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CHAPTER4 Hypermetabolic response toburns
Strategies toattenuate hypermetabolism
and catabolism
Improvements in the acute care regimen, such as aggressive uid resuscitation, have dramatically decreased burn mortality over the last two decades.
In addition, these interventions attenuate the hypermetabolic and catabolic
responses.
• Early excision and grafting:In patients with large burns (>50% TBSA),
excision and grafting within 2– 3days of the trauma reduce the
metabolic rate by 40% compared to the rate in burn patients not
undergoing wound coverage until 1 week after injury. Catabolism
is greatly reduced in these patients as well. In patients undergoing
complete excision and wound coverage within 72 hours of injury, the
net protein loss has been reported to be 0.03 μmol of phenylalanine
per minute per 100 mL of leg blood volume compared to 0.07 μmol in
patients who undergo excision 10– 21days after a burn. Cadaver skin
or biosynthetic skin substitutes are equally eective for immediate burn
wound coverage
• Nutrition:A better understanding of the nutritional requirements
of burn patients has improved outcomes and reduced the incidence
of the once- common post- burn sequelae of signicant weight loss.
Early enteral feeding initiated within 1day of the injury attenuates the
metabolic– catabolic response. Interestingly, intravenous feeding or
delayed enteral feeding after the acute phase does not provide this
benecial eect. The intravenous route should be reserved for scenarios
in which enteral feeding is not possible such as ileus. Nutritional
requirements are increased after a burn and can be established using a
metabolic cart to prevent over- or underfeeding. Importantly, the post-
burn metabolic– catabolic response is prolonged, thus the nutritional
requirements should be measured at regular intervals to ensure
continued optimal nutrition
• Environmental warming:Loss of insulating skin and reset of the body
temperature to 2°C above normal after a severe burn further enhances
hypermetabolism and catabolism. Simply increasing the environmental
temperature (room temperature) to 28– 33°C decreases resting energy
expenditure from 2.0 to 1.4 in patients with >40% TBSA burns, thus
decreasing hypermetabolism
• Treatment of infection:Prompt treatment of infections and sepsis
decreases catabolism, morbidity, and mortality. Septic burn patients
have a 40% increase in metabolic rate and catabolism compared to non-
septic patients with a similar burn size
• Pain and anxiety:Burn patients experience prolonged and constant
pain related to their injury. This pain is initially nociceptive in nature
but increasingly neuropathic components evolve during the healing
process. Additionally, burn patients undergo frequent painful procedures
such as dressing changes, debridement, intravenous line placements,
and physical therapy, all of which cause a signicant increase in pain.
Adequate and prompt pain control and treatment of anxiety decrease
the stress response and the associated negative metabolic eects
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STRATEGIES TOATTENUATE HYPERMETABOLISM & CATABOLISM
• Pharmacological modulation of the response:Investigational drug
therapies have been shown to successfully attenuate the hypermetabolic
and catabolic responses to a burn. Recombinant human growth
hormone (rHGH) increases protein synthesis, muscle mass, weight,
height, and bone mineral content, while decreasing wound and donor
site healing time. Recombinant HGH increases serum concentrations
of insulin- like growth factor 1 (IGF- 1) and insulin- like growth factor
binding protein 3 (IGFBP- 3), which mediate the eects of rHGH.
Administration of IGF- 1 together with IGFBP- 3 produces similar eects
• Androgenic hormones such as testosterone and oxandrolone have
been used to attenuate the post- burn hypermetabolic and catabolic
responses. Oxandrolone appears favourable as it has only 10% of
the masculinizing potency of testosterone. Additionally, oxandrolone
can be given via the enteral route, whereas rHGH is administered
intramuscularly or subcutaneously. Oxandrolone is also more costeective than rHGH. Oxandrolone improves height (in paediatric burn
patients), weight, lean mass, and bone mineral content. Insulin therapy
to maintain euglycaemia during the post- burn acute phase decreases
hyperglycaemia, improves protein synthesis and muscle mass, and
attenuates the proinammatory response. Insulin also improves wound
healing. Concerns regarding hypoglycaemia during insulin administration
have led to the investigation of other hyperglycaemia- attenuating
approaches including metformin, fenobrate, and glucagon- like peptide
1 (GLP- 1). The ecacy of these drugs is currently being studied in ongoing trials. As systemic catecholamines are elevated for several years
after a burn injury, studies of β- adrenergic receptor blockade with
propranolol have demonstrated improvements in body composition
with increased net protein synthesis, increased muscle mass, and a
decreased inammatory response. The administration of propranolol
for a full year is now being investigated
• Combination therapies using drugs with complementary action, such as
oxandrolone with propranolol or growth hormone with propranolol,
have been studied in small groups of patients with positive eects and
can also be considered
• Exercise:A physical therapy program is essential to rehabilitate a burn
patient by replacing the lost muscle and restoring function. Exercise
is necessary to increase protein synthesis and uptake into the muscle.
Resistance exercise programs produce better outcomes, such as
increased lean mass, strength, and function, than standard rehabilitation
programs. Exercise also enhances the positive eects of the previously
mentioned anabolic pharmacological approaches
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CHAPTER4 Hypermetabolic response toburns
Summary
Hypermetabolism and catabolism are typical responses to a severe burn
injury and can persist for several years. Early interventions including excision and grafting of wounds, enteral feeding, treatment of infections, and
pharmacological interventions (eg. anabolic hormones, adrenergic receptor
antagonists) and exercise can successfully attenuate this otherwise deleterious response.
Further reading
Jeschke MG. Postburn hypermetabolism:past, present, and future. Journal of Burn Care Research
2016;37:86– 96.
Diaz EC, Herndon DN, Porter C, etal. Eects of pharmacological interventions on muscle protein
synthesis and breakdown in recovery from burns. Burns 2015;41:649– 57.
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Chapter5
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The burns management
pathway I:assessing and
transferring patients
withan acute burn injury
The acute burn injury 36
Initial management at scene 37
Transfer to the local emergency department 38
Management of major burns at the local emergency
department 39
Assessment of burn area and depth at the local emergency
department 40
Initiating uid resuscitation at the local emergency
department 41
Referring a patient to a specialist burns unit 42
Essential referral information to ensure safe patient transfer 42
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CHAPTER5 The burns management pathway I
The acute burn injury
Burns lead to critical injuries that may, if inadequately or inappropriately
managed, result in multiple organ dysfunction and death.
Early management is undertaken almost exclusively by individuals with
relatively little experience in assessing and treating burns. In this chapter
we highlight the important steps in initially managing and safely transferring
burns patients to a specialist burns unit.
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INITIAL MANAGEMENT ATSCENE
Initial management atscene
Initial management involves:
• Safely extricating the patient
• Administering appropriate rst aid measures
• Analgesia
• Urgent transfer to the nearest emergency department
Burned areas should be:
• Exposed and cooled with copious amounts of cold water
• Wrapped with a protective dressing (eg. cling lm)
• Covered along with the rest of the patient to maintain the patient’s
body temperature during transfer
For chemical burns:
• Avoid direct contact
• Brush o any excess if a dry chemical
• Administer specic antidotes immediately if available
• If an antidote is not available, lavage with copious amounts of water for
a prolonged period; steps should be taken to ensure that this will not
cause an adverse reaction
For electrical burns:
• First aid should not be commenced until the patient is extricated to a
place of safety
Note
First aid cooling with water is temporary and stops on withdrawal from
the water source. Cooling with cold packs is widely used but acts beyond
the therapeutic window can subsequently reduce the patient’s core
temperature contributing to hypothermia. Cold packs should be applied
for a maximum time of 30 minutes.
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CHAPTER5 The burns management pathway I
Transfer tothe local emergency
department
Paramedic ambulance crews should immediately transfer patients to the
nearest emergency department (ED) or trauma centre, and should not attempt direct transfer to a distant specialist burns unit.
The paramedic team should:
• Take a history from the patient and any witnesses
• Protect the airway and cervical spine
• Administer high ow oxygen where indicated
• Provide appropriate analgesia
• Keep the patient warm
• Obtain an electrocardiogram and initiate cardiac monitoring for patients
with an electrical burn
• Inform the receiving emergency department of the incoming transfer
All standard basic and advanced life support assessment and treatment
measures should be taken, in particular those outlined by the Advanced
Trauma Life Support (ATLS®) and Emergency Management of Severe Burns
(EMSB) protocols.
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MAJOR BURNS AT THE LOCAL EMERGENCY DEPARTMENT
Management ofmajor burns atthe local
emergency department
Initial management should include:
• ABC’s and exclusion of other non- burn injuries
• Anaesthetic assessment of the airway
• Early intubation if indicated
• Cervical spine protection
• Administration of high ow oxygen unless contraindicated
• Application of an oxygen saturation measurement probe
• Arterial blood gas measurement, including carbon monoxide levels
• Wide bore peripheral venous access, through unburned skin where
possible
• Fluid resuscitation (see below)
• Cardiac monitoring
• Sending venous blood for standard investigations
• Measurement or estimation of the patient’s weight
• Early placement of an urinary catheter
• Regular assessment and management of pain
• Monitoring and maintaining the patient’s core and peripheral
temperature
• Drying the patient and removing any cooling agents.
• Minimizing exposure to that required to undertake a full
secondary survey
• Assessing the depth and extent of the burns
• Elevating limbs with circumferential burns and considering the need
for escharotomies; these are ideally performed at a specialist burns
unit if transfer times are minimal, but seek advice and undertake them
emergently in life or limb threatening scenarios
• Appropriate dressings
• Considering placement of a nasogastric tube
• Administering human tetanus toxoid and/ or immunoglobulin
• Other investigations as indicated
Arrangements should be made for urgent transfer to the nearest specialist
burns unit/ centre with an available intensive therapy or ward bed as required. In the UK, the National Burns Bed Bureau will assist in nding a bed,
and similar coordinating bodies are present in many other countries.
Special considerations
In patients at risk of abuse or non- accidental injury, the local emergency
department should raise any concerns and initiate appropriate local referral
pathways. This should not delay the patient’s transfer to a specialist burns
unit for denitive management.
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CHAPTER5 The burns management pathway I
Assessment ofburn area and depth
atthe local emergency department
The priorities for the ED physician are to:
• Rapidly assess and manage the burned patient
• Ensure no other specialist involvement is required due to
co- existent injury
• Identify the receiving specialist burns unit
• Communicate details of the patient and their injuries to them
• Transfer them safely after instituting all essential early interventions
• Do so in a way that minimizes the risk of hypothermia
The size and depth of the burn should be estimated to guide initial uid resuscitation. This should be done once and eectively to avoid unnecessary
exposure of the patient and hypothermia. The assessment of burns depth is
discussed in more detail later in this Handbook (see Chapter10).
Erythematous skin without blistering should be excluded from all uid calculations, with the caveat that burns can deepen with time and signicantly
alter injury severity. Skin with partial thickness burns is usually soft, blistered, painful, may be moist, and blanches on direct palpation or pressure.
Skin with full thickness burns is usually painless, sti, white, brown or black
in colour, dry and leathery, and may be charred with eschar.
The areas of the patient ’s body with partial or full thickness burns should
be accurately recorded on a Lund and Browder chart (Appendix 1)and the
overall percentage should then be estimated (see Chapter9).
Circumferential burns to the neck, torso and limbs should be identied
and documented as they may require early escharotomies.
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FLUID RESUSCITATION AT THE LOCAL EMERGENCY DEPARTMENT
Initiating fluid resuscitation atthe local
emergency department
The patient should be resuscitated using the modied Parkland formula if
the burn involves more than 15% of the total body surface area (TBSA) in
adults and 10% in children.
Fluid should be given as Hartmann’s or Ringer’s lactate. In children, maintenance uid should also be administered as dextrose/ saline. If the patient
presents late, uid due in the hours following the burn injury but prior to
presentation may be given as a single bolus if not contraindicated, or over
the remainder of the rst 8- hour resuscitation period (this can be discussed
with the accepting burns unit).
Fluid resuscitation over rst 8 hours post injury
(For adults >15% TBSA burn, Children >10% TBSA burn only)
0.25 mL × % TBSA burn × weight (kg)=mL/ hour
(Hartmann’s solution)
This is based on 3– 4 mL/ % TBSA burn/ kg in the 24 hours post injury
(not presentation), with half given over the rst 8 hours. Acatch- up bolus
may be required (please check with accepting unit).
The free Mersey Burns App will assist clinicians in estimating the %
TBSA and calculating uid requirements (www.merseyburns.com).
Paediatric cases:In addition to uid resuscitation, paediatric patients also
require maintenance uids using a dextrose/ saline solution (such as 5%
dextrose and 0.45% sodium chloride):
4 mL/ kg for the rst 10kg plus. . .
2 mL/ kg for the second 10kg plus. . .
1 mL/ kg for each additional kg
This is the volume of maintenance uid required hourly (in mL/ hour) in
the 24 hours post injury.
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Burns injuries should not prevent or delay the emergency department
from resuscitating the patient as per the ATLS® protocol when they rst
arrive. The volume of any uid bolus given on arrival should simply be deducted when calculating the initial hourly uid prescription using the modied Parkland formula.
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