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Resident Orientation Manual

Produced by Galveston Shriners Burn Hospital and
The University of Texas Medical Branch Blocker Burn Unit.
Contributors:  Sally Abston MD, Patricia Blakeney PhD, Manubhai Desai MD,
Patricia Edgar RN, CIC,John P Heggers PhD, David N Herndon MD,
Marsha Hildreth RD, Ray J Nichols Jr. MD

 

Acute Burn Management

INTRODUCTION

   Although burn injuries are frequent in our society, many surgeons feel uncomfortable in managing patients with major thermal trauma.  Every year, 1.2 million Americans sustain a burn injury requiring medical attention.  About 50,000 of these need hospitalization.  Up to 10,000 people die every year from burns and burn-related injuries or infections.  Only motor vehicle accidents cause more accidental deaths than burns.  Mortalities are highest among the very young and very old.  Two-thirds of all burn accidents occur at home and most commonly involve young adult males and children.  Young adults are most commonly burned by flammable liquids, while toddlers are most often scalded by hot liquids while in the kitchen.  16% of burns in children are due to child abuse.  Structural fires result in about 5% of burn-related admissions, but account for 45% of associated deaths.  Inhalation injury has the biggest impact on both early and late mortality.

   Advances in trauma and burn management over the past 3 decades have resulted in improved survival and reduced morbidity from major burns.  25 years ago, the mortality rate of a 50% body surface area (BSA) burn in a young adult was about 50% despite treatment.  Today, over 50% of these patients are surviving.  Improved results are due to advancements in resuscitation, surgical techniques, infection control and nutritional/metabolic support.  In the last year for which complete data is available (1998) 1/3 of the deaths were due to invasive fungal infection, 1/3 from anoxic brain injury and 1/3 from pulmonary failure.   


DEFINITIONS

   The skin is the largest organ in the body, comprising 15% of body weight and covering approximately 1.7 m in the average adult.  The function of the skin is complex:  it warms, it senses, and it protects.  Of its 2 layers, only the epidermis is capable of true regeneration.  When the skin is seriously damaged, this external barrier is violated and the internal milieu is exposed and altered.

Burn Injury
   A burn injury implies damage or destruction of skin and/or its contents by thermal, chemical, electrical or radiation energies or combinations thereof.  Thermal injuries are by far the most common and frequently present with concomitant inhalation injuries.

   A thermal injury involves the heating of tissues above the critical level at which damage occurs via protein denaturation.  Tissue injury is a function of the heat content of the burning agent, length of exposure and thermal conductivity of the involved tissue.  The hydrophilic human skin possesses a high specific heat and a low thermal conductivity.  Therefore, skin becomes overheated quite slowly, but also cools slowly. As a result, thermal damage continues after the burning agent is extinguished or removed.

The Burn Syndrome
  
Following a major burn injury a myriad of physiologic changes occur that together comprise the clinical scenario of the burn patient.

These derangements include:
1.  Fluid and Electrolyte Imbalance   The burn wound becomes rapidly edematous due to microvascular changes induced by direct thermal injury and by release of chemical mediators of inflammation.  This results in systemic intravascular losses of water, sodium, albumin and red blood cells.  Unless intravascular volume is rapidly restored, shock develops.

2.  Metabolic Disturbances   This is evidenced by an increased resting oxygen consumption (hypermetabolism), an excessive nitrogen loss (catabolism), and a pronounced weight loss (malnutrition).

3.  Bacterial Contamination of Tissues   The damaged integument creates a vast area for surface infection and invasion of microorganisms.  Burned patients with a major thermal injury are unable to mount an adequate immunologic defense, increasing the risks for septic shock.

4.  Complications from Vital Organs   All major organ systems are affected by the burn injury.  Renal insufficiency can result from hypoperfusion or from nephron obstruction with myoglobulin and hemoglobin.  Pulmonary dysfunction may be caused from initial respiratory tract damage of from progressive respiratory insufficiency due to pulmonary edema, adult respiratory distress syndrome or bronchopneumonia.  Gastrointestinal complications include paralytic ileus and gastrointestinal ulcerations.  Small bowel ischemia and stasis promote bacterial translocation as a mechanism for endogenous infection.  Multi-system organ failure is a common final pathway leading to late burn mortality.

 

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