Proper Treatment of Burn Victims To Minimize Scars Starts at Scene
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Treatment of victims of serious burns, both on the accident scene and in the hospital, that can minimize disfigurement and promote recovery were discussed at a seminar in Texas last July.
Procedures for saving lives and reducing the extent of scarring that have been pioneered at Shriners Burn Centers and other burn centers throughout the country were discussed at the seminar conducted by the Texas Society of Fire Service Instructors in cooperation with the Harris and Galveston County Firefighters Associations. Staff members from the Shriners Burns Institute and the University of Texas Medical Branch, both at Galveston, explained their treatment methods.
Through its experience in caring for burn victims, the Shriners Burns Institute has made many breakthroughs in treatment.
Classification of burns
A first step towards successful management is an accurate classification of burns. Dr. Donald Parks, acting chief of staff at the Galveston burn unit, described the characteristics of burns by classification according to depth and cause. He classified burns by depth as follows:
First degree: Usually the skin reddens and pain and discomfort are experienced. A good example is sunburn.
Second degree superficial: Additional thicknesses of tissue are damaged. Pain and discomfort are experienced and blistering usually occurs. Skin normally does not scar, but some discoloration may occur.
Third degree: Skin damage is deep enough for skin grafting to be necessary for healing to occur. In some cases, small burns heal from the outside toward the center by themselves. No pain is felt. The wound may look either white in color and be rather hard and leathery to the touch or be charred and burned away.
Knowing the cause of a burn helps the hospital determine what complications may occur. Parks classified burns by cause as follows:
Thermal burns: Thermal burns are frequently caused from flame exposure, scalds or contact with a hot object. Scald burns usually cause a first degree burn around the edge, second degree around the outer area of the wound, and third degree damage to the center. He cautioned that children can receive scald burns from the temperature of liquids that may merely feel very warm to adults.
Electrical injury: This type of injury may damage nerve and muscle tissue inside the body and limbs in addition to burning surface tissue. High voltage burns frequently result in limb amputation. Parks added that contact with lower voltages, such as household current, may result in cardiac arrest in addition to surface burns. Electrical shock victims respond very rapidly to simple CPR given promptly after electrical contact. He emphasized that extreme care must be used in extricating victims from the electrical source.
Chemical burns: These burns may result from contact with acid or alkaline materials. Alkaline burns appear to do much more damage than do acid burns.
Radiation burns: Burns of this type have been too few to research at this time.
Body Reaction
Knowing how the body reacts to a severe burn is the key to successful emergency treatment. Parks described how the burn alters some of the bodily functions. The skin tissue at the site of the burn can be either killed or injured and the following normal functions of the skin are disrupted:
- Body temperature regulation,
- Evaporative water loss barrier,
- Protein loss barrier, and
- Bacterial resistance (infection control).
Most blood supply to the skin is used for temperature regulation, whereas only 3 percent is used for nutrition— keeping the skin alive. With destruction from a burn, the temperature regulating device goes out of control, making the victim susceptible to cooling, or hypothermia. The skin also keeps fluids, electrolytes and other bodily constituents protected in the body and offers the first and major line of defense against the entry of bacteria. It is apparent that a loss of skin allows bacteria a free thoroughfare into the body.
The loss of fluid from the body can result in shock, which was a major cause of deat h among burn victims until the 1940s. Fluid is lost as the injured tissue begins to swell as a result of plasma leaking from area blood vessels. In larger burns, over 25 percent of the body surface, the plasma leakage problem extends throughout the body, that is, from vessels remote from the burn area. This massive leakage begins almost immediately following the injury and may continue for 24 hours, subsiding after that time. This massive fluid leakage can result in shock if fluids are not supplied intravenously. The shock state is characterized by:
- Increase in heart rate,
- Falling blood pressure, and
- Falling urine output.
Thickening of blood
Laboratory tests will demonstrate a marked increase in the hemoglobin and hematocrit since plasma leakage causes the blood, which is normally 60 percent fluid (plasma) and 40 percent solids (red and white cells) to thicken as the percent of cells increases due to the plasma loss. If untreated, shock ultimately results in loss of consciousness and death.
Other alterations in body function include dilatation of the stomach. The stomach gradually enlarges and does not absorb fluids taken orally. Although its cause is not clear, it is a definite problem, particularly in children. Onset can occur within hours of the burn injury and the stomach can become large enough to put pressure on the diaphragm, interfering with normal respiratory movements. Burn victims often request water to drink, but this should not be given, since it only adds volume to the liquids in the dilated stomach. The water is not absorbed, and the patient may ultimately vomit this large amount of fluid with subsequent aspiration into the lungs. Other major alterations in bodily functions occur.
Treatment at scene
What should be done for the burn victim at the scene?
Remove smoldering clothing as quickly as possible. Major additional burns to the face can result if hot synthetic materials stick to this area while the garment is being removed over the head. It is therefore advisable not to pull smoldering shirts over the victim’s head, but to cut them away.
Examine for associated injuries. Those common to electrical shock victims are broken bones and spinal injuries.
Assure an open airway and administer oxygen.
Cover the victim with clean sheets only.
Start an IV with Ringers lactate if possible.
Transport to the nearest medical facility. Patients who will probably need hospital admission are:
- Any third-degree burn on a child under six years of age.
- Any third-degree burn with area exceeding 10 percent for children over age 6 or 15 percent for adults.
- Any third-degree burn for older adults.
Emergency room
Parks described the admission procedure followed when a burn victim arrives at a Shriners Burn Center. When the patient is transferred into the hospital’s care, a brief physical examination is made that includes checking his airway, breathing, and circulatory status.
Special attention should be paid to these inhalation injury signs: singed nasal hair, direct throat and mouth burns, hoarseness, labored respiration, and color of face, ear lobes and fingernails.
In taking the accident history, Parks stated, details are important. They include the mechanism of burn (electrical, flame, etc.), whether the victim was in an enclosed space (important in spotting early respiratory problems), whether a fall was involved in the accident, the history of care after the burn, and allergies or pre-existing disease.
Lab test samples are drawn for baseline studies. An IV with Ringer’s lactate is started and a urine catheter is inserted. Oxygen is administered by mask and a masogastric tube is inserted to relieve stomach dilatation. The patient’s weight also is obtained.
An assessment of burn areas is done, using the rule of nines.
Once the above steps mentioned have been taken, the physician can accurately calculate fluid requirements based on body surface burned and patient’s weight. IV rate is adjusted according to the Parkland formula:
4cc/kg/% burn area
One-half of this volume would be given in the first eight hours and the second half over the next 16 hours.
Medical needs
Attention to medical needs include the injection of tetanus toxoid subcutaneously and occasionally other medication. Narcotics injections must be given intravenously only. Intramuscular injections collect in the muscle and do not disperse normally due to the decreased blood flow. Caution should be used in repeating injections because the patient did not respond as he would in a non-burn situation. Repeat injections could cause drug overdose once circulation is restored, Parks cautioned.
An escharotomy (slitting or cutting the burned skin) is performed if necessary by the surgeon. The burned skin must be split to prevent loss of circulation in the limbs and to avoid restricted breathing problems caused by constriction of the leathery damaged skin. For example, if the burned skin involves an arm circumferentially, the eschar may act as a tourniquet as unburned deeper tissues swell. If left untreated, an unnecessary amputation may result due to loss of circulation.
Burns are dressed with an antibiotic cream.
Bum center treatment
Dr. S.J. Blackwell, assistant professor of surgery at the University of Texas Medical Branch in Galveston described the typical treatment used at the Shriners Burns Institute and the University of Texas Medical Branch.
After the airway, catheter and IV have been started and the patient stabilizes, a warm dilute hypochlorite bath (1/120 or 1/240 Clorox solution) is prescribed to cleanse the wound on a daily basis.
Dead skin is removed from the wound. Removal prevents the dead skin from becoming a breeding area and food supply for bacteria. Infection is the current major killer of burn victims. Debris removal makes the wound much like a clean surgical wound. Temporary dressings may be prescribed at this time, using pigskin or human skin for a temporary protection from infection. Permanent grafting will usually begin three to five weeks after the accident.
Wounds are then wrapped with an antiseptic cream, presently Silvadene cream, and a fine mesh gauze.
Because of the stress of the burn injury, the victim may soon develop stomach ulcers. To minimize this complication, the patient is kept on a constant feeding of milk and/or Maalox.
The patient is encouraged to get out of bed at least twice a day and walk, if at all possible.
Calorie intake increased
Because a major burn victim loses an abnormally high amount of calories, a high calorie supplement is given orally to double the normal calorie intake.
Culture samples of the wounds are taken regularly to detect infections early.
Physical therapy, occupational therapy and splinting are started primarily after the skin grafting has been satisfactorily accomplished. One of the newest and most simple treatments goes on for 12 to 24 months after successful skin grafting. Scarring and disfigurement may be limited by using constant, controlled pressure on the burn area after the wound has healed.
The massive buildup of scar tissue starts after the wound has healed and continues to build and disfigure for up to two years. At first ACE bandage wraps were used with remarkable success. Now a Jobst elasticized garment is tailor-made for each patient. Ace bandages are still used in small burn areas. These pressure systems must be worn at all times, except when bathing, for up to two years, after the burn. Much of the massive scar and horrible disfigurement can be controlled if this simple system is used.
Is a burn center located in your area? Do you know where the nearest center is? Now is the time to promote an awareness of the burn problem and be familiar with some of the up-to-date burn treatment. A fellow fire fighter, you or your child may need it in the future.
