The first responsibility in the care of the burnpatient is to assess the patency of the airwayand to ensure that breathing is unimpaired. Ifsmoke inhalation or airway injury is suspected,intubation should be performed before edemamakes this impossible. Airway injury is mostlikely to occur after facial burns or smokeinhalation in closed spaces. A cough productiveof soot or charred material increases thelikelihood of inhalational injury.
The second task in burn care is to ensurecardiac output and tissue perfusion. Volumeresuscitation with crystalloid is given perstandard protocols; at the same time, urinaryoutput, blood pressure and pulse, body weights,and renal function are closely monitored toensure adequate hydration.
The immediate care of the burn itself involves theremoval of any overlying clothing and jewelry andthe irrigation of the affected tissues with coolwater, taking care to avoid excessively coolingthe body. To help prevent hypothermia andinfection, cover the burn wounds with steriledressings if available, or a clean sheet,separating burn wound surfaces. Gentle tissuedébridement should be followed by application ofnonadherent dressings, skin substitutes, topicalantiseptics, or autografts, as dictated bycircumstances. Tetanus prophylaxis is routinelygiven, usually with both tetanus toxoid andtetanus immune globulin.
In specific circumstances, additionalinterventions such as hyperbaric oxygen therapyfor carbon monoxide intoxication, escharotomyfor circumferential burns, antibiotic therapy forinfections, pressor support for hypotension, ornutritional support may be needed.
Patients with large or complex burn injuriesshould be transferred to regional burn centers orto the care of surgeons with special interest inburn management.
During rehabilitation, individually fitted elasticgarments are applied to prevent hypertrophicscar formation, and joints are exercised topromote a full range of motion. The patient isencouraged to increase activity tolerance, obtainadequate rest, strive for physical and emotionalindependence, and resume vocational and socialfunctioning. Referrals for occupational therapy,psychological counseling, support groups, orsocial services are often necessary.Reconstructive and cosmetic surgery may berequired. Support groups and services areavailable to assist the patient with lifeadjustments.
Patients' previous psychological states maypredispose them to injury and may have anadverse effect on recovery. Patients with burninjuries demonstrate a wide range of emotionalresponses including anger, frustration, irritability,and psychological states (delirium, anxiety,depression, and grief). Posttraumatic stressdisorder (PTSD) may occur after a burn injury.Often, the PTSD patient will need help fromprimary or specialized care providers to recoverpsychologically. Explain patient needs and careconcerns to family to help alleviate their caresand concerns (and varied psychologicalresponses). Involve them with you in patient careas permissible. Family members should beencouraged to sit with the patient, and to touch,speak to, read to, and otherwise communicatewith the patient. Providing patients with a senseof purpose will help to alleviate feelings ofhelplessness and will provide both patient andfamily with more comfortable and comfortingmemories.
The provision of optimal nutrition to burn patientsis an important component of recovery. Becauseof protein losses, the total protein consumed bya burn patient should be at least 2.5 g/kg ofbody weight daily. Total caloric needs mayexceed 30 kcal/kd/daily. The risk of infectionsmay be reduced by the provision of dietarysupplements, esp. arginine and glutamine.
The burn is irrigated with large volumes of water and dressed.
Loose dirt is carefully brushed away and the area is cleansed with soap and water. An antisepticsolution or ointment is applied and covered with a dressing. Tetanus toxoid or antitoxin is given ifrequired. A brush burn is also informally called a “road rash” as in the case of a motorcyclist whoslid across the pavement.
Irrigate with large quantities of water.
The eye should be washed immediately with the nearest available supply of water, even if it is notsterile. Irrigation may need to be continued for hours if burn is due to lye. Care must be taken toprevent runoff from draining into the uninjured eye.
Sloughing of skin, gangrene, scarring,erysipelas, nephritis, pneumonia, immunesystem impairment, or intestinal disturbancesare possible complications. Shock and infectionmust always be anticipated with higher-degreeor larger burns. The risk of complication isgreatest when more than 25% of the bodysurface is burned.
Burns may result from ultraviolet radiation,bursts of steam, heated liquids and metals,chemical fires, electrocution, or direct contactwith flame or flammable clothing.
A person in burning clothing should never beallowed to run. The individual should lie downand roll. A rug, blanket, or anything within reachcan be used to smother the flames. Care mustbe taken so that the individual does not inhalethe smoke. The clothing should be cut offcarefully so that the skin is not pulled away.Synthetic fabrics that have melted into the burnwound are best removed later in the emergencydepartment or burn center. Jewelry should beremoved even if not near the burn wounds due toconcerns for fluid shifts and swelling. Blistersshould not be opened, as this increases thechance for infection. Patients with large burnareas or third- and fourth-degree burns mustreceive appropriate tetanus prophylaxis.
In severe, widespread burns, the patient must betransferred to a burn center as soon as ispractical.