Medical Archive

Background

Initial Evaluation

??? ??
??: 9-9-18-18-1
??: 20-10-20-10
(?? – ? – ? ?? – ??)

Major burn: ???????? ?? ??
1. ?? ????(TBS)? 10% ?? ???? partial thickness burn
2. Any full-thickness burn
3. ??, ?, ?, ??, ???, ?? ???? ??
4. ????, ?? ??? ??, ????
5. ??? ??? ??? ??? ??, ???? ?? ??? ??? ??.

Classification of Burns

Thermal burns

Electrical burns

Lightning – Lichtenberg figures
Erythematous cutaneous marks in a fern-leaf pattern
Superficial burns are common. In contrast, deep-tissue burns are relatively rare d/t the short duration of electrical contact
The most common causes are fatal arrhythmias and respiratory failure.

• Skeletal muscle necrosis in patients with high-voltage electrical injuries
  • Because bone (with its high resistance to electrical current) generates the most heat as current passes through the body, thermal injury to internal tissues surrounding the bone (eg, skeletal muscle) often exceeds the visible injury to external tissues (eg, skin)
  • Acute compartment syndrome from intracompartmental muscle swelling.
  • Rhabdomyolysis, with leakage of muscle contents, including heme pigment, into the circulation
  • Heme pigment-induced AKI (eg, intratubular cast formation)

Chemical burns

Thermal burns

Burn Depth

Prognosis

Resuscitation

1. Formulas
   • Parkland formula consists of 4mL/kg/% burn of lactated Ringer’s.
     (?? %? 250ml ??)
   • 2? ??: lactate Ringer solution with dextrose
   • Half is given during the first 8 hours, and the remaining half is given over the subsequent 16 hours.
   • ? ?? ??? ??? ??: high voltage injury, inhalation injury, delayed resuscitation, drunken state?? burn.
2. Titration
   • To maintain adequate urine output (goal: ?0.5 mL/kg/hr), a marker of organ perfusion.
   • For accurate monitoring of urine output, a urethral catheter is required ASAP.

Transfusion

Inhalation Injury and Ventilator Management

Signs

• Burns on the face
• Hoarse voice
• Oropharyngeal inflammation
• Singed nasal hair, eyebrows
• Carbonaceous sputum
• Blistering or carbon deposits
• Stridor
• Carboxyhemoglobin level >10%

Management

• High-flow 100% oxygen via. non-rebreather mask
• Endotracheal intubation
  • Maintain a low threshold for intubation
  • D/t progressive airway edema may preclude intubation later.

Treatment of the Burn Wound

• NG tube
  • 25% ??? ??? ?? ??? ileus? ??? ?????.
• Foley
  • h/u? ?? ?? ??? ??? ??? ??.
• Analgesics
  • ??? IV (IM? ????)
• Sedative
  • Barbiturate > Valium
• Tetanus prophylaxis
• Antibiotics
  • Even for severe burns, systemic antibiotics are not used prophylactically b/c they do not prevent burn sepsis.

Chemical burn

• ??? ? ??, ??? ? ??
• ??? ??? CIx.

Electrical burn

• Resistance
  • ??? ?? ??/??/???? ?? ??.
  • Vein < artery < nerve < muscle < skin < tendon < fat
• Arrhythmia
  • High voltage injury ?? ?? ??. EKG monitoring ??
• Myoglobinuria
  • AKI ?? ?? hydration, IV NaHCO3, mannitol.
• Fasciotomy
  • Escarotomy?? ?? blood supply? ???? ???.
• Delayed effects
  • Cataract, neurologic deficits

Nutrition

Hypermetabolic response

• Etiology
  • Moderate to severe burn injury (eg, inhalational, high-voltage electrical, TBSA >20%)
  • Triggered by the profound release of inflammatory mediators from damaged tissue, leading to increased levels of catecholamines and glucocorticoids.
• Clinical features
  • Arises within the first 5 days postinjury, after an initial 24-48 hours of shock.
  • Hyperdynamic circulatory response: tachycardia, hypertension
  • Elevated basal body temperature (often up to 38.5?)
  • Hyperglycemia, increased protein and lipid catabolism.
• Treatment
  • Early burn excision & grafting
    • Decreasing the inflammatory source
  • Beta blockade
    • Blunting the catecholamine effects
  • Insulin
    • Glycemic control
  • Nutritional support & anabolic steroid therapy
    • Reducing lean muscle mass loss

Enteral nutrition (EN)

Preferred over parental nutrition.
EN is ideally initiated within 24 hours of the burn injury.
High-protein, high-calorie formulas are typically used.

Complications in Burn Care

# Burn wound infection, sepsis

• Etiology
  • Gram-positive organisms: common soon after injury
  • Gram-negative organisms and fungi: more common after 5 days.
• Clinical presentation
  • Change in appearance (partial-thickness injury turns into a full-thickness injury) of the wound or the loss of a viable skin graft.
  • Ileus from sepsis-induced splanchnic hypoperfusion
  • Acute enteral feeding intolerance may be an early sign.
• Diagnosis
  • Quantitative wound culture (>10^5 bacteria/g of tissue)
  • Biopsy for histopathology (to determine tissue invasion depth)
• Treatment
  • Invasive wound infections
    • Empiric, broad-spectrum IV antibiotics (eg, piperacillin/tazobactam, carbapenem)
    • With the addition of potential coverage for MRSA (eg, vancomycin) or MRPA (eg, an aminoglycoside)
  • Noninvasive wound infections
    • Narrower-spectrum antibiotics (eg, cefazolin, clindamycin) that target typical gram-positive skin bacteria.

Surgery

Compartment syndrome

• M/c in circumferential extremity burns, but abdominal and thoracic compartment syndromes also occur.
• The eschar that results from a circumferential, full-thickness (third degree) burn often leads to constriction of venous and lymphatic drainage, fluid accumulation, and resulting distal ACS
• Warning signs of impending may include paresthesias, pain, decreased capillary refill, and progression to loss of distal pulses.

Compartment decompression

• Escharotomy – ?????? ??.
  • In the case of circumferential burns. ?? ?/?? ??, ?? 2? ?? 3? ????.
  • ?? ? ??? 30mmHg ??? ??.
  • No within the first 8 hours unless indicated because of the terrible aesthetic sequelae
• Fasciotomy – ???? ?? ???? ??
  • 4? ???? ?? ???? ??.
  • Escharotomy ??? ?? ? ??? ???? ?? ??.

The strategy of early excision and grafting in burned patients revolutionized survival outcomes in burn care.

Wound excision and grafting

Removal of eschar through early (eg, within 5 days of injury) wound excision and grafting reduces the risk of both noninvasive and invasive burn wound infections.

Wound Coverage

Rehabilitation

Prevention

Radiation Burns

Future Areas of Study