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KEY POINTS

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KEY POINTS

  1. Care of the severely burned patient requires prompt resuscitation and definitive surgical management.

  2. Patients with major burns (≥ 25% total body surface area) require management in an intensive care unit.

  3. Burn survival correlates with 3 major factors: patient age, burn size, and presence of inhalation injury.

  4. Acute renal failure may result from severe hemodynamic instability, delayed or inadequate resuscitation during the initial burn treatment, or later as a result of sepsis or rhabdomyolysis.

  5. Compartment syndrome in the extremities, torso, or abdomen have been linked to the presence of deep, full-thickness circumferential burns and to the volume resuscitation.

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INTRODUCTION

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Caring for critically ill patients is even more challenging when the largest organ, the first barrier against any external insult, is damaged by a burn injury. Care of the severely burned patient requires prompt resuscitation and definitive surgical management to reduce morbidity and mortality. The approach is multidisciplinary and involves intensivists, surgeons, and skilled nursing teams among others. The need for psychologic and social support is considerable.

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Mortality rates from severe burn injuries have steadily declined over the last 30 years attributed in part to a multidisciplinary approach and specialized care delivered in burn centers. Most burns are the result of fire or scalding and involve less than 10% of the total body surface area (TBSA) with a mortality of close to 0.5%. Patients with major burns (≥ 25% TBSA) require management in an intensive care unit.

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Burn survival correlates with 3 major factors: patient age, burn size, and the presence of inhalational injury.

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CLASSIFICATION OF BURNS

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Burns are classified as thermal, electrical, chemical, friction, or radiation injuries that result in coagulative necrosis of tissues. The clinical severity is determined by the depth and extent of injury. Depending on the depth of injury, burns are further classified as superficial (first degree), partial thickness (second degree), and full thickness (third degree) when all skin layers are affected (Figure 61–1). A fourth degree burn signifies deeper tissue involvement down to bone or muscle.

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Figure 61–1

Classification of burn depth. (Reproduced with permission from Tintinalli JE, Stapczynski JS, Ma OJ, et al: Tintinalli ‘s Emergency Medicine: A Comprehensive Study Guide, 8th edition. New York: McGraw-Hill Companies, Inc; 2011.)

Graphic Jump Location
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Burns affecting the epidermis are usually red with mild pain and no blisters. Burns extending beyond the epidermis tend to be erythematous, painful and with blisters; a dry aspect is seen on deeper dermal burns due to the effect of coagulative necrosis sealing the tissues. Full thickness burns are always dry and in the vast majority insensible, as there is destruction of the entire dermis.

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A thermal injury triggers responses in every mayor organ system. Immediately after a burn, intense inflammation ...

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