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Appendix G

APPENDIX G

Treatment of Burns

(Extract from Manual of Therapy, European Theater of Operations)

A. Primary Surgical Treatment.

I. General Considerations.

1. A high percentage of burns are received accidentally through carelessness and negligence. Efforts should be made to prevent burns by emphasizing the dangers associated with handling gasoline and other inflammable materials, and instituting suitable safety measures.

2. In the early management of a burn casualty, the primary considerations are:-

a. Prevention and control of shock.
b. Prevention of contamination of the burn surface during treatment and evacuation.

II. Specific Considerations.

Initial care.

1. Control of pain by morphine administration. In extensive burns, grain doses of morphine may be necessary. If anoxia is present, large doses of morphine are dangerous, and under such circumstances the dose should not exceed grain. If the patient is in shock, absorption of subcutaneous or intramuscular morphine may be delayed, in which case repeated doses of morphine should be given with caution. Relief of shock and improvement in peripheral circulation may lead to rapid absorption and over-dosage if morphine has been repeated in such cases. Careful administration of intravenous morphine has the advantage that pain is more promptly and certainly controlled, and the danger of over-dosage from repeated subcutaneous or intramuscular administration is nullified. Doses of 1/6 to grain, given slowly in 10 cc. of sterile distilled water or saline, and repeated as necessary, is perhaps the safest method of intravenous morphine administration.

2. Early plasma replacement therapy should be instituted. If evacuation cannot be carried out quickly to a place for definite therapy, plasma should be started as part of the first aid measures. If one or two units of plasma can be given early, even in the first half-hour, lives may be saved. Quantities of plasma up to twelve units may be required in the first twenty-four hours for extensive burns. If the patient is in shock when plasma is started, the first two or three units should be given rapidly.

3. From the first, efforts should be made to prevent contamination of the burn surface by nose and throat organisms. Those handling the patient should always be masked. If masks are not available, they can be improvised. Aseptic technique, with gloves and instruments if possible, should be used at all times.

4. Casualties with 15% or over of body surface burned should be treated as litter patients immediately.

5. Clothing need not be removed unless too dirty, charred, contaminated or soaked with oil or chemicals.

6. No cleansing or debridement should be attempted in the field. This procedure should only be done in hospitals where complete facilities for definitive treatment are available.

7. Cover the wound with sterile dressings, triangular bandages, or clean sheets. Evacuate to hospital for definitive treatment of the burned area as quickly as possible. Boric acid ointment or Vaseline applied to a grossly contaminated burn complicates the later cleansing of the burn surface. If a local application is considered necessary, 5%


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sulfadiazine cream is preferred because of its bacteriostatic effect and its relative ease of removal later if cleansing and debridement are considered necessary.

8. Application of sulfadiazine cream, boric acid ointment or petrolatum to a grossly contaminated burn are not to be considered as definitive treatment.

9. Eyes should be gently irrigated with saline or boric solution, and a mild ointment (4% boric acid ointment), or oil instilled. Do not apply sulfadiazine cream to the eyes or lids, since it is extremely irritating to the conjunctiva. The lids should be closed with a pad of dampened gauze over them and a dry one held with adhesive, if possible, as the best dressing for the cornea is the lid. Cocaine or other anesthetics should not be used, as anesthesia of the cornea might lead to damage. If there is evidence of corneal injury, the case requires the attention of an ophthalmologist as early as possible.

10. Severe burns of the hands, or of one hand alone, should be considered as major burns and evacuated to a hospital for definitive treatment.

11. Tetanus toxoid is indicated for all patients with second or third degree burns.

12. Tannic acid, tannic acid jelly, triple dye, gentian-violet, gentian-violet jelly, and other membrane forming applications, should NOT be used.

13. RAPID EVACUATION TO DEFINITIVE TREATMENT SHOULD BE EFFECTED.

B. Definitive Surgical Treatment

I. General Considerations.

1. Each hospital should be prepared at all times with a burn team and a plan for admission, sorting and treatment of multiple burn casualties.

2. In the very early stages the treatment of shock and hemoconcentration takes precedence over local treatment of the burn.

3. Definitive treatment of the burned area is given at the first opportunity presented by the condition of the patient and the presence of adequate hospital facilities. It is aimed at obtaining and maintaining a wound free of contamination and infection.

II. Specific Considerations.

1. Systemic Treatment

a. Plasma must be given to maintain blood volume. A simple method of estimating the amount of plasma necessary is that of adding 100 cc. of plasma for every point the hematocrit determination exceeds the normal of 45. Another rough method is that of administering 500 cc. of plasma for each 10% of the body surface burned. The adequacy of plasma administration can be determined by frequent red blood cell, hemoglobin, and hematocrit determinations. An effort should be made to keep the red blood cell count at 5.5 million or below, the hematocrit reading below 50, and the hemoglobin down to 100%. The general condition of the patient, the pulse and blood pressure, are other invaluable guides.

Continued plasma therapy for three or four days may be necessary, and, following this, plasma should be given at intervals to maintain the blood proteins at a normal level.

b. A standard method of estimating body surface burned is by use of the Berkow formula, as follows:

Head

6%

Upper Extremities:

 

    

Both arms and forearms

13%

    

Both hands

5%

         

Total

18%

Trunk and Neck:

 

    

Anterior surface

20%

    

Posterior surface

18%

         

Total

38%

Lower Extremities:

 

    

Both thighs

19%

    

Both legs

13%

    

Both feet

6%

         

Total

38%

 


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c. The need for whole blood transfusion will develop in some cases as early as 2-3 days after the burn is incurred. Plasma is not a substitute for whole blood if secondary anemia is present.

d. A urinary output of 1,000 cc. to 1,500 cc. daily must be established as soon as possible. In the first 24 hours after an extensive burn, it is more important to effect adequate plasma replacement, than to give parenteral crystalloids. During this period it is believed that the salt requirements are met by the salt content of the plasma administered. The daily fluid intake should be maintained at 3,000 cc. to 4,000 cc., and, if parenteral fluids are necessary to reach this level, chief reliance should be placed on 5% glucose in distilled water. Saline should be given sparingly, usually only if there is vomiting or some other cause for salt depletion. As a general rule, not over 1,000 cc. of normal saline should be given over a 24-hour period.

e. During the critical phase (which may last up to 72 hours or longer), the patient must be closely observed for the development of pulmonary edema, shock, morphine overdosage, or the development of cerebral manifestations. Oxygen therapy is often indicated during this period.

f. From the first, the importance of maintaining the nutritional state of the patient should be kept in mind. Every effort should be made to give adequate food and liquids with a high content of carbohydrate, protein and vitamins.

g. A prophylactic dose of polyvalent gas bacillus antitoxin may be given for deep burns at the discretion of the medical officer.

2. Cleansing and Debridement

a. No attempt will be made to clean or debride the burn surface until shock is adequately controlled.

b. The wound will always be treated under standard operating room technique with patient and attendants fully masked.

c. Morphine sedation will be adequate to allow debridement and cleansing of the wound in the majority of cases. Intravenous morphine may be indicated in some instances. If general anesthesia is necessary, first consideration should be given to light intravenous Pentothal sodium. Inhalation anesthesia is contra-indicated if an associated blast injury is present or suspected.

d. In some cases, if the patient is received a short time after the burn is incurred, and if the wound is free of gross contamination, cleansing and debridement may be considered unnecessary.

e. Those burns showing gross contamination should be cleansed with neutral soap and water, and irrigated with saline. Lard, mineral oil or ether, in small amounts, may be used for removal of grease and heavy oil. The cleansing should be done gently with gauze or cotton swabs. Green soap and brushes will not be used. The cleansing should include the skin surrounding the burn.

f. Removal of loose shreds of epidermis and large blisters should be done after thorough cleansing. Small blisters may be left undisturbed, or removed, depending on the extent of the procedure necessary and the condition of the patient.

g. Immediate excision and grafting of burns has such limited application that it is not recommended.

h. Debridement should not include excision on loose skin from the eyelids, ears or fingers. Blisters in these areas may be incised after cleansing.

3. Dressing.

a. The burned area should be covered with single strips of fine mesh gauze (44-mesh gauze bandage), impregnated with 5% sulfadiazine cream, boric acid ointment or


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petrolatum. Sulfadiazine cream is preferred because of the early high local concentration of the drug obtained. It does not stand autoclaving and should be prepared at the operating table by spreading thinly on 44-mesh gauze bandage. Sulfanilamide powder may be used with boric acid ointment or petrolatum, but the total dose should not exceed 10 grams. Local sulfonamide therapy is only of value as a prophylactic against virulent infection in the early stages. It is useless after pus has developed from ordinary pyogenic infection of the deeply burned areas. Ordinarily there will be no indication for continuation of local sulfonamide therapy after the first dressing, which, in a favorable case, can be postponed to between seven and fourteen days.

b. The remainder of the dressing will consist of gauze, absorbent cotton, cotton waste, or cellulose. The dressing will be thickly applied over all the burn and will be bandaged on snugly with even pressure throughout. Stockinette or some form of elastic bandage may be used, if available, to maintain pressure. Care should be taken to prevent the pressure dressing from forming an area of constriction. In the case of extremities, the pressure dressing should include the entire extremity distal to the burn.

c. Immobilization of the part by plaster splints placed over the dressing should be effected when possible. Skin-tight plaster casts should not be used. If a complete plaster casing is applied, it should be split to allow for swelling.

d. Burned hands should be carefully dressed with pressure to, and including, the tips of the fingers. The hand should be in the position of function with fingers separated and flexed. Edema is further prevented by elevation, which is best accomplished by overhead suspension attached to plaster arm splints applied over the pressure dressings.

e. Pressure dressings are applied to the face as elsewhere, taking care to protect the eye, pad the ears, and leave an adequate respiratory airway.

f. Genitalia should be covered with 5% sulfadiazine cream and simple dressings. The dressings should be applied in such a manner that they can be changed separately as necessary.

g. Dressings should be changed infrequently in the early stages of a burn, and, if possible, the dressings should be done in the operating room with standard aseptic technique.

h. In some instances it may be necessary to change the dressing at four to five days on a clean and uninfected case, because of external soiling or soaking of the dressing by exudation of plasma. In such cases, it is often satisfactory to change the bulky outer portion of the dressing and not disturb that immediately over the burn surface.

4. Sulfonamide Therapy

a. If a sulfonamide is used locally, oral or parenteral administration of the drug should be postponed until adequate kidney function is demonstrated by a daily urinary output of 1,500 cc., and the blood sulfonamide has dropped to a low level. After this period, if evidence of sepsis develops, oral therapy should be instituted and continued as indicated.

b. All cases with moderate to severe burns, that have not had local sulfonamides applied, will be started on oral chemotherapy. Sulfadiazine is the drug of choice for oral administration (sulfanilamide may be substituted). It should be given with caution in the early stage of a burn, and the dose should not exceed 0.5 gram every four hours until the urinary output has reached a normal level. Frequent blood level determination should be done.

5. Further Care of Burned Surface

a. If virulent infection is prevented, healing of superficial burns will take place rapidly.

b. After a period of about two weeks, infection of deeply burned areas by ordinary pyogenic organisms will make frequent dressings necessary in order to maintain cleanliness and promote separation of slough.

c. Wet dressings using saline, boric, Dakin's or azochloramid solution for irrigation should be applied and changed daily.

d. Dressings should be wet before removal.


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e. If possible, saline baths should be used for ease of removal of dressings, for cleanliness and to promote active exercises.

f. Unhealed areas should be prepared for grafting, and grafts applied as early as possible. It is often possible to begin grafting within three or four weeks after the burn is incurred.

g. Active motion should be instituted in severe hand burns not later than seven days following the injury. This can be facilitated by removing the dressing and placing the extremity in an arm basin filled with saline.

6. General Care

a. Whole blood transfusions may be necessary as early as three or four days after the burn, and at regular intervals thereafter until the case is healed or grafted.

b. A diet high in calories, protein, carbohydrate and vitamins should be maintained.

c. The blood protein level should be observed and kept at a normal level by plasma transfusions as necessary.

d. Careful and sympathetic nursing care is an absolute essential.

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