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Innovation and clinical specialities: burns
often billed as suicide in newlywed young women. 13
Most burns occur in the home, commonly in the cooking area,
accounting for the high proportion of scald burns, followed by
flame burns. Combined, they account for over 80% of all burns
seen in low-income countries 4 . Electrical burns are also frequently
seen in low-income areas where building codes may be less
stringent and homes may be built near high tension wires.
Although most studies report higher burn rates in urban settings,
this could be due to a publication bias, with few district hospitals
having the means to carry out and publish results. 14 Given the lack
of first-aid resources and longer distances to travel to medical care
in rural settings, it is not surprising that outcomes are worse in
these locations. This is intuitively understood and is illustrated in a
South African study showing that the average pre-hospital delay
was 42 hrs in rural South Africa, with high rates of wound infection
(22%), contractures (6%) and prolonged length of stay 15 .
Prevention
At a population health level, the true magnitude of the problem is
not well defined with few standardized comprehensive statistical
collection systems in many low-income countries. Some authors
suggest that the global estimated death rate is a gross
underestimation 14 . It is widely accepted that the social and
economic costs of burn injuries to low-income populations are
great and efforts to develop, evaluate, and implement prevention
strategies specific to the local cultural and economic settings are
urgently needed. Successful examples have been shown to work
in developed countries such as Norway, where with a communitybased
prevention program, the rate of burn-related hospital
admissions was reduced by 52%. 5
With over 2 billion people worldwide preparing meals using
rudimentary traditional stoves or open fires 5 , much interest has
been directed toward developing safer domestic appliances and
energy sources. 14 An example of such a strategy is the inexpensive
redesigned flat kerosene lamp, designed by burn surgeon Dr.
Wijaya Godakumbura of Sri Lanka’s Safe Bottle Lamp Project. 16
Although outcome studies have not formally been performed, with
over 600 000 lamps distributed and accompanying community
based education addressing basic fire-safety, this project is
anticipated to have a major impact on the incidence of lamprelated
accidents.
Recognizing the complexity of the issue and its regional
challenges, the WHO, in collaboration with international partner
agencies, developed in 2008 an evidence-based global strategy
for burn prevention and care. 5
Pathophysiology of burns
There are several processes involved in the local tissue responses
after a burn. An increase in vascular permeability leads to the loss
of water, electrolytes, proteins and heat. 11 The complement and
coagulation cascades are activated and this results in thrombosis
and the release of histamine and bradykinin. These mediators
cause an increase in capillary leak and interstitial edema in distant
organs and soft tissue. In addition, the activation of the
inflammatory cascade can lead to immune dysfunction. All of
these responses increase the patient’s susceptibility to sepsis and
multiple organ failure. 17 These systemic responses are significant
once a burn exceeds 20 percent of the patient’s body surface.
Hypovolemia, immunosuppression, bacterial translocation from
the gut, and Acute Respiratory Distress Syndrome (ARDS) can
ensue. 11
Initial management
Primary survey
The rapid implementation of the ABCs of trauma management
(airway, breathing, circulation) also applies to burns. The initial
physical examination of the burn victim should focus on assessing
the airway and the patient’s hemodynamic status, as well as
estimating the size and depth of the burn. Airway edema can
result in airway obstruction and death. One hundred percent
oxygen should be administered from the outset. If there are any
concerns about the adequacy of the airway, prompt endotracheal
intubation is mandated. 18 In addition, signs of inhalational injuries
should be quickly recognized.
If there are concerns of cervical spine injuries, nasotracheal
intubation can be performed because it has the advantages of
decreased cervical spine manipulation and the tube can be easily
secured by suturing it to the nasal septum. The disadvantage of
nasotracheal tubes is that they tend to be of smaller caliber, which
are not as good for suctioning, and may increase the risk of
sinusitis. In difficult cases, fiber-optic bronchoscopy (if available)
can prove to be an invaluable tool in securing the airway. Vocal
cords, directly injured from smoke, may be resistant to usual
topical anesthesia and care must be exercised to avoid
laryngospasm. Consideration should be given to securing the
tube to the teeth with wires (or heavy sutures), rather than risking
further damage to burned facial skin with tie-tapes.
Once the airway has been addressed, the next step is to place
two large-bore (at least 14 gauge) peripheral intravenous catheters
through non-burned viable tissue. If necessary, these catheters
can be placed through burned skin because the eschar is still
sterile in the acute phase and more importantly, death can result
from delays in fluid resuscitation. A Foley catheter should be
placed to monitor urine output because this is the most
straightforward and reliable indicator of intravascular volume
status in the majority of these patients. Associated life-threatening
injuries such as cardiac tamponade, pneumothorax, hemothorax,
and flail chest must be identified and treated quickly 18 Tetanus
toxoid should also be administered routinely to all burn patients,
depending on immune status.
Assessment of injury
Quantifying the extent (Figures 1 & 2) of the burn is crucial in
determining subsequent management. Burns are dynamic injuries,
and damage to the skin can continue for 24 to 48 hours after the
initial injury due to edema, coagulation of small vessels, pressure,
desiccation, and infection. Thus daily evaluation is of paramount
importance in reassessing burn depth and success of excision 17 .
Superficial burns (1st degree) are generally red, painful, and
involve the most superficial aspect of the skin; as such, they are
not included in the calculation of total body surface area (TBSA).
These blanch to the touch 19 and have an intact epidermal barrier.
Examples include sunburn or a minor scald from a kitchen
accident. These burns will heal spontaneously, will not require
operative treatment, and will not result in scarring. Treatment is
aimed at comfort with the use of soothing topical salves with or
without aloe and oral non-steroidal anti-inflammatory agents.
Surgery is not required for these patients. 20
Hospital and Healthcare Innovation Book 2009/2010 55