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South Africa has a high incidence of burn injuries.

Standards for Patient Care

There is a high incidence of burn injuries in South Africa and peaks in the winter months when coal-burning fires are used to heat low-income homes. South Africa has a particularly high rate of childhood burns, with as many as 1 300 burn-related deaths each year. The alarming incidence of burn injury in South African is evident in the following burn statistics:

1.6 million burn wounds every year
12% of all fatal injuries due to burn wounds
68 severe burn wounds every month

The earliest known record of burn treatment is in the ancient Egyptian Ebers Papyrus (dated 1500 bc), which contains descriptions of applications of mud, excrement, oil, plant extracts, frogs boiled in oil, or fermenting goat dung. Luckily, burn therapy has evolved significantly over the years and the International Society for Burn Injuries (ISBI) long recognised a need to provide burn care practitioners with recommendations for patient care.

In 2012, the International Network for Training, Education, and Research in Burns (Interburns1) developed a set of operational standards for burn care services in resource-limited settings (RLS). RLS refers to medical situations in which there are inadequate personnel, training, supplies, and equipment, that mostly occur in low- and middle-income countries.

The mission of the ISBI Practice Guidelines Committee is to create a set of clinical guidelines to improve the care of burn patients and reduce costs by outlining recommendations for management of specific medical problems encountered in burn care.

Herewith a summary of the ISBI Practice Guidelines for Burn Care

(*Comprehensive guidelines incl. references available at Burns Journal)

Organisation and delivery of burn care
All regions should have an organised system of care for injured persons. This includes an organised system of burn care delivery.
An organised system of acute, chronic and rehabilitative care should be provided for patients with burns.

Initial assessment and stabilisation
Thermally injured patients should be evaluated using a systematic approach that first seeks to identify the greatest threat(s) to life.
Evaluation of burn should estimate total body surface area (TBSA) utilising a standardised method and delineate characteristics that require immediate attention from a designated burn center.
Appropriate resuscitation should be initiated promptly and tailored based on patient parameters to avoid over- and under- resuscitation.
Tetanus immunisation status should be evaluated and addressed if indicated.

Smoke inhalation injury: Diagnosis and treatment
Initial assessment of the burn patient should include evaluation of the airway and breathing.
Diagnosis of inhalation injury is suspected by a history of exposure within a closed space to products of incomplete combustion, in the physical examination by diminished consciousness, and by the presence of soot in the oral cavity and by facial burns. Normal oxygenation or chest radiographs do not exclude the diagnosis. However, signs such as hoarseness, carbonaceous sputum, wheeze, and dyspnea are strongly suggestive of inhalation injury.
Treatment for suspected or confirmed carbon monoxide poisoning is the administration of high-flow supplemental oxygen for at least 6 h.
Treatment of upper airway burns secondary to smoke inhalation includes observation and monitoring. Patients with upper airway burns should be nursed in the semi-upright position with moderate elevation of the head and trunk. Endotracheal intubation or tracheostomy is indicated if airway patency is threatened.
In those patients requiring ventilatory support, lung protective strategies should be employed. Prophylactic antibiotics and corticosteroids are not indicated for the treatment of smoke inhalation injury.

Burn shock resuscitation
Adult patients with burns greater than 20% total burn surface area (TBSA), and paediatric patients with burns greater than 10% TBSA should be formally resuscitated with salt-containing fluids; requirements should be based on body weight and percentage burn.
When IV fluid administration is practical, between 2 and 4 mL/kg body weight/burn surface area (% total body surface area, TBSA) should be administered within the first 24 h after injury, with alertness to over-resuscitation.

If only oral fluid administration is practical, drinking liquids (typical of the local diet) equivalent to 15% of the body weight every 24 h is recommended for two days. Five-gram tablets of table salt (or the equivalent) must be ingested for each liter of oral fluids.
When practical, monitoring the adequacy of resuscitation can be conducted by titrating salt-containing fluids. For adults, titrate provided fluids to average patients’ urine outputs of 0.3–0.5 mL/ kg/hour; in children titrate to 1 mL/kg/hour. For the first 3 h of resuscitation, values may still approach anuria, irrespective of the rate of fluid administration.

Escharotomy and fasciotomy in burn care
Escharotomy should be performed when circumferential or near circumferential eschar of the extremities compromises the underlying tissues or the circulation distal to it. Escharotomy should be performed when eschar on the trunk or neck compromises aeration and breathing.
Abdominal escharotomy should be performed when circumferential or near-circumferential eschar is associated with evidence of intra-abdominal hypertension (IAH) or signs of abdominal compartment syndrome (ACS).

Escharotomy should be performed in the longitudinal axes of the affected part near the neurovascular bundles. The extent of the incision in the eschar should range from normal skin to normal skin. If this is not possible, the range should extend from joint above to joint below. The depth of the incision is limited by reaching healthy tissue at the base.
Apart from high-voltage electrical injuries, fasciotomy is rarely indicated as a primary procedure in burns. Fasciotomy is more commonly performed once the diagnosis of compartment syndrome has been confirmed, particularly in cases of very deep burns, whatever their etiologies.

Wound care
Superficial partial thickness burns and donor sites of split-thickness skin grafts benefit from occlusion for long periods (at least one week). Humid and heat-preserving dressings are preferred. If these are not available, moist dressings should be used.
Cleansing with gentle washing is the most important component of burn wound cleansing. The beneficial effect of using antiseptics or antimicrobial agents for cleansing is unclear.
Raw areas should be dressed with a closed technique. Biologic dressings seem to be superior to non-biologic dressings. Type (temporary or semi-permanent) and frequency of dressing are decided according to the wound condition and availability of these products.

  • Closed dressing is the rule for deep partial thickness and full thickness burns.
  • If early excision is not feasible, deep partial and full thickness burns could be dressed by the open technique until eschar separation has begun.

Surgical management of the burn wound
An appropriately trained, prepared and equipped burn team is essential for any center treating serious burn injuries with excisional surgery.

  • An appropriate surgical plan should be designed for each major burn patient. The plan is determined by: the extent, site and depth of the burn injury; the general physical state of the patient; and the resources of the team treating the patient. Early excision and wound closure is the standard of care where resources permit, but a conservative approach to wound debridement is indicated where logistics and resources are outweighed by patient numbers or available skill sets.
  • Early surgery for small- to moderate-sized deep burns (less than approximately 20% TBSA) speeds recovery, might improve outcome and is cost-effective.
  • In high-voltage electrical injuries, urgent surgery may be life-saving and is necessary to allow the highest chance for limb salvage.
  • Tangential excision is the standard method of burn wound excision. Fascial excision may be indicated in very deep burns and high-voltage electrical conduction injuries. In a resource- limited setting (RLS), conservative wound management, staged removal of separated slough and delayed split skin grafting may be the most realistic approach, provided wound care is sufficient to prevent overt infection.
  • Burn wound excision and grafting can be undertaken without undue blood loss by using some or all of the following:
    􏰀

    • Subcutaneous infiltration of burn wound and donor site, or topical application of epinephrine solutions, or both 􏰀
    • Tourniquets for limb surgery
    • Fascial-type excision using electrocautery
    • Other topical hemostatic agents such as thrombin and fibrinogen
  • Prevention of hypothermia
    􏰀Compression dressings and limb elevation.
    After excision or debridement of the deep burn wound, it is essential that the wound is covered with autograft skin or an appropriate skin substitute.

Nonsurgical management of burn scars
Superficial burns (wounds that heal in <2 weeks) require topical emollients/humectants, sun protection, and massage after healing.

Deep dermal burns (wounds that heal in >3 weeks) require aggressive and monitored scar-prevention therapies augmented with appropriate pain relief and combined with early positioning regimens and physiotherapy for joint mobilisation to prevent hypertrophic scarring and joint contractures. These measures are required in addition to topical emollients, sun protection, and massage after healing.

  • All extensive burn hypertrophic scars should receive pressure therapy with silicone therapy as the first line of treatment.
  • Restraint should be applied in opting for the surgical modality before scar maturation unless the scar is functionally limiting because of a developing contracture.
  • The role of intralesional therapies is limited to small and discrete scar hypertrophy.

Infection prevention and control
A clean hospital environment should be maintained.
Hand hygiene guidelines should be taught, implemented and monitored.

Antibiotic stewardship
Avoid the use of prophylactic systemic antibiotics for acute burns.

Nutrition
Nutritional support should be provided during the acute phase of recovery.
Enteral nutritional support should be used in preference to parenteral nutritional support.
Conventional oral diets or enteral feedings should be initiated as soon as possible.
For patients with burns covering more than 20% of their body surface area, a high protein diet should be used with provision of adequate calories to meet energy needs. Adults should receive 1.5– 2 g of protein per kilogram body weight per day (g/kg/d), and children should receive 3 g/kg/d.
Energy requirements should be estimated by formulas that use variables such as burn size and age, and weight.

Rehabilitation. Part I—Positioning of the burn patient
Positioning of the burn patient in such positions so as to counteract contractile forces is critical in producing good functional outcomes in recovery and this positioning should be implemented along the continuum of care.

Rehabilitation: Part II—Splinting of the burn patient
Use orthotic and splinting devices to achieve appropriate positioning of the body surface area when immobilisation is warranted or to progressively stretch joints and maintain or promote movement.

Pruritus management
Routine care should include assessment for intensity, duration and impact of post-burn itching (pruritus) on activities of daily living (e.g., sleep, work, school, recreation).
Following wound re-epithelialization, skin hydration should be promoted and dryness minimised by using skin emollients. Such treatments are recommended for use multiple times per day.
When available, pharmacologic treatments should be considered to minimise significant post-burn pruritus.
Non-pharmacologic management of pruritus is appropriate whether or not pharmacologic treatment is available. Non-pharmacologic treatments that may assist in improving comfort include skin cooling (application of cool cloths), massage (in combination with hydrating lotions), localised pressure, oatmeal preparations, and electro-physical applications such as transcutaneous electrical nerve stimulation (TENS).

Ethical issues
Patient autonomy must be respected, with the patient him/herself making decisions regarding treatment. If the patient is unable to speak for him/herself, then a responsible surrogate must be appointed to provide decisions regarding care. The treatment team role resides in providing the best information to the patient and/or his/her surrogate regarding the likely course of care, alternatives, and prognosis.

The best course of burn treatment based on current evidence should be made available on a timely basis, with consideration for resource availability. All treatment decisions in burn care must provide direct benefit to the patient according to his/her wishes.

Systems of care for the significantly burned should be devised to provide services to all those with evidence of need. Burn care services should be provided regardless of ethnicity, gender, beliefs, or socioeconomic class.

Quality improvement
A burn center quality improvement program should include a regularly scheduled morbidity and mortality conference that incorporates peer review and loop closure.

A quality improvement burn program should include a registry that employs quality metrics which are benchmarked against burn-specific clinical norms.

These PGs (practice guidelines), intended for a primary audience of health professionals responsible for providing acute care and rehabilitation for burn patients, focus on acute care and rehabilitation.

These PGs can also be used by policy-makers, public health experts, and hospital managers. The information in these PGs can be included in tools for pre- and in-service training of health professionals, and to improve their knowledge, skills, and performance in burn care.

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Article credits: with full recognition to the following information sources:
www.arrivealive.co.za/Burns-Awareness-Campaign-Launch

*ISBI Practice Guidelines for Burn Care, Crossref DOI link: https://doi.org/10.1016/J.BURNS.2016.05.013. Published: 2016-08. Update policy: https://doi.org/10.1016/ELSEVIER_CM_POLICY.