Chapter 75

1. Hemodynamics in the early phase of severe burn injury are characterized by a reduction in cardiac output and increased systemic and pulmonary vascular resistance with or without pulmonary edema. Approximately 3 to 5 days after major burn injury, a hyperdynamic and hypermetabolic state begins with tachycardia, increased stroke volume, hyperthermia, and increased protein catabolism.

2. Patients with severe burn injury often suffer from nonthermal traumatic injuries. Failure to diagnose these associated injuries during initial evaluation can lead to serious morbidity and mortality. All burn patients should be approached initially as multiple-trauma patients.

3. Inhalation injury is a major source of mortality in burn patients. If the history and physical examination suggest inhalation injury, one should have a low threshold for early intubation.

4. Multiple fluid resuscitation formulas exist for estimating fluid needs and differ somewhat in their recommendations for the amount of crystalloid and colloid replacement. The Parkland formula, one of the most popular resuscitation regimens, recommends using 4 mL per percentage total body surface area (%TBSA) burn per kilogram administered over the first 24 hours, with half of this calculated volume administered during the first 8 postinjury hours. The remaining half is administered over the next 16 hours.

5. The magnitude of burns is classified according to percentage of total body surface area (TBSA) involved, depth of the burn, and the presence or absence of inhalational injury. TBSA burned in adults can be estimated using the "rule of 9s," an age-specific diagram, or by estimation using the palmar surface of the hand.

6. Electrical burns can have acute and chronic effects not occurring with other types of burn injury, and with morbidity far higher than expected based on burn size estimation alone. High-voltage injuries are typically associated with loss of consciousness, arrhythmias, myoglobinuria, and extensive deep tissue damage that can result in compartment syndromes. However, significant injury can also result from low- and midrange voltage burns.

7. Major burn injury results in pathophysiologic changes in virtually all organ systems. The perioperative care of burn patients requires knowledge of these changes from the initial period of injury through the period when wounds are covered and healed.

8. In patients with severe burn injury, massive heat loss can occur through the open wounds, making the maintenance of normothermia challenging. Multiple strategies are used to maintain body temperature in the operating room, including high ambient room temperatures, use of warming blankets, radiant warmers, blood/fluid warmers, and wrapping the head and extremities with plastic or thermal insulation.

9. Securing the endotracheal tube in a patient with facial burns can be difficult. It is essential to secure the endotracheal tube with a carefully secured harness to avoid the potential catastrophe of accidental extubation.

10. Transport of a burned patient to and from the operating room can be a high-risk event. A systematic approach to maintenance of the patient's respiratory, hemodynamic, and general support helps ensure patient safety. The need for continuous observation by the anesthesia team during patient transport cannot be overemphasized.

11. Burn patients develop tolerance to most narcotics and ...

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