02, Burns

[byungin]

Burns

1, General Principal
Burns can be caused by thermal, chemicals, electromagnetic or radiation energy. The vast majority are thermal burns. An open flame is the leading cause of burn injury for adults, while scalding is the leading cause of burn injury for children.
The aims of first aid should be to stop the burning process, cool the burn, provide pain relief, and cover the burn. Management of burns is conceptualized by the six "Cs": cooling, clothing cleaning, chemoprophylaxis, covering and comforting (i.e., pain relief). The most immediate treatment for both thermal and chemical burns is to stop the burn from progressing.

2, Acute management

Cooling
The heat source should be removed. Flames should be doused with water or smothered with a blanket or by rolling the victim on the ground. Tar burns should be cooled with water, but the tar itself should not be removed. In the case of electrical burns the victim should be disconnected from the source of electricity before first aid is attempted.
Active cooling removes heat and prevents progression of the burn. This is effective if performed within 20 minutes of the injury. Apply cold water as quickly as possible.If clean cold water is not available, apply anything cold such as cold juice or milk. Put a cold metalic utensile on the burn may stop further damage, A full thickeness burn can occur after just 1 second of contact with water that is at 158 degrees F (70 C), and after 30 seconds at 130 degrees F (54.4 C). Keep the affected part in cold water until the pain subsides (for 15 minutes or more). Soak it in a cool water bath or put in a cold wet towel.
Cooling also removes noxious agents and reduces pain, and may reduce oedema by stabilising mast cells and histamine release. Iced water should not be used as intense vasoconstriction can cause burn progression. Cooling large areas of skin can lead to hypothermia, especially in children. Chemical burns should be irrigated with copious amounts of water.
* If someone is on fire, tell the person to stop, drop, and roll. Wrap the person in thick material to smother the flames (a wool or cotton coat, rug, or blanket). Douse the person with water.

Clothing
Clothing can retain heat, even in a scald burn, and should be removed as soon as possible. Adherent material, such as nylon clothing, should be left on. If clothing is stuck to the skin and does not remove easily, only nonadherent material should be cut away, with adherent clothing left for removal in the cleaning phase.

Cleaning
Further cooling during the first several hours after injury effectively decreases burn pain. However, ice application should be avoided because of the risk of hyperthermia. It is important to realise that a new burn is essentially sterile, and every attempt should be made to keep it so. The burn wound should be thoroughly cleaned with soap and water or mild antibacterial wash such as dilute chlorohexidine.
There is some controversy over management of clean, intact blisters. Small blisters should be left intact but large ones should probably be de-roofed, by using a clean pair of scissors and a pair of tweezers. Dead skin of the ruptured blister should be removed with sterile scissors or a hypodermic needle. Blisters containing cloudy fluid or being likely to rupture imminently (e.g., blisters located over joints) should be unroofed. The persistence of blisters for several weeks, with no signs of resorption, typically indicates the presence of an underlying deep partial- or full-thickness burn. Blisters may be removed for ease of dressing, except for palmar blisters (painful), unless these are large enough to restrict movement.
To minimize infection, necrotic tissue should be removed manually. Tar and asphalt residues should never be debrided. Instead, they can be removed with a mixture of cool water and mineral oil. Embedded bits of clothing or other materials should be removed by copious irrigation using a large-gauge syringe. Applying copious amounts of ointment over several days should emulsify and remove residual tar.

Chemoprophylaxis
Once a burn is completely cleaned, apply a moisturizer or an antibiotic ointment to prevent drying. Do not apply disinfectants (e.g., chlorhexidine gluconate solution [Hibiclens], povidone-iodine solution [Betadine]) which can actually inhibit the healing process. Superficial burns do not require infection prophylaxis. Bacitracin rather than silver sulfadiazine for superficial partial-thickness burn may be used.
Most burns other than superficail burns should receive topical prophylaxis. Classically, silver sulfadiazine cream (Silvadene) is used to prevent burn infections. This agent should never be used on the face, in pregnant women, newborns or nursing mothers. Because of its lower cost, bacitracin is often favored over silver sulfadiazine cream (Silvadene) for topical treatment of burns. Bacitracin should always be used around mucous membranes. Do not apply any ointments on a major burn to preserve the wound appearance. This will permit accurate eval‎uation by the physician later.

Covering
If the skin is unbroken in superficial burn, moisturizing lotion without dressing may be enough. If the skin is broken, cover the burn with a dry gauze or bandage to protect the burned area from pressure and friction. Don't use fluffy cotton, which may stick to the skin. If the burn is extensive (the size of your palm or larger), cover it with a sheet and seek medical help. Wrap the gauze loosely to avoid putting pressure on burned skin. Make sure that clothing over the affected area is loose, so as to prevent chafing and rubbing.
Cover the clean burn with a simple gauze dressing impregnated with paraffin (Jelonet). Apply a gauze pad over the dressing, followed by several layers of absorbent cotton wool.
Limb burns should be elevated for the duration of treatment.

Comforting
Cooling and simply covering the exposed burn will reduce the pain. Anesthesia should not be applied topically to a burn or injected directly into the wound.

3, Late management
Ideally the dressing should be checked at 24 hours. The burn wound should be reassessed at 48 hours and the dressings changed, as they are likely to be soaked through. At this stage the depth of burn should be apparent, and topical agents such as Flamazine can be used. At each dressing change, the topical antibiotic should be removed as completely as possible using gentle washings. Scrubbing and sharp debridement are not necessary.
Depending on how healing is progressing, dressing changes thereafter should be every three to five days. If the Jelonet dressing has become adherent, it should be left in place to avoid damage to delicate healing epithelium. If Flamazine(silver sulfadiazine cream) is used it should be changed on alternate days. The dressing should be changed immediately if the wound becomes painful or smelly or the dressing becomes soaked ("strike through"). Many people worry needlessly about a yellowish or light green slime that covers raw second degree burns. This is part of the body’s normal response to a burn. The green/yellow color does not necessarily mean infection. Redness, swelling, pain and fever are much more reliable indicators of infection.
Healed burns will be sensitive and have dry scaly skin, which may develop pigmental changes. Daily application of moisturiser cream should be encouraged. Healed areas should be protected from the sun with sun block for 6-12 months.

Tiny opalescent islands of epithelium throughout the wound indicate epithelialization, with the wound typically healing completely in seven to 10 days.

4, Estimating severity
Following management includes minimizing further damage, identifying patients requiring hospitalization, preventing infection and relieving pain. This depend on its depth, extent, and location. If the burn appears to be a deep partial-thickness burn affecting more than 3 percent TBSA, surgical consultation should be obtained.

A, Three factors for estimating the severity

(a) Depth of burn
Burn depth has an impact on healing time, the need for hospitalization. These are classified as superficial, superficial partial thickness, deep partial thickness, and full thickness. Partial thickness burns do not extend completely through the dermis while full thickness burns do. Partial thickness burns (first degree and second degree) usually heal well and are easier to care for. This is because new skin can grow upward from the dermis. If the dermis is destroyed (full thickness or third degree burn), no skin can grow back in that area and deep scarring develops unless skin grafting is performed.
Thin skin is common on the volar surface of the arms and on the medial thigh, perineum and ears. All skin can be presumed to be thin in children younger than five years and in adults older than 55 years. It is best to assume that there are no shallow burns in these age groups.

(b) Extent of burn
The extent of a burn is expressed as the total percentage of body surface area (TBSA) affected by the injury. This methods are used for deep burns. The surface area of a patient's palm is considered to represent 1 percent of the TBSA.
Burns affecting 10 percent of a child's body and those affecting 15 to 20 percent of an adult's body are considered to be major injuries and require hospitalization and intravenous hydration.
A recent study demonstrated that the palm more accurately represents 0.4 percent of the TBSA, and the entire hand represents 0.8 percent of the TBSA.(Perry RJ, Moore CA, Morgan DB, Plummer DL. Determining the approximate area of a burn: an inconsistency investigated and re-eval‎uated. BMJ 1996;312:1338. )

(c) Location of burn
If the burn is on the face, hands, feet, groin or buttocks or over a major joint, these are major burns.

B, Minor vs major burns
Management of minor burns
A minor burn is defiened as a superficial burn limited to a depth to dermis and an area no larger than 2 to 3 inches in diameter. The skin is red and blisters may develop. This burn can be treated at home.
Management of major burns
A major burn is defined as a burn covering 25% or more of total body surface area, but any injury over more than 10% should be treated similarly. If the burned area is larger or if the burn is on the hands, feet, face, groin or buttocks or over a major joint, these are major burns.

Elevate the body part that is burned above the level of the heart. This prevents swelling.
If fingers or toes have been burned, separate them with dry gauze. 
Children are easily become hypothermic. This will lead to hypoperfusion and deepening of burn wounds. Patients should be covered and warmed as soon as possible.

5, Special situations

Facial burns
Simple sunburn should be left exposed as dressings can be awkward to retain on the face. The wound should be cleansed twice daily with mild diluted chlorohexidine solution. The burn should be covered with a bland ointment such as liquid paraffin. This should be applied every 1-4 hours as necessary to minimise crust formation. All patients should be advised to sleep propped up on two pillows for the first 48 hours to minimise facial oedema.

Eye burns
- Do not open eyelids if they are burned. Be certain burn is thermal and not chemical.  Apply moist sterile gauze pads to both eyes. 

Airway burns
Airway burns are caused by inhaling smoke, steam, superheated air, or toxic fumes. Airway burns can be very serious since the rapid swelling of burned tissue in the airway can quickly block the flow of air to the lungs. Symptoms of an airway burn include change in voice, difficulty breathing or coughing, singed nose hairs, or carbon-stained mucus. Most conscious patients are able to breathe more easily when placed in an upright (seated) position.
Airway burn will become oedematous over the following hours, especially after fluid resuscitation has begun. This means that an airway that is patent on arrival at hospital may occlude after admission. This can be a particular problem in small children.

Porotecting children from scalding burn
Scalding burns are the most common burn injury in younger children. These burns can occur as a toddler knocks over a coffee cup. Most serious cases are scalding burns sustained by pouring hot coffee over one's face. Do not carry high hot liquids(coffee) or food when children run around.
Children have a higher chance of complications from severe burns. The causes include kitchen accidents (such as a child climbing on top of a stove or grabbing a hot iron). Keep children from climbing on top of a stove or grabbing hot items like irons and oven doors.

Chemical Burns
*If there are chemicals, flush them off the skin surface using cool running water. Do not try to neutralize any chemical. Inactivation using neutralizing chemicals is dangerous because these neutralizing chemicals generate other chemical reactions that may worsen the injury.
During irrigation, remove contact lenses. Although soldiers will not generally be wearing contact lens, be aware of this precaution when treating aircrew members.
  Chemical burns to the eyes
During irrigation, remove contact lenses. Although soldiers will not generally be wearing contact lens, be aware of this precaution when treating aircrew members. Brush off dry chemicals on the skin before performing irrigation

(a)        Immediately flood the eyes with water

(b)        Hold eyelids open; wash medial (nasal) to lateral

(c)        Wash for at least 20 minutes; transport while washing

(d)        Cover both eyes with moistened pads

(e)        DO NOT use neutralizers such as vinegar or baking soda

Electrical Burn
Electrical burn is a special type of thermal injury. Arc burns are usually superficial despite the fact that the arc generates temperatures of over 10,000 0 C. Arc also causes the ignition of clothing and produces similar effects to those of ordinary burns. Electric injuries alter the microcirculation leading to massive oedema and decreased circulation in the injured limb. Immediate and adequate fluid resuscitation is therefore essential.
Alternating current (AC) tends to cause ventricular fibrillation if the pathway includes the heart. Direct current (DC) is much less dangerous than AC. However, electrochemical skin burns have been reported from DC current
  If the casualty is in contact with an electrical source, do not get within 20 feet of someone who is being electrocuted by high-voltage electrical current until the power is turned off. Objects commonly felt to be safe, i.e., wooden sticks, manila rope, firefighters gloves, may not be protective and may result in electrocution.
If electrical power line falls over vehicle, stay in the vehicle. Only if an explosion or fire theatens a car should anyone try to jump out.
Electricity entering the body and traveling through the tissues causes tissue damage. Skin burns at entrance and exit sites. Because of their small size, extremities usually have more significant tissue damage. They are burns where electrical energy enters and exits the body. A burn of exit wound is usually larger.
One-quarter of fatalities due to electric power are caused by natural lightning energy. Usually victims are briefly unconscious and can be successfully resuscitated. There were cases. A mother and her two children were struck by a bolt of lightning while sitting under an umbrella in a mountain area. All three sustained Ill-degree burns to the head, buttocks and feet,
The major problems caused by electrical shock are usually not from the burn. Respiratory and cardiac arrest are real possibilities. Be prepared to provide basic cardiac life support measures. It is impossible initially to determine the total extent of the damage in electrical burns. All electrical burn patients should be transported to the nearest treatment facility.

Sunburn
For the classic sun burn (first degree burn) with redness, slight swelling, and mild pain, home treatment is safe and works well for up to 50% of the body surface. Blistering burns (second degree) can be self-treated in many cases.
Unlike a thermal burn, sunburn is not immediately apparent. By the time the skin starts to become painful and red, the damage has been done. The pain is worst between 6 and 48 hours after sun exposure. In severe sunburns, blistering of the skin may occur. Sunburn is better prevented than treated. Physicians recommend a sunscreen SPF level of 30 or greater.
Try taking a cool shower or bath or placing wet, cold wash rags on the burn.
Avoid products that contain benzocaine, lidocaine, or petroleum (like Vaseline).
If blisters are present, dry bandages may help prevent infection.

If your skin is not blistering, moisturizing cream may be applied to relieve discomfort

For the classic sun burn (first degree burn) with redness, slight swelling, and mild pain, home treatment is safe and works well for up to 50% of the body surface.

Blistering burns (second degree) can be self-treated in many cases, but should be seen by a physician if:
 More than 1% of your skin surface is involved (more than the size of the patient’s palm).
 Face, neck, genital area, hands, or feet are involved.
 Any child under 12.

 When need hospital?

Go to an outpatient clinic:
If a blistering burn is larger than the size of your palm, see a doctor. If it is a full thickness burn, no matter how small, see a doctor. The risk of infection and scarring is too high.
Burns suitable for outpatient management are usually small and superficial and not affecting critical areas.

Call emergency:
Any electrical, steam, or inhalation burn (such as smoke, chemical, or extremely hot air or vapors) must be eval‎uated by a physician right away. These types of burns can have unusual complications despite mild symptoms at first.

When finish dressing?
Depending upon the size and depth of injury, you may need to continue the above process for 1-3 weeks. When the new skin beneath the dressings is dry (but not crusty or scabbed) and no longer stings to touch, you can stop the dressings. The new skin is pink, thin, and delicate. You may choose to protect it for another week with a single layer of gauze wrap until it is sturdier.
After epithelialization occurs, no further dressing changes are required. However, patients should be instructed to use a nonperfumed moisturizing cream (e.g., Vaseline Intensive Care, Eucerin, Nivea, mineral oil or cocoa butter)6 until natural lubricating mechanisms return.2 Use of preparations with a high lanolin content, thick waxes and ointments should be avoided.5 In addition, a sun block with a skin protection factor greater than 15 should be used to prevent hyperpigmentation until the wound loses its pink and red coloring.2 Depending on the depth of injury, it usually takes six months to two years for a burn wound to heal completely.

References

*Medline Plus. Medical Encyclopedia. Burns. Available from URL:http://www.nlm.nih.gov/medlineplus/ency/article/000030.htm
*Morgan ED, Bledis SC, Barker J. Ambulatory Management of Burns. In:American Family Physician 2000. Available from URL:http://www.aafp.org/afp/20001101/2015.html
*Hudspith J, Rayatt S. ABC of burns: First aid and treatment of minor burns. BMJ  2004;328:1487-1489. Available from URL:http://bmj.bmjjournals.com/cgi/content/full/328/7454/1487
*Hettiaratchy S, Papini R. Initial management of a major burn:overview. BMJ  2004;328:1555-1557. Available from URL:http://bmj.bmjjournals.com/cgi/content/full/328/7455/1555
*Babik J., Sandor, Sopko. ELECTRICAL BURN INJURIES. Annals of Burns and Fire Disasters; vol. XI.  Available from URL:http://www.medbc.com/annals/review/vol_11/num_3/text/vol11n3p153.htm
*Self care advisery. Minor burns (reviewed by The American Academy of Family Physicians Foundation). Available from URL:http://www.quickcare.org/skin/burns.html
*Keepkidshealthy.com. Burn safety. Available from URL:http://www.keepkidshealthy.com/welcome/safety/burn_safety.html

Blister of Heels
Should a large, but unopened blister be lanced? There is debate on that point - some argue that doing so opens you to infection. But I have found that lancing the blister with a sterile needle or scalpel blade reduces the risk of completely tearing the "roof" of the blister and exposing the raw skin beneath. To lance a blister, clean it thoroughly; pierce the blister from the side, and drain. Cover with a generous amount of Neosporin (or similar antibiotic cream), and bandage.
A torn blister can be a serious problem. Clean the area with Betadine or soap and water, and let dry. Spread antibiotic cream over the broken skin, and re-bandage with an adhesive bandage, or non-stick pads and tape or moleskin.
Better-fitting boots and blister-preventing socks should be used to prevent blisters.

Doug Gantenbein. Treating Blisters On and Off the Trail. In:Great Outdoos.com. Available from URL:http://www.greatoutdoors.com/published/camp/healthfitness/anounceofprevention/