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[Hypothermia in patients with burn injuries: influence of prehospital treatment]
Abstract
Hypothermia following pre-hospital treatment of burn patients is a common risk with increasing lethality. Soon after admission to our burn unit, the body temperature of 212 adult patients with more than 5% total body surface area burned was documented. We found no influence of the time of pre-hospital care and cold-water treatment alone on the body temperature. If the patients were not anesthetized, the initial temperature was normal. Only the anesthetized and artificial ventilated patients were hypothermic. We conclude that hypothermia is not a problem of the non-anesthetized and cold-water-treated patient. However, all anesthetized patients must be carefully treated to avoid hypothermia as an important complication in the pre-hospital management.
... Manual searching of non-traditional data forms (internet sources) identified a further 14 studies. These studies were also excluded because of the wrong setting (38,39) or patient group (40), the intervention was not assessed (8,(41)(42)(43)(44), were unpublished manuscripts (40) or were in vitro experimental studies. (45)(46)(47)(48)(49). ...
... The safety, suitability and effectiveness of HBD as a method of immediate cooling in specific patient groups (i.e. paediatric population) or in patients with burns of significant size and/or depth remains an area of both concern and controversy in the absence of adequate research (43). Nonetheless, HBD remain a widely used alternative burn first aid option in the USA, Asia, Europe, the UK, Australia, Canada and many other regions where they may be used to treat all sizes and depths of burn injury. ...
... However, this approach potentially contributes to clinical hypothermia, an area of particular concern to clinicians. Nonetheless, existing evidence in this area of concern also remains controversial (43,(54)(55)(56). ...
The aim of this systematic review was to determine the supporting evidence for the clinical use of hydrogel dressings as a first aid measure for burn wound management in the pre-hospital setting. Two authors searched three databases (Ovid Medline, Ovid Embase and The Cochrane Library) for relevant English language articles published through September 2014. Reference lists, conference proceedings and non-indexed academic journals were manually searched. A separate search was conducted using the Internet search engine Google to source additional studies from burns advisory agencies, first aid bodies, military institutions, manufacturer and paramedic websites. Two authors independently assessed study eligibility and relevance of non-traditional data forms for inclusion. Studies were independently assessed and included if Hydrogel-based burn dressings (HBD) were examined in first aid practices in the pre-hospital setting. A total of 129 studies were considered for inclusion, of which no pre-hospital studies were identified. The review highlights that current use of HBD in the pre-hospital setting appears to be driven by sources of information that do not reflect the paramedic environment. We recommend researchers in the pre-hospital settings undertake clinical trials in this field. More so, the review supports the need for expert consensus to identify key demographic, clinical and injury outcomes for clinicians and researchers undertaking further research into the use of dressings as a first aid measure.
© 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd.
... With Kurz et al. having shown similar results for surgical wounds, the process might be of even greater impact in the treatment of burn wounds which tend to be more extensive and deeper [62]. Prehospital cooling of minor burn wounds with cold water is a common firstaid measure and does not seem to cause severe hypothermia in patients with mild burns who are not anaesthetized [63]. However, in severely burned patients, the risks of prehospital cooling increase significantly with burn severity, expressed by TBSA and full-thickness depth, the presence of inhalation injury, as well as the need for pre-hospital intubation and anaesthesia [52,63,64]. ...
... Prehospital cooling of minor burn wounds with cold water is a common firstaid measure and does not seem to cause severe hypothermia in patients with mild burns who are not anaesthetized [63]. However, in severely burned patients, the risks of prehospital cooling increase significantly with burn severity, expressed by TBSA and full-thickness depth, the presence of inhalation injury, as well as the need for pre-hospital intubation and anaesthesia [52,63,64]. Among practices currently executed in the prevention and treatment of burn-associated hypothermia is raising the ambient temperature in preclinical rescue vehicles, as well as in the operating room (OR) and the intensive care unit (ICU), staged excision and grafting, limiting operating time if possible [65,66] and administering warm fluids [67,68]. ...
Background:
In this systematic review, we summarize the aetiology as well as the current knowledge regarding thermo(dys)regulation and hypothermia after severe burn trauma and aim to present key concepts of pathophysiology and treatment options. Severe burn injuries with >20% total body surface area (TBSA) affected commonly leave the patient requiring several surgical procedures, prolonged hospital stays and cause substantial changes to body composition and metabolism in the acute and long-term phase. Particularly in severely burned patients, the loss of intact skin and the dysregulation of peripheral and central thermoregulatory processes may lead to substantial complications.
Methods:
A systematic and protocol-based search for suitable publications was conducted following the PRISMA guidelines. Articles were screened and included if deemed eligible. This encompasses animal-based in vivo studies as well as clinical studies examining the control-loops of thermoregulation and metabolic stability within burn patients.
Results:
Both experimental animal studies and clinical studies examining thermoregulation and metabolic functions within burn patients have produced a general understanding of core concepts which are, nonetheless, lacking in detail. We describe the wide range of pathophysiological alterations observed after severe burn trauma and highlight the association between thermoregulation and hypermetabolism as well as the interactions between nearly all organ systems. Lastly, the current clinical standards of mitigating the negative effects of thermodysregulation and hypothermia are summarized, as a comprehensive understanding and implementation of the key concepts is critical for patient survival and long-term well-being.
Conclusions:
The available in vivo animal models have provided many insights into the interwoven pathophysiology of severe burn injury, especially concerning thermoregulation. We offer an outlook on concepts of altered central thermoregulation from non-burn research as potential areas of future research interest and aim to provide an overview of the clinical implications of temperature management in burn patients.
... Unfortunately this 20 minute marker is seldom achieved (15) as the desire for higher clinical intervention becomes paramount in the mind of the patient/responder combined with a concern for infection and causing hypothermia. Interestingly it is reported in papers by Singer et al and Lonnecker et al (6,7,16) that pre hospital cooling does not appear to contribute to hypothermia in the pre hospital setting. ...
... With all the clinical evidence now available from around the world advocating and supporting the benefits of early cooling of burn injuries (25), there are still those who continue to promote the use of a "no cooling with the application of a dry dressing only" protocol, or insisting that the area that may be cooled does not extend beyond a TBSA ranging anything from <10% to <50% with even less clinical support as to why these particular percentages are selected, the reasoning put forward is one of a concern for the onset of hypothermia, this concern has been evaluated and evidenced in more than one paper not to be the case (6,7,16), yet these same recommendations fail to address the concern for dry dressing adhesion to burnt tissue and the fact that they should not be applied circumferentially with the use of tape, as this may restrict the oedema taking place on site. Any supporting evidential clinical papers for this dry dressing protocol are at best scarce, against the weight of ongoing international evidence supporting a controlled cooling protocol. ...
... Despite these interventions, severe hypothermia often occurs in severely burned patients. [4][5][6][7][8]. ...
Background
Hypothermia in severely burned patients is associated with a significant increase in morbidity and mortality. The use of an oesophageal heat exchanger tube (EHT) can improve perioperative body temperatures in severely burned patients. The aim of this study was to investigate the intraoperative warming effect of oesophageal heat transfer in severe burn patients.
Methods
Single-centre retrospective study performed at the Burns Centre of the University Hospital Zurich. Between January 2020 and May 2021 perioperative temperature management with EHT was explored in burned patients with a total body surface area (TBSA) larger than 30%. Data from patients, who received perioperative temperature management by EHT, were compared to data from the same patients during interventions performed under standard temperature management matching for length and type of intervention.
Results
A total of 30 interventions (15 with and 15 without EHT) in 10 patients were analysed. Patient were 38 [26 - 48] years of age, presented with severe burns covering a median of 50 [42 - 64] % TBSA and were characterized by an ABSI of 10 [8 - 12] points. When receiving EHT management patients experienced warming at 0.07°C per minute (4.2°C/h) compared to a temperature loss of -0.03°C per minute (1.8°C/h) when only receiving standard temperature management (p<0.0001). No adverse or serious adverse events were reported.
Conclusion
The use of an oesophageal heat transfer device was effective and safe in providing perioperative warming to severely burned patients when compared to a standard temperature management protocol. By employing an EHT as primary temperature management device perioperative hypothermia in severely burned patients can possibly be averted, potentially leading to reduced hypothermia-associated complications.
... Protective mechanisms are activated when increasing or decreasing the body temperature. The biological tissues are subjected to heating or cooling, which leads to burns or frostbites of varying severity [2][3][4][5][6][7][8]. Burns and frostbites are classified into four degrees depending on the value and the action time of the temperature. ...
The experiment for determining intensity of heating and cooling the skin, fat, muscle and bone tissues was implemented in the article. The damage depth of the biological tissues from time of the action of the low and high temperatures was determined. The dependencies of the degree of damage and the fraction of the necrotic biological tissue from the value of the operating temperature were built. Key words: the biological tissue, the temperature, the damaged tissue indicator, the fraction of the necrotic tissue.
... Hypothermia was found to be related to the severity of the burn injury. Lönnecker and Schoder [58] reported similar findings in 212 adults admitted to a burn unit: no influence of cooling only on the body temperature, and hypothermia only occurred in the anesthetized and artificially ventilated patients. ...
... [6][7][8] It is also associated with anesthesia and mechanical ventilation, as in other types of trauma. 2,11,14 Moreover, the use of some methods of active external rewarming may be limited in large burns to avoid worsening thermal injuries of the skin, such as chemical heating pads in which the temperature may exceed 50°C (122°F). Active external rewarming was reported to be effective to prevent hypothermia in trauma victims; 11 active internal and extracorporeal rewarming seem to be the best method of treatment of severe accidental hypothermia. ...
Unlabelled Box: Contribution to Emergency Nursing Practice • The current literature on post-traumatic hypothermia indicates that burned skin loses its thermoregulatory properties.• This article contributes an example of the onset of severe hypothermia in burn victims due to negligence in thermal insulation.• Key implications for emergency nursing practice found in this article are the awareness of the impact of post-traumatic hypothermia on mortality and the need of careful insulation in burn victims. Maintaining normothermia can increase the chances of patient's survival.
... A European study of pre-hospital burns care demonstrated that each drop in temperature by 1 C significantly increases mortality. 17 Despite the susceptibility of burns patients to heat loss and hypothermia, 18 recording of patient body temperature was regularly omitted. The same publication from GSA-HEMS 16 found similarly low rates of temperature recording, which has since resulted in measures to address this, such as the placement of thermometers in accessible locations; however, given the influence on patient mortality, further emphasis should be placed on temperature recording in burns care. ...
Objectives:
The aim of this study was to describe patient demographics, injuries, physiology and interventions performed by retrieval physicians in the care of burns patients in both a pre-hospital and interhospital setting.
Methods:
A retrospective review of patient records from a large Australian Helicopter Emergency Medical Service was conducted. Demographics, injury, burn type, physiology and intervention data were extracted into a database for statistical analysis. Basic descriptive statistics were calculated, and patient physiology measures were compared at arrival and destination.
Results:
A total of 490 burns cases were identified from a 5 year period (January 2010-August 2015). The majority (78.6%) were interhospital transfers conducted by road (49.4%) or helicopter (36.9%). Patients were predominantly men (75.7%) with a median age of 37 years (interquartile range [IQR] 23-50). Median estimated total body surface area burned was 15% (IQR 8.5-20) and 18% (IQR 10-30) in pre-hospital and interhospital groups, respectively; however, retrieval physicians tended to overestimate total body surface area burned in comparison to destination burns units. Flash burn or explosion were the predominant aetiology of burn (49.4%), although the majority (95.3%) of patients had no associated traumatic injuries. Sixty patients were intubated by the Service. Escharotomies were performed on eight occasions resulting in improvement in circulation or ventilation. Overall mortality was 3.7% at 24 h.
Conclusions:
The Service cares for 80-100 burns patients annually, a proportion of whom require complex interventions such as intubation and escharotomy, which was performed by retrieval physicians appropriately. Associated traumatic injuries were infrequent in patients who sustained burns from flashes or explosions.
... Furthermore it is our experience and that of some others that active forced air warmers may actually enhance heat loss via latent heat of vaporisation of water when there are large areas of exposed wet raw tissue during surgical excision of a large burn area [1]. Despite active fluid warming, a warm underblanket, and an operating room maintained at 30 ∘ C, a passive warming technique which is very uncomfortable for staff, we and others often observe a gradual fall in patient core temperature during the course of large-area burn excisions [1][2][3]. Sometimes these procedures have to be performed in stages for this reason. ...
. Burns patients are vulnerable to hyperthermia due to sepsis and SIRS and to hypothermia due to heat loss during excision surgery. Both states are associated with increased morbidity and mortality. We describe the first use of a novel esophageal heat exchange device in combination with a heater/cooler unit to manage perioperative hypothermia and postoperative pyrexia.
Material and Methods
. The device was used in three patients with full thickness burns of 51%, 49%, and 45% body surface area to reduce perioperative hypothermia during surgeries of >6 h duration and subsequently to control hyperthermia in one of the patients who developed pyrexia of 40°C on the 22nd postoperative day due to
E. coli
/
Candida
septicaemia which was unresponsive to conventional cooling strategies.
Results
. Perioperative core temperature was maintained at 37°C for all three patients, and it was possible to reduce ambient temperature to 26°C to increase comfort levels for the operating team. The core temperature of the pyrexial patient was reduced to 38.5°C within 2.5 h of instituting the device and maintained around this value thereafter.
Conclusion
. The device was easy to use with no adverse incidents and helped maintain normothermia in all cases.
... [3] Early cooling of burns leads to less clinical and histological tissue necrosis, improves burn healing and helps relieve pain. [3][4][5] In porcine studies, decreased histological burn depth was noted after 20 and 30 minutes of cooling over 5 and 10 minutes (p<0.05). [6] Delayed cooling of porcine burns for 1 or 3 hours also showed improved wound re-epithelialisation and decreased the amount of scar tissue that developed. ...
Background:
Early cooling with 10 - 20 minutes of cool running water up to 3 hours after a burn has a direct impact on the depth of the burn and therefore on the clinical outcome of the injury. An assessment of the early cooling of burns is essential to improve this aspect of burns management.
Objectives:
To assess the rates and adequacy of prehospital cooling received by patients with severe burns before presentation to the Emergency Department (ED) at Edendale Hospital, Pietermaritzburg, South Africa. Patients with inadequate prehospital cooling who presented to the ED within 3 hours were also identified.
Methods:
A retrospective reviewof the burns database for all the patients with severe burns admitted from the ED at Edendale Hospital from September 2012 to August 2013 was undertaken. Demographic details, characteristics and timing of the burns, and presentation were correlated with burn cooling.
Results:
Ninety patients were admitted with severe burns. None received sufficient cooling of their burns, 25.6% received cooling of inadequate duration, and 32.3% arrived at the ED within 3 hours after the burn with either inadequate or no cooling. The median time to presentation to the ED after the burn was 260 minutes.
Conclusion:
Appropriate cooling of severe burns presenting to Edendale Hospital is inadequate. Education of the community and prehospital healthcare workers about the iiportance of early appropriate cooling of severe burns is required. Many patients would benefit from cooling of their burns in the ED, and facilities should be provided for this vital function.
... 19 Furthermore, patients who develop hypothermia in the context of burns or other trauma have been shown to have greater mortality and morbidity. 25,26 Although no patterns emerged to enable the prediction of patients who might develop hypothermia, only 24.8% of patients in our study had their temperature recorded. As paediatric burn patients are at particularly high risk of developing hypothermia, we recommend that temperature recording should be mandatory for all paediatric burn patients and that efforts to keep patients warm be made. ...
Objective
The present study evaluates the prehospital care of paediatric burn patients in Queensland (QLD). As first aid (FA) treatment has been shown to affect burn progression and outcome, the FA treatment and the risk of associated hypothermia in paediatric patients were specifically examined in the context of paramedic management of burn patients.Methods
Data were retrospectively collected from electronic ambulance response forms (eARFs) for paediatric burn patients (0–5 years) who were attended by Queensland Ambulance Service (QAS) from 2008 to 2010. Data were collected from 117 eARFs of incidents occurring within the Brisbane, Townsville and Cairns regions.ResultsInitial FA measures were recorded in 77.8% of cases, with cool running water FA administered in 56.4% of cases. The duration of FA was recorded in 29.9% of reports. The duration of FA was significantly shorter for patients in Northern QLD (median = 10 min, n = 10) compared with Brisbane (median = 15 min, n = 18), P = 0.005. Patient temperatures were recorded significantly more often in Brisbane than in other regions (P = 0.041); however, in total, only 24.8% of all patients had documented temperature readings. Of these, six (5%) were recorded as having temperatures ≤36.0°C. BurnaidTM was the most commonly used dressing and was applied to 55.6% of all patients; however, it was applied with a variety of different outer dressings. Brisbane paramedics applied Burnaid significantly less often (44.3%) compared with paramedics from Northern QLD (72.7%) and Far Northern QLD (60.9%), P = 0.025.Conclusions
Despite FA and patient temperatures being important prognostic factors for burn patients, paramedic documentation of these was often incomplete, and there was no consistent use of burns dressings.
... Dadurch kommt es zur systemischen Hypothermie des Kindes (Folge: Perfusionsund Gerinnungsstörungen, Immunsuppression mit Sepsis, Pneumonie und Wundheilungsstörungen) sowie zur lokalen Vasokonstriktion (Folge: Nachtiefen der Verletzung). Beide Effekte erhöhen signifikant die Morbidität und Mortalität von Brandverletzungen [10,21,24]. Besondere Risikogruppen sind Kinder, Mehrfachverletzte, narkotisierte Patienten und Verbrennungen mit mehr als 10% VKOF [13]. ...
Background
In Germany about 30,000 children per year suffer a thermal injury, whereby more than 50% of the children are under 4 years. Scalding is the cause in about 70% of cases; 10–20% of all burns and scalds in children under 10 years are a result of abuse or neglect.
Objectives
The purpose of this work is to provide a priority-oriented description of the pre- and in-hospital acute care of (severely) burned children – from emergency medical, anesthesiological and surgical points of view, including clear and easily to perform treatment recommendations.
Materials and methods
This review article is based on recommendations from professional societies, scientific data (literature review), and our own experience as a pediatric burn center.
Results and discussion
A few timely and effectively performed preclinical measures are critical for the safety and quality of the initial care of children with burns. Here, an approach using a modified ABCDE scheme is meaningful. After taking into consideration the immediate safety on site, the injury must be evaluated and if cooling had been initiated as part of first aid, this is stopped. Then, the following aspects must be considered: airway and analgesia (if needed, intranasal administration), breathing and evaluation of the medical findings (depth and extent of injured body surface or of any associated injuries), circulation, disability (target hospital and transportation) and documentation (including medical history and circumstances of the accident), and exposure and environmental control to maintain body temperature (e.g., with metal foil and covers) and repeated re-evaluation. Modern skin graft methods allow treatment that is less painful and improves functional and cosmetic outcome after burn injury.
... High percentage of hypothermia among the patients in the present study can be, like other studies, due to long distance of transportation and not paying attention to keeping the patients warm during the transportation. In the present study, like that of Lonnecker’s et al. , there was no significant association between patients’ burn cooling and hypothermia.[21] There was an association between keeping the patients warm during transportation and hypothermia (P = 0.003). ...
Burn is an irreparable event, which results in numerous physical, psychological, social, and economic complications. The burned patients should be merely treated in a professional burn center due to vast clinical range of these patients. Since, a percentage of mortality in burned patients is for the patients' transportation from other centers; this study has aimed to investigate the manner of their transportation to Imam Mosa Kazem Hospital.
This is a descriptive cross-sectional study on 98 subjects selected through sequential sampling from thermally burned patients being referred to Isfahan burn emergency center by ambulance from August 2011 to November 2011. The data including demographic information and event details, burned surface, burning grade and the province of origin were collected by a questionnaire, as well as a checklist related to caring team standards, transportation team, transportation equipment, and outcomes. The data were analyzed by descriptive statistical tests.
Based on the findings, the longest transportation time was 6.35 (4.30) hours. There was no significant association between patients' O2intake and hypoxemia. There was no association between patients' hypothermia and cooling the burn in the patients at the event location. There was a significant association between intake of fluid within transportation and urine output and hypovolemia (P = 0.00). Most of the defects of treatment were related to the equipments and infection control devices.
The findings showed that burned patients' transportation is so far from standards in Iran, and the authorities' should pay specific attention to that in form of vast national investigations.
... Bei letzteren muss die Entfernung der Noxe unter dem notwendigen Eigenschutz erfolgen. Galt vor einigen Jahren die sofortige Kühlung der Brandwunde noch als Qualitätsmerkmal der Erstversorgung, besteht heute Einigkeit, dass eine Kühlung nur noch bei kleinen Verletzungen (< 10 % der Körperoberfläche) bei nicht intubier− ten Patienten sinnvoll ist [6]. ...
Die kutane Verbrennung stellt eine häufige Verletzung dar. Verbrennungen werden bezüglich der Verbrennungstiefe in 1-, 2a-, 2b-, 3- und 4-gradige Verbrennungen eingeteilt. 2a-gradige Verbrennungen, die nur bis in die oberflächlichen Anteile der Dermis reichen und durch erhebliche Schmerzen und positive Rekapilarisierung erkennbar sind, werden konservativ behandelt. Großflächige Verbrennungen (> 15 %-2a-gradig bei Erwachsenen) und Verbrennungen an speziellen Lokalisationen (Gesicht, Hände, Genitale) sind jedoch stationär zu behandeln. Die konservative Behandlung wird mit topischen Salben und Wundauflagen durchgeführt. Ein Austrocknen des Wundgrundes ist zu vermeiden. Die Reepithelisierung sollte nach 14 Tagen abgeschlossen sein. Infizierte Wunden oder eine ausbleibende Heilung machen eine operative Intervention notwendig. Eine Nachbehandlung mit Narbenpflege und Kompression kann auch bei konservativ behandelten zweitgradigen Verbrennungswunden notwendig sein.
... Nicht selten werden Kleinkinder mit einer verbrannten Körperoberfläche von zwischen 5-10% mit einer Körpertemperatur von weniger als 32°C in unsere Zentren aufgenommen. Abgesehen von der Tatsache, dass eine Unterkühlung eines brandverletzten Patienten je nach Tiefe der Körpertemperatur einen lebensbedrohlichen Zustand darstellt, ist von Seiten der Verbrennungstiefe der Wunden davon auszugehen, dass diese in den nächsten Tagen als Folge der Unterkühlung in der Akutphase stark zunehmen wird [5]. ...
Groflchige Verbrennungen bei Kindern stellen den Notarzt vor besonders groe Herausforderungen. Dabei stehen zunchst die Sicherung der Vitalfunktionen und die Schmerzbekmpfung im Vordergrund. In der anschlieenden Ganzkrperuntersuchung mssen die Ausdehnung und Wundtiefe der Verbrennungen eingeschtzt, zudem muss ein Inhalationstrauma erkannt werden. Bei groflchigen Verbrennungen sollte sofort eine Infusionstherapie eingeleitet werden. Die Brandwunden sollten fr den Transport trocken abgedeckt werden, um eine Hypothermie zu vermeiden. Auch bei der Khlung der Brandwunden beispielsweise durch kaltes Wasser ist zu beachten, dass Kinder sehr viel schneller unterkhlen als Erwachsene. Der Transport in ein spezielles Zentrum fr brandverletzte Kinder erfolgt nach festen Kriterien, um den Patienten schnell einer adquaten weiterfhrenden Therapie zuzufhren.Extensive burns in children pose a particularly large challenge to the emergency physician. Initially the main focus is on stabilizing vital functions and managing pain. The ensuing physical examination must assess the extent and depth of the burn wounds and identify an inhalation injury. For burns affecting a large surface, infusion therapy should be initiated immediately. The burn wounds should be covered with a dry dressing during transportation to avoid hypothermia. When cooling the wounds, e.g., with cold water, consideration should be given to the fact that children become hypothermic much more rapidly than adults. Transfer to a center specialized in treating children with burns adheres to predetermined criteria to ensure that the patients receive appropriate further treatment.
... A prospective study has shown that each drop in temperature by one degree Celsius significantly increases the mortality rate of burn patients, i.e., there is a direct correlation between a reduced body core temperature and a deterioration in the prognosis. 17 Neither cooling of burn wounds nor the duration of the pre-hospital care had a significant impact on the further clinical course. The decisive factor was whether a patient was intubated or not. ...
Intensive care and the surgical therapy of burn injuries have made significant advancements. The immediate care on the scene of the accident, however, is not uniform. There is no 'golden hour' which will decide the further clinical process. The acute estimate of the percentage of the extent of the burns is of little relevance and does not facilitate the admission to a burn unit. The emergency calculation of the volume of intravenous infusion is not advisable. The choice of transport has no discernible impact on the prognosis of the patient. Avoiding hypothermia and perceiving associated trauma can be of crucial prognostic importance in the pre-hospital care of burn patients. Detailed knowledge about the circumstances of the injury is of exceeding importance.
... Cinat et al. [59] concluded in a retrospective study that one factor for increased survival after hemorrhage and subsequent massive transfusion was more effective and efficient rewarming. In burn victims not yet admitted to the hospital, hypothermia was defined as a risk factor that increased mortality, and the investigators suggested that hypothermia is an important complication in the prehospital management of such patients [60]. In two prospective studies, the admission Systemic Inflammatory Response Syndrome score was found to be an independent predictor of infection and outcome in blunt trauma. ...
Generally, hypothermia is defined as a core temperature <35 degrees C. In elective surgery, induced hypothermia has beneficial effects. It is recommended to diminish complications attributable to ischemia reperfusion injury. Experimental studies have shown that hypothermia during hemorrhagic shock has beneficial effects on outcome. In contrast, clinical experience with hypothermia in trauma patients has shown accidental hypothermia to be a cause of posttraumatic complications. The different etiology of hypothermia might be one reason for this disparity because induced therapeutic hypothermia, with induction of poikilothermia and shivering prevention, is quite different from accidental hypothermia, which results in physiological stress. Other studies have shown evidence that this contradictory effect is related to the plasma concentration of high-energy phosphates (e.g., adenosine triphosphate [ATP]). Induced hypothermia preserves ATP storage, whereas accidental hypothermia causes depletion. Hypothermia also has an impact on the immunologic response after trauma and elective surgery by decreasing the inflammatory response. This might have a beneficial effect on outcome. Nevertheless, posttraumatic infectious complications may be higher because of an immunosuppressive profile. Further studies are needed to investigate the impact of induced hypothermia on outcome in trauma patients.
Second-degree burns are the most common type of burn in clinical practice and hard to manage. Their treatment requires not only a consideration of the different outcomes that may arise from the dressing changes or surgical therapies themselves but also an evaluation of factors such as the burn site, patient age and burn area. Meanwhile, special attention should be given to the fact that there is no unified standard or specification for the diagnosis, classification, surgical procedure, and infection diagnosis and grading of second-degree burn wounds. This not only poses great challenges to the formulation of clinical treatment plans but also significantly affects the consistency of clinical studies. Moreover, currently, there are relatively few guidelines or expert consensus for the management of second-degree burn wounds, and no comprehensive and systematic guidelines or specifications for the treatment of second-degree burns have been formed. Therefore, we developed the Consensus on the Treatment of Second-Degree Burn Wounds (2024 edition), based on evidence-based medicine and expert opinion. This consensus provides specific recommendations on prehospital first aid, nonsurgical treatment, surgical treatment and infection treatment for second-degree burns. The current consensus generated a total of 58 recommendations, aiming to form a standardized clinical treatment plan.
Burn injury causes a coagulopathy that is poorly understood. After severe burns, significant fluid losses are managed by aggressive resuscitation that can lead to hemodilution. These injuries are managed by early excision and grafting, which can cause significant bleeding and further decrease blood cell concentration. Tranexamic acid (TXA) is an anti-fibrinolytic that has been shown to reduce surgical blood losses; however, its use in burn surgery is not well established. We performed a systematic review and meta-analysis to investigate the influence TXA may have on burn surgery outcomes. Eight papers were included, with outcomes considered in a random-effects model meta-analysis. Overall, when compared to the control group, TXA significantly reduced total volume blood loss (mean difference (MD) = -192.44; 95% confidence interval (CI) = -297.73 to - 87.14; P = 0.0003), the ratio of blood loss to burn injury total body surface area (TBSA) (MD = -7.31; 95% CI = -10.77 to -3.84; P 0.0001), blood loss per unit area treated (MD = -0.59; 95% CI = -0.97 to -0.20; P = 0.003), and the number of patients receiving a transfusion intraoperatively (risk difference (RD) = -0.16; 95% CI = -0.32 to - 0.01; P = 0.04). Additionally, there were no noticeable differences in venous thromboembolism (VTE) events (RD = 0.00; 95% CI = -0.03 to 0.03; P = 0.98) and mortality (RD = 0.00; 95% CI = -0.03 to 0.04; P = 0.86). In conclusion, TXA can potentially be a pharmacologic intervention that reduces blood losses and transfusions in burn surgery without increasing the risk of VTE events or mortality.
Zusammenfassung
Schwere Verbrennungen führen zu einer persistierenden hypermetabolen Antwort des Organismus mit signifikant gesteigertem Ruheenergieumsatz, Multiorgandysfunktion, Muskelabbau und erhöhtem Infektionsrisiko. Charakteristisch sind erhöhte Körperkern- und Hauttemperaturen. Eine weitere Steigerung der erhöhten metabolischen Rate kann durch Wärmeverluste ausgelöst werden, für die diese Patienten durch hohe Wärmeabgabe über Verdunstung von Feuchtigkeit und Beeinträchtigung der thermoregulatorischen und isolierenden Eigenschaften der verbrannten Haut besonders disponiert sind. Dies gilt besonders in allen Behandlungssituationen mit Exposition großer unbedeckter Hautflächen, wie bei der Primärversorgung, Verbandswechseln auf der Intensivstation und der Verbrennungschirurgie mit ausgedehntem sterilem Operationsfeld. Es konnte gezeigt werden, dass Hypothermie mit zahlreichen Risiken für den Verbrennungspatienten einhergeht. Ein konsequentes Wärmemanagement mit Messung der Körperkerntemperatur und Anwendung von externen und internen Wärmeprotektionsmaßnahmen wird empfohlen. Traditionell kommt hier eine Erhöhung der Raumtemperatur zum Einsatz. Dieser effektiven Maßnahme sind jedoch durch die Belastbarkeit der Behandler auf der Intensivstation und der Operateure Grenzen gesetzt. Zur Vermeidung einer perioperativen Hypothermie sind eine stringente Operationsplanung mit Begrenzung der Operationsdauer und eine enge intraoperative Kommunikation über das Hypothermierisiko von besonderer Bedeutung.
Bei der intensivmedizinischen Therapie ist die Differenzierung zwischen akzeptierter Temperaturerhöhung und infektiösem Fieber häufig erst durch die Einbeziehung weiterer Untersuchungsbefunde möglich. Als Kriterium für Sepsis gilt eine Temperatur über 39 °C oder unter 36,5 °C.
Objectives: To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children.
Design: A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised Burns Centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion.
Results: The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations.
Conclusion: Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.
Background
Thermal injuries are among the most common accidental injuries in childhood and can cause significant permanent functional and esthetic impairments.
Aim
In this review article the current recommendations for the treatment of thermal injuries in children are summarized. The special requirements and challenges in preclinical and inpatient treatment of children with thermal injuries are highlighted.
Material and method
In the context of the current literature clinical experiences are outlined to introduce treatment recommendations for children with thermal injuries. Contemporary treatment principles and special aspects are presented and discussed.
Results
The treatment of thermal injuries in children poses special challenges as it requires a differentiated approach adapted to the anatomy and physiology of the child. Acute preclinical treatment of thermal injuries is demanding, as a high standard has to be met even though the experience in pediatric emergencies is often limited. In the specialized clinic or center for children with severe burns, the treatment has to be adjusted to the severity of the burn or scald. In particular, special aspects of pediatric intensive care and surgical treatment have to be in focus to achieve satisfactory long-term functional and cosmetic results and decrease restrictions to a minimum.
Conclusion
The treatment of (severely) burnt children requires close interdisciplinary cooperation, starting from preclinical care through inpatient treatment and follow-up to long-term care.
Burn injuries are one of the most common accidents in children and are a very distressing event for the persons affected and their relatives. In Germany every year about 6,000 children are injured so severely that they have to be treated in a hospital. Although many burns spontaneously heal without scars, some injuries are so severe that, despite numerous operations, stigmatizing scars remain. The consequences for a child’s body are particularly important: if scar tissue does not give enough during growth, corrective procedures can be necessary until adulthood. In order to achieve the optimal functional and esthetic outcome and to avoid stigmatization as much as possible, the affected children should be treated from the beginning in specialized clinics or centers for serious burn injuries, depending on the degree of severity. Their teams have great expertise in the treatment and follow-up care of children with thermal burn injuries.
Das Kapitel umfasst aktuelle Behandlungskonzepte in der Primärversorgung thermischer Verletzungen und gibt einen Überblick über die sich anschließende konservative und chirurgische Therapie innerhalb der eingeschränkten Möglichkeiten an Bord. Es wird auf die Abschätzung der verbrannten Körperoberfläche, die Einteilung der Verletzungstiefe sowie auf die Notwendigkeit eingegangen, wann Passagiere oder Besatzungsmitglieder notfallmäßig ausgeschifft bzw. evakuiert werden müssen. Abschließend geht das Kapitel auf verschiedene Formen des Inhalationstraumas ein und behandelt die präklinische Erstversorgung und Stabilisierung schwerbrandverletzter Patienten an Bord. Letzteres kann dem Schiffsarzt begegnen, wenn das Schiff außerhalb der Evakuierungsreichweite ist oder innerhalb eines maritimen Großschadensereignis nach der Triage an Bord.
Necrosis in burns has a major impact on dermal regeneration, functional, and esthetic results. Thus patient’s satisfaction and quality of life is determined by the timely regeneration process of all dermal layers. Pathophysiological changes after burn trauma lead to different perfusion patterns (“zones”). Inflammation has been described having a key role in maintaining reduced subdermal perfusion with increased risk of burn necrosis. In addition, various key regulators of inflammation have been identified to play a critical role in activating burn necrosis. This chapter analyzes the impact of necrosis in acute burns and gives an overview of the currently available literature of pathophysiology, apoptosis, and inflammation in burns resulting in primary, secondary, or tertiary burn necrosis. Local therapeutic options are discussed, but it is not intended to be exhaustive with regard to systemic reactions and systemic therapy in case of burn necrosis. In summary, there is increasing evidence of pathophysiology of necrosis in burns in animal models, but there is still a lack of transfer to clinical application.
Thermische Verletzungen stellen im Kindesalter nach Verkehrsunfällen mit einer Häufigkeit von etwa 31500 pro Jahr die zweithäufige Unfallursache dar. Von diesen thermisch verletzten Kindern müssen jährlich etwa 6000 sta tionär, etwa 1500 in Spezialkliniken und davon sogar mehr als 100 intensivmedizinisch behandelt werden (Paulinchen e. V. 2013). Aktuell werden im Rahmen der Primärversorgung in den ersten vier Stunden nach dem Unfall 75 % der betroffenen Kinder in Abhängigkeit vom Verletzungsmuster in einer spezialisierten Klinik für Kinderbrandverletzungen versorgt.
Die Therapie von Verbrennungswunden unterliegt einem definierten Management, welches in die Prähospitalphase, das Schockraummanagement und die klinische Phase eingeteilt werden kann. Ein entscheidender Faktor für die Versorgung eines Verbrennungspatienten ist die adäquate Einschätzung des Verbrennungsausmaßes. Am Unfallort muss auf die Sicherung der Vitalfunktionen, die Anlage großlumiger Zugänge, den Beginn der Flüssigkeitssubstitution, die Entscheidung zur Intubation und eine ausreichende Analgesie geachtet werden. Die Aufnahme des Patienten im Schockraum sollte einem standardisierten Protokoll unterliegen, das von einem interdisziplinären Team rasch und effektiv durchgeführt wird. Das Schockraummanagement basiert auf einer mechanischen Reinigung und anschließenden exakten Bewertung der Verbrennungen, dem Monitoring der Vitalfunktionen, der Diagnostik und Therapie eines Inhalationstraumas sowie von Begleitverletzungen und der schweregradgerechten Versorgung der Brandwunden.
Severe burns due to electrical accidents occur rarely in Germany but represent a challenge for emergency physicians and their team. Apart from extensive burns cardiac arrhythmia, neurological damage caused by electric current and osseous injury corresponding to the trauma mechanism are also common. It is important to perform a survey of the pattern of injuries and treat acute life-threatening conditions immediately in the field. Furthermore, specific conditions related to burns must be considered, e.g. fluid resuscitation, thermal management and analgesia. In addition, a correct strategy for further medical care in an appropriate hospital is essential. Exemplified by this case guidelines for the treatment of severe burns and typical pitfalls are presented.
Brandverletzungen stellen in Deutschland die dritthäufigste Ursache schwerer Unfälle im Kindesalter dar, die meisten davon ereignen sich im 2.–4. Lebensjahr. Durch ein besseres Verständnis der kindlichen Verbrennungskrankheit sowie eine Optimierung der Intensivmedizin wurde die Mortalität schwerbrandverletzter Kinder deutlich reduziert. Die Primärversorgung beinhaltet die Rettung aus dem Gefahrenbereich und folgt im Weiteren notärztlichen Therapieempfehlungen. Das Ausmaß der VKOF (verbrannte Körperoberfläche) wird mit der Neuner-Regel nach Wallace oder der Handflächenregel abgeschätzt, genauere Werte ergibt die Methode nach Lund u. Browder. Die exakteste Abschätzung liefern moderne EDV-gestützte Programme. Die Indikationen zur Einweisung in eine Spezialeinheit bzw. ein Zentrum für Brandverletzte ergeben sich aus dem Alter der Kinder, der Schwere und Lokalisation der Verbrennung, dem Vorhandensein eines Inhalationstraumas und dem Unfallmechanismus. Abgesehen von der Flüssigkeitssubstitution kann — in Abhängigkeit von der Verbrennungstiefe — eine chirurgische Behandlung indiziert sein. Dies ist bei Verbrennungen höherer Grade als 2a der Fall. Die Therapie schwerer kindlicher Verbrennungen erfordert ein interdisziplinäres Team aus speziell für die Verbrennungsbehandlung ausgebildeten Plastischen Chirurgen bzw. Kinderchirurgen, Anästhesisten, Psychiatern bzw. Psychologen, geschultem Pflegepersonal, Krankengymnasten, Ergotherapeuten und Sozialarbeitern.
The skin, the largest human organ, provides the body shape and is the main organ
that protects our body against intruders such as heat, cold, trauma, or infections. A
number of important functions are listed here:
- Regulation of body temperature
- Sensory function: touch, feel and pain stimuli
- Regulation of water loss
- Production of vitamin D, needed for bone formation
- Food and oxygen supply to the body
- Communication: for example, red with embarrassment, pale with fear
- Protection from mechanical, chemical and radiation damage
- Innate immunity
Severe damage or disorders such as burns scars, giant melanocytic naevi have a
major impact on a person’s appearance and will influence not only the skin function
but also the interpersonal communication and behaviour.
The skin is built up of three main components: epidermis, dermis, and skin appendages
including the pilosebaceous follicle (hair follicle and sebaceous gland),
the eccrine sweat glands, and the apocrine glands.
Severe burns due to electrical accidents occur rarely in Germany but represent a challenge for emergency physicians and their team. Apart from extensive burns cardiac arrhythmia, neurological damage caused by electric current and osseous injury corresponding to the trauma mechanism are also common. It is important to perform a survey of the pattern of injuries and treat acute life-threatening conditions immediately in the field. Furthermore, specific conditions related to burns must be considered, e.g. fluid resuscitation, thermal management and analgesia. In addition, a correct strategy for further medical care in an appropriate hospital is essential. Exemplified by this case guidelines for the treatment of severe burns and typical pitfalls are presented.
The treatment of burn wounds is subject to a defined management which can be divided into preclinical treatment, emergency room management, and the clinical phase. A decisive factor for the care of a burn patient is correct assessment of the extent of the burn injury. At the location of the accident, vital functions, i.v. catheters, fluid management, the decision for intubation, and sufficient pain control are crucial. The admission of patients to the emergency room should be subject to a standardized protocol, which is quickly and effectively performed by an interdisciplinary team. Emergency room management consists of a mechanical cleaning and subsequent accurate assessment of the extent of the burn injury, monitoring of vital functions, diagnosis and treatment of an inhalation injury as well as associated injuries, and the appropriate care of the burn wounds.
607 M E D I Z I N D er vorliegende Artikel soll einen Einblick in die Pathophysiologie und die Therapie des Verbren-nungstraumas vermitteln. Epidemiologie und Pathologie Die Verbrennung der Körperoberfläche stellt eine komplexe Pathologie dar, die bereits kurz nach dem Unfall zahlreiche Körperfunktionen beeinflusst und schwerwiegende Folgen für die betroffenen Patienten haben kann. Der Begriff Verbrennungskrankheit be-schreibt den pathophysiologischen Zustand, in wel-chen Patienten geraten können, selbst dann, wenn nur kleine Körperareale von der Verbrennung betroffen sind. Plötzliche Freisetzung vasoaktiver Mediatoren aus den verbrannten Hautanteilen, wie zum Beispiel Kinine, Prostaglandine, Katecholamine, Glukokorti-koide, ein gesteigerter Energieverbrauch durch Wär-meverlust bei verloren gegangener Hautintegrität, Volu-menverschiebungen in den Extravasalraum durch eine systemische Störung der Kapillarintegrität ("capillary-leak-syndrome") und eine konsekutive Abwehr-schwäche führen zu einer multifaktoriellen Schädi-gung des Körpers. Negative Prädiktoren für das Out-come des Patienten sind hohes Alter und weibliches Geschlecht, sowie hohe Grade (III und IV) eines even-tuell vorliegenden Inhalationstraumas (IHT) und die Größe der betroffenen Körperoberfläche (KOF). Alle Qualitäten werden im "Abbreviated-Burn-Severity-Index" (ABSI) zusammengefasst. Sie sind ein direktes Maß für die Überlebenswahrscheinlichkeit des Patien-ten. Alleine ein Inhalationstrauma, das bei 15 bis 30 % aller Patienten vorliegt, steigert die Mortalitätsrate um das Neunfache (1). Aufgrund weiterentwickelter Arbeitsschutzmaßnah-men in Betrieben und technischer Innovationen in Ver-kehr und Haushalt geht die Anzahl schwerverbrannter Patienten in Industriestaaten zurück. In Deutschland müssen jährlich rund 10 000 bis 15 000 Menschen mit Brandverletzungen stationär behandelt werden. Im Jahr 2005 starben 481 Patienten an den Folgen einer Ver-brennung, weitere 141 an den Folgen einer Starkstrom-verletzung (Quelle: Deutsche Gesellschaft für Verbren-nungsmedizin). Etwa 60 % aller verbrannter Patienten erleiden mittelschwere Verbrennungen mit einem Anteil der Körperoberfläche von weniger als 10 % und können häufig ambulant behandelt werden. Etwa 30 bis 40 % der verbrannten Patienten müssen nach der notärztli-chen Erstversorgung in ein Schwerstverbrennungszen-trum aufgenommen und intensivmedizinisch betreut ZUSAMMENFASSUNG Hintergrund: Für den Notarzt ist es wichtig, die akute Erst-versorgung großflächiger und tiefdermaler Verbrennungen gewährleisten zu können und eine fundierte Entscheidung zu treffen, welche Patienten einem Schwerverbrennungs-zentrum zugewiesen werden müssen. In der späteren Wei-terbehandlung werden Ärzte verschiedener Disziplinen wegen langfristiger Komplikationen der Verbrennungs-krankheit konsultiert.
Im klinischen Alltag haben sich zwei Scores zur orientierenden Einschätzung der Verletzungsschwere und der damit verbundenen
Überlebenswahrscheinlichkeit eines Brandverletzten durchgesetzt. Der Banx-Index berücksichtigt ausschließlich die verbrannte
Körperoberfläche (VKOF) und das Lebensalter des Patienten und prognostiziert eine Überlebenswahrscheinlichkeit kleiner 10%
sobald die Summe beider Werte 100 überschreitet. Wesentlich differenzierter und damit prognostisch verlässlicher ist der ABSI-Score
(Abbreviated Burn Severity Index), der anhand mehrerer Faktoren über einen ermittelten Punktwert eine feinere Skalierung der
Überlebenswahrscheinlichkeit ermöglicht. Dennoch bleiben auch beim ABSI-Score Faktoren wie Adipositas, Nikotin- und Alkoholabusus
des Patienten unberücksichtigt. Das Vorliegen solcher Faktoren hat in Untersuchungen großer Brandverletztenzentren eine deutliche
Verschlechterung der Überlebenswahrscheinlichkeit des Patienten nachgewiesen [1,2]
In den vergangenen Jahren konnte die Mortalität schwerstbrandverletzter Kinder durch eine Verbesserung des intensivmedizinischen Managements erheblich reduziert werden. Gleichzeitig wurde durch die Optimierung der lokalen Wundbehandlung und der chirurgischen Transplantationstechnik das kosmetische und funktionelle Outcome deutlich verbessert. Der Erfolg der Behandlung brandverletzter Kinder hängt aber nicht zuletzt auch von der richtigen Primärversorgung ab. Diesbezüglich werteten wir 80 brandverletzte Intensivpatienten unserer Klinik der vergangenen vier Jahre aus. Die häufigsten Fehlerquellen bei der Erstversorgung von brandverletzten Kindern liegen in der Unterkühlung durch fehlerhafte Wundversorgung und zu lange Wundkühlung, fehlende Analgosedierung bis hin zu fehlerhaftem Infusionsregime durch Fehleinschätzung der verbrannten Körperoberfläche. Glücklicherweise enden diese Fehlbehandlungen nur selten letal und können durch eine enge Zusammenarbeit zwischen dem Intensiv-Pädiater und Kinderchirurgen korrigiert werden. Dennoch veranlassen gerade Einzelfälle von Missmanagement ein Überdenken der bisherigen Vorgehensweise, um eine Qualitätsverbesserung bei der Erstversorgung von kindlichen Verbrennungen zu erreichen. Daher hat der Arbeitskreis “Das schwerbrandverletzte Kind” die Therapieempfehlungen für die notärztliche Primärversorgung von Brandverletzten mit speziellen Empfehlungen für die Versorgung von Kindern ergänzt.
Hypothermia in burns is common and increases morbidity and mortality. Several methods are available to reach and maintain normal core body temperature, but have not yet been evaluated in critical care for burned patients. Our unit's ordinary technique for controlling body temperature (Bair Hugger®+ radiator ceiling + bed warmer + Hotline®) has many drawbacks e.g.; slow and the working environment is hampered.The aim of this study was to compare our ordinary heating technique with newly-developed methods: the Allon™2001 Thermowrap (a temperature regulating water-mattress), and Warmcloud (a temperature regulating air-mattress).
Ten consecutive burned patients (> 20% total burned surface area and a core temperature < 36.0°C) were included in this prospective, randomised, comparative study. Patients were randomly exposed to 3 heating methods. Each treatment/measuring-cycle lasted for 6 hours. Each heating method was assessed for 2 hours according to a randomised timetable. Core temperature was measured using an indwelling (bladder) thermistor. Paired t-tests were used to assess the significance of differences between the treatments within the patients. ANOVA was used to assess the differences in temperature from the first to the last measurement among all treatments. Three-way ANOVA with the Tukey HSD post hoc test and a repeated measures ANOVA was used in the same manner, but included information about patients and treatment/measuring-cycles to control for potential confounding. Data are presented as mean (SD) and (range). Probabilities of less than 0.05 were accepted as significant.
The mean increase, 1.4 (SD 0.6°C; range 0.6-2.6°C) in core temperature/treatment/measuring-cycle highly significantly favoured the Allon™2001 Thermowrap in contrast to the conventional method 0.2 (0.6)°C (range -1.2 to 1.5°C) and the Warmcloud 0.3 (0.4)°C (range -0.4 to 0.9°C). The procedures for using the Allon™2001 Thermowrap were experienced to be more comfortable and straightforward than the conventional method or the Warmcloud.
The Allon™2001 Thermowrap was more effective than the Warmcloud or the conventional method in controlling patients' temperatures.
The benefits of cold water therapy in stopping a burn injury from penetrating deeper into the tissues has been shown in some animal models, but only if the proportion of body surface that was burnt was 1–5% and the treatment was initiated immediately. Waiting for only a few minutes after the trauma has been sustained immediately negates any beneficial effect. If the treatment is administered for too long or the temperature is too cold then the tissue necrosis will be more extensive. The authors recommend cooling the burnt skin surface for (20 to) 30 minutes; a time period that we think is very clearly too long. In our view, cold water therapy is a lay or first-aid measure. The first step to be taken by the ambulance services or the emergency physician should be to immediately cease the cooling or heat treatment. The German Society for Burn Treatment (www.verbrennungsmedizin.de) recommends cooling therapy with tap water only for small burns; we think it is contraindicated in patients with large surface burns. The recommendations from the Deutscher Feuerwehrverband (the German Fire Services Association) express similar sentiments (2).
The statement that no guidelines are available for the nutrition of burned patients is incorrect. The European Society for Parenteral and Enteral Nutrition’s 2006 guidelines include such aspects and recommendations (3).
Our thanks go to the authors for reviewing burn injuries as these are often neglected or even ignored. The treatment objective especially in people with severe burns is not only the optimal reconstruction of the destroyed integrity of the skin, but also of form, function, and esthetic appearance. Because of self reinforcing scar formation, the treatment is by no means concluded when a patient is discharged from the inpatient setting. Special compression treatment and scar treatment are required as explained. Prescriptions for services often trigger prolonged discussions with the insurers and require their agreement. Scar developments such as hypertrophy, unstable, or functionally impairing scars sometimes occur only after a lengthy latency period. It is essential to recognize these in good time and to initiate the necessary treatment measures. This requires a high degree of specialist expertise that general practitioners—who, as the article mentions, are integral to the interdisciplinary treatment approach—are usually unfamiliar with; something that many affected patients have reported. Such patients should therefore present at regular intervals to burn care clinics in specialized units, so that aftercare can be delivered in a collaborative manner..
The physician that initially sees a patient with an extensive and deep dermal burn injury must be able to provide initial acute treatment and to make a well-founded decision whether to have the patient transported to a burn care center (BCC). Physicians from a variety of specialities will be involved in the management of long-term sequelae.
This article provides an overview of the treatment of severe burns and their commonest complications. Special attention is paid to initial emergency treatment (first aid) and to late complications, because physicians from multiple specialties are often involved in these phases of treatment. The data and guidelines that are summarized here were obtained through a selective Medline search and supplemented by the authors' experience in their own burn care center.
Analgesia, careful fluid balance, and early intubation are important elements of the initial emergency treatment. Long-term complications of burns, such as disfiguring scars on exposed areas of skin and functionally significant contractures, often require surgical treatment. Early measures for scar care may improve the outcome.
The effective treatment of severe burns is interdisciplinary, involving general practitioners and emergency physicians as well as plastic surgeons and physicians of other specialties. Knowledge of the basic principles of treatment enables physicians to care for patients with burns appropriately both in the acute setting and in the long term.
Severe burn injuries are rare and represent less than 1% of all medical emergencies. At the scene of the accident self-protection is important. The progress of thermal injury should be stopped, while cold water therapy is usually not indicated as the resulting hypothermia severely reduces the prognosis. A thorough body check reveals the burn size, depth and presence of co-injuries. Volume depletion is the main pathophysiological reason for burn shock. Early infusion therapy is of prognostic significance. Sufficient analgesia has to be established. Intubation is not generally indicated even with extensive burns, whereas early intubation can be life-saving in the case of circular thoracic burns, face burns and inhalation trauma. Local or systemic administration of corticosteroids is not indicated. Transfer to a specialized burn unit depends on burn size and depth. Emergency room management includes stabilization of vital functions, evaluation of co-injuries and initiation of the specific surgical and intensive care therapy.
This pilot study was designed to verify whether the spraying of coolant improves initial cooling in extensive burns. The cooling effects of 1l of sprayed water and 5l of poured water (at 22 degrees C) were tested; 53 healthy participants were cooled for 15 min over 18% of their total body surface, twice. Thermographic imaging measured the loss of skin temperature and assessed the homogeneity of cooling. With sprayed coolant the mean decrease of skin temperature was significantly higher (p < 0.003) throughout the entire cooling period and more homogeneous for the first 9 min (p < 0.003), compared with poured coolant. Infrared tympanic thermometry estimated core body temperature; neither poured nor sprayed water caused hypothermia. Even with a fifth of the volume of poured water, sprayed water cooled more efficiently. Thus, we conclude that spraying of coolant improves initial management.
Concern engendered by a previous study that showed inadequate first aid for burn injuries was prevalent in the community led to a novel multi-media public health campaign ensued to address the issue.
To determine whether this public health campaign influenced behaviour by altering first aid treatment for burn injuries (BFAT). DESIGN, SETTING AND POPULATION: Prospective intervention study. Consecutive patients with acute burn injuries over two 4-month intervals, presenting to a regional burn service, Auckland, New Zealand. This research was ethically approved by the Local Research Ethics Committee.
Demographics, burn size, adequacy of burn first aid, outpatient/inpatient wound care and operative intervention requirement.
Adequacy of BFAT improved following the campaign (59% versus 40%, P=0.004). Fewer inpatient admissions (64.4% versus 35.8%, P<0.001) and surgical procedures (25.6% versus 11.4%, P<0.001) were undertaken following the campaign with a corresponding increase in outpatient care. Greatest decreases were observed in Maori and Pacific Islanders, and in children <10 years old.
Adequacy of BFAT together with a reduction in the numbers of patients requiring inpatient surgical care was improved by a multi-media public awareness campaign.
ResearchGate has not been able to resolve any references for this publication.