Chapter 98. Burns

• A burn patient is a trauma patient; therefore, other injuries should be expected and sought.
• Endotracheal tubes should be large enough to allow ventilation and pulmonary toilet.
• Hypothermia is a major concern, and early, aggressive attempts at prevention are required.
• Modification of the standard lactated Ringer's resuscitation is often necessary in the massive burn or inhalation injury patient or in the very young and old. Additions of colloid, blood, and inotropes are often very useful in restoring hemodynamic stability. Fluid formulas should not be rigid.
• It is important to watch for local perfusion problems and chest wall restriction caused by the burn.
• The burn itself is a low priority for initial care.

Care of the burn patient has improved dramatically over the past 10 to 15 years, resulting in a marked decrease in mortality and morbidity, as well as improved functional outcome. The major reason for this improvement is the multidisciplinary approach by a team that has the clinical decision-making skills, experience, and scientific background to render care in a manner that avoids the predictable pitfalls while also maintaining critical care monitoring. A burn center is the best environment to provide this care.

The burn patient's condition changes dramatically over the course of the injury. The initial postburn period is characterized by cardiopulmonary instability caused by fluid shifts and direct smoke injury to the airways. With the onset of intense wound inflammation, immunosuppression, and infection, physiologic and metabolic parameters change substantially from those seen initially. Treatment therefore must be based on a clear understanding of these changes over time.1,2 This discussion thus will be divided into three time periods—the initial resuscitation period (0 to 36 hours; this chapter), the early postresuscitation period (2 to 6 days; Chap. 99), and the inflammation-infection period, which is usually most evident after the first week (Chap. 100).

Monitoring requirements are no different from those for any other ICU patient. However, vascular access is much more of a problem, and noninvasive measures are often all that are available. A typical burn unit has a procedure room for wound care and often an operating room, but wound care in the ICU is very feasible and actually essential in the unstable patient. Hyperbaric oxygen chambers are not a necessary component and are really only indicated in patients with such severe carbon monoxide exposure that the cytochrome system is saturated with carbon monoxide, which is not readily displaced with 100% oxygen alone (see Chap. 102). It is safe to say that 99% of patients with major burns and some degree of carbon monoxide inhalation do not benefit from hyperbaric oxygen. The secret to a successful patient outcome, however, remains in the knowledge base, judgment, and decision-making skills of the personnel, not in the external environment.1,2

Cardiopulmonary instability characterizes the resuscitation phase. Life-threatening airway and breathing problems are major concerns at this time, with ...

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