- •Burn Care and Treatment
- •Contents
- •1.1 Initial Assessment and Emergency Treatment
- •Box 1.1. Primary and Secondary Survey
- •1.2 Fluid Resuscitation and Early Management
- •1.2.1 Fluid Resuscitation
- •1.2.2 Endpoint of Burn Resuscitation
- •1.2.4 Role of Colloids, Hypertonic Saline, and Antioxidants in Resuscitation
- •1.2.4.1 Colloids
- •1.2.4.2 Hypertonic Saline
- •1.2.4.3 Antioxidants: High-Dose Vitamin C
- •1.3 Evaluation and Early Management of Burn Wound
- •1.3.1 Evaluation of Burn Depth
- •1.3.2 Choice of Topical Dressings
- •1.3.3 Escharotomy
- •1.3.4 Operative Management
- •References
- •2: Pathophysiology of Burn Injury
- •2.1 Introduction
- •2.2 Local Changes
- •2.2.1 Temperature and Time Effect
- •2.2.2 Etiology
- •2.2.3 Pathophysiologic Changes
- •2.2.4 Burn Size
- •2.3 Systemic Changes
- •2.3.1 Edema Formation
- •2.3.3.1 Resting Energy Expenditure
- •2.3.3.2 Muscle Catabolism
- •2.3.3.3 Glucose and Lipid Metabolism
- •2.3.4 Renal System
- •2.3.5 Gastrointestinal System
- •2.3.6 Immune System
- •2.4 Summary and Conclusion
- •References
- •3: Wound Healing and Wound Care
- •3.1 Introduction
- •3.2 Physiological Versus Pathophysiologic Wound Healing
- •3.2.1 Transforming Growth Factor Beta
- •3.2.2 Interactions Between Keratinocytes and Fibroblasts
- •3.2.3 Matrix Metalloproteinases (MMP)
- •3.3.1 Burn Wound Excision
- •3.3.2 Burn Wound Coverage
- •3.3.3 Autografts
- •3.3.4 Epidermal Substitutes
- •3.3.5 Dermal Substitutes
- •3.3.6 Epidermal/Dermal Substitutes
- •3.4 Summary
- •References
- •4: Infections in Burns
- •4.1 Burn Wound Infections
- •4.1.1 Diagnosis and Treatment of Burn Wound Infections
- •4.1.1.1 Introduction
- •4.1.2 Common Pathogens and Diagnosis
- •4.1.3 Clinical Management
- •4.1.3.1 Local
- •4.1.3.2 Systemic
- •4.1.4 Conclusion
- •4.4 Guidelines for Sepsis Resuscitation
- •References
- •5: Acute Burn Surgery
- •5.1 Introduction
- •5.2 Burn Wound Evaluation
- •5.3 Escharotomy/Fasciotomy
- •5.4 Surgical Burn Wound Management
- •5.5.1 Face
- •5.5.2 Hands
- •5.6 Treatment Standards in Burns Larger Than Sixty Percent TBSA
- •5.7 Temporary Coverage
- •5.9.1 Early Mobilisation
- •5.9.2 Nutrition and Anabolic Agents
- •Bibliography
- •6.1 Introduction
- •6.2 Initial and Early Hospital Phase
- •6.2.1 Blood Pressure
- •6.2.1.1 Resuscitation
- •6.2.1.2 Albumin
- •6.2.1.3 Transfusion
- •6.2.1.4 Vasopressors
- •6.2.2 Urine Output
- •6.2.4 Respiration
- •6.2.4.1 Ventilation Settings
- •6.2.5 Inhalation Injury
- •6.2.6 Invasive and Noninvasive Thermodilution Catheter (PiCCO Catheter)
- •6.2.7 Serum Organ Markers
- •6.3 Later Hospital Phase
- •6.3.1 Central Nervous System
- •6.3.1.1 Intensive Care Unit-Acquired Weakness
- •6.3.1.2 Thermal Regulation
- •6.3.2 Heart
- •6.3.3 Lung
- •6.3.3.1 Ventilator-Associated Pneumonia
- •6.3.4 Liver/GI
- •6.3.4.1 GI Complications/GI Prophylaxis/Enteral Nutrition
- •6.3.4.2 Micronutrients and Antioxidants
- •6.3.5 Renal
- •6.3.6 Hormonal (Thyroid, Adrenal, Gonadal)
- •6.3.7 Electrolyte Disorders
- •6.3.7.1 Sodium
- •6.3.7.2 Chloride
- •6.3.7.3 Phosphate and Magnesium
- •6.3.7.4 Calcium
- •6.3.8 Bone Demineralization and Osteoporosis
- •6.3.9 Coagulation and Thrombosis Prophylaxis
- •Conclusion
- •References
- •7.1 Introduction
- •7.2.1 Glucose Metabolism
- •7.2.2 Fat Metabolism
- •7.2.3 Protein Metabolism
- •7.3 Attenuation of the Hypermetabolic Response
- •7.3.1.1 Nutrition
- •Nutritional Route
- •Initiation of Nutrition
- •Amount of Nutrition
- •Composition of Nutrition (Table 7.1)
- •7.3.1.2 Early Excision
- •7.3.1.3 Environmental Support
- •7.3.1.4 Exercise and Adjunctive Measures
- •7.3.2 Pharmacologic Modalities
- •7.3.2.1 Recombinant Human Growth Hormone
- •7.3.2.2 Insulin-Like Growth Factor
- •7.3.2.3 Oxandrolone
- •7.3.2.4 Propranolol
- •7.3.2.5 Insulin
- •7.3.2.6 Metformin
- •7.3.2.7 Other Options
- •7.4 Summary and Conclusion
- •References
- •8.1 Introduction
- •8.2 Knowledge Base
- •8.2.1.1 Incidence
- •8.3 Aetiology and Risk Factors
- •8.3.1 Pathophysiology
- •8.3.1.1 Severity Factors
- •Box 8.1. Burn Severity Factors
- •8.3.2 Local Damage
- •8.3.3 Fluid and Electrolyte Shifts
- •8.4 Cardiovascular, Gastrointestinal and Renal System Manifestations
- •8.4.1 Types of Burn Injuries
- •8.4.1.1 Clinical Manifestations
- •Box 8.2. Primary Survey Assessment
- •Box 8.3. Signs and Symptoms of Hypovolemic Shock
- •Box 8.4. Physical Findings of Inhalation Injury
- •Box 8.5. Signs and Symptoms of Vascular Compromise
- •Box 8.6. Secondary Survey Assessment
- •8.5 Clinical Management
- •8.5.1 Nonsurgical Care
- •Box 8.7. Secondary Survey Highlights
- •Box 8.8. First Aid Management at the Scene
- •Box 8.9. Treatment of the Severely Burned Patient on Admission
- •Box 8.10. Fluid Resuscitation Using the Parkland (Baxter) Formula
- •Box 8.11. Properties of Topical Antimicrobial Agents
- •Box 8.12. Criteria for Burn Wound Coverings
- •8.5.2 Surgical Care
- •8.5.3 Pharmacological Support
- •8.5.4 Psychosocial Support
- •References
- •9.1 Electrical Injuries
- •9.1.1 Introduction
- •9.1.2 Diagnosis and Management
- •9.2 Chemical Burns
- •9.3 Cold Injury (Frostbite)
- •References
- •10.1 Introduction
- •10.2 Pathophysiology
- •10.3 Scarring
- •10.4 Therapy
- •10.5 Psychological Aspects
- •10.6 Return to Work
- •10.8 Exercise
- •10.9 Summary
- •References
- •11: Burn Reconstruction Techniques
- •11.1 From the Reconstructive Ladder to the Reconstructive Elevator
- •11.2 The Reconstructive Clockwork
- •11.2.1 General Principles
- •11.3 Indication and Timing of Surgical Intervention
- •11.4 The Techniques of Reconstruction
- •11.4.1 Excision Techniques
- •11.4.1.1 W-Plasty and Geometric Broken Line Closure
- •11.4.2 Serial Excision and Tissue Expansion
- •11.4.3 Skin Grafting Techniques
- •11.4.4 Local Skin Flaps
- •11.4.4.1 Z-Plasty
- •11.4.4.2 Double Opposing Z-Plasty
- •11.4.4.3 ¾ Z-plasty or half-Z
- •11.4.4.4 Musculocutaneous (MC) or Fasciocutaneous (FC) Flap Technique
- •11.4.5 Distant Flaps
- •11.4.5.1 Free Tissue Transfer
- •11.4.5.2 Perforator Flaps
- •11.4.6 Composite Tissue Allotransplantation
- •11.4.7 Regeneration: Tissue Engineering
- •11.4.8 Robotics/Prosthesis
- •11.5 Summary
- •References
- •Appendix
- •Sedatives and Pain Medications
- •Index
1 Initial Assessment, Resuscitation, Wound Evaluation and Early Care |
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permeability appears to resolve in 8–12 h post-injury. Typically, colloids are not recommended in the initial 12 h phase of resuscitation (however, there is no clear evidence as to the exact timing for initiation of colloids).
The colloid of choice is albumin (5 % concentration), given as an infusion to decrease the crystalloid requirements. There is some evidence that use of colloids in the resuscitation of the thermally injured patient does normalize the I/O ratios; however, the effect on morbidity and mortality is unknown at this time [36, 37]. In critical care literature, which typically excludes the burn patients, the studies have shown that the use of colloids is safe with no overall benefit to the patient [38], and the Cochrane review in 2011 concluded that “there is no evidence that albumin reduces mortality in patients with hypovolemia, burns or hypoproteinemia. For patients with burns or hypoproteinemia, there is a suggestion that albumin administration may increase mortality” [39]. So despite the extensive of use of albumin in burn resuscitation, there is paucity of evidence for its use, and the overall benefit remains controversial.
1.2.4.2 Hypertonic Saline
The role of hypertonic saline in burn resuscitation has been studied greatly with variable results. In recent years, there has been a shift in thinking in the use of hypertonic saline. Rather than using hypertonic saline as the sole resuscitative fluid with goals of reducing fluid requirements, it has been studied in the context of decreasing the inflammatory response and bacterial translocation and therefore infectious complications [40–42].
1.2.4.3 Antioxidants: High-Dose Vitamin C
It is well documented that following thermal injury, there is an increased in capillary permeability leading to edema. The initial studies conducted by Tanaka et al. and Matsuda et al. indicated the lower water content of burn wounds with high-dose vitamin C infusion, with decreased overall resuscitation fluid requirements [43–46]. More recently, studies have demonstrated that resuscitation with high-dose vitamin C reduces the endothelial damage post-thermal injury [47, 48], with decrease in overall fluid volumes administered with no increase in morbidity or mortality [48, 49].
In summary, the resuscitation of the burn patient is complex and requires use of all tools available. It can no longer be the domain of crystalloid resuscitation without consideration for colloids, hypertonic saline, and high-dose vitamin C along with other antioxidants. All aspects of burn shock requires treatment (not just the hypovolemic component), which might require the early use of vasopressors and inotropes. Finally, the end goals of resuscitation need to be better monitored to assess the effectiveness of the resuscitation and ensure improved patient outcomes.
1.3Evaluation and Early Management of Burn Wound
1.3.1Evaluation of Burn Depth
The evaluation of the burn wound is of utmost importance, and expert clinicians have been known to be incorrect in their assessment up to 30 % of the time.
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S. Shahrokhi |
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Table 1.4 Clinical appearance of dermal and full-thickness burns |
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Clinical appearance |
Superficial dermal |
Deep dermal |
Full thickness |
Presence of blisters |
Yes |
Yes |
No |
Dermal depth |
Papillary |
Reticular |
Entire depth |
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|
Color of exposed |
Pink |
Mottled/white |
White/charred/ |
dermis |
|
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leathery |
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|
Capillary refill |
Yes |
Delayed/none |
None |
Time to heal |
<21 days |
>21 days |
>21 days |
Moisture |
Moist |
Dry |
Dry |
Pain |
Very painful |
Minimal to none |
Insensate |
|
|
|
|
Dermal appendages |
Intact |
Not intact |
Not intact |
As previously indicated, multiple modalities have been examined to determine their efficacy and possible role in the determination of the burn depth (Table 1.3), but none has replaced the clinical examination as gold standard.
In general, first-degree burns are of minimal concern. They only involve the epidermis with erythema and no blisters and do not require medical attention. Seconddegree burns (dermal burns) and beyond are those that will require medical attention. Dermal burns are divided into superficial and deep. Their clinical characteristics are summarized in Table 1.4.
The depth of the burn determines not only the requirement for admission but also the management – operative versus conservative. The ideal treatment for all burns, which will not heal between 14 and 21 days, is to have operative excision and skin grafting. All others can be treated conservatively. The conservative management of burns includes appropriate wound care and therapy for maintenance of range of motion and overall function.
1.3.2Choice of Topical Dressings
There are various topical agents that are available for management of burns. Typically, the topical management of deep burns requires an antimicrobial agent to minimize bacterial colonization and hence infection. For superficial burns, the goal of the topical agent is to reduce environmental factors causing pain and provide the appropriate environment for wound healing. Table 1.5 summarizes some of the agents available for topical treatment of burns, and the choice of agent is dependent on their availability and the comfort and knowledge of the caregivers.
The choice of burn dressing needs to take into account the following factors:
•Eliminate the environmental factors causing pain
•Act as barrier to environmental flora
•Reduce evaporative losses
•Absorb and contain drainage
•Provide splinting to maintain position of function
The goals of topical antimicrobial therapy for deep dermal and full-thickness burns:
•To delay/minimize wound colonization
•Have the ability to penetrate eschar
1 Initial Assessment, Resuscitation, Wound Evaluation and Early Care |
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Table 1.5 Topical therapy for treatment of cutaneous burns |
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Agent |
Description |
|
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Bacitracin/polymyxin B |
Ointment for superficial burns |
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Mupirocin |
2 % Ointment for superficial burns |
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Activity against MRSA |
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Biobrane |
Artificial skin substitute bilayer – silicone film |
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with a nylon fabric outer layer and a tri- |
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filament thread with collagen bound inner |
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layer |
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For treatment of superficial dermal burns, |
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Biobrane can be left intact until wound fully |
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healed |
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Reduces pain and evaporative losses |
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Aquacel Ag |
Methylcellulose dressing with ionic silver for |
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superficial dermal burns |
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Can be left intact until wound fully healed |
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Wound base needs to be clean for dressing |
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adherence |
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Silver sulfadiazine |
1 % cream for deep dermal and full-thickness |
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burns |
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Has broad spectrum of activity |
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Intermediate eschar penetration |
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Mafenide acetate |
Available as 11 % water-soluble cream or 5 % |
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solution for deep dermal and full-thickness |
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burns |
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Has broad spectrum of activity, however, |
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minimal activity against staphylococcus |
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species |
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Excellent eschar penetration |
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Acticoat |
Sheet of thin, flexible rayon/polyester bonded |
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with silver crystal-embedded polyethylene |
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mesh |
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Can be left on the wound for 3–7 days |
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Has broad-spectrum activity |
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•Have activity against common pathogens
– S. aureus, Proteus, Klebsiella, E. coli, Pseudomonas
•Should not retard wound healing
•Have low toxicity (minimal systemic absorption)
1.3.3Escharotomy
In evaluation of wounds, consideration also needs to be given for possible need for escharotomy. All deep circumferential burns to the extremity have the potential to cause neurovascular compromise and therefore benefit from escharotomies. The typical clinical signs of impaired perfusion in the burned extremity/hand include cool temperature, decreased or absent capillary refill, tense compartments, with