Management of burns and wounds

Burns patients are especially prone to compromise of the airway and respiratory tract, and to fluid loss and hypovolemic shock. These issues are covered in detail in sections 5.1-5.3 and are not reiterated in section 5.10, which focuses on care of the burn wound itself.

The capability to assess the depth and extent of a burn wound is deemed essential at all levels of the health care system. These issues bear upon subsequent fluid requirements. The only resource needed for such assessment is training.

The capability for clean or sterile dressing of a burn wound, at least as an adjunct to transfer, is considered essential at all levels of the health care system. This implies training and basic clean or sterile dressing materials. As noted in section 5.3 (Circulation—Management of shock), sterile dressings would be ideal. These are essential at all hospital levels. Limited capabilities for sterilization prevent them from being considered essential at basic levels, where, instead, clean dressing material is deemed essential.

Many burn wounds can be treated definitively with topical antibiotics. The capability for this is deemed essential at all hospital levels. This capability is desirable at basic levels, but cost prevents it from being considered essential. Higher-level basic facilities, such as those run by formally trained nurses or medical assistants (as opposed to village health workers) might reasonably designate such items as essential. A variety of topical preparations are available for the treatment of burn wounds, including silver nitrate, mafenide acetate and silver sulfadiazine. Silver sulfadiazine is the most widely used worldwide. However, the Guidelines for essential trauma care do not make an endorsement of any specific preparation.

Debridement of necrotic tissue or external debris from burn wounds is considered essential at specialist and tertiary care hospitals, as is escharotomy (the removal or incision of dead skin in areas of third-degree burns). Capabilities for this imply the training of the clinician and the provision of basic surgical equipment to perform the procedures. These capabilities are possibly required in some GP-staffed hospitals in rural, low-income areas.

Skin grafting of non-healing burn wounds is considered essential at specialist and tertiary care hospitals. This implies the training of the clinician. It also implies the availability of a dermatome to harvest the graft. This capability is possibly required in some GP-staffed hospitals in rural, low-income areas.

Third-degree (full-thickness) burns are associated with the greatest mortality and most disappointing functional results. Early excision and grafting of these wounds has been shown to reduce mortality and improve functional outcome (42). Such early, aggressive therapy has the possible side-effect of increasing blood loss and hence mortality if not performed with adequate safeguards for haemosta-sis and adequate capabilities for fluid and blood resuscitation. The capability for early excision and grafting is deemed desirable at specialist and tertiary care hospitals. This would imply not only surgeons who are trained in the safe performance of the procedure, but also sufficient anaesthetic capability to adequately resuscitate patients during and after the procedure.

Burn wound contractures of the extremities are a frequent cause of disability in many countries. Most are eminently preventable through improved attention to splinting and physiotherapy during the period of wound healing. Further details of physiotherapy and rehabilitation are provided in section 5.11. However, as regards burns, at least basic expertise in splinting and physiotherapy are deemed essential at all hospital levels. The primary resource for this is training. Even if fully trained physiotherapists are not available, the needed expertise could be provided by other hospital staff (nurses, doctors, or other personnel) with supplemental training in physiotherapy. The only physical resources required are low-cost splints that could be fashioned from locally available materials, if need be.

Reconstructive surgery to correct burn wound contractures of extremities or other body parts, as well as for repair of poor cosmetic results of facial burns, are deemed to be desirable at specialist level hospitals and essential at tertiary care hospitals.

The general topic of management of wounds is partially considered in section 5.8 (Management of extremity injury). For the sake of completeness, it is covered more fully here. The capability to assess a wound for its potential for mortality and disability is considered essential at all levels of the health care system. Referral to the next highest level of the health care system would ordinarily be expected if a better outcome (both survival and functional status) would be likely to be achieved. Potential for disability includes both damage to underlying nerves, vessels and components of the locomotive system, as well as the extent and location of soft-tissue defects. Non-surgical management of uncomplicated wounds consists of cleaning and dressing. The capability for such is deemed essential at all levels of the health care system. Minor surgical management of wounds includes minor debridement and suturing. This implies the availability of expertise as well as basic surgical supplies, including anaesthetics (primarily local), antiseptics, surgical instruments and suture. These are considered essential at all hospital levels. They are possibly required at the basic level. It has been shown that a very high percentage of open wounds in rural low-income areas are cared for solely at basic facilities (43, 44). In such environments, assuring the capability of basic facilities to care for wounds would be very useful in assuring overall care of injured patients.

Major surgical management of complicated wounds includes extensive debri-dement and repair of injured structures, as indicated. It often implies repeat procedures and skin grafting. This capability is deemed essential at specialist and tertiary care hospitals. It is possibly required at GP hospitals. As indicated in the section on open fractures, the initial management of such complicated wounds is

TABLE IG Burns and wounds

Resources

Facility level

Burns

Basic

GP

Specialist

Tertiary

Assessment of depth and extent

E

E

E

E

Sterile dressings

D

E

E

E

Clean dressings

E

I*

I*

I*

Topical antibiotic dressings

D

E

E

E

Debridement

I

PR

E

E

Escharotomy

I

PR

E

E

Skin graft

I

PR

E

E

Early excision and grafting

I

I

D

D

Physiotherapy and splints to prevent contractures in burn wounds

I

E

E

E

Reconstructive surgery

I

I

D

E

Wounds

Assess wounds for potential mortality and disability

E

E

E

E

Non-surgical management: clean and dress

E

E

E

E

Minor surgical: clean, suture

PR

E

E

E

Major surgical debridement and repair

I

PR

E

E

Tetanus prophylaxis (toxoid, antiserum)

D1

E

E

E

* Irrelevant, as clean dressings are superseded by sterile dressings at all hospital levels. 1 Tetanus prophylaxis should be essential at any basic facility at which there is refrigeration.

* Irrelevant, as clean dressings are superseded by sterile dressings at all hospital levels. 1 Tetanus prophylaxis should be essential at any basic facility at which there is refrigeration.

often undertaken at GP-level hospitals for a period of hours to days before transport for referral can be arranged. Under these circumstances, assuring adequate early management of complicated wounds, with or without underlying open fractures, would be very useful in assuring adequate care of severely injured patients. The spectrum of training for management of such wounds includes a knowledge of when not to suture wounds in cases where they are too severely contaminated to be closed safely.

The capability for tetanus prophylaxis implies the training to categorize a wound by its tetanus risk (31) and to know the required tetanus prophylaxis based on local epidemiology (e.g. status of immunization of the population). This capability also implies the availability of both tetanus toxoid and tetanus antiserum. These are deemed essential at all hospital levels, and desirable at the basic level. Due to the fact that electricity and refrigeration are not always available at such facilities, the availability of medications for tetanus prophylaxis cannot be deemed essential. However, given its importance, tetanus prophylaxis should be considered essential at any basic facility that does have refrigeration.

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