27.3.1 Severity Factors

There are five factors to be considered when determining the severity of a burn injury (Box 27.1).

1. 1.
   
   
   

   Extent—There are several, paper-based methods available to accurately calculate the percentage of body surface area involved. The simplest and most easily recalled is the Rule of Nines (Fig. 27.1). However, it is only for use with the adult burn population. The Lund and Browder method (Fig. 27.2) is useful for all age groups, but is more complicated to use. For the pediatric population, there is a modified version of the Lund and Browder method (Fig. 27.3). If the burned areas are small and irregularly shaped, the Rule of Palm can be used. The palmer surface of the burned person’s hand, including the extended fingers, represents 1% body surface area. Reliability of the palmar surface area tool for obese patients has been questioned and alternative methods suggested [11]. There are also a number of internet-based or mobile technologies available to calculate the extent of the body burn, which might help to decrease the problems with both over- and under-estimation of burn size by pre-hospital, hospital, and burn team personnel [12–16].

   
   
    
   
   
2. 2.
   
   
   

   Depth—Two factors determine the depth of a burn wound—temperature of the burning agent and duration of exposure time. Previously, the terminology used to describe burn depth was first, second, and third degree. In recent years, these terms have been replaced by those more descriptive in nature: superficial partial-thickness, deep partial-thickness, and full-thickness (Table 27.3). The skin is divided into three layers, which include the epidermis, dermis, and subcutaneous tissue (Fig. 27.4). The dermis, which is about 30–45 times thicker that the epidermis, contains connective tissue, blood vessels, hair follicles, nerve endings, sweat glands, and sebaceous glands. Skin-reproducing cells are located along the shafts of the hair follicles, sweat glands, and sebaceous glands. The sufficient presence or absence of these re-epithelializing cells determines whether the wound will heal on its own or require skin grafting. At the present time, visualization with the naked eye, by experienced burn practitioners, is used to determine burn depth. However, there is ongoing research exploring the use of newer laser technologies to determine burn depth [17].

   
   
    
   
   
3. 3.
   
   
   

   Age—In patients less than 2 years of age and greater than 50, there is a higher incidence of morbidity and mortality. Infants, toddlers, and the elderly have thinner skin, making the risk of a deeper burn greater in these age groups. Persons of this age also have weaker physical resources to mount a resistance against the debilitating effects brought on by a burn [18, 19].

   
   
    
   
   
4. 4.
   
   
   

   Part of the body burned—Patients with burns to the face, eyes, neck, hands, feet, joints, or perineum have greater functional and esthetic challenges to overcome and require the specialized care offered by a burn center.

   
   
    
   
   
5. 5.
   
   
   

   Past medical history—A burn injury will exacerbate pre-existing conditions. Persons with diabetes or peripheral vascular disease have a more difficult time with wound healing, a central factor in burn recovery, particularly if the burns are on the legs and/or feet [20, 21]. Burn patients with poor nutritional status pre-burn or with previous drug and/or alcohol abuse patterns have fewer physical reserves to draw from and, as such, require more resources for a prolonged period of time.

   
   
    

Table 27.3

Classification of burn injury depth

Degree of burn	Cause of injury	Depth of injury	Appearance	Treatment
First degree	Superficial sunburn Brief exposure to hot liquids or heat flash	Superficial damage to epithelium Tactile and pain sensations intact	Erythematous, blanching on pressure, no blisters, sensate	Complete healing within 3–5 days with no scarring
Superficial partial-thickness (second degree)	Brief exposure to flame, flash, or hot liquids	Destruction of epidermis, superficial damage to papillary layer of dermis, epidermal appendages intact	Moist, weepy, blanching on pressure, blisters, pink or red color, sensate	Complete healing within 14–21 days with no scarring
Deep partial-thickness (deep second degree)	Exposure to flame, scalding liquids, or hot tar	Destruction of epidermis, damage to reticular layer of dermis, some epidermal appendages intact	Pale and less moist; no blanching or prolonged, deep pressure sensation intact, pinprick sensation absent	Prolonged healing time usually >21 days with scarring. Skin grafting may be necessary for improved functional and esthetic outcome
Full-thickness (third degree)	Prolonged contact with flame, steam, scalding liquids, hot objects, chemicals, or electrical current	Complete destruction of epidermis, dermis and, epidermal appendages; injury through most of the dermis	Dry, leathery, pale, mottled brown or red in color; visible thrombosed vessels insensitive to pain and pressure	Requires skin grafting
Full-thickness (fourth degree)	Major electrical current, prolonged contact with heat source (i.e., unconscious patient)	Complete destruction of epidermis, dermis, and epidermal appendages; injury involving connective tissue, muscle, and bone	Dry, black, mottled brown, white or red; no sensation and limited movement of burned limbs or digits	Requires skin grafting and likely amputation

27.3.2 Local Damage

Local, burn wound damage varies, depending upon the temperature of the agent, duration of contact time, and the type of tissue involved. The deepest zone of damage, coagulation (full-thickness), is the site of irreversible cell death, where blood vessels and re-epithelializing cells have been completely destroyed. These areas require skin grafting for permanent coverage. The middle layer, or zone of stasis, is the area of deep, partial-thickness injury where there are some skin-reproducing cells present in the dermis and circulation to the area is partially intact. Healing will occur generally within 14–21 days, as long as infection or desiccation is prevented. The outermost zone of hyperemia is the area of least damage. This superficial, partial-thickness wound has minimal cell involvement and will generally recover spontaneously within 7–10 days. Areas of partial-thickness injury , devoid of infection and desiccation, will heal by primary intention from the edges of the wound and from below. Full-thickness wounds require early excision and skin grafting. Over time, the collagen fibers and re-epithelializing cells continue to heal and add strength to the newly formed tissue. The healed areas initially look pale and flat. However, as the blood supply increases to those areas over the next month or so, they become red and raised. In addition to these scars forming, there is a natural tendency for burned tissue to shorten and contractures to develop. Over the next year to 18 months, the burn scars will fully mature and become less red and less raised [22, 23].

27.3.3 Fluid and Electrolyte Shifts

The immediate post-burn period is marked by dramatic circulation changes, producing what is known as “burn shock” (Fig. 27.5). Blood flow increases to the area surrounding the wound. The burned tissue then releases vasoactive substances, which results in increased capillary permeability. As early as 15 min post-injury, there is a shift of fluid from the intravascular compartment to the interstitial space, producing edema, decreased blood volume, and hypovolemia. There is also insensible fluid loss through evaporation from large, open body surfaces. A non-burned individual loses about 30–50 mL/h. A severely burned patient experiences intravascular volume depletion, with fluid loss anywhere from 200 to 400 mL/h. Following successful completion of the fluid resuscitation phase, capillary membrane permeability is restored. Fluids gradually shift back from the interstitial space to the intravascular space. The patient is no longer grossly edematous and diuresis is ongoing.

27.4.1 Thermal

Thermal injuries are caused by dry heat, such as flame and flash, moist heat, such as steam and hot liquids, and direct contact, such as hot surfaces and objects (Table 27.4). Thermal burns are a major source of morbidity and mortality across all age groups (Figs. 27.6 and 27.7).

Table 27.4

Causes of thermal burns

Cause	Examples
Dry heat—Flame	• Clothing catches on fire • Skin exposed to direct flame
Dry Heat—Flash	• Flame burn associated with explosion (combustible fuels)
Moist Heat—Hot liquids (scalds)	• Bath water • Beverages—coffee, tea, soup • Cooking liquids or grease
Moist Heat—Steam	• Pressure cooker • Microwaved food • Overheated car radiator
Contact—Hot surfaces	• Oven burner and door • Barbecue grill
Contact—Hot objects	• Tar • Curling iron • Cooking pots/pans • Heating pad • Hot water bottle

27.4.2 Chemical

The types of chemical injuries seen are usually related to the geography, industry, and culture of the local population. There are more than 25,000 chemicals in the world and most can be divided into two major groups: acids and alkalis. Necrotizing substances in the chemicals cause tissue injury and destruction (Fig. 27.8). Acids, in general, cause coagulation necrosis with protein precipitation. Alkalis produce liquefaction necrosis with loosening of the tissue, which allows the alkali to diffuse more deeply into the tissues. Therefore, on a volume-to-volume basis, alkaline material can produce far more tissue damage than acids. The extent and depth of a chemical injury is directly proportional to the amount, type and strength of the agent, its concentration, extent of penetration, mechanism of action, and length of contact time with the skin. Chemicals will continue to destroy tissue until they are inactivated by reaction with tissues, are neutralized, or are diluted with water. The burning process may continue for variable and, often prolonged, periods of time (i.e., up to 72 h) after the initial contact with the chemical agent. It is important to remove the person from the burning agent as soon as possible and to begin copiously flushing the area with water—the solution to the pollution is dilution [24]. Neutralizing agents should not be used as they may produce additional tissue damage through heat production. Dry chemicals should be gently brushed off the skin before flushing begins. Most industries have detailed information on the chemicals their workers are exposed to and are required, by Occupational Health and Safety law, to have portable eyewash and shower stations for first aid use. Chemical burns to the eye require an ophthalmology consult, on admission, and late complications, such as corneal ulceration, secondary glaucoma, and cataracts, are fairly common and require follow-up. Ingestion of caustic materials may cause chemical burns to the oropharynx, tongue, esophagus, stomach, and duodenum. The patient should be given nothing by mouth, closely monitored and fluid resuscitated. Laryngeal edema may occur, producing upper airway obstruction. Endotracheal intubation or tracheostomy may be required to maintain airway patency.

27.4.3 Electrical

Electrical injuries comprise a small portion of the burn population, but the outcomes can be devastating, including deep tissue damage and potential loss of one or more limbs (Fig. 27.9). Injuries occur mainly in males and are usually occupation related. When electrical current passes through the body, intense heat is generated and coagulation necrosis results. The severity of the electrical injury is determined by the type and voltage of the circuit (whether alternating current—AC or direct current—DC), amperage of the current, resistance of the body, pathway of the current, and duration of contact. Electrical current takes the path of least resistance through the body. Least resistance is offered by nerves and blood vessels, whereas bone and fat offer the most resistance. If major body organs, such as the heart, brain, or kidneys are involved, the damage is more profound than if the current only passed through tissue. In some situations, electrical sparks may ignite the person’s clothing, causing a flame burn, in addition to the electrical injury. If there is an explosion at an electrical panel and the clothing catches fire, but no electricity passes through the body, it is termed an electrical flash burn, not an electrical burn. It is an important distinction to make in the early hours post-injury. The severity of an electrical injury can be difficult to determine as most of the damage may be below the skin at the level of muscle, fat, and bone. This phenomenon is referred to as the “iceberg” effect. Contact points, produced at the time of the injury, may help determine the probable path of the current and potential areas of injury. The history of the event can provide valuable clues as to what actually transpired at the accident scene. Many electrical injuries occur when a worker is suspended from an aerial basket or ladder and makes contact with a live wire. If the person has fallen post-injury, precautions to protect the head and cervical spine must be taken during transport. Spinal X-rays and neurological assessment are necessary, following admission to hospital. Contact with electrical current can cause tetanic muscle contractions that may produce long bone and vertebral fractures.

The person, who has sustained an electrical burn injury, may have also experienced cardiac arrhythmias or asystole post-injury. Immediate CPR is essential following cardiac arrest. He/she then continues to be at risk for cardiac arrhythmias for 24 h post-burn and must be monitored and have an electrocardiogram performed on admission to hospital.

Severe metabolic acidosis develops shortly after the injury occurs because of extensive tissue destruction and cell rupture. Assessment includes arterial blood gas analysis and, if needed to maintain normal serum pH levels, infusions of sodium bicarbonate. The kidneys also need to be closely monitored because of potentially high circulating levels of hemoglobin from damaged red blood cells and myoglobin from damaged muscle. In small amounts, the kidney tubules can filter them sufficiently. In larger concentrations, however, there is a significant risk of developing acute tubular necrosis and possible renal failure. Treatment consists of the early initiation of Lactated Ringer’s solution at a rate that maintains a good urinary output of between 75 and 100 mL/h until the color of the urine is sufficient to suggest adequate dilution. In addition, an osmotic diuretic (e.g., mannitol) is usually given to establish and maintain acceptable urinary output.

27.4.4 Smoke and Inhalation Injury

In combination with a major burn, the presence of an inhalation injury can seriously increase mortality rates. Signs and symptoms of suspected, smoke inhalation include deep facial burns, history of being trapped in an enclosed space, and a laryngoscopic examination showing vocal cord swelling (Fig. 27.10). The most critical period for patients with inhalation injuries is 24–48 h post-burn. The airway becomes edematous and there is increased airway resistance. The respiratory mucosa sloughs, along with loss of ciliary function and poor diffusion of gases.

27.5.1 Subjective Symptoms

It is essential, throughout all phases of a burn patient’s recovery, to seek out his/her perspective, when possible, and attempt to incorporate individual wishes into the plan of care. During the emergent period, patients and their families are likely in a state of physical and psychological shock. As a result of hypoxia, patients may also be disoriented or not able to recall what happened. Others remain very lucid throughout the ordeal and recall events with remarkable clarity. Some may not realize how serious their injuries are and be unrealistic about the care they require. Others may be intubated and sedated and not be aware for weeks to come. Pain may be a concern, while some may experience little discomfort. Thirst may be a symptom, depending upon the degree of fluid loss.

Some may complain of feeling cold or shiver as a result of heat loss, anxiety, and pain. The combination of hypovolemic shock, facial edema, intubation, and analgesics/sedative agents may alter a patient’s sensory perception significantly over the first few days post-injury. If he/she is able to talk, common themes include “Will I die? What happened? Why me? I can’t believe this is happening.” In the acute phase, patients may experience varying levels of pain during dressing changes and physical/occupational therapy and might describe significant muscular discomfort, resulting from functional positioning and use of splinting materials. Unable to do any number of self-care activities, patients may become very frustrated about how dependent they have become on others. Concerns may be expressed regarding finances, family, and work obligations. Adaptation to the hospital environment and necessary treatments may absorb a considerable amount of the patient’s physical and emotional energy. Adjustment to a variety of losses (personal and property), feelings of grief, guilt and blame, a need for information about what to expect over the coming weeks, and a search for meaning behind the event, are also experienced. Patients may feel angry or depressed post-injury. Relationships with family may become strained as everyone seeks to readjust and cope with this unexpected and traumatic event. During the rehabilitative phase of care, patients come to realize that they have completed the most difficult part of their recovery. However, many experience impatience with the time required for complete healing and physical rehabilitation. There is usually a desire to resume as much independence as possible, sometimes coupled with slight fear and hesitation about leaving the protective environment of the burn center. Questions, such as “What will it be like when I leave the hospital? How will I manage when the nurses and therapists are no longer around to help?” reflect the primary concerns for patients and family members at this time. There may be concerns about resumed sexual intimacy with a partner and self-acceptance of an altered body image. A request may be made to speak with a recovered burn survivor, who can offer words of support and advice based on personal experience. Over time, burn patients express feelings of pride at having overcome such tremendous physical and emotional challenges and begin to reflect on the path their lives will take post-burn as they move from burn “victim” to “survivor” and, perhaps, burn “thriver.”

27.5.2 Objective Signs

The initial assessment of the burn patient is like that of any trauma patient and can best be remembered by the simple acronym “ABCDEF” (Box 27.2). Recently, recommendations for burn care management have been published to address the educational needs of both non-burn and burn specialists around the world [25, 26]. During the emergent period, burn patients quickly begin to exhibit signs and symptoms of hypovolemic shock (Box 27.3). Lack of circulating fluid volumes will also result in minimal urinary output and absence of bowel sounds. The patient may also be shivering due to heat loss, pain, and anxiety. If inhalation injury is a factor, the patient may demonstrate a number of physical findings upon visual assessment, laryngoscopy, and fiberoptic bronchoscopy (Box 27.4). The patient likely experiences pain, as exhibited by facial grimacing, withdrawing, and moaning when touched, particularly if the injuries are partial-thickness in nature. Some areas of full-thickness burn may be anesthetic to pain and touch, if the nerve endings have been destroyed. The loss of sensation may be temporary if the nerves have been compressed by resulting edema in the hypovolemic shock phase. It is important to examine areas of circumferential full-thickness burn for signs and symptoms of vascular compromise, particularly the extremities (Box 27.5).

Areas of partial-thickness burn appear reddened, blistered, and edematous. Full-thickness burns may be dark red, brown, charred black, or white in color. The texture is tough, leathery, and no blisters are present.

If the patient is confused, health care professionals need to determine if it is the result of hypovolemic shock, inhalation injury, substance abuse, pre-existing history or, more rarely, head injury sustained at the time of the trauma. It is essential to immobilize the c-spines until a full assessment can be performed and the c-spines cleared. At this time, a secondary survey assessment is performed (Box 27.6). Additional objective data can then be collected, analyzed, and a plan of care developed, which includes a set of Admission Orders. In the acute phase, the focus is on wound care and prevention/management of complications. At this point, the burn wounds should have declared themselves as partial-thickness or full-thickness in nature. Eschar on partial-thickness wounds is thinner and, with dressing changes, it should be possible to see evidence of eschar separating from the viable wound bed. Healthy, granulation tissue is apparent on the clean wound bed, re-epithelializing cells are seen to migrate from the wound edges, and the dermal bed will slowly close the wound within 10–14 days. Full-thickness wounds have a thicker, leathery eschar, which does not separate easily from the viable wound bed. Those wounds require surgical excision and grafting. Continuous assessment of the patient’s systemic response to the burn injury is an essential part of an individualized plan of care. Subtle changes, quickly identified by the burn team, can prevent complications from occurring or worsening over time. Physical examination by burn team staff and specialist consultants, laboratory tests, and diagnostic procedures will assist in the rapid identification and treatment of complications.

During the final, rehabilitative phase, attention turns to scar maturation, contracture development, and functional independence issues [27–29]. The areas of burn, which heal either by primary intention or skin grafting, initially appear red or pink and are flat. Layers of re-epithelializing cells continue to form and collagen fibers in the lower scar tissue add strength to a fragile wound. Over the next month, the scars may become more red from increased blood supply and more raised from disorganized whorls of collagen and fibroblasts/myofibroblasts. The scars are referred to as hypertrophic in nature. If oppositional forces are not applied through splinting devices, exercises, or stretching routines, this new tissue continues to heal by shortening and forming contractures. A certain amount of contracture development is unavoidable, but the impact can be lessened through prompt and aggressive interventions.

The scar maturation process takes anywhere from 6 to 18 months. During this time, the scars will progress from a dark pink/red to a pale pink/whitened appearance. The final color is usually lighter than the surrounding unburned skin. For people with darkly pigmented skin, the process of color return may be prolonged as the melanocytes work to produce pigment in the areas where it has been lost [30]. Increasing amounts of pressure may be necessary to gently and continually flatten the scars which, in turn, push the extra blood from the area, making them lighter in color. Custom-fitted pressure garments and/or acrylic face masks apply constant pressure over a gradual wearing period of up to 23½ h a day [31]. Extra pressure over concave and difficult-to-fit areas can be provided through elastomer inserts or silicone sheeting under the garments or face mask [32]. The length of time a person might have to wear the garments varies, but is in the range of 1–1½ years, depending upon the intensity of the scarring and the body’s response to pressure therapies. Patients will often experience itchiness and dry skin [33]. One of the best ways to decrease the itchiness is to get at the source of the problem: the dry skin. However, burned skin is different from healthy skin. Once the skin has been damaged by a burn injury, there are less natural oils available since the oil-reproducing glands have been destroyed, in whole or in part. In other words, the skin is “internally” dry as opposed to “externally” dry, such as when hands get chapped in the cold weather. Burned skin benefits from products that will be absorbed through the outer layer of the epidermis into the dry, dermal tissues. Water-based products do this. The more predominant products available are oil-based and contain mineral oil, petrolatum or paraffin. These ingredients coat the surface of the skin and, in essence, block the pores. This prevents loss of natural oils from the dermis, oils which burned skin is lacking. These ingredients are not absorbed into the dry dermis and do not bring moisture back into the skin. Mineral oil also breaks down elastic fibers in pressure garments and should be avoided. Suggested water-based products include Vaseline^® Intensive Care Advanced Repair or Smith and Nephew’s Professional Care^®. Medications, such as diphenhydramine (<Atarax>, <Benadryl>), gabapentin (<Neurontin>), or pregabalin (<Lyrica>) can also be ordered to help with moderate to severe itchiness on a short-term basis, as can massage therapy.

27.8.1 Non-surgical Care

Therapeutic management of the burned person is conducted within these same three phases of burn recovery—emergent, acute, and rehabilitative. The emergent phase priorities include airway management, fluid therapy, and initial wound care. The goals of care are initial assessment, management, and stabilization of the patient during the first 48 h post-burn.

Assessment: During the rapid, primary survey, performed soon after admission, the airway and breathing assume top priority. Particularly with a large body surface area burn admission, some staff may feel a tendency to be overwhelmed by the sight and smell of the burn wound. The wounds are, however, a much lower priority than the airway. A compromised airway requires prompt attention and breath sounds verified in each lung field. If circumferential, full-thickness burns are present on the upper trunk and back, ventilation must be closely monitored as breathing might be impaired and releasing escharotomies necessary. The spine must be stabilized until c-spines are cleared. The circulation is assessed by examining skin color, sensation, peripheral pulses, and capillary filling. Circumferential, full-thickness burns to the arms or legs need to be assessed via palpation or Doppler for evidence of adequate circulation. Escharotomies might be required. Typically, burn patients are alert and oriented during the first few hours post-burn. If that is not the case, consideration must be given to associated head injury, (including a complete neurological assessment), substance abuse, hypoxia, or pre-existing medical conditions. All clothing and jewelry need to be removed in order to visualize the entire body and avoid the “tourniquet-like” effect of constricting items left in place as edema increases. Adherent clothing needs to be gently soaked off with normal saline to avoid further trauma and unnecessary pain. Attention then turns to prompt fluid resuscitation to combat the hypovolemic shock. The secondary, head-to-toe survey then rules out any associated injuries. A thorough assessment ensures all medical problems are identified and managed in a timely fashion. Circumstances of the injury should be explored as care can be influenced by the mechanism, duration, and severity of the injury. The patient’s pertinent medical history includes identification of pre-existing disease or associated illness (cardiac or renal disease, diabetes, hypertension), medication/alcohol/drug history, allergies, and tetanus immunization status. A handy mnemonic can be used to remember this information (Box 27.7).

Management: The top priority of care is to stop the burning process (Box 27.8). During the initial first aid period at the scene, the patient must be removed from the heat source, chemicals should be brushed off and/or flushed from the skin, and the patient wrapped in a clean sheet and blanket ready for transport to the nearest hospital. Careful, local cooling of the burn wound with saline-moistened gauze can continue as long as the patient’s core temperature is maintained and he/she does not become hypothermic. Upon arrival at the hospital, the burned areas can be cooled further with normal saline, followed by a complete assessment of the patient and initiation of emergency treatment (Box 27.9). In a burn center, the cooling may take place, using a cart shower system, in a hydrotherapy room (Fig. 27.12). The temperature of the water is adjusted to the patient’s comfort level, but tepid is usually best, while the wounds are quickly cleaned and dressings applied.

Airway management includes administration of 100% oxygen if burns are 20% body surface area or greater. Suctioning and ventilatory support may be necessary. If the patient is suspected of having or has an inhalation injury, intubation needs to be performed quickly. Circulatory management includes intravenous infusion of fluid to counteract the effects of hypovolemic shock for adult patients with burns >15% body surface area and children with burns >10% body surface area. Upon admission, two large bore, intravenous catheters should be inserted, preferably into unburned tissue. However, if the only available veins are in a burned area, they should be used. Patients who have large burns, where intravenous access will be necessary for a number of days, benefit from a central venous access device inserted into either the subclavian, jugular, or femoral vein. The overall goal is to establish an access route that will accommodate large volumes of fluid for the first 48 h post-burn. The aim of fluid resuscitation is to maintain vital organ function, while avoiding the complications of inadequate or excessive therapy. Fluid calculations are based on the extent of the burn, the weight and age of the patient, pre-burn conditions (dehydration), or pre-existing chronic illnesses (respiratory, renal). The most commonly used fluid resuscitation regimen is the Parkland (Baxter) formula (Box 27.10). It involves the use of crystalloid (Lactated Ringer’s) solution. Fluids are calculated for the first 24 h post-burn with “0” hours being the time of the burn, not the time of admission to hospital. One-half of the 24 h total needs to be administered over the first 8 h post-burn as this is the period during which extravasation of fluid into the interstitial space is greatest, along with the risk of renal tubule blockage from hemoglobin and myoglobin pigments. The remaining half of the estimated resuscitation volume should be administered over the subsequent 16 h of the first post-burn day. It is important to remember that the formula is only a guideline. The infusion needs to be adjusted based on the patient’s clinical response, which includes vital signs, sensorium, and urinary output. For adults, 30–50 mL urine per hour is the goal and 1 mL/kg/h in children weighing less than 30 kg. An indwelling urinary catheter needs to be inserted at the same time as the IVs are established in order to reliably measure the adequacy of the fluid resuscitation. Vital signs should be trending around a systolic BP of ≥90–100 mgHg, a pulse rate of ≤120 for the older child/adult, <140 bpm in the child between 2 and 5 years of age and <160 bpm in the child under 2 years of age, with respirations at 16–20 breaths/min. The patient’s sensorium should be such that he/she is alert and oriented to time, person, and place. An exception is made regarding the sensorium assessment for the intubated patient. During the second 24 h post-burn, the need for aggressive fluid resuscitation is generally less as capillary permeability begins to return to normal. Colloids, such as albumin, can be given as volume expanders to replace lost protein and minimize ongoing fluid requirements. Earlier administration of colloid would result in leakage out of the vascular space because of the increased capillary permeability. Some patients require extra fluid above and beyond the formula guidelines in order to produce satisfactory urinary output, stabile vital signs, and an adequate sensorium. They include those with (a) high-voltage injury, (b) inhalation injury, (c) delayed resuscitation, or (d) prior dehydration. Those patients with a high-voltage injury require administration of a diuretic to produce a urinary output of 75–100 mL/h in order to clear the tubules of hemoglobin and myoglobin pigments. The usual choice is Mannitol 12.5 g/L of fluid. Since the heme pigments are more soluble in an alkaline medium, sodium bicarbonate can be added to the resuscitation fluid as needed to maintain a slightly alkaline urine. Patients with severe inhalation injury and body surface area burns may require 40–50% more fluid in order to achieve adequate tissue perfusion. The need for extra fluid must be balanced against the risk of pulmonary edema and “fluid creep”/overload. There are others who are considered “volume sensitive.” They are (a) ≥50 years of age, (b) ≤2 years of age, or (c) have pre-existing cardiopulmonary or renal disease. Particular caution must be exercised with these patients.

Wound care. Once a patent airway, adequate circulation, and fluid replacement have been established, attention can turn to wound care and the ultimate long-term goal of wound closure. Such closure will halt or reverse the various fluid/electrolyte, metabolic and infectious processes associated with an open burn wound. The burns are gently cleansed with normal saline, if the care is being provided on a stretcher or bed. If a hydrotherapy cart shower or immersion tank are used, tepid water cleans the wounds of soot and loose debris (Fig. 27.13).

Sterile water is not necessary. Chemical burns should be flushed copiously for at least 20 min, preferably longer. Tar cannot be washed off the wound. It requires numerous applications of an emulsifying agent, such as mineral oil, Tween 80^®, Medisol^®, or Polysporin^® ointment. After several applications, the tar will have been removed without unnecessary trauma to healthy tissue. During hydrotherapy, loose, necrotic tissue (eschar) may be gently removed (debrided) using sterile scissors and forceps. Hair-bearing areas that are burned should be carefully shaved, with the exception of the eyebrows. This serves to minimize the accumulation of organisms. Showering or bathing should be limited to 20 min in order to minimize patient heat loss and physical/emotional exhaustion. More aggressive debridement should be reserved for the operating room, unless the patient receives conscious or deep sedation. After the initial bath or shower, further decisions are made regarding wound care. There are three methods of treatment used in caring for burn wounds. The goals of any topical agent should include: elimination of pain from environmental factors, barrier to environmental flora, reduction in evaporative losses, absorption/containment of drainage, delay/minimization of wound colonization, ability to penetrate eschar, and provision of splinting to maintain a position of function. In the open method, the wound remains exposed, with only a thin layer (2.0–4.0 mm) of topical antimicrobial ointment spread on the wound surface using a sterile gloved hand or applicator. With the closed method, a dressing is left intact for 2–7 days. The frequency of dressing changes depending on the condition of the wound and the properties of the dressing employed. The choice of treatment method varies among institutions and also according to the severity of the burn wound. All treatment approaches have certain objectives in common (Table 27.6). In the emergent phase, wounds may be treated with a thin layer of topical antimicrobial cream. Topical coverage is selected according to the condition of the wound, desired results, properties of the topical agent (Table 27.7), availability and familiarity by the burn team.

Table 27.6

Objectives of burn wound care

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