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Patient Care Vignette
A 37-year-old male was involved in a house fire. He sustained inhalation injury of his airway and lungs, and a 50% total body surface area (TBSA) third-degree burn. The burns involved his head, neck, chest, abdomen, and his arms and legs. He required a breathing tube to be placed (i.e., intubated) at the scene, started on intravenous fluid, and transported to a burn center. He had longstanding high blood pressure, high cholesterol, as well as nicotine and alcohol dependence.
On admission to the Burn Center, he underwent large volume fluid resuscitation (18 L) in the first 24 hours. Fiberoptic bronchoscopy to examine his airway confirmed the presence of inhaled soot. Both arms developed compartment syndrome from muscle swelling (high pressure within an inelastic space that compromised blood flow and oxygen delivery) and required the full-thickness third-degree burns to be incised to allow the underlying tissue to expand. He remained on the ventilator due to his inhalation injury and required a tracheostomy for long-term ventilation.
He also needed his full-thickness burn wounds to be excised in the operating room followed by coverage with split-thickness skin grafting obtained from nonburned areas (donor sites). Areas of partial-thickness burn on his face, neck, and some parts of his legs did not require burn wound excision and healed with rigorous and specialized wound care. His hospital course was complicated by pneumonia, difficulty swallowing, alcohol withdrawal syndrome, and acute blood loss anemia; he required 40 units of red blood cells during hospitalization. As he recovered, his tracheostomy was removed, and he was discharged on hospital day 55 to an acute rehabilitation facility with nearly all wounds and donor sites healed.
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ICU CARE CONSIDERATIONS FOR MAJOR BURN INJURY
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Burns are typically characterized by “degree” into first, second, and third degree. Most are familiar with the first-degree burns as a minor sunburn. Second-degree burns are more intense, involve deeper layers of the skin, and are generally accompanied by blistering of the skin (aka “sun poisoning). Third-degree burns involve all layers of the skin, including the nerves, and are therefore painless. Despite being deeper and more severe, third-degree burns seem deceptive due to the lack of pain. Burns are also categorized as minor and major. Major burns are those that involve more that 20% of the body surface area, while minor burns involve a lesser total area. The initial management of such patients can challenge even the most capable intensivist. Burn pathophysiology is unique and requires modification of standard intensive care unit (ICU) algorithms to improve burn patient survival and subsequent quality of life. Such care is best delivered in a specialized burn center. Relatedly, burn injury is unique, in that the skin is the organ injured. As the largest organ in the body, the skin functions not just as a physical barrier against the environment, but also regulates body temperature, provides immune surveillance, senses pain, controls insensible fluid ...