Burns: Management of Burns- Acute or Intermediate phase

2. Acute phase/ Intermediate phase

Table : Fluid and Electrolyte Changes in the Acute Phase

Fluid remobilization phase (state of diuresis) Interstitial ﬂuid → plasma OBSERVATION	EXPLANATION
Hemodilution (decreased hematocrit)	Blood cell concentration is diluted as ﬂuid enters the intravascular compartment; loss of red blood cells destroyed at burn site
Increased urinary output	Fluid shift into intravascular compartment increases renal blood ﬂow and causes increased urine formation.
Sodium (Na+) deﬁcit	With diuresis, sodium is lost with water; existing serum sodium is diluted by water inﬂux.
Potassium (K+) deﬁcit (occurs occasionally in this phase)	Beginning on the fourth or ﬁfth post-burn day, K+ shifts from extracellular ﬂuid into cells.
Metabolic acidosis	Loss of sodium depletes ﬁxed base; relative carbon dioxide content increases.

Duration: From beginning of diuresis or mobilization of extra-celluar fluid to near completion of wound healing/closure. This may take weeks or many months.

Goals :

Interventions in acute phase

Wound care
Excision and grafting
TT
Antimicrobials
Pain management- Analgesics and sedatives
Physical and occupational therapy
Nutritional support, GI support
Psychosocial care
Hydrotherapy: in the form of shower carts, individual showers, and bed baths can be used to clean the wounds.
immersion hydrotherapy
Because of the high risk of infection and sepsis, thorough decontamination of hydrotherapy equipment and wound care areas are necessary
Temperature of the water- 37.8°C (100°F)
Should be limited to a 20- to 30-minute

Topical Antibacterial Agents Used for Burn Wounds

AGENT	INDICATION	APPLICATION
Silver sulfadiazine 1% (Silvadene) water soluble cream	Most bactericidal agent Minimal penetration of eschar	Apply 1⁄16-inch layer of cream with a sterile glove 1–3 times daily
Mafenide acetate 5% to 10 %(Sulfamylon) hydrophilic-based cream	Effective against gram-negative and gram-positive organisms Diffuses rapidly through eschar In 10% strength, it is the agent of choice for electrical burns because of its ability to penetrate thick eschar.	Apply thin layer with sterile glove twice a day and leave open as prescribed. Or if the wound is dressed, change the dressing every 6 hours as prescribed.
Silver nitrate 0.5% aqueous solution	Bacteriostatic and fungicidal Does not penetrate eschar	Apply solution to gauze dressing and place over wound. Keep the dressing wet but covered with dry gauze and dry blankets to decrease vaporization. Remoisten every 2 hours, and redress wound twice a day.
Acticoat	Effective against gram-negative and gram-positive organisms and some yeasts and molds Delivers a uniform, åntimicrobial concentration of silver to the burn Wound	Moisten with sterile water only (never use normal saline). Apply directly to wound. Cover with absorbent secondary dressing. Remoisten every 3–4 hours with sterile water.

Time of exercise: during and after wound cleansing when the skin is softer and bulky dressing is removed

Passive and active ROM exercises - on all joints

Neck burns- sleep without pillows or with the head hanging slightly over the top of the mattress to encourage hyperextension

Custom fitted splints

Nutritional therapy

Goal: to provide adequate calories and protein to promote healing
Should begin within the first 1 to 2 days of post bum: high calorie, high protein
Daily estimated caloric needs must be regularly calculated by dietician and readjusted as patients condition changes
NG tube - with complete liquid diet = for patients on ventilator and unable to consume by mouth
Parenteral nutrition
Swallowing assessment
Ideally weight loss should not be more than 10% of pre-burn weight
Weight check on a regular basis

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