THE EXPOSURE METHOD FOR BURNS

INDICATIONS See Section 58.12.

EQUIPMENT The equipment for cleaning a burn is simple, but it must be sterile. It includes aqueous chlorhexidine solution or saline (conveniently from a bottle of intravenous saline), a gallipot, and a sterile glove.

Figure 58.11: THE EXPOSURE METHOD is the most practical one for most burns in the hospitals for which we write.

METHOD Sedate the child with chloral hydrate or ketamine. Put him on a sterile mackintosh in a clean bed. Put a sterile theatre drape or a clean sheet on top of this. Leave the burn alone, the heat will have sterilized the burnt surface. Don’t prick the blisters unless they are tense and painful.

Local antibacterial agents are desirable, but not absolutely necessary. Some workers apply povidine iodine or cetrimide.

Put a cradle over the child and cover this with another sterile drape.

TEMPERATURE The room should be warm and moist (40C and 40% relative humidity is ideal). Monitor his temperature carefully. Feel his extremities. If necessary, close the windows and put a heater beside him. Electric fans heaters are the best, but with suitable precautions you can use a charcoal brazier. Don’t put him in the sun, except for short periods, because pink depigmented skin burns easily.

THE THIRD OR FOURTH DAY ONWARDS

Don’t do anything to the dry surface of a superficial burn after the first day. Continually dressing and scraping its surface interferes with healing. Tell the nurses that it is being dressed, but that it is being dressed with air! Let any dry part of the burn remain dry. If more blisters form, prick them. Try to preserve the dry crust until it falls off naturally. Clean only parts which remain wet. Use gauze swabs and chlorhexidine, or sterile saline, as for the initial toilet.

CAUTION! If there is any danger that a tight crust or eschar might be obstructing the child’s circulation, split it immediately (58.18).

You may not know it a burn is superficial or full thickness until about the 7th day.

SUPERFICIAL AND DEEP PARTIAL THICKNESS BURNS (B and C in Fig. 58-9) dry to form an eschar which falls off in 7 to 12 days in type B, or 10 to 21 days in type C, with little bleeding. They heal in 3 to 4 weeks.

FULL THICKNESS BURNS (D, and E) form thick sloughs and eschars. Choose between the following methods.

(1) Leave the eschar open to the air. Remove it in the theatre at 10 to 18 days, and then graft.

(2) Much the best, start the saline method at 48 hours. Either put the burnt part in a bowl of half strength saline 4 hourly or pour saline on the dressings 4 hourly (58.16). Some slough will come away in the dressings, remove large pieces by ’sloughectomy’ in the theatre, then graft.

DIFFICULTIES WITH THE EXPOSURE METHOD FOR BURNS

If a DEEP BURN CROSSES A FLEXURE, splint the patient’s limb in extension. You can safely do this for 3 weeks in an adult or 6 weeks in a child while the skin over it heals. Then mobilize it—see Section 58.24. Skeletal traction as in Fig. 58-15 may be the best way to maintain extension.

CAUTION! Appropriate splinting is essential to prevent contractures: (1) To prevent movement of the joint while the graft takes. (2) To maintain the positions in Fig. 58-16 until the burn has healed.

If DRY ESCHARS CRACK over a patient’s flexures, such as those of his elbows or axillae, splinting is required, so change methods.

If his burn is deep use the saline or the closed method for the deep part of it, and, if necessary, excise the slough.

If it is superficial, apply vaseline gauze or silver sulphadiazine cream. In deep burns the skin under these cracks always needs grafting and you will have to take great care to prevent contractures. You may also have to graft cracks in burns which are superficial elsewhere.

If he has EXTENSIVE BURNS ON HIS TRUNK, arrange his position so that he lies on normal skin, not on his burn. If his back and buttocks are burnt, turn him hourly, if he has burns all round his body, the only way to nurse him by this method is in a string hammock. His burns will probably be at least 50%, so his chances of surviving are not good.

If his BUTTOCKS AND PERINEUM HAVE BEEN BURNT, put him in gallows traction (78.2), if he is under 5, and expose his burn. If necessary, (and it seldom is) catheterize him, and don’t let overflow incontinence develop. Urine does not harm a burn, but moisture promotes infection. His perineum will be difficult to graft, and perineal grafts usually fail, so you may need to repeat them several times.

If his AXILLA has been burnt, try holding his arm above his head with skin traction—this is not easy. If he SCRATCHES HIS EXPOSED BURNS, try to prevent him doing so, because scratching can easily convert a superficial burn into a deep one. Immobilize both his elbows in padded plaster cylinders to keep them extended. Sedate him. Don’t try tying his hands to the sides of his cot, because this is cruel and dangerous.

If PUS APPPEARS, send a swab for culture daily. Dip a swab in sterile broth (or saline) and rub it widely over the burn.