Telemedicine evaluation of acute burns offers accurate, cost-effective access to a burn specialist during the crucial 48 hours after the burn injury.
Burn patients require a full trauma assessment, starting with “ABCDE” (airway, breathing, circulation, disability, exposure). Begin with airway assessment and management. Consider intubating patients with inhalation injuries early to maintain airway patency as this becomes increasingly more difficult as tissues become edematous. Administer supplemental oxygen (breathing) and obtain vascular access for fluid resuscitation (circulation) simultaneously with the initial resuscitation. Next, evaluate disability (neurologic status), followed by complete patient exposure and thorough examination to assess the extent of burn and associated injuries.
Early intubation is recommended in cases of smoke inhalation or direct thermal injury to the upper airway (indicated by singed eyebrows or facial hair and carbonaceous sputum) due to increasing edema caused by exposure to products of combustion and direct heat. Extubation is avoided for the first 48–72 hours given a risk of continued airway edema from the dynamic fluid shifts caused during early resuscitation. Serial assessments of airway and breathing are necessary because airway compromise and ARDS may develop, requiring endotracheal intubation or cricothyrotomy, particularly in those with inhalation injury. Initial chest radiographs are typically normal; however, they may develop an ARDS picture in 24–48 hours, especially with severe inhalation injuries. Monitoring of such patients requires serial blood gas testing and may require bronchoscopy. Depending on where the burn occurred, consider testing the patient for cyanide and other toxic gas exposures, as indicated. Routine administration of corticosteroids or antibiotics is not indicated.
Vascular access must be obtained on all burn patients. Large bore peripheral venous catheters are preferable. If peripheral lines cannot be placed or if the patient is in shock refractory to fluid resuscitation, then central or interosseous access should be established.
Burn injury over more than 15% of TBSA may cause generalized capillary leak. Patients with burns greater than 15% of TBSA require intravascular fluid administration of large volumes of crystalloid, ideally lactated Ringer solution or Plasma-Lyte. There are many guidelines for fluid resuscitation. The most widely recognized guideline for fluid resuscitation is the Parkland formula (https://www.mdcalc.com/parkland-formula-burns) in which the fluid requirement in the first 24 hours is estimated as 4 mL/kg × body weight per percent of body surface area burned. Half the calculated fluid is given in the first 8-hour period from the time of injury, not the time of arrival to medical care. The remaining fluid is delivered over the next 16 hours. An extremely large volume of fluid may be required. For example, an injury over 40% of the TBSA in a 70-kg victim may require 11.2 L in the first 24 hours [4 mL × 40(%) × 70 (kg) = 11,200 mL]. These are guidelines and should be adjusted according to patient response to resuscitation. Crystalloid solutions alone may be insufficient to restore cardiac preload during the period of burn shock. Conversely, clinicians must watch for clinical signs of volume overload as it may lead to pulmonary complications or to a compartment syndrome from edema. Electrical burns and inhalation injury may increase the fluid requirement.
Adequacy of resuscitation is determined by clinical parameters, including urinary output and specific gravity, blood pressure, pulse, temperature, and central venous pressure. A Foley catheter is essential for monitoring urinary output. Diuretics have no role in this phase of management unless fluid overload has occurred. Colloid administration is not warranted in routine burn resuscitation in view of its deleterious effect on glomerular filtration and its association with pulmonary edema. The need for fluid replacement of more than 150% of calculated values can indicate possible unrecognized injuries, comorbidities, and a worse prognosis.
Pain control is critical in burn injury patients. Treatment is with (oral or intravenous) nonsteroidal anti-inflammatory drugs and opioids (see Chapter 5). Sublingual or intravenous ketamine and regional nerve blocks can be used for additional analgesia.
Verify and update tetanus prophylaxis status in all burn patients. (See Chapter 33.)
All nonsuperficial wounds need to be covered with topical antibiotics. Prophylaxis with systemic antibiotics is not indicated.
As tissue swelling occurs, ischemia may develop under any constricting eschar of an extremity, neck, chest, or in circumferential full-thickness burns of the trunk. Escharotomy incisions can be life- and limb-saving and can be performed at the bedside in the emergency department or in the operating room.
Fasciotomy is indicated for any compartment syndrome to prevent further soft tissue, vascular, and nerve damage, when soft tissue edema produces high pressures in the deep tissue compartments divided by unyielding fascia such as in the arms and legs. Clinicians must frequently monitor patients for development of early signs of a compartment syndrome, particularly in those with circumferential burns.
C. DEBRIDEMENT, DRESSINGS, AND TOPICAL AND SYSTEMIC ANTIBIOTIC THERAPY
Minor burn wounds must be debrided to determine the depth of the burn and then thoroughly cleansed. Thereafter, daily wound care must consist of debridements as needed, topical antibiotics, and wound dressings. Transparent film or biosynthetic dressings, such as Tegaderm and Biobrane, can be reserved for clean superficial and partial thickness burns. Acute chemical burns are managed differently than thermal and electrical burns. Chemical burns are treated by immediate removal and copious rinsing off of the offending chemical. Specific wound treatment is based on the chemical involved. Consultation with a Poison Control Center specialist can be helpful. Burns caused by hydrofluoric acid may be treated by water rinsing followed by application of a topical calcium mixture. Patient compliance and adequate pain control is essential for successful outpatient treatment. The wound must be reevaluated by the treating clinician within 24–72 hours to evaluate for signs of infection.
The goal of burn wound management is to protect the wound from desiccation and avoid further injury or infection. Regular and thorough cleansing of burned areas is of critical importance. Minor (partial-thickness) burn wounds will spontaneously reepithelialize in 7–10 days. Topical antibiotics may be applied after wound cleansing. Topical antibiotics are painless, easy to apply, and effective against most skin pathogens. Research has shown benefits from medical grade honey, framycetin sulfate (soframycin), aloe vera cream, and moist exposed burn ointment (MEBO) as more cost-effective topical alternatives to silver sulfadiazine. Silver sulfadiazine is no longer recommended. Silver nylon dressings have been shown to be beneficial in decreasing length of stay, controlling pain, and preventing infection.
For severely burned patients, early excision and grafting of burned areas may be performed as soon as 24 hours after burn injury or when the patient can hemodynamically tolerate the procedure. Meticulous prevention of infections, seromas, hypergranulation tissue formation, and malnutrition all decrease the time to complete wound healing in skin-grafted patients. Skin autograft is the most definitive treatment. Prevention of autograft infection is paramount since autograft infection is the leading cause of autograft loss. Studies have shown that perioperative antibiotics reduce this risk but may increase the patient's risks of other antibiotic-associated complications (ie, colonization and multidrug resistance).
It is imperative to closely monitor for and treat systemic infection, since this remains a leading cause of morbidity among patients with major burn injuries. Nearly all severely burned patients have one or more septicemic episodes during their hospital course. Antibiotics should be targeted to the specific organism(s) identified on cultures. Health care–associated infections are increasingly common. Staphylococcus (coagulase-negative, and methicillin-resistant and methicillin-sensitive S aureus), vancomycin-resistant Enterococcus, and Pseudomonas aeruginosa are commonly cultured from burn wounds. P aeruginosa bacterial infections and fungal infection (cutaneous zygomycosis) have particularly high morbidity and mortality. Routine use of blood cultures is indicated in severely burned patients to elucidate systemic blood infections that do not manifest the clinical predictors of sepsis.
The goal of therapy after fluid resuscitation is rapid and stable closure of the wound. Wounds that do not heal spontaneously in 7–10 days (ie, deep partial-thickness or full-thickness burns) are best treated by a specialist through excision and autograft (eFigure 37–5) to avoid development of granulation and infection (eFigure 37–6). The quality of the skin in regenerated deep partial-thickness burns is marginal because of the very thin dermis that emerges.
Successfully grafted patient with 40% total body surface area burns. (Used, with permission, from Brent R.W. Moelleken, MD, FACS.)
Patient with burn wound sepsis prior to surgical debridement. (Used, with permission, from Brent R.W. Moelleken, MD, FACS.)
Cultured allogeneic keratinocyte grafts can provide rapid early coverage for superficial burn injuries. Skin substitution with cultured grafts may be life-saving for severe burns. Although the replaced dermis has nearly normal histologic dermal elements, there are no adnexal structures present, and very few, if any, elastic fibers. Intraoperative use of topical fibrin sealants may reduce blood loss, improve cosmetic results, and improve postoperative graft adherence. Wound infection remains the leading cause of skin graft rejection and failure.
E. ABDOMINAL COMPARTMENT SYNDROME
Abdominal compartment syndrome is a potentially lethal condition that may develop in severely burned patients, with mortality rates of approximately 60% despite surgical intervention. Markedly increased intra-abdominal pressures can cause pulmonary damage and multisystem organ failure. Diagnosis is confirmed by bladder pressures greater than 30 mm Hg in at-risk patients. Surgical abdominal decompression may improve ventilation and oxygen delivery but may not impact survival.
Burn patients require extensive supportive care, both physiologically and psychologically. It is important to maintain normal core body temperature and avoid hypothermia, by maintaining environmental temperature at or above 30°C, in patients with burns over more than 20% of TBSA; the hypermetabolic state of burns is exacerbated by subnormal room temperatures. Burn patients are at risk for many complications such as respiratory injury, ARDS or respiratory failure unresponsive to maximal ventilatory support, sepsis, multiorgan failure, and venous thromboembolism.
Burn patients have increased metabolic and energy needs for wound healing and require careful assessment and provision of optimal nutrition. Enteral feedings may be started once the ileus of the resuscitation period has resolved to meet the increased metabolic requirements after burn injury, due in large part to whole body synthesis and increased fatty acid substrate cycles. If the patient does not tolerate low-residue tube feedings, total parenteral nutrition must be started without delay through a central venous catheter. Contrary to conventional teachings, data indicate that most patients can be fed adequately with energy equal to 100% to 120% of estimated basal energy expenditure. A useful guide is to provide 25 kcal/kg body weight plus 40 kcal per percent of burn surface area. Early aggressive nutrition (by parenteral or enteral routes) reduces infections, recovery time, noninfectious complications, length of hospital stay, long-term sequelae, and mortality.
Prevention of long-term scars remains a formidable problem in seriously burned patients. The usual regimen consists of corticosteroid injections, silicone gel or patches, compression, and scar revision. Long-term sequelae can be reduced by the following strategies: (1) burn specialist consultation either directly or via telemedicine, (2) prevention of infection, (3) early nutrition, (4) early aggressive rehabilitation, (5) compressive garments, and (6) early and continual psychological support. Complex microsurgical reconstructions, including prefabricated reconstructive flaps, now benefit severely burned patients with injuries to neck, hand, and arm (eFigure 37–7).
Procedure for secondary burn reconstruction. A: Eyelid reconstruction. B: Oral commissure reconstruction. (Used, with permission, from Brent R.W. Moelleken, MD, FACS.)