European Practice Guidelines for Burn Care Based by the Copenhagen EBA meeting, September 2002 by B.F.Alsbjoern M.D., D.M.Sc.
Practice Guidelines for Burn Care
The present European guidelines for burn care are the results of an European Burn Association meeting held in Copenhagen, September 2002. The purpose of this meeting was to identify and clarify some European common practice guidelines in modern burn care. The meeting was announced in the EBA newsletter and as such open for everyone who had an interest in burn care.
The purpose of medical guidelines is to give a medical team some sound evidence for ensuring safe care of the patient. The present guidelines are based on scientific evidence and sound clinical experience. Guidelines should give the medical person references from which the treatment can be extracted. However, still the medical person holds the responsibility for the best treatment.
The medical person is free to choose what he or she feels is the best treatment. So, -guidelines are only intended to be aids for proper care of the patient.
Few items of burn care are here debated, but still other aspects of burn care need to be profoundly investigated, clarified and then recorded.
This is not a definitive work, but examples of topics for consideration and perhaps reconsideration.
A schedule for interpretation of the ideas has been:
- Accepted principles of treatment based on very high degree of clinical certainty
- Applied rigedly.
- Standards are rules.
- Strategies of treatment based on moderate clinical certainty.
- Should most often be followed and only broken if medical justified.
- Possible ways of treatment based on personal clinical observation.
- Should be submitted future clinical studies
The Burn Centre
- An organized medical system for total care of the burned patient.
- Includes a medical staff and an administrative staff dedicated to the care of the burned patient.
- Is properly equipped for the treatment of all aspects the burned patient.
- Treats adults and or children with burns.
- Sustains a very high level of experience in treatment of the burned patient.
- Conducts a certain minimal number of acute procedures and follow up reconstructive surgical procedures per year.
The burn centre director
- The burn centre should be directed by a physician with granted authority to run and coordinate all services for the burned patient.
- Must be highly experienced in all aspects of burn care with an education of at least 4 years in a burn centre
- Responsible for strategies, polices and procedures for care of the burned patient.
- Responsible for safe medical care and proper protocols.
- Responsible for sufficient qualifications amongst the staff.
- Responsible for appropriate training, education and research in the centre.
- Responsible for updated multiple casualty plans including triage, prehospital treatment and initial care.
- Responsible for accepted accreditation by a Joint Commission of Accreditation of Healthcare Organization
- Staff physicians must have a high expertise in burn treatment achieved by training in a burn centre for at least one year.
- Must participate in education and research in the burn centre.
- A burn centre must have at least one full time burn care surgeon (specialist) and one respiratory therapist available in the centre on a 24-hours basis.
- Should be led by a registered nurse with years of experience in burn care in a burn centre and sustain proper managerial experience.
- Patients should have access to a registered nurse, highly experienced in the care of the burned patient, on a 24-hour day level.
- The centre should be equipped with a sufficient amount of nurses to meet modern standards of care of the burned patient.
- The nurse should be able to handle all types and degrees of severity of burned patients, critical ill patients, different types of cutaneous wounds and ulcers and all aspects of rehabilitation.
- A burn Centre should permanently have assigned physical and occupational therapists to the burn team.
- Rehabilitation personal should have at least one year of experience in a burn centre.
- Rehabilitation personal should deal with inpatients as well as outpatients.
- A burn centre should have available social service consultations by an experienced social survive worker on a daily basis.
- A burn centre should have a dietitian service available on a daily basis for consultation.
Admission Level for a Burn Centre
In order to ensure a current high level of training and expertise in the treatment of all aspects of the burned patient, following items should be met by a burn centre:
- A burn centre should admit at least 75 acute burned patients annually, averaged over a three years period.
- A burn centre should always have at least 3 acute patients admitted in the centre, averaged over a three years period.
- A burn centre should perform at least 50 follow-up reconstructive surgical procedures annually.
In Europe, one burn centre is advisable per 5-10 million inhabitants.
- A burn centre should have at least 7acute beds especially equipped and designed for the care of a major burned patient, i.e. high room temperature, climate control, total isolation facilities, adequate patient surveillance, intensive care monitoring fascilities (level II).
- A burn centre should have access to an operating room, equipped with all needs for burn surgery and respiratory assistance service on a 24-hours basis.
- A burn unit should have an established current germ surveillance program.
- A burn centre should have or at least have access to a skin bank.
- A burn centre should have access to anaesthesiology, plastic surgery, orthopaedic surgery, cardiology, cardiacthoracic surgery, gastroenterology, urology, haematology, neurology, obstetics/gynocology, othorhoinolaryngeology, psychiatry, radiology and laboratory services on a 24-hours daily basis.
Burn Depths and Extent of Burned area
In the treatment of burns the first thing to be described is the depth of the burn and the proportion of the body being involved. In this way the severity can be clarified and the treatment designed. The classification of burn depth has throughout several years been under debate. Most often used terms are depths related to thickness or to degree. It is now proposed that burn depths should be referred to as:
|Previously||was replaced by||now to be replaced by|
|l degree||epidermal||epidermal burn|
|ll degree||second degree superficial||superficial partial thickness burn|
|lll degree||second degree deep subderma||
deep partial thickness burn
full thickness burn
(full thickness burn +)
Epidermal burn: skin erythema, intact skin, e.g. sunburn. Should not be calculated in the extent of the burned surface area.
Superficial partial thickness burn: involve epidermis and part of the papillary dermis. Is part of the % burned area. Should be left to heal by itself.
Deep partial thickness burn: involve epidermis, the entire papillary dermis down to reticular dermis. Is part of the % burned area. Should not be left to heal by itself, but instead be submitted to surgery.
Full thickness burn: involve the entire thickness of the skin and possibly subcutaneous tissue. Is part of the % burned area. No healing capacity and as such should always be submitted to surgery.
(Full thickness burn +: involve the entire skin and sub lying structures such as muscle or bone.)
The Extent of the Burn
Percentage burned surface area should be estimated by the Lund-Browder chart, supplemented by the use of the patients palm and fingers to represent 1% of the patients body surface area.
Burn Shock Resuscitation
The purpose of burn shock resuscitation is to counteract the hypovolemia seen during the first 24-48 hours after the trauma. A profound fluid shift in the body takes place even though a total body water can remain unchanged. However, evaporative water loss from the burned areas is massive.
- Burn shock resuscitation is defined as a controlled i.v. fluid administration securing vital organ function at the least physiological cost.
- Burned patients requiring burn shock resuscitation should always be transferred to a burn centre.
- Burn shock resuscitation is required if the % burned surface area exceeds:
- 10% for children
- 15% for adults
- 10% for the elderly (more than 65 years of age)
- Different i.v. fluid formulas only serve as guidelines for starting up the resuscitation.
Transferral Criteria to a Burn Centre
The treatment of the burned patient is difficult and resource demanding. In order to secure a high level of expertise at the lowest level of health cost, a certain centralization of the burn care into burn centres becomes necessary. By more or less constant dealing with burns in burn centres a certain level of expertise will be secured. Therefore, burn centres must constantly have access to the care of burned patients. It must be in the past to see one or two beds reserved for burns in a hospital. It is quite simple not enough to secure proper expertise. However, it is evident that all burns can not be treated in burn centres. They are not geared for this amount of patients. Fortunately, the large majority of burns are minor traumas and as such easy to deal with, -but still some of them need referral. It is therefore important to identify the patients who should be referred to a burn centre.
- Patients requiring burn shock resuscitation.
- Burns that involve face, hands, genitalia or major joints..
- Deep partial thickness burns and full thickness burns in any age group..
- Circumferential burns in any age group..
- Burns of any size with concomitant trauma or diseases which might complicate treatment, or prolong recovery, or affect mortality..
- Burns with a suspicion of inhalation injury..
- Any type of burns if any doubt about the treatment..
- Burned patients who require special social and emotional or long term rehabilitative support..
- Significant electrical burns.
- Significant chemical burns.
- Diseases associated to burns such as toxic epidermal necrolysis, necrotising fasciitis, staphylococcal scalded child syndrome etc., if the involved skin area is 10% for children and elderly and 15% for adults or any doubt of treatment..