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Chapter 4. Initial Management andResuscitation
135
elbow or knee, which should in turn be at or above the level of the heart [63]. Caution is advised with hand orthosis use during initial resuscitation, due to the risk of causing external pressure and tissue ischemia [63].
Burn injury location is important in determining the functional impact of the injury and the resultant therapy workload. The CFU concept is a way of quantifying this relationship. It is based on how skin is recruited and how it moves during joint range of motion. Based on this analysis, grossly 100 major CFUs were identified, excluding the neck and face [64]. Therapists can utilize the completed Lund­Browder diagram to identify CFUs at that are at risk of contracture or deformity. For instance, a burn to a single hand (dorsal and volar surface) only represents 2% TBSA, but comprises at least 30 CFUs accounting for approxi­mately 30% of all CFUs in the body. Thus, the hand is at very high risk for deformity and decreased function. We utilize the calculation of CFUs during the initial phases of burn injury to assist in determining therapy time and resource allocation [65, 66].
The rehabilitation team plays a vital role in the initial management and resuscitation of a burn injury. Therapists’ unique skill set places them in an ideal position to assist the multidisciplinary team in the identification of key elements vital to preservation of limb and function:
• Extremity perfusion, through the careful assessment of
edema and use of edema management techniques
• Neuromuscular status of the extremities, through
assessment and identification of sensory and/or motor
deficits
• Identification of tendon or bony anomalies such as exposed
tendons and fractures
136
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L. C. Cancio and J. M. Cancio
T . US Army Institute of Surgical Research Burn Resuscitation Checklist
Hour postburn
Mean arterial blood pressure
Lactate
Base deficit
-to-FiO2 ratio
PaO
2
Bladder pressure
Pulses
Urine output
Pressor doses
Crystalloid rate
Colloid rate
Total volume received to date (mL/kg)
Teamwork
The care of patients with burn shock is complex and requires the coordinated efforts of a multidisciplinary team [67]. At the US Army Burn Center, we have devoted significant effort to improving communication among members of our team by means of processes such as the following:
• Twice-daily multidisciplinary team rounds, starting with a
briefing by the bedside ICU nurse
• Task lists (“to-do lists”) managed by the charge nurse
• Custom (burn-specific) multivariable data display tools
• Three-way crisis communication techniques
• Focused after-action reviews
The first 48 hours is a time during which it is particularly important to employ all of these processes, and more. For example, we have found it helpful to schedule conference calls every 6 hours during the course of a difficult resuscita­tion among the various team members. During these calls, a standardized checklist of key variables can be used to guide the discussion (Table4.2):
Chapter 4. Initial Management andResuscitation
137
Final Thoughts
The successful initial evaluation and treatment of extensively burned casualties are challenging, but critical to both survival and optimal long-term outcomes. Early communication with a burn center and timely transport are keys to success. Under most circumstances, transport can and should be accom­plished within hours of injury. In austere, mass-casualty, or military environments, this may not be possible—if so, post­poning evacuation until after the resuscitation phase is com­plete, but before infection sets in, may be the best choice. Adherence to the principles described in this chapter will support the successful early care of burn patients.
Acknowledgments The opinions or assertions contained herein are the pri­vate views of the authors and are not to be construed as official or as repre­senting the views of the Department of the Army or the Department of Defense.
L.C.C. is an inventor of Burn Navigator (Arcos Medical, Inc., Houston, TX). He has assigned his rights to the US Army. He is funded by the Department of Defense to conduct studies of plasma for burn shock resuscita­tion. The authors declare no other conicts of interest.
The authors gratefully acknowledge Mr. W.Scott Dewey for helpful com­ments, and Ms. Susan Reyna, Library Assistant, US Army Institute of Surgical Research.
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Chapter 5
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Inhalation Injury
AxelRodriguez andAlexisMcQuitty
Introduction
Inhalation injury is major cause of death for patients burned in structural fires, which often occur in enclosed spaces with inability to flee the incident [1]. Smoke inhalation may be present in up to 20% of reported burn cases and is identified in 60–70% of patients who die in burn centers. The degree of injury depends on many factors: gas components of fire acci­dents, presence of soot (particulate matter), and magnitude of exposure to flame or steam [2]. If inhalation injury is sus­pected in a patient with any burn size, a referral to a burn center should occur promptly. Early intervention, treatment, and monitoring in a burn ICU may improve patient outcome. In addition to extremes of age and the total body surface area (TBSA) burn, inhalation injury is an important predictor of mortality [3–5].
A. Rodriguez · A. McQuitty (*) Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA e-mail: axrodrig@utmb.edu; almcquit@utmb.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. O. Lee (ed.), Essential Burn Care for Non-Burn Specialists,
https://doi.org/10.1007/978-3-031-28898-2_5
145
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