Burns
   Definition
     A burn is a coagulative destruction of the   surface layers of the body. It can be

• Thermal
  

• Electrical or
  

     

• Chemical burns
  

     Epidemiology
     The risk of burns is highest in
the 18 to 35   years age group. There is a higher incidence of scalds
(burn injury due to hot   liquids) in children and in the elderly. The
death rate is higher in the   extremes of age.

     Prevention
     Prevention is always better
than cure. Burn   injury can be accidental, suicidal or homicidal. In a
big country like India,   illiteracy is one of the root cause for all
such incidents.
Prevention can be   done in the following ways:
     

1. Increased awareness of specific hazards among the   public
   
2. Improved safety practices in the work environment
   
3. Education of the workforce on burn hazards and first aid   management.
   

     Structure of the   Skin
     Skin consists of two layers - the epidermis and   the dermis. Epidermis acts like the raincoat. The functions of the skin are:
     

1. It acts as a semipermeable barrier to evaporative water loss.
   
2. It protects the body from adversities of the   environment.
   
3. It controls the body temperature.
   
4. It is an important organ for sensation.
   

     The dermis is the most
important layer of the   skin and it supplies the strength and integrity
of the skin. Dermis is divided   into papillary layer (superficial
layer) and reticular layer (deep layer). It   contains the skin
appendages such as the hair follicles, sweat glands and   sebaceous
glands. These skin appendages contain epithelial cells that can  
proliferate and heal a partial-thickness wound by epitheilalization.

     Pathophysiology
     The effects of burn injury upon the patient can   be considered as follows:
     

1. Local effects
   
2. Regional effects
   
3. Systemic effects
   

     Local effects:
     Tissue necrosis is directly
proportional to the   temperature and duration of exposure. It is
related to the thickness of the skin   in different parts of the body
and in different ages.
       Heating of tissue   results in direct cell rupture or cell necrosis.

     There is a marked and immediate
inflammatory   response. There is release of inflammatory mediators
like histamine, kinin,   serotonin, arachidonic acid metabolites like
prostaglandins, interleukins (from   macrophages) and free oxygen
radicals.
     They increase the capillary
permeability and   vasodilatation thereby resulting in loss of plasma by
evaporation and radiation.   They also result in edema (fluid
collection within the intersitial spaces) and   third space losses
(fluid collection within the cavities).

     In a burn over 15 % of the
total body surface   area, the capillary leak may be systemic, causing
generalized oedema and a   significant fall in blood volume.
     The fluid shifts are maximum in the first 16 –18   hours after burns injury and decreases after 24 – 48 hours after injury.

     The burn wound is described as having three   zones:
     

1. Zone of coagulation ( tissue is irreversibly destroyed with   thrombosis of blood vessels)
   
2. Zone of stasis ( there is
   
   
   
   stagnation of the microcirculation;   treatment is aimed in saving this
   zone from progressing into the zone of   coagulation or irreversible
   tissue damage)
            
3. Zone of hyperaemia (there is increased blood flow; there is   minimal damage to the cells; spontaneous recovery is likely
   

     The damaged tissue represents a nidus for   infection. Infection is responsible for at least 50 % of deaths due to burns.
     Colonization (colony count
between 103 to 105) by   endogenous organisms will occur invariably
within 24-48 hours and this may   remain as a local wound or regional
infection. There may be, in addition, a   bacteraemia or septicaemia
(due to bacterial invasion when the colony count is   more than 106) and
metastatic infections may develop at other   sites.
       Bacteraemia is a common cause of fatality in a severe burn and
may   occur at any time from the first day until the point when all the
wounds have   entirely healed.
     b-hemolytic streptococci and Corynebacterium   diphtheriae are the commonest organisms to colonize in the burn wound.

     b-hemolytic streptococci and Pseudomonas produce   protease enzymes that prevent skin graft adhesion.
     Regional effects:
     Limb circulation may be
compromised. It can occur   due to direct vessel damage from high-
tension electrical burns, gross oedema in   a limb causing venous
obstruction (particularly in an eschar which is incapable   of
distending), or a muscle compartment syndrome.
     Accumulation of large
quantities of interstitial   fluid in the hand drives it into a claw
posture (MCP joint extension; PIP joint   flexion).

     Systemic effects:
     Fluid and electrolyte
abnormalities seen in burns   shock, are largely due to alteration in
cell membrane potentials with   intracellular flux of water and sodium
and extracellular migration of potassium   secondary to dysfunction of
the sodium pump. Loss of circulating plasma volume   leads to
haemoconcentration and hypovolemia, the severity of which increases  
with the severity of the burn.
     There may be multiple organ
failure (MOF). It may   be renal, hepatic or heart failure. The precise
cause of these complications is   unccertain. The theories postulated
are –1. Fluid loss 2. ‘toxemia’ from   infection 3. Uncontrolled
overreaction of the inflammatory response to   sepsis.
     In burns of > 60 % of BSA,
depression of   cardiac output is frequently observed with lack of
response to aggressive volume   resuscitation. Ultimately, the patient
will demonstrate signs of hypovolemic   shock as the cardiac output
falls.
     The end of the shock phase in
the adequately   resuscitated patient with burns is usually marked by a
diuresis. This occurs   approximately 48 hours after the burn and is usually associated with fluid   balance, which is more like that of a
normal patient.Hematologic derangements   include an increase in the hematocrit with increased blood viscosity during the   early phase followed by anaemia from erythrocyte extravasation and destruction.  
However blood transfusion is infrequently required for patients with
isolated   burn injury.

                                                           
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     First degree burns:
     It involves only the epidermal
layer of the skin.   (E.g.) Sunburn (it is caused by ultraviolet light
instead of thermal   injury).

     The burned skin is red, painful and tender   without blister formation.
     It usually heals in about 7 days without scarring   and requires only symptomatic treatment.
     Other examples include: scalds
by non-boiling   liquids; some chemical burns; and the edges of areas of
flame burns and flash   burns.

     Second degree burns:
     It involves the epidermis and extends into the   dermis.

                                                                                                                                                                                                                                                                                                                                                                                           

Superficial partial-thickness burns	Deep partial-thickness burns
Epidermis and superficial dermis are injured.	Epidermis, superficial dermis and   part of the deep dermis are injured.
Deeper layer of the dermis & the skin appendages are spared.	The skin appendages are damaged,   but the deeper portions usually survive.
They are very painful to touch	They are usually pain   insensitive
There is good perfusion of the dermis with intact capillary refill. They do   not blanch on pressure.	Blisters are present and the   exposed dermis is pale white and there is no capillary refill.
They heal in 14 – 21 days with minimal scarring	They heal in 3 weeks to 2 months’   time and scarring is common
Usually there is a full return of function.	Surgical debridement & skin   grafting may be necessary to obtain maximum function.
(e.g.) Hot water burns	(e.g.) Hot liquids, steam, grease   or flame injury

     Third degree burns (Full thickness   burns):
     It involves the entire
thickness of the skin. All   the epidermal & dermal structures are
destroyed. They are usually caused by   flame, hot oil, steam or
prolonged contact with hot objects {as in unconscious   state of
epilepsy or due to sensory loss (autonomic neuropathy) in diabetic  
patients}.

     The skin is charred, pale,
painless and leathery.   This charred layer consists of denatured,
contracted dermis and is called an   eschar. These injuries will not
heal spontaneously as all dermal elements are   destroyed. Surgical
repair and skin grafting are necessary and there will be   significant
scarring.
     Fourth degree burns:
     They extend through the skin to
the subcutaneous   fat, muscle or even bone. These are devastating,
life threatening injuries which   require amputation or extensive
reconstruction.      

                                                                                                                                                   

Classification of Burns
Type of burn	Tissue injury
Scalds              Fat burns              Flame burns              Electrical burns              Cold injury              Friction burns              Ionizing radiation              Chemical burn	Partial-thickness skin loss              Usually   full-thickness skin loss              Patches of partial and full –thickness              Full   thickness with deep extensions              Ice formation, tissue freezing, vasospasm              Heat plus abrasion              Early tissue necrosis, later tissue dysplastic   changes              Inflammation, tissue necrosis, systemic   effects

     Scalds
     Hot water produces a
particularly well-defined   type of skin damage. The temperature of
boiling water (100°C) or steam is   constant and the major determinant
of the severity of injury is the duration of   contact.
     People who are least able to
protect themselves   (the very young, the very old and the very drunk)
are particularly   vulnerable.
     The larger the volume of the agent, the more   severe is the injury in terms of area and depth.
     Although the spills cool
rapidly, limiting the   duration of damage, the worst injuries of this
type may leave permanent   scarring.
     Fat burns
     Cooking fat or oil has a much
higher temperature   (180°C) than boiling water and hot fat cools slowly
on the skin surface. Spills   therefore cause deep burns.
     Flame burns
     They have a varied etiology:
house fires,   clothing fires, spills of petrol on the skin, butane gas
fires. They often occur   in confined spaces and may be associated with
inhalation injury. Generally deep   burns will result.

     Electrical burns
     The passage of electric current
through the   tissues causes heating that results in cellular damage.
Heat produced is a   function of resistance of the tissue, the duration
of contact and the square of   the current. Bone is a poor conductor of
electrical current, whereas blood   vessels, nerves and muscles are good
conductors. Bone can therefore become very   hot and cause secondary
damage to tissues near the bone.
     Low voltage (<1000 V) such
as from a domestic   supply (240 V) causes significant contact wounds
and may induce cardiac arrest,   but no deep tissue damage.
     High voltage burns (>1000 V)
cause damage by   two mechanisms: flash and current transmission. The
flash from an arc may cause   a cutaneous burn and ignite clothing but
will not result in deep damage.   High-voltage current transmission will
result in cutaneous entrance and exit   wounds and deep damage.
     Lightning strikes cause very
high-voltage, very   short-duration discharge. A direct strike has a
high mortality. A side strike   may cause superficial burns to the skin
and deep exit burns to the feet.   Internal damage is not common, but
respiratory and then cardiac arrest can   occur.

     Cold injury
     It can occur in industries due
to spills of   liquid nitrogen or similar substances. It can cause acute
cellular damage   producing either a partial-thickness or a
full-thickness burn. Severe cooling   can freeze tissues and ice
formation is particularly likely to cause cellular   disruption.
Freezing injuries however seem to be less damaging to the connective  
tissue matrix than heat injuries.
     Frostbite is due   to prolonged
exposure to cold and there is often an element of ischaemic damage.  
Vasoconstriction reduces the resistance of the tissue to cold exposure
as the   warming effect of the circulation is reduced. There is therefore a combined   tissue damage from freezing, together with
vasospasm.
     Friction burns
     It is due to a combination of
heat and abrasion.   There is generally a superficial open wound that
may progress to full-thickness   skin loss. It may be associated with
degloving injuries where the damage is   judged to be deep. Early
surgical excision and skin cover is the best management   advised.
     Ionizing radiation
     X-ray irradiation may lead to
tissue necrosis.   The necrosis may not develop immediately. They are
limited in area. Surgical   excision and flap reconstruction may be
appropriate management. Of greater   significance is the long term
cumulative effect of ionizing radiation in   inducing skin cancers and
other tumors.

     Chemical burns
     Tissue damage depends on the
strength and   quantity of the agent and the duration of contact. Some
agents penetrate deeply   and have specific toxic effects. Chemicals
cause local coagulation of proteins   and necrosis, and some also have
systemic effects (e.g. liver and kidney damage   with tannic, formic and
picric acids). The harmful effect will continue until   the chemical is
diluted or neutralized. The most important initial treatment is  
dilution with running water.
     Acid burns cause tissue damage by coagulative   necrosis. Their action is rapid and relatively short-lived.
     Alkali burns cause tissue damage by colliquative   necrosis and are very penetrating and their effect is much more prolonged.
     Area of Burns
     Wallace’s rule of nines in adults:

       9 % - head and neck
         9 % - left   arm
         9 % - right arm
         9 % - front of chest
         9 % - back of   chest
         9 % - front of abdomen
         9 % - back of abdomen
         9 % -   front of left lower limb
         9 % - back of left lower limb
         9 % - front   of right lower limb
         9 % - back of right lower limb
         1% - external   genitalia (perineum)

     In children, this method is modified as the head   is relatively larger compared to the limbs.

     An approximate method of
calculating the area of   burns would be to measure the burned surface
area with the palm of the hand,   which corresponds to 1%.

     A more precise estimation of the percentage of   Body Surface Area burned is obtained by using Lund & Browder burn chart.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   

Particulars	Minor burns	Moderate burns	Major burns
Partial thickness burns in 10–50 yrs age group	<15 % BSA	15 –25 % BSA	>25 %BSA
Partial thickness burns in children under 10 or adults over 50 yrs	<10 % BSA	10 –20 % BSA	>20 % BSA
Full thickness burns in any person	<2 % BSA	<10 % BSA	>10 % BSA
Other associated injuries	Absent	To be excluded	Present
Treatment	Often managed as outpatient	General hospital with designated   team	Usually specialized burn care   facility
Note: BSA = Burned Surface Area

     Clinical Features
     A careful quick history should
be ascertained –   1. To know the person 2. To know the mechanism of
injury 3. To find out   associated injuries 4. To know the associated
illnesses the patient is suffering   from (e.g.) diabetes, epilepsy,
hypertension 5. To know the circumstances of   injury – whether it is a
closed or an open space injury.
     Pain
     Pain is immediate, acute and
intense with   superficial burns. It is likely to persist until strong
analgesia is   administered. With deep burns, there may be little pain.

     Acute anxiety
     The patient is often severely distressed at the   time of injury. It may result in secondary injury also.

     Fluid loss and dehydration
     This is more in case of
superficial burns where   there is extensive epithelial loss and plasma
oozes out of the burned surface   from the leaky capillaries. This is
manifested as tachycardia and a fall in   BP.

     Local tissue oedema
     Superficial burns will blister
and deeper burns   develop edema in the subcutaneous spaces. This may be
marked in the head and   neck with severe swelling which may obstruct
the airway. Limb edema may   compromise the circulation.
     Burns of the eyes occurs commonly in explosion   injuries or chemical burns.

     Coma
     This may be due to asphyxia or head injury,   hypovolemic shock or due to carbon monoxide or cyanide poisoning.

     Major burns also include:

• Burns involving the hands, face, feet or perineum
  

• Burns crossing the major joints
  

• Circumferential burns of an extremity
  

• Burns complicated by inhalational injury
  

• Electrical burns
  

• Burns in the infants and the elderly
  

     Inhalation   Injury
     It has emerged as the main cause of mortality in   the burn patient.
     This injury occurs in
association with   closed-space fires, conditions that decrease
mentation, such as overdose of   sedatives, alcohol intoxication, drug
abuse and head injury.
     Exposure to smoke includes exposure to heat,   particulate matter and toxic gases.
     Direct thermal injury is
limited to the upper   airway. Thermal injuries below the vocal cords
occur only in cases of steam   inhalation. This is manifest by stridor,
hoarseness of voice, cough and   respiratory obstruction.

     Inhalation of the products of
incomplete   combustion of organic material (particulate matter less
than 0.5m size) leads to   chemical burn to the bronchial tree and
lungs. This is manifest by hypoxia, ARDS   and respiratory failure.
     Systemic absorption of carbon
monoxide (as also   of hydrogen cyanide from burning plastics) causes
poisoning. Carbon monoxide   binds to the haemoglobin molecule
displacing oxygen and thus forming   carboxyhaemoglobin, thus reducing
the oxygen carrying capacity of the blood   resulting in tissue hypoxia
and coma. It has intracellular effects too.
     Burning mattresses can produce
nitrogen dioxide,   which is associated with a tri-phasic illness. The
first phase is characterized   by cough, wheeze and progressive
dyspnoea. In the second phase, there is   progression to pulmonary edema
at approximately 24 hours. After 2 – 6 weeks,   bronchiolitis
obliterans and chronic interstitial lung disease develop.

     Recognition of inhalation   injury:
     

1. History of fire in an enclosed space
   
2. Physical signs – facial burns, singed nasal hair, soot in the   mouth or nose, hoarseness of
   
   
   voice, carbonaceous sputum, expiratory   wheezing
              
            
3. Investigation – Bronchoscopy to determine the full extent of   injury; Arterial blood
   
   
   gas analysis; Carboxyhemoglobin levels if necessary.   Levels > 10 %
   are significant and levels > 50% are generally   lethal.

     Treatment:
This should be instituted in suspected cases   prior to definitive diagnosis.

       Humidified Oxygen 100 % by a non-rebreathing mask   should be administered.
       Bronchodilators
       Pulmonary toilet

     Control of upper airway   by prompt endotracheal intubation is done in conditions like:
     

1. Full-thickness burns of the face or perioral   region
   
2. Circumferential neck burns
   
3. ARDS
   
4. Progressive hoarseness of voice or air hunger
   
5. Respiratory depression
   
6. Altered mental status
   
7. Supraglottic edema and inflammation on bronchoscopy
   

     Systemic Complications of   Burns
     

1. Curling’s (gastric or duodenal) ulcer that may result in acute   haematemesis.
   
2. Immunosuppression increases the risk of septic   complications.
   
3. Catabolic response to trauma with severe weight   loss.
   
4. Nonspecific complications like UTI, DVT and pulmonary   embolism.
   
5. Toxic shock syndrome (life-threatening exotoxin mediated   disease caused by S. aureus) can
   
   
   
   occur in children with even small surface area   burns.

     Risk factors for death   after burn injury:
     

1. Age > 60 years
   
2. Burn surface area of more than 40 %
   
3. Presence of inhalation injury
   

     Management of the Burned   Patient
     The management of patients with moderate to major   burns can be divided into three phases:
     

1. Prehospital care
   
2. Emergency department resuscitation and   stabilization
   
3. Admission or transfer to a specialized burns unit
   

     I. Prehospital care - First aid
     

1. Stop the burning process
   
2. Cool the burn surface
   
3. Establish the airway
   
4. Initiate fluid resuscitation
   
5. Relieve pain
   
6. Protect the burn wound
   
7. Transport the patient to an appropriate center
   

     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 or pouring a readily available jug of cold
water or milk immediately over   the scalded area is advisable.
     Irrigation in cold water is
particularly valuable   for chemical burns.Hypothermia must be avoided.
The ideal temperature of cooling   water is 15ºC.The burn should then be
wrapped in any clean linen or plastic   ‘cling film’ and the patient
transported immediately to the hospital.

     II. Emergency Examination and Treatment

       A - Airway maintenance
         B - Breathing and   ventilation
         C - Circulation
         D - Disability – neurological   status
         E - Exposure and environment control – keep warm
         F - Fluid   resuscitation

     Emergency Department   Care:
     

1. Quick history of the incident and general history of the past   medical and surgical illnesses
   
2. ABCs should be reassessed and stabilized
   
3. The need for cervical immobilization should be   reassessed.
   
4. Examine for evidence of inhalation injury and if present,   endotracheal intubation should be performed.
   
5. Insert IV lines even through the burned area if required and   initiate fluid resuscitation according to the formula.
   
6. Burns size and depth are estimated and recorded initially and   at the end of 24 hours.
   
7. Patients with > 20 % partial-thickness burns routinely   require a nasogastric tube as ileus frequently occurs.
   
8. A Foley’s catheter should
   
   
   
   be inserted to measure urine output   and prevent urinary retention in
   the patients with perineal   burns.
            
9. Secondary survey – head- to-toe assessment should be   done.
   
10. Eyes are examined for corneal burns.
    

     Early escharotomy may be needed
in   circumferential chest or limb burns where respiratory or
circulatory disturbance   is observed.

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     Investigations
     Blood sample for CBC, BUN, Creatinine, Glucose,   Electrolytes & Blood grouping and Rh typing should be obtained.

       ABG                                         |
         Carboxy hemoglobin levels   | In   patients with inhalation injury
         Cyanmethaemoglobin levels |
         Chest   X-ray                           |
         ECG                                         |
     

     Fluid resuscitation:
     It is important at an early stage to secure two   large-bore IV lines.
     Burns involving > 10 % BSA in children or >   15 % of the BSA in adults need intravenous fluid resuscitation.
     Principles of fluid   resuscitation:
     

1. A fluid containing salt and water is required for the first 48   hours after the burn.
   
2. The total volume is between 2 and 4 ml / kg / % BSA burn and   should contain 0.5 mmol sodium /kg / %burn.
   
3. The total volume required can be reduced by the addition of   colloid or by using hypertonic saline solutions.
   
4. Water loss through the
   
   
   
   burn wound will vary according to the   environment but when nursed in
   conventional dressings, metabolic water   requirements will be of the
   order of 1.5 – 2 ml / kg /hour with a minimum of 30   ml / hour for
   infants.
            
5. Care must be taken to avoid overprovision of water with the   development of hyponatremia.
   

     Estimate the percentage burned surface area and   measure the body weight. The simplest formula (for adults) is:

                                                           

3 x Body weight x %   BSA

     Half of this volume is given in the first 8 hours   and the rest in the next 16 hours.

     The Baxter or Parkland formula
employs lactated   Ringer’s solution 4ml/kg/% burn, half of which is
given in the first 8 hours and   half in the next 16 hours. In the
second 24 hours the volume required is 2   litres of 5 % dextrose plus
colloid (0.5 ml x % burn x body weight in kg).
     Timings begin from the time of the burn, and not   from the time of hospital admission.
     50 % and above 50 % is considered to be 50 % BSA   only.Isotonic crystalloid usually Ringer’s
lactate solution is preferred, but   other isotonic fluids may also be
used.Metabolic fluid requirements are also   needed (either IV or orally as dextrose water 50 ml / kg / day)
     Formulae are only a guide and the adequacy of   fluid resuscitation is monitored by regular clinical assessment.

     Thermal injury in the presence
of concomitant   multisystem trauma generally requires fluids in excess
of calculated   needs.Inhalation injuries have been shown to increase
total fluid needs.Burns   patients with pre-existing cardiac or
pulmonary disease require much greater   attention to fluid management.
     A urinary catheter is
essential. Urine output is   the best guide to adequate tissue
perfusion; in an adult one should aim for 0.5   ml to 0.75 ml / kg /hour
(i.e. 30 – 50 ml /hour) and in children 1 ml / kg   /hour.

     Clinical assessment:
     

1. Vital signs – Body temperature (core and peripheral), pulse   rate, pulse volume, blood pressure, respiratory rate
   
2. Signs of cerebral and skin perfusion
   
3. Urine output hourly
   
4. Haematocrit & haemoglobin 4 hourly
   

     In deep burns, one unit of
blood should be given   for every 10 % deep burn and this should be
administered at the end of the   48-hour ‘shock phase’. Attempts should
be made to keep the haemoglobin levels   above 10g %.
     Further management:
     Adequate pain relief by IV Morphine. Anxiolytic   agents may be used as adjuvants in pain management.
     Good notes and drawing of the burned area are   needed.
     Smaller burns are managed
satisfactorily on an   outpatient basis with arrangements for further
dressing either at a hospital   follow-up clinic or by the General
Practitioner.
     Patients with major burns
should ideally be   treated in a specialized burns unit.Routine Tetanus
toxoid prophylaxis should be   administered based on the patient’s
immunization history. Tetanus immune   globulin should be administered
whenever necessary.

     III. Indications for   referral
     

1. Burns requiring fluid resuscitation – moderate and major   burns
   
2. Burns of special areas ( face, hands, feet, perineum, major   joints)
   
3. Full-thickness burns > 5 % of BSA
   
4. Circumferential limb or chest burns
   
5. Electrical burns including lightning injury
   
6. Chemical burns with the threat of functional or cosmetic   impairment
   
7. Inhalation injury with burns
   
8. Burns in the children or the elderly
   
9. Where non-accidental injury is suspected in the case of a   child
   
10. Associated medical conditions or pregnancy
    
11. Associated with concomitant trauma such as fracture
    

     Adequate assessment, resuscitation and fluid   administration should be secured before transfer of the patient.
     The burns unit is the ideal
place for regular   dressings to minimize the cross infection rate. It
should have facilities for   immediate physiotherapy and occupational
therapy to minimize limb stiffness.
     Nutritional requirement as advised by Sutherland   are in the order of:
     Adults: Calories – 20 kcal/kg + 70 kcal / % of burn
       Protein - 1g   / kg + 3 g / % burn
 
       Children: Calories –   40 kcal / kg
       Protein – 2 g / kg
     Supplemental iron and vitamins
are required   throughout the hospital stay and zinc supplements are
recommended in extensive   burns in a dose of 20mg Zinc sulphate / kg /
day
     Early normal feeding protects the small bowel   mucosa and prevents the translocation of endogenous Gram negative bacteria.
     Inhalation injuries are best managed in   respiratory intensive care units.

     Dressings:
     Epidermal burns with erythema and without   blisters do not need dressings. Analgesia and moisturising cream are used.

     Burns of the face are generally treated by   exposure.
     When there is much crusting, it
may be necessary   to apply an ointment such as petroleum jelly around
the eyes with frequent   toileting of the eyes and orifices.Burns of the
trunk and limb are dressed.

     The assessment of the area and
depth of the   burned surface is done initially and at the end of 24
hours by an experienced   doctor before any ointment or creams are
applied. Till then saline-soaked   dressings can be done.

     Superficial dermal burns with
blistering are   usually dressed to absorb exudate, prevent dessication,
provide pain relief,   encourage epithelialization and prevent
infection. Blisters are popped but not   removed.
     Appropriate dressings are plastic films,   hydrocolloids, preserved cadaver or pig skin, alginates or paraffin gauze.
     A thick layer of gauze may then
be placed on top   to allow transudation of any fluid and layers of
wool or padding are applied   over this to act as a sump for exudate.
Dressing changes are painful and can be   done under anaesthesia.Any
wound that remains unhealed or granulating at 3 weeks   or if the wound
is extensive or showing evidence of considerable slough   formation,
then surgical intervention is required.Enzyme preparations may be   used
to facilitate sloughing.
     Deep burns are managed by dressing with topical   antimicrobial agent such as 1 %silver sulphadiazine cream.
     Extremity burns should be elevated for 24 – 48   hours to prevent edema.
     Management of infections:
     There is a controversy about
the routine use of   prophylactic antibiotics as the burned surface will
be inevitably colonized by   microorganisms.Children suffering from
burn wounds are often given routine   antibiotics to limit the
possibility of metastatic infection.

     Frequent wound swabs should be cultured and when   there is rise in temperature, blood cultures should be taken.

     Monitoring for the onset   or progress of infection should consist of:
     

1. Routine temperature measurement
   
2. Frequent wound swab cultures
   
3. Wound inspection by an experienced doctor at the time of   dressing change
   
4. Blood cultures
   

     Surgical   treatment:
     Full thickness burns require surgical   management.
     There are two protocols:
     

1. Wait for spontaneous desloughing and apply split- skin grafts   at the end of 3 weeks.
   
2. Disadvantage – slow   healing and greater scarring.
   
3. Early excision of the burn wound with the application of a   skin cover by a graft or a flap.
            
            Advantage – rapid healing, early restoration of function & minimal   scarring.
   

     All grafts in children should be harvested from   the buttocks.
     Thighs are the first choice in adults and limbs   and trunks may be necessary in addition.
       Early mobilization and   rehabilitation is done to minimize the risk of infection, DVT & joint   contractures.

     Surgical reconstruction of the burn injury can be   done for scarring and it is called as “Scar therapy”.

     Counselling is a   very important aspect
in patients surviving after burns. It should be done both   for the
patients and their relatives. It helps to reduce the ‘flash-back  
phenomenon’ which can be very traumatizing to the patient and may last
for 2 – 3   months.

     Conclusion
   Prevention of Burns is the ideal treatment for   burns