TABLE. Immersion time to produce full-TABLE. Immersion time to produce full-thickness burnsthickness burns

Time Temperature (°F)Time Temperature (°F) 1 second1 second 158 158 2 seconds 1502 seconds 150 10 seconds 14010 seconds 140 30 seconds 13030 seconds 130 1 minute1 minute 127 127 110 minutes0 minutes 120 120

CausesCauses

ScaldsScalds % 72 % 72 FiresFires

– 85% of burn mortality85% of burn mortality ChemicalChemical Electrical high tension >1000VElectrical high tension >1000V

Low tension <1000VLow tension <1000V

ScaldsScalds % 72 % 72 FiresFires flame flame

– 85% of burn mortality85% of burn mortality Chemical Chemical Electrical high tension >1000VElectrical high tension >1000V

Low tension Low tension <1000V<1000V

PathophysiologyPathophysiology

Cell damage and death causes Cell damage and death causes vasoactive mediator release:vasoactive mediator release: Histamine, thromboxane, cytokineHistamine, thromboxane, cytokine

Increasing capillary permeability Increasing capillary permeability causes edema, third spacing and causes edema, third spacing and dehydrationdehydration

Possible obstruction to circulation Possible obstruction to circulation (compartment syndrome) and/or (compartment syndrome) and/or airwayairway

First degreeFirst degree Red, erythematous Very sensitive to touch Red, erythematous Very sensitive to touch Very painful .Usually moist No blisters Surface markedly Very painful .Usually moist No blisters Surface markedly and widely blanches to light pressure and widely blanches to light pressure Second degreeSecond degree Erythematous or Erythematous or whitish with a fibrinous exudate Wound base is sensitive to whitish with a fibrinous exudate Wound base is sensitive to touch Painful Commonly have blisters Surface may blanch touch Painful Commonly have blisters Surface may blanch to pressureto pressure Third degreeThird degree Surface may be:  White and pliable  Black, charred, and Surface may be:  White and pliable  Black, charred, and leathery  Pale and mistaken for normal skin  Bright red from leathery  Pale and mistaken for normal skin  Bright red from hemoglobin fixed in the subdermishemoglobin fixed in the subdermis Generally anesthetic or Generally anesthetic or hypoesthetichypoesthetic Subdermal vessels do not blanchNo Subdermal vessels do not blanchNo blisters .Hair easily pulled from its follicleblisters .Hair easily pulled from its follicle Fourth degreeFourth degree Involves deep Involves deep tissues including fascia, muscle, bone, and tendonstissues including fascia, muscle, bone, and tendons

Zones of BURNZones of BURN

ZONE 1: Coaggulation ZONE 1: Coaggulation Zone 2: Ischemia Zone 2: Ischemia Zone 3: Zone 3: ErrythemiaErrythemia

Burn extentBurn extent

The overall extent of the burn injury is best The overall extent of the burn injury is best estimated by recording the affected areas estimated by recording the affected areas on a burn diagram and estimating the on a burn diagram and estimating the percentage of the body surface area using percentage of the body surface area using the 'rules of nines' in the adult or using the the 'rules of nines' in the adult or using the Lund–Browder chart in children. Special Lund–Browder chart in children. Special consideration is necessary in children, in consideration is necessary in children, in whom the head forms a much greater whom the head forms a much greater percentage and the lower extremities a percentage and the lower extremities a lower percentage of the total body surface lower percentage of the total body surface area than in adults.area than in adults.

ManagementManagement Airway Airway

– Any respiratory complications consider PICUAny respiratory complications consider PICU– Most swelling occurs in first 24 hours to 3 daysMost swelling occurs in first 24 hours to 3 days– Oxygen for all burn patientsOxygen for all burn patients– Clinical signs to watch for:Clinical signs to watch for:

Hoarseness, stridor, cough, and visible redness of pharynxHoarseness, stridor, cough, and visible redness of pharynx Overt respiratory distress or hypoxiaOvert respiratory distress or hypoxia

– Consider early intubation for thermal injury to airway, face and neck, Consider early intubation for thermal injury to airway, face and neck, inhalation injury and central nervous system (CNS) dysfunctioninhalation injury and central nervous system (CNS) dysfunction

– For intubation use Vecuronium (no Succinylcholine due to possible For intubation use Vecuronium (no Succinylcholine due to possible high K+)high K+)

– Children burnt in confined spaces may suffer carbon monoxide Children burnt in confined spaces may suffer carbon monoxide poisoningpoisoning

Loss of consciousness, confusion or disorientation are likely signsLoss of consciousness, confusion or disorientation are likely signs Give high concentration oxygen even if SaO2 is high (Carbon Give high concentration oxygen even if SaO2 is high (Carbon

monoxide will bind with the hemoglobin causing a false SaO2 monoxide will bind with the hemoglobin causing a false SaO2 reading)reading)

Consider carboxyhemoglobulin levelConsider carboxyhemoglobulin level Consider hyperbaric oxygenConsider hyperbaric oxygen

Fluid resuscitation and maintenanceFluid resuscitation and maintenance– Two large bore IV’s (might need to be sutured),start with Two large bore IV’s (might need to be sutured),start with

forearm veins ,intraosseous catheter may be needed in forearm veins ,intraosseous catheter may be needed in children. children.

– Bolus with normal saline (NS) or lactated ringers (LR) to Bolus with normal saline (NS) or lactated ringers (LR) to restore perfusionrestore perfusion

Blood pressure might be high due to high systemic Blood pressure might be high due to high systemic vascular resistance (SVR) but perfusion poorvascular resistance (SVR) but perfusion poor

LR most often used because it has physiologic LR most often used because it has physiologic concentrations of Na+, K+, CL- & HCO3-concentrations of Na+, K+, CL- & HCO3-

– Albumin in the first 12 to 24 hours may leak into the Albumin in the first 12 to 24 hours may leak into the interstitium and can worsen tissue edemainterstitium and can worsen tissue edema

– Goal is to normalize vital signs and maintain end organ Goal is to normalize vital signs and maintain end organ perfusion thus improving capillary refill and urine outputperfusion thus improving capillary refill and urine output

– First degree burns: use normal maintenance formula First degree burns: use normal maintenance formula (tissue and fluid losses are minor)(tissue and fluid losses are minor)

– Second and Third degree burns use Parkland Formula:Second and Third degree burns use Parkland Formula: LR 4cc/Kg x % burned over 24hrs plus maintenanceLR 4cc/Kg x % burned over 24hrs plus maintenance Give half of the volume in 8 hoursGive half of the volume in 8 hours

– Important: clock starts when burned occurredImportant: clock starts when burned occurred Give second half in 16 hoursGive second half in 16 hours

ResuscitationResuscitation Rations % X wt. Rations % X wt. X 3 12 hr .X 3 12 hr .

(RL) (RL) oror ( NS )( NS ) X 2 12 hr. X 2 12 hr.

X 1 12 hrX 1 12 hr..

DD22 Maintanance + Ev. Water loss Maintanance + Ev. Water loss

(or colloid (or colloid ÷÷ 2 )2 )

Baxter 4 ml X wt. X % 1/2 8 hr.Baxter 4 ml X wt. X % 1/2 8 hr.

( RL )( RL ) 1/2 16 hr1/2 16 hr..

DD2 2 DD5 5 w Maintain U.O.P. 1 ml / kg/hr w Maintain U.O.P. 1 ml / kg/hr

Other Other

Brooke :colliod 0.5ml Xkg X%Brooke :colliod 0.5ml Xkg X% crystaliod 1.5ml Xkg X %crystaliod 1.5ml Xkg X % + 5%D + 5%D 2000ml/m22000ml/m2 Modefied Brooke Modefied Brooke

crystaliod 2ml Xkg X % Evans :colliod 1ml crystaliod 2ml Xkg X % Evans :colliod 1ml Xkg X%Xkg X% crystaliod 1ml Xkg Xcrystaliod 1ml Xkg X%% Monafo :250meq Na Monafo :250meq Na

150meq lactate150meq lactate100meq Cl titer to UOP 100meq Cl titer to UOP

Foley placementFoley placement– Normal urine output > 1cc/kgNormal urine output > 1cc/kg– Teenagers Teenagers >> 30cc/hr 30cc/hr– If urine output is low – increase fluidsIf urine output is low – increase fluids

Pain controlPain control– IV use of morphine, fentanyl or ketamineIV use of morphine, fentanyl or ketamine– IM route not well absorbedIM route not well absorbed

Wound controlWound control– Clean with sterile normal saline or sterile water and Clean with sterile normal saline or sterile water and

cover with non-adherent dressingcover with non-adherent dressing Asses neurovascular status of circumferential burnsAsses neurovascular status of circumferential burns

– Chest, limbs, fingers/toesChest, limbs, fingers/toes Keep patient warmKeep patient warm

– Cover with warm blanketsCover with warm blankets– No ice packs- hypothermia causes more tissue injuryNo ice packs- hypothermia causes more tissue injury

Chest X-rayChest X-ray I-Stat on transportI-Stat on transport Electrolytes, BUN, CreatinineElectrolytes, BUN, Creatinine

– Low K+ needs to be supplementedLow K+ needs to be supplemented– In compartment syndrome or excessive tissue burn: In compartment syndrome or excessive tissue burn:

Rhabdomyolysis (skeletal muscle decompostion) can Rhabdomyolysis (skeletal muscle decompostion) can occur causing a high K+, Phosphorus and CPK; low occur causing a high K+, Phosphorus and CPK; low Ph and Ca+ are commonPh and Ca+ are common

NaHCo3 1meq/kg will reduce the Serum K+ and NaHCo3 1meq/kg will reduce the Serum K+ and damage to kidneysdamage to kidneys

CaCl 10mg/kg will stabilize cardiac cell membrane CaCl 10mg/kg will stabilize cardiac cell membrane and lower phosphorusand lower phosphorus

Tetanus boosterTetanus booster should be given if tetanus is should be given if tetanus is incomplete or if > 5 years have elapsed since last givenincomplete or if > 5 years have elapsed since last given

Transport to a Burn Center (UCSD Transport to a Burn Center (UCSD

Burn centers referral criteriaBurn centers referral criteria

Second and third degree burns >10% body surface area (BSA) in Second and third degree burns >10% body surface area (BSA) in patients <10 or >50 years old.patients <10 or >50 years old.

Second and third degree burns >20% BSA in other groups.Second and third degree burns >20% BSA in other groups. Second and third degree burns with serious threat of functional or Second and third degree burns with serious threat of functional or

cosmetic impairment that involve face, hands, feet, genitalia, cosmetic impairment that involve face, hands, feet, genitalia, perineum, and major joints.perineum, and major joints.

Third-degree burns >five% BSA in any age group.Third-degree burns >five% BSA in any age group. Electrical burns, including lightening injury.Electrical burns, including lightening injury. Chemical burns with serious threat of functional or cosmetic Chemical burns with serious threat of functional or cosmetic

impairment.impairment. Inhalation injury with burn injury.Inhalation injury with burn injury. Circumferential burns with burn injury.Circumferential burns with burn injury. Burn injury in patients with pre-existing medical disorders that could Burn injury in patients with pre-existing medical disorders that could

complicate management, prolong recovery, or affect mortality.complicate management, prolong recovery, or affect mortality. Any burn patient with concomitant trauma (for example fractures) in Any burn patient with concomitant trauma (for example fractures) in

which the burn injury poses the greatest risk of morbidity or morality. which the burn injury poses the greatest risk of morbidity or morality. However , if the trauma poses the greater immediate risk, the patient However , if the trauma poses the greater immediate risk, the patient may be treated in a trauma center initially until stable, before being may be treated in a trauma center initially until stable, before being transferred to a burn center. Physician judgement will be necessary in transferred to a burn center. Physician judgement will be necessary in such situations, and should be in concert with the regional medical such situations, and should be in concert with the regional medical control plan and triage protocols.control plan and triage protocols.

Hospital without qualified personnel or equipment for the care of Hospital without qualified personnel or equipment for the care of children should Thermal injury suggested fluid resuscitation children should Thermal injury suggested fluid resuscitation (modified Parkland formula (modified Parkland formula

Inhalation injuryInhalation injury

Pulmonary problems are a major source of Pulmonary problems are a major source of morbidity and mortality in the burn patient. morbidity and mortality in the burn patient. To help clarify this process, the burn injury To help clarify this process, the burn injury can be divided into the following phases. 1) can be divided into the following phases. 1) The Resuscitation Phase, 2) The Early Post The Resuscitation Phase, 2) The Early Post Resuscitation Phase and the 3) Resuscitation Phase and the 3) Inflammation, Infection or Hypermetabolic Inflammation, Infection or Hypermetabolic Phase. The pulmonary problems specific to Phase. The pulmonary problems specific to each phase will be discussed each phase will be discussed

I) Resuscitation Phase (0-I) Resuscitation Phase (0-48 hrs)48 hrs)

Smoke Inhalation Injury ComplexSmoke Inhalation Injury Complex

Pulmonary insufficiency caused by the inhalation of heat and Pulmonary insufficiency caused by the inhalation of heat and smoke is the major cause of mortality in the fire-injured smoke is the major cause of mortality in the fire-injured person, accounting for more than 50% of fire-related deaths. person, accounting for more than 50% of fire-related deaths. The magnitude of the problem has been much better The magnitude of the problem has been much better appreciated in recent years. The use of many new synthetics appreciated in recent years. The use of many new synthetics in home furnishings and clothing have resulted in a much in home furnishings and clothing have resulted in a much more complex form of injury, due to the extremely toxic more complex form of injury, due to the extremely toxic combustion products of these advances in technology. A combustion products of these advances in technology. A closed space fire can result in a severe hypoxic insult as well closed space fire can result in a severe hypoxic insult as well as lung damage from the inhalation of the toxic fumes. The as lung damage from the inhalation of the toxic fumes. The exposure time, the concentration of fumes, the elements exposure time, the concentration of fumes, the elements release, and the degree of concomitant body burn are critical release, and the degree of concomitant body burn are critical variables. These factors cause a very complex injury with variables. These factors cause a very complex injury with morbidity and mortality risks, especially when combined with morbidity and mortality risks, especially when combined with a body burn. Improved knowledge of the pathophysiology a body burn. Improved knowledge of the pathophysiology combined with an aggressive treatment plan has made it combined with an aggressive treatment plan has made it possible to improve the outcome.possible to improve the outcome.

a) Carbon Monoxide Toxicitya) Carbon Monoxide Toxicity b) Upper Airway Injury from b) Upper Airway Injury from Smoke ExposureSmoke Exposure c) Chemical Burn to Upper c) Chemical Burn to Upper and Lower Airwaysand Lower Airways d) Restrictive Chest d) Restrictive Chest Wall BurnWall Burn

II) Post-Resuscitation Period (2-6 days)II) Post-Resuscitation Period (2-6 days)This period is often the calm before the This period is often the calm before the

storm of the hypermetabolic catabolic state. storm of the hypermetabolic catabolic state. However, during this period a number of However, during this period a number of major pulmonary problems can occur, major pulmonary problems can occur, especially the progression of a severe especially the progression of a severe

inhalation injury to respiratory dysfunction. inhalation injury to respiratory dysfunction. The most common disorders are described The most common disorders are described

below.below.

A. Continued Upper Airway InjuryA. Continued Upper Airway Injury B. Decreased Chest Wall B. Decreased Chest Wall ComplianceCompliance C. Tracheobronchitis C. Tracheobronchitis from inhalation injuryfrom inhalation injury d) Pulmonary d) Pulmonary Edema (High PressureEdema (High Pressure ) )

III. Pulmonary problems in III. Pulmonary problems in the inflammation-infection the inflammation-infection

phase (7 days to wound phase (7 days to wound closure)closure)

A) Nosocomial pneumoniaA) Nosocomial pneumonia B) Hypermetabolism Induced B) Hypermetabolism Induced Respiratory Dysfunction (Power Respiratory Dysfunction (Power Failure) Failure) C) Adult Respiratory Distress C) Adult Respiratory Distress Syndrome (Low Pressure Pulmonary Syndrome (Low Pressure Pulmonary Edema)Edema)

Adult Respiratory Distress Adult Respiratory Distress SyndromeSyndrome

The lung damage is the result of a systemic The lung damage is the result of a systemic process initiated by burn tissue, infection or process initiated by burn tissue, infection or inflammation rather than a direct lung injury. inflammation rather than a direct lung injury. Phase One oPhase One on the n the firstfirst, or , or initialinitial phasephase dyspnea and tachypnea dyspnea and tachypnea Phase Two Hypoxemia is Phase Two Hypoxemia is now evident, along with continuing now evident, along with continuing dyspnea.dyspnea. Phase ThreePhase Three acute respiratory failure acute respiratory failure Phase FourPhase Four progressive pulmonary fibrosis progressive pulmonary fibrosis and recurrent pneumonias and recurrent pneumonias

TreatmentTreatment Mortality rate of ARDS caused by burn Mortality rate of ARDS caused by burn inflammation and infection is extremely high. The inflammation and infection is extremely high. The major reason for the lethal nature of the process major reason for the lethal nature of the process is that resolution will not occur until the initiating is that resolution will not occur until the initiating process is removed: the wound especially in the process is removed: the wound especially in the large burn, cannot be readily excised and closed large burn, cannot be readily excised and closed at this stage of the post burn process. The most at this stage of the post burn process. The most important early treatment is prevention, i.e., early important early treatment is prevention, i.e., early removal of as much of the potential source of the removal of as much of the potential source of the systemic inflammatory response as is feasible. systemic inflammatory response as is feasible. A variety of new low pressure ventilation systems A variety of new low pressure ventilation systems are available for management, which appear to be are available for management, which appear to be effective. effective.

Escharotomies and Escharotomies and fasciotomiesfasciotomies

Edema may develop underneath Edema may develop underneath circumferential burns of extremities circumferential burns of extremities and compromise the arterial circulation and compromise the arterial circulation to the more distal aspects. Early after to the more distal aspects. Early after the injury, the adequacy of the the injury, the adequacy of the peripheral circulation can usually be peripheral circulation can usually be assessed by palpation of the peripheral assessed by palpation of the peripheral pulses, but these pulses frequently pulses, but these pulses frequently become impossible to identify as become impossible to identify as edema develops under a edema develops under a circumferential eschar circumferential eschar

Increased compartment pressures can Increased compartment pressures can completely obstruct arterial inflow, leading to completely obstruct arterial inflow, leading to distal ischemia, necrosis, and gangrene. distal ischemia, necrosis, and gangrene. Signs and symptoms of peripheral ischemia Signs and symptoms of peripheral ischemia can be difficult to identify in patients with can be difficult to identify in patients with large burns, who are often intubated, large burns, who are often intubated, receiving narcotics, and have peripheral receiving narcotics, and have peripheral edema due to administration of resuscitation edema due to administration of resuscitation fluid. The classic signs and symptoms of fluid. The classic signs and symptoms of peripheral ischemia (pain, paraesthesias, peripheral ischemia (pain, paraesthesias, pallor, pulselessness, and paralysis) may pallor, pulselessness, and paralysis) may therefore be masked, and Doppler therefore be masked, and Doppler ultrasonography is the only reliable method ultrasonography is the only reliable method for its early detection. When vascular for its early detection. When vascular compromise occurs, escharotomies (incisions compromise occurs, escharotomies (incisions made through burned epidermis and dermis) made through burned epidermis and dermis) are necessary to restore both arterial and are necessary to restore both arterial and venous circulation venous circulation

Nutritional supportNutritional support Protein should be infused at a rate of 1.5 to 2.5 g/kg Protein should be infused at a rate of 1.5 to 2.5 g/kg

per day, depending on the size of injury and the per day, depending on the size of injury and the presence of sepsis. This rate will maintain a positive presence of sepsis. This rate will maintain a positive nitrogen balance in adults and in children, but nitrogen balance in adults and in children, but neither the exact protein requirements nor the neither the exact protein requirements nor the optimal mixture of amino acids required by optimal mixture of amino acids required by seriously injured patients are known. Unfortunately, seriously injured patients are known. Unfortunately, studies of nitrogen balance do not produce the studies of nitrogen balance do not produce the exact information necessary to determine the exact information necessary to determine the quantity and composition of the proteins required. quantity and composition of the proteins required. Until rates of synthesis of muscle protein, collagen Until rates of synthesis of muscle protein, collagen components of host defense, and other proteins can components of host defense, and other proteins can be accurately measured be accurately measured in vivoin vivo, this protein-, this protein-replacement rate remains only an estimate.replacement rate remains only an estimate.

Calculating the caloric equivalent Calculating the caloric equivalent received by a seriously burned patient received by a seriously burned patient given glucose at 5 mg/kg per minute given glucose at 5 mg/kg per minute and protein at 2.5 g/kg per day shows and protein at 2.5 g/kg per day shows that their caloric requirement that their caloric requirement (calculated as basal metabolic rate × (calculated as basal metabolic rate × 2) is not achieved. Fats are therefore 2) is not achieved. Fats are therefore given to meet the remaining caloric given to meet the remaining caloric requirement, via either the enteral or requirement, via either the enteral or parenteral routes parenteral routes

Wound care and infectionsWound care and infections Infection of the burn wound is a major cause of Infection of the burn wound is a major cause of

complications and death in burn patients: the best complications and death in burn patients: the best approach to the problem is the prevention of wound approach to the problem is the prevention of wound infection. Infection is most likely to affect a large, infection. Infection is most likely to affect a large, open wound containing necrotic tissue; open wound containing necrotic tissue; susceptibility is increased by the lowered host susceptibility is increased by the lowered host resistance that results from serious trauma, and resistance that results from serious trauma, and this is more important than the virulence of most this is more important than the virulence of most infecting bacteria in determining the seriousness of infecting bacteria in determining the seriousness of the infection. Decreased host resistance must be the infection. Decreased host resistance must be corrected or prevented. Necrotic tissue must be corrected or prevented. Necrotic tissue must be removed and wounds properly closed. Secondary removed and wounds properly closed. Secondary derangements in physiology and metabolism derangements in physiology and metabolism leading to caloric and protein starvation must be leading to caloric and protein starvation must be corrected. Cross-contamination of wounds must be corrected. Cross-contamination of wounds must be prevented, and antibiotic treatment to prevent prevented, and antibiotic treatment to prevent invasive infections should be administered only at invasive infections should be administered only at times of increasedtimes of increased

The goals for therapy are to The goals for therapy are to 1.1. Delay colonization of the wound. Delay colonization of the wound. 2.2. Keep the wound bacterial Keep the wound bacterial

density lower than would otherwise density lower than would otherwise occur 3.occur 3.Keep the wound flora more Keep the wound flora more homogeneous and less diverse than homogeneous and less diverse than without therapywithout therapy

Prophylactic antibiotics may be useful against the Prophylactic antibiotics may be useful against the high incidence of bacteremia that occurs during and high incidence of bacteremia that occurs during and after excision of colonized burn eschar. Treatment after excision of colonized burn eschar. Treatment should begin immediately before the operation and should begin immediately before the operation and last through the immediate postoperative period, last through the immediate postoperative period, until normal cardiovascular hemodynamics are until normal cardiovascular hemodynamics are restored (usually within 24 h) and other normal restored (usually within 24 h) and other normal physiologic signs return. The perioperative antibiotic physiologic signs return. The perioperative antibiotic given should be chosen on the results of previous given should be chosen on the results of previous cultures from the burn wound and the sensitivities of cultures from the burn wound and the sensitivities of the organisms. If these are unavailable, general the organisms. If these are unavailable, general antimicrobial coverage for both Gram-positive cocci antimicrobial coverage for both Gram-positive cocci and Gram-negative rods is recommended. and Gram-negative rods is recommended. Intravenous antibiotics should be directed toward the Intravenous antibiotics should be directed toward the commonly encountered commonly encountered Staphylococcus aureusStaphylococcus aureus, , Pseudomonas aeruginosaPseudomonas aeruginosa, , E. coliE. coli, , EnterobacterEnterobacter, , KlebsiellaKlebsiella, , AcinetobacterAcinetobacter, and , and ProteusProteus spp. Serum spp. Serum concentrations of both vancomycin and concentrations of both vancomycin and aminoglycoside should be measured when these aminoglycoside should be measured when these antibiotics are used perioperatively but continued for antibiotics are used perioperatively but continued for more than 48 to 72 h.more than 48 to 72 h.

The risk of death for a burn patient without a The risk of death for a burn patient without a significant inhalation injury is highest from significant inhalation injury is highest from systemic sepsis. There are many dose-related systemic sepsis. There are many dose-related factors that make the burn patient highly factors that make the burn patient highly susceptible to the development of invasive sepsis. susceptible to the development of invasive sepsis. First is the burn wound itself, representing a major First is the burn wound itself, representing a major compromise in the body’s defense mechanism. compromise in the body’s defense mechanism. The burn wound, in addition to being locally The burn wound, in addition to being locally susceptible to infection, is associated with dose-susceptible to infection, is associated with dose-related immunosuppression of the specific and related immunosuppression of the specific and nonspecific immune systems. Further, because nonspecific immune systems. Further, because these patients are often critically ill, they are these patients are often critically ill, they are subjected to a variety of invasive devices that subjected to a variety of invasive devices that bypass normal defense mechanisms; these bypass normal defense mechanisms; these devices include endotracheal tubes, bladder devices include endotracheal tubes, bladder catheters, and arterial or venous intravascular catheters, and arterial or venous intravascular catheters. Depending on other associated injuries, catheters. Depending on other associated injuries, devices such as chest tubes, intracranial pressure devices such as chest tubes, intracranial pressure monitors, and pulmonary artery catheters may be monitors, and pulmonary artery catheters may be present for extended periods. present for extended periods.

Though the burn wound, especially when Though the burn wound, especially when covered with necrotic eschar, is a common covered with necrotic eschar, is a common site of primary infection in the septic burn site of primary infection in the septic burn patient, other sites are common, including patient, other sites are common, including the upper and lower respiratory tracts, the the upper and lower respiratory tracts, the urinary tract, and, less frequently, infections urinary tract, and, less frequently, infections from osteomyelitis or suppurative phlebitis. from osteomyelitis or suppurative phlebitis. By far the most common sites of primary By far the most common sites of primary infection in burn patients are the blood infection in burn patients are the blood stream, the burn wound, stream, the burn wound,

Silver sulfadiazine Silver sulfadiazine Broad antibacterial actionBroad antibacterial action AD Fair penetration of AD Fair penetration of eschar, Painless DIS.Occasional eschar, Painless DIS.Occasional sulfonamide sensitivity (rash)  Safety sulfonamide sensitivity (rash)  Safety in pregnancy unknown  Occasional in pregnancy unknown  Occasional leucopenia, which is reversibleleucopenia, which is reversible

Mafenide Mafenide Excellent antibacterial action Excellent antibacterial action AD.Good eschar penetration AD.Good eschar penetration DIS. Very painful(10%) sulfonamide DIS. Very painful(10%) sulfonamide sensitivity rash  Common carbonic sensitivity rash  Common carbonic anhydrase inhibition leading to anhydrase inhibition leading to metabolic acidosismetabolic acidosis

Silver nitrate Silver nitrate Universal antibacterial action Universal antibacterial action AD.Effective for donor sites, newly-AD.Effective for donor sites, newly-grafted areas, and burn wounds grafted areas, and burn wounds DIS.Poor penetration of DIS.Poor penetration of eschar(0.5%) Leaches sodium and eschar(0.5%) Leaches sodium and chloride, causing hyponatremia, or chloride, causing hyponatremia, or hypochloremic alkalosis  Stains all it hypochloremic alkalosis  Stains all it touchestouches

Wound debridements and Wound debridements and dressing changes dressing changes

Classical burn wound care has been performed in a Classical burn wound care has been performed in a Hubbard tank or some other immersion facility. This Hubbard tank or some other immersion facility. This

creates for the patient, a warm, pleasant, creates for the patient, a warm, pleasant, antigravity environment, where range of motion can antigravity environment, where range of motion can

be performed comfortably by physical and be performed comfortably by physical and occupational therapists. Concern regarding occupational therapists. Concern regarding

potential cross-contamination has led many burn potential cross-contamination has led many burn centers to shower patients on a cart rather than centers to shower patients on a cart rather than

immerse them, especially patients with large, deep immerse them, especially patients with large, deep burn wounds. This procedure is somewhat more burn wounds. This procedure is somewhat more uncomfortable for the patient and must be done uncomfortable for the patient and must be done

more quickly. There is a greater tendency towards more quickly. There is a greater tendency towards hypothermia, even with a high ambient hypothermia, even with a high ambient

temperature in the tub room. There are advantages, temperature in the tub room. There are advantages, however, in terms of infection control. Even however, in terms of infection control. Even

intubated patients can be debrided and cleansed intubated patients can be debrided and cleansed very adequately in this fashion.very adequately in this fashion.

Critically ill patients are still debrided and Critically ill patients are still debrided and dressed in their beds, though this is done dressed in their beds, though this is done less frequently with increased use of the less frequently with increased use of the shower cart. We still use tubbing for smaller shower cart. We still use tubbing for smaller wounds and in preparing patients to take wounds and in preparing patients to take care of their wounds after discharge. care of their wounds after discharge. Initially, dressings must be bulky in the Initially, dressings must be bulky in the presence of eschar to absorb the substantial presence of eschar to absorb the substantial exudate created. Post-grafting, after the exudate created. Post-grafting, after the graft is revascularized, a properly applied graft is revascularized, a properly applied dressing will protect the fragile grafts until dressing will protect the fragile grafts until they gain strength. However, if dressings are they gain strength. However, if dressings are too bulky, they may decrease range of too bulky, they may decrease range of motion. motion.

Recognition&management of Recognition&management of sepsissepsis

There are many dose-related factors that make the burn patient There are many dose-related factors that make the burn patient highly susceptible to the development of invasive sepsis. First is highly susceptible to the development of invasive sepsis. First is the burn wound itself, representing a major compromise in the the burn wound itself, representing a major compromise in the body’s defense mechanism. The burn wound, in addition to being body’s defense mechanism. The burn wound, in addition to being locally susceptible to infection, is associated with dose-related locally susceptible to infection, is associated with dose-related immunosuppression of the specific and nonspecific immune immunosuppression of the specific and nonspecific immune systems. Further, because these patients are often critically ill, systems. Further, because these patients are often critically ill, they are subjected to a variety of invasive devices that bypass they are subjected to a variety of invasive devices that bypass normal defense mechanisms; these devices include endotracheal normal defense mechanisms; these devices include endotracheal tubes, bladder catheters, and arterial or venous intravascular tubes, bladder catheters, and arterial or venous intravascular catheters. Depending on other associated injuries, devices such as catheters. Depending on other associated injuries, devices such as chest tubes, intracranial pressure monitors, and pulmonary artery chest tubes, intracranial pressure monitors, and pulmonary artery catheters may be present for extended periods. Though the burn catheters may be present for extended periods. Though the burn wound, especially when covered with necrotic eschar, is a wound, especially when covered with necrotic eschar, is a common site of primary infection in the septic burn patient, other common site of primary infection in the septic burn patient, other sites are common, including the upper and lower respiratory sites are common, including the upper and lower respiratory tracts, the urinary tract, and, less frequently, infections from tracts, the urinary tract, and, less frequently, infections from osteomyelitis or suppurative phlebitis. By far the most common osteomyelitis or suppurative phlebitis. By far the most common sites of primary infection in burn patients are the blood stream, sites of primary infection in burn patients are the blood stream, the burn wound, the lower respiratory tract, and the urinary tract. the burn wound, the lower respiratory tract, and the urinary tract.

Because of the immunocompromised Because of the immunocompromised state of these patients as well as their state of these patients as well as their

intense and long-lasting intense and long-lasting hypermetabolism, they do not exhibit hypermetabolism, they do not exhibit

the usual clinical parameters of the usual clinical parameters of infection found in other infection found in other

immunosuppressed populations (e.g., immunosuppressed populations (e.g., organ allograft recipients). Thus, the organ allograft recipients). Thus, the

burn surgeon must be constantly burn surgeon must be constantly aware of the clinical status of the aware of the clinical status of the patient and be alert for any subtle patient and be alert for any subtle changes. These are often the first changes. These are often the first

indicators of incipient sepsis. indicators of incipient sepsis.

The burn wound may change in appearance The burn wound may change in appearance with the development of sepsis. It may with the development of sepsis. It may exhibit softening of the eschar or exhibit softening of the eschar or surrounding cellulitis, purulent material may surrounding cellulitis, purulent material may begin to issue from the wound, or once-begin to issue from the wound, or once-healthy granulation tissue may begin to healthy granulation tissue may begin to deteriorate. Equally common, however, is deteriorate. Equally common, however, is the absence of change in wound the absence of change in wound appearance. Infection from the urinary or appearance. Infection from the urinary or lower-respiratory tract is infrequently lower-respiratory tract is infrequently accompanied by symptoms in these ill accompanied by symptoms in these ill patients. Thus, periodic culture surveillance patients. Thus, periodic culture surveillance is advisable to monitor the flora in these is advisable to monitor the flora in these areas.areas.

Careful serial clinical and laboratory monitoring of the Careful serial clinical and laboratory monitoring of the patient is the most sensitive method of diagnosing patient is the most sensitive method of diagnosing sepsis before disastrous hemodynamic effects occur. sepsis before disastrous hemodynamic effects occur. We perform twice weekly eschar biopsies for We perform twice weekly eschar biopsies for quantitative culture, though their value is debatable. quantitative culture, though their value is debatable. Wound colonization with >100,000 organisms/gram Wound colonization with >100,000 organisms/gram tissue is an indication to perform expedient eschar tissue is an indication to perform expedient eschar excision rather than to begin antibiotics. excision rather than to begin antibiotics.

Clinically, any change in the patient’s general status Clinically, any change in the patient’s general status should lead to a high suspicion of sepsis. Possible should lead to a high suspicion of sepsis. Possible changes include unexplained hypotension, tachypnea, changes include unexplained hypotension, tachypnea, spiking fevers above the patient’s daily baseline, spiking fevers above the patient’s daily baseline, tachycardia, new onset of ileus, altered mental status, tachycardia, new onset of ileus, altered mental status, thrombocytopenia, hyper- or hypoglycemia, hypoxia or thrombocytopenia, hyper- or hypoglycemia, hypoxia or hypothermia, and decreased urine output or hypothermia, and decreased urine output or progressive leukocytosis with “left shift,” including progressive leukocytosis with “left shift,” including myelocytes and promyelocytes in the peripheral myelocytes and promyelocytes in the peripheral smear. The development of hypothermia and smear. The development of hypothermia and leukopenia are particularly ominous signs in the leukopenia are particularly ominous signs in the patient who is clinically becoming septic and demand patient who is clinically becoming septic and demand aggressive intervention. aggressive intervention.

Pseudomonas aeruginosa and Staphylococcus Pseudomonas aeruginosa and Staphylococcus aureus are the dominant pathogens in burn aureus are the dominant pathogens in burn

centers. This is a generalization only; it is more centers. This is a generalization only; it is more helpful for each burn center to know and monitor helpful for each burn center to know and monitor

its own resident flora. Candida species are the its own resident flora. Candida species are the most commonly isolated fungal organisms most commonly isolated fungal organisms recovered from burn patients; other fungal recovered from burn patients; other fungal infections are uncommon. Viral infections, infections are uncommon. Viral infections,

particularly with cytomegalovirus, are reported particularly with cytomegalovirus, are reported with increasing frequency, though their clinical with increasing frequency, though their clinical

impact is undetermined. impact is undetermined.

There is little place for prophylactic antibiotic usage in There is little place for prophylactic antibiotic usage in burn patients. Penicillin G used to be recommended for burn patients. Penicillin G used to be recommended for

the first post burn week to prevent group A beta-the first post burn week to prevent group A beta-hemolytic Streptococcal burn wound cellulitis. There is hemolytic Streptococcal burn wound cellulitis. There is

still arguably a place for this prophylaxis if topical still arguably a place for this prophylaxis if topical antibiotics are not used (e.g., with Biobrane), but several antibiotics are not used (e.g., with Biobrane), but several

studies suggest it is not necessary in addition to usual studies suggest it is not necessary in addition to usual topical antibiotic treatment.topical antibiotic treatment.

Fungal infections are an uncommon but difficult problem. It is Fungal infections are an uncommon but difficult problem. It is our current practice to systemically treat burn patients with our current practice to systemically treat burn patients with fungus found in two sites (i.e., sputum, intravenous catheter fungus found in two sites (i.e., sputum, intravenous catheter tip, urine or wound). This is most often Candida species and tip, urine or wound). This is most often Candida species and occurs two to three weeks postburn. We have aggressively occurs two to three weeks postburn. We have aggressively treated these patients with systemic amphotericin B. This treated these patients with systemic amphotericin B. This drug has a number of side effects. It has clearly decreased drug has a number of side effects. It has clearly decreased

morbidity and mortality from fungal infections. Delaying morbidity and mortality from fungal infections. Delaying treatment until fungemia occurs is associated with a high treatment until fungemia occurs is associated with a high

mortality rate. mortality rate. Other adjunctive measures may be necessary in the patient Other adjunctive measures may be necessary in the patient with life-threatening infection. Adequate fluid must be given with life-threatening infection. Adequate fluid must be given to maintain intravascular volume and urine output. Invasive to maintain intravascular volume and urine output. Invasive

monitoring should be added as the clinical situation monitoring should be added as the clinical situation demands. Often a change in topical antibiotic or an increase demands. Often a change in topical antibiotic or an increase in the frequency of wound care is added to the management in the frequency of wound care is added to the management of the burn patient with invasive infection and a large eschar of the burn patient with invasive infection and a large eschar

burden. Certainly, if one topical agent has been used for a burden. Certainly, if one topical agent has been used for a long period, a change to another may be of benefit. In long period, a change to another may be of benefit. In

particular, mafenide has a much greater ability to penetrate particular, mafenide has a much greater ability to penetrate the burn wound than other topical agents. It should be the burn wound than other topical agents. It should be

strongly considered in the presence of invasive burn wound strongly considered in the presence of invasive burn wound

infection, keeping in mind its complications.infection, keeping in mind its complications.

When sepsis is suspected, support of the cardiopulmonary and When sepsis is suspected, support of the cardiopulmonary and GI system should be of primary concern. Consideration should GI system should be of primary concern. Consideration should

be given to eschar debridement, depending on the character of be given to eschar debridement, depending on the character of the burn wound. Empiric antibiotic therapy should be started the burn wound. Empiric antibiotic therapy should be started

after cultures are obtained. Depending on the resident flora of after cultures are obtained. Depending on the resident flora of a particular burn center, some combination of agents to cover a particular burn center, some combination of agents to cover

Staphylococcus aureus and gramStaphylococcus aureus and gram negative rods should be negative rods should be initiated. Aminoglycoside dosage requirements are difficult to initiated. Aminoglycoside dosage requirements are difficult to predict in burn patients; individualized therapy is mandatory. predict in burn patients; individualized therapy is mandatory. Drug level monitoring is also advised for Vancomycin, which is Drug level monitoring is also advised for Vancomycin, which is

used increasingly for methicillin-resistant Staphylococcus used increasingly for methicillin-resistant Staphylococcus aureus. It is important to obtain culture results as soon as aureus. It is important to obtain culture results as soon as

possible, including in vitro sensitivities. These may not possible, including in vitro sensitivities. These may not correlate with in vivo behavior. Antibiotic therapy should then correlate with in vivo behavior. Antibiotic therapy should then

be targeted for the likely infecting organism(s). The use of new be targeted for the likely infecting organism(s). The use of new antibiotics or untested combinations of antibiotics is antibiotics or untested combinations of antibiotics is

recommended only as part of an investigational study or with recommended only as part of an investigational study or with the assistance of a physician fully versed in their usage and the assistance of a physician fully versed in their usage and

complications.complications.

Order of excisionOrder of excision In the absence of significant inhalation injury, it is rare for burns to In the absence of significant inhalation injury, it is rare for burns to

cause significant infectious complications before the fifth through cause significant infectious complications before the fifth through the tenth post burn day. In the presence of a large burn, the the tenth post burn day. In the presence of a large burn, the highest priority is to diminish the overall necrotic tissue load. highest priority is to diminish the overall necrotic tissue load. Broad areas like the trunk and lower extremities are given priority Broad areas like the trunk and lower extremities are given priority for excision. Lower priority is given burns on the face and hands. for excision. Lower priority is given burns on the face and hands. They take more time to excise and cover with autograft. Delayed They take more time to excise and cover with autograft. Delayed excision of hands can result in very acceptable function if excision of hands can result in very acceptable function if accompanied by meticulous therapeutic assistance. accompanied by meticulous therapeutic assistance.

In a major burn, the posterior trunk should be given high priority In a major burn, the posterior trunk should be given high priority as the first area to be excised. The patient is stable and will as the first area to be excised. The patient is stable and will generally tolerate the prone position better than later in his generally tolerate the prone position better than later in his course. The posterior trunk and buttocks are frequent sites of burn course. The posterior trunk and buttocks are frequent sites of burn wound infection and are difficult to inspect and keep well wound infection and are difficult to inspect and keep well debrided; the flat, broad area lends itself well to quick excision debrided; the flat, broad area lends itself well to quick excision and grafting. Complete full-thickness burns of the back are quite and grafting. Complete full-thickness burns of the back are quite rare, due to the thickness of the skin. We therefore recommend rare, due to the thickness of the skin. We therefore recommend tangential excision for all but the most obvious full-thickness back tangential excision for all but the most obvious full-thickness back burns (for which excision to fascia is only rarely indicated).burns (for which excision to fascia is only rarely indicated).

Tangantial excisionTangantial excision Excision of full-thickness eschar may be assisted by Excision of full-thickness eschar may be assisted by

dressing the eschar with povidone-iodine foam 12 hours dressing the eschar with povidone-iodine foam 12 hours prior to operation. This dehydrates the eschar and prior to operation. This dehydrates the eschar and makes it more physically amenable to tangential makes it more physically amenable to tangential excision. A variety of dermatomes (manual and excision. A variety of dermatomes (manual and powered) may be used. Manual knives (e.g., Weck, powered) may be used. Manual knives (e.g., Weck, Goulian) are especially advantageous for small, irregular Goulian) are especially advantageous for small, irregular surfaces, such as the hands and face, while a powered surfaces, such as the hands and face, while a powered dermatome can be used to remove quickly uniform dermatome can be used to remove quickly uniform sheets of eschar from larger surfaces. Excision is sheets of eschar from larger surfaces. Excision is continued until punctate uniform brisk bleeding is seen. continued until punctate uniform brisk bleeding is seen. If there is dermis left when this viable tissue level is If there is dermis left when this viable tissue level is reached, it will be white and shiny. Gray, dull appearing reached, it will be white and shiny. Gray, dull appearing dermis is nonviable and will not support an immediately-dermis is nonviable and will not support an immediately-placed skin graft. If the dermis is completely destroyed, placed skin graft. If the dermis is completely destroyed, tangential excision should be continued into the tangential excision should be continued into the subcutaneous fatsubcutaneous fat

Tangential excision can be performed under Tangential excision can be performed under tourniquet control. The cadaveric appearance of the tourniquet control. The cadaveric appearance of the

tissues distal to the inflated tourniquet makes tissues distal to the inflated tourniquet makes differentiation of viable and nonviable tissues differentiation of viable and nonviable tissues

difficult, but with experience this can be difficult, but with experience this can be appreciated. With concern about blood transfusions, appreciated. With concern about blood transfusions, this technique is increasing in popularity. Tangential this technique is increasing in popularity. Tangential

excisions are bloody procedures, and adequate excisions are bloody procedures, and adequate blood should be available. We routinely type and blood should be available. We routinely type and

cross-match six units of packed red cells for major cross-match six units of packed red cells for major excisions of the trunk, four units for each lower excisions of the trunk, four units for each lower

extremity and four units for each upper extremity, extremity and four units for each upper extremity, including two units for hand excision alone (if including two units for hand excision alone (if

tourniquets are not used). Without a tourniquet, the tourniquets are not used). Without a tourniquet, the best method to limit blood loss is to work on only best method to limit blood loss is to work on only one area at a time, completing that area before one area at a time, completing that area before proceeding. Extremities should be excised from proceeding. Extremities should be excised from

distal to proximal so that hemostatic compressive distal to proximal so that hemostatic compressive dressings applied after excision do not produce a dressings applied after excision do not produce a

tourniquet effect.tourniquet effect.

Fascial excisionFascial excision Fascial excision is another method of immediate excision: it Fascial excision is another method of immediate excision: it

is reserved for limited indications. Fascial excision offers is reserved for limited indications. Fascial excision offers the following advantages over tangential excision: the following advantages over tangential excision:

1.1. A viable bed for grafting is reliably provided. A viable bed for grafting is reliably provided. 2.2. Excision may be easily performed on extremities Excision may be easily performed on extremities

under tourniquet control with decreased blood loss. under tourniquet control with decreased blood loss. 3.3. Less experience is required to obtain a good bed for Less experience is required to obtain a good bed for

grafting. Fascial excision has a number of disadvantages. grafting. Fascial excision has a number of disadvantages. Excised fat does not regenerate, and permanent cosmetic Excised fat does not regenerate, and permanent cosmetic deformity, which can be severe, is guaranteed—especially deformity, which can be severe, is guaranteed—especially in obese patients. With circumferential excision, there is a in obese patients. With circumferential excision, there is a risk of distal edema and a 100% risk of damage to risk of distal edema and a 100% risk of damage to superficial nerves and tendons. There is a greater incidence superficial nerves and tendons. There is a greater incidence of cutaneous denervation; loss of sensation may be of cutaneous denervation; loss of sensation may be permanent. The fascia over joint surfaces such as the permanent. The fascia over joint surfaces such as the elbow, knee, and ankle is relatively avascular, and eventual elbow, knee, and ankle is relatively avascular, and eventual flap coverage may be required in these areas. flap coverage may be required in these areas.

Operative treatmentOperative treatment

Improvements in resuscitation Improvements in resuscitation consistently present the burn surgeon consistently present the burn surgeon with patients who are physiologically with patients who are physiologically stable 48–72 hours postburn. These stable 48–72 hours postburn. These

patients carry a variable load of dead patients carry a variable load of dead tissue in immediate contact with tissue in immediate contact with healthy (or injured but potentially healthy (or injured but potentially salvageable) tissue. Leaving this salvageable) tissue. Leaving this

eschar in situ and waiting for eschar in situ and waiting for separation due to autolysis to occur separation due to autolysis to occur violates many surgical principles of violates many surgical principles of debridement developed in the 16th debridement developed in the 16th

century by Parécentury by Paré

physiologically stable 48–72 hours physiologically stable 48–72 hours postburn. These patients carry a postburn. These patients carry a variable load of dead tissue in variable load of dead tissue in

immediate contact with healthy (or immediate contact with healthy (or injured but potentially salvageable) injured but potentially salvageable)

tissue. Leaving this eschar in situ and tissue. Leaving this eschar in situ and waiting for separation due to autolysis waiting for separation due to autolysis

to occur violates many surgical to occur violates many surgical principles of debridement developed principles of debridement developed

in the 16th century by Paréin the 16th century by Paré

In 1970, a Yugoslavian plastic surgeon, Janzekovic, In 1970, a Yugoslavian plastic surgeon, Janzekovic, published a short paper in the Journal of Trauma. published a short paper in the Journal of Trauma. Using the knowledge that deep donor sites could Using the knowledge that deep donor sites could be overgrafted successfully with thinner autografts be overgrafted successfully with thinner autografts to hasten their healing and improve their to hasten their healing and improve their appearance, she applied this technique to dermal appearance, she applied this technique to dermal burns by repeatedly shaving layers of burned burns by repeatedly shaving layers of burned dermis until she reached a viable-appearing bed. dermis until she reached a viable-appearing bed. She covered this with an immediate autograft. She She covered this with an immediate autograft. She reported that graft take was excellent and reported that graft take was excellent and provided a clean, closed wound. Most of the burns provided a clean, closed wound. Most of the burns she treated in this way were small, but, in her she treated in this way were small, but, in her opinion, the hospital stay-related pain and need for opinion, the hospital stay-related pain and need for reconstructive procedures decreased dramatically. reconstructive procedures decreased dramatically. She reported that “esthetic disability” was also She reported that “esthetic disability” was also greatly reduced. greatly reduced.

Burke and associates in Boston also developed an Burke and associates in Boston also developed an active program of early excision and grafting in the active program of early excision and grafting in the early 1970s. Long-term results were much better in early 1970s. Long-term results were much better in their aggressively operated group of patients. their aggressively operated group of patients. Controversy still surrounded the procedure in the Controversy still surrounded the procedure in the late 1970s, however. Though there was general late 1970s, however. Though there was general agreement that small full-thickness burns could be agreement that small full-thickness burns could be safely excised and grafted with good results, the safely excised and grafted with good results, the issue of deep dermal burns had not been resolved. issue of deep dermal burns had not been resolved. A prospective randomized study was performed at A prospective randomized study was performed at the University of Washington. Results clearly the University of Washington. Results clearly showed that early excision and grafting of showed that early excision and grafting of indeterminate burns of <20% TBSA was superior to indeterminate burns of <20% TBSA was superior to spontaneous healing. It decreased hospital stay spontaneous healing. It decreased hospital stay and cost and decreased the need for secondary and cost and decreased the need for secondary reconstruction. These patients returned to work reconstruction. These patients returned to work twice as fast as the nonoperative group. twice as fast as the nonoperative group.

Burke and associates in Boston also developed an Burke and associates in Boston also developed an active program of early excision and grafting in the active program of early excision and grafting in the early 1970s. Long-term results were much better in early 1970s. Long-term results were much better in their aggressively operated group of patients. their aggressively operated group of patients. Controversy still surrounded the procedure in the Controversy still surrounded the procedure in the late 1970s, however. Though there was general late 1970s, however. Though there was general agreement that small full-thickness burns could be agreement that small full-thickness burns could be safely excised and grafted with good results, the safely excised and grafted with good results, the issue of deep dermal burns had not been resolved. issue of deep dermal burns had not been resolved. A prospective randomized study was performed at A prospective randomized study was performed at the University of Washington. Results clearly the University of Washington. Results clearly showed that early excision and grafting of showed that early excision and grafting of indeterminate burns of <20% TBSA was superior to indeterminate burns of <20% TBSA was superior to spontaneous healing. It decreased hospital stay spontaneous healing. It decreased hospital stay and cost and decreased the need for secondary and cost and decreased the need for secondary reconstruction. These patients returned to work reconstruction. These patients returned to work twice as fast as the nonoperative group. twice as fast as the nonoperative group.

Skeptics of this procedure have Skeptics of this procedure have continued to maintain that mortality is continued to maintain that mortality is not improved in large burns treated in not improved in large burns treated in this way. The reasons for this are this way. The reasons for this are threefold. First, as yet no ideal skin threefold. First, as yet no ideal skin substitute has been developed. This substitute has been developed. This means that in large burns, while the means that in large burns, while the eschar can be excised in a timely eschar can be excised in a timely manner, permanent and reliable wound manner, permanent and reliable wound closure still cannot be performed closure still cannot be performed simultaneously. simultaneously.

The second reason is that burns of The second reason is that burns of >70% TBSA or burns in the elderly are >70% TBSA or burns in the elderly are complex injuries with multi-factorial complex injuries with multi-factorial deleterious effects on multiple organ deleterious effects on multiple organ systems that lead to morbidity or death. systems that lead to morbidity or death. In this setting, reduction of the In this setting, reduction of the bacteriologic load from eschar excision bacteriologic load from eschar excision may, in fact, not be enough to decrease may, in fact, not be enough to decrease overall mortality. Further, the number of overall mortality. Further, the number of patients with these severe injuries is patients with these severe injuries is small.small.

Several important points should be kept in Several important points should be kept in mind. First, small burns that will eventually mind. First, small burns that will eventually heal should be able to be excised with 0% heal should be able to be excised with 0% operative mortality. This implies that early operative mortality. This implies that early excision requires an experienced surgeon. excision requires an experienced surgeon. Inadequate excision and skin grafting will Inadequate excision and skin grafting will lead to skin graft loss, adding the size of the lead to skin graft loss, adding the size of the donor site to the total wound area. This may donor site to the total wound area. This may necessitate another operation. Second, non-necessitate another operation. Second, non-life-threatening burns in patients with other life-threatening burns in patients with other medical problems should not be excised medical problems should not be excised until the associated problems are under until the associated problems are under control so that the operation is associated control so that the operation is associated with no mortality and minimal morbiditwith no mortality and minimal morbidit

ComplicationsComplications PulmonaryPulmonary Bronchogenic infections or pneumonia occur frequently, Bronchogenic infections or pneumonia occur frequently,

usually accompany inhalation injury, and are commonly due usually accompany inhalation injury, and are commonly due to the organism colonizing the burn wound. Prophylactic to the organism colonizing the burn wound. Prophylactic corticosteroid therapy is detrimental, and preventive corticosteroid therapy is detrimental, and preventive antibiotics are probably ineffective after inhalation injury. antibiotics are probably ineffective after inhalation injury. Daily sputum cultures are appropriate in the susceptible Daily sputum cultures are appropriate in the susceptible patient and dictate the choice of antibiotic if pneumonia does patient and dictate the choice of antibiotic if pneumonia does occur. Attention to pulmonary therapy and toilet is also occur. Attention to pulmonary therapy and toilet is also indicated.indicated.

The adult respiratory distress syndrome occurs frequently in The adult respiratory distress syndrome occurs frequently in thermally injured patients, but is particularly difficult to thermally injured patients, but is particularly difficult to distinguish from inhalation injury. In addition, cardiogenic distinguish from inhalation injury. In addition, cardiogenic pulmonary edema, bronchopneumonia, and severe pulmonary edema, bronchopneumonia, and severe tracheobronchial infection need to be excluded. The typical tracheobronchial infection need to be excluded. The typical chest radiographic findings and pulmonary gas-exchange chest radiographic findings and pulmonary gas-exchange abnormalities usually confirm the diagnosis in the absence of abnormalities usually confirm the diagnosis in the absence of significant inhalation injury and infectious processes. significant inhalation injury and infectious processes. Treatment is supportive, as in other critically ill patients with Treatment is supportive, as in other critically ill patients with associated organ failures. Pulmonary toilet is particularly associated organ failures. Pulmonary toilet is particularly important in these patients.important in these patients.

Gastrointestinal and biliaryGastrointestinal and biliary Curling first noted the association between Curling first noted the association between

bleeding duodenal ulcers and burn injury bleeding duodenal ulcers and burn injury in 1842. The incidence of diagnosed in 1842. The incidence of diagnosed gastric or duodenal ulceration in burn gastric or duodenal ulceration in burn patients was about 10 per cent in 1970; patients was about 10 per cent in 1970; however, ulcer-related complications have however, ulcer-related complications have markedly decreased in the last decade, markedly decreased in the last decade, probably due to the advent of continuous probably due to the advent of continuous tube feedings and exacting control of tube feedings and exacting control of gastric pH. The pathophysiology of the gastric pH. The pathophysiology of the initial mucosal injury appears to be related initial mucosal injury appears to be related to mucosal hypoxia, which increases to mucosal hypoxia, which increases susceptibility to damage by normal susceptibility to damage by normal concentrations of gastric acid. This concentrations of gastric acid. This hypoxia may be due to diminished organ hypoxia may be due to diminished organ blood flow or submucosal arteriovenous blood flow or submucosal arteriovenous shunting shunting

The other notable gastrointestinal The other notable gastrointestinal complication is impaired motility involving complication is impaired motility involving the gastrointestinal tract and the biliary the gastrointestinal tract and the biliary system. Acute gastric dilation and intestinal system. Acute gastric dilation and intestinal paralytic ileus are commonly seen; they are paralytic ileus are commonly seen; they are probably the result of frequent anesthesia, probably the result of frequent anesthesia, sepsis, fluid overload, and electrolyte sepsis, fluid overload, and electrolyte imbalances. Delayed gastric emptying and imbalances. Delayed gastric emptying and ileus frequently limit the success of enteral ileus frequently limit the success of enteral alimentation. Acute acalculous cholecystitis is alimentation. Acute acalculous cholecystitis is common in these critically ill patients. It common in these critically ill patients. It usually manifests as sepsis, pain and mass in usually manifests as sepsis, pain and mass in the right upper quadrant, and abnormalities the right upper quadrant, and abnormalities of liver function. An ultrasonographic of liver function. An ultrasonographic examination or radionuclide scan usually examination or radionuclide scan usually supports the diagnosis. Cholecystitis can supports the diagnosis. Cholecystitis can often be treated by antibiotics plus often be treated by antibiotics plus percutaneous cholecystostomy, or percutaneous cholecystostomy, or laparoscopic or open cholecystectomy.laparoscopic or open cholecystectomy.

RenalRenal Acute renal failure may be secondary to Acute renal failure may be secondary to

hypoperfusion and hypoxia occurring before hypoperfusion and hypoxia occurring before plasma volume was replaced in resuscitation. plasma volume was replaced in resuscitation. Failure may also be exacerbated by precipitation Failure may also be exacerbated by precipitation of free hemoglobin from damaged red blood cells of free hemoglobin from damaged red blood cells or muscular myoglobin from crush or electrical or muscular myoglobin from crush or electrical injuries; or it may be a result of nephrotoxic injuries; or it may be a result of nephrotoxic drugs, particularly antimicrobial agents, that are drugs, particularly antimicrobial agents, that are administered to these patients. These insults may administered to these patients. These insults may also be superimposed on pre-existing renal also be superimposed on pre-existing renal compromise. Oliguric or nonoliguric acute tubular compromise. Oliguric or nonoliguric acute tubular necrosis can result, with the additive attendant necrosis can result, with the additive attendant clinical problems of acute renal failure in clinical problems of acute renal failure in combination with management of the burn injury. combination with management of the burn injury. Careful attention to intravascular volume will Careful attention to intravascular volume will minimize renal dysfunction.minimize renal dysfunction.

CardiovascularCardiovascular Congestive heart failure occurs either Congestive heart failure occurs either

in the acute phase of the burn injury in the acute phase of the burn injury or during the mobilization of the or during the mobilization of the peripheral edema. Endocarditis may peripheral edema. Endocarditis may also complicate burn sepsis and also complicate burn sepsis and should be kept in mind as an should be kept in mind as an infrequent cause of infection. The use infrequent cause of infection. The use of digitalis and antiarrhythmics may of digitalis and antiarrhythmics may become necessary in specific become necessary in specific patients. Rapid atrial fibrillation is a patients. Rapid atrial fibrillation is a common arrythmia in elderly patients common arrythmia in elderly patients during burn resuscitation.during burn resuscitation.

NeurologicNeurologic Burn encephalopathy encompasses a Burn encephalopathy encompasses a

wide range of syndromes of cerebral wide range of syndromes of cerebral compromise whose causes include compromise whose causes include water intoxication, acute water intoxication, acute hypertension, drug narcosis, hypertension, drug narcosis, septicemia, hyperpyrexia, electrolyte septicemia, hyperpyrexia, electrolyte shifts, and dehydration. Autopsy at shifts, and dehydration. Autopsy at the endstage of this encephalopathic the endstage of this encephalopathic picture reveals cerebral edema and picture reveals cerebral edema and uncal or cerebellar herniation uncal or cerebellar herniation

Scaring Scaring Hypertrophic scars Hypertrophic scars keloid scars keloid scars

ACTIVITY OF DIFFERENT TYPES ACTIVITY OF DIFFERENT TYPES OF SCARS IN RELATION TO OF SCARS IN RELATION TO

TIMETIME

ACTIVITY OF DIFFERENT TYPES ACTIVITY OF DIFFERENT TYPES OF SCARS IN RELATION TO OF SCARS IN RELATION TO

TIMETIME

0 3/12 6/12 1 2

H.T.S.-H.T.S.-

KELOIDS-KELOIDS-INTERMEDIATE-INTERMEDIATE-

NORMAL-NORMAL-

AC

TIV

ITA

CTIV

ITYY