A 63-year-old man is extracted from fire in the house and brought to the hospital. According to the witness at the scene, the victim was unconscious in an upstairs bedroom of the house. His pulse rate is 110 beats/minute, blood pressure is 150/90 mm Hg, and respiratory rate is 28 breaths/minute. The pulse oximeter shows 91% oxygen saturation with oxygen by face mask. His face and the exposed portions of his body are covered with carbonaceous deposit. The patient has blistering open burn wounds involving the circumference of his left arm and left leg, in addition to his entire back and buttock areas.
Inference:The man presents with approximately a 45% TBSA burn(9+18+18) and inhalation injuries sustained in a house fire.
What should be first step for management of this thermal injury?
Definitive airway management by intubation is critical in this patient with likely inhalation injuries, carbon monoxide (CO) poisoning, and major burns.
FIRST-DEGREE BURN WOUNDS: Superficial burns that involve only the epidermis. These wounds appear red and are not blistered.
PARTIAL-THICKNESS BURN WOUNDS: (Formerly known as second-degree burns)
These are burns that extend beyond the epidermis and are classified as superficial or deep. Superficial partial-thickness wound appear as painful, pink wounds with blisters. With topical wound care such as silver sulfadiazine, superficial partial-thickness wounds often heal within 2 weeks without much impairment or scarring.
Deep partial-thickness wounds are often dried, mottled, and variably painful. These wounds can also be healed with topical wound care; however, spontaneous healing is often associated with scarring and functional impairment; therefore, deep partial thickness wounds are often treated by excision and skin-grafting.
THIRD-DEGREE (FULL-THICKNESS) BURNS: Full-thickness burn of the skin involving the entire epidermis and dermis layers. These wounds are painless, appear white or black with a leather-like appearance. Spontaneous healing occurs only by contraction from the surrounding skin, leading to significant scarring and functional losses.
PARKLAND FORMULA: One of the most commonly applied strategies for initial burn resuscitation. This formula calculates the volume and rate of fluid administration for the first 24 hours for adults with major burns.
(Affected TBSA%) × (4 mL of Lactated Ringer) × (weight of patient in kg). One-half of the calculated volume is given over the first 8 hours and the remainder given over the subsequent 16 hours. The rate and volume of administration are adjusted to keep urine output between 0.5 and 1.0 mL/kg/h.
MODIFIED BROOKE FORMULA: The main difference between this approach and the Parkland formula is the use of colloid solution during the second 24 hours. This formula can be applied for adults with burns and children weighing more than 10 kg, and the formula utilizes lactated Ringer 2 to 4 mL/kg×% TBSA during the first 24 hours, with one-half of the volume given in the first 8 hours and the remaining fluid in the subsequent 16 hours. During the second 24 hours, colloid fluid (5% albumin in lactated ringer) is given at 0.3 to 0.5 mL/kg × % TBSA titrated to maintain urine output of more than 0.5 mL/kg/h.
ESCHAROTOMY: Escharotomies are incisions made in the “leathery” and nonexpansive full-thickness burn sites to help improve tissue perfusion if there is a circumferential burn wound in the extremities. Escharotomies can be made in the truncal regions for individuals with circumferential burn wounds to the torso causing compromised perfusion of abdominal organs and/or compromised expansion of the chest with ventilation.
FASCIOTOMY: Fasciotomies are incisions made in the fascia of extremities to help release pressures in swollen muscle compartments. Deep compartment swelling is most common following high-voltage electrical burns causing injuries to muscles and other deep structures
CLINICAL APPROACH TO BURN PATIENT/THERMAL INJURY
Major burn wounds are generally defined as injuries with >20% TBSA involvement. The skin is the largest organ of the body, and it is responsible for maintenance of fluid balance, temperature regulation, protein regulation, and serves as a barrier against bacteria and fungus. Patients with major burns require inpatient care; whereas, some patients with minor burn wounds can be managed in the outpatient setting with appropriate input and follow-up from practitioners who are knowledgeable about burn care.
Phases of Care for Major Burns The hospital care of patients with major burn wounds can be viewed as three separate phases. The first phase encompasses day 1 to day 3, when complete evaluation of the patient and accurate fluid resuscitation are the primary goals. During the second phase, the main goals are initial wound excision and biologic wound coverage to prevent/minimize wound sepsis, systemic inflammation and sepsis. Ideally, second phase goals should be accomplished immediately following phase 1 treatments. The third phase priorities include definitive wound closure/coverage and treatment of injuries to complex anatomic regions such as the hands, face, and genitalia. Rehabilitation and some reconstructive processes are also undertaken during phase 3. It is important to bear in mind that the primary objectives in the care of hospitalized burn patients are to help patients return to work, school, community activities, and normal life.
