- •Preface
- •List of contributers
- •History, epidemiology, prevention and education
- •A history of burn care
- •“Black sheep in surgical wards”
- •Toxaemia, plasmarrhea, or infection?
- •The Guinea Pig Club
- •Burns and sulfa drugs at Pearl Harbor
- •Burn center concept
- •Shock and resuscitation
- •Wound care and infection
- •Burn surgery
- •Inhalation injury and pulmonary care
- •Nutrition and the “Universal Trauma Model”
- •Rehabilitation
- •Conclusions
- •References
- •Epidemiology and prevention of burns throughout the world
- •Introduction
- •Epidemiology
- •The inequitable distribution of burns
- •Cost by age
- •Cost by mechanism
- •Limitations of data
- •Risk factors
- •Socioeconomic factors
- •Race and ethnicity
- •Age-related factors: children
- •Age-related factors: the elderly
- •Regional factors
- •Gender-related factors
- •Intent
- •Comorbidity
- •Agents
- •Non-electric domestic appliances
- •War, mass casualties, and terrorism
- •Interventions
- •Smoke detectors
- •Residential sprinklers
- •Hot water temperature regulation
- •Lamps and stoves
- •Fireworks legislation
- •Fire-safe cigarettes
- •Children’s sleepwear
- •Acid assaults
- •Burn care systems
- •Role of the World Health Organization
- •Conclusions and recommendations
- •Surveillance
- •Smoke alarms
- •Gender inequality
- •Community surveys
- •Acknowledgements
- •References
- •Prevention of burn injuries
- •Introduction
- •Burns prevalence and relevance
- •Burn injury risk factors
- •WHERE?
- •Burn prevention types
- •Burn prevention: The basics to design a plan
- •Flame burns
- •Prevention of scald burns
- •Conclusions
- •References
- •Burns associated with wars and disasters
- •Introduction
- •Wartime burns
- •Epidemiology of burns sustained during combat operations
- •Fluid resuscitation and initial burn care in theater
- •Evacuation of thermally-injured combat casualties
- •Care of host-nation burn patients
- •Disaster-related burns
- •Epidemiology
- •Treatment of disaster-related burns
- •The American Burn Association (ABA) disaster management plan
- •Summary
- •References
- •Education in burns
- •Introduction
- •Surgical education
- •Background
- •Simulation
- •Education in the internet era
- •Rotations as courses
- •Mentorship
- •Peer mentorship
- •Hierarchical mentorship
- •What is a mentor
- •Implementation
- •Interprofessional education
- •What is interprofessional education
- •Approaches to interprofessional education
- •References
- •European practice guidelines for burn care: Minimum level of burn care provision in Europe
- •Foreword
- •Background
- •Introduction
- •Burn injury and burn care in general
- •Conclusion
- •References
- •Pre-hospital and initial management of burns
- •Introduction
- •Modern care
- •Early management
- •At the accident
- •At a local hospital – stabilization prior to transport to the Burn Center
- •Transportation
- •References
- •Medical documentation of burn injuries
- •Introduction
- •Medical documentation of burn injuries
- •Contents of an up-to-date burns registry
- •Shortcomings in existing documentation systems designs
- •Burn depth
- •Burn depth as a dynamic process
- •Non-clinical methods to classify burn depth
- •Burn extent
- •Basic principles of determining the burn extent
- •Methods to determine burn extent
- •Computer aided three-dimensional documentation systems
- •Methods used by BurnCase 3D
- •Creating a comparable international database
- •Results
- •Conclusion
- •Financing and accomplishment
- •References
- •Pathophysiology of burn injury
- •Introduction
- •Local changes
- •Burn depth
- •Burn size
- •Systemic changes
- •Hypovolemia and rapid edema formation
- •Altered cellular membranes and cellular edema
- •Mediators of burn injury
- •Hemodynamic consequences of acute burns
- •Hypermetabolic response to burn injury
- •Glucose metabolism
- •Myocardial dysfunction
- •Effects on the renal system
- •Effects on the gastrointestinal system
- •Effects on the immune system
- •Summary and conclusion
- •References
- •Anesthesia for patients with acute burn injuries
- •Introduction
- •Preoperative evaluation
- •Monitors
- •Pharmacology
- •Postoperative care
- •References
- •Diagnosis and management of inhalation injury
- •Introduction
- •Effects of inhaled gases
- •Carbon monoxide
- •Cyanide toxicity
- •Upper airway injury
- •Lower airway injury
- •Diagnosis
- •Resuscitation after inhalation injury
- •Other treatment issues
- •Prognosis
- •Conclusions
- •References
- •Respiratory management
- •Airway management
- •(a) Endotracheal intubation
- •(b) Elective tracheostomy
- •Chest escharotomy
- •Conventional mechanical ventilation
- •Introduction
- •Pathophysiological principles
- •Low tidal volume and limited plateau pressure approaches
- •Permissive hypercapnia
- •The open-lung approach
- •PEEP
- •Lung recruitment maneuvers
- •Unconventional mechanical ventilation strategies
- •High-frequency percussive ventilation (HFPV)
- •High-frequency oscillatory ventilation
- •Airway pressure release ventilation (APRV)
- •Ventilator associated pneumonia (VAP)
- •(a) Prevention
- •(b) Treatment
- •References
- •Organ responses and organ support
- •Introduction
- •Burn shock and resuscitation
- •Post-burn hypermetabolism
- •Individual organ systems
- •Central nervous system
- •Peripheral nervous system
- •Pulmonary
- •Cardiovascular
- •Renal
- •Gastrointestinal tract
- •Conclusion
- •References
- •Critical care of thermally injured patient
- •Introduction
- •Oxidative stress control strategies
- •Fluid and cardiovascular management beyond 24 hours
- •Other organ function/dysfunction and support
- •The nervous system
- •Respiratory system and inhalation injury
- •Renal failure and renal replacement therapy
- •Gastro-intestinal system
- •Glucose control
- •Endocrine changes
- •Stress response (Fig. 2)
- •Low T3 syndrome
- •Gonadal depression
- •Thermal regulation
- •Metabolic modulation
- •Propranolol
- •Oxandrolone
- •Recombinant human growth hormone
- •Insulin
- •Electrolyte disorders
- •Sodium
- •Chloride
- •Calcium, phosphate and magnesium
- •Calcium
- •Bone demineralization and osteoporosis
- •Micronutrients and antioxidants
- •Thrombosis prophylaxis
- •Conclusion
- •References
- •Treatment of infection in burns
- •Introduction
- •Clinical management strategies
- •Pathophysiology of the burn wound
- •Burn wound infection
- •Cellulitis
- •Impetigo
- •Catheter related infections
- •Urinary tract infection
- •Tracheobronchitis
- •Pneumonia
- •Sepsis in the burn patient
- •The microbiology of burn wound infection
- •Sources of organisms
- •Gram-positive organisms
- •Gram-negative organisms
- •Infection control
- •Pharmacological considerations in the treatment of burn infections
- •Topical antimicrobial treatment
- •Systemic antimicrobial treatment (Table 3)
- •Gram-positive bacterial infections
- •Enterococcal bacterial infections
- •Gram-negative bacterial infections
- •Treatment of yeast and fungal infections
- •The Polyenes (Amphotericin B)
- •Azole antifungals
- •Echinocandin antifungals
- •Nucleoside analog antifungal (Flucytosine)
- •Conclusion
- •References
- •Acute treatment of severely burned pediatric patients
- •Introduction
- •Initial management of the burned child
- •Fluid resuscitation
- •Sepsis
- •Inhalation injury
- •Burn wound excision
- •Burn wound coverage
- •Metabolic response and nutritional support
- •Modulation of the hormonal and endocrine response
- •Recombinant human growth hormone
- •Insulin-like growth factor
- •Oxandrolone
- •Propranolol
- •Glucose control
- •Insulin
- •Metformin
- •Novel therapeutic options
- •Long-term responses
- •Conclusion
- •References
- •Adult burn management
- •Introduction
- •Epidemiology and aetiology
- •Pathophysiology
- •Assessment of the burn wound
- •Depth of burn
- •Size of the burn
- •Initial management of the burn wound
- •First aid
- •Burn blisters
- •Escharotomy
- •General care of the adult burn patient
- •Biological/Semi biological dressings
- •Topical antimicrobials
- •Biological dressings
- •Other dressings
- •Exposure
- •Deep partial thickness wound
- •Total wound excision
- •Serial wound excision and conservative management
- •Full thickness burns
- •Excision and autografting
- •Topical antimicrobials
- •Large full thickness burns
- •Serial excision
- •Mixed depth burn
- •Donor sites
- •Techniques of wound excision
- •Blood loss
- •Antibiotics
- •Anatomical considerations
- •Skin replacement
- •Autograft
- •Allograft
- •Other skin replacements
- •Cultured skin substitutes
- •Skin graft take
- •Rehabilitation and outcome
- •Future care
- •References
- •Burns in older adults
- •Introduction
- •Burn injury epidemiology
- •Pathophysiologic changes and implications for burn therapy
- •Aging
- •Comorbidities
- •Acute management challenges
- •Fluid resuscitation
- •Burn excision
- •Pain and sedation
- •End of life decisions
- •Summary of key points and recommendations
- •References
- •Acute management of facial burns
- •Introduction
- •Anatomy and pathophysiology
- •Management
- •General approach
- •Airway management
- •Facial burn wound management
- •Initial wound care
- •Topical agents
- •Biological dressings
- •Surgical burn wound excision of the face
- •Wound closure
- •Special areas and adjacent of the face
- •Eyelids
- •Nose and ears
- •Lips
- •Scalp
- •The neck
- •Catastrophic injury
- •Post healing rehabilitation and scar management
- •Outcome and reconstruction
- •Summary
- •References
- •Hand burns
- •Introduction
- •Initial evaluation and history
- •Initial wound management
- •Escharotomy and fasciotomy
- •Surgical management: Early excision and grafting
- •Skin substitutes
- •Amputation
- •Hand therapy
- •Secondary reconstruction
- •References
- •Treatment of burns – established and novel technology
- •Introduction
- •Partial thickness burns
- •Biological membranes – amnion and others
- •Xenograft
- •Full thickness burns
- •Dermal analogs
- •Keratinocyte coverage
- •Facial transplantation
- •Tissue engineering and stem cells
- •Gene therapy and growth factors
- •Conclusion
- •References
- •Wound healing
- •History of wound care
- •Types of wounds
- •Mechanisms of wound healing
- •Hemostasis
- •Proliferation
- •Epithelialization
- •Remodeling
- •Fetal wound healing
- •Stem cells
- •Abnormal wound healing
- •Impaired wound healing
- •Hypertrophic scars and keloids
- •Chronic non-healing wounds
- •Conclusions
- •References
- •Pain management after burn trauma
- •Introduction
- •Pathophysiology of pain after burn injuries
- •Nociceptive pain
- •Neuropathic pain
- •Sympathetically Maintained Pain (SMP)
- •Pain rating and documentation
- •Pain management and analgesics
- •Pharmacokinetics in severe burns
- •Form of administration [21]
- •Non-opioids (Table 1)
- •Paracetamol
- •Metamizole
- •Non-steroidal antirheumatics (NSAID)
- •Selective cyclooxygenasis-2-inhibitors
- •Opioids (Table 2)
- •Weak opioids
- •Strong opioids
- •Other analgesics
- •Ketamine (see also intensive care unit and analgosedation)
- •Anticonvulsants (Gabapentin and Pregabalin)
- •Antidepressants with analgesic effects
- •Regional anesthesia
- •Pain management without analgesics
- •Adequate communication
- •Psychological techniques [65]
- •Transcutaneous electrical nerve stimulation (TENS)
- •Particularities of burn pain
- •Wound pain
- •Breakthrough pain
- •Intervention-induced pain
- •Necrosectomy and skin grafting
- •Dressing change of large burn wounds and removal of clamps in skin grafts
- •Dressing change in smaller burn wounds, baths and physical therapy
- •Postoperative pain
- •Mental aspects
- •Intensive care unit
- •Opioid-induced hyperalgesia and opioid tolerance
- •Hypermetabolism
- •Psychic stress factors
- •Risk of infection
- •Monitoring [92]
- •Sedation monitoring
- •Analgesia monitoring (see Fig. 2)
- •Analgosedation (Table 3)
- •Sedation
- •Analgesia
- •References
- •Nutrition support for the burn patient
- •Background
- •Case presentation
- •Patient selection: Timing and route of nutritional support
- •Determining nutritional demands
- •What is an appropriate initial nutrition plan for this patient?
- •Formulations for nutritional support
- •Monitoring nutrition support
- •Optimal monitoring of nutritional status
- •Problems and complications of nutritional support
- •Conclusion
- •References
- •HBO and burns
- •Historical development
- •Contraindications for the use of HBO
- •Conclusion
- •References
- •Nursing management of the burn-injured person
- •Introduction
- •Incidence
- •Prevention
- •Pathophysiology
- •Severity factors
- •Local damage
- •Fluid and electrolyte shifts
- •Cardiovascular, gastrointestinal and renal system manifestations
- •Types of burn injuries
- •Thermal
- •Chemical
- •Electrical
- •Smoke and inhalation injury
- •Clinical manifestations
- •Subjective symptoms
- •Possible complications
- •Clinical management
- •Non-surgical care
- •Surgical care
- •Coordination of care: Burn nursing’s unique role
- •Nursing interventions: Emergent phase
- •Nursing interventions: Acute phase
- •Nursing interventions: Rehabilitative phase
- •Ongoing care
- •Infection prevention and control
- •Rehabilitation medicine
- •Nutrition
- •Pharmacology
- •Conclusion
- •References
- •Outpatient burn care
- •Introduction
- •Epidemiology
- •Accident causes
- •Care structures
- •Indications for inpatient treatment
- •Patient age
- •Total burned body surface area (TBSA)
- •Depth of the burn
- •Pre-existing conditions
- •Accompanying injuries
- •Special injuries
- •Treatment
- •Initial treatment
- •Pain therapy
- •Local treatment
- •Course of treatment
- •Complications
- •Infections
- •Follow-up care
- •References
- •Non-thermal burns
- •Electrical injury
- •Introduction
- •Pathophysiology
- •Initial assessment and acute care
- •Wound care
- •Diagnosis
- •Low voltage injuries
- •Lightning injuries
- •Complications
- •References
- •Symptoms, diagnosis and treatment of chemical burns
- •Chemical burns
- •Decontamination
- •Affection of different organ systems
- •Respiratory tract
- •Gastrointestinal tract
- •Hematological signs
- •Nephrologic symptoms
- •Skin
- •Nitric acid
- •Sulfuric acid
- •Caustic soda
- •Phenol
- •Summary
- •References
- •Necrotizing and exfoliative diseases of the skin
- •Introduction
- •Necrotizing diseases of the skin
- •Cellulitis
- •Staphylococcal scalded skin syndrome
- •Autoimmune blistering diseases
- •Epidermolysis bullosa acquisita
- •Necrotizing fasciitis
- •Purpura fulminans
- •Exfoliative diseases of the skin
- •Stevens-Johnson syndrome
- •Toxic epidermal necrolysis
- •Conclusion
- •References
- •Frostbite
- •Mechanism
- •Risk factors
- •Causes
- •Diagnosis
- •Treatment
- •Rewarming
- •Surgery
- •Sympathectomy
- •Vasodilators
- •Escharotomy and fasciotomy
- •Prognosis
- •Research
- •References
- •Subject index
A. Arno, J. Knighton
tion burns, is the fit of the clothes themselves. Clos- er-fitting outfits decrease the incidence and mortality of clothing-related burns. Loose-fitting clothing, particularly if the person is in an upright position, allows for greater airspace between the fabric and skin, allowing to oxygen promote the flame, thereby worsening the burn. These facts explain why the safest sleepwear for children is considered to be a snugfitting cotton, flame-resistant garment. By definition, flame-resistant garments don’t ignite easily and must self-extinguish quickly.
Table 10. Burn prevention tips for impaired people
FLAME |
1. Use extreme caution when cooking. Wear |
burns |
close-fitting and flame-resistant clothes |
|
while cooking or near any heat source. |
|
2. Avoid throw rugs in the kitchen area and |
|
keep the floor clean to avoid falls. |
|
3. Use larger astrays. Smoke only while upright. |
|
Never smoke in bed or when drowsy. |
|
4. Maintain smoke detectors, alarms and |
|
prinkler systems in good working order. |
|
Check the smoke detector battery once a |
|
month. |
|
5. Determine emergency exit plans. Practice |
|
them routinely with household members. |
|
Keep all exit routes clear. |
|
6. Have a flashlight, keys, eyeglasses and |
|
whistle at the bedside to summon help if |
|
needed. |
|
7. Ensure that the local fire department is |
|
aware of any household members with |
|
special needs. |
CONTACT |
1. With individuals with decreased sensation, |
burns |
use all heating devices that are placed on |
|
or near the skin with caution (e.g., heating |
|
pad, hot water bottles, space heaters). |
SCALD |
1. For people cooking from a wheelchair, a |
burns |
mirror positioned over the stovetop allows |
|
one to see the contents of a pot during |
|
cooking. Avoid using heavy, large pans that |
|
may be awkward to use especially when |
|
filled with hot food. |
|
2. Check the temperature on the hot water |
|
heater; the recommended setting is 120 ºF |
|
(48.8 ºC). |
|
3. Install antiscald devices in bathroom |
|
plumbing. |
Adapted and modified from: Thompson RM, Carrougher GJ (1998) Burn prevention. In: Carrougher GJ (ed) Burn care and therapy. Mosby, St. Louis, pp 497–524 [18]
Prevention of scald burns
Scald burns are responsible for the majority of nonfatal burn injuries in the world. Furthermore, scald burns are the main cause of burn injury in toddlers, involving mostly splash burns from spilled liquids. These injuries are difficult to prevent, and the exact incidence is unknown. These burns are not usually fatal, but unintentional injuries are the leading cause of deaths in children. Other populations at high risk for scald burns, while bathing, are the elderly and people with epilepsy, where there is a heightened risk of seizures and falls and, in the elderly, thinner skin.
Preventive strategies include reducing temperature of hot water heaters to a maximum of 49 – 54ºC (Table 11), installing anti-scald devices to shower heads and faucets or inserting shut-off valves in the water circuit to detect temperatures over a certain level, using large round handles or push-and-turn type handles to prevent young children from turning on the hot water or using liquid-crystal thermometers in bathtubs to alert the caregiver to the water temperature. In some US states, it is imperative, by law, to install appropriate tempering valves in all new domestic dwellings, and water from shower heads and bathtub inlets cannot exceed 46 °C. Small children and disabled people should be constantly supervised when close to hot water. Special caution should also be paid when removing warmed foods – especially liquids – from the microwave oven to avoid steam and scald burns.
Table 11. Time/Temperature relationships in scalds
TEMPERATURE |
TIME TO PRODUCE |
|
|
|
FULL-THICKNESS BURN |
48.8 |
ºC = 120 ºF |
5 minutes |
51.6 |
ºC = 125 ºF |
1.5–2 minutes |
54.4 |
ºC = 130 ºF |
30 seconds |
57.2 ºC = 135 ºF |
10 seconds |
|
60 |
ºC = 140 ºF |
5 seconds |
62.9 |
ºC = 145 ºF |
3 seconds |
65.5 |
ºC = 150 ºF |
1.5 seconds |
68.3 |
ºC = 155 ºF |
1 second |
70
Prevention of burn injuries
Table 12. Pediatric burn prevention tips
FLAME burn |
1. Store all matches and lighters securely so they are inaccessible to children. |
|
|
2. |
Use only child-resistant lighters. |
|
3. |
Never leave children unattended near a heat source. |
|
4. |
Infants should wear flame-resistant sleepwear and costumes. |
|
5. |
Teach children to STOP, DROP and ROLL on the ground if their clothing were to catch |
|
|
fire and to place cool water on a burn. |
|
6. |
Install smoke detectors on each level of the house and outside all sleeping areas. (Be sure |
|
|
to read the manufacturer’s instructions). Test the batteries once a month, and allow |
|
|
children to hear the alarm so that they will recognize the sound. |
|
7. Practice EDITH (Exit Drills In The Home). |
|
|
8. |
Install a fire escape ladder in all bedrooms above the first floor. |
|
9. |
Review the home fire exit plan with all home childcare providers. |
|
10. |
If a child engages in fire play or fire-setting behaviour, contact the local fire department or |
|
|
burn center for educaton and counselling recommendations. |
CONTACT burns |
1. Use curling irons, irons and glue guns with caution when small children are present. |
|
|
2. |
If the outside temperature is high, use caution when placing children in car seats or using |
|
|
metal buckles. They should be examined by an adult before use by a child. |
|
3. |
Caution children about touching heated radiators, space heaters and floor furnace grates. |
|
4. |
Never leave a child unattended near a campfire. Make sure the child wears shoes to |
|
|
prevent injury from contact with hot coals. |
SCALD burns |
1. Check the temperature on the hot water heater; the recommended setting is 120 ºF |
|
|
|
(48.8 ºC). |
|
2. |
Install antiscald devices in bathroom plumbing. |
|
3. |
Never leave young childen unattended in the bathtub or in the kitchen while cooking; |
|
|
restrict a child’s access to the kitchen when cooking. |
|
4. |
Face children away from the bathtub faucet to reduce the likelihood of the child turning |
|
|
on the hot water. |
|
5. |
Double-check the temperature of the bath water before placing a child in the tub |
|
|
(recommended temperature is 36.1–37.8 ºC or 97–100 ºF) |
|
6. |
Review bathtub safety tips with all home childcare providers. |
|
7. When carrying or holding children, be sure to keep hot beverages away from the child. |
|
|
8. |
When cooking, use the back burners and always turn the pot handles inward. |
|
9. |
Keep appliances toward the back of the countertop. Wind cords up and out of reach. |
|
10. |
Avoid using tablecloths with young children present; they can pull them off easily. |
|
11. Supervise children closely when hot foods are being served and carried. |
|
|
12. |
Never microwave a child’s bottle or allow young children to remove items from the |
|
|
microwave. |
|
13. |
Take extra precautions when removing heated foods from the microwave oven when |
|
|
children are around. |
|
14. |
Use cool mist (not steam) vaporizers. |
CHEMICAL burns |
1. Keep all chemicals inaccessible to children and in their original container. |
|
|
2. |
When finished with a chemical, recap and discard the container appropriately. |
ELECTRICAL burns |
1. Make sure all electrical outlets are inaccesible to young children. Block outlets with heavy |
|
|
|
furniture and use outlet covers to prevent a child from attempting to insert things into |
|
|
them. |
|
2. |
Never place an electrical appliance near a water source (e.g., bathtub, sink). |
|
3. |
Use electrical extension cords with caution. Mouth burns have been associated with |
|
|
extension cords. |
|
4. |
Teach children never to extend objects near high-power lines. |
RADIATION burns |
1. Apply sunscreen to all exposed skin before sun exposure, reapply it as recommended and |
|
|
|
wear protective clothing. |
From: Thompson RM, Carrougher GJ (1998) Burn prevention. In: Carrougher GJ (ed) Burn care and therapy. Mosby, St. Louis, pp 497–524 [18]
71