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Thermal Burns

Medical Science Publication No. 4, Volume 1

THERMAL BURNS*

LIEUTENANT COLONEL EDWIN J. PULASKI, MC

With every war the menace of thermal injuries seems to be increasing. The expanded use of gasoline in transportation of supplies and troops on the ground and in the air, the use of napalm and high explosives both for military operations and the destruction of cities, culminating in the nuclear fission weapons with their prospect of thousands of burns casualties-all these compel us to ask what has been learned from Korea, and what, if anything, could be done in the event of another outbreak of hostilities to improve the care of burns casualties.

In the past, the standard of treatment of burned patients in both civilian and military hospitals has often been poor, usually because, compared to many other emergencies, the management of such patients is more difficult. Few hospitals receive sufficient numbers of patients to attract and maintain the interest of the senior surgeons, or to keep the standard of treatment at a high level. More often than not, the care of the occasional burn injury patient admitted to the general surgical service of a hospital becomes the responsibility of a junior member of the staff. After costly delay in terms of healing time, chronic anemia, avitaminosis and secondary infection, the patient is then transferred to another hospital for plastic surgery, before or after previous trials of skin grafting.

In 1948 the Surgical Research Unit located at Fort Sam Houston, Texas, established a burns study program as its major activity. The immediate returns from the program at the Surgical Research Unit included revision of the Berkow scale for estimating the extent of the burn to the "Rule of Nines" formula, recognition of the Brown Electrodermatome as a simple, rapid, efficient means of cutting skin for grafting, demonstration of untoward reactions following infusions of Swedish dextran in human volunteers, and definition of the potentialities of the exposure principle of local care of burns.

The opportunity was afforded Major Artz and me in November 1950, to extend these observations and make others on Korean burns casualties at Tokyo Army Hospital, where special facilities were provided.


*Presented 21 April 1954 to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


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One estimate is that thermal injuries constituted 2 percent of casualties in Korea admitted to hospitals. This is attested by the fact that in the 3 months of our stay, over 100 such casualties were admitted to Tokyo Army Hospital. In the overwhelming majority of instances (80 percent) the burns were accidentally incurred and were, therefore, preventable. There was no organized program for the care of burns casualties, for which reason the Unit was set up in Tokyo. Later another unit was established on the General Surgical Service, Osaka Army Hospital.

Principles of Treatment

1. Early, Accurate Diagnosis. It should be realized that any extensive deep thermal burn is a complex specialized problem. A brief history of previous illness, and a careful history of the details of the accident are essential. The latter may give clues as to the depth of the burn and the degree of the emergency which it presents. The minimum of information should include: (1) the possibility of respiratory tract burn; (2) the location, extent and estimated degree of surface burns, with a quick sketch of the burned area; (3) notation and assessment of associated injuries, and (4) a record of the agent causing the burn (fire, flash, chemicals, steam, electricity). Accurate diagnosis of the depth of the burn is not always possible on first inspection. A common tendency, even for the experienced observer, is to underestimate depth.* But the importance of diagnosing correctly burn depth lies in the fact that only thus can the magnitude of the problems facing the patient be appreciated.

2. Diagnosis of Extent. The "rule of nines" is a convenient measure. Each arm is 9 percent of body surface, the head is 9 percent, front of trunk 18 percent, back of trunk 18 percent, each leg 18 percent, and perineum 1 percent. The importance of correct estimate of extent lies in the fact that treatment will be partly guided by extent of the burn, and prognosis likewise.

3. Triage of Burns Patients. The risk of burns increases with the age of the patient and the body area burned. In general, the effects of burning are lethal in patients over 50 years of age with deep burns over 50 percent of the body surface. This trend has been expressed


*It seems preferable to classify depth in terms of partial thickness and full thickness. Partial thickness connotes first and second degree burns. A first degree burn, like a sunburn, is manifested by erythema and edema, small blisters and superficial desquamation, or the formation of serous bullae, under which is the familiar red, tender, painful, exudative skin. An obvious full-thickness burn can present as a firm, black or dark brown leathery eschar or a cold white marble or gray appearance with or without heavy desquamation and underlying pale pink or white dermis, or the presence of a network of thrombosed vessels within the corium. Such a burn is usually anesthetic to pinprick. It represents destruction of all epithelial elements and leads to separation of the eschar to an open granulating wound.


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in a chart of mortality probabilities for different combinations of ages and body area burned prepared by the Birmingham Burns Unit-the mortality is shown as a decimal of 1.0. Zero denotes less than 5 percent chance of dying and 1.0 denotes a greater than 95 percent chance. For example, a young adult with a 50 percent burn has a 50 percent chance of dying.

From the foregoing a preliminary classification of the burn patient can be made:

    1. Hopelessly burned (deep burns exceeding 70 percent of body surface).

    2. Emergency cases.

      a. Acute or impending respiratory emergency at the time of admission.

      b. Chemical burns and ocular burns.

      c. Extensive burns with concomitant visceral injuries, lacerations with profuse continuing hemorrhage, or compound fractures.

      d. Patients with burns involving 15 to 70 percent of the body surface, who can be saved by vigorous therapy.

    3. Patients with major burns in no immediate danger but requiring formal institutional care: partial-thickness burns of 10 to 15 percent of body surface, and full-thickness burns over 1 to 15 percent of body surface.

    4. Patients for ambulatory treatment: burns less extensive than above, with no respiratory or ocular injury.

Plan of Treatment

A major cause of death after thermal injury is shock, and infection is the second most common cause. Scarring is the chief cause of deformity and disability. All these complications are easier to prevent than to cure. Shock may be prevented by early and adequate restoration of the fluid lost from the circulation. Clinical infection may be prevented by protection of the burn against colonization by bacteria by immobilization and by early grafting. Contractures and fibrosis may be prevented by early elevation, prevention of infection, correct positioning of the patient, and early débridement and grafting.

Immediate (Emergency) Treatment. Prevention of the complications of burning begins with support of blood volume, appropriate sedation, dressing and transportation to experienced hands. After noting the extent and severity of the burn, the clothing is examined for possible smoldering, which, if detected, is extinguished by dousing with water. Otherwise, it is probably better that the clothes be left


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undisturbed until the patient reaches the hospital, and that the burn surface be covered with a clean sheet or towels held in place with a bandage. No local medications of any sort are applied. If the burn involves the face or perineum, it is left exposed. The only indications for immediate treatment of the local wound are the chemical burn, for which antidotes are applied if available, and the corneal burn, for which a protective dressing is applied over the eye.

Sedation is best effected with barbiturates given intramuscularly. The amount of morphine, if administered at all, should not exceed 15 mg. intramuscularly in the first 4 hours, and it is contraindicated in the patient with acute or impending respiratory emergency. Most burns greater than 10 percent of body surface will require intravenous fluid replacement therapy. If these are available at the emergency station, an infusion is started, with whatever fluid is at hand. Albumin, plasma volume expander, dextrose in saline, saline, or dextrose in water may be used, in that order of preference. The fluid administered should be correctly recorded. The patient is evacuated as soon as possible to a hospital.

Therapy in the Hospital. As a burned patient is first seen, the presence of established respiratory emergency is diagnosed by rapid respirations and cyanosis. Crowing noises, gasping, frothing, coughing, or hoarseness may or may not be present. Pulmonary signs of ronchi, rales or atelectasis are also variable. In the presence of any or all of these, tracheotomy should be considered. In the presence of cyanosis, it should be done at once. If there is a burn of the face along with any warning signs of respiratory injury, it is well to remember that burn edema soon to follow will make tracheotomy difficult and it should be done at once. Although severe respiratory tract injury may be below the trachea, the tracheotomy facilitates bronchial suction and direct oxygen insufflation. Oversedation with depression of respiration and cough reflex must be avoided. Fluid therapy must be administered with caution because of the tendency to pulmonary edema.

When respiratory emergency does not threaten, the patient's clothing is removed, the extent of the burn is mapped out according to the "rule of 9's," an estimate is made of the patient's weight (most patients can tell their weight with accuracy), an indwelling plastic tube or needle is inserted under local anesthesia into an accessible vein, and a blood sample is obtained for hemoglobin and hematocrit determination as well as for typing and cross-matching, and finally, an indwelling Foley-type catheter is placed in the bladder for hourly measurement of urine volume and detection of renal damage as evidenced by albumin, casts and hemoglobin. The extent of the surface area


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burned is a guide to planning the amount and kind of fluids needed. Renal output is the best guide by which to modify this plan.

There is general agreement that the main cause of burns shock is oligemia, chiefly due to loss of plasma. To the external loss into blisters and from open surfaces is added the edema of tissues deep to and surrounding those destroyed. Unlike patients with other forms of traumatic shock, in the burn patient fluid loss and threatened shock continue over a period of 24 to 36 hours. The aim of fluid replacement is to keep pace with this loss with a minimum of other disturbance. In addition, red blood cells are directly destroyed in a burn sufficiently deep to coagulate the dermal capillaries. There is also a delayed hemoglobinemia which may be due, either to intravascular hemolysis of cells not completely destroyed but rendered more fragile by some process, or to a hemolytic factor produced at the site of injury. In an extensive burn the blood loss in the initial phase amounts to 8 to 10 percent of the blood volume. The plasma loss approximates 0.5 to 1.0 cc. per kilogram of body weight for each 1 percent of body surface area burned. The loss of water and electrolytes into the burn, coupled with insensible and renal loss, approximates double or more the plasma loss. Unless these fluids are replaced, death from cell damage due to dehydration or tissue anoxia may supervene. If replacement is continuously accomplished, the continuing tendency toward shock will be avoided or relieved.

The treatment of burns shock is its prevention. This requires recognition of the cases which will develop shock, and the best guide is the extent of the burn as measured in percentage of the body area. Patients with less than 10 percent of body surface burned ordinarily will not require intravenous therapy. In these supplemental fluids by mouth may be given in the form of a solution containing 3.5 gm. of salt and 1.5 gm. of bicarbonate of soda dissolved in a quart of water, and chilled and flavored to taste. In more extensive burns, the following simple formula may be used as a starting guide to fluid replacement therapy, subject to extension upwards for children, and downwards for the elderly patient, the presence of pulmonary injury, and the involvement of more than 50 percent of the body surface.

Percent body surface burned X weight in kg. X 0.5 to 1.0 = ml. of colloid needed in 24 hours. The use of plasma carries with it the risk of jaundice. This risk makes it desirable to examine alternatives to plasma in the treatment of burns. Whole blood, albumin and dextran are suitable. Electrolytes and 5 percent dextrose in water should be administered in amounts sufficient to maintain a urinary output of no less than 30 ml. per hour. If whole blood or albumin are not used, it is wise to administer a liter of 1/6 Molar lactate to correct acidosis as part of the electrolyte replacement. For example, the fluid re-


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quirements in the first 24 hours for a 70 kg. man with a 30 percent burn can be illustrated as follows:

    Whole blood, or plasma volume expander

    0.5 X 30 X 70 = 1050 ml.

    Electrolyte solutions

    1.5 X 30 X 70 = 3150 ml.

    5 percent dextrose in water

    2000 ml.

     

    Total

    6200 ml.

These fluids are rationed so that one-fourth of the total amount is given in the first 6 hours after burning, the second one-fourth in the next 6 hours, and the remainder in the final 12 of the 24 hours. Oral fluid intake should be included in this calculation. It is reiterated that a common error is to overestimate the extent of the burn and to be overzealous in fluid replacement. If the urinary output exceeds 30 ml. per hour but not 60 ml., the amount and rate of fluid administration can be considered adequate. When the urinary output falls below this minimum, a test of the adequacy of fluid intake is the rapid intravenous administration of 500 ml. of 5 percent dextrose in water; if prompt diuresis follows, the fluid intake is cautiously increased.

Half the amount of fluid required in the first 24 hours is adequate to maintain the patient during the second 24 hours. Close observation of the urinary output and of the hematocrit will reveal exceptions, and the fluid ration should be altered as necessary. During the third 24 hours, spontaneous diuresis should be watched for and the fluid intake should be gauged accordingly. In general, oral and intravenous electrolyte therapy is not required after the first 48 hours. After the fourth day, the patient being stabilized, the urinary catheter should be removed.

Treatment of shock must be conditioned by simultaneous treatment of the injury under the following circumstances: (1) Chemical burns, which must be treated concurrently; (2) respiratory burns; (3) burns with extensive visceral injuries, lacerations with profuse hemorrhage and complicating fractures may require simultaneous treatment of these complications and the shock.

The local treatment of partial- and full-thickness burns is based on the triad of nursing care, resistance of the patient and rest of the affected part. By resistance of the patient, is implied avoidance of anything which might interfere with the reparative processes of the body. This means efforts are directed toward production and maintenance of a wound environment unfavorable to the growth of bacteria and favorable to wound healing. If the wound is grossly dirty, an effort is made to make it cosmetically clean without producing undue additional trauma. This is accomplished by general cleansing with a detergent and warm water, and débridement of loose tags of skin and blisters. Intravenous morphine analgesia usually is suffi-


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cient for this purpose. Following cleansing, the whole area is carefully dried by soft towels. No local antiseptics or antibiotics are employed. The resistance of the patient is best aided by obtaining and maintaining an early dry surface which is kept cool. A moist warm exudate is a suitable bacterial pabulum favorable to the rapid colonization of the burns surface with microorganisms; conversely, a dry cool surface is less favorable for bacterial growth.

The dry surface, once effected, consists of a coating of fibrin, which, in the partial-thickness burn, then acts as a matrix for the ingress and coalescence of epithelium from the depths and margins of the wound. In the full-thickness burn it seals off the wound from invading bacteria and provides optimal conditions for the demarcation and separation of the burn eschar. Fibrin deposition is aided by rest and immobilization, and elevation to limit edema, whenever practicable. Once fibrin formation has been completed, the burn is no longer painful unless it becomes infected.

At present, there are two principal methods of bringing about a dry wound surface: the open or "exposure" method, and the absorptive or occlusive dressings method. In connection with the latter, it should be noted that the word "pressure" has been left out. The importance of absorptive dressings has often been erroneously attributed to their ability to prevent or minimize, by compression, the leakage of plasma from the burn surface by a dressing which does not need changing for approximately 10 days. Therefore, absorptive dressings should be sufficiently bulky to serve their purpose, so that fluid is blotted up and fibrin deposition effected. The "open" or "exposure" method results in a dry fibrin-covered surface. Formation of this coagulum is hastened by immobilization and a cool, dry environment, and is retarded by motion and the abrasive action of linens, etc. Once the crust has formed, which takes about 36 hours, the term open or exposure no longer applies. As epithelization takes place, the crust separates and can be lifted or cut away. Partial-thickness burns so treated heal in 12 to 24 days, depending on their depth and location.

A large burn dressing developed by the National Research Council is best used on encircling burns of the trunk and extremities and burns with complicating mechanical injuries. Burns of the hands require a smaller type of dressing which will permit elevation and splinting of the part in the position of function. A simple sterile covering is employed for minor burns of limited configuration. If such materials are unavailable, or in short supply, burns of moderate extent may be covered with clean, dry, freshly laundered or sterilized linen or toweling loosely kept in place by a bandage.

The principal indications for the open method are: uncomplicated burns of the face and the perineum and profile burns so located that


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positioning will permit free access to the circulating air and recumbency of the patient on the unaffected side. Partial-thickness unilateral burns of the hand have also been successfully treated by the open method; however, full cooperation of the patient is required to maintain elevation and the position of function while the eschar forms. A combination of absorptive dressings and exposure has been employed in circumferential burns, such as those of the trunk and the thighs. This method carries with it the risk of suppuration in the areas which cannot be immobilized, where fibrin deposition is inhibited. In a disaster the closed method should preferably be used for all burns where complete eschar formation is unlikely to result following exposure.

The indications for the change of dressings may be categorized as either immediate or late. The immediate indications include: (1) excessive pressure as a result of faulty application or excessive edema formation, (2) soaking through of the dressings, (3) slipping, and (4) unexplained fever or pain. If none of these occur, the dressing is left in place for 7 to 14 days. At this time reassessment of the burn makes possible clearer definition of partial- or full-thickness involvement. If the burn is partial thickness in its entirety, it is redressed and removed after the fourteenth day, by which time re-epithelization should be nearly complete. If there are areas of full-thickness involvement, plans are made for skin grafting.

The defenses against infection are abetted in severe burns by prophylactic antibiotic therapy. Systemic penicillin or other antibiotic is given parenterally for about 5 days. In the severely burned patient, the initial dose is given in the intravenous infusion. The use of oral antibiotics early is inadvisable because of vomiting. Standard doses of tetanus antitoxin, tetanus toxoid, or both, are indicated. The prophylactic use of polyvalent gas gangrene antitoxin is not recommended. The use of ACTH or cortisone is also not recommended since recent observations indicate that fulminating spread of infection may attend their administration and, further, that their administration does not diminish the need of the burned patient for blood, colloid, electrolyte or water therapy.

By the end of 5 days the microorganisms colonizing a burn are likely to be drug-resistant. The concept of stopping antibiotics, waiting a few days depending on circumstances, and then reinstituting them, using a different drug or combination of drugs, has been practical and fruitful, particularly where the change of antibiotics may directly precede grafting. During the period of eschar separation the burn wound becomes increasingly painful as new nerve endings in the subcutaneous tissues become active receptors; this pain is aggravated by the presence of infection, motion or contact, until wound


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closure has been secured. Dressings should be done under anesthesia, in the operating room. The golden moment is the time at which débridement can be done safely and at which skin grafts can be placed. The concept that a burned area must show "healthy" granulations in order to be "ready" for a graft is erroneous and invalid. In the burned patient the wound is ready for grafting when the eschar permits easy removal and clinical manifestations of infection are absent. In most burns these conditions coexist sometime after the second week.

Nutritional Care. After a severe burn the nutritional state is profoundly affected. The metabolic rate rises rapidly and may remain elevated for several weeks. The "reaction to injury" occasions an increased loss of nitrogen in the urine and this loss is greatest in previously healthy adults. Nitrogen is also lost from the burned surface, particularly in extensive infected burns. Lastly, demands for protein are increased by the processes of repair and healing.

At present, exact requirements for the various nutritional elements are not fully defined. From the third day of injury a planned increase in oral intake should be instituted until the patient's fluid intake is established at the desired level. Immediately after burning, patients with severe burns reject food or have poor appetite. Fluid feedings with or without nasogastric intubation are usually indicated. Gavage feeding insures a measured caloric intake. Various formulae which provide a balanced food intake with an adequate number of calories are available for this purpose. An optimal intake is 3,500 calories, 450 gm. of carbohydrate and 250 gm. protein. Vitamins should be given parenterally with emphasis on vitamin C (up to 1,000 mg. a day). Blood transfusions to correct anemia are given as indicated. Tube feeding is continued until the patient's appetite is fully restored. Early muscle movement will increase the proportion of nitrogen retained from the diet and limit the process of bone decalcification.

Skin Grafting

The closure of the full-thickness burn by skin grafting should be initiated as soon as practicable. Surgical excision of the eschar is feasible when the area involved does not exceed 5 to 8 percent of the body surface and the risk of shock is not great. Other methods of management of the eschar, such as enzymatic débridement, are now under investigation.

The cutting of the graft is best effected by the use of some form of dermatome. The electrodermatome is especially suited for the casual operator because it will remove thin grafts, will not damage donor sites, takes grafts swiftly, and requires very little experience to insure


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proficiency. The grafts required are of intermediate thickness, 10 to 15 thousandths of an inch. Such grafts take in the presence of a mild infection, except when the wound is colonized with hemolytic Streptococci. Intermediate-thickness grafts also leave better donor sites, which can be used for a second crop of skin after 21 days. It is recommended that skin in excess of the amount required to surface the burn be taken and stored in bottles containing 10 percent human serum or in gauze moistened with saline solution. These bottles are stored in the ice box at 5° to 8° C. Such grafts can be used up to 4 weeks after cutting. Antibiotics are given 48 hours before and after operation as a precaution against spread of infection. The agent chosen should be on the basis of culture sensitivity tests of the wound exudate.

Grafts are maintained for 48 hours by the plasma circulation. Thereafter, ingress of capillaries begins and is complete in 5 to 10 days, depending on the body site and the thickness of the graft.

If the graft was applied to a clean area, the dressings are left alone during this period, that is, usually for 7 days or longer. If they were applied in the presence of suppuration, dressings are changed after 48 to 72 hours, using extreme care not to dislodge the graft. The wound is gently cleansed and carefully redressed, using the strictest aseptic precautions. Nonadherent grafts and overlapping tags of skin are trimmed away at the time of the first dressing.

The burned patient who is treated well can usually leave the hospital in 3 weeks to 3 months, depending upon the extent and depth of the injury. If the patient has not been treated well by failure to institute efficient systemic treatment, failure to prevent infection, or failure to institute grafting procedures at the right time, one is confronted with the vicious cycle of anemia, infection and malnutrition, which prolong the treatment for months, increase disability and deformity, and enhance the drain on hospital time and personnel. Patient morale is badly shaken, for which frequent, painful and exhausting dressings and despondency over failure to make progress are contributing factors. Such patients require repeated transfusions, usually twice a week until skin cover has been provided. Efforts to correct hypoproteinemia must be vigorous. Combined parenteral and oral alimentation will be necessary. Control of infection is initiated in the operating room where a total body cleansing is given to the anesthetized subject, with liberal use of a detergent and water. Débridement is indicated if dead tissue remains. Body defenses are aided by the use of antibiotics topically and parenterally, based on culture sensitivity tests. Septicemia is a threat in these patients until complete skin coverage has been attained.


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Plan for Treatment of Burns Casualties in a Major Disaster. The results of the experiment of setting up a Burns Treatment Center at Brooke Army Hospital and at Tokyo Army Hospital during the Korean action have been amply rewarding. It has been demonstrated beyond doubt that, provided patients are seen early after injury and a high standard of surgical and nursing care is given in suitable facilities, disability and complications can be prevented. In the event of another war, as a basis for discussion, the following suggestions are put forth:

1. A plan should be executed to provide a short training for a large number of doctors, nurses and corpsmen in the modern treatment of burns. This training should be started at once in the Army center now available, and should be extended as soon as other centers are organized. Surgeons should be taught the essential principles of preventive treatment of shock and infection, and simple technics of débridement and skin grafting. This force of partly trained personnel would form the nucleus in an emergency to direct others not so trained who would need to be recruited on the spot.

2. Establishment of Burns Specialty Centers in the theater of operations. Such a facility should have a sufficient number of beds to carry out its mission, but no more than 40 in one center. An adequate staff for 24-hour duty is essential if supervised shock treatment is to be carried out, as well as routine dressings and other ward work. The unit should have its own operating facilities, preferably one room for septic cases and one room for the care of clean cases.

An adequate shock room is necessary, preferably several individual rooms, which, when the incidence of burns is small, could be converted to isolation rooms. Efforts to combat infection during dressings changes envision the need for an operating room or its equivalent for older cases and another room for recent, presumably clean cases.

The treatment of burns is the responsibility of a team and not any one individual. It is full of problems which can be faced only by adequate staffing. The Brooke Center experience points to the wisdom of appointing an anesthetist, internist, psychiatrist, dietitian, bacteriologist, biochemist and physical therapist to work alongside the surgeon. Full recognition of the emergency nature of the treatment of burns and of the problems of the treatment of shock, control of fluid and electrolyte imbalance, nutrition, anemia, sepsis and psychiatric disturbances, will be sufficient to make a plea for a Burns Center so staffed justifiable.