BURNS

Lesions of the skin and subjacent tissue going as far as their destruction, burns raise big
problems of evaluating severity that conditions the patient’s reanimation and
hospitalization.

DIAGNOSIS
Patient history and/or data from their environment
 Antecedents, treatments done
 Circumstances of the accident
 Nature of the vulnerable agent: thermal, chemical, electric burn
 The first gestures done: cooling, washing…

LESION BALANCE
 Burn surface: Wallace’s “rule of 9”
 Dangerous locations: face, perineum, eyelashes, flexion areas, hands, legs,
circular lesions of the members
 The burns’ depth degree:
- Degree 1: simple rash
- Degree 2:
 superficial: extensive flictena, suppuration
 deep: partial anesthesia, adherent appendages
- Degree 3: anesthesia, non adherent appendages, cardboard skin, carbonization.

EVALUATING THE SEVERITY OF THE CASE

USA score (Standard Unity of Burn)

 USA = % of body surface burnt + (%degree 3x3).
 USA = 50-100: severe burn.
 USA = 100-150: very severe burn.
 USA > 150: extremely severe burn.

Baux index
 Index = age + % of the skin surface burnt.
 Index > 75: unfavourable diagnosis
 Index > 100: 95 % mortality.

FUNCTIONAL BALANCE

Neurological signs
 Glasgow score.

Breathing signs
 Dysphonia
 Coughing
  Signs due to gas inhaling
 Acute breathing insufficiency.

Cardiovascular signs
 tachycardia
 low blood pressure, forceps

Tracking the possible associated lesions

ETIOLOGY
 Thermal burns: fire, hot liquids…
 Chemical burns: acids, bases
 Electric burns
 Burns due to radiations: sun, ionizing rays

SEVERENESS ELEMENTS
 Extreme ages (infants, children, old people)
 Traumas, associated with intoxications.
 Burns of the face, perineum and external genital organs.
 Burns of the hands, flexion areas, members’ circular burns.
 Inhaling
 High severity index (USA > 50, Baux index >75).
 Electric burns
 Acute breathing insufficiency
 Convulsions, coma
 Shock state
 Cardiac-respiratory arrest

METHOD TO FOLLOW

In all cases
 Immediate cooling of the affected area with water flow for 5 minutes,
followed by the application of a “watergel” (Watergel® or Brulstop®),
bandage.
 We lay the patient in supine or on the unaffected areas
 We undress the patient, with the exception of adherent clothes
 We dry and aseptically bandage the lesions
 Peripheral venous approach (16G – 14G)
 Vascular filling: lacteous Ringer

Evans’ rule:
 2ml x % of burnt surface x weight (+ the basic need) from which half in the first
hours. In practice: in the case of a severely burnt patient, we perfuse 20-30 ml/kg
of crystalloid solutions in the first hour.
 Thermal protection.
  Analgy – sedation:
- Fentanyl 1 µg/kg IVD (to repeat if necessary)
- Hypnovel®: 0.05 mg/kg IVD.

In case of a chemical burn:

We abundantly wash it
Certain chemical burns require a specific treatment:
- Phosphorus: we wash the lesions and keep them moist (it burns
instantaneously at 34 degrees Celsius)
- Fluorhydric acid: we wash with warm water with bicarbonate (2 or 3 %).

In case of collapse
 Vascular filling: macromolecular solutions, 500-1000 ml under the control
of arterial pressure.

In case of signs of vital distress

 Acute respiratory insufficiency
 Convulsions
 Deep coma
 Cardiac-respiratory coma

Continue the treatment already started and

Mechanical intubation and ventilation
 Tracheal intubation:
- orally
- with a probe of sufficient caliber (7.5-8 mm),
- potentially after anesthetic induction:
Hypnovel® 0.05 mg/kg IVD, and
Hypnomidate®: 0.3 mg/kg IVD.
 Constants of the mechanical ventilation:
- FiO2 = I, to adapt according to SpO2
- VC = 8-10 ml/kg
- F = 12-14 cycles/minute

Treatment of lesions and associated complications

TRANSPORT
The patient is transported in supine.

Supervision
 State of consciousness
 cardio-pulmonary auscultation
 Arterial pressure, heart rate, monitor
 respiratory rate
 central heat
Supervision of mechanical ventilation
 FiO2
 Current volume, rate, spyrometry
 Insufflation pressure, capnometry

To know:
 The precocious and aseptic bladder probe is justified only in case of external
groin burns or transport over a long time span and allows the orientation of the
conduct of vascular filling according to dieresis, that must be of minimum 1
ml/kg/h.
 Cooling must be limited to the burnt areas: hypothermia risk
 Cooling in case of chemical burn limits its extent and meanwhile allows for the
product’s dispersion
 Sprinkiling with water the electric burns is not done but when these are extended
cutaneous (skin) -mucous
 In case of ocular burn: prolonged washing and fixing a bandage for both eyes
 In case of an explosion, the patient must be considered, until contradictory
evidence, as a traumatized through explosion.
 In case there is an associated trauma or suspicion of trauma, we must harvest
hemoglobin immediately after arriving to the intervention place
 Introducing a gastric probe is always justified in case of a burnt patient, as this
one constantly presents ileus reflex.
 Severe intoxications with fire smoke, burns of the face, neck and breathing ways
impose the oro-tracheal intubation and ventilation control
 Until conducting a peripheral venous approach we can intramuscularly administer
Ketalar® (6 – 10 mg/kg), thus assuring a good analgy which allows for the
continuation of applying medical care
 Palm represents 1 % of burnt surface

To avoid
 Hypothermia, either though badly controlled cooling, or through the absence of
thermal protection
 The central venous approach only for vascular filling
 The venous approach in the burnt areas
 Systematic antibiotherapy
 Applying certain local treatments