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Acs0714 Management Of The Patient With Thermal Injuries
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    Acs0714 Management Of The Patient With Thermal Injuries Acs0714 Management Of The Patient With Thermal Injuries Document Transcript

    • © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 14 MANAGEMENT OF THE PATIENT WITH THERMAL INJURIES — 1 14 MANAGEMENT OF THE PATIENT WITH THERMAL INJURIES Nicole S. Gibran, M.D., F.A.C.S., and David M. Heimbach, M.D., F.A.C.S. Optimal care of the burn patient requires not only specialized cleaned with sterile saline. In fact, burns can be effectively washed equipment but also, more important, a team of dedicated sur- during a daily shower or bath with regular tap water and nonper- geons, nurses, therapists, nutritionists, pharmacists, social work- fumed soap. A second misconception is that the patient must ers, psychologists, and operating room staff. Burn care was one of scrub the wound to debride all the superficial exudates. Simply the first specialties to adopt a multidisciplinary approach, and over wiping the wound with a soapy washcloth to remove the topical the past 30 years, burn centers have decreased burn mortality by ointment and wipe away the bacteria that have accumulated over coordinating prehospital patient management, resuscitation meth- the past day provides adequate care. Intact blisters can be left as a ods, and surgical and critical care of patients with major burns. protective wound cover if they do not prevent movement of a joint. Detailed practice guidelines for burn patients, as well as lists of the Dressings must allow full range of motion. resources needed in a burn center, have been developed.1,2 Physical therapy is an essential component of burn manage- ment. A common misconception is that burns over joints should be immobilized to promote healing. Actually, immobilization of Where to Treat Burn Patients extremities leads to swelling, which worsens burn wound pain and Patients with critical burns, as defined by the American Burn increases the risk of wound infection. Patients with hand burns Association [see Table 1], should be transferred to a specialized must be taught exercises to maintain range of motion. Likewise, burn center as soon as possible after their initial assessment and patients with foot burns must ambulate without assistive devices, resuscitation. A community general or plastic surgeon with an so that normal muscle contraction can facilitate lymphatic interest in burns could manage moderate burns that do not drainage of the lower extremity. Patients must be taught to elevate involve functionally significant body sites. However, even patients burned extremities when they are not actively exercising. with small burns benefit from the expertise of a specialized burn Inadequate pain management is a frequent reason for return care team. Furthermore, the burn center’s focused approach facil- visits to the emergency department or readmission to the hospital. itates patient and family education, reentry into society, long-term Often, inadequate pain control results from poor patient under- rehabilitation needs, and reconstructive surgical needs. standing of how to care for the burn (e.g., excessive scrubbing dur- ing wound care or inactivity and subsequent swelling). Although a OUTPATIENT VERSUS INPATIENT MANAGEMENT healing partial-thickness burn may become more painful as the Outpatient management may be appropriate for small burns epithelial buds begin to emerge and healing progresses [see 7:15 (1% to 5% of total body surface area [TBSA]) that do not involve Management of the BurnWound], an acute increase in stinging pain joints or vital structures. However, successful outcomes in such may be the first sign of a superficial wound infection. This is an cases require a well-organized plan and clear communication with indication that the burn should be evaluated for signs of infection, the patient and family. Many outpatient management plans fail including erythema and breakdown of a previously epithelized because insufficient teaching during a short visit to an emergency wound; cellulitis may or may not surround an infected burn. department leads to inadequate pain control, wound infection, Systemic antibiotics and a change in the topical antimicrobial and limited movement. agent are indicated in this situation. Three important reasons for hospitalizing a patient with a burn Socioeconomic issues can be important contraindications to injury are wound care, physical therapy, and pain management. A short hospital stay immediately after the injury gives the burn team the opportunity to teach the patient how to properly clean and dress the burn; this is especially important for burns to the extrem- Table 1 American Burn Association Criteria ities. A therapist should assess patient movement and educate the for Burn Injuries That Warrant Referral patient about expected activity levels and exercise programs. to a Burn Unit Background pain (pain experienced with ordinary daily activities) and procedural pain (pain experienced during wound care) should Partial-thickness burns of greater than 10% of total body be carefully assessed, and analgesic medications should be titrated surface area to the individual patient’s pain levels. Third-degree burns Electrical burns, including lightning injury Complex burn wound management is discussed in detail else- Chemical burns where [see 7:15 Management of the Burn Wound]. For outpatient Inhalation injury management, however, simplicity is the key to success. Patients Burn injury in patients with preexisting medical disorders that could and their families are unlikely to manage complicated dressing complicate management, prolong recovery, or increase mortality plans. For outpatient burn care, once-daily dressing changes are Burns with concomitant trauma adequate. A common misconception is that these wounds must be
    • © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 14 MANAGEMENT OF THE PATIENT WITH THERMAL INJURIES — 2 Table 2 Criteria for Outpatient Management mate of need; individual patients may have higher or lower fluid of Burn Patients requirements, depending on their overall condition and comor- bidity. Continuous monitoring and reliance on objective clinical Outpatient Management Outpatient Management outcomes must dictate patient management. Appropriate Inappropriate The reliability of the Parkland formula directly depends on accurate assessment of burn depth and percentage of TBSA Abused patients affected.5 There are two formulas for quick estimation of burn Demented patients size. One is the commonly used Rule of Nines: each arm is con- Patients with small burns* who have demonstrated understanding of Intoxicated patients sidered to be 9% of TBSA, each leg 18%, the anterior trunk 18%, wound care, pain control, and Homeless patients therapy the posterior trunk 18%, and the head 9% [see Figure 1]. Another Patients with comorbid conditions Patients with a language barrier easy method involves using the patient’s full palm, including digits, to represent 1% of TBSA. First-degree burns [see 7:15 *1%–5% of total body surface area. Management of the BurnWound] should not be included in the cal- culation of burned areas. Despite improvements in invasive monitoring techniques, the outpatient management of a burn wound [see Table 2]. Any sug- most reliable measures of adequate tissue perfusion for burn gestion of abuse—of a child or an adult—mandates admission for resuscitation continue to be mean arterial pressure (MAP) and full evaluation of the home situation by the burn team; if the his- adequate urine output (UOP). MAP should be maintained above tory and the burn distribution are consistent with a nonacciden- 60 mm Hg to ensure adequate cerebral perfusion. For an other- tal injury or potential neglect, the patient must be referred to pro- wise healthy adult, a UOP of 30 ml/hr should be adequate; for a tective services. Likewise, suggestion of a self-induced burn injury child, 1.0 to 1.5 ml/kg/hr should suffice. No evidence supports the should trigger admission for psychological evaluation. For exam- use of pulmonary arterial (PA) catheter measurements for routine ple, the presence of multiple small cigarette burns in various phas- resuscitation; in fact, reliance on PA catheters may lead to over- es of healing is an absolute indication for admission to the hospi- resuscitation and contribute to the development of fluid-related tal for psychological evaluation, even though the burns themselves complications (see below). Use of diuretics and inotropes should may be easily cared for at home with small adhesive bandages. be restricted to patients with underlying comorbidity, especially Although language barriers are not an absolute indication for hos- preexisting cardiac disease. Use of inotropes will not stop the leak pital admission, there must be assurance that patients fully under- of plasma into the extravascular space but may lead to ischemia in stand the treatment plan before they leave the emergency depart- the wound, resulting in conversion of a partial-thickness wound ment. Underinsured and homeless patients may not have the into a full-thickness wound. Use of mannitol may be appropriate resources to care for a wound outside the hospital and should be for patients with myoglobinuria who require an osmotic diuretic admitted for initial wound care and planning for transfer to a facil- to maintain a UOP of 100 ml/hr [see 7:16 Miscellaneous Burns and ity where they have access to a daily shower. Finally, the success Cold Injuries]. of outpatient burn wound management depends on the ability to arrange a follow-up visit with an outpatient health care provider who can assess the outcome. For patients with large burns, transition from inpatient to out- patient status is based on the same principles listed above. When 9% burn pain can be controlled with oral medication and the patient and family can provide wound care, perform range-of-motion exercises, and manage splints and other assistive devices, outpa- tient management is appropriate. In some cases, daily or weekly 18% outpatient therapy sessions to maintain range of motion may be FRONT included. If there are concerns about nonhealing wounds, weekly follow-up visits with the burn surgeon may be indicated initially. 18% BACK Because of possible long-term sequelae—scarring, contractures, and rehabilitation difficulties [see 7:17 Rehabilitation of the Burn 9% 9% Patient]—the burn team should follow burn patients for 1 to 2 years after injury; longer follow-up may be necessary for patients 1% with persistent contractures and scar formation. Prolonged fol- low-up is especially important with young children, who may encounter difficulties as they grow and may therefore require peri- 18% 18% odic monitoring until adulthood. Figure 1 The size of a Fluid Management burn can be estimated by In the late 1960s, Charles Baxter developed objective criteria means of the Rule of for resuscitation of the thermally injured patient.3,4 The Baxter Nines, which assigns per- formula (also known as the Parkland formula) calls for the infu- centages of total body sion, over 24 hours, of 3 to 4 ml of crystalloid per percentage of surface to the head, the TBSA burned. Half of this volume is delivered during the first 8 extremities, and the front and back of the torso. hours after injury, and the other half is delivered over the subse- quent 16 hours. It is important to remember that this is an esti-
    • © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 14 MANAGEMENT OF THE PATIENT WITH THERMAL INJURIES — 3 Table 3 Acute Physiologic Changes during Burn Resuscitation Signs of Signs of Measurement Comment Goal Underresuscitation Overresuscitation Fluid input generally exceeds output during the early post- Urine output: adults, 30 ml/hr; Urine output > 30 ml/hr; hyper- Fluid volume children < 20 kg, 1.0–1.5 Low urine output osmolar diuresis from hyper- burn period as edema develops ml/kg/hr glycemia must be excluded An accurate dry weight is Weight will increase because Body weight necessary for estimation of intravascular leak and Massive weight gain from Weight approaches dry weight of resuscitation fluid resuscitation volume anasarca requirements Body temperature Hyperthermia may indicate a Normothermia — — hyperdynamic state Dysrhythmias are uncommon Dysrhythmias may reflect poor Electrocardiographic status in young patients but may Tachycardia may reflect Normal sinus rhythm oxygenation, electrolyte complicate management of intravascular contraction imbalance, or pH abnormality older patients Although the first 24 hours after a burn is usually considered the gested that 12% of patients would require more than 4.3 resuscitative phase of a burn injury, stabilization of the flux of medi- ml/kg/%TBSA resuscitation fluid, subsequent reports suggest that ators and closure of capillary leaks in fact take place on a continu- more than 55% of patients receive this amount of fluid.8 Excessive um, occurring gradually from 12 to 48 hours after the burn injury. fluid resuscitation increases the risk of complications, including As capillary leakage resolves, the amount of fluids needed to main- poor tissue perfusion, compartment syndrome involving the abdo- tain a MAP of 60 mm Hg and a UOP of 30 ml/hr should progres- men or extremities, pulmonary edema, and pleural effusion. sively decrease. A patient with both a large, deep burn and a pro- Abdominal compartment syndrome (ACS) is an increasingly found inhalation injury or a patient in whom resuscitation has been well-recognized posttraumatic complication that occurs in pa- delayed may require significantly more fluid than predicted by the tients who require extensive fluid resuscitation. Increased abdom- Parkland formula to maintain blood pressure and UOP. inal pressure decreases lung compliance and impedes lung expan- Colloid administration (albumin or fresh frozen plasma) after sion, resulting in elevated airway pressures and hypoventilation. the capillary leak has closed (12 to 72 hours) may facilitate resus- The classic presentation includes high peak airway pressures, citation in the patient with persistent low urine output and hy- decreased venous return, oliguria, and intra-abdominal pressures potension despite adequate crystalloid delivery. In such cases, the exceeding 25 mm Hg.10 Sustained intra-abdominal hypertension formula used is 5% albumin, 0.3 to 0.5 ml/kg/% TBSA burned is often fatal. Bedside decompressive laparotomy can alleviate ACS over 24 hours. Alternatively, plasmapheresis may reduce intra- and can be performed safely through burn wounds,11 and its use venous fluid requirements in patients who are not responding to should be considered in patients with hemodynamic instability, resuscitation.6 Indications for plasmapheresis include a sustained hypoventilation, and elevated abdominal pressures. Whether the MAP of less than 60 mm Hg and a UOP less than 30 ml/hr in a patient survives, however, depends on the comorbid conditions patient with ongoing fluid needs that exceed twice the estimated that led to the requirement for large resuscitative volumes. volume requirements. Early plasmapheresis (12 to 24 hours after injury) may decrease the incidence of complications from admin- istration of excessive fluid (see below).Why plasmapheresis works Airway Management is unknown, but theoretically, the process should remove inflam- Abnormal pulmonary function commonly complicates the man- matory mediators that cause vasodilatation and capillary leak. agement of thermally injured patients. It may result from inhala- Once resuscitation is complete (24 to 48 hours after injury), tion injury or from the systemic response to the burn. Under- insensible losses and hyperthermia associated with a hyperdy- standing the management of pulmonary dysfunction in the ther- namic state may indicate the need for ongoing fluid administra- mally injured patient requires a working knowledge of pulmonary tion. The route of administration can be intravenous or, prefera- function measurements and of pulmonary pathophysiology [see bly, enteral. Reliable daily weights can be extremely valuable Tables 5 and 6]. for detection and measurement of insensible fluid loss or fluid INHALATION INJURY retention. Along with MAP and UOP, several laboratory variables can be Inhalation injuries occur in approximately one third of all major used to ensure that patients are receiving appropriate amounts of burns, and mortality is more than double that of cutaneous resuscitation fluid [see Tables 3 and 4]. burns.12-14 Curiously, isolated inhalation injuries do not result in high mortality.15 Presumably, the combination of inhalation injury COMPLICATIONS OF FLUID ADMINISTRATION and cutaneous thermal injury creates a double insult in which Before the development of current resuscitation formulas, inad- recurrent or persistent bacteremia aggravates the pulmonary equate resuscitation was a common cause of death in burn injury. patients, as a result of decreased tissue perfusion and subsequent Three distinct components of inhalation injury exist: carbon multiorgan failure.7 In addition, this ischemia caused conversion monoxide (CO) poisoning, upper airway thermal burns, and of the burn to a deeper injury, thereby increasing surgical require- inhalation of products of combustion. Diagnosis of an inhalation ments. However, there are also complications associated with injury requires a thorough history of the circumstances sur- overresuscitation, or so-called fluid creep.8,9 Whereas Baxter sug- rounding the injury and is often suggested by fire in a closed
    • © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 14 MANAGEMENT OF THE PATIENT WITH THERMAL INJURIES — 4 Table 4 Acute Biochemical and Hematologic Changes during Burn Resuscitation Signs of Signs of Measurement Comment Goal Underresuscitation Overresuscitation Normal baseline values rule out preexist- Serum creatinine and ing renal disease, which reduces urine Rising values may reflect blood urea nitrogen output reliability as an index of tissue Normal values underresuscitation or acute May be normal perfusion tubular necrosis Significant blood loss from incorrectly May be elevated with severe Hematocrit and performed surgical interventions such intravascular depletion; May be low in patients with Should approach normal excessive intravascular hemoglobin as escharotomies or central venous line this is typical with delayed placement may lower values resuscitation volumes The initial WBC may vary, depending on the stress response and cell margina- tion; the absolute value is not particu- May decrease, but this general- White blood cell count ly represents margination of larly useful during the early postburn Normal values May increase (WBC) circulating neutrophils into the period; once leukopoiesis increases, neutropenia resolves without treatment wound with stimulatory factors Increased release of catecholamines in Hyperglycemia, which may Hypoglycemia, especially in Levels maintained at Blood glucose burn patients may lead to hyperglyce- misleadingly increase urine infants (< 20 kg), who have ≤ 120 mg/dl mia; diabetic patients may require insulin output decreased glycogen stores Electrolyte status depends on the type of crystalloid used for resuscitation; hypernatremia and hyponatremia Electrolytes can be avoided by resuscitation with Normal electrolyte levels — — lactated Ringer solution; use of normal saline should be avoided because it can lead to hyperchloremic acidosis Myoglobinemia may result if Decreased albumin level Myoglobinemia may result excessive resuscitation leads Patients with very deep burns or electri- Plasma protein and within the first 8 hr from prolonged underresus- to compartment syndrome; cal burns may have elevated plasma myoglobin levels after burn injury may citation and tissue ischemia escharotomy should be myoglobin levels be normal performed to minimize rhabdomyolysis Unrecognized compartment Prolonged shock and underre- syndrome and delayed Prothrombin time, suscitation may lead to dis- escharotomy may cause tis- Initial values are useful to determine partial thromboplas- seminated intravascular sue ischemia and dissemi- whether the patient has preexisting Normal tin time, and platelet coagulation; coagulation fac- nated intravascular coagula- hepatic or hematologic disease count tors and platelets may be tion; a dropping platelet needed in such cases count may indicate heparin- induced thrombocytopenia space, carbonaceous sputum, and an elevated carboxyhemoglo- cardiac dysrhythmia (three cases), and eustachian tube occlusion bin level (> 15%). (two cases).18 Consensus is growing that when cardiac arrest com- plicates inhalation injury, the result is uniformly fatal regardless of Carbon Monoxide Poisoning aggressive therapy, including hyperbaric oxygen therapy.19 CO injury is the most commonly recognized form of inhalation injury and the most common cause of death in inhalation injury. Upper Airway Thermal Injury Clinical signs and symptoms of CO toxicity correlate with arterial Direct thermal damage tends to occur in the upper airway carboxyhemoglobin levels, which can be used to quickly and pre- rather than in the lower airway because the oropharyngeal cavity cisely determine the degree of CO intoxication [see Table 7]. CO has a substantial capacity to absorb heat. Upper airway thermal intoxication can be easily treated with 100% inhaled oxygen, injury constitutes an important indication for intubation, because which rapidly accelerates the dissociation of CO from hemoglobin it is mandatory to control the airway before airway edema devel- [see Table 8]. Hyperbaric oxygen therapy has been touted as a supe- ops during resuscitation. rior treatment for quickly reducing carboxyhemoglobin levels,16 The diagnosis of upper airway thermal injury is achieved with but the data are controversial and the studies are generally poorly direct laryngoscopic visualization of the oropharyngeal cavity. The controlled.17 Hyperbaric oxygen therapy may be appropriate in a decision whether to intubate should be based on visual evidence patient with impaired neurologic status and a markedly elevated of pharyngeal burns or swelling or carbonaceous sputum coming carboxyhemoglobin level (≥ 25%). However, the risks (including from below the level of the vocal cords. If a patient is phonating barotrauma) associated with isolation in a hyperbaric chamber without stridor, intubation can often be delayed. Singed facial and may be too significant for a burn patient (≥ 10% TBSA) undergo- nasal hair does not constitute an adequate independent indication ing resuscitation. In one study of 10 patients with combined for intubation. inhalation injury and burns treated acutely with hyperbaric oxy- Treatment of upper airway injuries includes hospital admission gen, seven patients survived but the complications included aspi- for observation and provision of humidified oxygen, pulmonary ration (two cases), cardiac arrest (two cases), hypovolemia with toilet, bronchodilators as needed, and prophylactic endotracheal metabolic acidosis (three cases), respiratory acidosis (four cases), intubation as indicated. Upper airway thermal burns usually man-
    • © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 14 MANAGEMENT OF THE PATIENT WITH THERMAL INJURIES — 5 ifest within 48 hours after injury, and airway swelling can be Table 6 Mechanisms of Pulmonary Dysfunction expected to peak at 12 to 24 hours after injury. A patient with a and Indications for Mechanical Ventilation true upper airway burn will likely require airway protection for 72 hours. A short course of steroids may facilitate earlier resolution of Mechanism Best Indicator airway edema in a patient with small cutaneous burns, but a patient with a burn larger than 20% TBSA should not be treated Inadequate alveolar ventilation PaCO2 and pH with steroids because of the risk of infection and failure to heal. Inadequate lung expansion Tidal volume, respiratory rate, VC The decision whether to extubate can be based on pulmonary weaning criteria but also on the presence of an air leak around the Inadequate respiratory muscle strength MIF; MVV; VC endotracheal tube. VE required to keep PCO2 normal; Lower Airway Burn Injury Excessive work of breathing VD/VT; respiratory rate Burn injury to the tracheobronchial tree and the lung Unstable ventilatory drive Breathing pattern, clinical setting parenchyma results from combustion products in smoke [see Table 9] and, under unique conditions, inhaled steam. Numerous Severe hypoxemia P(A-a)O2; PaO2/PAO2; PaO2/FIO2; Qs/Qt irritants in smoke or the vaporized chemical reagents in steam can cause direct mucosal injury, leading to mucosal slough and MIF—maximum inspiratory force MVV—maximum voluntary ventilation bronchial edema, bronchoconstriction, and bronchial obstruc- P(A-a)O2—alveolar-to-arterial PO2 gradient PaO2/FIO2—ratio of arterial PO2 to inspired O2 tion. Tracheo-bronchial mucosal damage also leads to neutro- Qs/Qt—intrapulmonary right-to-left shunt fraction VC—vital capacity VD/VT —dead space fraction VE —minute ventilation phil chemotaxis and release of inflammatory mediators into the lung parenchyma, accentuating the injury with exudate forma- tion and microvascular permeability. Together, these may prog- citation failures in burn victims with concomitant inhalation ress to pulmonary edema, pneumonia, and acute respiratory dis- injury. tress syndrome (ARDS). Reduced myocardial contractility sec- Inhalation injury can often be a clinical diagnosis.14 Lower air- ondary to smoke-toxin inhalation may also contribute to resus- way injury can be confirmed by bronchoscopy or xenon-133 ven- tilation-perfusion scan,20 but these modalities do not change ther- apeutic choices or clinical outcome.21 Table 5 Measures of Pulmonary Function ACUTE LUNG INJURY AND ACUTE RESPIRATORY DISTRESS SYNDROME Abnormal Values Measurement Normal Values Indicating Need for Understanding of the pathophysiology of ARDS has improved Mechanical Ventilation since its initial description in the late 1960s,22 and ARDS-relat- ed deaths were lower in the period 1995 through 1998 than in Tidal volume (VT ), ml/kg 5–8 <5 the period 1990 through 1994; however, 40% to 70% of patients Vital capacity (VC), ml/kg 65–75 < 10; < 15* with ARDS still die of the disease.23 ARDS is an independent Forced expiratory volume in risk factor for death in burn patients.24 Mortality in burn 1 sec (FEV1), ml/kg 50–60 < 10 patients with ARDS is attributable to overwhelming sepsis and Functional residual capacity 80–100 < 50 (FRC), % of predicted value Table 7 Clinical Manifestations of Carbon Respiratory rate (f), 12–20 > 35 Monoxide Poisoning breaths/min Maximum inspiratory force Carboxyhemoglobin Level (%) Clinical Manifestations (MIF), cm H2O 80–100 < 20; < 25; < 30* < 10 None Minute ventilation (VE), L/min 5–6 > 10 15–25 Nausea, headache Maximum voluntary ventila- tion (MVV), L/min 120–180 < 20; < (2 × VE)* 30–40 Confusion, stupor, weakness Dead space fraction (VD/VT), % 0.25–0.40 > 0.60 40–60 Coma PaCO2, mm Hg 36–44 > 50; > 55* > 60 Death 75–100 (breath- < 50 (room air); PaO2, mm Hg ing room air) < 70 (mask O2)* Alveolar-to-arterial PO2 gradi- 25–65 (breathing Table 8 Half-life of Carbon Monoxide–Hemoglobin > 350; > 450* ent [P(A-a)O2], mm Hg 100% O2) Bonds with Inhalation Therapy Arterial-alveolar PO2 ratio 0.75 < 0.15 (PaO2/PAO2) Carboxyhemoglobin Half-life Treatment Modality Arterial PO2–inspired O2 4 hr Room air 350–450 < 200 (PaO2/FIO2), mm Hg 45–60 min 100% oxygen Intrapulmonary right-to-left > 20%; > 25%; ≤ 5% shunt fraction (Qs/Qt), % > 30%* 100% oxygen at 2 atm (hyperbaric 20 min oxygen) *More than one value indicates lack of uniform agreement in the literature.
    • © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 14 MANAGEMENT OF THE PATIENT WITH THERMAL INJURIES — 6 Table 9 Clinical Findings Associated with Specific lung neutrophil sequestration, and platelet activation through Inhaled Products of Combustion alterations in microvascular permeability. Clinical studies have correlated infection—but not isolated inhalation injury—with Product of increased IL-2 levels, which reemphasizes the potential signifi- Source Clinical Effect cance of the double insult inflicted by the combination of a burn Combustion and an inhalation injury.31 Some data suggest that relative imbal- Carbon monoxide Poor tissue oxygen ances in levels of inflammatory mediators may be more important Organic matter delivery than absolute values. Carbon dioxide Narcosis An important cell in the inflammatory cycle is the pulmonary Wood, paper, anhy- Airway mucosal irrita- alveolar macrophage, a phagocytic cell that produces reactive oxy- Nitrogen oxides (NO, tion, pulmonary drous ammonia NO2) gen intermediates (ROIs) as a means of killing microorganisms. In edema, dizziness animal models, addition of a burn injury to a smoke insult exag- Polyvinyl chloride Hydrogen chlorine Airway mucosal gerates lipid peroxidation and hypoproteinemia, implicating reac- (plastics) irritation tive oxygen species in the pathophysiology of ARDS. With sys- Wool, silk, polyurethane Respiratory failure, temic inflammation, unchecked ROI production may lead to local Hydrogen cyanide (nylon) headache, coma tissue injury. ROIs damage cells by direct oxidative injury to cel- Petroleum products Carbon monoxide, lular proteins and nucleic acids, as well as by inducing lipid per- Airway mucosal irrita- oxidation, which leads to the destruction of the cell membrane. (gasoline, kerosene, nitrogen oxide, tion, coma propane, plastics) benzene ROIs are generated under conditions of ischemia-reperfusion (as Airway mucosal irrita- with failed resuscitations), which occurs when the flow of oxy- Wood, cotton, paper Aldehydes tion, lung parenchyma genated blood is restored to ischemic tissue such as unexcised damage eschar. During ischemia, there is increased activity of xanthine oxi- Airway mucosal dase and increased hypoxanthine production; when reperfusion Polyurethane (nylon) Ammonia irritation reintroduces oxygen, the xanthine oxidase and hypoxanthine gen- erate ROIs, which cause more tissue injury. multiple organ failure rather than to respiratory failure alone.25 Management of ARDS Clinically, ARDS is characterized by pulmonary edema, refrac- In spite of 30 years of advances in ARDS treatment, patients tory hypoxemia, diffuse pulmonary infiltrates, and altered lung with ARDS still must depend on mechanical respiratory sup- compliance. Pathologically, it is distinguished by diffuse alveolar port—not treatment—as the primary therapeutic intervention epithelial damage with microvascular permeability and subse- while the alveolar epithelium repairs itself, the capillary perme- quent inflammatory cell infiltration into the lung parenchyma, ability resolves, and the lung heals. Restricting fluids to prevent interstitial and alveolar edema, hyaline membrane formation, and, further edema formation has increased survival. The most encour- ultimately, fibrosis. aging strategy to prevent lung injury and increase survival has The development of ARDS is presaged by high fluid resuscita- been low tidal volume mechanical ventilation, commonly called tion requirements, reflecting increased microvascular permeability lung protective ventilation, with or without high levels of positive and leading to increased pulmonary edema. ARDS commonly end-expiratory pressure.32 Pharmacologic approaches to treating develops within 7 days after injury. The likelihood of death is sig- ARDS in burn patients parallel those used in other critically ill sur- nificantly increased in patients with a multiple organ dysfunction gical patients and are addressed elsewhere [see 8:5 Pulmonary score of 8 or higher and a lung injury score of 2.76 or higher. In Insufficiency]. one review, burn patients with inhalation injury had a 73% inci- For most patients with pulmonary complications from thermal dence of respiratory failure (with hypoxemia, multiple pulmonary injury, conventional ventilatory approaches will be adequate. infections, or prolonged ventilator support) and a 20% incidence However, the population at risk for development of ARDS may of ARDS, whereas patients without inhalation injury had a 5% need more sophisticated management to reduce barotrauma and incidence of respiratory failure and a 2% incidence of ARDS.24 pulmonary infection in the minimally compliant lung with in- Advanced age is also an important risk factor for the development creased airway pressures. In the past, conventional ventilator man- of ARDS—indeed, one small retrospective study has suggested agement of inhalation injury and ARDS, which emphasizes nor- that age is the only independent major predisposing factor for malization of blood gases, promoted high rates of barotrauma— ARDS.26 Curiously, acute lung injury rarely develops in patients that is, ventilator-induced lung injury that is physiologically and with inhalation injury but without cutaneous burns.27,28 histopathologically indistinguishable from ARDS itself. Over- distention and cyclic inflation of injured lung exacerbates under- Inflammatory Mediators in ARDS with Burn Injuries lying lung injury and perpetuates systemic inflammation. These Local and systemic inflammatory mediators released in effects can be minimized by maintaining low tidal volumes and response to burn injury include platelet-activating factor, inter- peak pressures and by applying positive end-expiratory pressure. leukins (IL-1, IL-2, IL-6, and IL-8), prostaglandin, thromboxane, Hence, the use of alternative modes of ventilation (e.g., volume- leukotrienes, hematopoietic growth factors (granulocyte- limited ventilation with or without inverse-ratio ventilation, prone macrophage colony-stimulating factor, macrophage colony-stimu- positioning, and tracheal gas insufflation) has increased in patients lating factor, and granulocyte colony-stimulating factor), cell at risk for ARDS. No single approach is likely to benefit all pa- adhesion molecules (intercellular cell adhesion molecule–1, tients, and adjustment of ventilatory controls must be based on endothelial-leukocyte adhesion molecule–1, and vascular cell individual clinical responses. adhesion molecule–1), and nitric oxide (NO).29,30 Systemic levels of circulating tumor necrosis factor–α (TNF-α) and IL-1 correlate Lung-protective ventilation Lung-protective ventilation with ARDS severity. IL-2 promotes multisystem organ edema, utilizes low inspiratory volumes (4 to 6 ml/kg) to keep peak inspi-
    • © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 14 MANAGEMENT OF THE PATIENT WITH THERMAL INJURIES — 7 ratory pressures below 40 cm H2O. This strategy is limited by the ance of tracheobronchial casts that occlude the airway and predis- accumulation of carbon dioxide (so-called permissive hyper- pose to pulmonary infection. Although HFPV is usually described capnia), although respiratory acidosis with a pH as low as 7.20 is as rescue therapy for patients in whom conventional therapy has tolerated. failed, there is some evidence that it can reduce mortality and the The ARDS Network Study found that ARDS patients ventilat- incidence of pneumonia in patients with inhalation injury.39,40 ed with low tidal volumes had a 22% lower mortality than patients Improved oxygenation and pulmonary toilet has been reported ventilated with conventional means.32,33 The volume-preset, assist- in patients treated early with HFPV,41 which suggests that a larg- control mode is recommended for tidal volume control, and the er-scale prospective trial is warranted to determine whether the respiratory rate should be slowly increased as tidal volume is benefits of HFPV justify the added cost and effort of maintain- reduced to maintain minute ventilation and prevent acute hyper- ing multiple types of ventilators and credentialing for respiratory capnia. Tidal volume can be increased for severe acidosis (pH ≤ therapists. 7.15).Ventilator inspiratory flow should be optimized to minimize A similar method, high-frequency oscillatory ventilation, may dyspnea. If dyspnea results in asynchronous breaths, sedation may have no impact on burn mortality. However, it may have a role in be necessary or the tidal volume can be titrated to 7 to 8 ml/kg, the supportive management of burn patients with severe oxygena- provided that peak inspiratory pressures are below 40 cm H2O. tion failure that is unresponsive to conventional ventilation.42 Pressure support levels between 5 and 20 cm H2O can be titrated to keep the respiratory rate below 35 breaths/min and may be use- Nitric oxide inhalation Endogenously produced NO plays ful for weaning. an important role in the changes in systemic and pulmonary One study of children with burns found that low tidal volume microvascular permeability seen in an animal model of combined ventilation was associated with low incidences of ventilator- smoke inhalation and third-degree burn.30 Clinically, inhaled NO induced lung injury and respiratory-related deaths,34 which sup- may be useful in burn patients with severe acute lung injury in ports the use of this modality in thermally injured patients. In fact, whom conventional ventilatory support is failing.43 The safety of in patients with large burns and inhalation injury, it may be war- inhaled NO in these patients is indicated by low methemoglobin ranted to use low tidal volume ventilation before ARDS develops. levels and absence of hypotension attributable to the NO. Strong, The early resuscitative phase may be the optimal time to initiate immediate, and sustained improvement in the PaO2/FIO2 and this approach. reduction in pulmonary arterial mean pressure in response to NO seem to correlate with survival. However, the use of inhaled NO Prone positioning Changing a patient’s position from has been reported in only small numbers of burn patients, and a supine to prone is emerging as a simple and inexpensive strategy prospective study is warranted. to improve gas exchange in acutely injured lungs. Studies report that despite concerns about airway protection, this is a safe inter- Corticosteroids The use of corticosteroids in the treatment of vention that may improve the ratio of arterial oxygen pressure to burns is problematic because of the negative effect these agents fraction of inspired oxygen (PaO2/FIO2) early in the course of have on wound healing. Nevertheless, there is some evidence that ARDS.35 Some data suggest that prone positioning in conjunction rescue treatment with corticosteroids in the late chronic fibropro- with NO administration may improve arterial oxygenation.36 liferative phase of ARDS may decrease mortality and lower the However, no clinical trials have examined the use of prone posi- PaO2/FIO2.44 Ongoing multicenter studies in patients with small tioning in burn patients. If prone positioning has a significant burns and inhalation injury are under way. effect, this positive result presumably would be evident during TRACHEOSTOMY VERSUS ENDOTRACHEAL INTUBATION operative procedures when a patient with an acute lung injury is placed in this position (e.g., for excision of a posterior torso burn). Transmural airway inflammation from inhaled gases and heat Furthermore, prone positioning may be relatively contraindicated necessitates endotracheal airway protection, yet the use of endo- in a patient with a burned head who is at extreme risk for loss of tracheal tubes in such cases may be complicated by tracheal pres- control of the airway because of facial swelling and difficulty secur- sure necrosis. Hence, survivors of inhalation injury may develop ing an endotracheal tube. laryngotracheal strictures. One report suggests that there is a 5.5% incidence of tracheal stenosis in patients with burns and inhalation Extracorporeal membrane oxgyenation Few centers have injury.45 The relative risks and benefits of tracheostomies and experience with extracorporeal membrane oxygenation (ECMO), endotracheal intubation have been debated since the early 1970s. and published information on its use for the treatment of ARDS Each modality has its own advantages and complications. in patients with inhalation injury and burns is mostly confined to Nasotracheal intubation is the least advantageous form of airway anecdotal case reports.37 Given its experimental nature and its protection because of its association with paranasal sinusitis,46 as high cost, ECMO is reserved for patients in whom other ventila- well as pressure necrosis of the alar rim of the burned nose, which tory modalities fail. Although ECMO has been shown to increase is nearly impossible to reconstruct. Therefore, nasotracheal intu- survival in some children with large burns and severe acute lung bation should be avoided unless absolutely necessary. injury, patients with higher ventilator requirements before under- Tracheostomies are also associated with complications, includ- going ECMO generally do not survive, suggesting that if ECMO ing tracheal malacia, tracheal stenosis, trachea–innominate artery is to be successful, it must be instituted early to prevent barotrau- fistulas, tracheoesophageal fistulas, and posttracheostomy dyspha- ma and irreversible lung injury.38 Early implementation of per- gia.47 However, complications associated with tracheostomy may missive hypercapnia may be equally effective. relate to previous long-term endotracheal intubation and to the underlying pathophysiology, suggesting that if tracheostomy is to High-frequency percussive ventilation High-frequency be done, it should be done early on; furthermore, the tracheosto- percussive ventilation (HFPV) is another strategy for maintaining my tube should be removed at the earliest possible time. In a 1985 low peak pulmonary pressure and preventing alveolar overdisten- study of airway management, tracheal stenosis and tracheal scar tion. HFPV has the added advantage of facilitating mucosal clear- granuloma formation were reported to be more frequent and
    • © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 14 MANAGEMENT OF THE PATIENT WITH THERMAL INJURIES — 8 more severe after tracheostomy than after translaryngeal intuba- tion.48 As expected, the duration of tube placement significantly Table 10 Formulas for Estimating Caloric affected the development of permanent damage, leading to the conclusion that initial respiratory support with translaryngeal Needs in Burn Patients tubes is preferable for up to 3 weeks. Burn patients who undergo HARRIS-BENEDICT FORMULA tracheostomy before postburn day 10 may have a lower incidence Basal energy expenditure (BEE)* × activity factor† = of subglottic stenosis with no difference in pneumonia incidence, calories needed daily when compared with orally intubated patients.49 Nevertheless, tra- CURRERI FORMULA cheostomy has been reported to provide no benefit for early extu- 25 kcal / kg + 40 kcal / %TBSA burned = calories needed daily bation or overall outcome for burn patients.50 One major consid- eration in deciding whether to perform a tracheostomy has been *Women: BEE = 65.5 + 9.6(weight in kg) +1.8 (height in cm) – 4.7 (age in years). the presence of eschar at the insertion site, which complicates tra- Men: BEE = 66.5 + 13.8(weight in kg) + 5.0 (height in cm) – 6.8 cheostomy-site care and increases the risk of airway infection. (age in years). Percutaneous dilatational tracheostomy may provide a reasonable, †For burns, the activity factor is 2, which may overestimate caloric needs for less invasive approach for patients who are likely to need pro- patients with smaller burns. TBSA—total body surface area longed ventilatory support.51 This procedure can be safely per- formed at the bedside, at one quarter the cost of a conventional tracheostomy. Given ongoing controversies over the relative risks and benefits of endotracheal intubation and tracheostomy in burn any type of trauma, primarily because the disease is so devastating patients and the rarity of complications from intubation in our and its prevention so simple. There are a few cases in modern own practice, we perform tracheostomies only when multiple medical literature of tetanus in patients who had received immu- attempts at extubation have failed; these failures usually occur nization during childhood.56 because the patients cannot protect their airway. For many years, all patients admitted with burn injuries received antibiotic prophylaxis against gram-positive organisms. This prac- tice often led to the development of gram-negative bacterial infec- Temperature Regulation tions or, even worse, fungal infections. Studies have now verified Because the burn patient has lost the barrier function of the that prophylactic antibiotics not only are unnecessary but may well skin, temperature regulation is an important goal of successful be contraindicated in patients with burns.57 Therefore, treatment management. Keeping a patient warm and dry is a major goal dur- of infections in patients with burns should be based on clinical ing resuscitation, especially during the pre–burn center transport judgment and supportive laboratory and radiologic findings. of patients. This includes maintaining a warm ambient tempera- The wound is a primary source of infection for patients with ture. Large evaporative losses52 combined with administration of burns [see 7:15 Management of the Burn Wound]. The mainstay of large volumes of intravenous fluids that are at room temperature both prevention and treatment is daily washing with soap and or colder may accentuate the hypovolemia, which will complicate water and application of a topical broad-spectrum antimicrobial the patient’s overall course and may lead to disseminated intravas- agent. As soon as it becomes evident that a burn wound will not cular coagulopathy. Mild hyperthermia may occur in the first 24 heal, excision and grafting should be performed. Preferably, the hours as a result of pyrogen release or increased metabolic rate53 decision to proceed with surgery should be made before postburn and may cause tachycardia that misleadingly suggests hypovo- day 21. For patients who undergo surgery, perioperative antibi- lemia. Because infection is unlikely early on, especially within the otics may reduce postoperative wound infection.57 first 72 hours after injury, elevated temperatures should be treated with antipyrogens to control the energy expenditure associated Nutrition with increased catabolism.54 About 72 hours after injury, patients with thermal injuries commonly develop a hyperdynamic state, the In the early 1970s, Curreri and others recognized that patients systemic inflammatory response syndrome (SIRS), which is char- with major thermal injury experience hypermetabolism, with an acterized by tachycardia, hypotension, and hyperthermia—classic increased basal metabolic rate, increased oxygen consumption, signs of sepsis that in this case do not have an infectious source. negative nitrogen balance, and weight loss; hence, these patients Although patients with burns are likely to have elevated tem- have exaggerated caloric requirements.58 Furthermore, inade- peratures and may even have elevated white blood cell counts, quate caloric intake can be associated with delayed wound heal- fevers in burn patients are not reliable indicators of infections.55 ing, decreased immune competence, and cellular dysfunction. At least one study has demonstrated that in pediatric burn A patient with a large burn may lose as much as 30 g of nitro- patients, physical examination is the most reliable tool for evaluat- gen a day because of protein catabolism. Not only is urinary excre- ing the source of fever.55 tion of urea nitrogen increased, but large amounts of nitrogen are lost from the wound itself.Therefore, total urea nitrogen levels do not accurately reflect all nitrogen losses in burn patients.59 A Infection Control patient with a small burn (≤ 10% TBSA) may lose nitrogen at a Infection is a major potential problem for patients with large rate of 0.02 g/kg/day. A moderate burn (11% to 29% TBSA) may thermal injuries. In one review, up to 100% of such patients be associated with nitrogen losses equaling 0.05 g/kg/day. A large developed an infection from one or more sources during the hos- burn (≥ 30% TBSA) may result in the loss of as much as 0.12 pital stay. It is important to apply sound epidemiologic practice g/kg/day, which may be equivalent to daily losses of 190 g of pro- to treating infections, both to limit development of opportunis- tein or about 300 g of muscle. tic infections in individual patients and to achieve good infection Catabolism generally continues until wounds have healed. control in the burn unit itself. However, once a patient becomes anabolic, preburn muscle takes Tetanus prophylaxis has been standard for patients admitted for three times as long to regain as it took to lose.60,61 Therefore, a
    • © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 14 MANAGEMENT OF THE PATIENT WITH THERMAL INJURIES — 9 patient in whom it takes 1 month for burn wounds and donor sites feeding.73 Hence, for burn patients with high caloric needs, the to heal may need 3 or more months to regain preburn weight and benefit of decreased aspiration with transpyloric feeds may only be muscle mass. These statistics underscore the importance of accu- theoretical and may be offset by the delay in feeding for confirma- rately estimating each patient’s caloric needs during hospitaliza- tion of tube placement; such confirmation is necessary because tion. Over the years, a number of equations have been developed these tubes can easily flip back into the stomach. to estimate calorie needs [see Table 10]. Probably the most widely Continuation of tube feedings during surgery in intubated used formula is the Harris-Benedict equation, which estimates patients who require multiple operations is a safe way to maximize basal energy expenditure according to gender, age, height, and caloric intake and decrease wound infection. There is no need to weight. The basal energy expenditure is then multiplied by an stop feedings for anesthesia induction and endotracheal intuba- activity factor that reflects the severity of injury or the degree of ill- tion74; however, intraoperative positioning, especially if the patient ness; for burns, this multiplier is 2, the maximal factor for this for- will be prone during surgery, may necessitate stopping feedings mula.The limitation of the Harris-Benedict equation is that it may preoperatively. Mayes and colleagues have presented data that overestimate caloric needs for patients with burns smaller than support continuation of tube feedings in critically ill burn patients 40% TBSA. A formula specific for patients with burns is the undergoing decompressive laparotomy.75 Curreri formula,62 which is based on patient weight and burn size; GLUCOSE LEVELS this formula may overestimate caloric needs for patients with large burns and therefore is best used for patients with burns less than The adverse effects of hyperglycemia on wound healing and 40% TBSA.63,64 morbidity highlight the importance of maintaining blood glucose Ongoing evaluation of metabolic status of the burn patient is levels at 80 to 110 mg/dl.76 In pediatric burn patients, poor glucose necessary to take into account changes in wound size and clinical control has been associated with bacteremia, reduced skin-graft condition. Metabolic demands decrease with burn healing or graft- take, and higher mortality.77 ing; on the other hand, donor sites create new wounds, which may ALBUMIN LEVELS increase catabolic rates. Development of infection or ARDS great- ly increases catabolism and may alter caloric needs.65 Simple Burn patients characteristically have hypoalbuminemia that per- assessment of nitrogen requirements can be determined by mea- sists until wounds are healed and the rehabilitation phase of recov- suring 24-hour total urea nitrogen levels in the urine. However, this ery has begun. In fact, patients with large burns have serum albu- does not account for nitrogen lost from the wound itself. Serum min levels that average 1.7 g/dl and never exceed 2.5 g/dl.66 albumin levels are notoriously unreliable markers of adequate Management of hypoalbuminemia is controversial, but there is nutrition because they lag behind clinical progress; they are espe- general agreement that once burn resuscitation is complete, infu- cially known to be low in patients with burns larger than 20% sion of exogenous albumin to serum levels above 1.5 g/dl does not TBSA.66 Transthyretin (also known as prealbumin, although it is affect burn patient length of stay, complication rate, or mortality.78 not related to albumin in structure or function) levels correlate NUTRITIONAL SUPPLEMENTS more closely with catabolic status,67 and a trend over several weeks may indicate whether the patient’s caloric needs are being met.68 Specialized nutritional formulas with purported effects on C-reactive protein levels also provide an indication of the patient’s metabolic rate and immunologic status have garnered a great deal general inflammatory state; high levels may correlate with increased of interest as adjuncts in the management of critically ill and catabolism.67 For intubated patients, indirect calorimetry may be injured patients.79 Much of the information on nutritional require- helpful in measuring caloric needs but may not be more exact than ments for critically ill patients was derived from an animal burn the Curreri formula.69 The so-called metabolic cart is a portable model,80 however, and studies on the efficacy of specialized nutri- gas analyzer that quantifies volumes of inspired O2 and expired tional supplements in humans have generated contradictory data. CO2 and calculates nutritional requirements according to the fol- A randomized trial of nutritional formulas that were intended to lowing formula: enhance immune status and that included essential amino acids and omega-3 fatty acids showed no clinical advantage in burn kcal/day = ([3.9 × VO2] + [1.1 × VCO2]) × 1.44 patients.81 However, another study demonstrated that glutamine This result can also be indirectly measured in patients with pul- supplementation in adult burn patients resulted in significantly monary artery catheters in place by using the Fick equation: lower mortality and infection rates.82 Other nutritional or meta- bolically active supplements that have demonstrated promise in kcal/day = cardiac output × (arterial PO2 − venous PO2) × 10 × 6.96 promoting anabolism in burn patients include insulin, recombi- ENTERAL NUTRITION nant human growth factor, the anabolic steroid oxandrolone, and propranolol.83 Oxandrolone in particular has produced marked As early as 1976, the benefits of enteral nutrition over parenter- improvements in weight gain, return to function, and length of al nutrition had already been identified for patients with function- hospital stay.84 Early administration of antioxidant supplementa- al gastrointestinal systems.70 The problems of prolonged ileus and tion with α-tocopherol and ascorbic acid has been shown to reduce Curling stress ulcers in burn patients have been largely eliminated the incidence of organ failure and shorten ICU length of stay in by early feeding.71 Multiple studies have shown that patients with critically ill surgical patients.85 Whether this is true for burn major thermal injury can receive adequate calories within 72 hours patients remains to be demonstrated, but the relative low cost and after injury.72 At the University of Washington burn center, tube the low risk of complications make this an attractive intervention feeding is started a median of 5 hours after admission. for burn patients at risk for ARDS. There is ongoing debate about the benefits of gastric feeding versus duodenal feeding. Although feeding distal to the pylorus should pose less aspiration risk, one study found evidence of enter- Anemia al formula in pulmonary secretions of 7% of patients receiving gas- Because acute blood loss is uncommon in a patient with an iso- tric feeds compared with 13% of patients receiving transpyloric lated burn injury, a rapidly decreasing hematocrit during resusci-
    • © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 14 MANAGEMENT OF THE PATIENT WITH THERMAL INJURIES — 10 tation should prompt an evaluation for associated injuries. oral narcotics or transmucosal fentanyl citrate90 work well for Procedures during resuscitation, such as central venous line place- wound care; I.V. morphine or fentanyl is used for uncontrolled ment or escharotomies, should not be associated with significant pain. For outpatients, oxycodone (5 to 15 mg) works well for daily blood loss. wound care. Anemia was a major problem in burn management before early Anxiety related to wound care is an underdiagnosed and under- excision and grafting became commonplace. As excision tech- treated source of discomfort that is often construed as pain, espe- niques have become more sophisticated [see 7:15 Management of cially in children. Therefore, patients with large burns requiring the Burn Wound], operative blood loss has decreased, as has the wound care once or twice a day should be evaluated to determine need for transfusion.86,87 Nevertheless, excision and grafting may whether they would benefit from a short-acting anxiolytic agent be associated with large blood loss, and the operating team must for procedures. be prepared for intraoperative blood transfusion. Learning to accurately assess pain in burn patients can help pre- Decisions about transfusion must be based on the patient’s age, vent complications related to excessive narcotic use, such as pro- overall condition, and comorbidity. The risks of viral transmission longed sedation, delirium, and, more urgently, loss of airway con- and transfusion reactions, as well as the cost, must also be careful- trol. This is especially true in young children and elderly patients, ly considered. For an otherwise healthy patient who does not need who may have decreased ability to tolerate narcotics.91,92 surgery, a hematocrit as low as 20% may be tolerated. However, Nonpharmacologic approaches are also an important compo- patients with inhalation injury or ARDS may benefit from the nent of pain management in burn patients. Hypnosis—adminis- greater oxygen-carrying capacity afforded by a higher hematocrit. tered either by trained health care providers or, more efficiently, by Patients with large burns and anticipated blood loss during hospi- patients themselves—has proved to be a useful tool for reducing talization should probably receive iron supplements. narcotic use in patients with burns.93 Another distraction modali- Given that the literature contains some indication that erythro- ty that has shown promise and garnered significant publicity has poietin levels may be elevated in patients with large burns, the ben- been virtual reality. Although it is not a standard of care for all efit of exogenous erythropoietin is debatable.88 At least one pro- patients admitted with burn injuries, preliminary observations spective study suggests that administration of recombinant eryth- suggest that use of virtual reality can enhance patient comfort dur- ropoietin in acutely burned patients does not prevent anemia or ing wound care and intense therapy. decrease transfusion requirements.89 Discomfort in the healed wound may persist for months after injury. In general, narcotics do not control such symptoms; exer- cise and deep massage are more effective. Itching can be a perva- Pain Management sive long-term symptom for which there is no reliable topical or Pain management for patients with burn injuries can be chal- systemic therapy. Diphenhydramine, cyproheptadine, or cetirizine lenging.The simplest approaches work best; polypharmacy is like- may relieve itching. There are also promising data on the use of ly to confuse both patient and health care providers and should doxepin ointment as a topical treatment for itching of healed therefore be avoided. Burn patients experience several different wounds.94 Keeping the wound moist with a topical salve may be as classes of pain: background, breakthrough, and procedural. Each effective as other pharmacologic approaches. responds to a different approach. Background pain is the discomfort that burn patients experi- ence throughout the day and night. It is best treated with long-act- Deep Vein Thrombosis Prophylaxis ing pain relievers. For a hospitalized patient with large burns, The incidence of deep vein thrombosis (DVT) and, thus, the methadone or controlled-release morphine sulfate may be the need for DVT prophylaxis in patients with thermal injury have most appropriate choice for background pain. In an outpatient never been clearly defined. Whereas some studies report DVT in with a small burn, a nonsteroidal anti-inflammatory drug (NSAID) as many as 25% of all hospitalized burn patients and advocate may be optimal; if excision and grafting are planned, the NSAID DVT prophylaxis,95 others report that thromboembolism is re- should be stopped at least 7 days before surgery to permit recov- sponsible for only 0.14% of deaths in burn patients and does not ery of platelet function. warrant the potential complications of anticoagulation therapy.96 Breakthrough pain results when activities of daily living exacer- At the University of Washington burn center, a quality-assurance bate burn-wound discomfort. Short-acting narcotics or aceta- review found that in patients with burns larger than 20% TBSA, minophen are used to alleviate breakthrough pain. Persistent clinically evident thromboembolic disease occurred in 9% of those breakthrough pain indicates that the dose of the long-acting med- who received prophylaxis with unfractionated heparin and in 18% ication should be increased. of those who received low-molecular-weight heparin. On the basis Procedural pain is the discomfort that patients experience dur- of these data, patients with burns larger than 20% TBSA receive ing wound care and dressing changes. This usually requires treat- prophylaxis with subcutaneous unfractionated heparin, 5,000 U ment with a short-acting narcotic. For inpatients with larger burns, twice a day.
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