Management of the burned patient First aid
Stop the burning process
Flames from burning clothing or from burning inflammable substances on the skin surface should be extinguished by wrapping the patient in a fire blanket or any other readily available garment such as the bystander’s own clothing. Some fire extinguishers are suitable for extinguishing flames on the skin surface. With electrical burns it is important that any live current is switched off, and with chemical burns the first-aid worker must avoid contact with the chemical. Burned or water-soaked clothing should be removed.
Cool the burn surface
Immediate cooling of the part is beneficial and should continue for 20 minutes. With scalds, irrigation with cold water under a tap is best and many a child has had scald damage successfully limited by pouring a readily available jug of cold water or milk immediately over the scalded area. Irrigation in cold water is particularly valuable for chemical burns. Hypothermia must be avoided. Do not use ice or iced water. The ideal temperature of cooling water is 150C, but 8—250C is effective. The burn should then be wrapped in any clean linen or plastic ‘cling film’ and the patient transported immediately to hospital.
Emergency examination and treatment
The order of priorities in the management of a major burn injury is:
• A: airway maintenance;
• B: breathing and ventilation;
• C: circulation;
• D: disability — neurological status;
• E: exposure and environment control — keep warm;
• F: fluid resuscitation.
Many of these observations and maneuvers are shared with those considered good practices in any trauma situation. In severe facial and neck burns early endotracheal intubation or tracheostomy should be considered. Early escharotomy may be needed in circumferential chest or limb burns where respiratory or circulatory disturbance is observed. An altered conscious level may be caused by carbon monoxide poisoning.
It is important at an early stage to secure large-bore intravenous lines. Samples are taken for haemoglobin, urea and electrolytes, and blood cross-matching. Blood gases and blood analysis for carbon monoxide or cyanide poisoning are required in the unconscious patient. Having estimated the percentage burned surface area and measured the body weight, initial fluid resuscitation can be planned. The simplest formula (for adults) is: 3—4 ml/kg body weight/% burn/in the first 24 hours.
Half of this volume is given in the first 8 hours and the rest in the next 16 hours. Timings begin from the time of the burn, not the start of resuscitation. Hartmann solution is preferred, but other isotonic fluids may be used. Metabolic fluid requirements are also needed. Formulae are only a guide and the adequacy of fluid resuscitation is monitored by regular clinical assessment. A urinary catheter is essential. Urine output is the best guide to adequate tissue perfusion; in an adult one should aim for 30—50 ml/hour.
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