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Surgical Management of Complications of Burn Injury

Introduction Various surgical complications can occur in burn patients resulting from pathologic progression of the burn injury itself or from iatrogenic etiologies. Multiple organ system injuries can exist that require both a thorough assessment and expeditious management according to advanced trauma life support (ATLS) guidelines. Patients with large (>30% of the total body surface area [TBSA]) burns generally require a prolonged hospital stay with numerous debridement…

Care of Geriatric Patients

Introduction The quality of life in developed countries has improved over the past 50 years, increasing the average lifespan by nearly 30 years. Individuals aged 65 years and over account for 13% of the U.S. population. This “elderly” population is projected to double from 40.2 million in 2010 to 88.5 million by 2050. Such population aging is unprecedented. By 2050, the number of older adults persons…

Special Considerations of Age: The Pediatric Burned Patient

Introduction According to the National Burn Repository, burn injuries are responsible for 40,000 annual hospital admissions, of which one third are pediatric patients. Despite the steady decrease of burn injuries over the past three decades, children continue to represent a disproportionately high proportion of this population. The pattern of burn injuries affecting children differs from the pattern observed in adult burns. House fires are among the…

Care of the Burned Pregnant Patient

Introduction Approximately 8% of women experience trauma during their pregnancies. Trauma in pregnancy is the most common cause of nonobstetric-related death; more generally, trauma is the leading cause of death in the age group under 40 in the United States. Women in their reproductive years are the population at the greatest risk of trauma. While it is rare to see a pregnant woman in the burn…

Burn Nursing

Introduction The bedside nurse caring for the severely burned patient is given more responsibility than in most types of serious illness. It is extremely important that the nurse be an integral part of the team of people caring for the burned patient. This is as important when modern burn care began as it is today. Care begins with the immediate resuscitation of the patient in the…

Critical Care in the Severely Burned: Organ Support and Management of Complications

Introduction Approximately 4000 burn victims die each year from complications related to thermal injury. Burn deaths generally occur in a bimodal distribution, either immediately after the injury or weeks later due to multisystem organ failure (MOF), a pattern covered in Chapter 30 . Recent reports reveal a 50% decline in burn-related deaths and hospital admissions in the United States over the previous 20 years. In 1949,…

Acute Renal Failure in Association with Thermal Injury

Introduction Acute renal dysfunction represents a critical complication of an acute thermal injury and is associated with a significant increase in morbidity and mortality. Currently, the incidence of acute renal failure (ARF) in burn patients varies between 0.5% and 30%, and the risk of mortality associated with renal failure in burn patients has been reported to be as high as 54–100%. Prior to 1965, there were…

Etiology and Prevention of Multisystem Organ Failure

Introduction Burn trauma begins via a cutaneous thermal injury with or without an inhalation injury. These local primary injuries initiate a series of pathophysiologic cascades previously discussed. Fluid shifts into thermally damaged tissue as well as global endothelial activation; glycocalyx damage and systemic inflammation cause burn edema. The resultant distributive shock combines with humorally mediated myocardial suppression to induce burn shock requiring fluid resuscitation. Immune hyperactivation,…

Modulation of the Hypermetabolic Response after Burn Injury

Introduction A severe burn elicits a stress response that initially assists the body in compensating for and adapting to a traumatic injury. There is an elevation in circulating concentrations of catecholamines such as epinephrine and norepinephrine alongside a concurrent increase in inflammatory cytokine production. This stress response is also associated with a significant increase in metabolic rate. Altered protein and glucose metabolism are key factors contributing…

Nutritional Needs and Support for the Burned Patient

Introduction The massive burn is as much a metabolic insult as it is a tissue injury. Clearly resultant tissue defects represent the critical factor in long-term functional complications from massive burns. In the acute phase of burn care, a persistent, overwhelming metabolic response to thermal injury compromises the functional integrity of virtually every organ system. This response compromises wound healing capacity and the integrity of the…

Hypophosphatemia

Certain humoral and metabolic responses to thermal and mechanical trauma that maintain homeostasis and prevent cellular dysfunction also produce alterations in electrolyte balance. An example is renal retention of sodium during the resuscitative phase of burn injury, which alters sodium balance in the course of preserving intravascular volume. Despite the markedly increased cardiac output and renal plasma flow that occur in the subsequent flow phase, a…

Micronutrient Homeostasis

Importance of Vitamins and Trace Elements Essential vitamins and trace elements, which are globally known as “micronutrients,” are fundamental to metabolism; they function as structures of enzymes or as their cofactors. Their requirements are influenced by the metabolic state and by increased nutritional needs after major burns. The first publications about elevated vitamin requirements go back to the 1940s and of trace elements to the 1960s.…

Importance of Mineral and Bone Metabolism after Burn

Metabolic Actions of Calcium, Phosphate, and Magnesium As insoluble elements, minerals are major inorganic components of bone tissue and confer weight-bearing properties to the skeleton. Soluble calcium (Ca), phosphate (PO 4 ), and magnesium (Mg) play important roles in metabolic pathways, acting as cofactors and regulators of numerous biochemical systems. Calcium Calcium functions in neurotransmission, cell depolarization, impulse propagation, and muscle contractility. In intracellular pathways, after…

The Hepatic Response to Thermal Injury

Introduction The extreme hypermetabolic and hypercatabolic stress responses induced by a severe burn injury are characterized by increased proteolysis, lipolysis, and production of endogenous glucose via glycogenolysis and gluconeogenesis. The critical organ controlling these processes is the liver. With major roles in metabolism, inflammation, immunity, and the acute-phase response, the liver orchestrates the basic functions that modulate survival and recovery in severely burned patients. The function…

Significance of the Hormonal, Adrenal, and Sympathetic Responses to Burn Injury

Introduction The endocrine system is central to coordinating the systemic response to burn trauma ( Table 23.1 ). Pathological and compensatory changes are seen in the hypothalamic-pituitary-adrenal (HPA) axis, thyroid, pancreatic, and gonadal hormonal secretions. These changes act in concert with the humoral effects of cytokines and immunological mediators discussed in the chapters on burn edema ( Chapter 8 ) and multisystem organ failure ( Chapter…

Hematology, Hemostasis, Thromboprophylaxis, and Transfusion Medicine in Burn Patients

Introduction Severe burn injury causes a myriad of hematologic perturbations. Burn excision as well as substantial in-hospital phlebotomy causes severe blood loss anemia and even hemorrhagic shock, requiring substantial transfusion. Large-scale fluid resuscitation and shock cause a significant coagulopathy. Surgical extirpation can similarly cause a significant dilutional coagulopathy requiring transfusion. Hematopoiesis, the generation of new blood cells, is directed away from red blood cell (RBC) production…

Biomarkers in Burn Patient Care

Introduction Each year, more than 8 million people are burned. Approximately 1 million sustain severe burn injuries covering more than 30% of the total body surface area (TBSA). Burns cause considerable morbidity and mortality; burn injuries are often complicated by inhalation injury, infections, and sepsis, all of which can lead to systemic inflammation, acute respiratory distress syndrome (ARDS), multiple organ dysfunction (MODS), and death. Despite advances…

Host Defense Antibacterial Effector Cells Influenced by Massive Burns

Introduction Infectious complications are one of the leading causes of death in patients with severe burn injuries. Increases in the total body surface area and depth of burn injuries correlate with the excessive risk of infectious complications. Burn patients are commonly treated with many components such as fluid resuscitation, wound excision, grafting and coverage, infection control, and nutritional support. Progress in each treatment has contributed significantly…

The Systemic Inflammatory Response Syndrome

Introduction Burn patients, with or without inhalation injuries, commonly exhibit a clinical picture that is largely produced by systemic inflammation. The term systemic inflammatory response syndrome (SIRS) was introduced to designate the signs and symptoms of this condition. SIRS has a continuum of severity ranging from physiologic alterations such as tachycardia, tachypnea, fever, and leukocytosis to refractory hypotension and, in its most severe form, shock and…

Respiratory Care

Introduction The multitude of respiratory complications caused by smoke inhalation, flame burns, and their treatment epitomize the clinical challenges that confront health care workers. Smoke inhalation injury and its sequelae impose demands on the practitioners who play a central role in its clinical management. These demands may range from intubation and resuscitation of victims in the emergency room to assistance with diagnostic bronchoscopies, performance of pulmonary…