Chapter 218. Burn Injury

Immediate resuscitation: follow the primary and secondary surveys of Advanced Trauma Life Support (ATLS).

• Airway:
  • Intubate early: airway edema can progress rapidly
  • Use ETT with ID ≥8 mm to allow subsequent bronchoscopy
  • Unconscious patient ⇒ full stomach and unstable neck
  • Succinylcholine safe during the first 24–48 hours, and then contraindicated up to 18 months after major burn
• Breathing:
  • Inhalation injury is the leading cause of death during the acute phase
  • Three components:
    • Thermal: hot smoke burns mucous membranes ⇒ edema ⇒obstruction (more in upper airway since smoke cools as it moves distally)
    • Chemical: smoke components toxic by themselves ⇒ alveolar damage
    • Systemic: carbon monoxide (CO) and cyanide (CN) can displace oxygen (O2) from hemoglobin (Hb), leading to tissue hypoxia
  • Face mask 100% O2; consider hyperbaric O2 for patients with neurologic symptoms and carboxyhemoglobin (HbCO) levels >25%
  • Suspect CN poisoning in comatose patients with HbCO <30%, particularly if high (>80%) Sv̅O2 and metabolic acidosis:
    • 100% O2
    • Full and prolonged CPR as needed
    • Sodium thiosulfate (150 mg/kg over 15 minutes IV infusion)
  • Circumferential chest wall injury: consider escharotomy
• Circulation:
  • During the first 24 hours, use one of the common formulas for fluid resuscitation
  • Estimate adequacy of resuscitation by U/O:
    • Adults: ≥0.5 mL/kg/h
    • Children: ≥1 mL/kg/h
    • Myoglobinuria: ≥2 mL/kg/h (consider adding NaHCO3 to IV fluids)
  • Also Hct ≤50%, serum Na ≤150 mEq/L, serum albumin ≥2 g/dL, urine Na ≥40 mEq/L, SBP ≥100 mm Hg, HR ≥120
  • After 24 hours, use 5% or 25% albumin to keep albumin ≥2 g/dL
  • Monitor for abdominal compartment syndrome (IAP ≥25 mm Hg) whenever IV fluid volumes ≥20 L
• Disability:
  • GCS score in all trauma patients
  • Assess for spinal cord injury (SCI)
  • Consider CO and CN poisoning as causes of coma
• Exposure:
  • Perform head-to-toe examination on a fully exposed patient while protecting from hypothermia
  • Assess for any associated injury
  • Assess burn injury taking into consideration burn size and depth as well as patient age (see Figure 218-1)
  • For thermal injury, follow the 6 C's approach:
    • Clothing: remove nonsticking clothing
    • Cooling: with clean water
    • Cleaning: with nonalcoholic solution such as chlorhexidine
    • Chemoprophylaxis: with topical antibiotic cream
    • Covering: with gauze impregnated with petroleum jelly and wrapped with absorbent gauze
    • Comforting (pain relief): with analgesics
  • For chemical burns, brush off dry chemical powder, rinse with water for 30 minutes (irrigate eye for 8 hours), and then treat according to causative agent
  • For electrical burns:
    • Internal injury (eye, heart, nerve, muscle) can far exceed external skin injury
    • CPK and K+ levels
    • Monitor EKG for arrhythmias
    • Myoglobinuria: maintain UO ≥2 mL/kg/h and add 50 mEq NaHCO3 plus 12.5 g mannitol to each 1 L IV fluids
    • High-voltage injury, measure compartmental intramuscular pressure (IMP) and perform fasciotomy if >30 mm Hg or neurovascular compromise