Diagnosis in the management of burns

Abstract

The diagnostic problems of burns are discussed in this paper in the order in which they are usually encountered clinically. The patient requiring resuscitation with colloid infusion may be diagnosed by the proportion of skin surface burned. The amount and rate of colloid infusion may be assessed from hour to hour by following the changing trend of five clinical guides taken together—the general condition of the patient, the haematocrit level, the urine output, a formula, and measurement of the blood volume. Whether blood transfusion is required depends on the degree of red-cell destruction. Although this varies greatly from case to case, both in amount and in time, it may also be assessed by five guiding factors—visible blood loss, evidence in a blood film, signs of shock with a normal haematocrit level, a falling haematocrit level without over-infusion, and direct measurement of the red-cell volume. A routine is suggested for the early diagnosis of renal insufficiency; this needs to be differentiated from the physiological oliguria which accompanies oligaemia in the shock stage, or dehydration in the subsequent week. Oliguric and non-oliguric types of renal failure must also be distinguished if appropriate treatment is to be given. The two criteria for suspecting electrolyte imbalance and for making daily blood chemistry examinations are renal insufficiency and failure to start oral feeding on the second day. Some suggestions are made. for avoiding serious deficit or excess. The rationale behind frequent bacteriological examination of the burn flora is given, and the early diagnosis of invasive infection and the choice of local treatment for the burn are discussed. Finally, in connexion with the diagnosis of the depth of burning, the deceptiveness of appearance and the value of sensitivity to pin-prick as a sign of partial-thickness skin loss are emphasized. Constant reassessment of the changing condition of the patient is an essential feature of successful burns treatment. Sometimes it can be measured, sometimes it must be an informed guess ; but always the surgeon must be seeking to forestall the likely complications and to recognize in time their small beginnings. © 1959, British Medical Journal Publishing Group. All rights reserved.