BURNS 18

 ANTIBIOTICS

In our country patients arrive late and some degree of

contamination may have occurred,it is necessary to give

prophylactic antibiotic therapy; and this can be provided by

giving full doses of penicillin.

- The further treatment of the burnt area, is guided by

recognition of areas of full thickness skin burn

- These will require early sloughectomy (Removal of the full

thickness skin burnt area with the scalpel under anaesthesia).

- The areas requiring this treatment will become apparent any day

after the 4th day this treatment can be undertaken, at the end

of first week or later.

- These areas will require covering with split thickness graft.

 

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BURNS 17

 SKIN GRAFT TECHNIQUE

Grafts are usually taken with a Blair or a Humby knife from the

limbs.

* An electric dermatome is used when a large amount of skin

is required.

A Padget's dermatome is most helpful for

obtaining skin from the abdomen.

* Full aseptic precautions are taken

. The donor parts are cleaned and drapped in sterile towels, and after taking the

  grafts, the parts are bandaged in an occlusive dressing

  before the burnt areas are exposed.

* The grafts are laid on tulle gauze raw surface up and cut

   into decent sized pieces.

* These are laid on the recepient area after it has been

   cleaned. Edge to edge covering is done and another layer

   of tulle gauze applied.

* The whole area is bandaged in an occlusive dressing given to

   hands, joints of the limbs, face and neck.

   Dressing is removed in seven days and the residual areas are grafted as

   soon as more skin is available.

 

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BURNS 16

Local treatment 3

Circmferential burns

A full thickness circumferential burn injury carries with it  the

risk of compression of structures underneath the wound. In the extremities the combination of increased extravascular fluid in

the wound and underlying tissues and the lack of elasticity of

the burn wound can lead to subeschar pressures.

All extremities with circumferential full thickness burns should

be elevated to minimize edema formation and should be evaluated

hourly for signs of vascular compromise.

An escharotomy is performed by making an incision through the

eschar or the lateral surface of the extremity. An additional escharotomy may need to be performed on the medial surface as

well.

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BURNS 15

Local treatment 2

* Indications for immediate removal of dressings may be:

Signs of excessive pressure

Soaking of the dressing due to discharge

Unexplained pain or fever

Slipped dressings

* Otherwise the dressing can be left on for several days

* Infection is dealt in the usual manner,by antibiotics, saline

or eusol dressings.
The areas of known full thickness burns

which should be obvious by now are desloughed by taking the

patient to the theatre and under anaesthesia removing the

eshcar with a knife in the second or third week.

* Cover with split thickness graft is undertaken, when the

sloughed areas cleared shows a healthy granulation

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BURNS 14

 

MANAGEMENT 4

2.3.3 LOCAL TREATMENT

* Light anaesthetic may be required for the the procedure in the

operation theater.

Under strict aseptic conditions the burns are cleaned with 1% cetrimide,loose tags removed and blisters punctured.

* The burns are now dressed with tulle gauze covering the entire

area

* If cotton wool is available in abundance, it is used in long

pads. These are placed in the long axis of the limb and extra

pads are reinforced in front and behind joints

* The limb is now encircled in crepe or ordinary bandage with

considerable cross garter using adhesive Elastoplast to

prevent slipping of the dressing.

* Hands are kept in position of maximum function,lightly elevated

to prevent swelling

* Exposure method is an equally good technique of treatment, if

the ward is dust proof.

* Flies can be kept away by using a mosquito net.

* This method may be useful in our country where hyper pyrexia is

a problem particularly during the summer.

 

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BURNS 13

MANAGEMENT 3

Patients who have sustained a major burns injury should have a

nasogastric tube placed to decompress the dilated stomach.

During transport and resuscitation every effort should be made to

maintain body temperature.

Patients are draped in clean sheets or blankets and in the

initial phase in the emergency care area the room is armed.

Resuscitation fluid should be warmed when fluid are given at

rates of greater than 200ml/h. burn injured extremities should be

elevated above the level of the heart.

Every guideline that has been developed carries with it the

mandate that the patient's response to resuscitation be used as

the actual determinant of fluid administration, not the formula!

The goal of resuscitation is to maintain adequate tissue

perfusion and therefore preserve organ function.

The traditional assessment of adequacy of resuscitation in burn

injury has been based on observation of blood pressure, heart

rate and urine output.

In this approach the patients is "titrated" with fluid to

maintain a normal blood pressure and heart rate and a urine

output of 1 ml/kg per hours or 30 to 60 ml/h in an adult patient.

 

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BURNS 12

MANAGEMENT (CONT)

General Principles

Because intravascularfluid loss beginstooccur immediately

after burn injury.

Peripheralvenous cannulation is preferred overcentral venous

access through noninjured sites is not available.

Patients withgreater than 20% total body surfaceareainjury

(15% inchildren) require intravenous fluidresuscitationand

should have a catheter placed in the urinary bladder.

* The treatment of the burnt area overlaps the above

measures. At any time, as soon as the condition of the

patient improves, local treatment is undertaken.

* Calculation for the record of 24 hours. 0.3-0.5 ml per kg

per% burnt area of celloid or plasma equivalent 5% dextrose

to maintain 30-50 (1 hr.) urine output.

* Invasive monitoring is for those where the response to

resusitive fluids is not adequate. SWAN-Ganz catheter will

reveal the need for improving myocardial function by the

use of dobutamine and other ionotrpic drugs.

 

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