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Chapter 10. Pediatric Burns
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Chapter 10. Pediatric Burns
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253
Chapter 11
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Elderly Burns
RobynRichmond andSharmilaDissanaike
Introduction
The 2010 United States Census shows that the fastest growing
demographic is people over the age of 65years [1]. A similar
pattern is seen across the globe, and this trend is expected to
continue over the coming decade. With an increasing elderly
population nationwide and worldwide, all healthcare
providers need to understand the influence of age on various
medical conditions; burns are no exception.
The elderly sustain burns more commonly than younger
adults, and their burns mostly occur at home [2, 3]. Because
of decreased alertness, impaired cognition, and slower reaction time, their ability to escape from harm is diminished [4,
5]. Impaired mobility can lead to greater contact time with
the thermal agent, resulting in larger total body surface area
(TBSA) affected, deeper burns, and an increase in inhalational injury [6, 7].
R. Richmond (*) · S. Dissanaike
Department of Surgery, Texas Tech University Health Sciences
Center, Lubbock, TX, USA
e-mail: robyn.richmond@ttuhsc.edu; sharmila.dissanaike@ttuhsc.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_11
255
256
R. Richmond and S. Dissanaike
Initial Assessment andResuscitation
The Advanced Burn Life Support course recommends a
standardized approach to the burned patient, starting with
initial assessment [8]. The primary survey follows a systematic
assessment of life and/or limb-threatening injuries [8].
Although the primary survey remains the same in the elderly
patient, there are several anatomic and physiologic changes
that impact initial assessment that should be considered.
When assessing the airway in elderly burn patients, it is
important to recognize that they are more likely to have loss
of protective airway reflexes, making aspiration more likely
[9]. Dentition can also affect the airway; poor dentition as
well as dentures can affect the ability to bag-valve-mask and
result in ineffective ventilation. Dentures may also become
dislodged and occlude the airway [9]. One tip is to keep dentures in place during bag-valve-mask ventilation to improve
the mask seal, but to remove dentures for intubation.
Checking for loose teeth prior to intubation is another
important step to guard against dislodgement and aspiration.
Range of mouth opening may be decreased, which can affect
the ability to open the mouth using standard “scissor” manual
technique during endotracheal intubation. Cervical immobility secondary to age and/or arthritis can impede neck extension making intubation more difficult [9]. Proper positioning
with support under the shoulders can improve visualization
during intubation, as can video laryngoscopes if available.
Elderly patients have decreased lung and chest wall
compliance, which can impair their ability to maintain normal
oxygenation and ventilation at baseline [10]. This places them
at high risk for respiratory failure [10]. Because of a limited
ability to increase their heart rate, they typically are less likely
to manifest tachycardia associated with hypoxia, which can
make respiratory failure more insidious and difficult to diagnose [9]. Early recognition of impending respiratory failure is
critical to prevent patients from emergent intubation with
possible cardiovascular collapse.
Chapter 11. Elderly Burns
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257
The circulatory system in the elderly has significant
changes compared to younger counterparts. The heart rate
and cardiac output are more likely to be fixed for a number
of reasons, including a blunted response to catecholamines
[11]. In addition to a blunted response to catecholamines,
myocyte mass decreases and afterload increases with age
which can contribute to a depressed cardiac function. A fixed
heart rate may also be a manifestation of a prescribed antihypertensive or antiarrhythmic medication. In the setting of
shock, a decrease in the ability to increase heart rate and
cardiac output results in significant vasoconstriction to maintain perfusion [12]. This response, in addition to hypertension
in many elderly patients, results in relative normotension
masking hypotension and hypoperfusion [12]. Because of
this, a systolic blood pressure of 110mmHg can be considered
hypotensive in some elderly [12].
Burn resuscitation in the elderly should look similar to
younger patients, and use of defined end points such as lactate, base deficit, and other organ system perfusion indicators
are important. It should be noted, however, that use of
advanced monitoring may be necessary in the elderly due to
their physiologic differences and possible pre-existing conditions [9, 12].
Physiologic changes to the renal system with age include a
decreased glomerular filtration rate and a decreased sensitivity to antidiuretic hormone [13]. This will affect the body’s
ability to concentrate urine, making urine output as a marker
of tissue perfusion potentially unreliable [13]. The elderly are
also at an increased risk for acute kidney injury, making
resuscitation and maintenance of renal perfusion critical in
these patients [13]. In addition, avoidance of nephrotoxic
agents is important to prevent acute kidney injury.
The endocrine system is also affected by the aging process,
with occult hypothyroidism and adrenal insufficiency being
common [14]. These should be screened for and treated
accordingly.
Loss of subcutaneous fat will affect depth of burn in the
elderly, with similar burns resulting in a deeper burn in an
258
R. Richmond and S. Dissanaike
older compared to a younger patient [15]. Thinner atrophic
skin also puts the elderly at an increased risk for hypothermia
following a large burn [16]. Avoidance and active treatment
of hypothermia are critical in any burn patient. Ensuring
warm rooms, warm blankets, and warmed intravenous fluids
are easy first steps in caring for burn patients. More aggressive central warming measures with central venous devices,
gastric tubes, urinary catheters, thoracostomy, or intraabdominal devices should be considered in severely hypothermic patients if initial rewarming attempts are ineffective.
In addition to loss of subcutaneous fat, reduced microcirculation and reduced turnover rate of the epidermis lead to prolonged wound healing in the elderly [16, 17].
Pre-existing Conditions andMedications
Knowledge of a patient’s history, including pre-existing
conditions (PECs) and home medications, is critical for care
following burn injury. Elderly patients are more likely to
suffer from PECs which can affect their response to injury,
their response to resuscitation, and increase the likelihood of
complications including mortality.
PECs that are associated with an increased mortality in
trauma patients from one statewide database include liver
disease, renal disease, cancer, and congestive heart failure
[18]. Another large study identified five PECs that influence
outcome in trauma: cirrhosis, congenital coagulopathy,
chronic obstructive pulmonary disease (COPD), ischemic
heart disease, and diabetes [19]. In addition, one quarter of all
patients in that study greater than 65years carried the diagnosis of at least one of the above listed PECs [19]. The burn
literature also suggests that PECs increase the likelihood of
complications following burns [20].
In addition to PECs, elderly patients are more likely to
take daily, scheduled medications, both prescription and over
the counter. One important consideration is beta blockers.
Beta blockers are used in approximately 20% of elderly
Chapter 11. Elderly Burns
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259
patients with coronary artery disease and 10% of patients
with hypertension [21]. Consumption of beta blockers can
impair interpretation of the physiologic response to a burn.
Anticoagulants and antiplatelets are also frequently taken
by the elderly. Since these agents impair blood clotting, their
effects must be considered when planning surgical treatment
of burns. When present, it is important to weigh the consequences of stopping these agents, which may vary from a
minor risk of stroke in a patient with atrial fibrillation and a
low CHA2DS2-VASc score to a major risk of in-stent thrombosis and death, in a patient who has recently received drugeluting stents for critical coronary stenosis. A thoughtful plan
to manage these competing risks, balance them against the
need for surgery, and prevent bleeding both intra-operatively
and in the immediate post-operative period, must be
developed.
Since COPD is a common disease in the elderly, most
commonly from emphysema after a lifetime of smoking, it is
not unusual to see burn injuries sustained while smoking on
oxygen; in fact, this is an injury pattern unique to this demographic. Smoking related burn injuries involving home oxygen can carry a significant morbidity and mortality, most
notably when inhalational injury is present and intubation is
required [22, 23]. One series cites a relatively high mortality
rate of over 14% despite most patients having a relatively
low TBSA burn (less than 5%) [22]. In another review of the
American Burn Association (ABA)’s National Burn
Repository, inhalational injury was found to be the strongest
predictor of mortality [23]. This is likely due to the baseline
disease state in these patients, and if inhalational injury
exists and intubation is required in these already pulmonary
compromised patients, they are more likely to have prolonged intubation, possible tracheostomy, and a discharge
destination other than home [23]. Inhalation injuries derived
from smoking on oxygen are a phenomenon seen in patients
with end-stage COPD. These patients almost always have
other medical comorbidities that can complicate their medical course. The outcome in these cases is primarily depen-
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