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Burn injuries in the ICU

A case scenario approach part 2.

Simko, Lynn Coletta PhD, RN, CCRN; Culleiton, Alicia L. DNP, RN, CNE

Lynn Coletta Simko is a clinical associate professor at the Duquesne University School of Nursing, Pittsburgh, Pa.

Alicia L. Culleiton is a practicing educator and clinician in Pittsburgh, Pa.

The authors have disclosed that they have no financial relationships related to this article.

This article is the second part of a case study about Abe, a young Amish patient with severe burn injuries. In Part 1, various types of burns were described, as well as initial resuscitative care for patients with severe burn injuries. In Part 2, the authors detail Abe's unfolding case scenario and conclusion, cultural concerns in nursing care for an Amish patient, and the treatment modalities necessary to manage patients with burn injuries in the ICU.

Part 1 of this two-part series ( Burn injuries in the ICU: A case scenario approach , March 2017) reviewed the various types of burn injuries and what critical care nurses need to know to provide initial resuscitative care for patients with severe burn injuries using the case study of a young Amish boy, Abe. This article is based on Abe's unfolding case scenario and conclusion and describes various treatment modalities necessary to manage the extended care of patients with burn injuries in the ICU. The article also outlines system-based nursing considerations and important cultural aspects of care for members of the Amish community.

Abe's story

Abe is a 14-year-old Amish boy who stoked a fire in a wood-burning stove and was hurt by a subsequent explosion. He was transported by helicopter to the local burn ICU (BICU). He sustained an 82% total body surface area (TBSA) thermal burn (calculated using the Lund-Browder chart). Abe's burns included bilateral full-thickness circumferential burns to his legs and feet, arms and hands, genitalia, and deep partial-thickness burns to his head, neck, and anterior trunk.

Before Abe's arrival to the BICU, the flight team stabilized Abe by initiating cervical spine precautions, endotracheally intubating him, and providing fluid resuscitation and sedation and analgesia with I.V. propofol and morphine via two large-bore peripheral venous catheters.

Once Abe was admitted to the BICU, a right brachial arterial line was placed along with a right internal jugular central venous catheter. Initial I.V. fluid resuscitation was calculated based on Abe's weight of 79 lb (36 kg), a urinary catheter was placed, and a tetanus injection was administered. The morphine drip was discontinued, an I.V. ketamine drip was started, and wound care began.

Upon reassessment, the nursing staff noted that Abe's pedal and radial pulses were absent bilaterally, and emergent bilateral upper and lower extremity escharotomies were performed. At this point of care, Abe's clinical status was critical but stable.

The road to recovery

Once the escharotomies were completed and Abe was stable, an enteral nasogastric tube was placed in the left nares and feedings began. Abe received standard wound dressings with silver sulfadiazine until his burn wounds were grafted (with the exception of his genital burns).

Abe experienced a slow recovery. Within 72 hours of his admission to the BICU, the first surgical excision and grafting on Abe's hands, feet, head, and neck were completed. His anterior trunk also required surgical excision and grafting at this time. Nurses explained to Abe's parents that further excisions and grafting procedures would be performed until all of Abe's burn wounds were closed. The excisions and grafting on Abe's arms and legs were completed over the next month.

A conservative approach was employed to treat Abe's genital burn. Initially, all obvious retained material (loose debridement) and contaminated remnants of Abe's clothing were removed. Next, the BICU nurses completed a prolonged cooling-down procedure with water. During the duration of Abe's admission, topical antibiotic ointments such as mupirocin were impregnated into gauze and applied over the perineal area and changed after every bowel movement. Scheduled and p.r.n. cleansing was accomplished using 4% chlorhexidine skin wash. This approach led to the successful healing of Abe's genital burns.

Abe was weaned from the ventilator on the third attempt during his second week in the BICU, and solid foods were introduced gradually. The following sections expand on Abe's care and address the cardiovascular, respiratory, integumentary, infection, nutrition, mobility, and pain management considerations Abe's nurses had to take into account during his stay in the BICU.

Cardiovascular management

The priority nursing diagnoses for cardiovascular management are decreased cardiac output (CO) related to increased capillary permeability, fluid volume deficit related to loss of plasma from the vascular space, and an alteration in tissue perfusion related to decreased CO and edema.

Fluid resuscitation for Abe was addressed in Part 1 and is based on the TBSA burned as well as his weight and age. Fluids may be titrated to keep the adult patient's urine output at 0.5 mL/kg/h, which is recommended by the American Burn Association. 1,2 Patients with electrical burns and/or inhalation injury may need increased fluid resuscitation. 3

The critical care nurse should monitor the patient's hemodynamic status: urine output, central venous pressure, CO, and mean arterial pressure. 4 Lactated Ringer solution is the crystalloid of choice for the first 24 hours because it contains electrolytes, and lactate may reduce hyperchloremic acidosis, which can occur with the very large volumes of 0.9% sodium chloride solution administered to patients with severe burns. 5 Hypertonic dextrose solutions and colloids may be administered when capillary permeability is restored. After the first 24 hours, colloid-containing solutions can help reduce edema and third-space fluid shifts by increasing oncotic pressure in the intravascular space and pulling fluid from the interstitial space. 3,5

Patients may be placed on digoxin to address myocardial dysfunction and decreased myocardial contractility after a burn injury. 2 Cardiac dysfunction occurs secondary to activation of the complement system, which generates anaphylatoxins. 2 Vasopressors, such as dopamine, also may be needed to help increase the patient's CO. 5 Monitor the patient's cardiac rate and rhythm. Remember that age-related alterations and reduced physiologic reserve put older adults at an increased risk for developing atrial fibrillation after a burn injury. 5

Patients with burn injuries also are at risk for venous thromboembolism (VTE, the umbrella term for deep vein thrombosis [DVT] and pulmonary embolism [PE]), due to endothelial injury, hypercoagulability, and venous stasis. DVT occurs in 1% to 23% of patients with burn injuries. 2

Abe developed a right lower extremity DVT in the BICU even though he was prescribed SQ heparin twice daily. Given the extent of his injuries and the amount of grafting remaining, the burn surgeon decided to insert a retrievable inferior vena cava filter. 6 This was done to help prevent Abe from suffering a PE. The filter was removed prior to discharge.

Administer VTE prophylaxis as prescribed; intermittent pneumatic compression and low-molecular-weight heparin are typically used. If the patients' legs are edematous from a burn injury, assessing leg edema from DVT is difficult. Further, pain can mask the patient's discomfort from a DVT, so look for signs and symptoms of a PE, including dyspnea and sudden shortness of breath. 2

If the patient has circumferential burns of the chest, abdomen, or extremities, like Abe, an emergency decompressive escharotomy may be needed to accommodate tissue edema or relieve mechanical constriction interfering with respiration. The eschar in a circumferential burn can compress the blood vessels in an extremity, decreasing distal perfusion. If the abdomen or thorax is involved, an abdominal compartment syndrome can develop along with decreased lung expansion. The escharotomy is done at the bedside and does not require analgesia because this dead tissue has no nerve endings. 5 In addition, eschar is avascular, so blood loss is minimal. In some patients, a fasciotomy (incision down to the muscle fascia) may be needed. 2 Postponing necessary escharotomies can result in limb loss and respiratory arrest. 4

Respiratory management

A priority nursing diagnosis involving the respiratory system is ineffective breathing pattern related to inhalation injury and airway obstruction. As discussed in Part 1, the signs and symptoms of inhalation injury include facial burns, hoarseness, soot in the nose or mouth, carbon in the sputum, lip edema, and singed eyebrows or nasal hair. 2

Fiberoptic bronchoscopy is a simple, accurate, and safe method of diagnosing acute inhalation injury. 2,7 It also allows for oxygen delivery, deep suctioning, and removal of necrotic tissue. The endotracheal tube should be secured without putting pressure on the ears or other burned areas. The head of the bed should be elevated to decrease airway and facial edema from fluid resuscitation, unless medically contraindicated. 2

When patients with burn injuries are admitted to the ED or the ICU, plan to obtain a chest X-ray and sputum culture and sensitivity. Typically, patients with an inhalation injury are intubated and placed on mechanical ventilation. Aim to maintain a PaO 2 over 90 mm Hg and an SaO 2 over 95%. 2 Because these patients' carboxyhemoglobin (COHb) levels typically are elevated due to the inhalation of carbon monoxide, they will receive 100% oxygen until their COHb level is 5% to 10% or lower. 2

Hyperbaric oxygen therapy (HBOT) may be indicated for some patients; this treatment displaces carbon monoxide from intracellular stores and may improve mitochondrial function. 8 HBOT should be considered in patients with COHb levels greater than 40%, who are unresponsive, have other neurologic deficits, or have severe metabolic acidosis (pH less than 7.1). 8

Patients with inhalation injury also are treated for cyanide poisoning because of the number of household synthetics (such as upholstered furniture, window coverings, plastics, vinyl flooring) that, when combusted, produce cyanide. Cyanide, one of the toxins released when these products burn, inhibits intracellular respiration and oxygen utilization. Cyanide binds with cytochrome oxidase, which is in high concentrations in the mitochondria. This decreases cell metabolism and adenosine triphosphate, which then causes a shift from aerobic to anaerobic metabolism. Anaerobic metabolism leads to lactic acidosis and cell death. 2 The liver detoxifies cyanide to thiocyanate, which is excreted by the kidneys. Although it will not reverse cyanide poisoning, 100% oxygen is an important intervention for all patients involved in enclosed-space fires. Antidotes for cyanide poisoning such as hydroxocobalamin should be given by I.V. infusion. 2 Patients with acute kidney injury may need hemodialysis.

Patients who were taking corticosteroids before the injury may experience adrenal insufficiency and should receive stress doses of corticosteroids. Bronchodilators may also be used to reverse bronchospasms. 5,9

Patients with severe inhalation injury may need extracorporeal membrane oxygenation (ECMO), in which blood is oxygenated via machine before being returned to the body. By taking over lung function, ECMO lets the lungs heal. (See Extracorporeal membrane oxygenation: A review in our July 2017 issue.) Patients who develop acute respiratory distress syndrome may need a neuromuscular blocking drug such as cisatracurium to allow uninterrupted ventilation and better gas exchange. 2,5,7

Although most pulmonary damage is self-limited and resolves in 2 to 3 days, patients with inhalation injuries may need a tracheostomy with prolonged mechanical ventilation or at the surgeon's discretion. 3,5 In the past, tracheostomy was discouraged because of potential pulmonary contamination with burn wound bacterial flora. But advances in burn care have decreased the risk of pneumonia associated with tracheostomy in patients with burn injury. 2,10

Nursing care includes meticulous pulmonary hygiene to decrease the patient's risk of ventilator-associated pneumonia (VAP). Interventions to decrease VAP risk include regular oral care, eliminating cross-contamination when suctioning, glove use, elevating the head of the bed 30 to 45 degrees unless medically contraindicated, and use of a secretion evacuation port on the endotracheal tube or tracheostomy. Also assess the patient's breath sounds, and monitor for tachypnea, fever, leukocytosis, pulmonary infiltrates, and purulent secretions. 2 Turn and reposition the patient at least every 2 hours, perform chest physical therapy, and encourage ambulation.

Abe experienced an inhalation injury and was intubated on a ventilator for 2 weeks. He also had difficulty with extubation, and to help decrease the complications of immobility he was ambulated to a bedside chair while intubated on mechanical ventilation.

Integumentary management

Integumentary management includes restoring skin integrity and preventing skin loss. Once successfully resuscitated, patients with larger burns begin a period of chronic inflammation, hypermetabolism, and lean body mass wasting, all of which can prolong and impair wound healing. 11

Debridement . A major focus of burn wound management is debridement, which removes eschar and other cellular debris from the wound to promote skin restoration by natural wound healing or grafts. Debridement methods include mechanical, enzymatic, surgical, and autolytic methods.

When Abe initially presented to the BICU, mechanical debridement was completed on all of his burn wounds. Mechanical debridement is often done via hydrotherapy, which is defined as application of water for therapy. 2,5 Shower trolleys are used to let water flow over the burn wound and immediately drain away, or alternatively, wounds are cleansed at the bedside with water. It is no longer recommended that patients be immersed in a tube or whirlpool as this increases the risk of infection. 5 Hydrotherapy allows for visualization and cleansing of the burn wound. During this therapy, previously applied topical agents, exudate, necrotic tissue, and fibrous debris are removed from the wound to expose healthy tissue.

Other methods of mechanical debridement include wet-to-dry dressings. Because mechanical debridement may damage newly formed viable tissue, this method is most often effective for large areas of unhealthy tissue when used with discretion. 12

Enzymatic debridement can occur naturally by autolysis or by applying topical proteolytic enzyme ointments that digest necrotic tissue. Enzymatic debridement is usually performed on deep partial- or full-thickness burns that cover a small area. 2,5

Surgical debridement is done early in the burn rehabilitation process, typically 1 to 3 days postinjury. Performed in the OR, surgical debridement involves excising necrotic tissue until brisk punctate bleeding occurs, indicating a wound that is ready to be grafted. 13

Surgical debridement can cause a great deal of blood loss, yet the literature discourages aggressive transfusions. 13 Current recommendations for a patient with a burn injury not at considerable risk for acute coronary syndrome (ACS) include transfusion of two units of packed red blood cells only if the hemoglobin falls below 8 g/dL. In contrast, for patients at risk for ACS, use a transfusion threshold of 10 g/dL. 13

Autolytic debridement is a process in which the body uses its own wound fluids to digest necrotic tissues. The process promotes the application of a moisture-retentive dressing, which is left in place for several days. The wound fluid trapped beneath the dressing softens and liquefies the necrotic tissue, while growth factors and inflammatory cells within the wound encourage and hasten the early phases of wound healing. 2,5

Prior to any type of wound cleansing and/or debridement, explain the procedure to the patient and family. The room temperature should be maintained between 85° F and 90° F (29.4° C and 32.2° C) to prevent excessive body heat loss and chilling. Analgesia and/or anxiolytics must be administered prior to the procedure per healthcare provider order or hospital protocol. In addition, techniques such as hypnosis, massage, relaxation, distraction, music therapy, and guided imagery may be useful adjuncts for reducing anxiety and enhancing pain relief. Any hair noted around the wound should be shaved, with careful attention not to shave the eyebrows. 2,5

Dressings . Various dressings may be used after the wound is cleansed, such as standard wound dressings and biologic, biosynthetic, and synthetic dressings.

The standard wound dressing involves applying a thin layer of a topical antimicrobial agent to the area, covering the wound with a fine, nonadherent mesh gauze, and holding the gauze in place with either a tubular net bandage or gauze wraps. Common topical antimicrobial agents include, but are not limited to, silver sulfadiazine, mafenide acetate, and silver nitrate. 5 Silver sulfadiazine use is contraindicated in patients with a sulfa allergy. Following the application of silver sulfadiazine, the patient is at risk for the development of leukopenia. 2,5 Therefore, the nurse should monitor the patient's white blood cell count.

Burn wounds may be left open to air after an antimicrobial agent is applied (open method) or covered with a gauze dressing immediately after the agent is applied (closed method). Another variation of the closed method is the application of gauze dressing soaked with a topical antimicrobial agent.

Biologic dressings protect granulation tissue in patients with healing partial-thickness burns, and granulating, clean, eschar-free full-thickness wounds. They also are used as a temporary skin cover to decrease infection, heat loss, and pain. These dressings are skin or membranes collected from human tissue donors (homografts) or animals (heterografts; see the section on grafting, below).

Biosynthetic dressings (a combination of biologic and synthetic materials) are commonly used to cover superficial burns and partial-thickness burn areas. They are made up of nylon fabric that is partially embedded into a silicone film. Collagen is incorporated into both components, and when the nylon is applied to the wound surface it adheres and promotes epithelialization.

Synthetic dressings are made up of solid silicone and plastic membranes and are used to cover donor sites. This type of dressing is applied to a prepared wound and remains intact until it falls off or is removed.

Grafting . As previously discussed, the depth of the burn injury will determine whether skin grafting is required. Full-thickness and deep partial-thickness burns require grafting. Skin grafting is the process of placing skin on a healthy, well-vascularized burn wound bed. Prior to grafting, the necrotic tissue of the burn wound is surgically removed. Grafts are usually secured to the burn wound by surgical staples, dressed, and the affected area kept immobile for 3 to 5 days. Several types of skin can be used for grafting: homografts, heterografts, or autografts. 2,5

Homografts , also called allografts, are obtained from cadavers via skin banks. Disadvantages associated with homografts include their high cost and the potential to transmit infection. In contrast, heterografts , or xenografts, are most commonly obtained from an animal such as a pig.

Autografts are the only permanent type of skin grafting. They are transplanted skin from unburned areas on the patient's body used as wound coverings. The unburned areas where the skin is removed are referred to as donor sites, which can be reharvested once they have healed. 2,5

Common nursing care for all graft sites includes immobilizing and/or splinting the grafted site and elevating grafted extremities. Initial and subsequent graft dressing changes are completed per the healthcare provider orders. Once the dressings are removed, the nurse should apply basic wound care knowledge and principles to evaluate and care for the wound. All graft sites should be monitored for nonvascularization, nonadherence, infection, and graft necrosis. 2,5

Abe underwent many surgical excisions and grafting procedures. Initially, autografts were applied to Abe's hands, feet, head, and neck. Skin was harvested from Abe's back (donor site) and heterografts were applied until his donor site could heal. As the weeks went by, Abe returned multiple times to the OR to have the burns on his arms and legs grafted.

Following surgery, the graft sites were dressed with bulky cotton dressings and left in place for 5 days to permit vascularization of the newly grafted skin. Abe's limbs were immobilized/splinted to prevent movement and shearing, and to promote graft adherence. Abe's extremities were elevated to prevent pooling of blood and edema formation that could lead to increased pressure and graft loss.

After the dressings were removed, Abe's graft sites were inspected for pockets of serous/serosanguineous fluid that could compromise graft adherence. His left foot graft was found to contain fluid, which was evacuated by needle aspiration and rolling a cotton tip applicator over the graft toward the skin edges. Following these interventions, the graft remained viable.

Abe's donor site offered unique challenges for the nursing staff. When grafting procedures are completed on the posterior of the body, or the donor sites involve the posterior body, the patient must remain immobilized for 7 to 10 days in a prone or side-lying position. After 2 days in the side-lying position being repositioned every 2 hours, the nursing staff placed Abe on an air-fluidized and low air loss bed to reduce donor-site ischemia and prevent skin breakdown and pressure injuries. 14

Infection management

The primary risk for infection is related to altered skin integrity and immunosuppression. Patients with severe burns are at a high risk for infection, especially drug-resistant infection. 15 Drug-resistant infection can lead to longer hospital admission stays, delayed wound healing, higher costs, and higher mortality. 16

Assess burns frequently for signs of infection and dysfunctional wound healing. Patients with extensive burns are considered immunosuppressed because the burn destroys the skin barrier to pathogens, and cytokine and neutrophil activity are altered. Pathogens can colonize burn eschar and enter the tissues, causing secondary bacteremia. 5 Localized signs and symptoms of burn wound infection include conversion of a partial-thickness injury to a full-thickness wound, eschar separation, worsening cellulitis of surrounding normal tissue, and tissue necrosis. 17

Infection often leads to a pronounced immune response, accompanied by sepsis or septic shock. Resultant hypotension and impaired perfusion of the end organs, including the skin, prolong wound healing. The leading causes of death following a severe burn are multiorgan failure and sepsis. 18

Sources of infection are invasive monitoring, peripheral and central venous catheters, urinary catheters, endotracheal tubes, and treatments such as debridement. These interventions may be a necessary adjunct to the patient's medical regimen. Maintain sterile technique during invasive and wound care procedures to decrease the risk of infection. (See Fighting infection .)

To avoid encouraging antibiotic resistance, healthcare providers rarely prescribe prophylactic antibiotics for patients with burn injuries. Systemic antibiotics are prescribed and administered only for patients with documented wound infection or other positive culture. 19

Nutrition management

The priority nursing diagnosis for nutrition management is nutrition imbalance related to increased metabolic demands from stress and the physiologic demands of wound healing. 2,5 The patient's resting energy expenditure can be double its normal level because of heat loss from the burn wound, pain, infection, and an increase in beta-adrenergic activity. 5 Some patients may need 4,000 to 6,000 kcal per day. The patient's daily estimated caloric needs should be regularly calculated by a dietitian and readjusted as the patient's condition warrants. The goals of care are to provide optimal nutrition, maintain skeletal muscle, prevent weight loss, promote wound healing and graft adherence, prevent sepsis, and achieve an anabolic state and positive nitrogen balance.

Patients with burn injuries have hyperdynamic circulatory, physiologic, catabolic, and immune system responses. Muscle wasting, increased body temperature, increased infection risk, and peripheral insulin resistance are some characteristics of this hypermetabolic state, which begins within 5 days of a major burn injury and can last as long as 3 years. Persistent elevations of stress mediators such as serum cytokines, catecholamines, and basal energy requirements, as well as impaired glucose metabolism and insulin sensitivity, also may persist for up to 3 years after a severe burn injury. 2,5

Nutrition (enteral, parenteral, or a combination) generally is initiated immediately or 24 to 72 hours postinjury. For enteral feedings, a nasointestinal feeding tube is placed under fluoroscopy into the duodenum or jejunum; the tip of the tube should extend past the pyloric sphincter to prevent reflux and aspiration. Enteral feedings are contraindicated if the patient has a Curling ulcer, bowel obstruction, septic ileus, pancreatitis, intra-abdominal hypertension, or a feeding intolerance. 2,5

Parenteral nutrition is only started when the enteral route cannot be used. Specific indications for parenteral nutrition include inadequate enteral intake because of clinical status, weight loss greater than 10% of normal body weight, prolonged wound exposure, or debilitated condition before injury. 4 When the patient can tolerate an oral diet, a high-calorie, high-protein diet with vitamin and mineral supplements should be prescribed.

Monitor the patient for evidence of enteral feeding intolerance such as diarrhea, constipation, emesis, excessive gastric residual, increased abdominal pressure, and/or abdominal distension. Weigh the patient daily, and monitor serum protein, iron, glucose, and albumin levels. Subtherapeutic values indicate inadequate nutritional intake. 11 Among nonnutrition treatments, research findings support the use of propranolol, a beta blocker, to spare muscle tissue and reduce the patient's heart rate, and it is considered standard of care for patients with burns. 20

Abe was given enteral nasogastric tube feedings upon admission to the BICU. On day 2 he was taken to interventional radiology and a nasoduodenal tube was inserted into his duodenum and secured by a nasal bridle clip. Once extubated he was started on an oral high-calorie, high-protein diet with vitamin and mineral supplements along with enteral tube feedings.

Mobility management

Patients with burns may experience impaired physical mobility and an inability to perform self-care related to contractures, splinting, or immobilization after skin grafts. As burn wounds heal, contractures can develop and significantly limit mobility, especially if a joint is involved. 2,5 Patients with burns also may experience permanent physical changes that can affect their psychosocial status (see Understanding body image issues ). Patient-care goals are to avoid permanent joint dysfunction and return patients to their normal routine with no or few adjustments.

Physical therapy should begin at the early stages of treatment, with ambulation and a planned exercise regimen starting as soon as the patient's condition stabilizes. Exercises should help patients to regain their strength and endurance, and balance needed for activities such as standing, getting into a chair, and early ambulation after the wounds are closed. Intervene to prevent contracture development and implement measures to decrease edema such as elevating burned extremities. Nurses can also facilitate mobility by optimizing pain management (see the next section). 2,5,21

Occupational therapists can help prevent deformities and contractures with the use of passive and active range of motion (ROM) exercises, elevation of the limbs, use of wedges and splints to prevent edema, scar management, and assisting the patient to perform activities of daily living (ADL). 21

There is debate as to which treatment(s)—pressure treatment garments, 3D-printed transparent facemasks, and/or use of fractional CO 2 laser treatment for mature burn scars, and so on—are the best therapy to help decrease scarring. More randomized trials need to be conducted to inform evidence-based practice. 22-24

Nursing interventions associated with mobility include performing active and passive ROM exercises on all joints, maintaining limbs in functional alignment, early ambulation, and applying splints as directed while monitoring the splinted area for vascular compromise, nerve compression, and skin breakdown.

Other interventions used to combat the complications of immobility include deep-breathing exercises, use of an incentive spirometer, turning, and proper positioning to prevent atelectasis and pneumonia. 25

Abe experienced difficulty with extremity movement and his ADL. For the first 4 to 6 weeks he could not feed himself because of his hand grafts and the splints placed on his hands and fingers. Once the splints were removed and he had complete ROM in his wrists and hands, he began to participate in his ADL with the help of an occupational therapist.

Pain management

Patients may have acute pain related to burn injury and treatments, and related to the exposed nerve endings in damaged dermis. Assess the patient's need for and response to pain medication, with the ultimate goal of the patient reporting pain relief and satisfaction with the level of pain control. Pain can be: 5

• background: pain that is present while the patient is in a resting state, and is of lower intensity and longer duration than acute pain.
• procedural: an intense, short-lived pain produced by wound care, activities, or therapies.
• breakthrough: pain that breaks through the ongoing treatment for persistent pain.

General nursing interventions associated with each type, phase, or stage include using a reliable pain intensity rating tool, administering analgesics before performing painful procedures, administering I.V. analgesics as prescribed, explaining all procedures and the expected associated level of discomfort beforehand, using nonpharmacologic methods of pain management such as guided imagery, music therapy, and meditation in combination with analgesics and/or anxiolytics, and encouraging patients to verbalize their pain experience.

I.V. analgesia is recommended during the acute postburn period because shock or paralytic ileus can impair gastrointestinal function. 5 Avoid I.M. injections because the medication often is not absorbed adequately in burned or edematous areas, and can pool in the tissues. When fluid mobilization begins, the patient may be inadvertently over- or undermedicated from the interstitial accumulation of previously received I.M. injections. 2,5

A variety of analgesics are used for patients with burn injuries; however, I.V. morphine is the drug of choice. 2 Remember that depending on the severity and extent of the injury, these patients may require much higher doses compared with other patients. 13 In the case of central nervous system depression from a morphine overdose, administer naloxone, an opioid-receptor antagonist. 26

Continuous I.V. infusions of morphine are reserved for patients with severe burns who need mechanical ventilation. Morphine may be delivered via a patient-controlled analgesia (PCA) pump for severe background pain. The PCA pump is ideal for patients who are neurologically intact and can actively participate in their pain management. Mild-to-moderate background pain can be treated with oral oxycodone and acetaminophen in patients who are hemodynamically stable and without an ileus.

Because patients with burns usually receive higher-than-normal morphine dosages, closely monitor their vital signs, level of consciousness, respiratory rate and rhythm, end-tidal carbon dioxide levels, and oxygen saturation. 26 Be alert for signs and symptoms of opioid-induced sedation, respiratory depression, and hypotension, and have emergency equipment readily available. Morphine-induced hypotension may occur in patients who have hypovolemia secondary to burn shock or sepsis.

Abe did not respond well to the standard doses of morphine; it did not provide him with adequate analgesia. His healthcare provider ordered a low-dose ketamine infusion in combination with an I.V. infusion of propofol. Ketamine, a nonbarbiturate general anesthetic agent, can be used to provide adequate levels of analgesia for burn wound care. 27 It can also be successfully used for bedside sedation procedures. The literature shows that a combination of ketamine and propofol can provide better relief than morphine for some patients, and is a worthy treatment choice for pain during burn dressing changes as noted in Abe's care. 28

Cultural considerations

Many cultural considerations came into play throughout Abe's hospitalization. For example, education ends at the eighth grade in the Amish community (age 14 years). Amish children then enter the workforce, which is mostly farming. Thus, when interacting with the Amish patient, nurses should use age-appropriate language and educational material. 29

The Amish devote their entire life to God. As in the case of Abe's family, most Amish avoid modern conveniences such as telephones, electricity, hot water lines, or bathtubs, and their most common mode of transportation is a horse and buggy. These restrictions affected Abe's family as they related to communication with the healthcare team, and the parents' ability to stay with Abe throughout his hospitalization. After much back-and-forth with the hospital social worker and the leaders of Abe's community, it was decided Abe's family could be provided with a hospital track phone and stay in provided hospital housing. This was necessary for them to actively participate in Abe's extended plan of care. 29

The Amish do not have health insurance. They feel that it is a worldly product and purchasing it shows a lack of faith in God. The Amish prefer to use folk medicine (faith healing, herbal treatments, and vitamins). However, each Amish family contributes a predetermined amount of money to a community fund on a regular basis for community needs such as healthcare expenses. The church elders in Abe's community agreed to pay for Abe's hospital costs. Costs were mitigated by a discount offered by hospital representatives after negotiations with Abe's community leaders. 29

These examples only scratch the surface of cultural considerations when caring for an Amish community member. Given the extended hospitalization of a burn injury patient, it is the healthcare team's responsibility to take a holistic approach that ensures a hospital course that meets each individual patient's specific needs.

Throughout Abe's hospitalization, he had a very positive outlook and relied on his Amish upbringing for his spiritual strength. During the 18 weeks of his hospitalization his father, mother, aunts, and community members were either visiting, in the waiting room of the BICU, or in hospital housing nearby.

By the 18th week of his hospitalization, Abe's grafting procedures were complete, and he was discharged from the hospital. The interdisciplinary team, in tandem with the hospital's social worker, developed a rehabilitation plan for Abe to receive physical and occupational therapy at home, as well as twice-weekly visits by a home healthcare nurse.

Abe left the hospital with the ability to walk and perform all of his ADL. Abe was fitted with compression garments and completed all the physical and occupational activities as prescribed.

Fighting infection 2,5,15

• Monitor the burn wound daily for general signs and symptoms of infection. Remove all topical medications and wound exudate so the entire wound can be visualized.
• Culture all body secretions and wounds as indicated.
• Administer antimicrobial therapies as prescribed, based on culture and sensitivity results.
• Monitor blood culture results for possible bacteremia.
• Assure that the patient is up-to-date with tetanus immunization; patients with severe burns are at risk for anaerobic infection caused by Clostridium tetani .
• Monitor white blood cell counts and report leukocytosis, which may indicate infection.
• Monitor vital signs as prescribed, remembering that fever in the absence of other signs and symptoms of infection does not indicate infection. Patients with burn injuries have a hypermetabolic response that automatically increases their core temperature (often to 101.3° F [38.5 °C]).
• Monitor for signs and symptoms of pneumonia. Wean patients from the ventilator as soon as possible.
• Maintain appropriate nutritional support.
• Maintain an aseptic environment at all times, and use standard precautions and sterile technique for procedures when indicated.
• Avoid cross-contamination during wound care. Wear a cap, mask, protective eye wear, gown, and gloves; perform hand hygiene before and after contact; expose, clean, and rewrap uninfected areas first.
• Be aware that cross-contamination can occur from the air, healthcare providers, and visitors. Visitors who are ill should not be permitted to see the patient.
• Avoid autocontamination from the oropharynx, fecal flora, and unburned skin.

Understanding body image issues

Patients with burn injuries can suffer profound losses. These may include an inability to work, loss of personal property, loved ones, and their home. 28 As a result, nurses should continually assess the patient's psychosocial status. Consider asking the following questions:

• What are your concerns or fears?
• Are you afraid of pain or changes in physical appearance?
• Do you feel powerless?
• Are you afraid of being rejected by family and loved ones?
• Do you have concerns or fears concerning sexual function?

An important goal of care is for patients to adapt to their altered body. Assess patient response to changes based on their ability to verbalize feelings related to changes in physical appearance, interest in resources that may improve function and appearance (such as wigs, cosmetics, and prostheses), and readiness to socialize with family and usual social groups. Being aware of patient anxieties and fears will better prepare nurses to provide support and request referrals specific to patient needs.

Amish; burn ICU; critical care; cultural competency; severe burn injuries; thermal burns; trauma; wound care

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Lisa Agor, Ansley Knipper and Jessica Rogers

Brad is 32 year old male. He was cooking methamphetamine in his kitchen when the substance caught on fire at 2300. The entire house was engulfed in flames when the fire department arrived on scene. The neighbor called 911 when he smelt smoke. Brad was found unconscious by the firefighters and was pulled out. He was stabilized on scene and was rushed to West Hills ED via ambulance. While enroute, the paramedics started an 18 gauge IV in the right C and had Brad on 100% O2 non-rebreather. Paramedics alerted ED of an estimated ETA of 5 minutes. Upon arrival at the ED, Brad was found to have stage 3 burn wounds on his anterior and posterior torso and entire left arm with stage 2 burns on his anterior neck. Brad was at risk for smoke inhalation and a compromised airway, so RT intubated him and fluid resuscitation was initiated.

En Route to Emergency Department

Paramedics alerted the emergency department of incoming arrival at 2350 and gave an estimated time of arrival of 10 minutes. Vital signs were as follows: blood pressure of 92/58, heart rate of 112, oxygen saturation of 91% respiratory rate of 22, and a temperature of 97.4°F. During transportation an 18 gauge IV was started in right AC and 1 liter of Lactated Ringers (LR) was administered. A non-rebrether O2 applied on 100% and 15 L to achieve a saturation of 93%. HIs reported weight in the ED was 75 kg, and a body surface area of 2.0 m2.

Emergency Department Assessment Findings

Per the advanced trauma assessment, using the ABCDE format, the following was noted at 0000:

• Airway- Brad’s airway is compromised and RT placed an endotracheal tube
• Breathing- Crackles were heard bilateral upon auscultation
• Circulation- Thready pulses in all four extremities
• Disability- Brad was unable to move left arm and upper body. His neck was beings stabilized until cervical injury was ruled out
• Examine – associated injuries and maintain warm environment- Nurse increased ED room temperature to 90°F

Further Assessment of Brad Revealed the following findings and interventions:

• Rule of Nines: 27% of Brad’s body was burnt (anterior and posterior torso, entire left arm, and anterior neck)
• Fluid Resuscitation: administration of LR
• Pain Medication – 1 mg IV dilaudid for pain
• Initial Labs – Pending (drew CBC, chem panel, lactic, toxicology screen [also got a urinalysis])
• Ruled out cervical spine injury
• Additional nursing Interventions that occurred in the ED were the placement of a second IV – a 20 gauge in right foot, a second liter of LR was hung, and a foley catheter was inserted

Brad was transferred to the Burn Intensive Care Unit (BICU) at 0030, where fluid resuscitation was continued. At this time Brad had already received 2 bags of LR. The formula used to determine the total fluid is as follows:

(1,500 mL/m2) + [(25 + % TBSA burned) x (m2 x 24)] = total maintenance fluid (mL) to be given over 24 hours. (1,500 mL/2.0) + [(25 + 27% TBSA) x (2.0 x 24) = (750) + [52 x 48] +750 +  2,496 = 3,246 mL to be given over 24 hours for fluid resuscitation at a rate of 270.5 mL/hr.

Urine output is the gold standard for monitoring fluid resuscitation. An adult male should have an output of 0.5-1.0 mL/kg/hr. Brad is 75 kg; this would equate to 0.5-1.0 mL/75/hr = 37.5-75 mL/hr of urine output. Urine output during first hour in the BICU was 20 mL/hr. HR was 130 bpm, BP 96/60, and labs related to fluid resuscitation status are: elevated lactate of 3 mmol/L, and K of 5.5. These signs and symptoms indicated the need for increased fluid resuscitation. After increasing the hourly rate of the Lactated Ringer’s infusion, urine output during 3rd and 4th hour increased to 60 mL/hr, HR lowered to 90 bpm, an BP stabilized to 124/86. Further care in the BICU included burn dressings for coverage until surgical interventions, hourly vital signs, and continuous pain management via a morphine drip. Inhalation injury was ruled out after a bronchoscopy was performed. Signs of respiratory distress (increased RR, tachycardia, wheezing/hoarseness, increased work of breathing) were continuously monitored. An NG tube was placed to suction to prevent aspiration.

Operating Room

Due to the severity of Brad’s burns, he was taken on the OR at 0500 for a debridement of and allograft placement on the stage 3 burns of his torso and arm. Brad returned to the OR multiple times during his admission for additional phases of allograft placement. Eventually he was a candidate for autograft placement. Skin from both inner thighs was used for grafting on his torso and left arm.

Brad was admitted to the burn unit at 0700 post surgery, and remained a patient on the burn unit for 4 weeks. Goals of his stay included monitoring vital signs, preventing infection, pain management, wound care, adequate nutrition, physical therapy, and psychosocial support.

Discharge Plans / Case Management

Brad is a candidate for various types of case management referral due to his drug addiction, recent housing loss, burn PTSD, body image issues, follow-up wound care therapy, and need for pressure garments. Maslow’s Hierarchy of Needs addresses multiple needs that Brad has presented: physiological, esteem, and self-actualization needs. Before discharge, the nurse will make sure Brad is aware of the medications he will be taken, how often and what times. The nurse will also explain the importance of a well-balanced diet and maintaining physical activity to avoid joint stiffness and muscle loss. The nurse will also show how to perform proper wound care and make sure Brad is able to perform the tasks on his own. The nurse will collaborate with case management to make sure Brad has compression garments in order to treat scars. Lastly, the nurse will assure that Brad has his follow-up appointments arranged.

Three Open-Ended Questions

1.During the initial fluid resuscitation for Brad’s burn, lactated ringers was the fluid of choice to be infused. Why would the nurse choose lactated ringers a the preferred fluid of administration?

2. A nurse is assessing a burn patient that came to the burn ICU. What total body surface area needs to be burnt in order to administer fluid resuscitation?

3. Brad experienced a variety of complex complications after his burn injury. He suffered physiological issues with the burns and psychological referrals Brad would need?

Perin, K.O. & Macleod, C.E. (2018). Understanding the Essentials of Critical care nursing. Boston: Pearson

Question 1: Lactated Ringer’s solution is the fluid of choice for burn resuscitation because it is slightly hypotonic, treating both intravascular volume losses and extracellular sodium losses.

Question 2: 20 % total body surface area.

Question 3: Psychosocial, occupational therapy, physical therapy, housing assistance, drug rehabilitation.

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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The Roles of Clinical Psychologists in Burns Care: A Case Study Highlighting Benefits of Multidisciplinary Care

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Burn - Case Summary

2. Symptoms of shock include increased heart rate, increased respiration rate, pale cool skin, and possibly falling blood pressure. While a first or second-degree burn is painful, third-degree burns destroy sensory neurons and are therefore without pain. Coughing or difficulty breathing may indicate damage to the lungs from smoke inhalation. Core body temperatures are typically high because the body's thermostat in the hypothalamus is reset.

3. The amount of body surface area burned can be estimated using the rule of nines. The severity of the burn is assessed by redness only (first degree), blistering (second degree), or marble-white to mahogany or dry charred skin (third degree).

More information about the extent of internal damage from the burn is assessed using a CBC, Chemistry panel, Urinalysis, Carboxyhemoglobin, and Chest X-ray. In this patient, an elevated WBC count with an elevation of neutrophils indicated widespread inflammation from the burn. An elevated Hct was due to loss of plasma and fluids. Glucose levels are slightly elevated from the patient's stress response. Extremely elevated levels of creatine kinase indicate muscle breakdown. High levels of BUN indicate kidney damage. Total proteins levels are low from a loss of blood plasma and proteins.

The Chest X-ray indicated no lung damage. Low levels of carboxyhemoglobin along with the chest x-ray results, indicated there was little smoke inhalation in this burn.

4. Shock is treated by laying the patient down and raising and supporting the legs. The patient should be kept warm and the patient's airway and breathing should be constantly monitored. CPR should be performed if the patient is not breathing.

Major concerns with a burn patient are the loss of fluids, infection (from loss of the protective barrier of the skin), and lung damage from smoke inhalation. In this patient, edema in the face and neck was obstructing the airway. Mechanical ventilation was used to open the airway and breathe for Anna until the swelling subsides. IV fluids were used to treat the fluid loss. Urinary output was carefully monitored so that enough fluids are given to replace fluid loss. Silver, antimicrobial dressings guard against infection until the patient is stable enough for surgery. Skin debridement prepares the area for skin grafting which will replace the lost skin barrier.

A nasogastric tube is used for enteral feedings. Caloric intake must be greatly increased (as much as 5000 calories/day) to counteract the high metabolic rate induced by a burn).

5. There are approximately 450,000 burn injuries that receive medical treatment each year in the United States (American Burn Association, 2013). The amount of deaths from smoke inhalation is reported as 3,400/year with 40,000 hospitalizations each year from burn-related injuries.

The prognosis of a burn patient depends on the extent and severity of the burn. The very young and the very old also have a more difficult time recovering from a major burn. First and some second-degree burns may heal within days to weeks. Deep second-degree burn and third-degree burns take weeks to months to heal and usually cause scarring. Most of these burns require skin grafts. A burn that involves more than 90% of the total body surface (more than 60% in an older person), is usually fatal.

6. Burn prevention and fire safety tips are discussed in this link. Most of the suggestions are common sense. In Anna's case, if she had realized the proper way to put out a grease fire, she could have prevented the explosion. When the bacon grease started to smoke, she should have removed the pan from the stove. The depth of the frying pan should have been double the amount of grease. If she had 1 inch of grease, the frying pan should have been at least 2 inches deep. She could have used a screen to cover the pan to reduce the chance of splatters. Water should never be used to extinguish a grease fire. Anna could have covered the pan with a metal lid, used baking soda to extinguish the flame, or used a Class B dry chemical fire extinguisher. A fire extinguisher will contaminate the kitchen but it's better than burning up the house!

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Acute Intermittent Porphyria in a Burn Patient: Case Study and Review of the Literature

Affiliation.

• 1 Department of Surgery, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, TX 79430, USA.
• PMID: 37728521
• DOI: 10.1093/jbcr/irad135

Healthcare providers evaluating patients presenting with neurological, visceral, or cutaneous symptoms that are disproportionate to the expected severity may need to consider porphyria in the differential. Porphyria is an inherited condition in which toxic metabolites of the heme pathway are increased. Carriers of porphyrias are asymptomatic and will not present with classical symptoms, nor will levels be elevated, until the disease is induced by certain drugs, hormones, or idiopathic causes such as the stress of trauma. Acute intermittent porphyria (AIP), a form of acute porphyria, is a rare autosomal dominant disease that results in a dysfunctional porphobilinogen deaminase. This consequently increases neurotoxic porphobilinogen and subsequent increase in δ-aminolevulinic acid. Both of these metabolites cause neurovisceral symptoms that afflict the patient in acute attacks. We present a rare case of AIP manifested in a burn patient suffering a burn injury. The patient presented with symptoms indicative of AIP, including altered mental status and abdominal pain accompanied with a chronic history of alcoholism and smoking. A negative work-up, including imaging and findings of associated manifestations consistent with AIP led to a discovery of elevated porphyrins. The patient's course and death due to his injuries gives insight into the presentation of AIP in a burn patient.

Keywords: autologous skin cell suspension; burn; porphyria; split thickness skin graft; trauma.

© The Author(s) 2023. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For commercial re-use, please contact [email protected] for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact [email protected].

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Annals of the American Thoracic Society

Care of the critically injured burn patient.

• 1 Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine,
• 2 Department of Medicine,
• 3 Division of Plastic Surgery, Department of Surgery, and
• 4 Indiana University Center for Aging Research, Regenstrief Institute Inc., School of Medicine, Indiana University, Indianapolis, Indiana

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Care of the critically injured burn patient presents unique challenges to the intensivist. Certified burn centers are rare and geographically sparse, necessitating that much of the initial management of patients with severe burn injuries must happen in the pre–burn center setting. Severe burn injuries often lead to a wide range of complications that extend beyond the loss of skin integrity and require specialized care. As such, medical intensivists are often called on to stabilize these critically injured patients. This focused review outlines the clinical care of these medically complex patients, including airway management, postburn complications, volume resuscitation, nutrition, and end-of-life care.

Patients presenting with any burn injury should be evaluated as trauma patients using the Advanced Trauma Life Support protocol, which includes a primary and secondary survey ( 1 ). The primary survey is easily remembered using the mnemonic “ABCDE” and consists of airway maintenance with restriction of cervical spine motion, breathing and ventilation, circulation with hemorrhage control, disability (assessment of neurologic status) and exposure or environmental control.

Once complete, adjunct tests such as chest X-ray, pelvic X-ray, and focused assessment with sonography for trauma examination are completed. During the secondary survey, including a head-to-toe examination, it is imperative to calculate the percentage total body surface area (TBSA) involvement of partial- and full-thickness burns to determine whether the burn patient must be transferred to a burn center for optimal care ( 1 ). Burn thickness can be determined on the basis of histological staining, thermography, nuclear medicine tests, or microanatomy, but burn depth is most common. The degree of burn wounds is based on burn depth, which is usually determined by serial clinical examination, as it evolves over several days after injury. Some less commonly used adjuncts include laser Doppler imaging, spectrometry, infrared thermography, and high-definition ultrasonography. The terms “first degree,” “second degree,” and “third degree” are used less frequently. The journal Clinical and Experimental Emergency Medicine gives the following terms: superficial burns are limited to the epidermis, and partial-thickness burns extend into the superficial papillary dermis or reticular dermis. Full-thickness burns can extend into the entire thickness of the dermis or even underlying fat, tendon, muscle, or bone ( 2 ). The American Burn Association criteria for initiating a referral to a certified burn center are listed in Table 1 ( 3 ). Some common methods used to calculate TBSA are the Lund-Browder diagram and the rule of “nines” ( Figure 1 ). The outstretched palm with fingers together is generally about 1% TBSA ( 4 ).

Definition of abbreviation : TBSA = total body surface area.

* If the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit.

Figure 1. Defining TBSA. ( A ) The Lund-Browder diagram ( 79 ) is a slightly more complex grading system and gives a more precise TBSA ( 79 ). ( B ) The rule of “nines” is a more simplified version but is easier to remember ( 3 ). Reprinted by permission from Reference 3. TBSA = total body surface area.

Characterization of the context of an inhalation injury is critical to inform future treatment decisions. Three classifications of inhalation injury exist: thermal injury, chemical injury, and systemic toxicity from metabolic asphyxiants ( 5 ). These classifications are not mutually exclusive and often occur together. Thermal injury is usually restricted to the upper airways, whereas chemical injury often extends into the lower airways and causes damage to the endothelial cells of the lower airways. Hence, airway obstruction occurs more often after chemical injury. Systemic injury is caused by products of combustion, usually carbon monoxide and hydrogen cyanide, and causes dysfunction in the delivery of oxygen to peripheral tissues. Length of exposure, location at the time of injury, and relation to smoking are all key factors to consider when taking a history and can help identify the types of inhalation injury. For example, fires occurring indoors may lead to combustion of foam rubber, wool, plastics, and other household items that emit cyanide, leading to hydrogen cyanide toxicity, whereas smoking-related injuries increase the risk of catastrophic airway compromise ( 6 ). These factors should be shared with the accepting facility at the time of transfer.

One of the most important decisions in the pre–burn center setting is whether to intubate a patient with suspected inhalation injury. Approximately 40% of patients transferred to certified burn centers arrive endotracheally intubated ( 7 ). Although supraglottic injury is often apparent on physical examination, subglottic injury can be more subtle. Failure to recognize early warning signs of developing upper airway edema can lead to catastrophic airway compromise. Direct thermal injury to the upper airway causes edema that can lead to significant airway compromise in minutes to hours ( 5 , 7 ). History of initial injury is often an unreliable predictor of underlying disease, especially subglottic injury ( 8 , 9 ). Table 2 lists symptoms that should encourage a provider in the pre–burn center setting to consider endotracheal intubation before transfer to a certified burn center. However, Cai and colleagues found that up to 37% of burn patients arriving to a certified burn center endotracheally intubated are able to be extubated within two hospital days ( 10 ). These signs of impending airway compromise help in making a judicious decision to establish an advanced airway in the pre–burn center setting and reduce unnecessary intubation.

If endotracheal intubation is necessary, postintubation care is of paramount importance to maintain the airway. Inhalation injury can lead to increased mucosal sloughing, resulting in obstruction of the endotracheal tube. This requires frequent (hourly or more) suctioning ( 7 ). Securing an endotracheal tube in a patient with facial burns also presents a challenge. Accidental extubation, especially in this cohort of patients, risks losing a patent airway and necessitating emergent cricothyroidotomy. Endotracheal tube fasteners that use adhesion to the face are inappropriate in these patients ( 11 ). Alternative solutions, such as nonadhesive linen (twill) tape tied in a clove-hitch method, are often used to secure the endotracheal tube during transport and have been found to be equivalent to commercial endotracheal tube fasteners in securing an endotracheal tube ( 11 ). Several other techniques, such as Ivy-loop wiring and circummandibular wiring, are used by surgeons to stabilize an endotracheal tube in this patient population ( 11 ). Representative examples of these techniques are shown in Figure 2 .

Figure 2. Airway securement in facial burn injury. ( A ) Circummandibular wiring is a process that uses a stainless-steel wire that is passed around the mandible and used to secure the endotracheal tube. ( B ) Circummolar wiring is a process that uses a stainless-steel wire that is looped around the first and second molars and used to secure the endotracheal tube.

In inhalation injuries, airway obstruction results from edema, sloughed epithelial cells, mucous, inflammatory cells, and fibrin. Fibrin has been a specific therapeutic target in multiple randomized control studies. Aerosolized heparin in combination with N -acetylcysteine gained favor as initial studies demonstrated decreased mortality, although a 2008 study by Holt and colleagues showed no reduction in mortality ( 12 ). More recent studies have demonstrated decreased mechanical ventilation days with nebulized heparin with burn centers using 5,000–10,000 U heparin without increased bleeding events ( 13 , 14 ).

Nebulized short-acting β 2 -agonists have multiple mechanisms that theoretically may improve inhalation injury, although straightforward randomized control studies have yet to demonstrate this. These medications induce bronchodilatation and improve airway resistance. Their antiinflammatory effects have been shown to decrease tumor necrosis factor-α, suppress the release of leukotrienes and histamine from mast cells, and decrease microvascular permeability ( 15 ). For these reasons, albuterol is advised in inhalation injury.

There is no consensus on the diagnostic criteria for inhalation injury. Fiber-optic bronchoscopy (FOB) is considered the gold standard by most certified burn centers in the evaluation of inhalation injury ( 16 ). However, the impact of FOB on clinical outcomes and therapeutic decision making is debated ( 17 ). Several published grading systems can be used to indicate the severity of an inhalation injury. Table 3 shows the most used grading system, the Abbreviated Injury Scale (AIS), which grades inhalation injury from 0 (no injury) to 4 (massive injury). The AIS is particularly helpful in estimating survival; subjects with grade 0 and 1 injuries had a survival rate of 84%, compared with 57% among those with grade 2–4 injuries ( 18 ). Figure 3 shows examples of different degrees of inhalation injury taken from our patients. Most certified burn centers perform FOB within the first 24 hours of admission to assess initial airway injury. We follow the same practice and perform bronchoscopy within 24 hours with bronchoalveolar lavage (BAL). If there are signs of inhalation injury that warrant continuous mechanical ventilation, follow-up FOB with BAL is performed after 72 hours of mechanical ventilation ( 19 ).

Figure 3. Inhalation injury. Examples of different Abbreviated Injury Scale grades seen using fiber-optic bronchoscopy: ( A ) grade 0, no injury; ( B ) grade 1, mild injury; ( C ) grade 2, moderate injury; ( D ) grade 3, severe injury; and ( E ) grade 4, massive injury ( 80 ).

The presence of inhalation injury significantly affects clinical outcomes. The Baux score is a commonly used calculation to estimate the likelihood of mortality in burn patients by adding the percentage of TBSA affected to the age of the patient. This score was developed in the 1960s on the basis of personal observations. Modifications have been made to the Baux score to better estimate mortality as data have been collected to validate and hone the scoring system. The revised Baux score is based on nearly 40,000 burn patients from the National Burn Repository. One change made was the addition of the presence of any degree of inhalation injury. If inhalation injury is present, 17 points are added to the Baux score, irrespective of the patient’s age, degree of inhalation injury, or TBSA involved ( 20 ). Although mathematically simple, this calculation has performed similarly with respect to mortality prediction compared with more complex equations, such as the Thermal Injury Mortality Model. Both the revised Baux score and AIS tend toward overestimation of mortality, and further calibration is needed ( 21 ).

In addition to assessing the degree of injury, FOB is useful for obtaining quantitative BAL samples to assess for ventilator-associated pneumonia (VAP). There is a significant increase in pulmonary complications, including VAP, after thermal airway injury. The presence of VAP increases mortality by at least 40% with concomitant inhalation injury ( 19 , 22 ). Patients who are intubated in the field or emergency department carry a higher risk of developing pneumonia. Bacterial colonization occurs rapidly after intubation in burn patients. In 2008, Mosier and colleagues ( 22 ) found that more than 80% of patients with burn injuries had bacteria present on initial BAL, and 23% had bacteria in counts exceeding 10,000 colony-forming units, the threshold used to define pneumonia and justify treatment. Despite its common occurrence, diagnosis of VAP can be challenging in patients with inhalation injury. Classic signs such as hypoxia, fever, pulmonary infiltrates, and increase in sputum production are often present after inhalation injury and do not necessarily represent pneumonia. Sputum cultures can be misleading from colonization of the endotracheal or tracheostomy tube and not from the lower airways ( 23 ). Serum procalcitonin is often falsely elevated in burn patients without infection, despite its utility in identifying bacterial pneumonia in other patient populations ( 24 ).

In our center, a BAL sample is obtained during initial airway inspection and then as needed with any significant clinical change suggestive of a developing VAP (worsening infiltrates or hypoxia). It has been proposed that a routine schedule of FOB as a prophylactic measure to identify pneumonia early may reduce morbidity, ventilator days, and length of stay, but this has not been validated in the literature ( 25 ). As with any invasive procedure, FOB carries inherent risk; in 2019, Ziegler and colleagues found that in patients with lower TBSA burn injury, FOB was correlated with an increase in ventilator days and incidence of pneumonia ( 17 ). The data from initial BAL can be compared with any follow-up BAL performed to help discriminate between colonizer and pathogen. This can limit unnecessary treatment with antimicrobials to reduce the incidence of multidrug-resistant infections ( 19 ).

A subset of burn patients with special considerations includes those with smoking-related and home oxygen therapy (HOT)–related burn injuries. These patients have a higher rate of inhalation injury and longer hospital stays even though their TBSA tends to be lower ( 26 , 27 ). Between 14% and 51% of patients admitted to smoking while on HOT, though these percentages are likely an underestimation ( 28 ). Although smoking cigarettes while on oxygen is itself hazardous, the medical equipment further increases that risk. Nasal cannulas are made from polyvinyl chloride, which emits an intense flame when ignited. Nasal cannulas are designed to direct oxygen into the nose; however, a significant amount of oxygen does not make it to its intended destination, making the lower face an oxygen-rich environment that can ignite into a flash fire ( 29 ).

Some organizations have taken steps to ensure patient safety when prescribing HOT. For example, the Veterans Health Administration has recommended that thermal fuses be inserted in line with patients’ oxygen tubing. These fuses melt when exposed to heat and block further flow of oxygen. Although the addition of a fuse does not make it safe to smoke while on HOT, it does significantly reduce a major source of fire acceleration, potentially limiting injury ( 30 ).

The Baux score can be misleading in smoking-related burn injury, as these patients tend to have less severe inhalation injury and decreased overall mortality from inhalation injury compared with those with inhalation injury not related to smoking ( 31 ). Although patients who smoke are likely to have stigmata of inhalation injury, such as singed nose hairs or soot in the oropharynx, examination with laryngoscopy demonstrates that only one-third have upper airway edema. Patients who smoke are more likely to be intubated but often have less severe inhalation injury because of shorter exposure time ( 6 ). Burn injuries evolve quickly over the first 24 hours, so there should be a low threshold to endotracheally intubate most burn patients. However, in patients who smoke, this evolution is less dramatic because of chronic exposure to irritants, resulting in a less robust immune response. Intubation can often be avoided despite underlying lung disease ( 31 ). Laryngoscopy can quickly assess the extent of inhalation injury, focusing on upper airway edema. This is helpful to determine the need for endotracheal intubation before transfer to a burn center ( 32 ).

Carbon monoxide (CO) toxicity results from tissue hypoxia and direct damage at the cellular level through a binding affinity for hemoglobin 200 times that of oxygen ( 32 ). Tachycardia, tachypnea, headache, nausea, and vomiting are common symptoms and easily mistaken for viral illness, especially during winter months.

Although venous blood samples are often adequate for measurement of carboxyhemoglobin, arterial blood gas analysis with cooximetry is most reliable. A normal ratio of carboxyhemoglobin to hemoglobin is up to 1–3% and in smokers up to 10% ( 33 ). Pulse oximetry may not be accurate in carbon monoxide poisoning, as oxyhemoglobin and carboxyhemoglobin have similar light refraction. The Pa O 2 on an arterial blood gas is not useful in diagnosis, as it measures the dissolved oxygen in the plasma and not the amount bound to hemoglobin ( 34 ). Carboxyhemoglobin measurement alone is insufficient for diagnosis, as disease severity is not dependent on the concentration ( 35 ). Further workup should include complete blood count, complete metabolic panel, lactate, and chest X-ray. Lactate has been studied at multiple institutions and is an independent risk factor for mortality in burn patients ( 36 ).

High-flow oxygen, ideally 100% F i O 2 , should be administered immediately to facilitate the displacement of the bound carbon monoxide. The half-life of carboxyhemoglobin in ambient air is 250 minutes but can be reduced to 60 minutes with 100% oxygen ( 37 ). If a patient has received a high concentration of oxygen for a prolonged period before a carboxyhemoglobin concentration is obtained, one should be aware that the initial carboxyhemoglobin concentration could be higher initially.

Hyperbaric oxygen chambers have been indicated for coma, but their efficacy has not been shown in other situations ( 26 ). Nevertheless, the benefits of hyperbaric oxygen could include delayed neurologic sequalae and reduced cerebral edema but must be cautiously balanced with the risk of adding a physical barrier that encumbers quick action in an emergency ( 34 ).

Cyanide toxicity occurs when smoke is inhaled from fires involving burning textiles such as furniture or rubber and can result in cardiac or respiratory arrest. Oxidative phosphorylation is inhibited, and anaerobic metabolism leads to lactic acidosis refractory to fluid resuscitation. Cyanide is rapidly absorbed through the respiratory tract and mucous membranes but can also be absorbed through skin ( 35 ). Clothing must be removed quickly to avoid skin absorption.

When to empirically treat for cyanide toxicity remains controversial. Studies show that cyanide concentrations often do not correlate to degree of toxicity, and because of laboratory turnaround times, utility is limited. Hydroxocobalamin is the most widespread option for treatment and will directly chelate cyanide to form a nontoxic cyanocobalamin that is renally excreted. This treatment has been shown to diminish the incidence of respiratory infections and decrease mechanical ventilator days ( 38 , 39 ). The most common adverse effects seen with treatment include chromaturia, skin discoloration, hypertension, and acute kidney injury ( 40 ). Other treatments for cyanide toxicity include induction of methemoglobinemia with amyl nitrite or sodium nitrite and detoxification of cyanide by transforming it to thiocyanate with sodium thiosulfate. However, induction of methemoglobinemia can severely impair tissue oxygen delivery in patients with concomitant carbon monoxide poisoning by shifting the hemoglobin–oxygen dissociation curve to the left, and thus extreme caution is required. Consultation with a poison control center is imperative when considering induction of methemoglobinemia. A survey sent to 90 burn center directors across North America demonstrated that most centers do not routinely test cyanide concentrations and empirically treat on the basis of clinical suspicion of poisoning alone. In the context of inhalation injury, 31% of centers use empirical treatment, 17% do not, and the majority have mixed opinions ( 41 ).

Serum lactate concentration is useful in determining the risk of cyanide poisoning, and treatment should be considered at concentrations greater than 8 mmol/L, which has been shown to be 94% sensitive and 70% specific for cyanide blood concentration > 1 mg/L ( 42 ). Our burn unit protocol calls for administering hydroxocobalamin in any of the following situations: cardiac arrest, Glasgow Coma Scale score ⩽ 8, hypotension despite 100% oxygen and fluid resuscitation, and serum lactate concentration > 10 mmol/L.

With all facial burns, damage to the eye and eyelid should be considered. Corneal burns can occur with or without damage to the eyelid ( 43 ). In mechanically ventilated patients in the intensive care unit, corneal burns can be subtle and easily missed on examination. The key to management is early ophthalmology consultation for any facial burns, both chemical and thermal ( 44 ). Before an examination, eye pH should be obtained, and if it is not between 7 and 7.2, the eyes should be irrigated with lactated Ringer’s solution until physiologic pH is achieved ( 45 ). Irrigation should be done early, especially with suspected chemical burn, and can be initiated by emergency medical services. Tap water flushes before emergency medical services arrival have also been shown to have clinical benefit ( 46 ). Irrigation should be performed from the nasal side and drained out the lateral side, with the head tipped away from the other eye to prevent contamination. Each affected eye should be irrigated with at least 1 L for 30 minutes but can take up to 10 L for pH to normalize ( 44 ).

During examination, the Roper-Hall or the Dua classification can be used for prognostic purposes. Both scales are based on the amount and depth of damage to the cornea and conjunctiva ( 47 ). Lower grade burns tend to have better outcomes with medical management, but higher grade burns may benefit from surgical intervention, such as tenonplasty ( 48 ). Examination should include fluorescein staining, slit-lamp examination, and intraocular pressure. Intraocular pressures of 30 mm Hg or higher are concerning for orbital compartment syndrome. If left untreated, these injuries can lead to anterior ischemic optic neuropathy, with potential loss of vision. Ongoing assessment by an ophthalmologist is warranted and may require canthotomies to release the orbital compartment syndrome. Fluorescein staining in combination with the slit lamp is used to identify foreign bodies or corneal abrasion. If intraocular pressure is elevated, acetazolamide or topical β-blockers can be administered ( 49 ). Often, these patients require artificial tears, steroid eye drops, and antibiotic ointment. Maxillofacial and orbital computed tomography are not typically required unless the injury was sustained from blast force and projectiles are suspected ( 49 ).

Fluid resuscitation has been an important topic in burn injury, and prompt fluid resuscitation increases survival ( 50 ). Although there are similarities between this patient group and other more common patient groups encountered in an intensive care unit setting, such as patients with traumatic injury or sepsis, significant differences exist. Lack of proper resuscitation leads to prolonged shock and an increase in burn depth. Any patient with burns >20% TBSA, partial or full thickness, should undergo formal fluid resuscitation ( 51 ). Formal fluid resuscitation is the process of receiving adequate fluid resuscitation as calculated by an approved formula. Multiple formulas have been adapted to determine initial fluid needs and have been unchanged over decades. Charles Baxter described the Parkland formula in 1974, and it remains universally accepted in burn resuscitation ( 52 ).

This formula, as well as the modified Brooke’s formula, advises 2–4 ml fluid per kilogram per percentage TBSA over the first 24 hours of resuscitation. This marks a difference from more commonly encountered patient groups in critical care. For example, this method is a more tailored approach compared with the Surviving Sepsis Campaign guidelines, which recommend a 30 ml/kg crystalloid bolus within the first 3 hours of resuscitation in all comers with septic shock ( 53 ). Another example can be drawn with trauma surgery. The most recent edition of Advanced Trauma Life Support focuses on a balanced resuscitation approach, recommending the early use of blood products in combination with crystalloid fluids. However, total volume infused averages only about 3–4 L ( 54 ). In comparison, a 70-kg patient with a 70% TBSA burn might receive 9.8–19.6 L using the Parkland formula.

Using the Parkland formula, the first half of the fluid bolus is given over 8 hours, and the second half is given over the remaining 16 hours. These formulas are guided by hourly urine output, with a goal of 0.5–1 ml/kg/h ( 51 ). Fluid resuscitation formulas are only guides to assist in the estimation of fluid requirements, as each patient reacts differently to burn injury and fluid resuscitation. Patients with inhalation injury, full-thickness burns, or delayed presentation may require increased fluids beyond what is estimated ( 55 ). Other risk factors for exceeding the Parkland formula for resuscitation include electrical burns, an elevated ethanol concentration, and drugs such as methamphetamine and opioids ( 56 , 57 ).

The most used fluids are crystalloids, often lactated Ringer’s solution. Immediately after a burn injury, vascular permeability increases, leading to extravasation of both small and large molecules to the extravascular space. This is known as capillary leak, and early use of colloids is not routinely recommended, because of third spacing. When the amount of crystalloid needed is excessive, systematic approaches may be used to deliver the large volume required. This topic is one of the most controversial burn management topics and can vary among burn centers. One approach is known as “early rescue,” where half the total volume is given over the first 8 hours of resuscitation, as recommended by the Parkland formula. In our burn unit, after 8–12 hours postinjury, the fluids are switched to what we call “half and half,” a procedure called “later substitution.” In later substitution, the total rate of fluid is kept the same, half being 5% albumin and the other half lactated Ringer’s solution. The timing of the addition of colloid coincides with closing of the capillary leak, though other centers use different criteria to initiate colloids, such as high crystalloid requirement, persistent hypotension, low plasma albumin concentration (<2.5 g/dl), or decreased urine output ( 58 ). Although albumin has been weakly linked to decreased crystalloid requirement, decreased intraabdominal pressure, and decreased incidence of compartment syndrome, current data are not strong enough to either support or reject its use in fluid resuscitation in burn patients ( 59 ). If the patient develops coagulopathy with an international normalized ratio greater than 1.5 during high-volume resuscitation, fresh-frozen plasma is added to substitute one-fourth the current total fluid rate per hour. This can be challenging in patients who are anticoagulated.

Regardless of solution type or estimated need, fluid resuscitation should be titrated hourly to maintain adequate perfusion to end organs. Failure to titrate fluid input appropriately may result in organ dysfunction ( 60 ). Fluid should be titrated by patient hemodynamics and urine output. Hourly urine output should be maintained at 0.5–1.0 mg/kg/h in adults. An increase or decrease in hourly urine output is managed by titrating the hourly total fluid rate by 10–20%. To provide a steady state of intravascular volume expansion, fluid boluses are not recommended. When the fluid resuscitation exceeds 250 ml/kg in the first 24 hours, the risk of complications increases, including abdominal compartment syndrome, difficulties with ventilation and oxygenation, and increases in intraocular pressure ( 57 , 61 ).

Adequate nutrition is key to improving survival in patients with major burns, as they have increased nutritional requirements far beyond those of other critically ill patients ( 62 ). Hypermetabolism occurs in these patients because of a combination of factors, including increasing amounts of adenosine triphosphate–consuming reactions in response to burn injury, increased protein synthesis, increased adenosine triphosphate production for hepatic gluconeogenesis, and uncoupling of oxidative phosphorylation resulting in thermogenesis.

Nutritional status should be assessed with documentation of nutritional laboratory values, including prealbumin, C-reactive protein, liver function testing, and vitamin D concentration on admission and biweekly thereafter. Supplementation should begin as early as possible. Intubated patients should receive enteral nutrition within 6 hours of admission, reaching goal tube feed rate by 24 hours ( 63 ). Carbohydrates should be the primary source of nonprotein calories, with lipids added in small proportions.

Indirect calorimetry, the most accurate method to determine nutritional needs, should be used in intubated burn patients, often weekly. Indirect calorimetry does not account for leaks in the ventilator circuit or around the endotracheal tube or the instability of the delivered oxygen ( 64 ). Formulas are often used when indirect calorimetry is not feasible, but most tend to over- or underestimate caloric needs. The Curreri formula is often used and is calculated as follows: (40 kcal × TBSA) + (25 kcal × ideal body weight in kilograms). Tube feeds are initiated at 50 ml/h and advanced by 25 ml every 4 hours until goal rate. Protein intake should be 1.5–2 g/kg/d ( 65 ). Patients with burns more than 10% of TBSA should receive standard doses of multivitamins, vitamin C, vitamin E, zinc, and selenium. Low vitamin D concentrations should be repleted and checked weekly until in the normal range.

Nutritional status should be closely monitored during the hospital stay to titrate to the patient’s needs. Although albumin and prealbumin are often trended, their role in monitoring the efficacy of nutritional support remains controversial, as they decline in the setting of inflammation ( 66 ). Indirect calorimetry and 24-hour urine urea nitrogen can be obtained in intubated patients to assess nitrogen balance and titrate appropriately ( 67 ).

Many burn patients are malnourished on admission and have risk factors such as old age, chronic obstructive pulmonary disease, and polysubstance abuse. During initiation of high-calorie, high-volume feeding, these patients can develop refeeding syndrome, which can manifest with acute decompensation and severe electrolyte derangements, especially hypophosphatemia ( 67 ). If suspected, feeding should be advanced slowly with close laboratory monitoring and appropriate electrolyte repletion.

Stress-induced insulin resistance is often seen in burn victims and is important to identify for improved wound healing. Poor glucose control often results from a loss in hepatic and skeletal muscle as well as decreased insulin sensitivity, which has been shown to persist up to 3 years after injury ( 67 ).

Burn injury alone is a risk for lung injury, as it stimulates a systemic inflammatory response, and this risk is increased further in patients with inhalation injury. The risk of acute respiratory distress syndrome (ARDS) in ventilated burn patients is 34–43%, and severe ARDS increases the risk of mortality up to 59% ( 68 ). Strategies used in conventional ARDS management, such as prone positioning, low–tidal volume ventilation, and administration of neuromuscular blockade, are helpful in ARDS after severe burn injury ( 69 ). If these strategies fail to improve respiratory status (e.g., Pa O 2 :F i O 2 ratio), extracorporeal membrane oxygenation can be introduced early, as this has been shown to be a possible early intervention to improve mortality in some small trials ( 70 ). Survival among burn patients with severe ARDS is similar to that among nonburn patients, although data remain scarce because of the rarity of extracorporeal membrane oxygenation use in these patients ( 68 ).

When considering extubation in burn patients with inhalation injuries, the approach is like the approach in other critically ill patients. However, classic extubation criteria can be misleading in patients with inhalation injury ( 71 ). There is evidence that the rate of extubation failure is up to 30% higher in burn patients, though the presence of inhalation injury has not been found to increase the chance of extubation failure and may be protective because of the conservative strategies used in these patients ( 71 , 72 ). The increase in extubation failure is most likely related to poor pulmonary toileting and damage to the mucociliary elevator, causing impaired management of secretions ( 73 ). Timing of extubation is variable and correlated to degree of inhalation injury. Spontaneous breathing trials of at least 30 minutes have been validated in burn patients and shown to reduce extubation failure ( 72 ). The rapid shallow breathing index, commonly used in critically ill patients, has also been shown to be predictive in burn patients, although it is more useful when combined with measuring secretions and cough peak flow. Smailes and colleagues demonstrated that patients whose cough peak flow was less than 35 ml/min were 7 times more likely to experience failed extubation ( 74 ).

Another criterion used to establish readiness for extubation is a cuff leak test, which has controversial evidence. American Thoracic Society guidelines recommend checking for cuff leak before extubation in patients who are at elevated risk for postextubation stridor, including burn patients ( 73 ). Conclusive studies are lacking to support the administration of corticosteroids to prevent extubation failure in this subset of patients, though American Thoracic Society guidelines recommend a trial of systemic corticosteroids at least 4 hours before extubation if cuff leak is absent ( 73 ).

Palliative care, though often wrongly synonymous with end-of-life care or discussions, is a vital aspect of burn unit care ( 75 ). In addition to care provided by burn surgeons and intensivists, a dedicated palliative care team can assist with management of physical symptoms and provide an extra layer of emotional support for families and patients. The most common physical symptom that providers palliate in these patients is pain.

Pain management in burn patients is highly variable. During the first 48 hours after injury, blood flow to vital organs fluctuates. Deteriorating renal function can cause decreased clearance of pain medications. Plasma proteins are also reduced, decreasing protein bound drug and increasing free active drug. After the first 48 hours, patients enter a hypermetabolic state with increased drug clearance, further complicating dosing ( 76 ). These patients have significant background pain but also have procedural pain during dressing changes and hydrotherapy that requires breakthrough coverage ( 77 ). Opioids are the cornerstone of treatment, though when used consistently they have the consequence of opioid hyperalgesia in addition to the hyperalgesia that most burn patients experience. Other medications, such as ketamine and dexmedetomidine, are commonly used adjuncts with opioid therapy ( 77 ). Hypnosis and virtual reality technology have also shown evidence in alleviating pain. This is especially helpful in relieving procedural pain ( 78 ). Dosing will be variable depending on burn stage, and regular monitoring of pain scales is indicated for monitoring efficacy of pain management, as pain will become a significant barrier to discharge if the patient is unable to participate in physical therapy or dressing changes.

The authors thank Alethea Clore, R.D., C.D., for her contributions to the N utritional C onsiderations section.

CME will be available for this article at www.atsjournals.org .

Author disclosures are available with the text of this article at www.atsjournals.org .

New User Registration  •  A Unique User Profile that will allow you to manage your current subscriptions (including online access)  •  The ability to create favorites lists down to the article level  •  The ability to customize email alerts to receive specific notifications about the topics you care most about and special offers Click to see any corrections or updates and to confirm this is the authentic version of record Burns and Smoke Inhalation Authors: Mark Saks, MD, MPH, Pollianne Ward Bianchi, MD, FAAEM, Crozer-Chester Medical Center, Upland, Pennsylvania Editor: James Ham, MD, University of Hawaii Updated March, 2019 By the end of this module, the student will able to: List the basic function of skin Describe the initial evaluation and assessment of the burned patient List the different types of burns and their distinguishing characteristics Name the potential comorbid injuries in inhalational injury List the basic principles of burn management regarding: Minor burn treatment Fluid resuscitation Infection control Management of inhalation injuries A patient presents to the Emergency Department with burns from a house fire. He was extracted by firefighters, and it has been two hours since the initial call. He is young, approximately 20-30 years old, unconscious, with burns to his face, trunk and extremities, with charred clothing, and covered in soot. How will you evaluate and treat this patient? Introduction Each year approximately 500,000 burn patients seek medical care in the US. Burn injury can result from heat (thermal burn), chemicals, cold (frostbite), or electricity (flash or internal). However, the clinical significance of a burn depends more on the depth of the burn, the total body surface area (TBSA) involved, the specific area involved, associated injuries, and the promptness of therapy than on the mechanism. Inhalational injuries may result from heat, carbonaceous particles, or the inhalation of abnormal gases such as smoke, carbon monoxide, or cyanide. Quickly and accurately evaluating the burned or inhalational injured patient in the Emergency Department is difficult because the extent of injury is not always obvious, often evolves over time, and may mask other, more immediately life-threatening injuries. Therefore, it is very important for the emergency physician to understand the complex pathophysiology and clinical management of these patients. Skin is the body’s largest organ system and is composed of three layers: the epidermis, dermis, and hypodermis. The epidermis is the outermost layer, does not contain any neurovascular structures, and constantly regenerates mitosis and keratinization. The dermis is the middle layer and contains hair follicles, sweat and sebaceous glands, and lymph and blood vessels. The hypodermis is the deepest layer, is comprised of adipose and larger neurovascular structures, and acts to anchor the skin to underlying muscle, bone, and fascia. For figure see here. Intact skin has many functions including: Fluid retention Electrolyte homeostasis Thermoregulation Metabolic (vitamin D synthesis) All of these functions are potentially disrupted with burns, regardless of the severity of injury, source of damage, or the mechanism of burn. In general, the extent of the burn injury worsens as temperatures that the skin is exposed to increases. For example, with temperatures between 40-44ºC, enzymes begin to malfunction, proteins denature, & cellular pumps fail. With temperatures above 44ºC, this damage occurs faster than the skin cells can heal and injury develops. This injury typically exhibits three zones: Zone of Coagulation: In this area, cell death is complete. This is usually nearest to the energy source and forms the eschar of the burn wound Zone of Stasis: In this area, cells are viable but circulation is impaired. If the injury continues, then increased damage and tissue ischemia may result Zone of Hyperemia: In this area, there is minimal cellular injury but there is increased blood flow due to vasodilatation. This tissue usually recovers without intervention Initial Actions and Primary Survey Burns often occur as a result of explosions, building collapse, or motor vehicle accidents. In addition, patients involved in fires will often go to extremes, including jumping out of tall buildings, to get out of harm’s way. Therefore, it is important to remember that ALL burn patients should be thought of as trauma patients and the initial assessment and stabilization should be conducted according to the principles of Advanced Trauma Life Support (ATLS). Primary Assessment: Airway, Breathing, Circulation, Disability, Exposure Secondary Assessment: Detailed head to toe examination, AMPLE history The burn-specific assessment occurs during both the Primary and Secondary Assessments and is focused on the following areas (in addition to the ATLS survey): Airway: Is there carbonaceous sputum? Soot? Hair singed? Stridor? Airway edema? If noted, a patient may require prophylactic intubation or laryngoscopy/bronchoscopy. Breathing: Are there burns to the lung or chest wall? Gas/toxin inhalation? Check pulse oximetry. If noted, a patient may require a variety of interventions, including an ABG to check pH, a carbon monoxide level, or an escharotomy, a procedure to release tension due to scar formation. Circulation: Are there signs of decreased perfusion or circulatory collapse? Check pulses and perfusion in affected extremities. Monitor vital signs and volume input/output. All significant burns require IV access – obtain intraosseous access if indicated. The patient may require central line access for volume resuscitation, hemodynamic monitoring, etc.  Disability/Exposure: Carefully examine all skin areas to determine wound location & depth, remove all jewelry and clothing. This may require detailed drawings to document the injuries and to calculate the extent of burned tissue (discussed below in more detail). Decontaminate if the burn is from a chemical source. Presentation The classic presentation of a burn patient usually depends on the extent and depth of injury. The diagnosis is made based on a careful clinical evaluation, rather than specific laboratory or radiologic studies. If possible, a burn history should be elicited regarding: The circumstances & mechanism of injury Type(s) of material burning and length of exposure to them Exact time of injury Actions taken prior to arrival Associated signs and symptoms Classification of Burns Superficial Burns Minor burn injury; may involve epidermis and parts of the dermis Superficial injury Formerly called “First degree.” Superficial burns are limited to the epidermis. Wound is red, painful, and well-demarcated. Superficial Partial Thickness Formerly called “Second degree, superficial partial thickness.” Superficial partial thickness burns involve the epidermis and part of the dermis. May involve hair & glands. Wounds are painful, blister, & blanch with pressure. Tends to be wet & slippery to touch. Deep Burns Significant burn injury involving multiple skin layers Deep Partial Thickness Formerly called “Second degree, deep partial thickness.” Deep partial thickness burns involve deeper parts of the dermis, but not all. May involve hair and glands. Wounds are painful, blister, and blanch with pressure. Tends to be wet and slippery to touch.  Full Thickness Formerly “Third Degree.” Full thickness burns involve all epithelial and dermal elements. Specific wound is painless (but will often be surrounded by painful tissue so patients may report pain). It is depressed, non-edematous, and leathery. May be white, brown, or black, often with a “charred appearance.” Burns involving fascia and muscle Formerly “Fourth Degree.” Deep tissue burns that extend through all layers of skin and involves underlying fascia, muscle and/or bone. Wound is painless but injury is extensive and often requires amputation. Electrical burns Electrical energy is converted to heat which causes thermal injury and burns. However, unlike conventional thermal burns, the electricity may flow in unpredictable pattern and significant injury may not be evident at site of entry. Therefore, a detailed skin exam, including evaluation of the palms and soles is essential. Cardiac arrhythmias are common in electrical burns if the flow of electricity crosses through the thorax and across the heart. Extent of injury is determined by voltage type, voltage strength, the resistance of tissue, and the duration of contact. Rule of Nines Burns are classified according to the percentage of the total body surface area (%TBSA) that they involve. This area can be estimated by either the “palm estimate” or the “rule of 9s.” The burned patient’s palm (ventral surface of the hand excluding the fingers) is estimated to be equal to 1% of the TBSA and then used to measure the size of the burn. The entire head and each arm are estimated at 9% of the TBSA while each entire leg, the anterior thorax plus abdomen & back is each estimated at 18% of the TBSA. The perineum is estimated at 1% of the TBSA. In children, due to their relatively larger head size, the head is estimated at 18% with the other areas adjusted for this change. Figure 4. Estimation of Total Body Area.  Dibildox M., Jeschke M.G., Herndon D.N. (2012) Burn Injury, Rule of Nines. In: Vincent JL., Hall J.B. (eds) Encyclopedia of Intensive Care Medicine. Springer, Berlin, Heidelberg Accessed https://link.springer.com/referenceworkentry/10.1007%2F978-3-642-00418-6_380 Classic Presentation of Inhalational Injury The evaluation of inhalational injury is difficult since patients will often have few external signs of injury. Therefore, in addition to the detailed history and physical exam described above, a chest x-ray, detailed oropharyngeal exam, nasopharyngeal laryngoscopy, or bronchoscopy should also be considered in order to fully assess the extent of inhalational injury. Complete vital signs including continuous pulse oximetry are essential. Laboratory tests such as an ABG, carboxyhemoglobin level, or methemoglobin level may also be useful at detecting poisonings or metabolic disturbances. More specifically, inhalational injuries may be grouped as temperature-related, smoke-related, or gas-related. Heat tends to affect the upper airway more than the lower airways. There are two likely explanations for this: Vocal cord spasm protects the lower airway from the heat or the air is cooled and moisturized as it enters through the nose and mouth. Patients will develop edema, erythema, and ulcerations of lips, tongue, posterior oropharynx, and upper airway. Onset may be delayed for up to 24 hours and resolve in 4-5 days. Early signs include erythema and superficial burns to tongue, lips and pharynx and soot in mouth and nares. Stridor can develop quickly. There is generally a low threshold for early intubation before edema develops, and then tracheostomy if edema continues. Smoke-related airway injuries Smoke tends to affect the lower airways more than the upper airways. There are several explanations for this including: injury occurs when particles & soot settle in the medium and distal airways, direct thermal injury occurs when hot particles contact alveolar membranes and smaller airways are at increased risk of occlusion due to debris accumulation. Smoke-related damage leads to reduced mucociliary function. Early signs and symptoms include wheezing and respiratory distress with increased work of breathing, hypoxia, and coughing or gagging. Patients may develop pneumonia as a complication, in part due to impaired clearance. Gas-related airway injuries Oxygen is consumed during combustion. Fires create hypoxic environments and patients may be hypoxic on scene as well as on arrival in the ED. Carbon dioxide (CO2) & carbon monoxide (CO) are produced by combustion. Symptoms of CO toxicity are related to the amount of carboxyhemoglobin present in the blood as well as age and health of the patient. Presentation can range from a slight headache, nausea, or confusion to chest pain and vomiting. Severe or prolonged exposure can cause seizures, coma, and death. Burning of home furnishings and other synthetic materials release various toxins into the environment such as plastics releasing cyanide. Cyanide toxicity most often presents with depressed mental status or respiratory or cardiac arrest and should be suspected in any burn patient with change in mental status or hemodynamic instability. Water-soluble chemicals (ammonia, chlorine, etc.) can lead to bronchospasm and airway edema causing wheezing and pneumonitis. Lipid soluble chemicals (phosgene, nitrous oxide, etc.) can cause direct cell damage and impaired ciliary clearance. Diagnostic Testing Given that the diagnosis of burns is largely clinical, there may be some testing that is helpful in the Emergency Department. Diagnosis of any traumatic injury may require radiologic imaging such as chest X-ray to assess for pneumothorax or rib fractures and CT scans to assess for intraperitoneal, cervical spine, or traumatic brain injury.  Laboratory studies should include basic metabolic panel (BMP), creatine kinase (CK), complete blood count (CBC), and coagulation studies (PT and PTT). These may be helpful in diagnosing electrolyte abnormalities, such as hyperkalemia and rhabdomyolysis that can be associated with severe burns or coagulopathies and anemia that may be associated with hemorrhage and trauma. ABG or VBG with  carboxyhemoglobin levels are useful in diagnosing carbon monoxide toxicity and lactate will be significantly elevated in cyanide toxicity and severe burns. Treatment of Minor Burns The management of the patient with minor burns (either by extent of TBSA involved or by depth of burn) can be treated with basic local wound care and is focused on the following principles. First, stop the burning process by removing clothes or other materials and running cool (not cold) water over the area until the skin temperature has normalized. Next, initiate pain control with NSAIDs (anti-inflammatory properties) and/or opioids. Follow this with washing the burned area thoroughly with soap & water before careful drying of the area. Finally, apply topical ointment and sterile dressing. There are numerous options for this. Generally, bacitracin is used for burns on the face. A combination of bacitracin and petrolatum gauze dressings are used for many areas of the body. Silver sulfadiazine (SSD) used to be the mainstay for burn management for burns that can be easily and thoroughly washed off before reapplication. SSD should not be used on the face and can cause abnormal pigmentation. SSD has recently fallen out of favor for everything less than very deep burns as it can be messy to apply and also impair wound healing.  A newer complement to burn management is the use of new, commercially-available skin-like dressings that are applied to the cleaned burn and remain in place as the burn heals. Each specific brand has its own indications and contraindications. Mepilex is one of the most common and can be impregnated with silver. As the burn heals, dressings should be changed at a minimum of once daily by the patient with the same procedure as above with careful monitoring for cellulitis and wound healing. Arranging for follow up may include returning to the ED for a wound check, with a primary care doctor, or at a regional burn center. There is debate in the literature about whether to debride intact bullae. In general, intact bullae (blisters) have been considered to be sterile dressings and may be left intact unless they are quite large, painful, or in areas that interfere with functioning. However, recently there has been a trend to debride the bullae and then dress the wound under sterile technique as this also provides a sterile barrier and some evidence suggests that the material within the bullae is cytotoxic. Tetanus vaccination status should be verified and may need to be administered. There is no need to treat with oral or IV antibiotics on initial presentation for prophylaxis. Treatment of Significant Burns The management of the patient with significant burns is focused on accounting for the impaired functioning of the damaged skin, especially regarding the role of skin in fluid retention and as a barrier to infection. Significant burns are considered partial thickness burns involving greater than 20% TBSA. Fluid Resuscitation: Large, deep burns can lead to the loss of massive amounts of fluids and electrolyte imbalances for several reasons including: increased microvascular permeability that leads to extracellular edema and cell membrane defects that contribute to intracellular swelling. Additionally, burn patients have increased metabolic and respiratory rates that lead to increased evaporation and other insensible losses and often become hypoproteinemic leading to decreased intravascular oncotic pressures. Therefore, adequate fluid resuscitation is of paramount importance. The resuscitative fluid of choice is Lactated Ringer’s (LR) solution, given according to the Parkland formula: %TBSA burn x wt in kg x 4 mL/kg = volume of LR that should be administered over the first 24 hours Half should be given in the first8 hours following the burn and the remaining half should be given over the next 16 hrs (24hrs total). Remember, this is extra fluid in addition to the patient’s baseline fluid requirements. There is new evidence to suggest that we do not need to give fluids as aggressively as previously thought. Large amounts of fluids can create complications of their own such as third spacing with massive edema, heart failure, and electrolyte abnormalities. The modified Brook formula is the same as the Parkland formula except is 2 mL/kg instead of the Parkland formula’s 4 mL/kg and is aimed at prevention of over-resuscitation with fluids of burn patients. Clinicians also typically overestimate the size of burns, further leading to over-resuscitation. Infection Control: Sepsis is the leading cause of death in patients with large burns, accounting for up to 75% of deaths. Although the specific pathogens vary from patient-to-patient and between burn centers, patients with large burns have increased susceptibility to infection for several reasons: the normal skin barrier is lost and they are in a hypermetabolic & catabolic state. Patients develop depleted energy stores and various metabolic deficiencies. The local release of cytokines, breakdown of normal tissues, and circulating cellular components contribute to a global immune system impairment. Burned tissue creates a favorable bacterial environment. Eschar has increased moisture, acidic pH, and little blood flow. More specifically, the prevention and control of infection in the burned patient takes three main forms: Debridement of devitalized tissue: cut away dead, necrotic tissue and expose underlying viable tissue. A fasciotomy or escharotomy may be necessary in severe, circumferential burns that limit chest mobility or compress vital structures. Wound management : limit bacterial invasion by covering affected areas with antibiotic dressings and through early wound closure with skin grafting and/or commercial products. Preventing the delayed development of pneumonia and sepsis : universal precautions and general infection control practices are of paramount importance. Contact isolation with gown, gloves, and mask. Frequent changing of intravenous lines, etc. Aggressively evaluate fevers by pan-culturing and initiating broad-spectrum antibiotics. Disposition: Patients with superficial or localized burns are generally treated in the Emergency Department and discharged with close outpatient follow-up with a burn surgeon. Adult patients with >20% TBSA burns are generally transferred or admitted to a regional burn center for evaluation. There are other criteria, usually elucidated by prehospital EMS, to determine transfer such as burns to the hands, face, feet and genitalia, chemical burns, inhalational injury, or the possibility of major trauma associated with the burn. Pediatric patients with >10% TBSA burns are generally transferred to a regional pediatric burn center for evaluation. Treatment of Inhalational Injury Patients with suspected inhalation injury should be placed on 100% oxygen by a non-rebreather mask as soon as possible. Patients with any signs of airway burns (soot in nares, burns to oropharynx) or impending edema (swelling of face or oropharynx, stridor, voice changes) should be intubated as soon as possible to avoid loss of airway.  Non-invasive pulse oximetry is not a reliable method to diagnose CO toxicity, as levels can actually be normal. Carboxyhemoglobin levels greater than 4% in non-smokers and 10% in smokers should be treated for acute CO toxicity. Patients with carboxyhemoglobin levels greater than 25%, children, pregnant patients, older patients or those with significant comorbidities or altered mental status should be considered for hyperbaric oxygen therapy to prevent delayed neurologic sequelae. Patients with altered mental status, respiratory or cardiac arrest should be considered for treatment of cyanide toxicity. There are two approaches to this. The old “Cyanide Antidote Kit” contained sodium thiosulfate and involved a two-step approach which included inducing methemoglobinemia. This has fallen by the way-side in favor of hydroxocobalamin administration, which is faster acting and safer. Case Conclusion You evaluate your burn patient using the burn classification system and rule of nines above after fully undressing him and performing the ATLS survey. Since he is unconscious, with a depressed mental status and signs of inhalation injury, such as soot in the airway and facial burns, you decide to intubate him in the resuscitation bay. A chest X-ray is performed, showing no pneumothorax and appropriate endotracheal tube placement. It is determined that he has 20% TBSA deep partial thickness and full thickness burns. You send laboratory studies including complete blood count, basic metabolic panel, arterial blood gas, carboxyhemoglobin, and coagulopathy studies. While he is in CT scan you calculate his fluid requirement using the Parkland Formula. His weight is 70 kg.  (70 kg) x (20%) x (4 cc/kg) = 5,600 mL Remembering that he gets half of this in the first 8 hours and half in the next 16 hours, you calculate he’ll need two boluses, each being 5,600 mL / 2 = 2,800 mL. Since two hours of the first 8 hours has already passed from the initially injury, he will need to get that first bolus over the next six hours. 2,800 mL / 6 hrs = 467 mL/hr (additional fluid given over the next 6 hours) The remaining 2,800 mL would have to be administered over the next 16 hours. 2,800 mL / 16 hrs = 175 mL/hr (additional fluid given over the next 16 hrs) This is in addition to his maintenance fluids, which for a 70 kg man would be 104 mL/kg. So his final fluid orders would be: 467 mL/hr (bolus) + 104 mL/hr (maintenance) = 571 mL/hr (for the first 6 hrs) 175 mL/hr (bolus) + 104 mL/hr (maintenance) = 279 mL/hr (for the following 16 hrs) Remember, these calculations are just a general guide. You must also monitor urine output to ensure adequate fluid resuscitation and adjust fluids as necessary to achieve a target urine output: Adult urine output: 0.5 mL/kg/hour Pediatric urine output: 1-2 mL/kg/hour Pearls and Pitfalls Don’t be distracted by the sight and smell of the burns. Burn patients are trauma patients and often have concomitant injuries that must be addressed. Fully undress the patient to expose all skin and remove charred or burning clothing that can further contribute to burn injury. Be liberal with pain medications. Most patients with significant burns will require large doses of pain medications. Most patients may have burned areas with a mix of depths including superficial and deeper areas. Inhalation injuries are common but difficult to assess initially. Don’t forget to carefully assess burn patients for potential delayed airway compromise and have a low threshold for intubation as airway edema can progress within minutes. Altered mental status can be due to trauma injury or inhalational injury. Don’t forget to give oxygen, check carboxyhemoglobin levels and have a low threshold to treat for cyanide toxicity. Do not place moist towels, gauze, or sheets on burned areas as this will contribute to hypothermia. Clean burns cover burns with petrolatum gauze or antibacterial medications and gauze. Children have different total body surface area calculations compared to adults. Significant fluid losses only occur with deeper burns greater than 20% TBSA. Superficial burns do not generally require extra fluid resuscitation beyond maintenance fluids. Alharbi, Z, et al. Treatment of burns in the first 24 hours: simple and practical guide by answering 10 questions in a step-by-step form. World J Emerg Surg. 2012.7:13 American Burn Association. Multiple educational resources and a listing of US burn centers is available on line at  http://www.ameriburn.org . Cuttle L, Pearn J, McMillan JR, and Kimble RM. A Review of First Aid Treatments for Burn Injuries. Burns. 2009. 35(6):768-75. Gomez R and Cancio LC. Management of Burn Wounds in the Emergency Department. Emergency Medicine Clinics of North America. 2007. 25(1):135-46. Hall, A, Dart, R, Bogdan, G. Sodium Thiosulfate or Hydroxocobalamin for the Empiric Treatment of Cyanide Poisoning. 2007. 49(6):806-813 Hampson, N, et al. Practice Recommendations in the Diagnosis, Management, and Prevention of Carbon Monoxide Poisoning. Am J Resp Crit Care Med. 2012. 186(11): 1095-1101. Latenser BA. Critical Care of the Burn Patient: The First 48 Hours. Critical Care Medicine. 2009 37(10):2819-26. Singer AJ, Brebbia J, Soroff HH. Management of Local Burn Wounds in the ED. American Journal of Emergency Medicine. 2007. 25(6):666-71. Log in using your username and password Search More Search for this keyword Advanced search Latest content Current issue BMJ Journals You are here Volume 41, Issue 10 Major burns in adults: a practice review Article Text Article info Citation Tools Rapid Responses Article metrics Alice Gwyn-Jones 1 , Tijesu Afolabi 1 , http://orcid.org/0009-0005-6634-8653 Samantha Bonney 2 , Dilnath Gurusinghe 1 , Ascanio Tridente 1 , Tushar Mahambrey 3 , http://orcid.org/0000-0002-2419-049X Patrick Nee 1 , 4 1 Emergency Department , St Helens and Knowsley Hospitals NHS Trust , Prescot , UK 2 Transfusion Department , Whiston Hospital , Prescot , UK 3 Intensive Care , Stockport NHS Foundation Trust , Stockport , UK 4 Liverpool John Moores University , Liverpool , UK Correspondence to Professor Patrick Nee; patrick.nee{at}sthk.nhs.uk There are approximately 180 000 deaths per year from thermal burn injury worldwide. Most burn injuries can be treated in local hospitals but 6.5% require specialist burn care. The initial ED assessment, resuscitation and critical care of the severely burned patient present significant challenges and require a multidisciplinary approach. The management of these patients in the resuscitation room impacts on the effectiveness of continuing care in the intensive care unit. The scope of the present practice review is the immediate management of the adult patient with severe burns, including inhalation injury and burn shock. The article uses an illustrative case to highlight recent developments including advanced airway management and the contemporary approach to assessment of fluid requirements and the type and volume of fluid resuscitation. There is discussion on new options for pain relief in the ED and the principles governing the early stages of burn intensive care. It does not discuss minor injuries, mass casualty events, chemical or radiation injuries, exfoliative or necrotising conditions or frost bite. resuscitation critical care https://doi.org/10.1136/emermed-2024-214046 Statistics from Altmetric.com Request permissions. If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways. Handling editor Jason E Smith X @SamSambonney Contributors All authors made substantial contributions. AG-J proposed the project and wrote an early introduction. TA wrote the discussion on initial assessment and resuscitation. SB wrote the discussion on transfusion of blood and products. DG wrote the discussion on surgical management. AT wrote the discussion on the organisation of burn services and some parts of the discussion on ICU management. TM wrote the discussion on fluid management. PN prepared the final draft for submission and is the guarantor for the paper. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Competing interests None declared. Provenance and peer review Not commissioned; externally peer reviewed. Read the full text or download the PDF: An official website of the United States government The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site. The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Publications Account settings The PMC website is updating on October 15, 2024. Learn More or Try it out now . Advanced Search Journal List Ann Burns Fire Disasters v.21(1); 2008 Mar 31 Language: English | French A Geriatric Patient with Major Burns:Case Report Gülhane Military Medical Academy, Haydarpa¾a Training Hospital, Plastic and Reconstructive Surgery and Burns Unit, T›bbiye Cad. 34668 Üsküdar, Turkey E. Ülkür B. Çeliköz. As is predictable, mortality and morbidity among geriatric patients are higher in patients with major burns. Decreased radiopulmonary reserves and malnutrition characterized by protein/energy deficiency and ageing of skin are predisposing factors which increase mortality and morbidity. In this study, we present a 90-yr-old patient with 46% total body surface area of 2nd-3rd degree burns. We had to overcome difficulties which can be seen in elderly patients and which succeeded in our treatment. Comme on peut prévoir, le taux de mortalité et de morbidité chez les patients gériatriques est plus élevé quand ils sont atteints de brûlures importantes. Les réserves radiopoumonaires diminuées et la malnutrition caractérisées par l'insuffisance protéinique/énergétique et le vieillissement de la peau sont des facteurs prédisposant qui augmentent la mortalité et la morbidité. Les Auteurs présentent dans cette étude le cas d'un patient de 90 ans atteint de brûlures de deuxième et troisième degré. Ils ont du surmonter les difficultés que l'on peut avoir chez les patients d'un certain âge, et notre traitement a eu succès. Introduction Geriatric patients, usually defined as those older than 65 years of age, comprise approximately 10% of the major burns population. 1 Burns in this age group constitute more serious injuries than in the general population and burns larger than 30% total body surface area (TBSA) cause an extremely high mortality. Co-morbid factors are responsible for this increase in morbidity and mortality. 2 Elderly people have thinner skin, poorer microcirculation, and increased susceptibility to infection 3 , 4 and the rate of burn shock, inhalation injury, pulmonary pathology, septicaemia and renal failure is higher than in younger people. If we compare the number of elderly burn patients over 80 years old with those between 65 and 80 we can see that both these groups are small, but the survival rate, especially in patients with more than 40% TBSA burns, is very low. In this article we present a 90-yr-old patient who presented challenging difficulties in therapy and care. A 90-yr-old male patient was admitted to our burns centre after a water heater blast accident at home. Altogether 46% TBSA was burned by flame (2nd-3rd degree). The regions affected were the face, posterior neck, posterosuperior trunk, right anterosuperior trunk, the right lumbar and dorsal side of both upper extremities and both lower extremities (Figs. 1 , 2 , 3 ). After sedation with 2 mg midazolam i.v. and 50 mg ketamine i.v., the burned areas were scrubbed with distilled water and 7.5% povidine iodine in our washroom. The wounds were closed with 0.5% chlorhexidine acetate and petrolatum gauze. After the initial dressing, the patient was taken to the intensive care unit and fully monitored with central venous, arterial, urinary, and nasogastric catheterization. On day 1, fluid resuscitation was administered according to the Parkland formula, i.e. 4 ml/kg/% TBSA. Crystalloid (Ringer’s lactate) was preferred. The speed of the fluid resuscitation was monitored in relation to urine output and central venous pressure. Dressings were changed daily. Respiratory support was ensured by postural drainage, respiratory, and Tri-flow exercises, plus cold vapour. Fluid replacement was continued in order to maintain urine output at 0.5-1 cc/kg. Periodically, quantitative and exfoliative wound, urine, and haemocultures were taken. Sefoperazon + Sulbactam 1 g twice daily were initiated owing to high fever on day 3 post-burn. Acinetobacter baumanii was isolated in the haemoculture on day 8. Appropriate antibiotherapy with a sensitive antibiotic was performed. Following the onset of gastroenteritis on day 10, the oral nutritional support solutions were suspended and total parenteral nutrition was commenced. Pseudomonas aeruginosa was isolated in the wound culture on day 17 post-burn, and meropenem and amikacin were given for respectively 32 and 7 days. At the same time silver-coated dressings were applied (Acticoat, Smith and Nephew, USA). 6 , 7 Following subdermal epinephrine infiltration, debridement and grafting were performed in 25% TBSA on post-burn day 19. An intensive physical therapy and exercise programme was initiated after post-operative day 7. We assessed the patient’s hypotensive and oliguric state on day 26, and therapy with an inotropic agent (dopamine, 2 mg/kg/min) was initiated. After ten days’ therapy this state diminished and inotropic therapy was terminated. Altogether the patient was hospitalized for 40 days, after which he was discharged as cured (Figs. 4 , 5 , 6 ). Discussion and conclusion Although burn treatment has improved during the past few years with the advent of better topical treatments, improved resuscitation, and early burn eschar excision, the prognosis still remains poor for older adult patients, and burn injuries rank forth among the causes of injury-related deaths in the geriatric age group. Mortality in young adults with an 80% TBSA burn is 50%; in persons aged 60-70 yr, a 35% TBSA burn has 50% mortality, and in persons over 70 a 20% TBSA burn will have 50% mortality. Pre-morbid conditions such as chronic obstructive pulmonary disease (COPD) and coronary artery disease may lead to longer hospital stay, increased ventilation requirements, and elevated complication rates. Agarwal et al. demonstrated that the greater fluid requirements in elderly burn patients led to an increase in congestive heart failure, pulmonary oedema, and pneumonia. The mortality rate also increases owing to an impaired response to infection and sepsis, as also to decreased ability to tolerate prolonged stress and physiological insult. 11 , 12 , 13 , 14 , 15 , 16 The deficient nutritional state seen in elderly burned patients may also cause impaired wound healing. Materials used for the purpose of smoking and stoves are reported as frequent sources of injury in older persons, who are most frequently burned during the course of routine daily tasks. In our case the burn was a flame burn. Physical and physiological differences such as diminished manual dexterity, vision, and hearing, decreased mobility and judgement, and slower reaction times cause injuries in this age group. 18 Because of the diminished reaction time, the severity of burn injuries and the incidence of inhalation injury increase in the geriatric population, and this reduces the size of survivable burn injuries. Prolonged immobilization and ongoing physiological stress contribute to the significant morbidity related to inhalation injury. Elderly people have decreased pulmonary reserves for gas exchange and lung mechanics and they are prone to pulmonary failure, which is a major cause of death in all burns. Even when inhalation injury symptoms are totally absent, the early administration of humidified oxygen and nebulization and the use of mycotic agents, position changes, chest physiotherapy, and early ambulation discourage the development of pulmonary problems or attenuate their clinical course in burns caused by flame. In the case we describe, even though there were no signs of inhalation injury, thanks to the early application of respiratory physiotherapy we did not have to treat pulmonary problems. In elderly people there are several well-recognized risk factors with age, such as chronic illnesses, cardiovascular disease, and decreased pulmonary reserve. The major causes of mortality and morbidity in the elderly following thermal injury are not the burn, but rather alterations due to concomitant disease processes. In this age group, pre-morbid states like COPD and coronary artery disease prolong hospitalization time and increase the need of ventilation support due to the complications. In elderly people fluid resuscitation is important. These people, like children, are volume-sensitive and may be at risk of hypotensive renal damage. It is advocated that resuscitation fluid should be administered to elderly people with injuries of more than 5% TBSA burns. Resuscitation solutions should be initiated at a rate of 3-4 ml/kg/% burn and titrated to specific outcome parameters, evaluating any evidence of systemic overload or underhydration. Adequacy of resuscitation should be surmised at 30-50 ml/h urine output, clear mentation, and appropriate blood pressure. Even after surviving the earliest days of trauma, an oliguric and hypotensive state can be interfaced at any time during therapy, as in our patient, who presented such a condition on day 26 post-burn. Wound healing is of great concern in older people. There are significant changes in the skin with ageing that are responsible for the greater percentage of deep burns in the elderly, e.g. progressive thinning of the dermis and epidermis. Many factors cause a greater amount of deep burns and a decrease in healing in all phases, such as decreased epidermal turnover and a decrease in skin appendages, vascularity, collagen and matrix, fibroblast, and macrophage levels. 20 , 21 , 22 These unfavourable factors cause a delay in epithelialization, an increase of burn depth, especially in second-degree burn areas, and healing problems at the donor site. In the case reported, areas that did not epithelialize spontaneously were grafted on post-burn day 19. One such problem, protein energy malnutrition (PEM), has been reported to be present in at least one-third (30-60%) of elderly patients admitted to hospital. PEM has also been found to be three to four times more likely in patients over 65 years of age than in younger patients. 23 , 24 , 25 Malnutrition and involuntary weight loss have been shown to be major risk factors for increased infection, impaired wound healing, and overall disability, the major reason being a loss of body protein and lean body mass. Mortality and morbidity rates seem to be accentuated owing to the addition of a post-burn catabolic state to an existing body protein and energy deficit. 26 , 27 , 28 By giving our patient a high-energy, calorie-rich diet after day 2 post-burn we prevented him from developing a state of protein and energy malnutrition. Elderly patients need to be aggressively managed to avoid early loss of function or muscle strength, which will be difficult to recover. These patients are capable of restoring muscle strength with resistance exercise and should not be managed conservatively. 29 As with children, providing support and guidance for the family or caretakers is an integral part of care. We performed muscle physiotherapy, beginning with range of motion exercises on post-operative day 10, plus muscle strength exercises. As a result, despite the high mortality seen in elderly burned patients, it is possible - with early respiration physiotherapy, fluid resuscitation without overload or underhydration, challenge of infection, early surgery, and post-operative physiotherapy - high mortality and morbidity rates can be decreased in this age group. 464 IMAGES SOLUTION: Burn injury case study and plan of care Burn injury case study Case Study burn Burn Injury Nursing Care Management and Study Guide Burn CASE Study for NUR 409 (PDF) The view of severely burned patients and healthcare professionals VIDEO Case study on burn patient #bsc nursing # Patient Case Study Example Mastering Burn Patient Care Burn case study / case presentation #medicalstudent #casestudy #casepresentation Management of Burn Injuries Client Testimonial COMMENTS Evaluation and Management of the Burn Patient: A Case Study and Review Abstract. Advances in the management of burn patients have contributed to significant improvements in morbidity and mortality over the last century. The physiologic insult from this injury pattern, however, still requires extensive surgical intervention, resuscitation and multidisciplinary care. This paper will review the standard of care of ... A 94-year-old patient with severe burns: a case report A 94-year-old man with severe burns caused by an explosion of a fuel tank was transferred from a local hospital to our hospital at 24 h after the injury. Prior to admission, the patient was initially resuscitated at the local hospital. On admission, the patient was conscious, with a Glasgow Coma Score of 13 and body mass index (BMI) of 21.63. Burn injuries in the ICU: A case scenario approach : Nursing2020 ... The following case study, about a young male patient named Abe, illustrates a common situation. This article reviews various types of burn injuries and what you need to know to provide initial resuscitative care for patients with severe burn injuries. A future article will be based on Abe's unfolding case scenario and will describe various ... Burn Case Study: Fatima Jafar Burn patients tend to have third-spacing and re at an increased risk for shock and hypothermia. Therefore, it is critical to administer isotonic fluids (preferably Lactated Ringer's) to replace the fluid loss. ... Litt, J.S. (2018). Evaluation and management of the burn patient: A case study and review. Missouri Medicine, 115 (5), 443-446 ... Burn Case Study Burn Case Study. A kitchen grease fire ignites causing 2nd and 3rd degree burns in patient Anna Sites. 40,000 hospitalizations occur each year in the United States from burn related injuries (American Burn Association, 2013). In this case, we'll explore the assessment, pathophysiology, and treatment of a major burn and subsequent shock. ... Burn injuries in the ICU: A case scenario approach Part 2 A case scenario approach Part 2. This article is the second part of a case study about Abe, a young Amish patient with severe burn injuries. In Part 1, various types of burns were described, as well as initial resuscitative care for patients with severe burn injuries. In Part 2, the authors detail Abe's unfolding case scenario and conclusion ... Nursing care directed to burned patients: a scoping review Case study/3B/B: Report the evolution of healing in a patient with second-degree burns treated with 0.2% hyaluronic acid (HA) and biocellulose film. ... (BSHS-R) can be used, which has the function of assessing the health status of patients who have suffered burns. The studies (31,38) that applied the scale reported improvement in the levels of ... Evaluation and Management of the Burn Patient: A Case Study ... Abstract. Advances in the management of burn patients have contributed to significant improvements in morbidity and mortality over the last century. The physiologic insult from this injury pattern, however, still requires extensive surgical intervention, resuscitation and multidisciplinary care. This paper will review the standard of care of ... Evaluation and Management of the Burn Patient: A Case Study and Review The study revealed that the main source of burns was flame (52.38%) and hot water (28.57%), or 71 % were with 11-40% of burn surface with 48.41% having burn size between 11 and 20% of total burn ... Management of Burns For burns covering more than 60% of total body-surface area, the current philosophy is to excise the burns within the first few days, cover the wounds with as much of the patient's own, widely ... Burn Case Study: Brad Brad was admitted to the burn unit at 0700 post surgery, and remained a patient on the burn unit for 4 weeks. Goals of his stay included monitoring vital signs, preventing infection, pain management, wound care, adequate nutrition, physical therapy, and psychosocial support. Discharge Plans / Case Management Burn Case Scenarios Pediatric Burn Scenarios - #1. A 9 year old boy weighing 48 kgs and Ht. 135 cms, sustained burns today while playing with matches in a garage. Unknown accelerant and his pants caught on fire, which he attempted to put out using his hands. He sustained burns on both lower extremities. The burns are circumferential on the right lower extremity ... "Living Well" After Burn Injury: Using Case Reports to Illustrate Using case study methodology with three adult burn survivors, we highlight the impact and individual significance of program findings and reinforce the recognition that the value of any clinical research must have relevance to the lives of the study population. ... Nadler D, et al. Cognition in patients with burn injury in the inpatient ... The Roles of Clinical Psychologists in Burns Care: A Case Study This study describes current screening practices and provider beliefs regarding screening for stress disorders in patients with burns in the US. This was a 31-question survey distributed to the ... Burn Burn - Case Summary. 1. Anna burned about forty percent of her body in a kitchen grease fire. Third-degree burns were present on her right shoulder, upper anterior right arm, and part of the anterior trunk. Second-degree burns with blistering were present on the remaining burn areas. Anna experienced subsequent shock with tachypnea, tachycardia ... Acute Intermittent Porphyria in a Burn Patient: Case Study and Review Both of these metabolites cause neurovisceral symptoms that afflict the patient in acute attacks. We present a rare case of AIP manifested in a burn patient suffering a burn injury. The patient presented with symptoms indicative of AIP, including altered mental status and abdominal pain accompanied with a chronic history of alcoholism and smoking. Care of the Critically Injured Burn Patient Abstract. Care of the critically injured burn patient presents unique challenges to the intensivist. Certified burn centers are rare and geographically sparse, necessitating that much of the initial management of patients with severe burn injuries must happen in the pre-burn center setting. Clinical review: The critical care management of the burn patient A recent study of patients with severe burn injury defined as TBSA >40% with AKI treated with continuous venovenous haemofiltration with a maintenance dose of 20 to 35 ml/kg/hour compared with historical controls prior to the availability of continuous venovenous haemofiltration found the use of continuous venovenous haemofiltration to be ... Burns and Smoke Inhalation Case Study. A patient presents to the Emergency Department with burns from a house fire. He was extracted by firefighters, and it has been two hours since the initial call. ... burn patients have increased metabolic and respiratory rates that lead to increased evaporation and other insensible losses and often become hypoproteinemic leading to ... Major burns in adults: a practice review There are approximately 180 000 deaths per year from thermal burn injury worldwide. Most burn injuries can be treated in local hospitals but 6.5% require specialist burn care. The initial ED assessment, resuscitation and critical care of the severely burned patient present significant challenges and require a multidisciplinary approach. The management of these patients in the resuscitation ... Educational Case: Burn Injury—Pathophysiology, Classification, and The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. ... The hypermetabolic state seen in burn patients is partly due to muscle catabolism, which provides amino acids to rebuild skin tissue. ... One study of more than ... A Geriatric Patient with Major Burns:Case Report Introduction. Geriatric patients, usually defined as those older than 65 years of age, comprise approximately 10% of the major burns population. 1 Burns in this age group constitute more serious injuries than in the general population and burns larger than 30% total body surface area (TBSA) cause an extremely high mortality. assignment essay homework paper phd report resume review speech thesis