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Hypothalamic function altered: increased
glucagon/cortisol/catecholamines.
GI barrier function breaks down, leads to bacterial
translocation.
Nutritional needs dramatically increase (2-3 times normal).
Overall catabolic state.
Strategies to alter the hypermetabolic state have included
antipyretics, β-adrenergic blockade, and NSAIDs.
INITIAL BURN EVALUATION AND
MANAGEMENT
BURN INJURY SEVERITY
Calculating total body surface area (TBSA) burned and
presence of inhalation injury are the most important.
Depth of burn can be affected by mechanism, temperature,
duration of contact, and thickness of skin.
Patient comorbidities and age are other important factors.
Patients may have coexisting traumatic injury (motor vehicle
accidents, explosions, etc.).
Patients should always be treated initially via Acute Trauma Life
Support (ATLS) guidelines.
TBSA can be estimated by the “Rule of Nines” (Fig. 10-1)
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Figure 10-1 A-C.Percent total body
surface area burn as estimated by location
in adults (A), children (B), and infants (C).
(“Rule of Nines”). (Modified from Dimick
JB, ed. Mulholland & Greenfield’s Surgery.
7th ed. Wolters Kluwer; 2022. Figure
12.2.)
The Rule of Nines is altered for children and infants whose
heads are larger and extremities smaller than adult
patients.
The size of a patient’s palm is a reasonable estimate of 1%
of TBSA.
DEPTH OF BURN
Superficial Burns (First Degree)
Involve the epidermis.
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Symptoms similar to a bad sunburn and include
hyperemia, blanching skin, and tenderness to palpation.
Blisters are not present.
Partial-Thickness Burns (Second Degree)
Involve the dermis and are categorized into superficial
partial-thickness and deep partial-thickness burns. This
distinction is the most important, as it will determine the
need for excision and grafting vs dressings and
observation.
Superficial partial thickness.
Painful
Papillary dermis involved without involvement of skin
appendages.
Raw surfaces are deeper red and tender to palpation.
Blisters (either intact or ruptured) will be present.
*Blanches with pressure.
If the dermal appendages are intact, then healing
without skin grafting is possible.
Deep partial thickness
Reticular dermis involved with skin appendages
No capillary refill
White
*Decreased to absent sensation
Full-Thickness Burns (Third Degree) result in destruction of
the epidermal and dermal layers
Burns extend into the subcutaneous tissues, muscle, or
bone.
Skin is white and nonblanching or, in deeper burns, dry
and leathery in appearance. No sensation is present. If a
burn is painful, it is not full thickness (sensory nerves are
preserved).
Will not heal on its own and will require excision and
coverage.
INHALATION INJURY
Occurs in ~10% of burn patients.
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History often includes fire in an enclosed space such as a
basement.
Physical Examination: singed nasal hairs, facial burns,
carbonaceous sputum, and/or hoarseness
Agitation or shortness of breath may be caused by hypoxia.
Fluorescein eye examination is mandatory for patients with
facial burns to rule out corneal abrasions.
*Definitive diagnosis is made by direct airway examination
using nasopharyngeal scope or fiberoptic bronchoscopy.
Early intubation for airway protection is mandatory.
Intubation becomes much harder when the airway swells.
Extubation criteria: passed spontaneous breathing trial (with
a cuff leak), reasonable fluid balance, able to protect airway
and manage secretions, CXR assessed for remaining
edema/pneumonia, no OR planned in next 24 hours.
BiPAP will likely not be an option due to facial burns, but
heated high flow through a nasal cannula is an alternative.
Inhalation injury can be graded according to the
Abbreviated Injury Score (AIS) on bronchoscopy
Grade 0 (no injury)—absence of carbonaceous deposits,
erythema, edema, bronchorrhea, or obstruction
Grade 1 (mild injury)—minor or patchy areas of erythema or
carbonaceous deposits in the proximal or distal bronchi
Grade 2 (moderate injury)—moderate degree of erythema,
carbonaceous deposits, bronchorrhea, or bronchial
obstruction
Grade 3 (severe injury)—severe inflammation with friability,
copious carbonaceous deposits, bronchorrhea, or
obstruction
Grade 4 (massive injury)—evidence of mucosal sloughing,
necrosis, endoluminal obliteration
HAM Treatment for Intubated Patients With Suspected or
Known Inhalation Injury
Nebulized heparin 100 000 IU/3 mL NS,
Nebulized albuterol 2.5 mg,
Nebulized Mucomyst (N-acetylcysteine) 3 mL of 20%
solution
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Therapy to continue for 7 days or until patient is extubated
Systemic Toxicity
Carbon monoxide (CO) poisoning
Should be suspected in any patient who was in an
enclosed space fire.
Occurs because CO has 200 times affinity for
hemoglobin compared to O2.
CO will shift oxygen disassociation curve to the left and
create tissue hypoxia.
Physical examination demonstrates cherry red color of
mucous membranes, altered level of consciousness,
and agitation.
Pulse oximetry may be normal (cannot distinguish
between CO and O2).
Treatment is 100% oxygen because CO half-life is 4
hours on room air vs 1 hour on 100% FiO2.
Cyanide toxicity
Hydrogen cyanide is released during combustion of
synthetic polymers.
Should be suspected in any patient who was in an
enclosed space fire, is unconscious, or has a lactic
acidosis (lactate >4).
Interferes with oxygen transfer in mitochondria, which
results in tissue anoxia.
Pulse oximetry is unreliable because oxygen uptake
and carrying capacity are normal.
Patients should be treated if in enclosed space fire
exposure within the past 6 hours and any of the
following: hypotension with SBP < 90, almond odor, or
GCS ≤ 9.
*Treatment is Cyanokit (hydroxocobalamin 5 g IV).
Will turn the urine dark pink and will cause wound
exudate to develop pink hue. No need to repeat
dose.
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CRITERIA FOR TRANSFER TO BURN
CENTER
Partial- or full-thickness burns >10% TBSA
Burns involve the face, hands, feet, genitalia, perineum, or
major joints
Electrical or chemical burns
Inhalation injuries
Children in hospitals not equipped to treat pediatric patients
Patients with significant comorbid medical conditions
Trauma patients where the burn injury poses the greatest risk of
morbidity or mortality
Patients with burns who require social, emotional, and
rehabilitative services
FLUID RESUSCITATION
*The Parkland formula is widely used to estimate fluid
requirements in the first 24 hours
*First 24-hour requirement = 4 cc × %TBSA × weight in
kilograms
For fluid resuscitation, only partial- and full-thickness
burns count toward TBSA; do not include superficial
degree burns.
Lactated Ringer solution should be used as its
composition is closest to extracellular fluid.
Do not resuscitate with colloids (though some studies
show patients with low albumin might benefit).
*Administer half of the above volume during the first 8
hours (calculated from the time of injury, not the time of
hospital admission), and the other half over the next 16
hours.
Pediatric patients
Add maintenance fluid with D5 lactated Ringer solution.
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Infants and children have limited stores of glycogen in
liver, which can quickly lead to hypoglycemia.
*The adequacy of resuscitation is best judged by
hourly urine output (0.5 mL/kg/h in adults or 1 mL/kg/h
in children).
Also important to follow trend of base deficit, lactate and
pH. These should continue to go down with adequate
resuscitation.
Swan Ganz Catheter or bedside ultrasound (IVC filling and
cardiac contractility) can also be used to assess fluid status.
*Jackson burn model describes the distinct areas within
every burn wound (Fig. 10-2)
Figure 10-2 Recommended
escharotomy incisions are marked with
dotted lines.
Zone of coagulation
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Tissue is severely damaged and will not recover.
Treatment: excision and grafting.
Zone of stasis
Tissue is inflamed with impaired vasculature.
Tissue may recover with appropriate resuscitation.
Surrounds zone of coagulation.
Treatment: aggressive resuscitation.
Zone of hyperemia
Tissue has intense vasodilation with increased blood
flow and should recover.
Treatment: aggressive resuscitation.
Fluid resuscitation should be assessed on an hourly basis
Fluids should be regularly adjusted to maintain adequate
urine output as both under- and over-resuscitation have
severe consequences. Keep in mind that urine output might
lag early in the resuscitation and it is important to avoid
giving too much fluid to just increase urine if other
parameters continue to improve.
Jackson zone of stasis can potentially be salvageable with
judicious fluid resuscitation. Under- or over-resuscitation
may result in additional tissue loss.
Over-resuscitation can predispose to:
Pulmonary edema with prolonged ventilator
requirements.
Increased tissue edema with subsequent need for
escharotomy.
CIRCUMFERENTIAL BURNS AND
ESCHAROTOMY (FIG. 10-3)
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Figure 10-3 Jackson burn model.
Circumferential Burns
Can produce a tight, inelastic contraction with limited ability
for expansion of tissues.
As tissue edema develops during resuscitation,
supraphysiologic pressures can develop with subsequent
tissue ischemia and necrosis.
Burned Extremities
Physical signs are often obscured by the burn injury or
tissue edema. However, physical examination remains your
best clinical diagnostic tool.
Doppler examination is unreliable in estimating tissue
perfusion.
Burned Chest: circumferential burns can cause difficulty in
ventilation with high peak pulmonary pressures.
Burned Abdomen
Circumferential burns can create an abdominal
compartment syndrome.
Bladder pressure is a good estimate of intra-abdominal
pressure and can be measured via the Foley catheter.
Escharotomy is an incision of burned skin to relieve
constriction.
When designing escharotomy incisions, remember that all
burned skin will eventually be excised, so standard rules
(eg, not making an incision perpendicular to a joint) do not
apply.
Electrocautery incision is the method of choice and can
be performed at the bedside, as the burned skin is
anesthetic.
Need to connect unburned skin to unburned skin.
Burn eschar will “pop” when the constriction is released
and a gap between edges of burned tissues will be
created.
Healthy, viable tissue (usually fat) should be present at
the wound base.
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