Introduction:
Burns is a critical care problem; priorities of advanced treatment include stabilizing the patient, preventing infection, and providing functional recovery. Extensive burns are not only linked to severe illness but also the development of psychological issues.
What Are the Pathophysiology of Burn Wounds?
Burns occur from dry or wet sources. It causes not only local injury at the site of the burn but also thermal injury to a large area of skin, resulting in an acute systemic response collectively called burn shock. Burn shock is explained as capillary permeability, increased hydrostatic pressure, and movement of fluid from intravascular space to interstitial space. Results in hypovolemia and reduced cardiac output require fluid resuscitation. Edema formed in the interstitial space immediately in the first eight hours after the burn injury. Then it continuously slowly forms for the next 18 hours. The volume required for resuscitation depends on the type, site of the burn, patient weight, presence of inhalational injury, time of injury, and extent of a full-thickness burn. Fluid resuscitation was done hourly based on the response of the patient, like urine output. Following resuscitation in a large burn wound patient may fall into hypermetabolism and muscle wasting, which leads to poor wound healing. Chemical burns can be alkali or acid type. Alkali type of burn is penetrating, and it penetrates deep into the skin by liquefying the skin(liquefaction necrosis). The acid type is less penetrating as it causes coagulation necrosis. Electrical burns can cause more effects with an entry and an exit point. There may be internal organ injury. Thermal burns are common, and they can be superficial or deep. Patients have systemic responses toward burns.
How Are Burns Evaluated for Treatment?
Major factors used in the evaluation of burns are the extent and depth of burns. The extent of the burn is calculated by the percentage of total body surface area, and the depth of burns is the superficial, partial, or full thickness.
How Is the Extent of Burns Calculated?
In calculating the extent of burns, several methods are there to calculate the percentage of total body surface area burned. They are-
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Rule of Nines- In this head represents nine percent, each arm nine percent, anterior chest and abdomen eighteen percent, posterior chest and abdomen eighteen percent, each leg eighteen percent, and perineum one percent. For children, heads are eighteen percent, and legs are thirteen point five percent each.
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Lund and Browder Chart- More accurate in children, each arm is ten percent, the anterior and posterior trunk is thirteen percent, and the percentage for head and leg varies depending on patient age.
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Palmar Surface- For small burns patient palm, excluding the finger, is five percent of the body surface area, and the hand, including the palm and finger, represents one percent of the body surface area.
How Is the Depth of Burns Calculated?
The depth of burns is calculated based on their extension into the epidermis and dermis. Superficial burns are first-degree burns involving only the epidermis. They are painful, soft, red, and blanch when touched and not blistering. Partial thickness burns are second-degree burns that extend through the epidermis into the dermis. Its depth can be superficial or deep. These burns are painful, red, blistered, and blanched on touching. Full-thickness burns are third-degree burns that extend deep into the epidermis and dermis into the subcutaneous tissue or even deeper. These types are white, brown leathery, with no pain or blanching due to high-temperature gas, hot flame, or liquid. In calculating the extent of burns, only partial or full thickness is considered. Superficial is excluded.
What Are the Medical Treatment of Burn wounds?
After giving first aid to the patient, medical treatment is done to promote healing.
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Water-Based Treatment- Uses methods like ultrasound mist therapy to clean the wound tissue.
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Fluid to Prevent Dehydration- IV fluids prevent dehydration and organ failure.
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Pain and Anxiety Medication- Healing of burns is painful; thus, certain medications are used to reduce pain and anxiety, usually while dressing or changing.
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Burn Creams and Ointments- Bacitracin and Silver Sulfadiazine-like topical agents are used to preventing infection and closure of wounds.
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Dressings - To cover the area from infection.
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Drugs That Fight Infection- IV (intravenous) antibiotics are given to prevent infection.
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Tetanus Shot - To avoid spread of infection.
What Are the Surgical Treatments for Burn Wounds?
Various surgical methods are used in the treatment of burns. One of the major concerns for the patient is deciding the treatment plan, conservative or operative treatment. In operative treatment, surgeons should decide when and how to remove the burned tissue and determine the extent of tissue involvement. In seriously burned patients, surgery should be done.
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Escharotomy and Limb Decompression- Used to treat compartment syndrome. In this procedure, eschar division uses a scalpel incision down into the long axis of the limb through the dermis deep into the fascia extending to the unburned tissue. This procedure should be done in an operating room under sterile conditions with an aseptic technique and the ability for hemostasis.
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Early Excision and Grafting- Before this procedure, remove loose burned tissue and treat it with sterile medications to prevent the risk of infection. Once achieved, superficial burns will heal within two weeks, and deep will take some more time. Early excision is used because removal of all devitalized tissue reduces mortality, morbidity, colonization of bacteria, length of hospital stay, and cost. This procedure is used to reduce the risk of scarring and infection. Excision is done when the patient is hemodynamically stable. Burn wounds are surgically treated with tangential excision, fascial excision, or amputation. In tangential excision, all necrotic tissues are removed, and the viable dermis is preserved. The deep donor site for skin graft is treated with a split-thickness skin graft. Advantages are contoured, better preserved, the length of hospital stay is reduced, and quick healing. Fascial excision is an alternative, quicker method. Blood loss is less, but the damage to the contour and lymphedema is evident. Fascial excision is done in full-thickness burns and life-threatening invasive wounds. Amputation is done in unsalvageable limbs, deep burns, and electrocutions. It eliminates functions and so is considered an invalid procedure, but it is used to treat electric and war wounds.
In all procedures, all the non-viable tissues should be removed. Bleeding tissues should be intact and create a viable wound bed. In a few procedures, blood loss is seen, so precautions like adrenaline on the wound will produce vasoconstriction and reduce blood loss. Excision should be done in the first 24 hours to reduce blood loss. In deep fascial burns using Silver Sulfadiazine, a conservative approach is made; full-thickness burns are treated with unmeshed skin grafts because of aesthetic consideration.
In patients with greater burn, allografts are used due to a lack of donor sites. Viable human allograft from a cadaveric source is found to be effective. The benefits of allografts are wound protection against desiccation and bacterial colonization by acting as a physical barrier.
What Are the Skin Substitutes and Future Strategies Used in the Treatment of Burns?
Skin substitutes help in wound closure, preventing desiccation and fluid loss. They can also be used along with allograft.
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Biobrane - It is a biosynthetic dressing material of nylon mesh bonded to silicone mesh coated with porcine polypeptides. It is used as a temporary cover for clean, debrided burns.
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Integra- It is a dermal regeneration template composed of two layers. The outer layer is a silicone sheet, and the inner layer is a bovine collagen matrix as a dermal analog. It is used in acute burn resurfacing with cultured keratinocytes.
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Alloderm - It is an acellular dermal regeneration matrix from human skin developed on the basis that acellular dermal matrices do not undergo degeneration.
Conclusion:
The management of burns is done by an interprofessional team, including surgeons, anesthesiologists, burn specialists, wound care specialists, pulmonologists, nurses, etc. The treatment is done to prevent complications and restore function. The outcome depends on the degree and extent of the burn.
