Overview of Burn Resuscitation and Management
Small burns are usually treated at home or by local healthcare providers. This section is about treating severe burns. The severity of a burn is determined by a person’s age, how much of their body was burned, how deep the burn is, the type of burn, and which parts of the body were affected. A burn is considered severe if any of the following apply:
- More than 10% of the body is burned in children under 10 years old or adults over 50 years old
- More than 20% of the body is burned in adults
- More than 5% of the burn is full thickness (a deep burn)
- The person has burns from a high-voltage electric shock
- Important body parts like the face, eyes, ears, joints, or genital area are burned
Other factors that can make the burn more serious and increase the risks for the patient include breathing in smoke or fumes (inhalation injury), other injuries that happened at the same time, and any existing health conditions like heart disease or lung disease. Some people may be more likely to have complicated injuries due to certain factors.
Severe burns cause not only the local damaged area but also affect the body’s system. The body responds by releasing substances that can lead to leakage of fluid from blood vessels, loss of fluid within the body, and large shifts of body fluids. These responses mostly happen within the first 24 hours after getting burned, with the strongest reactions occurring about 6 to 8 hours after the injury. This reaction, together with decreased blood flow and increased blood vessel resistance, can lead to significant fluid loss and poor blood flow, a condition commonly known as “burn shock”.
To manage this, the patient must receive adequate “aggressive” fluids and closely monitored. It is important to note that initially, burns themselves do not cause significant low blood pressure, and “burn shock” develops over the first few hours. If a patient has extremely low blood pressure immediately after getting burned, other causes of low blood pressure should be considered.
Anatomy and Physiology of Burn Resuscitation and Management
Burn injuries that affect the face, eyes, ears, joints, hands, or genital area are usually deemed as serious. These types of burns need specialized care from a burn center to ensure proper treatment and recovery.
Why do People Need Burn Resuscitation and Management
If a person, regardless of being an adult or child, has burns on over 20% of their body, it’s crucial that they receive fluids immediately. These fluids, known as crystalloids, help prevent dehydration and are measured based on the individual’s weight and the size of the burn. Generally, for each kilogram the person weighs and for each percent of their body that’s burned, they’ll need 2 to 4 milliliters of fluids in the initial 24 hours after the burn occurs.
When a Person Should Avoid Burn Resuscitation and Management
For burn patients who are stable, giving too much fluid can be harmful. This is because it can lead to a condition known as edema, where excess fluid gets trapped in the body’s tissues, causing swelling.
Preparing for Burn Resuscitation and Management
If there’s a chance that a person has been in an accident with serious burns, the medical team needs to be ready to carry out a process called burn resuscitation. This involves giving fluids to the person, preparing sterile sheets, and making sure that pain relief medications can be given to them quickly.
How is Burn Resuscitation and Management performed
If you have been severely burnt, it’s vital that medical staff treat you in a similar way to someone who has been through a major accident. That being said, the first thing to do for someone with burns is to stop the burn from getting worse – this is done by removing anything that is hot or burning from touching your skin. After this, medical staff need to ask you some key questions about things like your allergies, medication, medical history, when you last ate or drank something, and details of how the burn happened.
Doctors then assess if there is any immediate threat to one’s life. This means they would make sure you’re not having difficulty breathing as a result of the burn and check your blood pressure, heart rate, and pulses. If needed, they would also provide immediate medical intervention.
Next, doctors fully inspect the body to determine the extent of the burn. Burns have different severity levels – superficial (or first degree), partial-thickness (or second degree), or full-thickness (or third degree), depending on how much skin is burned and how deep the burn is. Doctors measure the total body surface area burned (% TBSA) i.e., how much of your body is burnt.
If more than 20%-25% of your body is burnt, you would need intensive fluid therapy through an IV to prevent “burn shock.” The Parkland Formula is commonly used to calculate how much fluid you’ll need in the first 24 hours, starting from when you got burned.
As an example, say you weigh 75 kilograms and 55% of your total body surface is burned. According to the Parkland Formula, you would need about 16,500 mL of fluid in the first 24 hours. Half of this amount, or 8,250 mL should be given in the first 8 hours, which would be approximately 1 liter/hour. Children would get additional fluid to meet their normal needs.
The calculated fluid amount is just a guide and will be adjusted based on how well you’re doing – doctors would be checking your vital signs, mental status, capillary refill, and urine output. A target urine output of 0.5 mL/kg/hr (or about 30-50 mL/hr in adults) and 0.5-1.0 mL/kg/hr in children who weigh less than 30 kg is aimed for to ensure adequate fluid resuscitation.
For managing severe burns, doctors would recommend inserting a nasogastric tube, as most patients develop ileus, a disruption of the muscular activity in the intestines. To monitor urine output, Foley catheters would be placed. You would be given pain relief through an IV. As burns may make one prone to tetanus, you may be given a booster if you haven’t had one in the last 5 years. In case of flame burns, doctors would also check for possible inhalation injury, carbon monoxide, or cyanide poisoning.
Primarily, the management of severe burns should be addressed by a specialized burn center. There, they would clean and redress your wounds. It’s important to keep the wound clean and dry until it’s assessed by your local burn center. If you need to be transferred urgently, application of topical antibiotics or cream might not be necessary.
In some situations, you might need an escharotomy before transfer. This is a surgery performed to ease the tight effect of full-thickness burns. Since these burns are hard, leathery, and inflexible, they can prevent normal swelling. If the burns surround an extremity or abdomen, this can lead to compartment syndrome – a dangerous condition where pressure builds up and affects blood flow. If the burn involves a large chest area, breathing may become difficult. An escharotomy is performed by making an incision deep into the fat layer which allows the burned ‘eschar’ or scab to split open. This procedure usually doesn’t require anesthesia as the skin has lost sensation due to the burn.
Possible Complications of Burn Resuscitation and Management
If someone has had a severe or extensive burn, they might experience some issues afterwards. This could include trouble breathing or moving, a very low body temperature, not enough blood in the body, or scarring. One of the most serious complications is an infection called sepsis. Another potential problem after a burn is tetanus, a bacterial infection that can affect your nervous system.
The most common problem after a burn is an infection. This can lead to things like pneumonia, which is an infection in your lungs, or cellulitis, an infection of your skin. Some people might also have a urinary tract infection or difficulty breathing. Burn victims often contract pneumonia if they’ve also breathed in smoke or fumes.
Burns can be divided into two main types: superficial partial-thickness burns and deep partial-thickness burns. Superficial burns cause blisters to form within 24 hours and affect the topmost layer of the skin. They cause redness, pain and leakage of fluid, and the skin becomes paler when pressure is applied. Often, these burns may appear to be not so serious to begin with, but later they might be categorized as more severe, or partial-thickness. However, these burns usually heal within three weeks and rarely leave scars, although they might change the skin’s color.
On the other hand, deep burns go beyond the surface of the skin, affecting hair follicles and sweat glands. These burns usually appear as blisters, and the skin around them might look mashed up, wet, or dry and waxy. The affected skin may also have a mottled color, and it does not become pale when pressure is applied. These burns can take much longer to heal, from two to nine weeks, and can leave hypertrophic scars, which are raised and thickened. If a deep burn doesn’t start to heal within two weeks, it’s generally considered as a full-thickness burn, meaning it involves the entire thickness of the skin and can lead to functional issues and cosmetic changes.
There may also be other complications from extensive burns. For example, if more than 10% of the total surface area of the skin is affected, it can lead to anemia, which is a low red blood cell count. Electrical burns might cause compartment syndrome (a dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues) or rhabdomyolysis (breakdown of damaged skeletal muscle). There is a risk of blood clots forming in the leg veins in between 6-25% of patients with extensive burns.
Other possible issues following a major burn injury include a condition called hypermetabolism that can persist for years, leading to a reduction in bone density and muscle mass, and formation of keloids, which are irregular, raised scars. Serious burns can also lead to a disturbance in body image because of scarring, and in developing countries, it might lead to social isolation, poverty, or child abandonment. Psychological trauma and post-traumatic stress disorder can also occur after a burn.
What Else Should I Know About Burn Resuscitation and Management?
Burns can usually be avoided. How they’re treated depends on how serious they are. Minor, or superficial, burns can be managed simply by cleaning the wound and taking pain medicine. More severe burns need long-term treatment.
Burns that affect part of the thickness (“Partial-thickness”) of the skin should be cleaned with soap and water and then dressed with protective coverings. Burns that extend through the full thickness of the skin (“Full-thickness”) often require surgery, like getting a skin graft which is taking healthy skin from one part of the body to put onto the burned area.
Severe burns can cause a lot of fluid to escape from your blood vessels and can make your tissues swell up. This fluid loss and swelling mean that people who have big burns often need lots of fluid given to them through an IV (a tube that’s inserted into your veins).
One of the most common problems linked to burns is infection – burns create open wounds that germs can easily get into. Because of this, burning wounds are at high risk for tetanus (a bacterial infection). A vaccine that protects against tetanus should be given every 5 years if the patient is not already up-to-date with their shots.
Burns are a major health issue; they cause more than 30 million injuries and lead to about 3 million hospital stays and 240,000 deaths every year in the United States. Despite these large numbers, it’s worth noting that approximately 96% of people who are admitted to a burn center in the United States do survive their injuries. Quick and appropriate treatment is vital for this successful recovery.
That’s why all healthcare providers should know how to properly assess a burn and when to refer the patient to a specialist for further treatment.