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"PROTEZIONE CIVILE EDUCATIONAL" - www.casaleinforma.it/pcivile V° Contingente CRI at the Italian Red Cross Hospital in Baghdad September – October 2003 PROTOCOL FOR THE TREATMENT OF BURNS AT THE ITALIAN RED
CROSS HOSPITAL IN BAGHDAD
Document drawn up by Dr. Sandro Gregorio doctor at the Orthopaedic and Trauma O.U at the "G. Gaslini" Institute in Genova. Background
During the mission in Baghdad, the greatest types of emergencies treated were burns. Therefore in this way we were able to actually establish "non conventional" lines of treatment that I would like to First of all I would like to explain what "non conventional" means: we found ourselves in a situation where we had to face extensive burns that very often involved 100% of the body surface, without the aid of resuscitation or intensive care units when the sacred medical tests state that burns that involve more than 30% of the body surface have to be treated in the intensive care unit. Clearly this document is not intended to revolutionize the cure and treatment of burns but it is aimed only to give indications that can be helpful in case of medical emergencies that could be verified immediately after a natural I also have to add another point: the following is the result of about 40 days constant work on burns and reflexes from my personal point of view as well as the experience of the other members of the Italian Red Cross mission in Baghdad. It is therefore my intention to open a debate to actually verify what has been done and to actually improve our knowledge. "PROTEZIONE CIVILE EDUCATIONAL" - www.casaleinforma.it/pcivile Initial Receiving Procedure
1. Freeing of clothes and evaluation of injury: it is of the utmost
importance to "waste time" at this stage to evaluate the priority of the treatment and therefore the initial positioning of the injured on the bed. 2. Venous access for sedation and analgesic therapy: it is quiet clear that
without a certain venous entry the treatment is without effect; in Baghdad the most commonly used drug to control pain during medication is Ketamina; other positively used drugs are cocktails of Fentanest and Diprivan. Naturally this is done also by controlling saturation and oxygen always close at hand. 3. If the burns involve more than 20% of the body surface: urinary
4. Blood samples to evaluate haematic parameters: when possible
5. Start hydration with milk white Ringer and physiological solution
(at least 1000 cc during medication, 500 cc children) 6. Wash injuries with 5% Chlorhexidine solution (0.25% as active
constituent): bowls of solution were used and the gauzes are dipped and then picked up by the use of pincers. 7. Washing of the inside of the mouth with 4% Chlorhexidine (0.2% as
active constituent) in the case the burns include the area which is inside the mouth. This can also be done with gauzes that have been dampened with the Chlorhexidine solution in the case of unconscious patients or as a mouth wash in conscious patients. Chlorhexidine is absorbed by the mucous membrane and released in the 6-8 hour period following the treatment to guarantee the reduction of the saliva bacteria flora for the entire period. 8. Extirpation of the delimited necrotic parts and of the uplifted skin.
Removal of the flictene if present, leaving the superficial surface intact: leaving the skin of the flictene is possible only if they are isolated; the emptying injection must be carried out in sterile conditions. 9. Disinfection of the injuries with Betadine: sterile gauzes soaked in
Betadine are passed over the injuries trying to avoid rubbing them.

"PROTEZIONE CIVILE EDUCATIONAL" - www.casaleinforma.it/pcivile 10. Application of Sofargen cream
on the injuries: this cream is
composed of silver nitrate which actually stimulates the granulation process of the injury. 11. Covering with fatty gauzes
and layers of sterile gauzes and
further bandaging: we had
Cuticerin gauzes available and we noted that it was better to add liquid paraffin in the pack before the application. The bandaging must be characterized by sufficient absorbent properties, to take into consideration the notable secretions that are produced. Naturally the fingers of the hands must be bandaged separately, or at least separate between themselves inside the bandage. it is also necessary to keep the folds of the skin separate such as armpits to avoid painful adherence. 12. If the patient is catheterised the quantity of urine must be controlled
to evaluate the further necessity of infusions. 13. Start of antibiotic treatment with wide scale antibiotics.
Start gastro protective therapy with Ranitidina 50 mg 3 times a day for adults, twice a day for children by means of injections: the antibiotic therapy that was used was based on Piperacillina with the addition of Flagyl and Gentamicina in the following phases if necessary. Take into consideration that these were the antibiotics that were available: we would have also liked to have used Vancomicina, but it was difficult to obtain. Patients in hospital
The day after admission it is necessary to control the laboratory parameters, urine quantity as well as body temperature. The calculation of the quantity of liquid to be introduced as well as the anti pain treatment necessary for the day. "PROTEZIONE CIVILE EDUCATIONAL" - www.casaleinforma.it/pcivile Liquids must be plentiful: 6000 cc a day at least for adults and 4000 for children. The flow of urine can cause confusion because the patients are hemo- It is better to not give the patients food the first day. For the infusion therapy it is better to use not more than 500 cc of Ringer and it is preferable to use glucose and Normosol solutions with the addition of a physiological solution for the alternatives. The Ringer is gradually abandoned during the following days. Subsequent Medication
§ Blood samples for laboratory exams on the basis of which the subsequent therapy is to be decided. § Removal of bandages. § Washing of injuries with a 5% Chlorhexidine solution. § Removal of the delimited necrotic parts: this is an ideal environment for germs. It is better to remove them with surgical instruments: the blade must cut the edge between healthy and necrotic and to make the cut easier it must be tractioned perpendicular to the surface that is to be separated § Disinfection with Betadine and the application of Sofargen cream: the Sofargen cream is not to be used on the granulated parts where only the fatty gauzes are to be applied . § Covering with fatty and sterile gauzes and following bandaging. Sofargen: do not use this cream on the exposed under epidermis and on
granulation areas. Granulation: if hypertrophic it is better to reduce the area with touches of
silver nitrate. Gloves : are to be changed often during medication, they must
be changed after washing of the injuries and whenever soiled. Pincers: it is better to use pincers to pick up the gauzes from the
Chlorhexidine solution so as not to pollute it.

"PROTEZIONE CIVILE EDUCATIONAL" - www.casaleinforma.it/pcivile Chlorhexidine: this was available in a 5% active solution, the above
mentioned solutions are prepared by diluting the product as it is. The real concentration of the active material is to be reported. Chlorhexidine is not compatible with normal detergents due to its cationic nature. It is necessary to avoid mixing it with detergents. Betadine solution: 10% active principal (Iodopovidone). The application is to
be carried out with the product as it is.
Sofargen: this is a local wide scale
antimicrobic, with a silver sulfadiazine base,
it is a metallorganic substance obtained by
the reaction between the silver nitrate with
the sulfadiazine. It was available in cream
with 1% active principal.

Cuticerin: Gauze (AG) consists of a gauze
dressing made from fibers of cellulose
acetate, impregnated with a cream composed of petrolatum, mineral oil,
mineral wax and wool-wax alcohol.
Conclusion
This was our treatment of patients with burns. However the silver nitrate in a pencil form was impossible to obtain so therefore we treated the hypertrophic granulations with dry medications that however have the disadvantage of being painful when removed or with the surgical reduction. I hope that this information will be a source of further discussion. My e-mail address is : [email protected] "PROTEZIONE CIVILE EDUCATIONAL" - www.casaleinforma.it/pcivile V Contingente 2003 Baghdad – Italian Red Cross Hospital
PROTOCOL FOR TREATMENT OF BURN PATIENTS Washing with Chlorhexidine
solution (2-2.5%)
Washing with Betadine
(Not soapy solution)
Extirpation of the
Silver Nitrate on the
necrotic parts (
granulations (Doctor)
Application of Silver Sulfadiazine cream
Covering with fatty gauzes, layers of sterile gauzes and further
Plastering application to keep the limbs in the correct
position
Soft bandage

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