and oliguric. His serum osmolarity will rise and he may die from circulatory failure. So, keep a careful watch on his fluid balance chart, even if he is taking fluids by mouth. Calculate the water loss from his burn from Fig. 58-8. It is based on his surface area. Read this off from Fig. 58-6.
Fig. 58-8 is only a rough guide to the fluid a patient needs. Add it to his daily fluid requirements (scale E in Fig. 58-6), and adjust the fluid you give him in the light of the following factors.
(1) The ambient temperature. He will need more fluid if the weather is hot.
(2) The stage of healing of his burn. His fluid requirements will become less as it heals.
(3) Oedema is not a good guide to his electrolyte and fluid needs, because he can be both oedematous and salt depleted.
(4) His urinary output. Unfortunately, this too is an imperfect guide because a diuretic phase commonly follows the shock phase.
Sodium A patient can also lose much sodium from a severe burn. Calculate his sodium loss from Fig. 58-8. To find out how many mmols of sodium there are in the commonly used fluids, consult Fig. A 15-6 in Primary Anaesthesia.
If your laboratory tests are limited, the safest fluid to give him will be 0.18% saline in 5% dextrose for maintenance (for ‘shock' he needs Ringer's lactate or 0.9% saline). Take care not to overload young children and cause water intoxication as described in the next section.
58.10 Difficulties with fluid and blood replacement
There are many of these. Here are some of the more common ones. One of your more serious problems is likely to be lack of fluids. If so, Section 58.6 should be some help.
DIFFICULTIES WITH FLUIDS IN A SEVERELY BURNT PATIENT
If a burns patient PASSES NO URINE, suspect that there is probably a drainage problem with the catheter. Even in acute renal failure the kidneys can usually manage to produce some urine
If his URINE FLOW FALLS below 0.5 ml/kg per hour after the first 12 hours, this is likely to be serious. During the first 12 hours a low urine flow is not of great significance. But after 12 hours a urine volume of less than 35 ml an hour in an adult (10 ml/hr in an infant) is a clear sign that a patient's kidneys are not being adequately perfused, or are failing. If it is less than this for two consecutive hours, give an adult a test dose of a litre of saline over half an hour. Before you do so, make sure that the bases of his lungs are not wet.
If a test dose of a litre of saline increases his urine output, previous transfusion was inadequate.
If a test dose of a litre of saline falls to increase his urine output, give him 15% mannitol (1 g/kg) or frusemide. If this does not increase his urine output, his kidneys are failing, so consider referring him for renal dialysis. Even if this is possible, his prognosis is so bad that it may not be justified.
Acute renal failure occurs in about 5% of patients with extensive burns, and usually kills them. Half of them are oliguric. The other half pass a normal volume of urine, but cannot concentrate it. A burns patient normally passes a concentrated urine, so a fixed specific gravity of 1.010 indicates renal failure, even if his urine volume is normal. Remember that protein or dextran in it will raise its specific gravity, and make it appear normal when it is not.
If RENAL FAILURE is established, and you cannot refer a patient, don't stop transfusion treatment for shock, or he will be grossly hypovolaemic at the end of the 48 hour shock period. After 48 hours he will only need oral or intravenous fluid to replace water loss from his burns, plus his insensible loss (Scale E in Fig. 58-6).
If a burnt child becomes irritable, vomits, twitches, has fits, becomes apathetic or comatose, has hyperpyrexia, goes blue, and breathes slowly and shallowly, suspect that he is HYPONATRAEMIC. Although all these signs are unlikely to occur in the same child, when several of them occur together, they suggest that he may have cerebral oedema caused by water intoxication which may kill him. It is the result of not giving him enough sodium in the fluid used to correct shock. Because it is due to inadequate treatment, it should never happen. Watch for `twitches', if he has them, give him diazepam. He may have a generalized convulsion at any moment. If he does have convulsions, control them with diazepam or barbiturates, and give him chlorpromazine, or some more powerful vasodilator. Correct his hyperpyrexia gently. Don't try to correct it with fans, because by increasing vasocontraction they may reduce heat loss, and raise his temperature. Correct his hyponatraemia by giving sodium in the following quantity:-: mmol of sodium needed = (140 minus his serum sodium in mmol/1)x(60% of his body weight in kg).
If you cannot estimate his serum sodium, assume it is 125 mmol/1. Be cautious, give half the calculated dose to begin with, and observe his response.
If a severely burnt patient: (1) vomits, or feels nauseated, (2) has absent bowel sounds and abdominal distension (indicating PARALYTIC III or (3) has GASTRIC DISTENSION, pass a nasogastric tube, and leave it down. Paralytic ileus and gastric distention are common after severe burns. Aspirate the tube and give him his hourly oral fluid requirement. If this is returned when you aspirate at the next hour, then he is not absorbing fluid from his gut, and needs intravenous fluid. Continue to aspirate his stomach hourly. This will not prevent acute dilatation of his stomach, but it will control it and prevent vomiting.
Make sure that his potassium intake is adequate and, as far as is possible, exclude hyponatraemia, hypovolaemia, septicaemia, and constipation.
If a patient becomes OEDEMATOUS, this is unlikely to be serious, and will soon go if his kidneys are functioning normally and a high protein diet starts on the 3rd or 4th day.
If a burns patient becomes becomes ANAEMIC, the reasons include: (1) Destruction of his red cells at the time of burn. (2) Depression of his bone marrow as the result of sepsis. (3) Loss of blood from the burnt area each time it is cleaned or desloughed. If his haemoglobin falls below 10 g/dl, healing slows, and grafts do not take, so transfuse him when necessary, but remember that one unit of blood will only raise an adult's haemoglobin by 1 g/dl. When his haemoglobin has fallen to 75%, he will need transfusions equal to 25% of his blood volume. A severely burnt adult may need 10 units of blood and perhaps more.
A burn of a given percentage will reduce a patient's haemoglobin by an approximately equal one. Damaged red cells are inefficient, so, if he needs blood, give it early. His haemoglobin may fall to 5 g/dl or less a week or more after severe burn, so measure it often.
MEASURE A PATIENT'S HAEMOGLOBIN REGULARLY
58.11 Feeding a burn patient (or any severely injured patient who can eat)
Fluid infusions during the first 48 hours may increase the weight of a severely burnt patient by 20%. Thereafter he may steadily lose up to 40% of it and die. Losses of 10% and 20% are common, and often overlooked. They are the result of the intense tissue catabolism that follows a burn, combined with sepsis and malnutrition. So weigh him, if you can, on admission, and each week thereafter. You can prevent most of this loss and improve his chances of recovery f you can feed him enough. His needs are huge, and are given below. You may not be able to achieve all of them, but the less weight he loses, the more likely he is to live, so persist in your efforts to get food into him. He should not be losing weight when you graft him.
Intravenous feeding is expensive, impractical, and seldom necessary. So you have two choices: (1) You can try to make a patient eat larger quantities of ordinary foods. (2) You can have diets for tube feeding made with a blender in your hospital kitchen. The lists below give the composition of some of the foods you may be able to blend. Eggs are likely to be the most practical high protein food. Anorexia, vomiting, and diarrhea are the main difficulties. If a patient has diarrhoea, try reducing the carbohydrate content of his feed to reduce its osmolarity.
DON'T LET ANYONE CONNECT A PATIENT'S FOOD DRIP TO HIS INTRAVENOUS LINE
FEEDING
INDICATIONS (1) A severely burnt patient. (2) Any severely injured patient.
If what follows is too difficult, at least make sure that every day a severely burnt adult has at least 2 eggs, 500 ml of reconstituted milk, and the vitamins listed below. It also applies to any severely injured patient who is able to eat, whatever the nature of his injuries.
If he cannot take food by mouth, try to give him at least through a central venous line (A 19.2).
Here are the needs of adults and children:
ADULTS
Energy 80 kJ/kg (20 kcal/kg) of body weight + 300 kJ (70 kcal) for each 1% of the burn.
Protein 1 g/kg + 3 g for each 1% of the burn.
CHILDREN
Energy 250 kJ/kg (60 kcal/kg) + 150 kJ (35 kcal) for each 1 % of the burn.
Protein 3 g/kg + 1 g for each 1% of the burn.
A FOOD TABLE
I n the following list the first figure is the weight of food containing 40 g of reference protein, while the second is the weight containing 10 MJ (about 2,500 kcal), these being a normal adult's daily requirements.
Dried skim milk powder 150 g, 660 g; full cream powder 210 g, 480 g; cow's milk 1500 g, 3,700 g; soya beans 210 g, 590 g; beans (dry) 430 g, 700 g; peas (dry) 410 g, 690 g; shelled groundnuts 360 g, 440 g; meat (beef) 320, 1,100 g; liver 390, 1,700 g; eggs 330 g, 1,700 g; maize meal 910 g, 660 g; margarine nil, 330 g; cooking oil or fat nil, 270 g.
NASOGASTRIC FEEDS FOR BURNS
These are mostly needed in children.
If a patient has no bowel sounds, you cannot feed him by mouth. Intravenous feeding is his only hope.
If he has got bowel sounds, but is unable to eat normally (because he is too weak, too old or too sick to feed himself by mouth, or is unconscious), pass a small nasogastric tube (2.5 mm 8 Ch in a child or about 4.5 mm 14 Ch in an adult).
CAUTION ! Make sure that the tube is in the patient's stomach, and not in his trachea, by the methods in Section 4.9.(2) Always aspirate the stomach before giving a feed, to make sure that it is emptying properly. In an unconscious patient, overdistension may cause regurgitation and aspiration of feed.
If the patient has previously not been eating, start with half or quarter strength feeds initially, until you are sure that he has adapted adequately to his new method of feeding.
Give him some water by mouth to lubricate his oesophagus. Give him small blenderized feeds to start with, well spaced throughout the day and night. Filter them through gauze to prevent them clogging the tube and give them as a continuous drip from a drip set. If the feed clogs the drip set, give it intermittently with a syringe. Remember that the fluid part of the feed is part of his daily intake. Before giving them aspirate his stomach to detect retention. If you aspirate 100 ml, reduce the next tube feed by this amount.
Work up to his required intake over several days. 15 MJ (3,500 calories) and 180 g of protein are about as much as an adult can take by mouth. If he can eat, encourage him to do so, with the incentive that his tube will be removed as soon as he eats normally. Reduce his intake as his burn heals.
Give him enough water (about 30 ml/kg) in addition to his non-renal losses to excrete the breakdown products of his diet.
Give him at least 10% of his energy needs as fat. You will probably be unable to estimate his urinary potassium losses which may be large. As a rough guide, give him 100 mmol a day by mouth. This is 100 ml of the commonly used potassium solution containing 1 mmol/ml (A15.1).
CAUTION ! (1) A blenderized feed is readily infected, so boil it and keep it cold. (2) Don't add salt or you will overload him with sodium.
Alternatively, give him 250 ml of feed with a 50 ml syringe every 3 hours, followed by 25 to 50 ml of water to flush out the tube and make up the daily fluid requirements.
VITAMINS Each day give the patient capsules of vitamins B, A, and D, 600 mg of ascorbic acid, and 600 mg of ferrous sulphate.
DIFFICULTIES WITH TUBE FEEDING
If you DON'T HAVE A BLENDER, you will have to give a patient milk, eggs, and sugar, vegetable oil, and gruel of various kinds.
If he gets DIARRHOEA, the feed may be hypertonic. Try diluting it.
If he REGURGITATES AND ASPIRATES the feed (which may be fatal), you probably failed to check that his stomach was being emptied, before giving him more feed. So, check on his gastric residue, and raise the head of his bed.
FEED HIM UP
GIVE HIM SMALL REGULAR FEEDS
DON'T FORGET THE VITAMINS
58.12 How deep are the patient's burns?
The depth of a patient's burns will determine whether or not you need to graft them. His sweat glands and hair follicles are epidermal structures and penetrate deep into his dermis. If his epidermis is destroyed it can regenerate from these deep epidermal structures-provided that his burn is not so deep that it has destroyed them also. There is still no universally accepted way of classifying burns, so we will call them types A, B, C, D, and E.
Type A In the mildest burns (first degree) there is erythema only and no blistering. Protect them from infection.
Type B In slightly more severe burns, blisters form within 24 hours and break to leave a wet pink surface. These are burns with superficial partial thickness skin loss (psl). Most of the deep epidermal structures are still alive, so burns of this type heal in less than three weeks. The pain fibres in the skin are also still alive, so they are sensitive to the prick of a sterile needle. Most flash burns and scalds are of this type.
Type C Burns of the next grade of severity kill all a patient's epidermis except for the bottoms of his sweat glands. Although they may look like a burn of Type B above, they take 6 weeks to heal because the epithelial cells at the bottom of his sweat glands take this long to grow out and cover his dermis. When they eventually do so, the quality of the skin they produce is poor, so burns of type C are sometimes better grafted, especially if the patient has a black skin. The skin that regenerates is pink, of poor quality, and prone to epitheliomas later. The nerves in the dermis are destroyed, so burns of this type are insensitive to pin prick. They are an important type of burn, because some of them may be suitable for excision and grafting at 3 to 5 days. They show deep partial thickness loss (dpsl). Burns of types B and C are sometimes classified as second degree burns.
Type D In these burns the whole thickness of a patient's epidermis, including the bottom of his sweat glands, has been killed. Unless his burn is very small, you will have to graft it. His dead skin looks white, or greyish brown, and is completely insensitive to pin prick
Type E The deepest burns char a patient's fat and muscles, and sometimes even his bones and joints. Types D and E are third degree burns, full thickness burns, or burns showing whole thickness skin loss (wsl).
In practice, it is often convenient to use this classification loosely, and to disregard burns of type A entirely. The critical distinction (which is often difficult) is between: (1) Superficial burns (B and C above) in which enough of the epidermis remains to regrow without grafting, even if it grows slowly and (2) deep burns (D and E) in which the epidermis is totally destroyed, and which need grafting.
Unfortunately, you often cannot diagnose the depth of a burn. The most certain way is to wait and see what happens. If the crust separates to leave clean new skin underneath, the burn was superficial. If no epidermis appears to cover a wet granulating surface, or if a slough or eschar remains firmly stuck, it is deep. A burn which is sensitive to pin prick (B) never needs grafting, but one which is insensitive (C, D, or E), may or may not do so. The ability to feel a pin is thus more significant when it is present than when it is absent.
Burns are dynamic injuries, so that the distinction between superficial burns and deep ones is not permanent. The deep epidermal structures which survived after a partial thickness burn can easily be destroyed by infection later. One of your main aims must be to prevent this. The signs which follow are very approximate. You will be most interested in knowing the depth of small deep burns which you might be able to excise and graft early (58.17). You can assess the depth of a burn most reliably at about the 7th day.
HOW DEEP ARE A PATIENT'S BURNS?
Burns of types A and E are easily diagnosed. You are most interested in the differences between B and C. Be guided by these signs.
What was the temperature of the agent and the time of exposure? The depth of a patient's burn is a function of both.
The thickness of the burnt skin The thin skin on the back of his hand is more likely to be deeply burnt than the thick skin on the front.
How alert was he at the time of the burn? His burns are more likely to be deep if he is or was drunk, drugged, paralysed, feeble, or very old, or if he was burnt in an epileptic fit.
Blisters usually indicate a superficial burn.
Red fat if haemoglobin from destroyed red cells has stained his subcutaneous fat, his burn is deep.
Thrombosed veins visible through translucent subcutaneous fat, or hairs which can easily be pulled out, are both signs of a full thickness burn.
Speckling If at 2 weeks you see fine dots (skin regenerating from the bottom of sweat glands), a patient's burn is partial thickness (D). These dots are grey in a black skin and red in a white one.
If his burn has shrunk below the level of the surrounding skin, it is probably full thickness.
THE PIN PRICK TEST This is a test of pin prick, not pin pressure. The patient must be conscious and cooperative, and understand the difference between pain and pressure.
Take a sterile hypodermic needle and practise first on normal skin by asking him if he can feel its sharp or blunt ends. Then test the burn.
If he mostly says "sharp", the burn is almost certainly Type B (superficial partial thickness) and it will heal in less than three weeks without grafting.
If he mostly says "blunt", the test is of less significance it might be Type C (deep partial thickness) or type D (full thickness).
If the pin pricks bleed, this is a useful sign that his burn is superficial (B).
58.13 How should the burn itself be treated?
You will probably find yourself treating burns in overcrowded wards with more than one patient in the same bed, with few imperfectly trained nurses, and with the minimum of dressings drugs and equipment. Which methods are best suited to these extreme limitations? Here are the possibilities: (1) The open (exposure) method which leaves a burn open to the air and encourages it to form a dry crust. (2) The closed (occlusive) method in which the burn is isolated from the environment by thick dressings. (3) A method in which the burn is kept continuously wet with saline. (4) The plastic bag method for burnt hands or feet. (5) Early excision and grafting. Each method has its own advantages and disadvantages, and there is no `best method'. Instead, combine the best of all methods to suit the needs of a particular patient. The combination that you are likely to and best is the exposure method for a patient's superficial burns, sane soaks for his deep ones, and the plastic bag method for his hands and feet.
HOW SHOULD A BURN BE TREATED?
These indications apply to conditions where nursing care and dressings are minimal. Where they are not, the closed method has wider indications.
THE EXPOSURE METHOD FOR BURNS
INDICATIONS (1) Scalds. (2) Burns of a patient's face. (3) Large partial thickness burns anywhere except his hands. (4) Full thickness burns anywhere except his hands, when dressings are scarce or nursing care minimal. (5) The exposure method or the saline method are mandatory if a severely burnt patient is hyperpyrexic.
CONTRAINDICATIONS An extensive burn in a cold environment with lack of adequate heating.
THE CLOSED (OCCLUSIVE DRESSING) METHOD FOR BURNS
INDICATIONS (1) Smaller burns if a patient is to be treated as an outpatient, especially if the burns are on his limbs. (2) Smaller burns of his hands. (3) A larger burn for which he has to be transported elsewhere.
CONTRAINDICATIONS All other burns.
THE SALINE METHOD FOR BURNS
INDICATIONS This is probably the best method for all burns which are severe enough to be admitted, but if nursing skills are scarce, reserve it for deep ones.
THE PLASTIC BAG METHOD FOR BURNT HANDS AND FEET
All but the most minor burns of the hands.
EARLY EXCISION AND GRAFTING FOR BURNS
INDICATIONS Small (less than 2%) full thickness burns during the first 3 days, if you have plenty of blood and are good at skin grafting.
58.14 The exposure method
In this method nothing touches a patient's burn except air, and preferably an antibacterial agent, such as povidone iodine. Air keeps it cool and encourages the dry eschar to form, both of which minimize the growth of bacteria. The exposure method is excellent if his burn is superficial and the climate warm. It is economical in nursing time, you can examine it easily; it avoids expensive dressings, it is useful for parts of his body which cannot easily be dressed, such as his face, buttocks, and perineum, and it is less dependent on local antibacterial agents than is the
occlusive method. If you manage the exposure method properly, flies are seldom a problem, but if they are, you can put the patient under a mosquito net.
In a superficial burn, the crust separates like the skin of a snake to leave new, pink, well healed skin underneath.
In a deep burn the dead tissues form a tough eschar (sometimes with pools of pus underneath it), or less often they remain as a moist slough. You can leave these sloughs and eschars open to the air, but the best way to treat them is to cover them with saline soaks. Dry or moist, the dead tissue will have to be removed and the burn grafted.
A common modification of the exposure method is to put vaseline gauze over the whole burn, and then expose this to the air. The exudate flows through the holes in the gauze and dries. This is no longer strictly the exposure method, and there is no evidence that it is any better than the unmodified exposure method, except perhaps on the flexures. Nor is it certain that impregnating vaseline gauze with expensive antibiotics, such as soframycin, improves it in any way. Some experienced surgeons say that to modify the exposure method, by applying vaseline gauze, is a compromise which combines the disadvantages of both the open and the closed methods.
Patients treated by the exposure method should ideally be barrier nursed. Unfortunately, this is quite impossible in the hospitals for which we write. Even if they cannot be barrier nursed, the exposure or saline method is likely to be better than the occlusive method done badly-which is the common alternative.
The following description describes the care of a child by the exposure method, because children so often need this treatment.
THE EXPOSURE METHOD FOR BURNS
INDICATIONS See Section 58.12.
EQUIPMENT The equipment for cleaning a burn is simple, but it must be sterile. It includes aqueous chlorhexidine solution or saline (conveniently from a bottle of intravenous saline), a gallipot, and a sterile glove.
METHOD Sedate the child with chloral hydrate or ketamine. Put him on a sterile mackintosh in a clean bed. Put a sterile theatre drape or a clean sheet on top of this. Leave the burn alone, the heat will have sterilized the burnt surface. Don't prick the blisters unless they are tense and painful.
Local antibacterial agents are desirable, but not absolutely necessary. Some workers apply povidine iodine or cetrimide.
Put a cradle over the child and cover this with another sterile drape.
TEMPERATURE The room should be warm and moist (40°C and 40% relative humidity is ideal). Monitor his temperature carefully. Feel his extremities. If necessary, close the windows and put a heater beside him. Electric fans heaters are the best, but with suitable precautions you can use a charcoal brazier. Don't put him in the sun, except for short periods, because pink depigmented skin burns easily.
THE THIRD OR FOURTH DAY ONWARDS
Don't do anything to the dry surface of a superficial burn after the first day. Continually dressing and scraping its surface interferes with healing. Tell the nurses that it is being dressed, but that it is being dressed with air! Let any dry part of the burn remain dry. If more blisters form, prick them. Try to preserve the dry crust until it falls off naturally. Clean only parts which remain wet.. Use gauze swabs and chlorhexidine, or sterile saline, as for the initial toilet.
CAUTION ! If there is any danger that a tight crust or eschar might be obstructing the child's circulation, split it immediately (58.18).
You may not know it a burn is superficial or full thickness until about the 7th day.
SUPERFICIAL AND DEEP PARTIAL THICKNESS BURNS (B and C in Fig. 58-9) dry to form an eschar which falls off in 7 to 12 days in type B, or 10 to 21 days in type C, with little bleeding. They heal in 3 to 4 weeks.
FULL THICKNESS BURNS (D, and E) form thick sloughs and eschars. Choose between the following methods.
(1) Leave the eschar open to the air. Remove it in the theatre at 10 to 18 days, and then graft.
(2) Much the best, start the saline method at 48 hours. Either put the burnt part in a bowl of half strength saline 4 hourly or pour saline on the dressings 4 hourly (58.16). Some slough will come away in the dressings, remove large pieces by 'sloughectomy' in the theatre, then graft.
DIFFICULTIES WITH THE EXPOSURE METHOD FOR BURNS
If a DEEP BURN CROSSES A FLEXURE, splint the patient's limb in extension. You can safely do this for 3 weeks in an adult or 6 weeks in a child while the skin over it heals. Then mobilize it-see Section 58.24. Skeletal traction as in Fig. 58-15 may be the best way to maintain extension.
CAUTION ! Appropriate splinting is essential to prevent contractures: (1) To prevent movement of the joint while the graft takes. (2) To maintain the positions in Fig. 58-16 until the burn has healed.
If DRY ESCHARS CRACK over a patient's flexures, such as those of his elbows or axillae, splinting is required, so change methods.
If his burn is deep use the saline or the closed method for the deep part of it, and, if necessary, excise the slough.
If it is superficial, apply vaseline gauze or silver sulphadiazine cream. In deep burns the skin under these cracks always needs grafting and you will have to take great care to prevent contractures. You may also have to graft cracks in burns which are superficial elsewhere.
If he has EXTENSIVE BURNS ON HIS TRUNK, arrange his position so that he lies on normal skin, not on his burn. If his back and buttocks are burnt, turn him hourly, if he has burns all round his body, the only way to nurse him by this method is in a string hammock. His burns will probably be at least 50%, so his chances of surviving are not good.
If his BUTTOCKS AND PERINEUM HAVE BEEN BURNT, put him in gallows traction (78.2), if he is under 5, and expose his burn. If necessary, (and it seldom is) catheterize him, and don't let overflow incontinence develop. Urine does not harm a burn, but moisture promotes infection. His perineum will be difficult to graft, and perineal grafts usually fail, so you may need to repeat them several times.
If his AXILLA has been burnt, try holding his arm above his head with skin traction-this is not easy.
If he SCRATCHES HIS EXPOSED BURNS, try to prevent him doing so, because scratching can easily convert a superficial burn into a deep one. Immobilize both his elbows in padded plaster cylinders to keep them extended. Sedate him. Don't try tying his hands to the sides of his cot, because this is cruel and dangerous.
If PUS APPPEARS, send a swab for culture daily. Dip a swab in sterile broth (or saline) and rub it widely over the burn.
DON'T DISTURB THE CRUST, LET IT SEPARATE SPONTANEOUSLY
DON'T LET HIM GET COLD
58.15 The closed (occlusive dressing) method
At the moment of burning a burn is sterile. The aim of the closed method is to keep it so, as far as possible, by sealing it off from the environment with an effective dressing, before it has become seriously contaminated. The bigger the burn, the more difficult this is. To be effective the dressing which coversa burn must be about 2 cm thick as in A, Fig. 58-10, so that it absorbs the exudate and prevents it reaching the surface where it can become infected. Gauze is more absorbent than cotton wool, but is more expensive. In practice, asepsis is difficult to achieve, especially with larger burns, so you should put some local antiseptic agent on the burn (58.22). Some surgeons would say you must do this. The best local agents are silver sulphadiazine cream or 0.5% silver nitrate with 0.2% chlorhexidine.
The closed method: (1) Demands more and better nursing care than the exposure method. (2) Needs abundant dressings. (3) Is more dependant on a local antiseptic agent than the exposure method. (5) Can cause hyperpyrexia in large burns in hot environments.
Done well, the closed method can be wonderfully successful. When you remove a dressing from a partial thickness burn which you have left undisturbed for 10 days, you may find perfect new skin underneath. But this method can be very dangerous if you forget that: (1) Dressing a burn is a surgical procedure, which must be done aseptically. (2) The aim of the dressings is to contain exudates, and prevent organisms reaching the burn. This means that you must change them on the indications given below.
Done badly, this method is a disaster, and too easily converts a partial thickness burn into a full thickness one. Doing it badly includes: (1) Not applying enough dressings (sometimes only a thin layer of gauze). (2) Letting exudates soak through without changing them. (3) Not bringing the dressing well beyond the edges of the wound.
Unfortunately, the closed method, badly done, is in widespread use. As such, it is painful, messy, expensive, and hinders healing. There should be no compromise-either a burn should be left open with nothing on it at all, or it requires 2 cm of dressings. There is a strong body of opinion which considers that the closed method has no place whatever for inpatients in the hospitals for which we write. Under our circumstances it is only suitable for parts of the body where the necessary dressings will stay in place. In effect, this means the limbs. In practice, because of the cost of the dressings and the labour involved, you will only find the closed method suitable for superficial small burns on the extremities of outpatients. It becomes increasingly difficult with larger burns, and on the trunk.
THE MERE APPLICATION OF A FEW ‘DRESSINGS’ IS NOT THE CLOSED METHOD
THE CLOSED (OCCLUSIVE) METHOD FOR BURNS
LOCAL ANTISEPTIC AGENTS are highly desirable for larger burns. Use: (1) Silver sulphadiazine cream. (2) 0.5% silver nitrate with 0.2% chlorhexidine changed every 4 days. (3) Povidone iodine. Or, less satisfactorily, use (4) cetrimide, or (5) chlorhexidine. In practice, you will probably have to use no antiseptic, or one of these last two.
APPLYING THE DRESSINGS FOR THE OCCLUSIVE METHOD
Use a 'no touch technique'. Use sterile forceps or sterile disposable gloves so that no human hand touches the burn or the dressings, and no sterile glove touches anything else in the room. If necessary, sedate the patient, or give him ketamine. Clean his burn and the skin around it with chlorhexidine solution. There is no need to puncture the blisters.
If a deep burn encircles a limb, you may need to do an escharotomy before applying a dressing.
Using a sterile spatula, spread one of the local antiseptic agents listed above on sterile gauze and apply this to the burn. Alternatively, and less satisfactorily, apply vaseline gauze.
Cover this with 2.5 cm of cotton wool and a crepe bandage. The dressing must extend 10 cm beyond the wound margins. If there is a wound over a flexure, apply the dressing with the joint in extension to prevent contractures (58.24). A thin plaster cast may prevent a child from removing his dressings.
CHANGING THE DRESSINGS WITH THE OCCLUSIVE METHOD
Partial thickness burns If you are sure that a burn really is only partial thickness, you can leave the dressing on for 10 days, unless the indications given below require that you should remove it. When you remove the dressing the burn should be healed.
Full thickness burns The limit for leaving a dressing on is about 4 days which is about the limit of the effectiveness of the local antibacterial agent. This is the usual interval for changing the dressings of minor burns in outpatients. Remove the dressing earlier than this on the following indications: (1) If the exudate soaks through the dressings. (2) Smell. (3) Swelling. (4) Pain. (5) Fever. (6) Regional lymphadenitis. (7) Restriction of the distal circulation. (8) Hyperpyrexia (this is only a danger in large burns). If changing the dressing is painful, give the patient ketamine ( A 8.1).
If you are using 0.5% silver nitrate, change the dressing daily.
If the inner layer of a dressing sticks to the wound and is not stinking, leave it, or it will tear off valuable epithelium as you try to remove it. Allow it to come off by itself later. If it stinks, soak it with saline and remove it. Dab the wound dry, don't rub it.
Deep burns may shed their sloughs in the dressings. If sloughs have not separated in 2 weeks, remove them surgically under anaesthesia.
BACTERIOLOGY If possible, send a swab for culture each time you change a dressing.
IF THE DRESSINGS HAVE STUCK AND DO NOT STINK, LEAVE THEM
58.16 The saline method for burns
The aim of this method is to keep a burn constantly wet with half strength saline until it heals-full strength physiological saline is painful. As usually described this method requires that the burnt part be dipped into a bath of saline. If it is large, this is inconvenient. A simpler alternative is to pour saline over the burn from a jug, and catch the excess in a mackintosh. This makes the saline method practical in a ward, rather than always in a sluice room.
The saline method: (1) Reduces the time in hospital compared with the exposure method. (2) Uses the minimum of equipment and materials. (3) Is painless, and so enables a patient to start moving his joints early, thus minimizing stiffness and contractures. (4) Allows partial thickness burns to heal promptly and eschars to separate early, leaving healthy granulation tissue nearly ready for grafting. (5) Uses the minimum of dressings and no topical antiseptics. (6) Is popular with mothers and nurses.
This is probably the best method for deep burns in district hospitals, especially if they are extensive-provided: (1) your nursing care is not too bad, (2) your sluice arrangements are reasonable, (3) the climate or the ward is warm about 28 ° C). In practice, you will find the saline method very usefull for full thickness burns, while using the exposure method for superficial ones.'
Early on, a wide variety of organisms are likely to be present including Pseudomonas. Later on, the predominant organisms will probably be Staphylococci. These are unlikely to need treating unless a patient has symptoms of generalized infection. If he does, he will be easier to treat than he would be if he were infected by Pseudomonas.
THE SALINE METHOD FOR BURNS
EOUIPMENT A mackintosh sheet and a variety of buckets, jugs, and basins.
SALINE Make half strength (0.5%) saline. You can make small quantities by dissolving a teaspoon of salt in a litre of ordinary tap water. Make larger ones by dissolving some suitable measure of salt in a much larger quantity of water. Learn what half strength saline should taste like, and test its concentration by tasting it first.
TEMPERATURE Keep the room comfortably warm. A patient should not go out into a cold bathroom.
METHOD Start at 48 hours with minor burns, and as soon as shock is over with major ones. Meanwhile, keep the burn moist with saline.
If you are using a jug, put a thick gauze dressing on the burn, and put a plastic sheet under it. If convenient, arrange this so that saline poured over the burn flows into a bucket. Keep the saline in a jug beside the patient's bed. If he is a child, ask his mother to pour a little saline over the burn every hour or so to keep it wet. Renew the dressing and clean the wound 4 hourly. Some sloughs will come off in the dressing.
CAUTION ! Keep the sloughs wet.
If you are going to immerse a burn, find some suitably sized container, such as a baby's bath, fill this with saline. Encourage the patient to keep dipping his burnt limb into it. Renew the saline at least daily. If you cannot let him have his own bath all the time, let him dip his burn into a bath of saline for 20 minutes twice a day. Let him exercise his burnt joints passively and actively while his burn is in the bath. If he has a deep burn, apply soaks between the baths.
The sloughs on a deep burn will usually separate about the 12th day, and be ready for grafting on about the 15th to the 17th day. As soon as the granulations are favourable, graft them (58.19). If possible, do regular culture and sensitivity tests.
DIFFICULTIES WITH THE SALINE METHOD
If SLOUGHS DO NOT COME OFF COMPLETELY in the dressings, take the patient to the theatre for 'sloughectomy' (58.18).
If BATHING A BURN IS PAINFUL, sedate him first. Make sure the saline is not too strong.
If he has EXTENSIVE BURNS, he should ideally be lowered into a stainless steel bath.
If his FACE IS BURNT, wash it in saline gently and continually.
If he is in danger of DEVELOPING CONTRACTURES, splint his limb appropriately (58.24).
58.17 Early excision and grafting for a full thickness burn
A logical method of treating a deep burn is to excise the dead tissue in the first few days before it becomes infected and then to graft it immediately, instead of waiting to deslough at about 14 days. Skilled surgeons in well equipped hospitals can do this in stages for burns of up to 30%. If you try it, you would be wise to use it in special sites only, such as the back of the hand, and in burns of less than 2% in which there is no shock.
There are difficulties: (1) Knowing which burns it is suitable for. You must be sure the burn is full thickness by the criteria in Section 58.12. If you excise and graft a partial thickness burn which is going to recover without grafting, you worsen the patient's chances of recovery. You can easily sacrifice living tissues, and injure important structures, such as tendons and cutaneous nerves. (2) Severe bleeding is the main danger and can be fatal, so the burn must be small, and even so, you must have plenty of blood for transfusion. (3) Early excision and grafting is only practical early, before the slough separates, usually at 3 to 5 days, sometimes up to 7 days.
There are various methods of early excision and grafting. The one described below is the only one which deserves to be used more widely in district hospitals. It is often a very effective method for deep burns on the palm of the hand. If left to themselves these may take many weeks to heal.
THE EARLY EXCISION OF A FULL THICKNESS BURN
INDICATIONS This method is only indicated if all these indications apply. (1) You are sure the burn is full thickness. (2) You can do the excision within the first 3 days. (3) The burn is small, certainly less than 10% and preferably only 2%. (4) You have plenty of blood for transfusion. (5) You are a good skin grafter.
METHOD Use s scalpel or, better, bend the blade of a Humby knife and use it to shave away thin layers of burnt tissue until you reach a layer which you know is alive because it bleeds.
If the bed is suitable, graft the burn immediately, or by delayed primary grafting at 3 days.
If the bed is unsuitable, for example, if it is formed by dead bone, you may have to refer the patient for the wound to be covered with a flap. Alternatively, gouge down to healthy cancelleus bone, wait 3 days to allow granulations to start forming, and then graft.
58.18 Sloughs and eschars
The dead tissues over the surface of a burn have to separate. If the burn is superficial, they peel off as pieces of dry membrane. If it is deep, they either form: (1) a slough, which is moist, soft, grey, and stinking. Or, (2) they form an eschar which is dry,
hard, and dark and which may be so brittle that it cracks. There is no sharp distinction between sloughs and eschars, the main difference being how dry or how wet they are. The exposure method tends to form eschars, while the occlusive and saline methods form sloughs. Pieces of slough and eschar can: (1) Fall off spontaneously, if you wait long enough for infection to rot them. Even burnt bone will sequestrate eventually. (2) Come off in small pieces in the dressings of the occlusive method. (3) Be removed by escharotomy or 'sloughectomy' in the theatre. However sloughs and eschars separate, they leave wet granulations underneath them, which you must graft. Maggots also deslough most effectively, although few people have the courage to use them deliberately.
Sloughs and eschars have three dangers: (1) Eschars (but not sloughs), may restrict the circulation. Both eschars and sloughs may, (2) become infected, or (3) cause severe bleeding when you remove them, especially if you remove them from a large area.
A thick, tough, dry eschar can act like a tourniquet, and may constrict a patient's neck, or his chest, or the circulation in his limbs or his fingers. His oedematous tissue swells, but the eschar round it is rigid and cannot expand. Escharotomy can thus be an emergency procedure.
If only a patient's skin is dry and dead, the underlying tissues can remain uninfected for several weeks, during which the patient's fat liquefies. But if muscle is dead, infection occurs much more easily, and a rise in temperature about the 10th day usually shows that it has started. Infection under an eschar is difficult to localize, but pain is a useful sign. When infection is further advanced, you may be able to feel a dry eschar floating in a pool of pus. If there is much dead muscle, beware of anaerobic infection, particularly gas gangrene and tetanus, and deslough early.
ESCHAROTOMY CAN BE AN ACUTE EMERGENCY
BEWARE OF PUS BENEATH THE ESCHAR
IF MUSCLE IS DEAD, DESLOUGH EARLY
Manipulating any infected tissue may cause bacteraemia, and removing an extensive slough or eschar may shower so many bacteria into a patient's circulation that it causes septic shock (53.4). So, if a burn is severely infected, deslough it under antibiotic cover. Usually, this is not necessary.
Sloughs and particularly eschars don't usually bleed until you try to remove them. Then they may bleed massively, especially if the area is large. So remove them a little at a time, in stages separated by a day or two. Remove them gently, and stop when
the patient has had enough. Be guided in how much to remove by his pulse and blood pressure, and by the amount of blood he loses.
After you have removed a slough, you can either graft the raw area immediately, if the surface is suitable, or you can wait until there are favourable granulations. Control infection first.
Desloughing can vary from a minor procedure, if a burn is small, to an extensive 'sloughectomy' in the theatre, if it is large and deep. Most desloughing is done piecemeal by the nurses as they dress a wound, especially when they apply saline soaks. One of the commonest mistakes is not to deslough a burn-as long as any slough remains, you cannot graft it.
REMOVE SLOUGH WHICH SEPARATES EASILY
DON'T REMOVE TOO MUCH SLOUGH AT ONCE
'SLOUGHECTOMY' AND ESCHAROTOMY FOR A DEEP BURN
ANTIBIOTIC COVER is essential if the patient's slough or eschar is severely infected. If Streptococci are present, use penicillin, if Pseudomonas are present they may be sensitive to gentamicin. If possible do sensitivity tests.
INDICATIONS Full thickness burns only. (1) A constricting eschar needs immediate splitting as an emergency procedure. (2) Most other eschars are best removed at about 2 weeks. There is usually a clear line of demarcation for surgical desloughing at this time. (3) Fever (which is not malarial) and toxaemia.
ANAESTHESIA Full thickness burns have no sensation, so anaesthesia is theoretically unnecessary. But be kind and give the patient ketamine, or morphine. If he feels pain, either an escharotomy is not necessary because the burn is only superficial, or you are cutting in the wrong place.
SLOUGHECTOMY Clean the burnt areas with chlorhexidine. Use any convenient instrument, such as scissors, a scalpel, or an elevator. Or, open the gap between the blade and roller of a Humby knife and shave away the slough.
EMERGENCY ESCHAROTOMY Incise the eschar down the length of the patient's limb; if necessary in two or more sites, and avoiding tendons and vessels. You may have to incise any burnt area, and cut across joints, so don't be limited by Figure 58-12.
ROUTINE ESCHAROTOMY Cut very lightly partly through the tough thickened dermis. Thrust the points of artery forceps through into the subcutaneous fat, then separate them to open the incision. Like this, you will avoid cutting vessels. Pull off the tough stinking pieces of eschar. The patient's wound will gape open, and bleed, perhaps for some hours, so watch him carefully.
CAUTION ! (1) Don't make deep cuts. (2) Never deslough more than 10% of the surface of his body at one time. Bleeding may be troublesome. Control it with pressure and warm packs, or hydrogen peroxide (10 vols %), and tie or undersew larger vessels. If necessary, apply haemostatic gauze. Raise his limb.
If the raw area is suitable (57.3), graft immediately. This is the best choice if it is practical.
If his burns are not clean or if there Is excessive bleeding, either: (1) Apply an antibacterial dressing or (SIC) vaseling gauze and send him back to the ward. Clean his wounds with saline baths three times daily for a week. Then bring him back to the theatre later for grafting. Or, (2) take skin grafts now, store them (57.8), and apply them a few days later in the ward when his wound is clean.
Alternatively, use soaks, as in the saline method (58.16).
58.19 Grafting burns
Grafting is described in Chapter 57. All full thickness burns more than 2 cm in diameter need it. Before you can graft a burn, the dead tissue over it has to be removed. You can do this in two ways: (1) In some small deep burns you can, very occasionally, excise the wound and graft it, either immediately or in the first 3 days, as in Section 58.17. Or, (2) you can allow the dead tissue to demarcate itself, and graft the wound after desloughing, usually between the 10th and 18th day.' There is thus an early and a late period for grafting, and seldom any indication to graft between the 3rd and 10th day. As a general rule, don't delay beyond the 18th day. One of the commonest errors is not to graft early enough, or not to graft at all!
Is the patient's skin regenerating naturally? Don't graft his burn if you can see that the skin is starting to regenerate. This is easy to see in a black skin-look for little greyish patches of regenerating skin at regular intervals in the depths of the burn. In a white skin, look for dull white or pink patches the size of a pin's head or larger ('leopard spots'.)
Graft any burn where grafting might possibly help, and don't delay merely because skin is slowly growing inwards from the edges. If you wait to allow a large burn to heal from the edges, you may have to wait a long time and when skin does finally cover the burnt area, it will be thin, pale, and more likely to become cancerous, or to break down later. Grafts take best on favourable granulation tissue (57.3), especially if this forms on the remains of the dermis. They take badly on yellow fat, and are likely to take better on the deep fascia. If granulations are favourable, a graft will probably take. If they are unfavourable, apply saline dressings (if possible three times daily), or 1% acetic acid, or hypochlorite ('Eusol'). If you are not sure the graft is going to take, be sure to mesh it.
Timing is critical. If you graft too early, you may occasionally graft unnecessarily. If you wait too long, you may find that in a few burns grafting was not necessary after all, but in most cases the granulations will be older, the graft will take less well, and the fibrosis and contractures will be worse. Make the mistake of grafting too often rather than not often enough.
When you have grafted a full thickness burn, it may look rather nice to begin with, but during the following months the scar is likely to become larger, ugly, bumpy, vascular, red, and itchy. If a patient is fortunate during the following years, it will becomes flatter and paler, and stop itching. If he is unfortunate, a keloid will form and grow.
THE TIMING OF A GRAFT IS CRITICAL
DON'T GRAFT MORE THAN 10% OF THE BODY AT ONE OPERATION
GRAFTING BURNS
If skin for grafting is scarce, use it as patches or mesh (56-7), except over joints where sheet grafts will be better at preventing contractures. Place these sheets so that the joins between them go across a joint rather than along it, and thus minimize the risk of a serious contracture forming. You will use the grafts most efficiently if you leave a little space between them, because the epithelium will grow across the spaces.
If there is not enough skin to graft all a patient's burns, give priority to the areas in Fig. 58-14, because these are the places where contractures are most likely to develop.
Skin readily regenerates from the scalp and the beard area, so these have a low priority for grafting. In practice, you will usually find yourself grafting whatever area is fit for it.
CAUTION ! Never graft more than 10% of a patient's surface area at one operation (unless you are expert and have good facilities), or he may die from hypovolaemic shock. An adult may, lose a litre of blood, or more, when you graft a 10% burn, so have blood ready. Before you graft, make sure his haemoglobin is more than 10 g/dl, and that he is not losing weight.
58.20 Preventing infection in burns
It is here that crowded district hospitals differ most significantly from the sophisticated burns units of the industrial world, although these too have problems with infection. You may have no facilities for barrier nursing, or even for boiling the linen.
Sterile supplies, gloves, dressing, and sometimes even soap and water may be scarce. You will probably have few nurses, who change rapidly, and have only hazy ideas about bacteria and how they spread. The care of burns is an enormous burden to them. The patient's relatives may be at the bedside 24 hours a day, bringing with them bacteria from the outside world. How can you improve your present practice? What is the bare minimum of preventive measures that you should insist on? Here are some ideas.
PREVENTING INFECTION
Cover raw burnt surfaces as soon as possible with: (1) a dry crust (the exposure method), or (2) a clean dressing (the occlusive method), or (3) a biological dressing (skin grafting).
Make sure the staff know how bacteria spread (1) by staff-to-patient and patient-to-patient contact, and (2) by flies. So exclude flies with mosquito nets, or gauze on the windows, and make the staff wash their hands.before and after touching any patient or his bed. Set the example by doing it yourself.
Keep a separate plastic apron for each patient. Make the staff wear this when they handle him. If possible, they should wear disposable plastic gloves when they do so.
Use antiseptic rather than antibacterial topical agents, because resistance is less likely to develop to them. Don't rely on antibiotics. Have an antibiotic policy (2.7), and change the antibiotics, and particularly the topical agents you use every few months.
WASH YOUR HANDS!
58.21 Systemic antibiotics for burns
Organisms are found on all burns, so their mere presence in a burn is not an indication for chemotherapy (the only exception is Strep pyogenes). The signs of clinical infection are fever, cellulitis, lymphangitis, lymphadenitis, and septicaemia. Of the patients who die from infection, about half die from septicaemia, and the rest from bronchopneumonia.
There is no evidence that prophylactic antibiotics are effective, so only give them when there are signs of systemic infection, such as fever or toxicity. Penicillin is perhaps the only exception, so give all severe burns a five day course immediately on admission, and then stop it. This will help to control Streptococci, and Clostridia, including Cl tetani. If you isolate or suspect Pseudomonas infection, and have only been using gentamicin sparingly, it is likely to be the antibiotic of choice.
Above all, don't forget to let out pus! If it is under an eschar, drain it. If it is under a failed occlusive dressing, remove the dressing. If pus is present and is not removed, antibiotics will not help!
58.22 Local (topical) antibacterial agents
Local antibacterial agents (chlorhexidine, povidone iodine, and silver sulphadiazine, etc.) are not essential, and local antibiotics (soframycin, etc.) are useless. Local antibacterial agents must be safe, because they can readily be absorbed through the surface of a burn. The cheapest local application for a burn is open air, which the exposure method makes good use of. Another is saline (58.16). Soap and water are useful, preferably as a shower, rather than a bath, because of the risk of cross infection.
Vaseline gauze is sometimes useful for its physical rather than its antibacterial properties, and if you don't have any, make it. For use on burns it should if possible be impregnated with an antibacterial agent, such as 0.5% chlorhexidine. In any wound you can use vaseline gauze once only, but not again. If you use it repeatedly, enough small pieces may be left behind to form a granuloma. Instead, use plain gauze and soak it off.
The occlusive method of treating a burn should have an antibacterial agent to control the growth of bacteria under it. The few useful ones are expensive and include: (1) 1% silver sulphadiazine cream. This has most of the advantages of silver nitrate, without its disadvantages. Unfortunately, few hospitals can afford it. It is cheaper if your pharmacy can make it as described below. Don't rely on it because it is laborious to make and big burns need a lot of it. (2) 0.5% silver nitrate alone or with 0.2% chlorhexidine. The difficulty with silver nitrate is that it is very messy and stains everything brown. You may have to discard all stained linen and blankets. If it were not for this it would be much more widely used.
Outpatients need a dressing on their burns. If you don't put something on a child's burn, his mother will treat it herself, and she may even use dung. Make sure that his burn has a satisfactory dressing, and that she knows how to care for it.
TOPICAL ANTIBIOTICS HAVE NO PLACE IN BURNS
MAKING DRESSINGS FOR BURNS
VASELINE GAUZE
Spread vaseline onto layers of ordinary gauze. Place them in a tin and autoclave them.
SILVER SULPHADIAZINE FOR BURNS
REAGENTS Sulphadiazine (or sulphadimidine) 146 500 mg tabs. Silver nitrate crystals 48.5 g. Sodium hydroxide pellets 11.5 g. Glycerine 1440 ml. Liquid paraffin 560 ml. Non-ionic emulsifying wax 1100 g. Hibitane solution (ICI), 5% 320 ml. Sterile distilled water as required.
METHOD Find a 10 litre bucket, a mixer, a mixing rod, a beaker, and a heater.
Dissolve the sodium hydroxide in about 100 ml of water. Dissolve the silver nitrate in 4000 ml of water.
Suspend the sulphadiazine tabs in 1000 ml water and stir. Heat to boiling point and add to the suspension the solution of sodium hydroxide while stirring.
Slowly add the solution of silver nitrate to the suspension of sulphadimidine and sodium hydroxide. A white precipitate of silver sulphadiazine will form.
Stop adding more silver nitrate when a brown precipitate of silver oxide shows that the formation of silver sulphadiazine is complete. Boil for some minutes to make the precipitate finer and more easily filterable.
Separate the precipitate: (1) by centrifugation, or (2) with an old glass filter, or (3) by letting it stand overnight, and pouring off the supernatant. Wash the precipitate many times with water until you can detect no more silver ions in the supernatant (add a few drops to some saline and watch for a white precipitate of silver chlride).
Mix together the glycerine, the liquid paraffin, and the, emulsfying wax, and sterilize them at 150°C for an hour. Let them cool and add the Hibitane solution warmed to 80°C.
Mix the two preparations and stir vigorously to obtain a fine pink cream. Put the bucket into cold water and mix until cold. Meanwhile, add enough distilled water to bring the volume up to 8 litres before the preparation becomes cold.
58.23 Difficulties with infected burns
If a patient's temperature rises, watch his temperature chart. Fever is the first sign of infection. In adults, it often indicates septicaemia, but a child may have an intercurrent viral infection. Sometimes, a patient's temperature does not rise when he becomes septicaemic, so the diagnosis can be difficult.
Other causes of fever include: (1) Infection of the burn itself. (2) Infection of an infusion site (change the drip). (3) Urinary infection (examine his urine). (4) Respiratory infection (X-ray his chest). Septicaemia may follow infection by any of these routes, and causes many deaths in severe burns. Even a small burn can be a source of infection. Fever continuously over 39.5°C with mental confusion makes a diagnosis of septicaemia likely. Petechial haemorrhages in unburnt areas and an enlarged spleen are rare in the septicaemia caused by burns, so don't expect to find them.
If possible, take a blood culture, and culture the burn before giving the patient any antibiotic. At least stain a film and find out if he has predominantly Gram positive cocci, or Gram negative bacilli. This will be some help in deciding which antibiotic to give (2.7). Pseudomonas is a common and deadly invader. Give the most appropriate antibiotic intravenously in high doses.
DIFFICULTIES WITH INFECTED BURNS
If a CHILD IS APATHETIC and is obviously NOT WELL, look for petechial haemorrhages in his burn. If you find them suspect streptococcal infection, and give him penicillin-urgently!
If you DON'T KNOW THE ORGANISMS, give him intravenous gentamicin, unless you know you have gentamicin resistant organisms in the ward. If so amikacin is an alternative. If possible, isolate him.
If a patient's TEMPERATURE RISES to 39.5°C, and you have no other way of reducing his fever, expose his burn and turn a fan on it. He may develop hyperpyrexia. Chlorpromazine may help if his blood pressure is adequate.
If RIGORS AND FEVER are followed by a sudden fall in blood pressure, mental confusion, and apathy, with occasionally diarrhoea hypothermia, oliguria, and hypotension, he is probably in septic shock (53.4).
If he shows SIGNS OF SEPTICAEMIA OR SEPTIC SHOCK and there is a GREEN STAIN on the dressings, suspect Pseudomonas septicaemia. give him gentamicin, and apply hypochlorite (`Eusol') to the burn.
If SEPSIS IS EXTENDING and is going deeper, the possible agents which might control it are silver sulphadiazine, or silver nitrate.
58.24 Preventing contractures
You can minimize all contractures and prevent many of them completely by using quite simple methods. Failure to apply these methods is one of the commonest mistakes in treating burns. Some of them have already been discussed: (1) Prevent full thickness skin loss where possible, by preventing infection from making superficial burns into deep ones (58.20). (2) If skin for grafting is scarce, make sure you always graft burnt joints (58.19). (3) When you graft them use sheets, rather than patch grafts or mesh. (4) Arrange the sheets of grafted skin so that the joins between them go across the flexor surface of a joint rather than along it (58-15). This will avoid lines of healing along a joint that will later form contractures. (5) Before you graft, scrape away most of the granulation tissue, so that only a thin layer remains. This will reduce the subsequent fibrosis under the graft.
The scar tissue that forms a contracture was once granulation tissue. The deeper a patient's burn, and the longer you leave it ungrafted, the more granulation tissue there will be, the worse his scar, and the greater the risk of contracture-so graft early!
UNGRAFTED
GRANULATIONS-FIBROSIS -CONTRACTURES
The great danger of a scar is that as it contracts it will pull part of the patient's body into an abnormal position, particularly if he is a child, because he will grow but his scar will not. The abnormal position is usually the position of rest, and a bad one for function. Most contractures are the result of burns on the flexor surfaces-they flex a patient's elbows, his hips, his knees, and his neck, and they adduct his arms, as in A, Fig. 58-18. The exceptions are the extensor contractures of his wrist and fingers, which commonly follow deep burns on the back of his hand.
Preventing contractures is usually a compromise between: (1) Splinting a patient's burnt joint in extension for several months, which will prevent the contracture, but may stiffen the joint permanently, often in a bad position for function. And, (2) trying to mobilize a burnt joint early, which will increase its mobility, but will not prevent the contracture. The best compromise between splinting and mobility depends on the joint and how cooperative its owner is. For example, a hand has priority for early grafting, and should be mobilized as soon as it is healed. An intelligent and cooperative patient, who can be trusted to exercise and mobilize his burnt joint, and will apply a night splint, can be told to do so. A less intelligent and cooperative one will be best with his joint in a cast in the extended position. For example, go for mobility with a burnt finger of a teacher, but, if an epileptic of subnormal intelligence has burnt his popliteal fossa, put him in a plaster cylinder for several months. These represent the extremes, with other cases you will have to achieve a compromise.
Stiffness is seldom serious until a joint has been immobilized for 3 weeks in an adult or 6 weeks in a child, so the usual compromise is to splint a joint in extension continuously, or not more than 3 weeks in an adult (6 weeks f necessary in a child), while the skin over it heals, and then to mobilize it. After this it can be splinted only at night for a few more weeks, if the patient is fortunate, or for many months if he is not. Three weeks immobility allows partial thickness burns to heal, so contractures should not form. It is deep burns which take longer to heal that are at risk.
Use splints and traction to keep a patient's limb in the opposite position from that of the expected contracture. Use any simple splint that will do this. The dynamic splints in Fig. 58-19, are ideal in the later stages, but in the earlier ones any simple splint is much better than nothing. No two burns are exactly the same, so you will need considerable ingenuity. There are two important kinds of splint: (1) Those applied initially which a patient wears all the time, and (2) those applied later which he only wears at night. Splints need care-don't let them cause ulcers in newly grafted skin!
A patient's contractures may continue to form for a year or more after discharge, so continue the appropriate night splinting while he is an outpatient, and see him regularly. Even splinting for a year may be followed by contractures during the next six months. Earlier on, they can form in a few days. If he is the child of a village mother, try hard to make her understand what a night splint is for, and why she must apply it. Only too often you will see a contracture, which you have carefully released, recur, because she did not understand or use the night splint you gave her.
You will need the continued help of a physiotherapist, and if you don't have one, you will have to train somebody to fill this role. Make sure he understands what he has to do.
Hypertrophic scars can be prevented by applying a pressure garment for several years if necessary, but you will probably find this impractical.
Finally, remember that if a patient lies continually in the same position because of a burn elsewhere, contractures can form in his unburnt limbs, as happened to Pepita in Fig. 58-1!
PREVENTING CONTRACTURES
NURSING BURNT JOINTS
Nurse a burns patient in the positions shown in Fig. 58-16. Protect all his bony points from pressure sores-his elbows, trochanters, ischial tuberosities, and his heels. Use a combination of padding, pillows, frequent turning, and splinting. Putting him in the right position to begin with may be painful, so, if necessary, sedate him, or give him ketamine while you do it.
CAUTION ! Pressure sores can form in a burnt patient almost as easily as in a paraplegic.
SPECIAL SITES FOR CONTRACTURES IN BURNS PATIENTS
NECK Try to keep a patient's burnt neck away from his chest. Put a pad under his shoulders to extend his neck, as in C, Fig. 58-16. If he is lying on his front, put a pad under his forehead to extend his neck and free his airway (D). Examine his back and the front of his head repeatedly for pressure sores.
Or, place a mattress under him only as far as his shoulders, so that his head falls backwards. If you raise the head of his bed, he will probably tolerate this well.
Continue with a bulky neck bandage for 6 to 12 months, or use a plastic foam collar, or a neck cast, watching carefully for pressure sores.
AXILLA Abduct his arm to 90°. In a child try forearm traction as in Fig. 72-11, or use traction to raise his arm above his head.
ELBOW Extend the patient's elbow, and apply a splint, or maintain this position with pillows and sandbags.
CAUTION ! (1) Don't let his arm fall backwards, because the head of his humerus may be forced forwards and injure his brachial plexus. (2) Don't let pressure cause sores on his elbow, or an ulnar paralysis.
HANDS See Section 58.29.
HIPS AND KNEES Extend a patient's hips and knees and abduct his legs about 15°. Use roller towels held in place by sandbags, or a plaster splint between his lower legs.
Ask him to keep his hips and knees as straight as he can for several weeks, and don't let him flex his knees when sitting on a chair. If necessary, fit him with a posterior plaster slab for a few weeks.
CAUTION ! (1) Make sure that pressure over the head of his fibula does not cause foot drop. (2) Some loss of flexion in a knee is not important, and is probably inevitable anyway. But you must preserve full extension. If necessary, apply a plaster cylinder for 12 weeks or longer.
FEET AND ANKLES Prevent foot drop or contractures behind a patient's heels. Keep his feet at 90° with right angle splints or foot blocks or sand bags. Support his thighs and legs on pillows to prevent pressure sores forming on his heels. In infants use blocks of plastic foam as pillows.
If contractures are starting to form, serial casting (26.1) may correct them.
KEEP THE LIMB IN THE OPPOSITE POSITION TO THE CONTRACTURE
PREVENT STIFFNESS BY MOBILIZING BURNT JOINTS EARLY
PREVENT CONTRACTURES BY EARLY SPLINTING IN EXTENSION
58.25 Treating broad burns contractures
You might be surprised that as a 'generalist' you should ever have to release a burns contracture! Unfortunately, if you don't, it is likely that nobody else will, because your nearest plastic surgeon will probably have a waiting list which is years long. While a child is waiting for a bed in a referral hospital, his contracture is likely to become an incurable deformity. In the district hospital studied in Section 1.4, releasing contractures formed 2% of all the operations done under general anaesthesia, so this is not an uncommon task. If you are persistent and careful, you will not find them as difficult as you might expect. You have skin loss to cope with, so they are more difficult than polio contractures (26.2). Postoperative care is half the battle.
Contractures of a patient's larger joints are not too difficult, but those of his hand are tasks for an expert, yet you may have to try. They are certainly not the contractures to start with. If you do have to attempt them, gain experience with larger joints first. Contractures on the palm are slightly less difficult than those on the back of the hand, where a patient's MP joints readily become hyperextended, as part of a claw hand. They are close to the surface and are easily burnt. Fortunately, a child's joints don't become stiff nearly so easily as those of an adult. After you have grafted the flexor surfaces of a child's fingers, you can safely immobilize them in extension.
Contractures may be linear or, more commonly, broad. Aim to: (1) Excise linear ones with a Z-plasty (58.26). (2) Release broad ones widely without excising them, then graft the bare area with a medium or thick split skin graft. Splint the patient's limb in a position opposite from the contracture, and start exercises as soon as the graft has taken.
We advise you to graft with sheets of thick split skin. If the graft is large and you are inexpert, you may be wise to mesh them. Experts seldom do this and often use full thickness grafts, especially for hands.
Make children your first priority, you will be much less successful with adults. Don't try to relieve burns contractures by using serial casts (26.1)!
THE GENERAL METHOD FOR A BROAD CONTRACTURE
Wait until the patient's burn has healed completely.
ANAESTHESIA Ketamine or general anaesthesia. This is not a task for the minor theatre. Check that the patient's haemoglobin is over 10 g/dl. Have blood cross matched.
Start by taking skin from the donor site. When his contracture is straightened out, you will need more skin than you expect.
Infiltrate into and under the contracture a mixture of saline 80 ml, 2% lignocaine 20 ml, adrenaline 1:1000 0.5 ml, and preferably hyaluronidase 1 ampoule ('jungle juice' see A 5.4). This solution will: (1) Demonstrate the tissue planes more clearly. (2) Allow you to separate the scar more easily. (3) Control bleeding. (4) Reduce the amount of general anaesthetic he needs.
Cut through the scar down to the patient's subcutaneous tissue, in the middle of the contracture. Keep it under tension as you do so. If necessary, cut right down to his tendons. If possible, separate the scar from his deeper tissues by blunt dissection. Push your scissors into the tissues, then open them. This will help you to avoid any superficial veins. You will probably be wise not to try to excise the scar, either in the main part of the contracture, or at its upper or lower ends.
CAUTION! (1) Release the contracture first, and then decide if you need to excise any scar tissue. (2) Don't cut his deep fascia, unless the scar tissue extends right through it. (3) Contractures will take longer to release than you expect. (4) Beware of congested veins, especially in his axilla and neck.
Carry the incision beyond the limits of the scar tissue, and beyond the axes of the joint on each side. If you don't do this, the contracture will recur. Or, make a double-Y, as in Fig. 58-21; this will reduce the length of the incision you need to make.
Cover the bare area with a sheet split skin graft, and sew it in place. If you are worried about it taking, mesh it.
CAUTION ! Graft the exposed raw areas immediately, especially over joints. This will reduce the risk of the contracture recurring, and the risk of infecting the joint.
Splint the patient's limb in the opposite position to the contracture, until the graft has taken. When the time comes to remove the dressing, do this yourself. Keep him in a night splint for at least 3 months. Review him regularly and add more skin as necessary.
NECK CONTRACTURES FOR RELEASE E
If a patient's chin is contracted down on his sternum as in Fig. 58-18, refer him if you possibly can. His anaesthetic problems are considerable.
ANAESTHESIA You cannot intubate a patient while he has a contracture of his neck. So, give him ketamine, infiltrate the scar with anaesthetic solution, release it, and then, if necessary, intubate him.
METHOD Incise the scar transversely, if necessary almost from ear to ear. Carefully release the scar tissue by blunt dissection to reveal a huge gap in the front and sides of the patient's neck.
Apply a sheet of split skin graft and a wet cotton wool dressing, as for the axilla. Immobilize his neck with his head well extended. To prevent recurrence, keep his neck in extension. Apply a soft collar as soon as his skin is soundly healed, and l eave it there for at least 6 months. He must wear a night splint for several more months.
If necessary, repeat the procedure, several times if required, to obtain a little more movement each time.
AXILLARY CONTRACTURES FOR RELEASE
Try to restore full abduction and elevation in a single operation. A Z-plasty will probably be best if the contracture is narrow (58.26).
If the patient has a broad contracture, incise the scar as above, and abduct his arm. Apply a large medium thickness split skin graft to the bare areas, and dress it with wet wool (57-7), so as to fill the dome of his axilla. Cover this with plenty of dry wool, and bandage this (preferably with crepe bandages) to include his whole arm as well as his axilla and chest.
If he is a small child, a large ball of cotton wool bandaged into his axilla may hold his arm in the right position.
If he is an older child or an adult, raise his head and back on a suitable support (as for a hip spica Fig. 77-4), and apply a plaster shoulder spica to include his arm and hand, with his arm at 90° from his chest, his elbow flexed, and his wrist dorsiflexed. This is the most comfortable position.
CAUTION ! (1) Don't injure a patient's axillary vessels or nerves. (2) Don't hyperabduct his shoulder, or you may paralyse his brachial plexus.
ELBOW CONTRACTURES FOR RELEASE
A large scar may involve the whole flexor surface of a patient's elbow. Make a cautious transverse incision across the fold of his elbow, starting laterally, and trying to avoid any congested veins. If the whole width of his elbow is involved, extend the incision into healthy tissue beyond the axis of the joint on each side.
Find a fatty layer and then work gently medially. If you have found the right fatty plane, you should be able to slide the scar tissue up and down his arm. When the incision is complete, divide any deeper strands of fibrous tissue.
Fill the large diamond shaped gap with a medium thickness split skin graft. Cover it with a wet cotton wool stent, as in Fig. 57-7. Immobilize his extended and supinated elbow in a cast which should also immobilize his hand. Dress the graft at 7 to 10 days. When it has taken, apply a cast in extension, for at least 6 to 12 weeks. You are operating for a flexion contracture, so lack of flexion will not be a problem.
HAND CONTRACTURES FOR RELEASE
Try one of the dynamic splints in Fig. 58-19. If the patient's contracture is mild, this may cure it. If it is severe, a dynamic
splint may partially correct the deformity, so that operation will be easier.
If a patient's metacarpophalangeal joints are hyperextended as part of a claw hand, try to refer him, particularly if he presents late with a gross deformity. This is a particularly difficult contracture, because the capsules of his joints may need opening up and freeing. If you cannot refer him, make transverse incisions over their dorsal surfaces, flex them, graft the gap, and splint his hand in the position of function.
If his wrist is hyperextended, and he presents reasonably early, divide the scar transversely, and apply a medium thickness split skin graft-beware of his median nerve and ulnar artery!
If he has contractures on the flexor surfaces of his fingers, incise them transversely well beyond the axis of the joint, and fill the gap with a full thickness graft, or a thick split skin graft sewn into place.
If he is a child, splint his fingers in extension for 3 months, or the contracture will recur. To help the cast stay in place, apply it with his wrist extended. Examine the cast daily at first, and later weekly, to make sure it has not slipped.
If he is an adult, don't immobilize his extended fingers for more than 10 days. If necessary, use dynamic splints as in Fig. 58-19, and night splints.
If a patient has a very severe finger deformity, you may need to amputate a finger, or arthrodese it in the position of function.
GROIN, KNEE, ANKLE, AND FOOT CONTRACTURES FOR RELEASE
Follow the general method, as described above, taking care to extend the incision well beyond the axis of the joint.
DIFFICULTIES WITH BURNS
If you CANNOT GET SUFFICIENT RELEASE of a contracture in a single stage, release it as much as you can; consider splinting it, leaving it open, trying to release it further in a few day's time, and then grafting it.
If there is an ULCER within a scar, excise it.
MANY SEVERE CONTRACTURES ARE LARGELY THE RESULT OF POOR CARE
58.26 Z-plasties for narrow contractures
A Z-plasty is a useful way of releasing a patient's contracture-if it is narrow enough. It is not an easy method, but if your result is not perfect, you can always graft any bare areas that remain. Good results are easier to achieve than with a wide contracture which needs inset grafts. Make a Z-plasty by excising the scar and then cutting two flaps in the form of equilateral triangles which share one common limb, and so form a Z. When you extend the patient's limb, the triangular flaps will change their positions spontaneously.
Initially, the two triangles together form a parallelogram, with its shorter diagonal in the line of the contracture, and its longer diagonal transversely across it, as in C, Fig. 58-20. Releasing the contracture and transposing the two triangles changes the shape of the parallelogram, so that the new contracture diagonal is the same length as the transverse diagonal was before, as in D, in this figure. The difference in length between the two diagonals determines the amount of lengthening in one direction and shortening in the other.
Transposing the triangular flaps: (1) Gains length in the line where the contracture was and so relieves it. (2) Makes any extra elasticity that there may be across a scar available up and down it. It may extend the length of the contracture diagonal by a least a third, at the expense of the skin on either side. (3) Changes the direction of a scar, from one which runs along a flexure to one which runs across it. Expert plastic surgeons find this useful for changing the direction of a facial scar, so that it lies in a line of election (61-3).
If you make one large `Z', all the transverse shortening, and all the tension is concentrated in one transverse diagonal (E, and F, in Fig. 58-20). But, if you make multiple `Zs', the lengthening is additive, because all the contracture diagonals are in the same line, but the transverse shortening is spread out over several smaller ' Zs' (G, and H). In practice, you will not achieve quite as much lengthening with multiple `Zs' as you would expect, but it is still a very useful method.
Unfortunately, most burns usually cause scarring in all directions, so that there is no lax tissue at either side, and a Z-plasty is unsuitable. But in those burns where it is suitable, it is very effective.
Z-PLASTIES
INDICATIONS The occasional patient with a narrow contracture of his axilla, elbows, fingers, knee, or neck, especially
one of the bowstring type, provided the surrounding tissues are reasonably lax and undamaged. Only a few burns contractures are of this kind. If there is no transverse slack tissue to start with, a Z-plasty will not work.
A single 'Z' extending the whole length of the patient's contracture. There is a large quantity of lax tissue to be brought in from the sides, and the bowstring is sufficiently deep for the base of the flaps not to extend much onto the surrounding flat skin-if they do, multiple 'Zs' would be wiser.
Multiple 'Zs' The available lax tissue is not available at one point, but is spread out along the length of the scar.
CONTRAINDICATIONS (1) Narrow contractures, when the surrounding tissues are not reasonably lax, or the flaps would be scarred. (2) Broad contractures. If you cannot refer the patient, proceed as follows.
SINGLE 'Z' Use a pen to draw the position of the central limb on the patient's skin, the longer it is the more length you will gain. Its length will however be limited by the amount of loose tissue available at the sides.
You have two alternative ways of choosing the flaps. Select the best one like this. Draw equilateral triangles on either side of the central limb, in both of the possible ways. Choose the flaps which: (1) have the better blood supply, (2) avoid scarring across the base, (3) will give the best cosmetic result, and (4) are likely to rotate most easily. If you complete the quadrilateral, with its contractural and transverse diagonals, you will see how much increase in length you can expect, after you have transposed the flaps.
CAUTION ! (1) Angle the flaps as near to 60° as you can. Use a precut 60° pattern. Remember that the angles of an equilateral triangle are 60°. (2) Make the sides the same length as the central limb, except that if one flap is scarred, cut it a little longer than the other. (3) If you are worried about the possible viability of a flap, curve it a little, as in B, Fig. 58-20. (4) The tip of a 'Z' is most likely to necrose, so make sure you cut it deep enough. If necessary include some of the underlying scar tissue.
Check the geometry of your flaps by joining their free ends. The transverse diagonal should pass through the middle of the contracture diagonal.
Extend the patient's limb to show the full extent of the scar, and then excise it in a narrow elliptical incision. Don't make the flaps out of the scarred band itself, or they will slough.
Undermine the triangles so formed, so as to raise two flaps as thickly as the tissue will allow, while obeying the rules in Fig. 58-20. Extend the patient's limb so as to allow the flaps to fall into the opposite positions, and stitch them up with fine monofilament. At the tips use a half buried horizontal mattress suture (54-8).
If you have designed the flaps properly, you will not need to transpose them actively; they will fall naturally into position.
CAUTION ! (1) Handle flaps with skin hooks. (2) Control bleeding meticulously. (3) If bare areas remain (as they often do), don't close the plasty under tension, instead graft them. (4) Bandage the limb in the mid position, not at the extreme of extension, or you will impair the circulation in the flaps.
MULTIPLE 'Zs' Cut these in the same way. Either keep the Zs' separate, as in G, and I, or join them together, as in K, and L.
SPECIAL SITES FOR Z-PLASTIES
AXILLA The contracture must be linear, on one or other of the axillary folds, usually the anterior one, as in A, Fig. 58-18. If possible, avoid transferring axilliary skin, which contains hair and apocrine glands, outside the patient's axilla. Incise the scar longitudinally. If it is thick and rigid, excise it, with a 'Z' release at either end. Bring one limb of the 2' anteriorly, and the other one posteriorly.
If you cannot get sufficient abduction with a Z-plasty, make it in the central part of the web, and make V-shaped incisions at either end. When the patient's elbow is fully abducted, these will leave bare areas which you will have to graft.
DIFFICULTIES WITH Z-PLASTIES
If you HAVE TO GRAFT BARE AREAS, sew the grafts in place with fine monofilament, and apply a firm dressing.
58.27 Burnt respiratory tract
Most people who are removed from a smoke filled building cough, retch, and then recover in 48 hours or less. But a burnt patient can injure his respiratory tract by inhaling smoke, and die from asphyxia due to laryngeal oedema. He can also die from pulmonary oedema, or from respiratory infection. Bronchopneumonia after burns is common, even if a patient's respiratory tract was not burnt, and unfortunately antibiotics don't prevent it. The danger signs to watch for are severe dyspnoea and wheezing 12 to 36 hours after a burn. If this does not respond to simple measures, there is usually little to be done.
RESPIRATORY BURNS
Admit the patient to a small room with steam from a steam kettle, or humidification from a cold humidifier. Record his pulse, temperature, and respiration 4 hourly. Take a baseline X-ray on admission and another 24 hours later. Watch for multiple fluffy shadows (the snow storm effect), interlobar shadows, hilar flare, fine linear crescentic shadows, and pneumothoraces (following explosions). Examine his sputum for soot.
If he has no abnormal signs, discharge him at 48 hours.
THE COMPLICATIONS OF RESPIRATORY BURNS
If a patient's temperature rises, give him a broad spectrum antibiotic. If he is producing sputum, examine this and prescribe the appropriate antibiotic. Often, the same organism causes both chest and skin infections.
If he has mild signs of respiratory discomfort, encourage him to cough effectively and do breathing exercises; try postural drainage and suck out secretions.
If physiotherapy fails to clear the secretions from his respiratory tract, intubate him and apply suction using careful sterile precautions. If this fails, his only hope is tracheostomy.
If intubation is going to be necessary, try to do it in the first few hours, before his face has a chance to swell. Early prophylactic intubation is better than intubation later. It may save a tracheostomy, or make it easier.
If he has inspiratory stridor or wheezing, or shows i nspiratory intercostal, supraclavicular, or abdominal recession, intubate him. If this fails, do a tracheostomy.
If he wheezes, or shows prolonged expiration and rates or crepitations, his bronchi are in spasm. If these signs are mild, give him bronchodilators, such as salbutamol or aminophylline. If they are severe, give one dose only of hydrocortisone or methyl predisolone under antibiotic cover. But avoid steroids if you can.
If he shows signs of pulmonary oedema, restrict his fluid i ntake, give him frusemide, and repeat it after some hours if necessary.
If he shows increasing respiratory distress, with dyspnoea, tachypnoea, cyanosis, tachycardia, inability to cough, exhaustion, restlessness, and altered consciousness, he will probably die. He needs mechanical ventilation and oxygen. If he also has pulmonary oedema, try PEEP (A 19.4).
CAUTION ! Don't give him too much oxygen because this may precipitate the adult respiratory distress syndrome and make him worse. 2 to 4 I/min is enough.
58.28 Burnt eyes
Burnt eyelids are much more common than burnt eyes. A patient is usually able to shut his eyes before the fire burns his corneae, so his sight is more often in danger from the burns to his lids, or from the late effects of scarring. His burnt swollen lids make his eyes shut for a few days, after which they open again.
At any time from 3 weeks onwards, his eyelids, particularly the lower ones, may start to contract and expose his cornea (ectropion). This causes conjunctivitis, exposure keratitis, corneal ulceration, perforation, and finally infection of his globe. Try to prevent this deadly sequence by making sure that his corneae are always covered and moist. The easiest way to do this is to keep them covered with an antibiotic eye ointment. The most radical way is to sew his eyelids together (tarsorrhaphy).
If the full thickness of the skin of his eyelids is burnt, graft them. Grafts take well on eyelids, so that grafting them is not as difficult as you might think.
If contractures start to occur, you may have to release them, do a tarsorrhapy and then graft them. Unfortunately, this is usually only partially successful.
Treat chemical burns in the same way. The most important measure is to apply quantities of water to burnt eyes at the earliest possible moment.
BURNT EYES
EXAMINATION Examine the patient's eyes early, before they start to swell. While his eyes are closed, he will be very anxious, so see that the ward staff talk to him often.
If they have already closed, you may be able to open them using gauze and sterile gloves, or eyelid retractors. A bright shiny cornea is a good sign. Stain the patient's conjunctivae with fluorescein and look for ulcers. There are 4 grades of corneal injury. In the first two his prognosis is good.
Grade One. There is epithelial injury only.
Grade Two. The patient's cornea is hazy but you can see the details of his iris clearly.
Grade Three. There is total epithelial loss, and stromal haze. You cannot see the details of his iris. His sight will probably be impaired, but perforation is rare.
Grade Four. His opaque cornea completely obscures his iris and his pupil. His globe will probably perforate.
THE TREATMENT OF BURNT EYES
If a patient's cornea is hazy, apply chloramphenicol ointment, and atropine or homatropine eye drops.
If there are particles in his eyes, irrigate them away with saline.
If his punctae or canaliculae are damaged, pass a style or indwelling suture through them to keep them open while they scar.
If his palpebral and ocular conjunctivae start sticking to one another, separate them with a smooth glass rod, or the movements of his globe will later be limited.
If his eyelids are not completely destroyed, they will protect his eyes for about 3 weeks, before they disintegrate. Refer him early for reconstruction of his eyelids.
If all or most of his eyelids have been destroyed, dissect the conjunctiva of both lids free of his orbicularis muscle and his tarsal plates, and cover his globes by suturing the remains of his lids together. Graft their exposed surfaces. Refer him to an expert later. If necessary, use his conjunctivae only, as in Fig. 60-2.
If an eye is hopelessly damaged, it will have to be removed at some stage.
KEEPING AN EXPOSED CORNEA MOIST AFTER AN INJURY
If a patient's cornea is exposed, try the following methods of keeping it moist, in the order you see below. If one is not successful. try the next down the list.
(1) Fill the patient's cornea with chloramphenicol ointment, and renew it four times daily. This is all that most patients need.
(2) Seal goggles over his orbit with adhesive strapping and cream. These will keep his cornea moist for 12 to 24 hours, but don't use them for longer, because they will macerate his whole orbit.
(3) If his eyelids are charred and tight, make relaxation incisions, if necessary combined with traction sutures from his cheeks. Try to prevent retraction of his upper eyelids, because these are the ones that protect his cornea in sleep.
(4) If these methods fail, consider an early inlay split skin graft, it may avoid tarsorraphy.
CAUTION ! (1) Don't use steroids. (2) Never apply an eye pad directly to a patient's cornea, because it may rub and ulcerate through. Even vaseline gauze can cause ulceration. If his cornea cannot be covered with its own lids, an open eye covered with antibiotic cream is safer.
TEMPORARY TARSORRHAPHY FOR AN INJURED EYE
INDICATIONS If you have kept a patient's cornea moist by the above methods, tarsorrhaphy should very rarely be necessary. It is unnecessary in the early days when his oedematous lids cover his cornea, and is unsatisfactory if his lids have been severely damaged.
ANAESTHESIA Ketamine.
METHOD Use fine monofilament and a curved needle. Make two horizontal mattress sutures through the patient's eyelids as in Fig. 58-23. Site them away from his cornea. Pass them through the skin, and out through the flat free margin of one lid, across to the flat free margin of the other lid, and then through small pieces of plastic tube.
If the burn prevents you getting his lids together, make relaxing incisions in each lid, as in A, Fig. 58-24. Cover the bare areas with split skin grafts and hold them in place by the tieover method (57-8).
CAUTION ! (1) Make sure that the sutures do not rub against his cornea, or cross it at the grey line. If possible, place them to one side of his cornea. (2) Make sure that the sutures avoid
his punctuae and his canaliculae. (3) Make sure that no eyelashes press against his cornea. If he feels any scratching sensation, re-examine his eyelids immediately.
All the time that his lids are closed, irrigate his eyes with saline every 12 hours. Don't open his lids for 12 weeks.
If a patient's eyelids are burnt, graft them. If convenient, put a thick split skin graft over both lids, and cut the lids apart later. You can do this under local anaesthesia.
CONTRACTURES OF THE LIDS
INDICATIONS I f contractures are already starting to expose a patient's eyelids and expose his corneae, you may have to release his lids and graft them.
Put stay sutures through his lids (23-2), so that you can move them up or down as necessary. Make the relaxation incisions shown in Fig. 58-24.
When you have prepared a satisfactory bed for the graft, and controlled bleeding, stretch it, apply a piece of split skin graft, and hold it in place with tieover sutures, or 4/0 monofilament.
If the graft contracts a few weeks later, apply another one. Don't worry too much about what the patient's eye looks like at this stage. What matters is that his cornea should not be exposed.
CAUTION ! Stretch the lid first so that there will be some slack tissue when it contracts later. The thinner the graft, the more the shrinkage. If you are skilled, apply a full thickness graft.
Primary skin grafting will not prevent ectropion, and you may need 2 or 3 operations to insert enough skin.
DON'T DELAY GRAFTING THE LIDS
58.29 Burnt hands and feet
The thick skin on the palms of a patient's hands usually protects them, so most burns are on the back. This swells, and as the oedema organizes his hand stiffens. Minimize this oedema by raising his burnt hand. Hang it from a drip pole, as in A, in Fig. 75-1, or put it in a St. John's sling as in C, in that Figure.
Severely burnt hands are not suited to the exposure treatment because the crust cracks when a patient's uses his fingers; nor are they well suited to the occlusive method because he cannot exercise his hand inside a big bulky dressing. The plastic bag method is usually best. This keeps his fingers moist and mobile, and makes even a severe burn almost completely painless. Even if both his hands are burnt he can still do many things for himself. An antiseptic in the bag is desirable but not essential. If you use one, you can leave his hand in the bag for more than a day. If you don't use one you will have to remove his hand and wash it daily.
Recognizing the depth of a burn is difficult in the hand, but is important, because small deep burns may be best treated by immediate excision and grafting (58.17).
RAISE ALL BURNT HANDS AT ALL TIMES
When grafting a burnt hand is needed, graft early, or the patient will lose the function in his hand unnecessarily. His next most urgent need is a splint to prevent contractures, especially if he is a child. The common deformities that can follow are the 'bunch of bananas hand' B, Fig 58-26, or in its more extreme form the 'claw hand' shown as E, and F, in this figure. The patient's wrist extends, his MP joints extend and adduct, and his IP joints flex. Sometimes, his proximal interphalangeal joint is flexed and the distal one extended, producing the boutonniere deformity shown in Fig. 75-22.
If you are aware of the deformities that can happen, you can usually prevent them, by: (1) Splinting a patient's burnt hand in the position of safety as in A, in Fig. 58-26, and Fig. 75-8. (2) Starting physiotherapy as early as is practical. There is no universal splint for a burnt hand, so consider each patient's needs separately.
SPLINT A PATIENT'S HAND WITH HIS WRIST IN DORSIFLEXION
Dynamic (lively) splints are ideal when a patient's hand starts to recover, so change his fixed splint for one which allows him to move his fingers, but still holds his hand in the best position when it is resting. The easiest way to make a dynamic splint is to make, a plaster cock-up splint, and to fix a piece of thick wire to it as shown in B, Fig. 58-19. Attach rubber bands to the wire and pass these round his proximal phalanges to allow him to exercise his fingers.
BURNT HANDS
WHICH METHOD IS THE BEST FOR A BURNT HAND?
Superficial burns. the exposure method or the occlusive dressing method is best.
Deep partial thickness burns on the dorsal surfaces. Use the handbag method, or if you are skilled, treat the patient's burn by tangential excision and grafting in 3 to 5 days (58.17).
Small (less than 20 mm) full thickness burns. Excise the patient's burn, especially if it is on the palmar surface, and apply a split skin graft. If you are not very skilled, the hand bag method might be wiser.
Burns with bare tendon, bone, cartilage, or joints. The patient is usually in so much pain that you cannot find out if his nerves and tendons have been injured or not. His hand requires skin flaps which is a highly skilled task, so refer him. Before doing so, remove any obviously burnt tissue from the remains of his hand.
If referral is impossible, you will have to: (1) treat him by the hand bag method. Meanwhile, (2) wait for the exposed tissues to slough, and for his wound to granulate, and then, (3) graft what is left of it.
If a burn is very severe, you may have to amputate, but don't do this unless it is absolutely necessary. You may be able to graft the stumps of his fingers, and preserve some useful function. The same indications for amputation apply in burns as in other hand injuries (75.24).
If you are in doubt to what to do, use the hand bag method until granulations appear, and then graft.
THE HAND (OR FOOT) BAG FOR SEVERE BURNS
MATERIALS Any big clean plastic bag of a suitable size. There must be plenty of room for the patient's hand to move about inside it. Don't use a plastic glove. If possible, use one of the following antiseptics: (1) Silver sulphadiazine 0.5% changed every 1 or 2 days. Or, (2) povidone iodine.
METHOD Smear the patient's hands with silver sulphadiazine, or povidone iodine.
Wrap a piece of gauze round his wrist and hold it in place with a piece of strapping. Place his hand in the bag with some more antiseptic, and secure the bag round his wrist with a bandage. The gauze already round his wrist will help to form a watertight joint, or sweat band, and prevent the exudate in the bag from dripping down his raised forearm.
CAUTION ! A burnt hand swells alarmingly, so suspend it beside his head, by the method in Fig. 75-1.
Encourage the patient to move and use his hand inside the bag right from the start. Let him feed himself, and shave, etc. Large volumes of a murky fluid will collect in the bag. If this alarms him, explain that it is normal. Change the bag each day. Take his hand out of the bag, wash it with soap and running water. Apply more antiseptic, and put it back in a new bag, or in the old bag washed clean.
CAUTION ! (1) Early movement is important. If he is reluctant to use his hand, encourage him. (2) If silver sulphadiazine or some other antiseptic is not available, daily washing is absolutely essential. (3) Full thickness burns of the digits inside a plastic bag may still need an escharotomy (58.18), so observe the circulation in his fingers carefully.
DESLOUGHING A BURNT HAND Sloughs will usually fall off in pieces into the bag by themselves, so that desloughing with scissors is usually unnecessary.
GRAFTING A BURNT HAND Small islands of new skin will appear in a superficial burn. If these are not enough to cover the raw areas, graft them. Graft early, before three weeks. A hand which stays uncovered with skin longer than this is more likely to become stiff.
If you put a patient's grafted hand back in the bag, the grafts may float off, or be rubbed off. So take his hand out of the bag, graft it, splint it (a wire frame is convenient), and treat it by the exposure method (58.14) or with an occlusive dressing (58.15).
If you are in doubt as to whether to graft or not, (this is common with the bag method), keep his hand in the bag, wait for granulations to appear, and then graft his wound with split skin.
SPLINTS FOR A BURNT HAND A plaster cock-up splint is generally the most useful one. Place it outside the dressing or the plastic bag and then bandage it in place. Keep a pad or splint in the space between the patient's thumb and index to prevent an adduction deformity.
If the dorsum of a patient's hand is burnt, so that it is likely to assume the deformity in C, Fig. 58-26, splint his hand with his MP joints flexed and widely abducted, his IP joints in 15° of flexion, and his thumb widely abducted and forward of his palm (the position of safety in Fig. 75-8).
If his palm is burnt, splint his MP joints in 30° of flexion, and his IP joints in 15° of flexion.
To begin with he should wear his splint day and night. Later, he will only need it at night. Splinting may need to last three months.
THE OCCLUSIVE METHOD FO R A BURNT HAND
Apply this as in Section 58.15. Put gauze between the patient's fingers to prevent webs forming between them. Cover each finger separately to prevent them sticking together, and change the dressings daily. Dress his hand in the position of safety.
DIFFICULTIES WITH A BURNT HAND
If the JOINTS OF A PATIENT'S HAND ARE EXPOSED, aim for an arthrodesis in the position of function (usually 30° of flexion of his IP and MP joints). Remove any dead cartilage and fix the position with crossed Kirschner wires, left in place for 3 weeks.
If ONE FINGER REMAINS STIFF, consider amputating it.
If ALL A PATIENT'S FINGER JOINTS HAVE BEEN DAMAGED, fix his ring and little fingers well flexed to act as hooks for carrying, and his index and middle finger only mildly flexed, so that his thumb can grasp things against them.
58.30 Burnt face and ears
Burnt face Warn the patient's family that massive oedema may greatly distort his face, but that this will disappear. Raise his head to 30° and have intubation and tracheostomy equipment ready. If you have to do a tracheostomy, do it in the theatre after intubating him first. Oedema will be at its maximum 12 to 24 hours after the burn, so watch him carefully, because respiratory obstruction may be sudden.
Full thickness burns of the beard area are rare, because the hair follicles extend so deep. Use thin split skin sheet grafts, not mesh grafts, and apply them to complete anatomic areas of his face. Sew the grafts in place, and hold them by the tieover method (57-8). The most common cause of failure to take is not keeping the graft still. So try to stop him talking and give him liquid food.
Burnt ears Inflammation of the cartilages of the ears can occur 2 to 5 weeks after a severe facial burn, when the skin over a patient's ear may have healed. His burnt ear becomes acutely, painful, red, and tender, because its cartilage has become necrotic. If you don't excise the dead cartilage, it becomes infected and sloughs. Once this has happened he will need his ear reconstructed.
CHONDRITIS OF THE EAR
PREVENTION Treat a burnt ear carefully. When you dress it, put a pad of gauze behind it to prevent it bending.
If a collection of fluid gathers on a patient's ear, incise it urgently, if necessary, more than once. If you leave it, the cartilage under it may necrose.
If his ear cartilage becomes necrotic, block his greater auricular and auriculotemporal nerves with lignocaine (A 6.6). Incise the outer border of his ear, so as to separate its anterior and posterior surfaces. Remove any soft yellow cartilage which lacks the normal resilience of healthy hyaline cartilage. Pack his ear with fine gauze, being careful not to bend it. Keep it moist with saline. Examine it 24 hours later, under local anaesthesia. If necessary, remove more necrotic cartilage.
If there is sepsis and abscess formation, drain the septic area with a wide incision, and remove all necrotic cartilage. If you fail to do this, the whole cartilage will become infected.
58.31 Burns of the trunk
Follow up a child with severe burns of the trunk carefully. As growth occurs, they may prevent the normal development of his (or her) breasts, abdominal wall, or buttocks.
Follow up a little girl with burns of the front of her chest until her breasts develop at puberty. Severe scarring may distort them and require further grafting. A scar on the abdominal wall of a pregnant mother may need to be released as her abdomen expands.
GRAFTING A DEVELOPING BREAST If you cannot refer the girl, make a semilunar incision just below her contracted breast. Continue it into her intermammary cleft. Cut down to the deep fascia, lift her breast upwards, and correct its position by gauze and scalpel dissection. Apply split skin grafts, and hold them in place with tieover sutures over wet wool. Cover them with dry wool and crepe bandages. Lie her flat until the grafts have taken.
If her nipples have been destroyed and she becomes pregnant, you may need to suppress lactation.
58.32 Burnt bones and joints
The tibia, the ulna, and the skull are often burnt when an epileptic falls into the fire. If the tissues over his periosteum are burnt, it dies, and so does the bone under it, even if it escaped being burnt directly. As the slough falls away you may see grayish yellow bone protruding from among pink granulations round the edge of the burn. Granulations don't form on dead bone, although they sometimes form under it as it separates, so speed up this process by chiseling it away.
BURNT BONES AND JOINTS
As soon as you see that a patient's bone is dead, chisel it away, until you see some bleeding which shows that you have reached living bone. Wait for granulations to form, usually in 5 to 10 days. Then apply split skin grafts.
If a patient's skull has been burnt, its outer table is usually dead. Chisel this away, and graft the granulations that form on the inner table. If the whole thickness of his skull has been burnt, graft his dura.
If a burnt joint becomes infected and pus pours from it, nibble away its articular cartilage and let an arthrodesis form in the position of function (7-16). If it does not fuse spontaneously, refer the patient for a formal arthrodesis; this may require the use of a compression clamp.
If an amputation is necessary, graft the stump.
IF HE IS EPILEPTIC, HAVE YOU CONTROLLED HIS FITS ADEQUATELY?
