BURN TREATMENT

This explains how burns are treated and the many problems that can occur. Patients and parents most often complain that they don't understand what is going on with their treatment and that doctors don't talk to them, or that medical staff talk in an unnecessarily complicated way. We hope this helps. It may be further simplified in the future.

Modern burn treatment started around the Second World War when sulphanilamide, penicillin and plasma became available for clinical use. They were effective remedies against the two most common killing complications of extensive burns, shock and infection. Before 1940 in Europe, a person with more than 30 per cent of the body surface area burned, might have had her pain eased and then been left at home to die among her relatives. Now such a patient is given costly multi-disciplinary care in a well-ventilated, highly staffed specialist unit.

In Southern Africa such facilities are also available but it depends where the child is hurt as to whether they get to a good hospital in time or not. Immense improvements have evolved since the 1940s, measurable by mortality, healing time and restored function. This is due to the formation of burn research units, a better understanding of the burn wound and new improved techniques.

First concerns
The medical team's first concern is not the burn wound, but the patient's life-sustaining systems of respiration and blood circulation. The patient can die from shock or from breathing problems. Shock is a decreased rate of circulation to vital organs. If there is not enough blood is circulating to these organs, they are deprived of the oxygen they need to work. The severity of shock generally matches the amount of the body that has been burned, expressed as a percentage of the entire body surface. There are respiratory problems if the lungs cannot supply oxygen to the body. This is more likely if the patient has smoke inhalation burns.

Shock, smoke inhalation, burn size and how much of the total burn is third-degree determines a person's immediate chances for survival after a burn injury. The younger and fitter the patient is, and the smaller the burn is, the better the chances for survival, if smoke inhalation is not severe.

Bandaging
Burns are judged by the size of the burn in relation to the whole body and by the depth of the burn (determined by how much of the skin thickness is involved). The burn wound is cleaned by hospital staff once or twice a day and then dressed, usually with a medication designed to kill germs (a burn cream called a topical antibiotic), gauze and bandages. "Dressings" means anything the nurses put on or around the wound. Paraffin-impregnated gauze is good because it doesn't stick to the wound. Modern see-through dressings are best, as the wound can heal beneath what looks like clear plastic sheeting. The healing progress can be watched and the skin doesn't need to be disturbed so often and so heals more quickly. The see-through dressings are very expensive - but not if measured in terms of minimising pain, less scarring and quicker healing. Many Southern African hospitals cannot or will not provide these dressings though. Conventional bandages can be washed and reused while plastic-like sheets are used once.

Pain
Changing burns dressings is painful and the patient will get pain relief medicine. There is initial pain, pain during transportation, dressings, debridement and skin grafting. Pain can be eased, but no medicine will completely remove a patient's pain. Medication may be prescribed to allow the patient to sleep or to feel calm. Nervous tension, excitation, persistent sleeplessness and worries about surgery (i.e. skin grafting) require treatment. Patients also receive fluids to make up the huge body fluid losses that seep out from the burn.

Sepsis
Hospitals debride the skin - removing loose, dead skin and old creams or sweat. Infection or sepsis is the enemy of burn patients and is a big threat after the first week. No one with a major burn is safe from the complication of sepsis until the burn wound is completely grafted or has healed, all intravenous lines are removed and the patient is eating, all antibiotics have been finished, and the patient has no fever for a few days. Dead tissue from the burn is a medium for bacterial growth, but dead and damaged tissue has a poor blood supply. Antibiotics administered through the bloodstream then have difficulty reaching the burn wound. So dead skin is removed.

Skin grafts
If the patient has deep second-degree or third-degree burns, the wounds must be covered with new skin, to prevent infection and to limit scarring, which may interfere with the person's ability to move properly. The recipient area is prepared to accept the donor skin by excision. The eschar (scab made by heat) is removed with a long razor blade in layers until all the dead tissue is gone and the surface is only healthy tissue. This is a quick way of removing large amounts of burned skin and getting a healthier grafting surface. Then a sliver of the patient's skin is removed from a healthy, unburned area (the donor area) and fixed to the area destroyed by the burn (the recipient area), by stitches or staples. Donor sites must receive good nursing care and if treated correctly, will heal in 7-10 days. Donor sites are like new shallow burns and are covered with gauze dressings. They are also painful and will leave scars. If the wound smells offensive, it is infected. Often when a patient is recovering at home, it is difficult for carers to be sure when to interfere with a wound and when to leave it alone. We have learned from experience that common sense is often a better guide than instruction from junior nurses.

Donor sites can be used again for future grafts after they have healed. Grafts do not always 'take'. Take is often expressed as a percentage of the grafted area. A take of more than 85 percent means the procedure was a success. If the take is less than 60 percent, another patching procedure must be performed. Infection, movement and complications can interfere with the take rates.

Grafted skin will always look different from normal skin, is less sensitive to touch and will always be more easily damaged than normal skin. After the burn wounds have healed, a lubricating lotion can be applied regularly in the day and after washing.

Infection
Early on during burn treatment intravenous (IV) lines for the administration of antibiotics, blood products and other fluids are often needed. The IV site dressing must be meticulously monitored against infection. A hospital burn unit is a reservoir of potential infection as each patient is admitted with bacterial flora on and in his/her burn wound, unburned skin, gastrointestinal tract and respiratory tract. The patient's contacts with the other patients, nursing staff, visitors, waste and soiled utensils expose her to other sources of infection. Visitors should wash and put on hospital overalls before they enter the unit.

The burn care staff tries to decrease contamination with a surgical scrub at the beginning of the shift with thorough hand washing after helping each patient. Scrub suits are put on at the beginning of each shift and changed as needed. Masks and sterile gloves are worn when working on open wounds. Diseases (such as measles and diarrhoea) often complicate burn healing in children. Pneumonia is also a frequent complication.

Nutrition
A burn patient requires two to two-and-a- half times her pre-burn calorie intake in order to minimise weight loss and support wound healing. She needs to eat a lot of good food, even if she isn't hungry. Liquid dietary supplements are given in the form of commercially available high calorie, high protein solutions.

Activity and function
A burn patient must be kept as physically active as her condition permits. Activity starts a few days after burns have been treated and continues throughout the hospital course. Patients should turn, sit, walk, eat, and brush their own teeth as soon as possible. This is combined with physical therapy, to maintain the function and strength of joints and extremities and increase the patient's sense of well-being. There will be periods when the patient has to be immobile while skin grafts heal and little activity takes place to help the wound to close.

Comfort
Off all the discomforts that a burn patient has, the one most commonly complained of is, always feeling cold. This is especially true after surgery and washing or wound cleaning. The loss of heat due to surface evaporation after such procedures may drop the patient's temperature and leave them shivering. A patient's surroundings are also important in promoting a sense of well being. Favourite toys can be provided by the parents and mobiles can be placed over the beds of infants. In state hospitals particularly the toys may be stolen - write the child's name prominently on the toy.

As the wound begins to heal, it becomes very itchy; the patient tries to scratch through the bandages, even in their sleep. Medicine can control the itching. Wounds that do not need to be covered but still itch can be re-infected by dirty fingernails.

In addition to the immobility and major metabolic complications of burns, physical treatment is traumatic. Grafting sessions, dressing changes, potent medications and potential long-term surgical corrections seem to continue indefinitely.

Contractures may cause permanent disability as well as a grotesque appearance that have major effects on the patient's well being. Contractures mean the skin shrinks and so burned fingers, for example, might not be able to bend. The burned patient may be isolated for long periods to try to prevent infection.

Burn types
Major burn injuries are classified by how much of the body surface area is involved (BSA) and presence or absence of respiratory burns. Burns are caused by flames, scalds, electricity, chemicals, flash burns (explosions of natural gas, propane, gasoline and other inflammable liquids) and contact burns resulting from hot metals, plastic, glass or hot coals. The degree of burn is classified as first, second or third in order of severity. First-degree burns, such as sunburn, involve only losing epidermal tissue (the top layer of skin) and are not typically serious. Second degree burns are deeper, destroying dermis and nerve endings. Third degree burns are the deepest and most severe. They destroy all skin tissue and nerve endings and involve fatty tissue. Third degree burns generally must be skin grafted. Some surgeons refer to fourth degree burns where heat damage extends to deep structures, such as muscle, tendon and bone. Treatment may require elaborate debridement or even amputation.

Burns leak plasma. For a 60 per cent burn, this can be 7 litres a day. Even after the shock period, water loss through such a burn can be 2-3 litres a day, but this can usually be replaced by drinking liquids. The protein loss through the burn may be 60-90g a day, or more than a man's normal protein intake. Leucocytes (white blood cells) are also lost, escaping through the burned tissue to correct the raised metabolic rate. Extensive burns are usually nursed at 27°C, but water vapour is lost at 10 times the rate of that from normal skin. A burn with its warm, moist, nutritious slough, grows bacteria very easily, which encourages infection and septicaemia.

While oedema fluid is flowing out through a recent burn under pressure, topical drugs can be absorbed into the body "against the tide". Oedema is the excessive accumulation of fluid in body tissues.

A burn is a three-dimensional lesion; and whether looked at from the surface or in sections, there are three zones of intensity of burning - the zones of hyperaemia, stasis and coagulation. Partial skin loss will heal in 3 weeks; full thickness skin loss or deep partial skin loss takes 4 or more weeks to heal and may result in considerable scarring.

With destruction of skin there is a loss of protection and devastating illness may occur. There can be infection, fluid loss due to external weeping and capillary permeability, coagulation necrosis, electrolyte imbalance with hyponatremia (too little sodium in the blood) and hyperkalemia (too much potassium in the blood) and heat loss through evaporation of 5-8 litres of fluid per day with subsequent negative nitrogen balance and anaemia. Fluid loss causes the condition of "burn shock" which involves hypovolemia (too little blood circulating), oliguria, decreased cellular hydration, hypotension (low blood pressure) and decreased organ perfusion.

Scars and contractures
Wound healing is complex with many processes happening at the same time to help the wound to close quickly. The extensive repair process involves large scars and severe contractures. Normal scar formation produces an ugly appearance and contractures that lead to deformity and dysfunction. These effects are amplified in hypertrophic scarring. This develops between 3 and 13 months after the injury, persisting 1-2 years before settling at their final appearance. It most frequently occurs in children and usually follows the healing of deep skin loss. In such wounds healing is delayed.

Pressure garments
A wound which takes longer than 2 weeks to heal is at a high risk of hypertrophic scarring and ideally pressure garments should used on healed or grafted skin, worn 22 - 24 hours a day. These are like Lycra bandages - specially made stretchy material that is tight around the skin and sewn into the shape of a sleeve, a glove or a mask. Much can be done to restore function but the skin is never restored to normal.

No sweat, no hair
Skin grafts have the same problems as burn scars, as they form contractures, have loss of sweat gland function, hair growth and altered pigment formation. A burn to the chin would mean a man could not grow a beard nor even feel if he had dribbled food there while eating. Skin grafts can improve appearance a lot but physical limitations such as cold and heat intolerance, difficulty with sun exposure, altered sensation, or painful scars may persist indefinitely. Black skin scars more dramatically than white skin.

The power of the contracting forces in scars, especially hypertrophic scars, is great, so the burn survivor cannot keep joints in the correct shape without help. These joints need to be splinted in position to oppose the contracting forces of the scars.

Where burns cover an entire extremity such as a hand, as the scar tissue shortens, it may affect more than one joint. So the entire band of scar tissue must be stretched to achieve full combined joint motion as well as full individual joint motion.

Bone damage
Muscularskeletal changes (bone and joint changes) occur in between 2 per cent and 5 per cent of severely burned patients. They are particularly devastating when they occur in children. Bone growth disturbances can occur in children if the epiphyses are damaged or if scar tissue crosses a joint. This prevents normal growth from occurring. Kyphotic (hump-like) deformities may develop owing to burns of the chest wall and shoulders in combination with faulty positioning and poor exercise techniques. Scoliotic deformities, owing to asymmetric burns of the trunk, can cause permanent bony changes in the vertebrae if a child is in a growth phase. Proper positioning and exercise techniques may alleviate part of the problem.

This was a problem with Irene - see elsewhere on the website. Her parents died in the fire that left Irene injured. After initial hospital care she was sent to live with an illiterate grandmother who had no concept of Irene's need for physiotherapy. Most burned babies in Southern Africa are carried around out of perceived kindness but the damage from the lack of exercise, let alone the lack of appropriate exercise, is permanent.

It is difficult to get a balance between positioning, splints, and maintaining mobility to prevent stiffness.

Physiotherapy
Most southern African children won't have regular access to physiotherapists and occupational therapists. A problem of joint dislocation that can be found in patients and that can be provoked by faulty positioning during the acute stage of burns or can be a result of scar tissue contracture after wound closure. At this stage of splinting and positioning, for the recovering patient, the mobility exercises that the physiotherapist and occupational therapists give them to do, are often painful. Wounds have not completely healed and the contractures make movements stiff and awkward.

Pain and depression
Many recovered burn-injured patients, even after successful rehabilitation, say that if they should ever have another burn injury, they would prefer to die than to go through the ordeal of being treated for a burn again.

The most common reason given for this statement is 'pain'. In both the treatment and recovery from a burn injury, there can be continuous chronic pain. This has to be dealt with to allow patients to move into the reconstruction and rehabilitation. Failure to do so can lead to despair, depression and even suicidal behaviour.

Behaviour changes
A change in behavioural pattern of the burns survivor is common. A fever accompanies the injury and the emotional changes take place at the time when the adrenal cortex (part of a gland covering the kidney) is increasing its secretion in response to the stress of injury. The behavioural changes might be instigated by this adrenal outburst. The development of ulcers in the duodenum and stomach supports the presence of such physiologic components. Curling's ulcer (a stress ulcer) occurs in 12 per cent of burn patients. [Physiology is the science of the functioning of living organisms and their component parts.]

Delirium and seizures
Delirium can occur during the acute phase of burn treatment because of metabolic changes. Delirium is usually an early reaction that occurs during the immediate post-burn phase, when patients may be intubated, heavily medicated with narcotic analgesics, over-stimulated or sleep and sensory deprived. Delirium usually occurs before completion of grafting procedures and is most common in patients with a more than 35 per cent burn. Delirium is more likely when patients have a history of drug abuse. This delirium is also a form of brain injury and brain dysfunction, usually lasting for weeks but it can persist for months and may gradually improve or even become permanent. Seizures may also occasionally occur or vascular accidents happen because of extreme cardiovascular conditions, immobility, or underlying conditions in the patient. Seizures may occur with cellular over-hydration, cerebral oedema, sepsis and hypertension. Many adult patients may seize due to withdrawal from previously unknown drug and alcohol addiction.

Smoke inhalation
A burn injury frequently goes beyond skin damage; this may include fractures, trauma to the head or other vital organs and inhalation burns. Smoke inhalation can be devastating, not only because there is damage to the lungs, but also because of subsequent diminished oxygenation to the brain. In smoke inhalation alone (without the complications of burns), the brain is the target organ. If the brain survives, lung dysfunction is usually minimal. Smoke inhalation can damage the respiratory epithelium, shown in oedema, hoarseness, bronchorrhea, wheezing, air trapping and occasionally small airway closure. Burn injury without smoke inhalation can also lead to respiratory failure by upper-airway injury and oedema during the early acute phase. Upper airway damage and oedema should be suspected in all patients with facial burns.

Respiratory failure due to inhalation burns and infection can kill burn patients. In the past, respiratory failure was the major cause of death in burn patients and it still poses a problem for patients today. Burns that occur in an enclosed space like a shack often result in inhalation injury to the respiratory system. Patients with severe inhalation injuries may require a tracheotomy long after the burn has healed. When closure of the stoma is delayed to allow intubation, infection needs to be monitored.

Infection control is crucial and every burn unit needs to monitor its own bacterial and resistance patterns continuously. At most burn centres, 80 to 85 per cent of the deaths following severe burns are now due to sepsis. If there has been adequate resuscitation and good fluid management, infectious complications pose a big threat to survival of critically burned patients.

Immune functions are decreased after burns. Nutritional therapy in burned patients is vital for resistance to infection. A patient must eat well to meet the unique metabolic demands for healing from burn trauma. Nutritional support beyond voluntary intake is required for most burns greater than 30 per cent total body surface area. Failure to meet increased energy and protein requirements results in impaired wound healing, and cellular dysfunction.

Sleep deprivation
Another complication with burn-injured patients is sleep deprivation. With only REM sleep deprivation, irritability, fatigue, increased sensitivity to pain and momentary illusions can occur. Processes that take place during sleep are essential to good health, one of which is an increase in growth hormone which regulates growth of the body, influences healing of fractures, lowers the level of blood cholesterol and stimulates tissue healing.

The burn patient has to deal with the pain of the burn and difficulty moving whilst sleeping, but also the trauma of the accident. When patients are attached to life-saving monitoring equipment, sensory deprivation can occur. Debridement, tubings and surgical procedures become a way of life. As the threat to survival lessens for the patient, their concern develops over possible disfigurement. Throughout this entire process, pain is prevalent.

Mental disorders
Psychosis (mental disorder that includes loss of contact with reality) is another problem that often happens in the second phase of treatment. It is not uncommon to see mild psychotic behaviour in the first phase of recovery. Hallucinations and problems with reality testing can occur, but usually quickly clear once metabolic, physiologic and pharmacological effects have been resolved.

Renal failure can occur in the acute and second phase of treatment. It is one of the major complications of burns and is accompanied by a high death rate. Most renal failure occurs either immediately after the injury or at a later period when sepsis develops. Renal (kidney) failure occurring in badly burned patients is associated with failure or dysfunction of in a multiple organ dysfunction syndrome. Acute renal failure occurring immediately after burns is mostly due to reduced cardiac output, which is mainly caused by fluid loss and is usually reversible.

With dramatic advances in burn treatment, many patients with severe burn injuries are surviving. Healing on the outside may not reflect healing on the inside. The psychological injuries suffered can cause many children to become addicts and to withdraw socially. The trauma endured for many, is too much to bear.

Some of this information is sourced from research by Charissa Bloomberg.