Healthy, granulation tissue is apparent on the clean wound bed, and re-epi- thelialising cells are seen to migrate from the wound edges and the dermal bed to slowly close the wound within 10–14 days. Full-thickness wounds have a thicker, more leathery eschar, which does not separate easily from the viable wound bed. Those wounds require surgical excision and grafting. Continuous assessment of the patient’s systemic response to the burn injury is an essential part of an individualised plan of care. Subtle changes quickly identified by the burn team can prevent complications from occurring or worsening over time.

•During the final, rehabilitative phase, attention turns to scar maturation, contracture development and functional independence issues. The areas of burn, which heal either by primary intention or skin grafting, initially appear red or pink and are flat. Layers of re-epithelialising cells continue to form, and collagen fibres in the lower scar tissue add strength to a fragile wound. Over the next month, the scars may become more red from increased blood supply and more raised from disorganised whorls of collagen and fibroblasts/ myofibroblasts. The scars are referred to as hypertrophic in nature. If oppositional forces are not applied through splinting devices, exercises or stretching routines, this new tissue continues to heal by shortening and forming contractures. A certain amount of contracture development is unavoidable, but the impact can be lessened through prompt and aggressive interventions.

8.5Clinical Management

8.5.1Nonsurgical Care

Emergent Phase Priorities: airway management, fluid therapy, initial wound care Emergent Phase Goals of Care: initial assessment, management and stabilisation of

the patient during the first 48 h post-burn

Emergent Phase Assessment

•During the rapid, primary survey, airway and breathing assume top priority. A compromised airway requires prompt attention and breath sounds verified in each lung field.

•If circumferential, full-thickness burns are present on the upper trunk and back, ventilation must be closely monitored as breathing might be impaired and releasing escharotomies necessary (Fig. 8.8).

•Spine must be stabilised until c-spines are cleared.

•Circulation is assessed by examining skin colour, sensation, peripheral pulses and capillary filling. Circumferential, full-thickness burns to the arms or legs must be assessed via palpation or Doppler for evidence of adequate circulation. Escharotomies might be required.

•Typically, burn patients are alert and oriented the first few hours post-burn. If that is not the case, consideration must be given to associated head injury

Fig. 8.8 Full-thickness flame burn with releasing escharotomies

(including a complete neurological assessment), substance abuse, hypoxia or pre-existing medical conditions.

•All clothing and jewellery need to be removed in order to visualise the entire body and avoid the “tourniquet-like” effect of constricting items left in place as oedema increases.

•Adherent clothing needs to be gently soaked off with normal saline to avoid further trauma and unnecessary pain.

•Prompt fluid resuscitation must be initiated to address hypovolemic shock.

•Secondary, head-to-toe survey rules out any associated injuries. All medical problems are identified and managed in a timely fashion.

•Circumstances of the injury must be explored to understand the mechanism, duration and severity of the injury.

•Patient’s pertinent medical history includes identification of pre-existing disease or associated illness (cardiac or renal disease, diabetes, hypertension), medication/alcohol/drug history, allergies and tetanus immunisation status. A handy mnemonic can be used to remember this information (Box 8.7).

Box 8.7. Secondary Survey Highlights

126 J. Knighton

Box 8.8. First Aid Management at the Scene

Emergent Phase Management

•The top priority of care is to stop the burning process (Box 8.8). During the initial first aid period at the scene, the patient must be removed from the heat source, chemicals should be brushed off and/or flushed from the skin, and the patient wrapped in a clean sheet and blanket ready for transport to the nearest hospital. Careful, local cooling of the burn wound with saline-moistened gauze can continue as long as the patient’s core temperature is maintained and he/she does not become hypothermic.

–Upon arrival at the hospital, the burned areas can be cooled further with normal saline, followed by a complete assessment of the patient and initiation of emergency treatment (Box 8.9). In a burn centre, the cooling may take place, using a cart shower system, in a hydrotherapy room (Fig. 8.9). The temperature of the water is adjusted to the patient’s comfort level, but tepid is usually best, while the wounds are quickly cleaned and dressings applied.

•Airway management includes administration of 100 % oxygen if burns are 20 % body surface area or greater. Suctioning and ventilatory support may be necessary. If the patient is suspected of having or has an inhalation injury, intubation needs to be performed quickly.

•Evidence-based procedures for the insertion of central lines and care of ventilated patients have resulted in impressive reductions in central line blood stream infection rates and ventilator-acquired pneumonia (VAP) [3].

•Circulatory management includes intravenous infusion of fluid to counteract the effects of hypovolemic shock for adult patients with burns >15 % body surface area and children with burns >10 % body surface area. Upon admission, two large bore, intravenous catheters should be inserted, preferably into, but not limited to, unburned tissue.