Burn Care: Results of Technical and Organizational Progress

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Burn Care Results of Technical and
Organizational Progress

• Sheridan, Robert L.
  MD
• JAMA. 290(6)719-722,
  August 13, 2003

92-09-03 Reporter ????? Instructor ?????
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Fluid Resuscitation

• Diffuse capillary leak syndrome that
  characterizes the early period following a burn
  is unique and will lead to cardiovascular
  collapse
• Patients with injuries covering more than 20 of
  the total body surface generally will require
  fluid resuscitation using primarily isotonic
  crystalloid

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Monitor

• Peripheral temperature and perfusion, vital
  signs, and urine output. Selected laboratory and
  invasive parameters, such as hemocrite, base
  deficit, and central venous pressure, can be
  helpful. Pulmonary artery catheterization or
  cardiac ultrasonography less frequently are
  valuable, except in the setting of coexisting
  cardiac conditions.

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Inhalation Injury

• Inhalation injury remains a major source of
  morbidity and mortality
• early airway obstruction and bronchospasm and
  later pulmonary infection and respiratory
  failure.

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CO intoxication

• Provision of 100 oxygen constitutes reasonable
  treatment. No clear beneficial effect on burn
  wound healing has been demonstrated with use of
  hyperbaric oxygen treatments
• Hyperbaric oxygen treatment only after severe
  carbon monoxide poisoning in otherwise stable
  patients

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Support of Hypermetabolism

• An effective surgical procedure for burn wounds
  remains the most powerful modulator of the
  inflammatory response.
• Support of this physiological state, through
  provision of adequate quantity and quality of
  nutrient solutions, is an important component of
  burn critical care

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Surgical Treatment of the Wound

• Topical antimicrobial agents play a supportive
  role in the treatment of burn wounds, preventing
  desiccation, improving pain control, and slowing
  bacterial proliferation. None of the many agents
  available can prevent infection or eliminate the
  need for surgical treatment of full-thickness
  injuries

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Surgical Treatment of the Wound

• Temporary skin substitutes are designed to foster
  healing of partial-thickness burns or donor
  sites, or to provide temporary coverage of
  full-thickness injuries while donor sites heal
• No specific membrane has emerged as clearly
  superior

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Pain and Anxiety Control

• Burn units increasingly have implemented explicit
  pain and anxiety protocols based on opiate and
  benzodiazepine synergy, titrating doses to
  comfort, and monitoring effectiveness with a
  variety of objective scales

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Guidelines for Emergency Tracheal Intubation
Immediately after Traumatic Injury

• Dunham, C. Michael MD et.
• ournal of Trauma-Injury Infection Critical
  Care. 55(1)162-179, July 2003.

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Inhalation injury

• acute respiratory system insufficiency can be
  caused by carbon monoxide toxicity and thermal or
  combustion-product tissue injury
• Carbon monoxide can create central nervous system
  hypoxia and tissue injury can lead to
  supraglottic, glottic, or infraglottic airway
  obstruction

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Incidence

• Tracheal intubation is needed at some time in
  16.6 (range, 427) of burn patients
• Incidence of smoke inhalation injury for patients
  who have burn injury is 10.7 (range, 360).

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Indication for intubation

• Close-space injury
• Facial burn
• Singed nasal vibrissae
• Soot in oropharynx
• Oropharyngeal burn
• Horseness
• Airway obstruction
• Wheezing
• carbonaceous sputum
• Unconsciousness