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By Andy Green, DipClinPharm, MRPharmS andNicola Rudall, MSc, MRPharmS

The treatment of burns must be timely andappropriate to ensure the best outcome for patients.Basic first aid measures are described in Box 1

(p250). Pharmacists involved in the management ofpatients with burns must have an understanding of factorssuch as altered pharmacokinetics in burns patients,nutritional requirements and appropriate wound dressings.

Pharmaceutical considerationsPharmacokinetics Patients with burns have alteredpharmacokinetics for a variety of reasons. In the first 48hours following a burn, hypovolaemia, hypoalbuminaemiaand oedema lead to reduced organ perfusion and,therefore, decreased renal drug clearance. Once the bodybecomes hypermetabolic, clearance is increased. This iscaused by increased cardiac output and contractilityleading to higher blood flow to the kidneys and liver, aswell as potential loss of drugs via the exudate. Hence,burns patients may require higher doses or more frequentadministration of medicines than non-burns patients.Extensive fluid shifts and an increase in the synthesis ofliver proteins can cause abnormal distribution of protein-bound drugs. Therapeutic drug monitoring may be of usefor some medicines, particularly antibiotics and drugs withnarrow therapeutic windows.1

Drug administration Initially, patients with extensiveburns are likely to be sedated and intubated. There may bedifficulty obtaining venous access because the skin iseither burnt or a potential donor site for grafting; a centralline may be required. Intubated patients will usually havean enteral feeding tube since drug administration isimportant and adequate nutrition essential. The mostappropriate route for drug administration must beestablished to ensure that patients do not miss essentialmedicines.

Intravenous fluidsAs discussed in the accompanying article (p245), burnspatients have a reduced circulating blood volume. This iscaused by exudating fluid from the burn site, elevated skintemperatures (leading to evaporation) and capillaryleakage.2 Early fluid resuscitation increases tissueperfusion (particularly to the burn site) and blood flow toorgans. Adequate fluid resuscitation is essential for patientswith burns to more than 15% (10% for children) of bodysurface area (BSA), particularly in the first 48 hoursfollowing the burn.3 The Parkland formula calculates thevolume of fluid (in litres) that should be given in the first24 hours:

Fluid (L/24h) = 3–4 (ml) x patient weight (kg) x BSA burnt (%)

Half of the volume should be given in the first eighthours after the burn (not from the time the patientpresents for treatment) and the other half over thesubsequent 16 hours. The infusion rate should be adjustedaccording to response; requirements are affected by factorssuch as burn depth, age, delay in resuscitation,escharotomies (see below), and drug or alcohol abuse.

Timely and appropriate management ofburns can improve the outcome for victims

Burnsmanagement

Andy Green is senior lead clinical pharmacist forsurgical services and Nicola Rudall is senior leadclinical pharmacist for perioperative and critical care,both at Newcastle Upon Tyne Hospitals NHSFoundation Trust.E: andrew.green@nuth.nhs.uk

SUMMARYAppropriate management of the patient in the first 48 hours after a burn isessential for optimal recovery. Principally, this will include fluid resuscitationand emergency surgery. Later, optimum conditions for healing and tissueregeneration must be maintained and skin grafting may be needed. The patient will require a range of therapeutic interventions, including

nutritional supplementation, use of antimicrobials, analgesia and appropriatewound dressings. In the long term, patients are at greater risk of sundamage and the healed burns can form contractures and are often itchy.

Surgeon transplanting a meshed skin graft onto a patient’s burn

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Additionally, patients with inhalational injuries may needmore fluid.3–5

The preferred fluid is generally the crystalloid solutionknown as Hartmann’s (compound sodium lactate).3

Sodium chloride can cause hyperchloraemic acidosis andshould be avoided.3

Although there is no evidence that colloids (eg,gelatins) provide better fluid resuscitation in burns, theymay reduce the volume of fluid that needs to be given.However, colloids can leak into the extravascular spacewhile the patient has increased vascular permeability andthis may prolong oedema.2,5

A Cochrane meta-analysis6 demonstrated an increasedmortality with albumin administration for burns patients.One possible reason for this is an increased incidence ofoedema caused by albumin redistribution via capillaryleakage. Despite this, a recent survey of fluid practice inburns units showed that albumin is widely used.7

Although fluids are essential in the initial managementof burns patients, they should be assessed regularly andadjusted, where appropriate, to minimise the risk of fluidoverload. Fluid overload can increase oedema leading toimpaired healing and can also worsen respiratoryproblems such as acute respiratory distress syndrome. Thetarget minimum urine output is 0.5ml/kg/h unlessrhabdomyolysis or myoglobinuria is suspected, in whichcase the target should be doubled.

AnalgesiaPain control is important in the acute phase and long term.Multiple factors influence pain, including the nature andextent of the burn, anxiety (and other psychologicalconditions), environment and an individual’s painthreshold. Pain can originate from the burn itself, dressingchanges, donor graft sites or nerve regrowth.8,9 Regularpain assessment and appropriate analgesia are essential.

Strong opioids are a good choice for initial analgesia.Morphine can provide the additional benefit of a reducedincidence of post-traumatic stress disorder.8 Variablepharmacokinetics in burns patients means that carefultitration of opioids, based on response, is necessary. Thedose should be stepped down as the patient’s painimproves; this is done gradually to minimise the risk ofsymptomatic withdrawal. It is worth noting that opioidscan cause hyperalgesia, exacerbating the existing pain.8,9

Simple analgesia, including paracetamol, should beprescribed as an adjunct to opioid therapy.

Regenerating nerves frequently cause pain or alteredsensation. Patients with nerve damage may benefit fromtreatment with medicines that target neuropathic pain,such as gabapentin or amitriptyline. Gabapentin also hasan opioid-sparing effect and may reduce itching associatedwith burns.8 Medicines for neuropathic pain should beinitiated early in treatment (since they can take weeks toreach their full analgesic effect).

Patients requiring higher levels of analgesia for shortperiods (eg, for dressing changes) have been shown tobenefit from an infusion of the very-short-acting opioidremifentanil.8,9 Remifentanil should be administered bystaff trained in anaesthesia because of the risk ofrespiratory depression. The patient’s background painrelief should be managed appropriately to ensure there isno break in analgesia once the infusion is stopped. Inhalednitrous oxide or the anaesthetic ketamine may bealternatives to remifentanil for short-burst analgesia;ketamine provides pain relief and causes a dissociativestate.

SedationPatients with extensive burns or burns affecting theirairway are routinely intubated and mechanicallyventilated.10 The neuromuscular blocker suxamethoniumshould be avoided during intubation because it canexacerbate hyperkalaemia to a potentially fatal level.1

Initially patients will be continuously sedated. This isachieved using a combination of sedatives (usuallypropofol and an opioid such as morphine or fentanyl).Sedated burns patients who require paralysis may needsubstantially higher doses of neuromuscular blockerscompared with non-burns patients because of alteredpharmacokinetics.1 The patient should be sufficientlysedated to allow essential procedures to be carried out andto minimise distress. However, the patient should beregularly assessed for over-sedation (since this may lead tocomplications such as ventilator-associated pneumonia).

As the patient’s condition improves, sedation should beweaned. During weaning, it is important to ensure analgesiaremains adequate — patients with insufficient pain reliefare at an increased risk of delirium once sedation is ceased.

Box 1: First aid for burns

� Ensuring your own safety, remove the person from the source of theburn. For electrical burns, the power must be switched off before goingclose to the patient

� If the person’s clothing is alight, her or she should be told to drop to thefloor and roll over to extinguish the flames (“drop and roll technique”)

� The burn should be immediately cooled with lukewarm running water for at least 20 minutes (not too cold as this can cause too much vasoconstriction and can lead to hypothermia). The same technique isvitally important for chemical injuries to dilute the toxic substance

� The patient should be assessed for severity of the injury. Be aware of therisk of inhalational injury, which can result from fire in an enclosed space

� Cling film can be used as an initial dressing that protects the wound,reduces pain and allows visual inspection. Care should be taken not towrap the wound too tightly because the area will swell

Specialists examine a skin graft on a child’s leg

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Patients should be screened regularly for delirium and, if itis found, underlying causes should be treated.9

NutritionPatients with extensive burns are in a catabolic state and,therefore, require 50–75% more calories than non-burnspatients.3 Inadequate nutrition can impair wound healing,increase risk of infection and cause more pronouncedcatabolism.

Enteral, rather than parenteral, nutrition is preferred.For patients with burns covering more than 20% of BSA,nutritional requirements will not be met with oral intakealone; additional enteral feeding will be required.5

The 2006 European Society for Clinical Nutrition andMetabolism guidelines11 recommend that trace elements,specifically copper, zinc and selenium, should be given for30 days after the burn. The burns unit at Newcastle uponTyne Hospitals NHS Foundation Trust gives traceelements as an intravenous infusion, once daily for eightdays, to all patients with burns >25% of BSA. A suitableoral multivitamin preparation (eg, Forceval) can be usedfor ongoing supplementation when oral administration isappropriate. Glutamine should also be added to standardenteral feeds because, along with trace elements, it hasbeen shown to reduce infection, shorten hospital stay andreduce mortality.11 One paper suggests that, because of itsfree radical-scavenging properties, high-dose ascorbic acidmay benefit burns patients.5

InfectionBurns patients will often display a systemic inflammatoryresponse syndrome (which includes raised temperature,heart rate, respiratory rate and white cell count) and so canappear septic in the absence of infection.5 Systemicantibiotics should therefore be guided by cultures andsensitivity testing and should not be given prophylactically.

Topical antimicrobials or antiseptics are often used toprevent the development of infection in the burn areas,grafted tissue or donor sites (see Box 2).4 Localisedinfection in a wound can impair healing or cause failure ofgrafted tissue. Choice of treatment is usually governed bythe results of wound swabs and physical inspection of thewound.2,5 Common pathogens include Staphylococcus aureus,Pseudomonas aeruginosa and Acinetobacter baumannii.

It has been suggested that selective decontamination ofthe digestive tract in burns patients can reduce theincidence of hospital-acquired pneumonia.12 The aim is tokill gastrointestinal pathogens before they transfer to thelungs. However, the evidence to support this practice isinconclusive and practice varies widely between units.

Management of chemical burnsBefore the severity of strong acid or alkali burns can beassessed, the burn must be irrigated with water for as longas possible (at least 20 minutes) to dilute the chemical andnormalise the pH; indicator paper can be used to checkwound pH. Identification of the chemical is important(alkali burns tend to be deep and hydrofluoric acid [HF]burns require specific management).4

Hydrofluoric acid burns HF is one of the strongestinorganic acids and is used mainly for industrial purposes

(eg, metal processing). If any concentration of HF affectsmore than 5% of BSA, or if concentrated HF affects aslittle as 1% of BSA, injury will be severe. Deaths haveoccurred following concentrated HF burns affecting aslittle as 2.5% of BSA.

HF causes direct tissue injury by two mechanisms:corrosive burn and chemical damage. Hydrogen ions causecorrosive injury typical of a strong acid, which tends to besuperficial. Absorbed fluoride ions cause chemical tissuedamage. Additionally, fluoride ions cause systemic toxicitythrough formation of insoluble salts with calcium andmagnesium ions (resulting in hypocalcaemia andhypomagnesaemia).

Solutions of HF often penetrate tissues deeply beforeinjury becomes apparent and surface damage can beminimal despite significant injury. Exposure to dilute HFtends to cause little immediate damage but pain and toxicitycan manifest several hours after. Concentrated (>50%) HFwill cause immediate erythema, blistering and necrosisaccompanied by deep burning or throbbing pain. Often thepain associated with a HF burn seems disproportionatelyworse than visual symptoms would indicate.13

Initial treatment of a HF burn is to decontaminate withcopious amounts of water, even if there is no apparent injury.Repeated topical application of calcium gluconate gel 2.5%to any HF burn may limit damage and give some pain relief.

Box 2: Topical antimicrobial treatments

AVAILABLE VEHICLES

Cream(Flamazine)

Silver matrixdressings

Ointment incombination withcerium nitrate(Flammacerium)

Ointment or sheetdressings

Cream (Furacin)

Gel (FlaminalHydro andFlaminal Forte)

Solution, spray,ointment,dressings(Inadine)

TREATMENT

Silversulfadiazine

Honey dressing

Nitrofurazone

Alginate/glucose oxidase/lactoperoxidase

Povidone iodine

ACTIVITY

Broad spectrumagainst Gram-negative and Gram-positive bacteriaincludingPseudomonas spp

Naturalantimicrobialproperties

Wide range ofGram-negative andGram-positivebacteria; limitedactivity againstPseudomonas spp

Meticillin-resistantStaphylococcusaureus (MRSA),Candida albicans,Pseudomonas spp,Escherichia coli

Antimicrobialactivity against awide range oforganisms,including MRSA,viruses and fungi

USES AND LIMITATIONS

Used on wounds withknown or suspectedPseudomonas sppcolonisation. Penetrates escharwell. Not for initialuse since it altersappearance of woundmaking assessmentdifficult

Used to aid autolysiswhen surgery is notappropriate and onsloughy wounds

Unlicensed productused on infectedwounds or grafts inconjunction withdressings

Used on heavilycolonised wounds toreduce microbial loadand aid healing

Used on infectedwounds or graftsSystemic toxicity isseen if applied overlarge wounds

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If pain is severe, calcium gluconate 10% solution can beinjected subcutaneously under the burnt tissue.

The patient must be monitored for hypocalcaemia — ifthe patient displays symptoms (eg, weakness, paraesthesia,tetany, convulsions, coagulation disturbances orelectrocardiogram changes), intravenous calciumgluconate 10% should be administered immediately, evenif calcium levels are not known. Potassium, phosphate andacid-base balance should be monitored closely.10

Surgical managementSurgical procedures for burns patients includeescharotomy (see below), debridement, skin grafting andscar revision. Extensive burns can require multipleoperations separated by periods of recovery to allow forwound healing and regrowth of donor skin for skin grafts.

Escharotomy A complication of an extensive burn is thatthe burnt tissue (eschar) quickly loses elasticity. A largeburn on the thorax can compromise chest expansion or acircumferential burn (one that extends all the way around)on a limb can restrict blood flow critically. To release thistourniquet-like effect, deep longitudinal excisions aremade in the affected area; this is called an escharotomy.2,4

Excision and grafting Blistered skin (unless small) isremoved if broken or “deroofed” in the case of largeblisters.4 When treating deep dermal burns, using acombination of excision and grafting is common. Forsuccessful grafting, all necrotic tissue needs to be removed.This is achieved using a device called a dermatome (seeFigure above) or a specially designed knife that cangradually remove thin layers of necrotic tissue until aviable wound bed is reached (identified by capillarybleeding in the wound).14 An alternative technique is to usea high pressure water jet system that is sprayed parallel tothe wound bed to remove non-viable tissue.

Once haemostasis is achieved, a skin graft or skinsubstitute can be applied. The most successful technique isto use a portion of the patient’s own skin, which is removedfrom an unaffected part of their body (donor site). Mostcommonly a “split skin graft” is performed, where a

dermatome is used to remove a thin layer of skin at acontrolled depth (usually mid-dermal). This can then beapplied to the wound bed intact (sheet graft) or, where alarger area of coverage is needed it can be meshed, using adevice that makes regular small incisions (fenestrations) inthe graft, and then stretched to up to six times the originalarea. The graft can be stapled, stitched or applied usingtissue glue. Mesh grafts result in a fishnet-like appearanceafter healing, so sheet grafts should be used in areas wherecosmetic appearance is important (ie, face, hands, neck).

Donor sites should heal within two to three weeks,providing the graft taken is not removed too deeply andthat the area is protected and does not become infected.14,15

If donor skin is in short supply, skin substitutes (eg,Integra) or donated cadaver skin (allografts) can be used.These are only temporary measures because infectionrates are higher when skin substitutes are used and cadaver skin will eventually be rejected (unlessimmunosuppressants are used).14 In the case of full-thickness or fourth-degree burns, a “skin flap” may berequired. This involves using full-thickness donor tissueincluding underlying muscle and blood supply.15

DressingsOptimum management of burn sites, skin grafts and donorsites relies on the expertise and experience of practitioners(particularly nurses) who have worked in specialist burnscentres for many years. A burn site is typically coveredwith two or more layers of dressings (see Box 3, p254).

A primary dressing should provide an optimumenvironment for wound healing (moist, oxygenated andprotected from trauma and microbes). It should also allowinspection of the wound, absorb exudate and be easilyremovable with minimal trauma to underlying healingtissue. A secondary dressing should absorb any excessexudate and provide protection to the wound from pressureand shearing forces.4 The primary and secondary dressingsmay need to be secured in place by suitable bandages.Many modern dressings are manufactured in multiplelayers so that a single dressing has several propertiespreviously only available using a combination of dressings(eg, a non-adherent layer bonded to absorbent foam).

New skin grafts are often covered with dressingsimpregnated with antibacterials (eg, silver) or are used inconjunction with topical antibacterials or antiseptics toprevent infection that can cause a graft to fail. Donor siteswill also require dressings to aid healing and to preventinfection.

Other therapiesLaxatives Because burns patients often receive high dosesof opioids, constipation can become a problem. Patientsshould be assessed regularly and laxatives prescribed asappropriate. Patients with burns on the back or around thebuttocks are at risk of infection following contamination ifthey soil themselves while in bed. As such, some patientshave a bowel management system inserted to removefaeces. Faeces need to be fluid for the system to work sopatients may be given laxatives for this purpose.

Anticoagulation Burns are a risk factor for developingvenous thromboemboli and therefore most patients should

Surgeons using a dermatome to excise burnt skin

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�EXTENSIVE BURNSCAN REQUIREMULTIPLEOPERATIONSSEPARATED BYPERIODS OFRECOVERY TOALLOW FOR WOUNDHEALING ANDREGROWTH OFDONOR SKIN FORSKIN GRAFTS

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11 Martindale RG, McClave SA, Vanek VW, et al. Guidelines for the provisionand assessment of nutrition support therapy in the adult critically illpatient. Critical Care Medicine 2009;37:1757–61.

12 De La Cal MA, Cerda E, Garcia-Hierro P, et al. Survival benefit incritically ill burned patients receiving selective decontamination of thedigestive tract: a randomized, placebo-controlled, double-blind trial.Annals of Surgery 2005;241:424–30.

13 Wilkes G. Hydrofluoric acid burns. http://emedicine.medscape.com/article/773304-overview (accessed 18 June 2010).

14 Orgill DP. Excision and skin grafting of thermal burns. New EnglandJournal of Medicine 2009;360:893.

15 Dunn R. Grafts and flaps. Surgery 2006;24:27–32.

16 Berman B. Keloid and hypertrophic scar.http://emedicine.medscape.com/article/1057599-overview (accessed 28June 2010).

17 Shelley OP, Dziewulski P. Late management of burns. Surgery2006;24:15–7.

Box 3: Burn dressings

DESCRIPTION

Simple gauzemesh impregnatedwith white softparaffin orchlorhexidine

Forms gel withexudate. Sheetdressing

Transparentsemipermeablefilm

Non-adherentsilicone sheet orfoam dressing

Alginate gel orsheet — formsgel with calciumions from plasma

Amorphous,cohesivesubstance thathydrates wound

Allevyn-Ag: Silver-impregnatedpolyurethanefoam Iodosorb:Hydrogelcontaining iodine

Dressing withthree layers(silver, foam andwaterproofbacking)

TYPE

Paraffin andchlorhexidinegauze (eg,Paratulle,Jelonet,Bactigras)

Hydrocolloid(eg, Granuflex,Aquacel)

Film dressing(eg, Opsite)

Non-adherentdressing (eg,Mepitel, Telfa,Urgotul)

Alginatedressing (eg,Sorbsan,Kaltostat)

Hydrogel (eg,Intrasite,Mesitran)

Antimicrobial-impregnateddressing (eg,Allevyn-Ag,Iodosorb)

Multilayerdressing (eg,ActicoatMoistureControl)

ADVANTAGES

Inexpensive, easyto use. Relativelynon-adherent souseful for first aid

Helps absorbexudate, good onsmall or difficultareas such as hands

Barrier to bacteriaand reducesmoisture loss fromwound. Allows easyinspection of wound

Easily removed andprovidesmechanicalprotection of wound

Suitable forexudating orbleeding wounds.Can be left in placeuntil it falls offduring healing

Suitable for cavitiesor dry, sloughywounds. Promotesautolysis of necrotictissue so is usefulfor burns unsuitablefor surgery

Useful for infectedwounds and skingrafts

Useful for infectedwounds withexudate. Backingcontrols moisturelevel

DISADVANTAGES

Does not absorbexudate or aidhaemostasis; adheresto deeper woundsmaking removaldifficult

Layer of gel may bedifficult to removeand obscuresinspection

Not suitable forheavily exudatingwounds. Canmacerate wound

Silicone sheet is non-absorbent. Unsuitablefor exudating orbleeding wounds

Gel quickly falls offfull-thickness orheavily exudatingwounds requiringfrequentreapplication

Not suitable forheavily exudatingwounds

Expensive

Expensive

be treated prophylactically with a low molecular weightheparin.5

Acid suppression Burns are a risk factor for developingduodenal ulcers (Curling’s ulcers). Patients should receivea proton pump inhibitor or H2-receptor antagonist.5

Long-term managementPatients who have severe burns will need ongoing follow-up in an outpatient clinic for months or years.

Scarring Hypertrophic (erythematous, pruritic andraised) scars16 can occur following treatment and mayneed to be managed using excision surgery or topicalsilicone gel (eg, Kelo-cote). Over-granulation duringhealing can also cause scarring that can be reduced usingcorticosteroids (eg, topical betamethasone ointment orintralesional injection of triamcinolone).17

Contractures Grafted skin, particularly across joints, willcontract and tighten causing reduced mobility. This canbe lessened with regular physiotherapy and scar massageusing topical emollients.4 Contractures may requirerevision surgery to release tight areas.

Dry skin and itching Lack of normal sweat and oilglands in grafted areas means that patients will have alifelong requirement to use emollients and will often needto take antihistamines to control itching.17

Sun sensitivity All patients are advised to avoid sunexposure or use total sunblock following significant burninjury.3,4 Depigmented areas are common, especially inpatients with darker skin — skin camouflage products canimprove the cosmetic appearance of these areas.

RecoveryRecovery from extensive burns is often slow and painfuland can involve frequent bouts of infection and multipletrips to theatre for skin grafts. Intensive physiotherapy isrequired to ensure the patient has maximal movement.Psychological trauma following the burn is common andmay require psychiatric input or counselling to aidrecovery.3

References1 Blanchet B. Influence of burns on pharmacokinetics and

pharmacodynamics of drugs used in the care of burn patients. ClinicalPharmacokinetics 2008;47:635–54.

2 Duncan RT, Dunn KW. Immediate management of burns. Surgery2006;24:9–14.

3 Enoch S, Roshan A, Shah M. Emergency and early management of burnsand scalds. BMJ 2009;338:937–41.

4 Benson A, Dickson WA, Boyce DE. ABC of wound healing: Burns. BMJ2006;332:649–52.

5 Latenser BA. Critical care of the burn patient: the first 48 hours. CriticalCare Medicine 2009;37:2819–26.

6 Cochrane Injuries Group Albumin Reviewers. Human albuminadministration in critically ill patients: systematic review of randomisedcontrolled trials. BMJ 1998;317:235–40.

7 Greenhalgh DG. Burn resuscitation: the results of the ISBI/ABA survey.Burns 2010;36:176–82.

8 Richardson P, Mustard L. The management of pain in the burns unit.Burns 2009;35:921–36.

9 Gregoretti C. Analgo-sedation of patients with burns outside theoperating room. Drugs 2008;68:2427–43.

10 National Poisons Information Service. Management of skin exposure tohydrofluoric acid. www.toxbase.org (accessed 18 June).

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