CHAPTER 7 - Burns Glenn D. Warden David M.

Heimbach
INTRODUCTION Thermal burns and related injury are a major cause of death and disability in the United States. The introduction of burn centers in 19 ! heralded a ra"id im"ro#ement in sur#i#al and reduction of morbidity of burn "atients and "ro#ided the basis for re$ional s"ecialty treatment centers in other disci"lines. The interacti#e multidisci"linary team has "ro#ed to be the least e%"ensi#e and most efficient method of treatin$ major burn injury& a lon$' term disease of (hich the initial acute care is only a small "art of the total treatment. )urn "atients often re*uire years of su"er#ised rehabilitation& reconstruction& and "sychosocial su""ort. Omission of any ste" in the treatment re$imen by any of the burn team members& includin$ the burn sur$eon& the nursin$ staff& and rehabilitation& nutrition& and "sychosocial su""ort staff& can result in less than o"timal outcome. +,ID+-IO.O/0 In the United States a""ro%imately 1 million indi#iduals annually are burned seriously enou$h to see2 health care3 about 45&555 of these re*uire hos"itali6ation& and about !555 die. -ore than 95 "ercent of burns are caused by carelessness or i$norance and are com"letely "re#entable3 nearly half are smo2in$' or alcohol'related. 7hile "re#ention of burns is still the lon$'term solution to burn care& ad#ances in the care of burned "atients durin$ the "ast 15 years are amon$ the most dramatic in medicine. The annual federal e%"enditure for research in cancer& heart disease& and stro2e e%ceeds by 1! times that for trauma and burns& des"ite the fact that trauma and burns account for a loss of "roducti#e "erson years from injury $reater than cancer& heart disease& and stro2e combined. The number of burn deaths in the United States has decreased from 1!&555 in 1945 to !555 in 1998. O#er the same "eriod the si6e of burn associated (ith a !5 "ercent sur#i#al rate has increased from 95 "ercent of the total body surface area :T)S;< to o#er =5 "ercent T)S; in other(ise healthy youn$ adults. >os"ital stay has been cut in half. Ninety'si% "ercent of "atients admitted to burn centers sur#i#e& and ei$hty "ercent of them return to their "reburn "hysical and social situation (ithin a year of the injury. The *uality of burn care is no lon$er measured only by sur#i#al& but also by lon$'term function and a""earance. ;lthou$h small burns are not usually life'threatenin$& they need the same attention as lar$er burns to achie#e functional and cosmetic outcome3 in the lar$est burn centers the a#era$e burn si6e is less than 1! "ercent T)S;. The "hysician?s $oal for any burn is (ell'healed& durable s2in (ith normal function and near'normal a""earance. Scarrin$& a #irtual certainty (ith dee" burns& can be minimi6ed by a""ro"riate early sur$ical inter#ention and lon$'term scar mana$ement. These $oals re*uire indi#iduali6ed "atient care "lans& based on burn characteristics and host factors. ;s (ith other forms of trauma& burns fre*uently affect children and youn$ adults. The hos"ital e%"enses and the social costs related to time a(ay from (or2 or school are sta$$erin$. -ost burns are limited in e%tent& but a si$nificant burn of the hand or foot

may 2ee" manual (or2ers a(ay from (or2 for a year or more& or "ermanently. The e#entual outcome for the burned "atient is related to the se#erity of the injury& the indi#idual "hysical characteristics of the "atient& the moti#ation of the "atient& and the *uality of the treatment.

AETIOLOGY
Cutaneous burns are caused by the a""lication of heat& cold& or caustic chemicals to the s2in. 7hen heat is a""lied to the s2in& the de"th of injury is "ro"ortionate to the tem"erature a""lied& the duration of contact& and the thic2ness of the s2in. Scald Burns In ci#ilian "ractice& scalds& usually from hot (ater& are the most common cause of burns. 7ater at 1 5@A :85@C< creates a dee" dermal or full' thic2ness burn in 9 s. ;t 1!8@A :89@C< the same burn occurs in 1 s. Areshly bre(ed coffee from an automatic "ercolator $enerally is about 1=5@A :=1@C<3 boilin$ (ater al(ays causes dee" burns& and thic2 sou"s and sauces& (hich remain in contact lon$er (ith the s2in& also in#ariably cause dee" burns. +%"osed areas tend to be burned less dee"ly than areas co#ered (ith thin clothin$. Clothin$ retains the heat and 2ee"s the li*uid in contact (ith the s2in for a lon$er "eriod. Immersion scalds are al(ays dee"& se#ere burns. The li*uid causin$ an immersion scald may not be as hot as (ith a s"ill scald& but the duration of contact is lon$er and these burns fre*uently occur in small children or elderly "atients (ith thin s2in. Deliberate scalds are the commonest form of re"orted child abuse and are res"onsible for about ! "ercent of admissions of children to burn centers. The "hysician should note any discre"ancy bet(een the history "ro#ided by the care $i#er and the distribution and "robable cause of the burn. ; sus"icious burn must be re"orted "rom"tly. Scald burns from $rease or hot oil are usually dee" dermal or full'thic2ness burns. Coo2in$ oil and $rease may be in the ran$e of 55@A. Tar and as"halt burns are a s"ecial 2ind of scald. The Bmother "otC at the bac2 of a roofin$ truc2 maintains tar at a tem"erature of 55 to !55@A :15 to 185@C<. )urns caused by tar directly from the Bmother "otC are in#ariably full'thic2ness burns. )y the time the tar has been s"read on the roof or street& its tem"erature has been lo(ered to the "oint (here most burns caused by it are dee" dermal in nature. The tar should be remo#ed by a""lication of a "etroleum'based ointment under a dressin$. The dressin$ may be remo#ed and the ointment rea""lied e#ery 1 to h until the tar has dissol#ed. Only then can the e%tent of the injury and the de"th of the burn be estimated accurately. Flame Burns Alame burns are the ne%t most common. ;lthou$h the incidence of injuries caused by house fires has decreased (ith the use of smo2e detectors& smo2in$'related fires& im"ro"er use of flammable li*uids& automobile accidents& and i$nition of clothin$ from sto#es or s"ace heaters still e%act their toll. ,atients (hose beddin$ or clothes ha#e been on fire rarely esca"e (ithout some full'thic2ness burns. Flash Burns Alash burns are ne%t in fre*uency. +%"losions of natural $as& "ro"ane& $asoline and other flammable li*uids cause intense heat for a #ery brief time. Clothin$& unless it

i$nites& is "rotecti#e a$ainst flash burns. Alash burns $enerally ha#e a distribution o#er all e%"osed s2in& (ith the dee"est areas facin$ the source of i$nition. Alash burns are mostly dermal& their de"th de"endin$ on the amount and 2ind of fuel that e%"lodes. These burns $enerally heal (ithout re*uirin$ e%tensi#e s2in $raftin$& but they may co#er a lar$e s2in area and be associated (ith si$nificant thermal dama$e to the u""er air(ay. Contact Burns These burns result from contact (ith hot metals& "lastic& $lass& or hot coals3 they are usually limited in e%tent& but in#ariably #ery dee". It is common for "atients in#ol#ed in industrial accidents to ha#e associated crush injuries because these accidents are commonly caused by contact (ith "resses or other hot& hea#y objects. ;utomobile accidents may lea#e #ictims in contact (ith hot en$ine "arts. The e%haust "i"es of motorcycles cause a characteristic burn of the medial le$ that& althou$h small& usually re*uires e%cision and $raftin$. Toddlers (ho touch or fall a$ainst irons& o#ens& and (ood'burnin$ sto#es (ith outstretched hands are li2ely to suffer dee" burns of the "alms. Contact burns are often fourth'de$ree burns& es"ecially those in unconscious or "ostictal "atients& and those caused by molten materials.

Burn Prevention
The number of burns occurrin$ annually in the United States remains un2no(n des"ite an e%tensi#e $o#ernment'funded study3 ho(e#er& a number of states ha#e "assed le$islation ma2in$ a burn a re"ortable disease& so more accurate information may be forthcomin$. One'third of the #ictims are children under the a$e of 1!. In children under = years of a$e& the most common burns are scalds& usually from the s"illin$ of hot li*uids3 in older children and adults& the most common burns are flame' related& usually the result of house fires or the ill'ad#ised use of flammable li*uids for burnin$ brush or trash& li$htin$ barbecues& etc.& or smo2in$' or alcohol'related. Industrial accidents are most often caused by chemicals or hot li*uids& follo(ed by electricity and then molten or hot metal. -ore than 95 "ercent of all burns are "re#entable by usin$ common sense and ta2in$ ordinary "recautions. O#er the "ast 15 years se#eral critical le$islati#e actions& such as that mandatin$ flame'resistant slee"(ear for children& ha#e decreased burns and burn mortality. Smo2e detectors are re*uired in all rental units and ne( construction& and are "robably the most si$nificant factor in the major decrease in burn mortality durin$ the "ast decade. -any states ha#e initiated le$islation mandatin$ that the ma%imum tem"erature for home and "ublic hot (ater heaters be set to belo( 1 5@A :85@C<. Indi#idual burn centers& the ;merican )urn ;ssociation :;);<& and the International Society for )urn Injury ha#e all "roduced multi"le tele#ision "ublic ser#ice announcements re$ardin$ hot (ater& carburetor flashes& barbecue burns& scalds& etc. Numerous "ro$rams are directed to schools3 for e%am"le& the BSto" Dro" and RollC se*uence is 2no(n by most school children. BChan$e your cloc2& chan$e your smo2e detector batteryC is a national "ro$ram remindin$ e#eryone to 2ee" their detector batteries fresh.

HOSPITAL AD ISSIO! A!D B"#! CE!TE# #EFE##AL

The need for hos"ital admission and s"eciali6ed care is dictated by the se#erity of sym"toms from smo2e inhalation and the ma$nitude of associated burns. ;ny "atient

(ho is sym"tomatic (ith smo2e inhalation and has more than tri#ial burns should be admitted to a hos"ital. If the burns co#er more than 1! "ercent T)S;& the "atient should be referred to a s"ecial care unit. In the absence of burns& admission de"ends on the se#erity of sym"toms& the "resence of "ree%istin$ medical "roblems& and the social circumstances of the "atient. Other(ise healthy "atients (ith mild sym"toms :only a fe( e%"iratory (hee6es& minimal s"utum "roduction& CO le#el D15& and normal blood $ases< (ho ha#e a "lace to $o and someone to stay (ith them can be obser#ed for an hour or t(o and then dischar$ed. ,atients (ith "ree%istin$ cardio#ascular or "ulmonary disease (ho ha#e any sym"tom related to smo2e inhalation should be admitted for obser#ation. ,atients (ith moderate sym"toms :$enerali6ed (hee6in$& mild hoarseness& moderate s"utum& CO le#els ! to 15& and normal blood $ases< are admitted to a medical'sur$ical unit for close obser#ation and treatment. ,atients (ith se#ere sym"toms :air hun$er& se#ere (hee6in$& co"ious Eusually carbonaceousF s"utum< should be admitted to an intensi#e care unit or& "referably& a burn unit.

Burn Severit$ and Classi%ication

The se#erity of injury caused by burns is "ro"ortionate to the si6e of the total burn& the de"th of the burn& the a$e of the "atient& and associated medical "roblems or injuries. )urns ha#e been classified by the ;merican )urn ;ssociation and the ;merican Colle$e of Sur$eons Committee on Trauma as minor& moderate& and se#ere. -inor burns are su"erficial burns of less than 1! "ercent T)S;. -oderate burns are defined as su"erficial burns of 1! to 1! "ercent T)S; in adults or 15 to 15 "ercent in children3 full'thic2ness burns of less than 15 "ercent T)S;& and burns not in#ol#in$ the eyes& ears& face& hands& feet& or "erineum. )ecause of the si$nificant cosmetic and functional ris2s associated (ith burns& all but #ery su"erficial burns of the face& hands& feet& and "erineum should be treated by a "hysician (ith an interest in burn care in a facility that is accustomed to dealin$ (ith burns. -ajor burns& as described abo#e& and most full' thic2ness burns in infants and elderly "atients& or "atients (ith associated diseases or injuries& should also be cared for in a s"eciali6ed facility. -oderate burns can be cared for in a community hos"ital by a 2no(led$eable "hysician& as lon$ as the other members of the health care team ha#e the resources and 2no(led$e to ensure a $ood result. Ne(er techni*ues of early (ound closure ha#e made burn care more com"le%& and an increasin$ number of "atients (ith small but si$nificant burns are bein$ referred to s"eciali6ed care facilities. The criteria for hos"ital admission of "atients (ith minor or moderate burns #ary accordin$ to "hysician "reference& the "atient?s social circumstances& and the ability to "ro#ide close follo('u". In some circumstances su"erficial burns as lar$e as 1! "ercent can be successfully mana$ed on an out"atient basis. In other circumstances& burns as small as 1 "ercent may re*uire admission because of the "atient?s inability or un(illin$ness to care for the (ound. The "hysician should ha#e lo(' threshold criteria for admission of elderly "atients and infants. ;ny "atient :child or adult< (ith sus"icion of abuse must be admitted.

Burn Center #e%erral Criteria

The ;); has identified the follo(in$ injuries as those re*uirin$ referral to a burn center after initial assessment and stabili6ation at an emer$ency de"artment.

:1< Second' and third'de$ree burns $reater than 15 "ercent T)S; in "atients under 15 or o#er !5 years of a$e. :1< Second' and third'de$ree burns $reater than 15 "ercent T)S; in other a$e $rou"s. :9< Second' and third'de$ree burns in#ol#in$ the face& hands& feet& $enitalia& "erineum& and major joints. : < Third'de$ree burns $reater than ! "ercent T)S; in any a$e $rou". :!< +lectrical burns& includin$ li$htnin$ injury. :8< Chemical burns. :4< Inhalation injury. :=< )urn injury in "atients (ith "ree%istin$ medical disorders that could com"licate mana$ement& "rolon$ the reco#ery "eriod& or affect mortality. :9< ;ny burn "atients (ith concomitant trauma :e.$.& fractures< (here the burn injury "oses the $reatest ris2 of morbidity or mortality. If the trauma "oses the $reater immediate ris2& the "atient may be treated initially in a trauma center until stable before bein$ transferred to a burn center. The "hysician?s decisions should be made (ith the re$ional medical control "lan and tria$e "rotocols in mind. :15< )urn injury in children admitted to a hos"ital (ithout *ualified "ersonnel or e*ui"ment for "ediatric care. :11< )urn injury in "atients re*uirin$ s"ecial social& emotional& andGor lon$'term rehabilitati#e su""ort& includin$ cases in#ol#in$ sus"ected child abuse& substance abuse& etc. Trans"ort and Transfer ,rotocols Once an air(ay is established and resuscitation under (ay& burned "atients are eminently suitable for trans"ort. Resuscitation can continue en route because the "atient (ill usually remain stable for se#eral days. This (as (ell demonstrated durin$ the Hiet Nam (arI about 1555 burn #ictims (ere first trans"orted from Hiet Nam to Ja"an& and then from Ja"an to the military )urn Center in San ;ntonio& Te%as3 the trans"ort (as usually accom"lished durin$ the first 1 (ee2s "ostburn (ith #ery fe( com"lications. >os"itals (ithout s"eciali6ed burn care facilities should ha#e transfer a$reements and treatment "rotocols (ith a burn center (ell in ad#ance of the need for transfer. Definiti#e care be$ins at the initial hos"ital and continues (ithout interru"tion durin$ trans"ort and at the burn center. Transfer should be from "hysician to "hysician& and contact should be established as soon as the "atient arri#es in the emer$ency room of the initial hos"ital.

The mode of trans"ort de"ends on #ehicle a#ailability& local terrain& (eather& and the distances in#ol#ed. Aor distances of less than !5 miles :=5 2m<& $round ambulance is usually satisfactory. >elico"ter trans"ort is often "referred (hen the distance is bet(een !5 and 1!5 mi :=5 and 1 5 2m<3 ho(e#er& "atient monitorin$& air(ay mana$ement& and effectin$ chan$es in thera"y are #ery difficult to achie#e in a helico"ter. In all cases in (hich the time of trans"ort (ill be lon$& it is the res"onsibility of the referrin$ "hysician to ensure that the "atient?s condition (ill "ermit the trans"ort. ;ll "atients trans"orted by air should ha#e a naso$astric tube inserted and "laced on de"endent draina$e& because nausea and #omitin$ ine#itably result durin$ the fli$ht. T(o lar$e'bore intra#enous lines are mandatory. Aor distances o#er 1!5 mi :1 5 2m<& fi%ed'(in$ aircraft are most satisfactory. -odern air ambulances are com"letely e*ui""ed intensi#e care units& and the "ersonnel are usually (ell trained for critical care. The air(ay must be secured. ;t 95&555 ft the "lanes are "ressuri6ed to an altitude of about !!55 ft. Su""lemental o%y$en can be $i#en in fli$ht& but if the "atient?s o%y$enation is mar$inal& it may be best to intubate and "lace the "atient on a #entilator for the trans"ort. Intubation is difficult en route3 if there is *uestion of u""er air(ay edema& the "atient should be intubated "rior to trans"ort. )urned "atients ha#e difficulty maintainin$ body tem"erature& and they should be (armly (ra""ed "rior to trans"ort. )ul2y dressin$s& a blan2et& and a mylar sheet :usually a#ailable from the fli$ht team< can hel" maintain body tem"erature. If the "atient has any cardiac irre$ularities& the "lane must be e*ui""ed (ith monitorin$ ca"ability& because noise and #ibrations in'fli$ht ma2e clinical monitorin$ difficult. If there is dan$er of com"romised circulation due to circumferential full' thic2ness burns& escharotomies should be done at the referrin$ hos"ital& unless the total hos"ital'to'hos"ital time (ill be less than 1 h. )urn Center Herification and a National )urn Re$istry In 199!& in conjunction (ith the ;merican Colle$e of Sur$eons Committee on Trauma :;CS'COT<& the ;); initiated a "ro$ram of )urn Center Herification. ; resource document outlines the resources and "rocess necessary to "ro#ide o"timal care of the burn "atient. )urn centers may be re#ie(ed to #erify that they "ro#ide state'of'the'art care for burn "atients& a "rocess in#ol#in$ a len$thy *uestionnaire& a site #isit& a (ritten re"ort& and a""ro#al by the joint #erification committees. )y 1998& o#er 1! centers had $one throu$h this "rocess. ; national burn re$istry is 2e"t by U.S. burn centers to "ro#ide national statistics re$ardin$ incidence& e"idemiolo$y& and outcome of burn cases. +-+R/+NC0 C;R+ Care at the Scene ;ir(ay Once flames are e%tin$uished& initial attention must be directed to the air(ay. Immediate cardio"ulmonary resuscitation is rarely necessary& e%ce"t in electrical injuries that ha#e induced cardiac arrest or in "atients (ith se#ere carbon mono%ide "oisonin$ (ith hy"o%ic cardiac arrest. ;ny "atient rescued from a burnin$ buildin$ or e%"osed to a smo2y fire should be "laced on 155K o%y$en by ti$ht'fittin$ mas2 if there is any sus"icion of smo2e inhalation. If the "atient is unconscious& and a""ro"riately trained "ersonnel are "resent& an endotracheal tube should be "laced and

attached to a source of 155K o%y$en. If the air(ay has to be su""orted by a ti$ht mas2& there is a si$nificant dan$er of as"iration of $astric contents& because air forced into the stomach (ill distend it and cause #omitin$. The mas2 "re#ents e%"ulsion of the fluid& and $astric contents can flood the tracheobronchial tree. Other Injuries and Trans"ort Once an air(ay is secured& the "atient is assessed for other injuries and then trans"orted to the nearest hos"ital. If a burn center is (ithin a 95' min dri#e and the burn is se#ere& the "atient may be ta2en directly to that facility. ,atients should be 2e"t flat and (arm and be $i#en nothin$ by mouth. If a""ro"riately trained& the emer$ency medical technicians should "lace an intra#enous line and be$in fluid administration of crystalloid solution at a rate of a""ro%imately 1 .Gh. Aor trans"ort& the "atient should be (ra""ed in a clean sheet and blan2et. Sterility is not re*uired. )efore or durin$ trans"ort& constrictin$ clothin$ and je(elry should be remo#ed from burned "arts& because local s(ellin$ be$ins almost immediately. Constrictin$ objects increase s(ellin$& and remo#in$ ti$ht je(elry in the "resence of distal edema is time' consumin$ and difficult. Cold ;""lication Smaller burns& "articularly scalds& are treated (ith immediate a""lication of cool (ater. It has been mathematically demonstrated that coolin$ cannot reduce s2in tem"erature enou$h to "re#ent further tissue dama$e& and that histolo$ic dama$e is similar (ith or (ithout coolin$& but there is e#idence in animals that coolin$ delays edema formation& "robably by reducin$ initial thrombo%ane "roduction. ;fter se#eral minutes ha#e ela"sed& further coolin$ does not alter the "atholo$ic "rocess. Iced (ater should ne#er be used e#en on the smallest of burns. If ice is used on lar$er burns& systemic hy"othermia may follo(& and the associated cutaneous #asoconstriction can e%tend the thermal dama$e. +mer$ency Room Care The "rimary rule for the emer$ency "hysician is& BAor$et about the burn.C ;s (ith any form of trauma the ;)C "rotocolLair(ay& breathin$& circulationLmust be follo(ed. ;lthou$h a burn is a dramatic injury& a careful search for other life' threatenin$ injuries is the first "riority. Only after ma2in$ an o#erall assessment of the "atient?s condition should attention be directed to the burns. The assessment of "atients (ho ha#e not been thermally injured is discussed in Cha". 83 the follo(in$ sections a""ly s"ecifically to "roblems encountered in the burn "atient. +mer$ency ;ssessment of Inhalation Injury The history is im"ortant. Inhalation injury should be sus"ected in anyone (ith a flame burn& and assumed& until "ro#ed other(ise& in anyone burned in an enclosed s"ace. The acrid smell of smo2e on a #ictim?s clothes should raise sus"icion. The rescuers are the most im"ortant historians and should be *uestioned carefully before they lea#e the emer$ency facility. Careful ins"ection of the mouth and "haryn% should be done early. >oarseness and e%"iratory (hee6es are si$ns of "otentially serious air(ay edema or smo2e "oisonin$. Co"ious mucus "roduction and carbonaceous s"utum are sure si$ns& but their absence does not rule air(ay injury out. Carbo%yhemo$lobin le#els should be obtained3

ele#ated carbo%yhemo$lobin le#els or any sym"toms of carbon mono%ide "oisonin$ are "resum"ti#e e#idence of associated smo2e "oisonin$. ; decreased ,GA ratio& the ratio of arterial ,O 1 to "ercenta$e of ins"ired o%y$en :AiO 1< in arterial blood $ases is one of the earliest indicators of smo2e inhalation. ; ratio of 55 to !55 is normal3 "atients (ith im"endin$ "ulmonary "roblems ha#e a ratio of less than 955 :e.$.& a ,aO 1 of less than 115 (ith an AiO 1 of 5. 5<. ; ratio of less than 1!5 is an indication for a$$ressi#e "ulmonary su""ort rather than for increasin$ the ins"ired o%y$en concentration. Aibero"tic bronchosco"y is ine%"ensi#e& is *uic2ly "erformed in e%"erienced hands& and is #ery useful for accurately assessin$ edema of the u""er air(ay. ;lthou$h bronchosco"y documents tracheal erythema& it does not materially influence the treatment of "ulmonary injury. Aluid Resuscitation in the +mer$ency Room ;s burns a""roach 15 "ercent T)S;& local inflammatory cyto2ines esca"e into the circulation and result in a systemic inflammatory res"onse. The ca"illary lea2& "ermittin$ loss of fluid and "rotein from the intra#ascular com"artment into the e%tra#ascular com"artment& becomes $enerali6ed. Cardiac out"ut decreases as a result of mar2ed increased "eri"heral resistance& hy"o#olemia secondary to the ca"illary lea2& and the accom"anyin$ increase in blood #iscosity. The resultin$ intense sym"athetic res"onse leads to decreased "erfusion to the s2in and #iscera. Decreased flo( to the s2in may con#ert the 6one of stasis to one of coa$ulation& thereby increasin$ the de"th of burn. Decreased cardiac out"ut may de"ress CNS function& and& in e%treme cases& lead to se#ere cardiac de"ression (ith e#entual cardiac failure in healthy "atients& or to myocardial infarction in "atients (ith "ree%istin$ coronary artery atherosclerosis. Im"airment in CNS function manifests as restlessness& follo(ed by lethar$y& and finally by coma. If resuscitation is inade*uate& burns of 95 "ercent T)S; fre*uently leads to acute renal failure& (hich& in the case of se#ere burn& almost in#ariably results in a fatal outcome. Resuscitation be$ins by startin$ intra#enous Rin$er?s lactate solution at a rate of 1555 m.Gh in adults and 15 m.G2$ in children. )urn "atients re*uirin$ intra#enous resuscitation :$enerally those (ith burns o#er 15 "ercent T)S;< should ha#e a Aoley catheter "laced and urine out"ut monitored hourly. ,atients (ith burns less than !5 "ercent T)S; can usually be resuscitated (ith a sin$le lar$e'bore "eri"heral intra#enous line. )ecause of the hi$h incidence of se"tic thrombo"hlebitis lo(er e%tremities should not be used as "ortals for intra#enous lines. U""er e%tremities are "referable& e#en if the intra#enous line must "ass throu$h burned s2in. ,atients (ith burns o#er !5 "ercent T)S;& (ho ha#e associated medical "roblems& (ho are #ery youn$ or #ery old& or (ho ha#e concomitant smo2e inhalation should ha#e additional central #enous "ressure monitorin$. )ecause of the hemodynamic instability in "atients (ith burns o#er 8! "ercent T)S;& these "atients should be transferred as *uic2ly as "ossible so they can be monitored in an intensi#e care settin$ (here S(an'/an6 catheters for measurin$ "ulmonary (ed$e "ressures and cardiac out"uts can be "laced. Tetanus

)urns are tetanus'"rone (ounds. The need for tetanus "ro"hyla%is is determined by the "atient?s current immuni6ation status. ,re#ious immuni6ation (ithin ! years re*uires no treatment& immuni6ation (ithin 15 years a tetanus to%oid booster& and un2no(n immuni6ation status hy"erimmune serum :>y"er'Tet<. /astric Decom"ression -any burn centers be$in tube feedin$ on admission& to "rotect the stomach from stress ulceration and the "atient from a "aralytic ileus and decreasin$ catabolism. If the "atient is to be trans"orted& the safest course is usually to decom"ress the stomach (ith a naso$astric tube. ,ain Control Durin$ the shoc2 "hase of burn care& medications should be $i#en intra#enously. Subcutaneous and intramuscular injections are absorbed #ariably de"endin$ on "erfusion and should be a#oided. ,ain control is best mana$ed (ith small intra#enous doses of mor"hine& usually 1 to ! m$& $i#en until "ain control is ade*uate& (ithout affectin$ blood "ressure. ,sychosocial Care ,sychosocial care should be$in immediately. The "atient and family must be comforted and $i#en a realistic assessment re$ardin$ the "ro$nosis of the burns. In house fires& "atients? lo#ed ones& "ets& and "ossessions may ha#e been destroyed. If the family is not a#ailable& some member of the team& usually the social (or2er& should determine the e%tent of the dama$e. If the "atient is a child& and if the circumstances of the burn are sus"icious& "hysicians in all states are re*uired by la( to re"ort any sus"ected case of child abuse to local authorities. Care of the )urn 7ound ;fter all other assessments are com"lete& attention should be directed to the burn. If the "atient is to be transferred durin$ the first "ostburn day& (hich is almost al(ays the case& the burn (ounds can be left alone. >o(e#er& the si6e of the burn should be calculated to establish the "ro"er le#el of fluid resuscitation& and "ulses distal to circumferential full'thic2ness burns should be monitored. The "atient can be (ra""ed in a clean sheet and 2e"t (arm until arri#in$ at the definiti#e care center. +scharotomy and Aasciotomy Chest +scharotomy The ade*uacy of res"iration must be monitored continuously throu$hout the resuscitation "eriod. +arly res"iratory distress may be due to com"romise of the #entilatory function caused by a cuirass effect related to a dee" circumferential burn (ound of the chest. ,ressures re*uired by #entilation increase and arterial ,CO 1rises. Inhalation injury& "neumothora%& or other causes may also result in res"iratory distress. 7hen escharotomy is re*uired in a "atient (ith a circumferential chest (all burn& it is "erformed in the anterior a%illary line bilaterally. If there is si$nificant e%tension of the burn onto the adjacent abdominal (all& the escharotomy incisions should be e%tended to this area and should be connected by a trans#erse incision alon$ the costal mar$in :Ai$. 4'1<.

+scharotomy of +%tremities +dema formation in the tissues under the ti$ht unyieldin$ eschar of a circumferential burn of an e%tremity may "roduce si$nificant #ascular com"romise that& if unreco$ni6ed and untreated& (ill lead to "ermanent& serious neurolo$ic and #ascular deficits. ;ll rin$s& (atches& and other je(elry must be remo#ed from injured limbs to a#oid distal #ascular ischemia. S2in color& sensation& ca"illary refill& and "eri"heral "ulses must be assessed hourly in any e%tremity (ith a circumferential burn. The occurrence of any of the follo(in$ si$ns or sym"toms may indicate "oor "erfusion of the distal e%tremityI cyanosis& dee" tissue "ain& "ro$ressi#e "aresthesia :loss of sensation<& "ro$ressi#e decrease or absence of "ulse& or sensation of cold e%tremities. ;n ultrasonic flo(meter is a reliable means for assessin$ arterial blood flo(& and the need for an escharotomy& and can also be used to assess ade*uacy of circulation after an escharotomy. Direct monitorin$ of intramuscular com"artment "ressure "ro#ides objecti#e e#idence for ade*uacy of circulation. It is useful for assessin$ not only the need for& but also the ade*uacy of& escharotomy andGor fasciotomy. ;n 1='$au$e needle is attached to the transducer tubin$ that is used for monitorin$ arterial "ressure and inserted into the com"artment3 "ressure is measured on the monitor. In burn "atients the threshold "ressure for "erformin$ escharotomy or fasciotomy is 95 mm>$. 7hile ele#ation and mani"ulation of the e%tremity may relie#e minor de#iations of "ressure& escharotomy is necessary for 95 mm>$ or hi$her. )oth escharotomies and fasciotomies may be done as bedside "rocedures (ith a sterile field and scal"el. .ocal anesthesia is unnecessary because third' de$ree eschar is insensate3 small doses of intra#enous narcotics may be utili6ed to control an%iety. The incision& (hich must a#oid major ner#es& #essels& and all tendons& should be "laced alon$ the mid'medial or mid' lateral as"ect of the e%tremity and& to "ermit ade*uate se"aration of the cut ed$es for decom"ression& should e%tend throu$h the eschar do(n to the subcutaneous fat. The incision should e%tend throu$h the len$th of the constrictin$ third'de$ree burn& and should be carried across in#ol#ed joints :see Ai$. 4'1<. 7hen a sin$le escharotomy incision in an e%tremity does not result in ade*uate distal "erfusion& a second escharotomy incision on the contralateral as"ect of the e%tremity should be "erformed. ; fin$er escharotomy is seldom re*uired& and should be "erformed only after consultation (ith the recei#in$ burn center "hysician. +scharotomy andGor fasciotomy is rarely re*uired (ithin the first 8 h "ostburn and should only be done under the su"er#ision of a trained sur$eon. )ecause burn "atients are at ris2 for de#elo"in$ a com"artment syndrome u" to 41 h "ostinjury& any in#ol#ed e%tremity should be reassessed continually for si$ns of the dan$erous ele#ation in com"artment "ressures that can occur after initial decom"ression. )URN S+H+RIT0 The se#erity of any burn injury is related to the si6e and de"th of the burn and to the "art of the body that has been burned. )urns are the only *uantifiable form of trauma. The sin$le most im"ortant factor in "redictin$ burn'related mortality& need for s"eciali6ed care& and the ty"e and li2elihood of com"lications is the o#erall si6e of the burn as a "ro"ortion of the "atient?s total body surface. Treatment "lans& includin$

initial resuscitation and subse*uent nutritional re*uirements& are directly related to the si6e of burn. )urn Si6e ; $eneral idea of burn si6e can be made by usin$ the Rule of Nines. +ach u""er e%tremity accounts for 9 "ercent of T)S;& each lo(er e%tremity accounts for 1= "ercent& the anterior and "osterior trun2 each account for 1= "ercent& the head and nec2 account for 9 "ercent& and the "erineum accounts for 1 "ercent. ;lthou$h the Rule of Nines is reasonably accurate for adults& a number of more "recise charts ha#e been de#elo"ed. -ost emer$ency rooms ha#e a chart a#ailable com"arable to the one sho(n in Ai$. 4'1. ; dia$ram of the burn can be dra(n on the chart& and& theoretically& a "recise calculation of burn si6e can be made from the accom"anyin$ T)S; estimates $i#en. Children under years old ha#e much lar$er heads and smaller thi$hs in "ro"ortion to body si6e than do adults. In infants the head accounts for nearly 15 "ercent of the T)S;3 infant body "ro"ortions do not fully reach adult "ercenta$es until adolescence. +#en (hen usin$ "recise dia$rams& indi#idual obser#er #ariation may differ by as much as M15 "ercent. ;n obser#er?s e%"erience (ith burned "atients rather than his or her educational le#el a""ears to be the best "redictor of accuracy of estimation. To increase accuracy in burn si6e estimation& es"ecially (hen burns are in scattered body areas& the obser#er should calculate the unburned areas on a se"arate dia$ram. If the calculations of the unburned areas and the burned areas do not add u" to 155 "ercent& the obser#er should be$in a$ain (ith a ne( dia$ram. Aor smaller burns an accurate assessment of burn si6e can be made by usin$ the "atient?s hand& (hich amounts to 1.! "ercent T)S; :see Ai$. 4' 1<. The dorsal surface& includin$ the fin$ers& accounts for 1 "ercent& the "almar surface& includin$ the fin$ers& for 1 "ercent& and the #ertical surface for 5.! "ercent. )urn De"th ;lon$ (ith burn e%tent and "atient a$e& de"th of burn is a "rimary determinant of mortality. )urn de"th is also the "rimary determinant of the "atient?s lon$'term a""earance and function. )urns not e%tendin$ all the (ay throu$h the dermis lea#e behind e"ithelium'lined s2in a""enda$esI s(eat $lands& and hair follicles (ith attached sebaceous $lands. 7hen dead dermal tissue is remo#ed& e"ithelial cells s(arm from the surface of each a""enda$e to meet s(armin$ cells from nei$hborin$ a""enda$es& formin$ a ne(& fra$ile e"idermis on to" of a thinned and scarred dermal bed. S2in a""enda$es #ary in de"th& and the dee"er the burn the fe(er the a""enda$es that contribute to healin$ and the lon$er the burn ta2es to heal. The lon$er the burn ta2es to heal& the less dermis remains& the $reater the inflammatory res"onse& and the more se#ere the scarrin$. 7hen nono"erati#e treatment is the routine& as it is in many de#elo"in$ countries& an accurate assessment of burn de"th is of little im"ortance e%ce"t for "redictin$ mortality. On the other hand& (ith a$$ressi#e sur$ical treatment& an accurate estimation of burn de"th is crucial. )urns that heal (ithin 9 (ee2s usually do so (ithout hy"ertro"hic scarrin$ or functional im"airment& althou$h lon$'term "i$mentary chan$es are common. )urns that ta2e lon$er than 9 (ee2s to heal often

"roduce unsi$htly hy"ertro"hic scars3 fre*uently lead to functional im"airment3 and "ro#ide only a thin& fra$ile e"ithelial co#er for many (ee2s or months. State'of'the' art burn care& at least in "atients (ith small and moderate burns& in#ol#es early e%cision and $raftin$ of all burns that (ill not heal (ithin 9 (ee2s. The challen$e of course is to determine (hich burns (ill heal (ithin 9 (ee2s and are thus best treated by daily local care. Other burns should be treated sur$ically. ;n understandin$ of burn de"th re*uires an understandin$ of s2in thic2ness. The li#in$ e"idermis is an intensely acti#e layer of e"ithelial cells under layers of dead 2eratini6ed cells and is su"erficial to the acti#e structural frame(or2 of the s2in& the dermis. The thic2ness of s2in #aries (ith the a$e and se% of the indi#idual and the area of the body. The thic2ness of the li#in$ e"idermis is relati#ely constant& but 2eratini6ed :dead and cornified< e"idermal cells may reach a hei$ht of 5.! cm on the "alms of hands and the soles of feet. The thic2ness of the dermis #aries from less than 1 mm on eyelids and $enitalia to more than ! mm on the "osterior trun2. The "ro"ortional thic2ness of s2in in each body area in children is similar to that in adults& but infant s2in thic2ness in each s"ecific area may be less than half that of adult s2in3 the s2in does not reach adult thic2ness until "uberty. Similarly& in "atients o#er !5 years of a$e dermal atro"hy be$ins3 all areas of s2in become thin in elderly "atients. The de"th of burn is de"endent on the heat of the burn source& the thic2ness of the s2in& the duration of contact& and the heat'dissi"atin$ ca"ability of the s2in :blood flo(<. ; scald in an infant or elderly "atient (ill be dee"er than an identical scald in a youn$ adult. ; diabetic (ith im"aired sensation& or an inebriated "atient (ith an im"aired sensorium& (ho lies on a heatin$ "ad :e#en of tem"erature less than 158@A : 1@C< all ni$ht may sustain full'thic2ness burns because of the lon$ duration of contact (ith the "ad and the "ressure of the body (ei$ht (hich occludes cutaneous blood flo( and "re#ents heat dissi"ation. )urns are classified accordin$ to increasin$ de"th as first'de$ree& second' de$ree :su"erficial dermal and dee" dermal<& third'de$ree :full'thic2ness<& and fourth'de$ree. )ecause most dee" burns are remo#ed sur$ically and $rafted& such a "recise characteri6ation is not necessary for non'life' threatenin$ burns. ; more "ertinent classification mi$ht be Bshallo( burnsC and Bdee" burns.C Ne#ertheless& distin$uishin$ bet(een dee" burns that are best treated by early e%cision and $raftin$ and shallo( burns that heal s"ontaneously is not al(ays strai$htfor(ard& and many burns ha#e a mi%ture of clinical characteristics& ma2in$ "recise classification difficult. Shallo( )urns Airst'De$ree )urns Airst'de$ree burns in#ol#e only the e"idermis. Airst'de$ree burns do not blister& but become erythematous because of dermal #asodilation& and are *uite "ainful. O#er 1 to 9 days the erythema and the "ain subside. )y about day & the injured e"ithelium des*uamates in the "henomenon of B"eelin$&C (hich is (ell 2no(n after sunburn. Su"erficial Dermal )urns :Second'De$ree< Su"erficial dermal burns include the u""er layers of dermis& and characteristically form blisters (ith fluid collection at the interface of the e"idermis and dermis. )listerin$ may not occur for some hours after injury& and burns ori$inally a""earin$ to be first'de$ree may be dia$nosed as su"erficial dermal burns after 11 to 1 h. 7hen

blisters are remo#ed& the (ound is "in2 and (et and currents of air "assin$ o#er it cause "ain. The (ound is hy"ersensiti#e& and the burns blanch (ith "ressure. If infection is "re#ented& su"erficial dermal burns heal s"ontaneously in less than 9 (ee2s& and do so (ith no functional im"airment. They rarely cause hy"ertro"hic scarrin$& but in "i$mented indi#iduals the healed burn may ne#er com"letely match the color of the surroundin$ normal s2in. Dee" )urns Dee" Dermal )urns :Second'De$ree< Dee" dermal burns e%tend into the reticular layers of the dermis. Dee" dermal burns also blister& but the (ound surface is usually a mottled "in2 and (hite color immediately after the injury& because of the #aryin$ blood su""ly to the dermis :(hite areas ha#e little to no blood flo(3 "in2 areas ha#e some blood flo(<. The "atient com"lains of discomfort rather than "ain. 7hen "ressure is a""lied to the burn& ca"illary refill occurs slo(ly or may be absent. The (ound is often less sensiti#e to "in"ric2 than the surroundin$ normal s2in. )y the second day& the (ound may be (hite and is usually fairly dry. If infection is "re#ented& these burns (ill heal in 9 to 9 (ee2s& but in#ariably do so (ith considerable scar formation. Unless acti#e "hysical thera"y is continued throu$hout the healin$ "rocess& joint function can be im"aired& and hy"ertro"hic scarrin$& "articularly in "i$mented indi#iduals and children& is common. Aull'Thic2ness )urns :Third'De$ree< Aull'thic2ness burns in#ol#e all layers of the dermis and can heal only by (ound contracture& by e"itheliali6ation from the (ound mar$in& or by s2in $raftin$. Aull' thic2ness burns a""ear (hite& cherry red& or blac2& and may or may not ha#e dee" blisters. Aull'thic2ness burns are described as bein$ leathery& firm& and de"ressed (hen com"ared (ith adjoinin$ normal s2in& and are insensiti#e to li$ht touch or "in"ric2. The difference in de"th bet(een a dee" dermal burn and a full'thic2ness burn may be less than a millimeter. The clinical a""earance of full'thic2ness burns can resemble that of dee" dermal burns. .i2e dee" dermal burns they may be mottled in a""earance. They rarely blanch on "ressure& and they may ha#e a dry& (hite a""earance. In some cases the burn is translucent& (ith clotted #essels #isible in the de"ths. Some full'thic2ness burns& "articularly immersion scalds& ha#e a red a""earance& and may be confused (ith su"erficial dermal burns. They can be distin$uished& ho(e#er& because they do not blanch (ith "ressure. Aull'thic2ness burns de#elo" a classic burn escharI the structurally intact but dead and denatured dermis that& o#er days and (ee2s& se"arates from the underlyin$ #iable tissue. Aourth'De$ree )urns Aourth'de$ree burns in#ol#e not only all layers of the s2in& but also subcutaneous fat and dee"er structures. These burns almost al(ays ha#e a charred a""earance& and fre*uently only the cause of the burn $i#es a clue to the amount of underlyin$ tissue destruction. +lectrical burns& contact burns& some immersion burns& and burns sustained by "atients (ho are unconscious at the time of burnin$ may all be fourth' de$ree. The ;ssessment of )urn De"th The standard techni*ue for determinin$ burn de"th has been clinical obser#ation of the (ound. The difference in de"th bet(een a burn that heals in 9 (ee2s& a dee"

dermal burn that heals only after many (ee2s& and a full'thic2ness burn that (ill not heal at all may be only a matter of a fe( tenths of a millimeter. ; burn is a dynamic "rocess for the first fe( days3 a burn a""earin$ shallo( on day 1 may a""ear considerably dee"er by day 9. Aurther& the 2ind of to"ical (ound care used can dramatically chan$e the a""earance of the burn. Aor these reasons& and because of the increasin$ im"ortance of an accurate assessment of burn de"th for "lannin$ definiti#e care of burn (ounds& there is considerable interest in technolo$y that (ill hel" determine burn de"th more "recisely than clinical obser#ation. +#aluation by an e%"erienced sur$eon as to (hether an intermediate'de"th dermal burn (ill heal in 9 (ee2s is about !5 "ercent accurate. In e%"erienced hands& ho(e#er& early e%cision and $raftin$ "ro#ides better results than nono"erati#e care for such indeterminate burns. Other techni*ues in#ol#e :1< the ability to detect dead cells or denatured colla$en :throu$h bio"sy& ultrasound& #ital dyes<& :1< assessment of chan$es in blood flo( :throu$h fluorescein& laser Do""ler& and thermo$ra"hic assays<& :9< analysis of the color of the (ound :throu$h li$ht reflectance methods<& and : < e#aluation of "hysical chan$es& such as edema :throu$h nuclear ma$netic resonance :N-R< techni*ues. )io"sy )io"sy and histolo$ic e%amination (ould seem the most accurate techni*ue for determinin$ burn de"th& but bio"sies are e%"ensi#e& lea#e "ermanent scars in (ounds that (ould not be e%cised& and re*uire an e%"erienced "atholo$ist to distin$uish li#e from denatured colla$en and cells. In addition& (ound de"th chan$es durin$ the first = h& and Jac2son re"orted that 4 days (ere necessary to $et re"roducible results from burn bio"sies. 7hate#er the timin$ of bio"sy& it re*uires another day or t(o to $et "ermanent sections& and there is no $uarantee that s"ecimens from areas adjacent to the bio"sy are the same de"th as the bio"sy s"ecimens. Aor these reasons bio"sies are rarely used in clinical "ractice& and to the authors? 2no(led$e no studies ha#e demonstrated a correlation bet(een bio"sy findin$s and healin$ (ithin 9 (ee2s. Hital Dyes Theoretically& a #ital dye directly a""lied to the burn (ound (ould be useful in detectin$ dead tissue and also in determinin$ the needed de"th of sur$ical e%cision. Da#ies& in 19=5& described im"ortant characteristics of such a dye. It should stain only dead tissue& not be remo#able (ith (ound treatment& be nonto%ic& "ro#ide a shar" demarcation bet(een li#in$ and dead tissue& "enetrate all dead tissue& and be com"atible (ith to"ical treatments usually used in burn care. In a rat model methylene blue& toluidine blue& try"an blue& +#ans blue& and sul"han blue (ere e#aluated. -ethylene blue& (hich is metaboli6ed to a colorless com"ound by li#in$ cells& (as selected for "reliminary testin$ in "atients. 7hen methylene blue (as mi%ed (ith sil#er sulfadia6ine and a""lied to"ically (ithin = h& a si$nificant blue discoloration a""eared that remained e#en after #i$orous (ashin$. +%cision (as carried do(n to dermis that (as unstained. The authors re"orted encoura$in$ results in this "reliminary study. >o(e#er& casual use of this techni*ue in our burn centers did not "roduce a satisfactorily shar" demarcation to $uide e%cision. Aluorescein Aluorometry

Aluorescein& injected systemically& is deli#ered throu$h a "atent circulation and fluoresces under ultra#iolet li$ht. It has been (idely used to determine #iability of fla"s& intestine& and e#en (hole e%tremities. The use of fluorescein fluorescence to determine burn de"th (as first re"orted in 19 9& but this techni*ue (as unused until more "recise instrumentation (as de#elo"edLa fibero"tic "erfusion fluorometerL (hich could measure the ma$nitude of fluorescence. /atti studied 89 burns (ith the fluorometer after intra#enous administration of sodium fluorescein. The fluorescein 2inetics (ere monitored for 1 h (ithin the first = h& and a$ain bet(een the third and si%th days "ostburn& and com"ared to the 2inetics in adjacent normal s2in. De"th of burn (as confirmed by bio"sy and healin$ characteristics. Aluorometric analysis durin$ both study "eriods consistently distin$uished bet(een "artial'thic2ness and full'thic2ness burns. ,artial'thic2ness burns uniformly e%hibited fluorescence (ithin 15 min3 full'thic2ness burns sho(ed no fluorescence. >o(e#er& (hen this techni*ue (as re"orted in 19=1& most burn sur$eons only e%cised full' thic2ness burns& lea#in$ "artial'thic2ness burns to heal on their o(n& and there (as therefore an ad#anta$e to distin$uishin$ bet(een "artial' and full'thic2ness burns. /atti?s results (ere confirmed in 19= . >o(e#er& a 19=8 re"ort by )lac2 could not confirm si$nificant differences bet(een "artial' and full'thic2ness burns usin$ a similar techni*ue because standard de#iations in both cate$ories (ere too lar$e to distin$uish bet(een $rou"s& let alone be "redicti#e in any $i#en burn. Our o(n e%"erience (ith fluorescein indicates that it confirms the clinical dia$nosis in #ery dee" and #ery shallo( burns& areas (here there is little confusion& but that it cannot distin$uish bet(een intermediate and dee" dermal burns. .aser Do""ler Alo(metry .aser Do""ler flo(metry has been used since 194! for monitorin$ cutaneous circulation. .i$ht from a helium'neon laser is carried by a fibero"tic cable to the s2in (here it interacts (ith stationary structures and mo#in$ blood cells (ithin a sam"le #olume of a""ro%imately 1 mm. )ac2' scattered li$ht from the mo#in$ cells is shifted in #elocity usin$ the Do""ler "rinci"le& (hile bac2'scattered li$ht from stationery objects remains at its ori$inal fre*uency. The mi%in$ of these li$ht(a#es is translated into an electrical si$nal& and mathematical estimations of blood flo( can be made in normal #ersus study areas of s2in. This techni*ue is easy to use and nonin#asi#e :althou$h the "robe must be held a$ainst the s2in<& and "ro#ides immediate results. SNrensen?s $rou" in Denmar2 first re"orted the use of a laser Do""ler flo(meter on a burn unit. Initial studies in our burn center sho(ed e%cellent correlation (ith full' thic2ness burns :no flo(< and shallo( burns :normal or increased flo(<& but considerable #ariation from "atient to "atient (ith com"arable burns& and& at different times& in the same area in the same "atient (ith moderate and dee" dermal burns. Readin$s #aried "articularly (ithI :1< tem"erature :immediately after bathin$& a (arm room& etc.<& :1< the "atient?s state of an%iety :catecholamine res"onse<& and :9< ele#ation of an e%tremity :e.$.& cutaneous blood flo( essentially disa""eared (hen the hands (ere ele#ated<. In further studies& the cutaneous circulation o#er time (as follo(ed in burned "atients and rats to determine (hether measurin$ chan$es in cutaneous blood flo( (ould hel" "redict the ultimate fate of indeterminate burns that (ere not ob#iously shallo( or dee". ; laser Do""ler flo(meter (as used to study cutaneous "erfusion for at least 41

h in "artial' thic2ness (ounds on "atients (ith burns of less than 1! "ercent T)S;& and in e%"erimental (ounds of similar si6e on rats. Clinical (ounds that healed (ithout $raftin$ (ithin 9 (ee2s consistently sho(ed ele#ated "erfusion le#els that continued to increase o#er 41 h. 7ounds e#entually re*uirin$ $raftin$ demonstrated lo(er "erfusion le#els (ith no ob#ious "attern of increase. The obser#ed trends of increased flo( for healin$ burns and flat flo( for nonhealin$ burns (ere constant. Thus for "atients to be follo(ed for se#eral days& this method has merit in decidin$& after day 9& (hich "atients (ill benefit from e%cision and $raftin$. ;s instrumentation has im"ro#ed& so ha#e the results of serial measurements of burn blood flo(. ; differential analysis of multi"le "arameters durin$ measurement has brou$ht accuracy to the =5 to 95 "ercent ran$e in "redictin$ healin$ (ithin 9 (ee2s. Thermo$ra"hy Diminished blood flo( to dee" dermal and full'thic2ness burns ma2es them cooler to touch& a findin$ confirmed by thermo$ra"hy in 194 by >ac2ett. Initial studies of thermo$ra"hy as a tool for "redictin$ the need for e%cision and $raftin$ of dee" dermal (ounds in 95 "atients "resented by -ason in 19=1 su$$ested that thermo$ra"hy mi$ht be more accurate than clinical jud$ment. Thermo$ra"hic findin$s& li2e laser Do""ler flo(metry& are hi$hly de"endent on room and "atient tem"erature& the "atient?s an%iety and stress le#el& and the area of the body bein$ considered& as (ell as the coolin$ effect of e#a"orati#e (ater loss. Des"ite these dra(bac2s& Cole& in 1995& com"ared thermo$ra"hy to clinical assessment of 91 burned hands. Su"erficial and dee" "artial'thic2ness burns (ere treated conser#ati#ely& (ith e%cision and $raftin$ only of those that had not healed 1 to 9 (ee2s after injury. The $rou" that had under$one the delayed sur$ical "rocedure and the healed $rou" (ere analy6ed retros"ecti#ely to determine the "redicti#e #alue of the initial clinical e#aluation and thermo$ra"hy as assessments of the de"th of the burns. Ob#ious full'thic2ness burns (ere e%cised and $rafted (ithin ! days and (ere not included in the study. Initial thermo$ra"hic assessment correctly "redicted the outcome :(hether healed or e%cised and $rafted< in 99 of 98 burns. This relationshi" (as hi$hly si$nificant& (hile initial clinical assessment of de"th had no si$nificant relationshi" (ith the time ta2en to heal. Ultrasound -osero#O& usin$ an industrial ultrasound de#ice in 19=1& (as able to detect differences bet(een normal "i$ s2in and "i$ s2in that had been scalded for ! and 1! s. >is initial (or2 (as e%"anded as technolo$y im"ro#ed. Cantrell (as able to detect denatured from normal colla$en in "i$ s2in. One "roblem (ith this techni*ue is that colla$en denatures at 1 9@A :8!@C< (hile e"idermal cells& from (hich the burn must heal& are 2illed at about 114@A : 4@C<& so ultrasonic a""arent de"th is li2ely to be underestimated. Aurther refinements in instrumentation enabled )rin2 to demonstrate a si$nificant correlation bet(een ultrasound burn de"th and histolo$y in "i$s. 7achtel& in fi#e burn "atients& re"orted that ultrasound com"arisons (ith clinical e#aluation and histo"atholo$ic studies of burn (ound bio"sy s"ecimens of the same burned areas failed to sho( any substanti#e im"ro#ement in "redictin$ the de"th of burn by the ultrasonic scannin$ techni*ues. Technolo$y in this area has dramatically im"ro#ed& so this may still be a techni*ue of the future. Nuclear -a$netic Resonance

Aull'thic2ness burns result in slo(er resor"tion of (ound edema than "artial'thic2ness burns. ,roton N-R "arameters correlate (ith tissue (ater content& and Poruda tested (hether "roton N-R could distin$uish bet(een full'thic2ness and "artial'thic2ness burns. +arly after burnin$& N-R could distin$uish hi$her (ater content in "artial' and full'thic2ness rat burns than in adjacent normal s2in. )y = h& the "artial'thic2ness burn had returned to control #alues& (hile the full'thic2ness burn remained edematous. >o(e#er& the rat s2in had to be e%cised in order to use N-R& and so there is no useful clinical a""lication for the techni*ue. In "artial' and full'thic2ness scald (ounds& reductions in ,CrG,i ratios correlated (ith burn de"th and im"ro#ed o#er time "ostinjury. Auture ad#ances in technolo$y mi$ht enable more "recise measurements in the clinical situation. .i$ht Reflectance The s2in is relati#ely trans"arent to short'(a#elen$th infrared li$ht& and reduced hemo$lobin absorbs more of the li$ht than o%y$enated hemo$lobin. ;nselmo and Qa(ac2i& in 1949& reasoned that thrombosed #essels in full'thic2ness burns (ould become #isible in infrared li$ht& and could be distin$uished from the o"en #essels of "artial'thic2ness burns. Com"uter analysis of "hoto$ra"hs ta2en (ith red& $reen& and infrared filtered li$ht $enerated ratios of the $reenGinfrared& redGinfrared& and redG$reen ima$es "oint by "oint o#er the entire surface that accurately distin$uished shallo(& dee" dermal& and full'thic2ness burns. The techni*ue& ho(e#er& (as too e%"ensi#e& time'consumin$& and slo( for clinical decision ma2in$. >eimbach and ;fromo(it6 de#ised a "ortable& nonin#asi#e :the (ound is not touched< electronic de#ice that could instantaneously measure the s"ectral characteristics of red& $reen& and infrared li$ht reflected from the burn. The de#ice (as essentially 155 "ercent accurate in differentiatin$ shallo( and full'thic2ness (ounds. Aor intermediate (ounds& usin$ the end"oint of (ound healin$ in less than or more than 9 (ee2s& clinical assessment by t(o e%"erienced sur$eons (as com"ared to readin$s from the de#ice. In about one'third of cases& the sur$eons (ere un(illin$ to commit to a "rediction. 7hen sur$eons (ere (illin$ to ma2e a "rediction& they (ere incorrect about 1! "ercent of the time. The reflectance de#ice (as si$nificantly more accurate than the clinical assessment in those burn (ounds "redicted not to heal3 an accuracy of 49 "ercent (as achie#ed in the clinically indeterminate (ounds. The dynamic *ualities of the burn (ound are em"hasi6ed in these studies because the li$ht reflectance de#ice clearly sho(ed chan$es each day for the first 9 to days& and it (as most accurate on day 9. ,>0SIO.O/IC;. R+S,ONS+ TO )URN INJUR0 )urn "atients (ith or (ithout inhalation injury commonly manifest an inflammatory "rocess in#ol#in$ the entire or$anism3 the term systemic inflammatory res"onse syndrome :SIRS< (as introduced to summari6e that condition. The most common cause of SIRS is the burn se"sis. SIRS (ith infection or bacteremia is a major factor determinin$ morbidity and mortality in thermally injured "atients. ,atholo$ic alterations of the metabolic& cardio#ascular& $astrointestinal& and coa$ulation systems occur (ith hy"ermetabolism& an increase in cellular& endothelial& and e"ithelial "ermeability& ty"ical hemodynamic alterations& and often e%tensi#e microthrombosis. The circulatory manifestations of the systemic inflammatory res"onse lar$ely disa""ear (ithin 1 h& but the "atient remains in a hy"ermetabolic state until (ound co#era$e is achie#ed.

)urn Shoc2 )urn shoc2 is a com"le% "rocess of circulatory and microcirculatory dysfunction& not easily or fully re"aired solely by fluid resuscitation. >y"o#olemic shoc2 and tissue trauma result in formation and release of local and systemic mediators& (hich "roduce an increase in #ascular "ermeability or an increase in micro#ascular hydrostatic "ressure. -ost mediators act to increase "ermeability by alterin$ #enular membrane inte$rity. The early "hase of burn edema& lastin$ from minutes to an hour& is attributed to mediators such as histamine& brady2inin& and #asoacti#e amines& "roducts of "latelet acti#ation& and the com"lement cascade of hormones& "rosta$landins& and leu2otrienes. Hasoacti#e amines also may act directly by increasin$ micro#ascular blood flo( or #ascular "ressures& accentuatin$ the burn edema. >istamine is "robably res"onsible for the early "hase of increased ca"illary "ermeability after burn injury& because it is released in lar$e *uantities from mast cells in burned s2in immediately after injury. >istamine increases lea2a$e of fluids and "roteins from systemic micro#essels3 its major effect is on the #enules& in (hich an increase in intra#ascular junction s"ace is characteristic. Serum histamine "ea2s in the first se#eral hours "ostinjury& su$$estin$ that histamine is in#ol#ed only in the #ery early increase in "ermeability. Serotonin is released immediately u"on "ostburn "latelet a$$re$ation and acts directly to increase "ulmonary #ascular resistance and indirectly to am"lify the #asoconstricti#e effects of nore"ine"hrine& histamine& an$iotensin II& and "rosta$landin. ,rosta$landins& #asoacti#e "roducts of arachidonic acid metabolism& are released in burn tissue and contribute to formation of burn edema. These substances do not directly alter #aso"ermeability& but increased le#els of #asodilator "rosta$landins& such as ,/+1& and "rostacyclin& ,/I1& result in arterial dilatation in burn tissue& increasin$ blood flo( and hydrostatic "ressure in the injured microcirculation& accentuatin$ the edema "rocess. Increased concentrations of ,/I1 and the #asoconstrictor thrombo%ane ;1 ha#e been demonstrated in burn tissue& burn blister fluid& lym"h& and (ound secretion. The acti#ation of the "roteolytic cascades& includin$ those of coa$ulation& fibrinolysis& the 2inins& and the com"lement system& occurs immediately after burn injury. Pinins& s"ecifically the brady2inins& increase #ascular "ermeability& "rimarily in the #enule. In addition to the loss of ca"illary inte$rity& thermal injury also causes chan$es at the cellular le#el. )a%ter demonstrated a $enerali6ed decrease in cellular transmembrane "otential in#ol#in$ nonthermally injured and thermally injured cells. ,latelet acti#atin$ factor is released after burn injury and increases ca"illary "ermeability. The reduction of cardiac out"ut after burn injury is a result of hy"o#olemic and cellular shoc2& increased systemic #ascular resistance due to sym"athetic stimulation and hy"o#olemia& (ith release of catecholamines& #aso"ressin& an$iotensin II& and neuro"e"tide 0. ;fter successful resuscitation& cardiac out"ut normali6es after 1= to 1 h and increases to su"ernormal le#els durin$ the (ound'healin$ "hase of burn mana$ement. -etabolic Res"onse to )urn Injury >y"ermetabolism

Restin$ ener$y e%"enditure :R++< after burn injury can be as much as 155 "ercent abo#e "redictions based on standard tables for si6e& a$e& se%& and (ei$ht. Some debate "ersists re$ardin$ the $enesis of this "henomenon& but increased heat loss from the burn (ound and increased b'adrener$ic stimulation are "robably "rimary factors. Radiant heat loss is increased from the burn (ound secondary to hi$h blood flo(. -easurement of restin$ ener$y e%"enditure is hel"ful in assessin$ nutritional status. On a#era$e& restin$ ener$y metabolism e*uals a""ro%imately 1.9 times the "redicted basal ener$y e%"enditure obtained from the >arrison')enedict e*uation. /lucose metabolism is ele#ated in almost all critically ill "atients& includin$ those (ith burn injuries& but studies ha#e focused "articularly on burn "atients because their relati#ely stable condition allo(s re"roducible e%"erimental conditions. /luconeo$enesis& "articularly from alanine& and $lyco$enolysis are increased. ,rotein is e%creted "rimarily in the urine as urea& contributin$ to the "ro$ressi#e de"letion of body "rotein stores. ,roteolysis in burn "atients is increased as com"ared to normal indi#iduals (ho are fed the same amount of "rotein and calories. This results in increased efflu% of amino acids from the muscle& includin$ $luco$enic amino acids. ;lanine& in "articular& is released at an increased rate. Increased $luconeo$enesis from amino acid renders these amino acids una#ailable for reincor"oration into the body "rotein. ,lasma insulin le#els that are usually normal are ele#ated in burn "atients. The basal rate of $lucose "roduction is ele#ated des"ite a normal or ele#ated "lasma insulin le#el& (hich can be defined as he"atic insulin resistance. Aatty acids are released at a rate in e%cess of re*uirements of fatty acids and ener$y substrates. In burn "atients& o#er 45 "ercent of released fatty acids are not o%idi6ed& but rather reesterified into tri$lyceride& resultin$ in fat accumulation in the li#er. This is unfortunate because utili6ation of fat for ener$y (ould decrease de"endence on "roteolysis. ; number of studies ha#e been desi$ned to assess the o"timal form of carbohydrate and fat. )oth %ylitol and fructose ha#e been "osed as alternati#e carbohydrates& and a (ide #ariety of fats ha#e been ad#ocated& includin$ fish oil& medium'chain tri$lycerides& and structured li"ids in (hich medium' and lon$'chain fatty acids are incor"orated into the same tri$lyceride molecule. Rylitol and fructose re*uire ener$y for trans"osition to $lucose before utili6ation for ener$y. Rylitol in lar$e *uantities is he"atoto%ic& and fructose may cause lactic acidosis. -ajor trauma& burns& and se"sis ha#e in common a ra"id net catabolism of body "rotein& as (ell as a redistribution of the nitro$en "ool (ithin the body. -uscle "rotein brea2do(n is accelerated (hile Bacute "haseC "roteins are "roduced at an increased rate in the li#er. 7ound re"air re*uires amino acid "rotein synthesis and increased immunolo$ic acti#ity& and may re*uire accelerated "rotein synthesis. ,rotein inta2e o#er 1 $G2$Gday has been recommended for thermally injured "atients3 for thermally injured "atients (ith normal renal function& the recommended "rotein inta2e is 1 $G2$Gday. The im"ortance of $lutamine inta2e in critically ill "atients has been in#esti$ated. Current oral and enteral formulations ha#e lar$ely omitted $lutamine& but some beneficial effects ha#e been found (ith enteral $lutamine. Includin$ $lutamine in intra#enous formulations results in im"ro#ed nitro$en balance& (hich& (hile statistically si$nificant& "robably is not biolo$ically si$nificant because of its insufficient ma$nitude. Neuroendocrine'-ediator Res"onse

Catecholamines a""ear to be the major endocrine mediators of the hy"ermetabolic res"onse in thermally injured "atients. ,harmacolo$ic bloc2ade of beta rece"tors diminishes the intensity of "ostburn hy"ermetabolism. Thyroid hormonal serum concentrations are not ele#ated in "atients (ith lar$e burns. Total thyronine :T9< and thyro%ine :T < concentrations are reduced& and re#erse T9concentrations are ele#ated (hile cellular concentrations are li2ely normal. Concentrations of free T9 and T fall mar2edly in the "resence of se"sis in burned "atients. )urn injury abolishes the normal diurnal #ariation in $lucocorticoid concentrations& but these hormones do not a""ear to influence metabolic acti#ity directly and only ha#e a "ermissi#e role in catecholamine stimulation. They are& ho(e#er& "rimarily res"onsible for increased "roteolysis. /luca$on concentrations are related directly to metabolic rate and cortisol concentrations and may modulate restin$ metabolism throu$h anti'insulin effects. Immune Res"onse to )urn Injury The immune status of the burn "atient has a "rofound im"act on outcome in terms of sur#i#al& death& and major morbidity. The $reatest difficulty in attem"tin$ to deci"her the body?s res"onse to injury is the com"le% interaction of the cyto2ine cascade& the arachidonic acid cascade& and the neuroendocrine a%is. Cyto2ine Cascade Cyto2ines (ere considered ori$inally to be re$ulatory chemicals secreted by cells of the immune system& and $ro(th factors (ere seen as chemicals ori$inatin$ from inflammatory and re"arati#e tissue. The distinction bet(een $ro(th factors and "e"tides& hormones& and cyto2ines is no lon$er distinct. -any of these cyto2ines and $ro(th factors are released from dama$ed tissues at the (ound site& (here they e%ert local and systemic effects. ;fter injury& a number of cyto2ines are induced ra"idly& includin$ tumor necrosis factor :TNA<& interleu2in'1 :I.'1<& and interleu2in'8 :I.'8<. The timetable of induction is similar in burned andGor injured "atients. Tumor necrosis factor al"ha :TNA'a< is detectable early in the "eriod of burn shoc23 the ma%imum le#el of TNA'a throu$hout the course is of "ro$nostic si$nificance. )ecause the "hysiolo$ical effects of TNA are almost indistin$uishable from endoto%in& the induction of TNA has been held res"onsible for the clinical effects of endoto%emia. ;fter initial induction of I.'1& synthesis is im"aired si$nificantly for se#eral days after injury. )y contrast& there is u"'re$ulation of local "roduction of I.'1 and I.'8 in inflammatory sites& inducin$ "olymor"honuclear neutro"hil chemoattraction. Interleu2in'1 :I.'1< is a 2ey cyto2ine in the mediation of the cellular immune res"onse& and "atients (ith lar$e burns ha#e si$nificantly su""ressed "roduction of I.'1& (hich correlates (ith the len$th of time from injury. In#esti$ations of "ulmonary "roduction of I.'= after res"iratory distress syndrome are not inconclusi#e. Interleu2in'8 :I.'8< is a ubi*uitous cyto2ine that is "roduced by a #ariety of cells& and is detected in increased concentration in blood or tissues after disturbances of "hysiolo$ical homeostasis& includin$ thermal injury. Its most im"ortant role is the induction of he"atic synthesis of acute "hase res"onse "roteins that include antibacterial "roducts& such as a'$lyco"rotein& C9& and fibronectin.

;rachidonic Cascade The major "roduct of arachidonic acid cascade after thermal injury is "rosta$landin +1 :,/+ 1<& "roduced by macro"ha$es and "artially mediated by endoto%in. ,/+1 e%erts its immunosu""ressi#e effect "rimarily by inhibition of lym"hocyte I.'1 "roduction and T'cell acti#ation and do(n' re$ulation of I.'8. The induction of the arachidonic acid cascade is com"le%& and is a""arently de"endent at least on t(o "ath(ays& one calcium'channel' de"endent and one calcium'inde"endent. There are massi#e increases of another arachidonic acid deri#ati#e& thrombo%ane )1& in the "lasma of burn "atients& "articularly immediately "ostburn and durin$ se"tic e"isodes. .eu2otriene ) & another arachidonic acid "roduct& is a "otent neutro"hil chemotactin that is "roduced after thermal injury. Cell'-ediated Immunity Cell'mediated immunity is im"aired after burn injury& includin$ documented delays in allo$raft rejection& im"airment in mito$enic and ano$enic res"onsi#eness of lym"hocytes& burn'si6e'related su""ression of $raft' #ersus'host acti#ity& su""ression of delayed cutaneous sensiti#ity tests& and diminution of "eri"heral lym"hocytes and thoracic duct lym"hocyte concentration. There is a$reement that the functional ca"acity of thymode"endent lym"hocytes :T cells< to "erform their normal "hysiolo$ical res"onse is im"aired. 7hether this failure is the result of Bo#eruseC or indirectly the result of do(n're$ulation by cyto2ine cascades and other "roducts of the inflammatory reaction is unclear. -acro"ha$es -acro"ha$e function is im"aired after thermal injury. -acro"ha$e "roducts su""ress mito$enic res"onsi#eness in normal lym"hocytes. ,roinflammatory cyto2ines are "roduced by macro"ha$es in short bursts& "robably inhibited by a feedbac2 loo" (ith decreased rece"tor e%"ression. ;cti#ation includes "ulmonary macro"ha$es and may "ro#ide the bac2$round for the de#elo"ment of the adult res"iratory distress syndrome seen in burn "atients. ) Cells The function of bone marro(Sderi#ed thymocytes& or ) cells& after thermal injury is less (ell documented than that of the macro"ha$es or T cells. The )'cell "o"ulation is subject to the same nons"ecific acti#ation as the rest of the lym"hocyte "o"ulation. Neutro"hils Neutro"hil dysfunction after thermal injury has been e%tensi#ely studied3 it is manifested by a decreased Ac rece"tor e%"ression& de"ressed intracellular 2illin$ ca"acity& and leu2ocyte chemota%is that is accom"anied by a brief increase in neutro"hil res"iratory burst. In addition& e%"ression of CD18 :AcR& Ac& I$/ rece"tors< and CD11 :adhesion molecules< on neutro"hils is im"aired after thermal injury& and this reduction seems to be directly related to the a""earance of bacteremia and "neumonia. )aseline $ranulocyte o%idati#e acti#ity in burn neutro"hils is increased. Induction of neutro"hil acti#ation "robably re*uires se#eral different stimulants& but it is 2no(n that TNA and endoto%in can both acti#ate neutro"hils3 Il'8 is also a "otent inducer of su"ero%ide "roduction by the neutro"hil. >umoral Immunity

;fter thermal injury there is a mar2ed diminution of total serum I$/ concentration and all subclasses. These le#els return to normal bet(een 15 and 1 days "ostburn. +%tremely lo( le#els of I$/ on admission are "redicti#e of a "oor "ro$nosis. These chan$es ha#e been ascribed to a combination of lea2a$e throu$h the burn (ound& "rotein catabolism& and a relati#e diminution in synthesis of I$/. I$- and I$; le#els a""ear to be relati#ely unaffected. The classical and the alternati#e com"lement "ath(ays are de"leted& but the alternati#e "ath(ay is more "rofoundly altered. Com"lement inacti#ation by heat a""ears to ameliorate cell'mediated immunosu""ression& su$$estin$ that some of the im"airment of the cell' mediated immunosu""ression "ostburn may be due to a com"lement' associated mechanism. The "roduction of $ranulocyte colony' stimulatin$ factor :/CSA< and of $ranulocyte'macro"ha$e colony'stimulatin$ factor :/-'CSA< is also im"aired. Unidentified or "artially identified immunosu""ressi#e factors are "resent in burn serum and in burn subeschar tissue fluid. ; lo('molecular'(ei$ht immunosu""ressi#e "e"tide has been found in blood that is ca"able of su""ressin$ neutro"hil chemota%is& T'cell blasto$enesis& and )'cell blasto$enesis. A.UID -;N;/+-+NT ,ro"er fluid mana$ement is critical to sur#i#al in major thermal injury. In the 19 5s& hy"o#olemic shoc2 or shoc2'induced renal failure (as the leadin$ cause of death after burn injury. -ortality related to burn'induced #olume loss has decreased considerably (ith increased 2no(led$e of the massi#e fluid shifts and hemodynamic chan$es that occur durin$ burn shoc2. ; #i$orous a""roach to fluid thera"y has led to reduced mortality rates in the first = h "ostburn& but !5 "ercent of the deaths occur (ithin the first 15 days after burn injury from a multitude of causes. One of the most si$nificant causes is inade*uate fluid resuscitation thera"y. Aluid mana$ement after burn shoc2 resuscitation is also im"ortant. >istorical ,ers"ecti#e The necessity for fluid resuscitation after burn injury (as a""reciated o#er a century a$o& but the ma$nitude of the fluid loss (as not a""arent until the studies of Aran2 Underhill of the #ictims of the Rialto Theater fire in 1911. That burn shoc2 (as due to e%tra#ascular fluid loss (as further elucidated by Co"e and -oore& (ho conducted studies on "atients from the Coconut /ro#e disaster in 19 1. They de#elo"ed the conce"t of burn edema and introduced the body (ei$htSburn formula for fluid resuscitation. In 19!1& +#ans de#elo"ed a burn surface areaS(ei$ht formula that became the first sim"lified means of calculatin$ fluid resuscitation needs for burn "atients. Sur$eons at the )roo2e ;rmy -edical Center modified the ori$inal +#ans formula and this became the standard for the ne%t 1! years. ,atho"hysiolo$y of )urn Shoc2 )urn shoc2 is hy"o#olemic and cellular in nature& and is characteri6ed by s"ecific hemodynamic chan$es includin$ decreased cardiac out"ut& e%tracellular fluid& and "lasma #olume& and oli$uria. ;s (ith other forms of shoc2& the "rimary $oal is to restore and "reser#e tissue "erfusion. In burn shoc2& resuscitation is com"licated by obli$atory burn edema& and the #oluminous trans#ascular fluid shifts that result from a major burn are uni*ue to thermal trauma.

One major com"onent of burn shoc2 is the increase in total body ca"illary "ermeability. Direct thermal injury results in mar2ed chan$es in the microcirculation. -ost of the chan$es occur locally at the burn site3 ma%imal edema formation occurs bet(een = and 11 h "ostinjury in smaller burns& and 11 and 1 h "ostinjury in major thermal injuries. The rate of "ro$ression of tissue edema is de"endent u"on the ade*uacy of resuscitation. -ulti"le mediators ha#e been "ro"osed to e%"lain the chan$es in #ascular "ermeability. The "ro"osed mediators "roduce an increase in #ascular "ermeability or an increase in micro#ascular hydrostatic "ressure. The end result of the chan$es in the micro#asculature due to thermal injury is disru"tion of normal ca"illary barriers se"aratin$ intra#ascular and interstitial com"artments& and ra"id e*uilibrium bet(een these com"artments. ,lasma #olume is se#erely de"leted& clinically manifested as hy"o#olemia& (ith a mar2ed increase in e%tracellular fluid. Thermal injury also causes chan$es at the cellular le#el. )a%ter has demonstrated that in burns $reater than 95 "ercent T)S;& there is a systemic decrease in cell transmembrane "otential& in#ol#in$ nonthermally injured cells. This decrease in cell' transmittin$ "otential& defined by the Nernst e*uation& results from an increase in intracellular sodium concentration secondary to a decrease in sodium ;T,ase acti#ity res"onsible for maintainin$ the intracellular'e%tracellular ionic $radient. Resuscitation only "artially restores the membrane "otential and intracellular sodium concentrations to normal le#els& demonstratin$ that hy"o#olemia& (ith its attendant ischemia& is not totally res"onsible for the cellular s(ellin$ seen in burn shoc2. -embrane "otential may not return to normal for many days "ostburn des"ite ade*uate resuscitation. If resuscitation is inade*uate& cell membrane "otential "ro$ressi#ely decreases& resultin$ ultimately in cell death. -oyer& )a%ter& and Shires established the role of crystalloid solutions in burn resuscitation& and delineated the fluid #olume chan$es in the early "ostburn "eriod. -oyer?s studies& in 198!& demonstrated that burn edema se*uesters enormous amounts of fluid& resultin$ in the hy"o#olemia of burn shoc2. )a%ter and Shires in 198=& usin$ radioisoto"e dilution techni*ues& demonstrated that edema fluid in the burn (ound is isotonic (ith res"ect to "lasma& and contains "rotein in the same "ro"ortions as that found in blood. This (as further e#idence of the com"lete disru"tion of the normal ca"illary barrier in major burns& (ith free e%chan$e bet(een "lasma and e%tra#ascular e%tracellular com"artments. In a canine model& they also established the end "oints of crystalloid resuscitation as o"timal cardiac out"ut and restoration of +CA at the end of 1 h. Clinical studies confirmed the efficacy of restorin$ +CA to (ithin 15 "ercent of controls (ithin 1 h. This became the basis for the )a%ter :,ar2land< formula. The associated mortality rate (as com"arable to that obtained (ith a colloid'containin$ resuscitation formula. -oncrief and ,ruitt characteri6ed the hemodynamic alterations in burn shoc2 (ith and (ithout fluid resuscitation. Their efforts culminated in the )roo2e formula modification& (hich (as based on 1 m. "er 2ilo$ram of body (ei$ht "er "ercenta$e of T)S; burned :1 m.G2$ body (ei$htGK burn< durin$ the first 1 h. Aluid needs (ere estimated initially accordin$ to the modified )roo2e formula& but the actual #olume for resuscitation (as based on clinical res"onse. In their study& resuscitation

"ermitted an a#era$e decrease of about 15 "ercent in both e%tracellular fluid and "lasma #olume& but no further loss accrued in the first 1 h. In the second 1 h "ostburn& "lasma #olume restoration occurred (ith the administration of colloid. Cardiac out"ut& initially lo(& rose o#er the first 1= h "ostburn& des"ite "lasma #olume and blood #olume deficits. ,eri"heral #ascular resistance rose durin$ the initial 1 h& but decreased as cardiac out"ut im"ro#ed. 7hen "lasma #olume and blood #olume loss ceased& cardiac out"ut rose to su"ranormal le#els (here it remained until healin$ or $raftin$ occurred. -oylan and associates in 1949& usin$ a canine model& defined the relationshi"s bet(een fluid #olume& sodium concentration& and colloid in restorin$ cardiac out"ut. No si$nificant colloid effect on cardiac out"ut (as noted in the first 11 h "ostinjury. In addition& 1 me* of sodium (as found to e%ert an effect on cardiac out"ut e*ual to 19 times that of 1 m. of salt' free fluid #olume. Thus& any combination of sodium and fluid #olume (ithin the broad limits of the study (ould effecti#ely resuscitate a thermally injured "atient. ;rturson?s 1949 studies characteri6ed the nature of the Blea2y ca"illaryC in the "ostburn "eriod. In a canine model& increased ca"illary "ermeability (as found locally and in remote nonburned tissue (hen the T)S; burned e%ceeded 1! "ercent. >e "ro"osed that the burn (ound is characteri6ed by ra"id edema formation due to dilatation of the resistance #essels :"reca"illary arterioles<& increased e%tra#ascular osmotic acti#ity due to the "roducts of thermal injury& and increased micro#ascular "ermeability to macromolecules. The increased "ermeability "ermits molecules (ith molecular (ei$hts of u" to 9!5&555 to esca"e from the micro#asculature& a si6e that allo(s essentially all elements of the #ascular s"ace& e%ce"t red blood cells& to esca"e. Studies by Demlin$ and co'(or2ers ha#e demonstrated that in !5 "ercent T)S; burns& one'half of the initial fluid resuscitation re*uirement may end u" in nonthermally injured tissues. Resuscitation from )urn Shoc2 The "rimary $oal of fluid resuscitation is to re"lace fluid se*uestered as a result of thermal injury. The critical conce"t in burn shoc2 is that massi#e fluid shifts can occur e#en thou$h total body (ater remains unchan$ed. 7hat actually chan$es is the #olume of each fluid com"artment& (ith intracellular and interstitial #olumes increasin$ at the e%"ense of "lasma #olume and blood #olume. The edema is accentuated by the resuscitation "rocess. The National Institutes of >ealth consensus summary on fluid resuscitation in 194= (as not in a$reement in re$ard to a s"ecific formula& but there (as consensus on t(o major issuesI $eneral $uidelines to be used durin$ the resuscitation "rocess& and ty"e of fluid. The #olume infused should be the least amount of fluid necessary to maintain ade*uate or$an "erfusion and should be continually titrated to a#oid under' or o#erresuscitation. Re"lacement of the e%tracellular salt lost into the burned tissue and into the cell is essential for successful resuscitation. Crystalloid Resuscitation Crystalloid& in "articular lactated Rin$er?s solution (ith a sodium concentration of 195 me*G.& is the most "o"ular resuscitation fluid. ,ro"onents of the use of crystalloid solution ar$ue that other solutions& s"ecifically colloids& are no better& and certainly more e%"ensi#e& than crystalloid for maintainin$ intra#ascular #olume after

thermal injury. +#en lar$e "roteins lea2 from the ca"illary after thermal injury& ne$atin$ any theoretical ad#anta$e from colloid. Ca"illaries in nonburned tissues may maintain relati#ely normal "rotein "ermeability characteristics. The *uantity of crystalloid needed is de"endent u"on the "arameters used to monitor resuscitation. If a urinary out"ut of 5.! m.G2$ of body (ei$htGh indicates ade*uate "erfusion& a""ro%imately 9 m.G2$GK burn (ill be needed in the first 1 h. If 1m.G2$ body (ei$htGh is o"timal& considerably more fluid (ill be needed& and more edema (ill result. The ,ar2land formula recommends m.G2$GK burn in the first 1 h& (ith one'half of that amount administered in the first = h :Table 4'1<. The modified )roo2e formula recommends be$innin$ burn shoc2 resuscitation at 1 m.G2$GK burn in the first 1 h :Table 4'1<. In major burns& se#ere hy"o"roteinemia usually de#elo"s (ith these resuscitation re$imens. The hy"o"roteinemia and interstitial "rotein de"letion may result in more edema formation. >y"ertonic Saline The resuscitation of burn "atients (ith salt solution of 1 5 to 955 me*G. rather than lactated Rin$er?s solution results in less edema because of the smaller total fluid re*uirements Urine out"ut is used as the indicator of ade*uate resuscitation. Demlin$ and collea$ues demonstrated in an animal model that the net fluid inta2e (as less if burned animals (ere resuscitated (ith hy"ertonic saline to the same cardiac out"ut as com"ared (ith lactated Rin$er?s. Urine out"ut (as much hi$her (ith hy"ertonic solution. Soft tissue interstitial edema in burned and nonburned tissue& as reflected by lym"h flo(& (as increased (ith hy"ertonic saline to a similar e%tent as (ith lactated Rin$er?s. ; shift of intracellular (ater into e%tracellular s"ace occurs as the result of the hy"erosmolar solution. +%tracellular edema increases as intracellular fluid decreases& $i#in$ the e%ternal a""earance of less edema. Se#eral studies ha#e re"orted that this intracellular (ater de"letion does not a""ear to be deleterious& but the issue is contro#ersial. Current recommendations are that the serum sodium le#els should not be allo(ed to e%ceed 185 me*Gd.. /unn and associates in a "ros"ecti#e randomi6ed study of "atients (ith 15 "ercent T)S; burns e#aluated hy"ertonic sodium lactate #ersus lactated Rin$er?s solution and (ere not able to demonstrate decreased fluid re*uirements& im"ro#ed nutritional tolerance& or decreased body (ei$ht $ain "ercenta$e. 7e ha#e used a modified hy"ertonic solution in major thermal injuries of $reater than 5 "ercent T)S;. The resuscitation fluid contains 1=5 me* N;T :lactated Rin$er?s T !5 me* Na>CO9<& and is used until re#ersal of metabolic acidosis has occurred& usually by = h "ostburn. Resuscitation is be$un at m.G2$GK burn& but the administered #olume is titrated to maintain urine out"ut at 95 to !5 m.Gh. ;fter = h& lactated Rin$er?s is administered to maintain urine out"ut at 95 to !5 m.Gh. >y"ernatremia is a#oided in infants and in the elderly. Colloid Resuscitation ,lasma "roteins $enerate the in(ard oncotic force that counteracts the out(ard ca"illary hydrostatic force. 7ithout "rotein& "lasma #olume could not be maintained. ,rotein re"lacement (as an im"ortant com"onent of early formulas for burn mana$ement. The +#ans formula used 1 m.G2$ body (ei$htGK burn each for colloid and lactated Rin$er?s& o#er the first 1 h. In the ori$inal )roo2e ;rmy >os"ital formula& 5.! m.G2$GK burn (as administered as colloid& and 1.! m.G2$GK burn as

lactated Rin$er?s. -oore?s formula "ro"osed a substantial amount of colloid. Considerable confusion e%ists concernin$ the role of "rotein :albumin< in a resuscitation formula. There are three a""roachesI :1< ,rotein solutions are not $i#en in the first 1 h because durin$ this "eriod they are no more effecti#e than salt containin$ crystalloid (ater in maintainin$ intra#ascular #olume. ,rotein may also "romote accumulation of lun$ (ater (hen edema fluid is absorbed from the burn (ound. :1< ,roteins& s"ecifically albumin& should be $i#en from the be$innin$ of resuscitation (ith crystalloid. :9< ,rotein should not be $i#en bet(een = h to 11 h "ostburn because of the massi#e fluid shifts durin$ this "eriod& after (hich they should be used. Demlin$ demonstrated that restoration and maintenance of "lasma "rotein content are not effecti#e until = h "ostburn& (hen ade*uate le#els can be maintained (ith infusion. )ecause nonburned tissues a""ear to re$ain normal "ermeability shortly after injury and because hy"o"roteinemia may accentuate the edema& the first alternati#e is the least a""ro"riate. >eat'fi%ed "lasma "rotein solutions& e.$.& ,lasmanate& contain some denatured and a$$re$ated "rotein& (hich decreases the oncotic effect. ;lbumin solutions are clearly the most oncotically acti#e solutions. Aresh fro6en "lasma contains all the "rotein fractions that e%ert the oncotic and the nononcotic functions. The o"timal amount of "rotein remains undefined. Demlin$ uses bet(een 5.! and 1 m.G2$GK burn of fresh fro6en "lasma durin$ the first 1 h& be$innin$ at = to 15 h "ostburn& and also ar$ues that (hile all major burns re*uire lar$e amounts of fluid& the follo(in$ $rou"s of "atients de#elo" less edema and better maintain hemodynamic stability if fresh fro6en "lasma is used durin$ resuscitationI older "atients (ith burns& "atients (ith burns and concomitant inhalation injury& and "atients (ith burns in e%cess of !5 "ercent T)S;. Slater and co'(or2ers used fresh fro6en "lasma durin$ burn shoc2& lactated Rin$er?s& 1 .G1 h& and fresh fro6en "lasma& 4! m.G2$G1 h :Table 4'1<. The #olume of fresh fro6en "lasma is calculated& but the #olume infused is titrated to maintain an ade*uate urine out"ut. These authors use colloid early in the burn shoc2 "eriod& but most burn "atients ha#e recei#ed lactated Rin$er?s in si$nificant #olumes durin$ field mana$ement. In the youn$ "ediatric burn "atient (ith major burn injury& colloid re"lacement is fre*uently re*uired because serum "rotein concentration ra"idly decreases. De%tran De%tran is a colloid consistin$ of $lucose molecules that ha#e been "olymeri6ed into chains to form hi$h'molecular'(ei$ht "olysaccharides. This com"ound is a#ailable commercially in a number of molecular si6es. De%tran& (ith an a#era$e molecular (ei$ht of 5&555& is referred to as lo(' molecular (ei$ht'de%tran. )ritish de%tran has a mean molecular (ei$ht of 1!5&555& but the de%tran used in S(eden has a molecular (ei$ht of 45&555. De%tran is e%creted by the 2idneys& (ith 5 "ercent remo#ed (ithin 1 h& and the remainder is slo(ly metaboli6ed. Demlin$ and associates used de%tran 45 in a 8K solution to "re#ent edema in nonburned tissues. De%tran 45 is associated

(ith some ris2 of aller$ic reaction& and can interfere (ith blood ty"in$. De%tran 5 im"ro#es the microcirculatory flo( by decreasin$ red blood cell a$$re$ation. The net re*uirements for maintainin$ #ascular "ressure at the baseline le#els (ith de%tran 5 are about half those noted (ith lactated Rin$er?s alone durin$ the first 1 h "ostburn& (ith an infusion rate of de%tran 5 and saline of 1 m.G2$Gh (ith sufficient lactated Rin$er?s to maintain ade*uate "erfusion. ;t = h& an infusion of fresh fro6en "lasma at 5.! to 1.5 m.G2$GK burn o#er 1=h is instituted (ith necessary additional crystalloid :see Table 4'1<. S"ecial Considerations in )urn Shoc2 Resuscitation Aluid Resuscitation in the Thermally Injured ,ediatric ,atient The burned child re"resents a s"ecial challen$e& because resuscitation thera"y must be more "recise than that for an adult (ith a similar burn. Children ha#e a limited "hysiolo$ical reser#e. Children re*uire "ro"ortionately more fluid for burn shoc2 resuscitation than adults (ith similar thermal injury3 fluid re*uirements for children a#era$e !.= m.G2$GK burn. Children commonly re*uire intra#enous resuscitation for relati#ely small burns of 15 to 15 "ercent T)S;& a findin$ confirmed by )a%ter. /ra#es and associates $i#e children 8.9 M 1 m.G2$GK burn. The Cincinnati Shriners )urns Institute uses the ,ar2land formula& addin$ maintenance fluid to the resuscitation fluid #olume& to be$in burn shoc2 resuscitation& m.G2$GK burn& "lus 1!55 m. maintenance fluid "er s*uare meter of burn surface area :)S;<& "er 1 h :Table 4'1<. /ra#es found that if maintenance fluids (ere subtracted from the resuscitation fluid re*uirements& the resultin$ resuscitation #olume a""roached m.G2$GK burn. ;t the /al#eston Shriners )urns Institute& fluid re*uirements are estimated accordin$ to a formula based on T)S;& and burned )S;& in s*uare meters. Total fluid re*uirements for the first day are estimated as follo(sI !555 m.Gm1 K burnG1 h T 1555 m.Gm1 )S;G 1 h. Inhalation Injury Inhalation injury increases the fluid re*uirements for resuscitation from burn shoc2 after thermal injury. ,atients (ith documented inhalation injury re*uire !.4 m.G2$GK burn& as com"ared to 9.9= m.G2$GK burn in "atients (ithout inhalation injury. Inhalation injury accom"anyin$ thermal trauma increases the ma$nitude of total body injury and re*uires increased #olumes of fluid and sodium to achie#e resuscitation. Choice of Aluids and Rate of ;dministration ;ll the solutions re#ie(ed are effecti#e in restorin$ tissue "erfusion. -ost "atients (ith burns under 5 "ercent T)S; (ith no "ulmonary injury can be resuscitated (ith isotonic crystalloid fluid. In "atients (ith burns of o#er 5 "ercent T)S;& andGor in "atients (ith "ulmonary injury& hy"ertonic saline can be used in the first = h "ostburn& after (hich lactated Rin$er?s is infused to com"lete resuscitation. In "ediatric and elderly burn "atients& usin$ less concentrated but hy"ertonic concentrations of sodium :e.$.& 1=5 me*G.< $i#es the benefits of hy"ertonic resuscitation (ithout the "otential com"lications of e%cessi#e sodium retention and hy"ernatremia. In "atients (ith massi#e burns& youn$ "ediatric "atients& and burns com"licated by se#ere inhalation injury& a combination of fluids can be used to achie#e the desired $oal of tissue "erfusion (hile minimi6in$ edema. In these "atients& the re$imen of modified hy"ertonic :lactated Rin$er?s T !5 me* Na>CO9< saline fluid containin$ 1=5 me* NaG. is used for the first = h. ;fter correction of the metabolic acidosis&

(hich usually re*uires = h& the "atients are $i#en lactated Rin$er?s only for the second = h. In the last = h& !K albumin in lactated Rin$er?s solution com"letes the resuscitation. The resuscitation solution used in /al#eston for "ediatric "atients is an isotonic $lucose'containin$ solution to (hich a moderate amount of colloid :human serum albumin< is added. The solution is "re"ared by mi%in$ !5 m. of 1!K human serum albumin :11.! $< (ith 9!5 m. of !K de%trose in a lactated Rin$er?s solution. The #olume of infused fluid should maintain a urine out"ut of 95 to !5 m.Gh in adults and 1 m.G2$Gh in children. In children (ei$hin$ more than !5 2$& the urine #olume should not e%ceed 95 to !5 m.Gh. >eart rate and blood "ressure are not indicati#e of fluid #olume status in the burn "atient3 therefore& fluid #olume status and cardiac out"ut should be measured directly #ia thermodilution "ulmonary artery catheteri6ation& but a lo( measured fillin$ "ressure (ith e#idence of ade*uate "erfusion is common. ,lacement of a S(an'/an6 catheter to monitor burn shoc2 resuscitation should be reser#ed for burn "atients (ith limited cardiac reser#e& such as the elderly or "atients (ith si$nificant concomitant disease& or burn "atients (ho re*uire lar$e #olumes. None of the resuscitation formulas can be more than $eneral $uidelines for burn shoc2 resuscitation. The ,ar2land formula& for instance& decreases the #olume administered by !5 "ercent at = h "ostburn. The relationshi" bet(een the fluid #olume re*uired and time "ostburn de"icted by the smooth cur#e in Ai$. 4'9 re"resents the influence of tem"oral chan$es in micro#ascular "ermeability and edema #olume on fluid needs. The $entle chan$es de"icted by that cur#e are in shar" contrast (ith the abru"t chan$es in fluid infusion rate "rescribed by the formula. Resuscitation is considered successful (hen there is no further accumulation of edema fluid& usually bet(een 1= and 95 h "ostburn& and the #olume of infused fluid needed to maintain ade*uate urine out"ut a""ro%imates the maintenance fluid #olume& (hich is the "atient?s normal maintenance #olume "lus e#a"orati#e (ater loss. Aluid Re"lacement Aollo(in$ )urn Shoc2 Resuscitation >eat'injured micro#essels may manifest increased #ascular "ermeability for se#eral days& but the rate of fluid loss is considerably less than that seen in the first 1 h. )urn edema at 1 h "ostburn is near ma%imal& and the interstitial s"ace may (ell be saturated (ith sodium. ;dditional fluid re*uirements de"end on the ty"e of fluid used durin$ the initial resuscitation. If hy"ertonic salt resuscitation (as used durin$ the entire burn shoc2 "eriod& a hy"erosmolar state is "roduced& and the addition of free (ater is re*uired to restore the e%tracellular s"ace to an iso'osmolar state. If colloid (as not been used durin$ burn shoc2 and the serum oncotic "ressure is lo( because of intra#ascular "rotein de"letion& "rotein re"letion fre*uently is needed. ,rotein re*uirement #aries (ith the resuscitation used. The )roo2e formula "ro"oses 5.9 to 5.! m.G2$GT)S; burn of !K albumin durin$ the second 1 h. The ,ar2land formula re"laces the "lasma #olume deficit& (hich #aries from 15 to 85 "ercent of the circulatin$ "lasma #olume& (ith colloid. 7e ha#e used colloid re"lacement based on a 15 "ercent "lasma #olume deficit durin$ the second 1 h :circulatin$ "lasma #olume U 15 "ercent<.

In addition to colloid& the "atients should recei#e maintenance fluids. The total daily maintenance fluid re*uirement in the adult "atient is calculated by the follo(in$ formula& (here m1 is s*uare meters of T)S;I Total maintenance fluid V :1!55 m.Gm1< T e#a"orati#e (ater loss E:1! T K burn< U m1 U 1 F This fluid may be $i#en intra#enously or #ia enteral feedin$. The solution infused intra#enously should be !5K normal saline (ith "otassium su""lements. )ecause of the loss of intracellular "otassium durin$ burn shoc2& the "otassium re*uirement in adults is about 115 me*Gday. ;fter the initial 1 to = h "ostburn "eriod of resuscitation& urinary out"ut is an unreliable $uide to sufficient hydration. Res"iratory (ater losses3 osmotic diuresis secondary to $lucose intolerance3 hi$h'"rotein& hi$h' calorie feedin$s3 and deran$ements in antidiuretic hormone :;D>< mechanisms contribute to increased fluid losses& des"ite an ade*uate urine out"ut. ;dult "atients (ith major thermal injuries re*uire a urine out"ut of 1!55 to 1555 m.G1 h3 children re*uire 9 to m.G2$Gh. -easurement of serum sodium concentration is not only a means of dia$nosin$ dehydration& but the best $uide for mana$in$ successful fluid re"lacement. Other useful laboratory indices of the state of hydration include body (ei$ht chan$e& serum and urine nitro$en concentrations& serum and urine urea $lucose concentrations& the inta2e and out"ut record& and clinical e%amination. Aor #ery lar$e burns& and in the "ediatric burn "atient& continuous colloid re"lacement may be re*uired to maintain colloid oncotic "ressure -aintainin$ serum albumin le#els abo#e 1.5 $Gd. is desirable. +lectrolytes& calcium& ma$nesium& and "hos"hate should also be monitored and maintained (ithin normal limits. R+S,IR;TOR0 INJUR0 Of the nearly !5&555 fire #ictims admitted to hos"itals each year& smo2e or thermal dama$e to the res"iratory tree may occur in as many as 95 "ercent. Carbon mono%ide "oisonin$& thermal injury& and smo2e "oisonin$ are three distinctly se"arate as"ects of clinical inhalation injury& and thou$h sym"toms and treatment are distinct& they may coe%ist and re*uire concomitant treatment. Carbon -ono%ide ,oisonin$ ;s many as 85 to 45 "ercent of deaths from house fires can be attributed to carbon mono%ide "oisonin$. Carbon mono%ide is a colorless& odorless& tasteless $as that has an affinity for hemo$lobin 155 times $reater than o%y$en. 7hen inhaled and absorbed& carbon mono%ide binds to hemo$lobin to form carbo%yhemo$lobin :CO>b<. CO>b interferes (ith o%y$en deli#ery to tissues by at least four mechanisms. Airst& it "re#ents re#ersible dis"lacement of o%y$en on the hemo$lobin molecule. Second& CO>b shifts the o%y$en'hemo$lobin dissociation cur#e to the left& thereby decreasin$ o%y$en unloadin$ from normal hemo$lobin at the tissue le#el. Third& carbon mono%ide inhibits the cytochrome o%idase a9com"le%& resultin$ in less effecti#e intracellular res"iration. Aourth& carbon mono%ide may bind to cardiac and

s2eletal muscle& causin$ direct to%icity& and act in the central ner#ous system in a "oorly understood fashion& causin$ demyelination and associated neurolo$ic sym"toms. The de$ree of en6ymatic andGor muscle im"airment may not be directly correlated (ith the le#els of blood carbo%yhemo$lobin. .e#els of carbo%yhemo$lobin are measured easily. CO>b le#els less than 15 "ercent do not cause sym"toms& althou$h "atients (ith e%ercise'induced an$ina may sho( a decreased e%ercise tolerance. ;t le#els of 15 "ercent& healthy "ersons com"lain of headache& nausea& #omitin$& and loss of manual de%terity. ;t 95 "ercent& "atients become (ea2& confused& and lethar$ic. In a fire& this le#el can be fatal because the #ictim loses the ambition and the ability to flee the smo2e. ;t le#els bet(een 5 and 85 "ercent& the "atient la"ses into coma& and le#els abo#e 85 "ercent are usually fatal. In #ery smo2y fires& carbo%yhemo$lobin le#els of 5 to !5 "ercent can be reached after only 1 to 9 min of e%"osure. Carbon mono%ide is re#ersibly bound to the heme "i$ments and en6ymes and& des"ite its intense affinity& readily dissociates accordin$ to the la(s of mass action. The half' life of carbo%yhemo$lobin& (hen breathin$ room air& is bet(een and ! h. On 155K o%y$en& the half'life is reduced to ! to 85 min. In a hy"erbaric o%y$en chamber at 1 atm& it is about 95 min& and at 9 atm it is about 1! to 15 min. The im"ortance of carbon mono%ide "oisonin$ in #ictims of isolated smo2e inhalation injury durin$ fires (as dramatically demonstrated in the 1949 -/- /rand >otel and 19=1 >ilton >otel fires in .as He$as. ;lthou$h only a small number of burn injuries occurred& 119 "eo"le died at the scene& "rimarily from carbon mono%ide into%ication. ;t the same time& the efficacy of "rom"t assessment and treatment of smo2e inhalation (as demonstrated. Of more than 55 indi#iduals (ho recei#ed hos"ital e#aluation for smo2e inhalation injury& mortality (as less than 1 "ercent& and the rate of si$nificant com"lications :myocardial infarction& res"iratory failure& or "neumonia< (as 1 "ercent each. ,atients burned in an enclosed s"ace or ha#in$ any su$$estion of neurolo$ic sym"toms should be "laced on 155K o%y$en (hile a(aitin$ measured carbo%yhemo$lobin le#els. The use of hy"erbaric o%y$en :>)O< is contro#ersial. Only t(o randomi6ed studies ha#e been conducted. In a $rou" of "atients (ith CO e%"osure but no unconsciousness& half recei#ed normobaric o%y$en& and the other half recei#ed one treatment in a hy"erbaric chamber. There (as no difference in immediate or delayed neurolo$ic se*uelae. /rou" t(o included "atients (ho lost consciousness and (ho recei#ed either one or t(o >)O treatments. ;$ain there (ere no differences. >y"erbaric o%y$en (as not useful in "atients (ith moderate CO e%"osure& (hether or not they lost consciousness& re$ardless of their CO>b le#els at admission. Nor (ere t(o sessions of >)O in "atients (ith a brief loss of consciousness better than a sin$le session. It is not clear that hy"erbaric o%y$en is better than normobaric o%y$en. 7hile hy"erbaric o%y$en treatment may be innocuous in isolated CO "oisonin$& in the "resence of associated burns and smo2e "oisonin$& the rate of "otentially fatal com"lications durin$ treatment in the chamber is e%tremely hi$h. ,atients (ho ha#e not lost consciousness and (ho ha#e a normal neurolo$ic e%amination on admission (ill almost al(ays reco#er com"letely (ithout treatment beyond administration of

155K o%y$en. ,atients (ho remain comatose in the emer$ency room ha#e a "oor "ro$nosis and rarely a(a2en. Thermal ;ir(ay Injury The term B"ulmonary burnC is a misnomer. True thermal dama$e to the lo(er res"iratory tact and lun$ "arenchyma is e%tremely rare& unless li#e steam or e%"lodin$ $ases are inhaled. The air tem"erature near the ceilin$ of a burnin$ room may reach ! 5@C :1555@A< or more& but air has such "oor heat'carryin$ ca"acity that most of the heat is dissi"ated in the naso"haryn% and u""er air(ay. The heat dissi"ation in the u""er air(ay& ho(e#er& may cause si$nificant thermal injury. Thermal injury to the res"iratory tract is usually immediate& and consists of mucosal and submucosal edema& erythema& hemorrha$e& and ulceration. Thermal injury is usually limited to the u""er air(ay :abo#e the #ocal cords< and trachea for t(o reasonsI :1< the naso"haryn% and oro"haryn% "ro#ide a #ery effecti#e mechanism for heat e%chan$e because of their relati#ely lar$e surface area and associated air turbulence& as (ell as their mucosal (ater linin$ that acts as a heat reser#oir& and :1< sudden e%"osure to hot air may tri$$er refle% closure of the #ocal cords& reducin$ the "otential for lo(er air(ay injury. ;nimal e%"eriments ha#e demonstrated that si$nificant heat e%chan$e also occurs in the air(ay se$ment bet(een the #ocal cords and the tracheal bifurcation& "rotectin$ the lo(er air(ay. Thus& the lo(er air(ay is rarely e%"osed to hot& ambient $as at a fire scene. ;n e%ce"tion is su"erheated steam inhalation& (here because of ener$y released in the res"iratory tract as the steam condenses to (ater& se#ere injury has been re"orted in the lo(er air(ays (ith measurable injury in the al#eoli. In these "atients the lo(er air(ay is ra"idly obstructed& and they usually die from untreatable as"hy%iation. ,atients (ith $reatest ris2 of u""er air(ay obstruction are those injured in an e%"losion :$asoline #a"or& "ro"ane& butane& or natural $as< (ith burns of the face and u""er torso& and those (ho ha#e been unconscious in a fire. -ucosal burns of the mouth& naso"haryn%& and laryn% result in edema formation and may lead to u""er air(ay obstruction at any time durin$ the first 1 h "ostburn. ;ny "atient (ith burns of the face should ha#e a careful #isual ins"ection of the mouth and "haryn%& and& if these are abnormal& the laryn% should be #isuali6ed immediately. Red or dry mucosa or small mucosal blisters raise the "ossibility of air(ay obstruction3 in the "resence of a closed s"ace fire si$nificant smo2e "oisonin$ may be "resent. The "resence of si$nificant intraoral and "haryn$eal burns is a clear indication for early endotracheal intubation& as "ro$ressi#e edema can ma2e later intubation e%tremely ha6ardous& if not im"ossible. -ucosal burns are rarely full'thic2ness& and can be successfully mana$ed (ith $ood oral hy$iene. Once the "atient is intubated& the tube should remain in "lace for 9 to ! days& until the edema subsides. Smo2e Inhalation ; ni$htclub fire that claimed = li#es in Dublin in 19=1 added a $reat deal to our understandin$ of smo2e inhalation injury because the disaster site (as meticulously reconstructed and the e#ent reenacted for scientific study. 7ithin minutes& #isibility (as reduced to less than 1 m and ambient tem"eratures reached 1185@C. Near the fire& dramatic chan$es in inhaled $as concentrations (ere noted3 o%y$en (as reduced to less than 1 "ercent& carbon mono%ide increased to $reater than 9 "ercent& hydro$en

cyanide (as measured at 1!5 ""m& and hydro$en chloride (as measured at =!55 ""m. >ydro$en cyanide& a common "roduct of "olyurethane combustion& is a more effecti#e inhibitor of cellular res"iration than carbon mono%ide& and also interferes (ith normal o%y$en utili6ation at the tissue le#el. )y inhibitin$ the final ste" of o%idati#e "hos"horylation at the cytochrome a9 le#el& cyanide halts aerobic metabolism& inducin$ lactic acidosis and cellular as"hy%ia. The effects of cyanide are s"ecifically injurious to tissues (ith little anaerobic reser#e& i.e.& the central ner#ous system. Combined e%"osure to cyanide and carbon mono%ide results in a deadly syner$istic decrease in tissue o%y$en utili6ation. ; #ast array of to%ic "roducts are released durin$ combustion :flamin$< or "yrolysis :smolderin$<& de"endin$ on the ty"e of fuel that is burned& (hether burnin$ occurs in a hi$h' or lo('o%y$en en#ironment& and the actual heat of combustion. Some 1=5 to%ic "roducts ha#e been identified in (ood smo2e. ,etrochemical science has "roduced a (ealth of "lastic materials in homes and automobiles that& (hen burned& "roduce nearly all of these and many other "roducts not yet characteri6ed. ,rominent by' "roducts of incom"lete combustion are o%ides of sulfur& nitro$en& and many aldehydes. One aldehyde& acrolein& causes se#ere "ulmonary edema in concentrations as lo( as 15 ""m. ;fter inhalation& the hi$hly soluble or$anic aldehydes "roduced by combustion and "yrolysis :e.$.& formaldehyde& acetaldehyde& acrolein< ra"idly dissol#e in (ater linin$ the mucosa of the u""er and lo(er air(ays& causin$ direct e"ithelial injury. The result is e"ithelial necrosis& edema& and submucosal hemorrha$e& "rimarily in the lo(er air(ays. ;mmonia is also hi$hly soluble& and reacts (ith res"iratory tract (ater to form ammonium hydro%ide& a stron$ al2ali. Inhaled sulfur dio%ide becomes similarly hydrated and then o%idi6es to form sulfurous and sulfuric acid. These caustic acids :includin$ hydro$en chloride< and bases cause si$nificant mucosal coa$ulation and li*uefaction necrosis& "roducin$ an injury "attern similar to that of the aldehydes. Smo2e inhalation can cause direct e"ithelial dama$e at all le#els of the res"iratory tract& from oro"haryn% to al#eolus. The anatomic le#el at (hich the dama$e occurs is de"endent on the #entilatory "attern& the smo2e constituents :e.$.& "articulate concentration& "articulate si6e& and chemical com"onents<& and the anatomic distribution of "articulate de"osition. ;lthou$h the chemical mechanisms of injury may be different (ith different to%ic "roducts& the o#erall end'or$an res"onse is reasonably (ell defined. There is an immediate loss of bronchial e"ithelial cilia and decreased al#eolar surfactant. -icroatelectasis& and sometimes macroatelectasis& results and is com"ounded by mucosal edema in small air(ays& (ith immediate de#elo"ment of atelectasis that is only slo(ly re#ersible by normal #entilation. The re$ional hy"o#entilation results in si$nificant al#eolar atelectasis& intra"ulmonary shunt& and subse*uent hy"o%emia. Chemical irritation of the res"iratory tract& "articularly the u""er and lo(er air(ays& causes an acute inflammatory res"onse. The initial res"onse is an a""ro%imately tenfold increase in bronchial blood flo(. Concurrent (ith this is the stimulation of al#eolar macro"ha$es& the release of chemotactic factors& the acti#ation of circulatin$ neutro"hils that locali6e to the site of injury& and the release of o%y$en radicals and tissue "roteases resultin$ in chan$es in

#ascular "ermeability. De#elo"ment of air(ay edema& combined (ith slou$hin$ of necrotic e"ithelial mucosa and im"airment of mucociliary clearance of secretions& "roduces air(ay obstruction in small and lar$e air(ays& and the result is #entilatory inhomo$eneity. The mismatch bet(een #entilation and "erfusion leads to hy"o%emia. 7hee6in$ and air hun$er are common early sym"toms of smo2e inhalation. In a fe( hours& tracheal and bronchial e"ithelium be$ins to slou$h& and a hemorrha$ic tracheobronchitis de#elo"s. The "ulmonary "arenchymal injury a""ears to be dose' de"endent. ;l#eolar macro"ha$es are acti#ated and attract other (hite blood cells to the "ulmonary endothelium (here their release of inflammatory mediators and o%y$en free radicals further disru"ts the endothelial'e"ithelial barrier. ,ulmonary lym"h flo( increases (ith an increased "rotein content after the double insult of smo2e inhalation and cutaneous burns. The se#ere im"airment of chemota%is of "ulmonary al#eolar macro"ha$es undoubtedly contributes to the hi$h incidence of late "neumonia seen in "atients (ith associated cutaneous burns. In #ery se#ere cases& the hemorrha$ic tracheobronchitis and small air(ay "lu$$in$ result in se#ere #entilatory difficulty durin$ the first = h and "atients succumb to a se#ere res"iratory acidosis because of their inability to clear CO1. In moderately se#ere cases (ith associated e%tensi#e burns interstitial edema becomes "rominent& resultin$ in adult res"iratory distress syndrome :;RDS<& (ith difficulty in o%y$enation. Concomitant cutaneous burn injury results in the systemic release of inflammatory mediators& includin$ "rosta$landins and o%idants that can a$$ra#ate "ulmonary injury inde"endent of smo2e inhalation. Thrombo%ane ;1 released from burned tissue causes a #ariety of chan$es in the lun$& includin$ "ulmonary hy"ertension& reduced dynamic com"liance& and increased li"id "ero%idation. O%idants $enerated as a conse*uence of neutro"hil acti#ation and increases in %anthine o%idase contribute to lun$ injury. Decreased "lasma oncotic "ressure from the loss of "lasma "rotein throu$h increasin$ly "ermeable #essels in both burned and unburned tissue creates an abnormal oncotic "ressure $radient in the lun$ that& (hen combined (ith "ulmonary hy"ertension& results in transient hydrostatic "ulmonary edema. These chan$es hel" e%"lain the de$ree of comorbidity in cases of combined inhalation and burn injuries. +arly in the course of smo2e "oisonin$ "ulmonary function is #ariable. Ty"ically& decreased lun$ #olume :functional residual ca"acity EARC F<& decreased #ital ca"acity& and e#idence of obstructi#e disease (ith reduction in flo( rates& an increase in dead s"ace& and a ra"id decrease in com"liance occur. -uch of the #ariability in "ulmonary res"onse a""ears to be related more to the se#erity of the associated cutaneous burn than to the de$ree of smo2e inhalation. 7ithout associated cutaneous burns& the mortality from smo2e "oisonin$ is #ery lo(& the disease rarely "ro$resses to ;RDS& and sym"tomatic treatment usually leads to com"lete resolution of sym"toms in a fe( days. In the "resence of burns& smo2e "oisonin$ a""ro%imately doubles the mortality from burns of any si6e. ,ulmonary sym"toms are usually "resent on admission& but they may be delayed for 11 to 1 h. The earlier the onset& the more se#ere the disease. Dia$nosis

The incidence of smo2e inhalation injury in #ictims of fire #aries (ith dia$nostic criteria. The incidence may be as lo( as 1 to 1! "ercent (hen sin$le or restricti#e criteria based on history and "hysical e%amination are used& but as hi$h as 15 to 95 "ercent (hen based on tests such as fibero"tic bronchosco"y. The o#erall incidence of smo2e inhalation in the United States has fallen in the "ast t(o decades& "rimarily because of the use of home smo2e detectors. ;nyone (ith a flame burn and anyone burned in an enclosed s"ace should be assumed to ha#e smo2e "oisonin$ until "ro#ed other(ise. The acrid smell of smo2e on the #ictim?s clothes should raise sus"icion. In obtainin$ a history& em"hasis should be "laced on data s"ecific to the smo2e e%"osure and to the ty"e of thera"y instituted "rior to hos"itali6ation. 7hen e%"osure occurs in a closed s"ace& such as a buildin$ or an automobile& the smo2e is less diluted by ambient air& resultin$ in $reater "ulmonary e%"osure to carbon mono%ide and smo2e constituents than in an o"en' s"ace e%"osure. The duration of e%"osure correlates (ith the se#erity of lun$ injury. ;n e%amination should be "erformed& includin$ e#aluation of the face and oro"haryn$eal air(ay :edema& stridor& or soot im"action su$$estin$ smo2e inhalation<& chest auscultation :(hee6in$ or rhonchi su$$estin$ injury to lo(er air(ays<& le#el of consciousness :decreased (ith hy"o%emia& carbon mono%ide "oisonin$& or cyanide "oisonin$<& and testin$ for the "resence of s"ecific neurolo$ic defects that mi$ht be associated (ith carbon mono%ide ; careful ins"ection of the mouth and "haryn% should be done early. >oarseness and e%"iratory (hee6es are si$ns of "otentially serious air(ay edema or smo2e "oisonin$. Co"ious mucus "roduction and carbonaceous s"utum are si$ns of injury& but their absence does not indicate that injury is absent. Carbo%yhemo$lobin le#els should be obtained3 ele#ated carbo%yhemo$lobin le#els or any sym"toms of carbon mono%ide "oisonin$ are "resum"ti#e e#idence of associated smo2e "oisonin$. ;nyone sus"ected of smo2e "oisonin$ should ha#e a set of arterial blood $ases dra(n. One of the earliest indicators is a fallin$ ,GA ratio& the ratio of arterial ,O 1 to the "ercenta$e of ins"ired o%y$en :AiO 1<. ; ratio of about 55 is normal3 "atients (ith im"endin$ "ulmonary "roblems ha#e a ratio of less than 9!5 :e.$.& an arterial ,O 1 of less than 1 5 (ith an AiO 1 of 5. 5<. ; ratio of less than 1!5 is an indication for #i$orous "ulmonary thera"y& not an indication for increasin$ the ins"ired o%y$en concentration. The early need for bronchosco"y remains contro#ersial. Some recommend the routine use of fibero"tic bronchosco"y& notin$ that it is ine%"ensi#e& *uic2ly "erformed in e%"erienced hands& and useful in assessin$ edema of the u""er air(ay. ;side from documentin$ the "resence of tracheal erythema and carbon de"osits& ho(e#er& it does not materially influence the treatment for smo2e "oisonin$. To determine the role of this e%amination in "atients (ith smo2e inhalation& fibero"tic bronchosco"y (as "erformed in 155 consecuti#e "atients admitted to a re$ional burn unit "resentin$ (ith at least one (arnin$ si$n of inhalation injury :closed's"ace smo2e e%"osure& facial burn& sin$ed nasal #ibrissae& "erioral burn& "haryn$eal edema& hoarseness& carbonaceous s"utum& bronchorrhea& or (hee6in$<. ; 98 "ercent correlation (as found bet(een "ositi#e bronchosco"ic findin$s and the triad of closed's"ace fire& CO>b le#els W15 "ercent& and carbonaceous s"utum. If t(o items of the triad (ere "resent& the correlation dro""ed to 45 "ercent& and if only one (as "resent& the

correlation (as less than 95 "ercent. No other "ositi#e correlations (ere detected. U""er air(ay edema could best be correlated (ith an e%"losion :flash burn< that in#ol#ed both the face and the u""er torso. Nearly !5 "ercent of these "atients had si$nificant u""er air(ay edema and under(ent "ro"hylactic air(ay intubation. )ased on these obser#ations and the limitations of fibero"tic bronchosco"y& it is recommended that a history& clinical e%amination& and laboratory studies be used to ma2e the dia$nosis of inhalation injury& and the use of fibero"tic bronchosco"y be reser#ed for e%ce"tional cases :e.$.& e%"ansion of lobar atelectasis or remo#al of obstructin$ intrabronchial secretions<. T(o clinical studies of burn "atients (ith clinical si$ns of smo2e inhalation found "oor correlation of bronchosco"ic findin$s (ith the need for #entilatory su""ort or the subse*uent de#elo"ment of ;RDS& concludin$ that immediate bronchosco"y neither indicates the le#el of res"iratory su""ort that (ill be re*uired nor "redicts its duration. Alo( #olume loo"s may be useful& but are com"le% to "erform and difficult to inter"ret. The sim"le admission chest %'ray is notoriously insensiti#e in detectin$ se#erely injured lun$ early after smo2e e%"osure& (ith false'ne$ati#e rates as hi$h as 91 "ercent. Com"uted tomo$ra"hy :CT< may be useful in demonstratin$ early atelectasis and bronchial edema& but it is e%"ensi#e and delays treatment& and& li2e bronchosco"y& has no "ractical im"lications for thera"y. Treatment U""er ;ir(ay No standard treatment has e#ol#ed to ensure sur#i#al after smo2e "oisonin$. In the "resence of increasin$ laryn$eal edema& nasotracheal or orotracheal intubation is indicated. ; tracheostomy is ne#er an emer$ency "rocedure and should not be used as the initial ste" in air(ay mana$ement in "atients (ith burns to the face and nec2. Instead& a soft'cuffed endotracheal tube should be "laced& and left in "lace for about 41 h or until the $enerali6ed oro"haryn$eal edema subsides. ;n adult "atient?s ability to breathe around the tube (ith the cuff deflated is an indication for remo#al of the tube. This assessment is difficult in children due to their smaller anatomy& the use of uncuffed endotracheal tubes& the increased incidence of "oste%tubation stridor& and the fre*uent need for reintubation. The incidence of "oste%tubation stridor in burn #ictims is as hi$h as 4 "ercent& com"ared to "ercent in electi#e sur$ical "atients. The treatment of "oste%tubation stridor includes the administration of racemic e"ine"hrine and helium'o%y$en :>elio%< mi%tures. .o(er ;ir(ay and ;l#eolar Dama$e Tracheobronchitis& commonly seen in smo2e and to%ic $as inhalation #ictims& "roduces (hee6in$& cou$hin$& and retained secretions. The #entilation'"erfusion mismatch "resent in these "atients can result in mild to moderate hy"o%emia& de"endin$ on the de$ree of underlyin$ lun$ disease3 therefore& su""lemental o%y$en should be administered routinely. Increased air(ay resistance is more often the result of decreased air(ay caliber :from mucosal andGor submucosal edema and retained secretions< than true bronchos"asm. ;lthou$h a trial of bronchodilators is indicated in those (ith "ree%istin$ bronchos"astic disease& its efficacy is *uestionable. Nebuli6ed or metered dose thera"y (ith )1a$onists or racemic e"ine"hrine& subcutaneous terbutaline& or intra#enous amino"hylline is used most commonly.

The "resentin$ si$n of lo(er air(ay dama$e is hy"o%emia& dia$nosed by "ulse o%imetry or& "referably& arterial blood $as analysis. )ecause most inhalation #ictims recei#e su""lemental o%y$en& si$nificant al#eolar'arterial o%y$en $radients can be missed by "ulse o%imetry3 saturations less than 9! "ercent do not occur until arterial ,O 1 is less than =5 mm>$. ;rterial blood $as analysis is the monitor of choice in assessin$ o%y$enation after inhalation injury. Initial thera"y should al(ays include the administration of hi$h'flo( o%y$en& to su""lement o%y$enation and to reduce carbo%yhemo$lobin in cases of carbon mono%ide inhalation. U""er air(ay "atency must be assured& and air(ay resistance minimi6ed (ith chest "hysiothera"y andGor bronchodilators. Central hy"o#entilation caused by carbon mono%ide or cyanide "oisonin$ should be treated immediately (ith endotracheal intubation and assisted #entilation& and efforts to re#erse into%ication. Treatment for smo2e "oisonin$ is su""orti#e& (ith the $oal of maintainin$ ade*uate #entilation and o%y$enation until the lun$ heals itself. -ild cases of smo2e "oisonin$ are treated (ith hi$hly humidified air& #i$orous "ulmonary toilet& and bronchodilators as needed. The need for mechanical #entilation to su""lement o%y$enation is determined by re"eated blood $as measurements. ;s a $uideline& the ,aO 1GAiO 1 :,GA< ratio may be calculated (ithout mi%ed #enous blood sam"lin$ and used as an a""ro%imation of the shunt fraction. ; ,GA ratio bet(een 155 and 55 indicates mild to moderate injury& usually re*uirin$ only su""lemental o%y$en thera"y. ; ,GA ratio belo( 155 is e#idence of serious "arenchymal lun$ injury& and usually indicates a need for intubation and #entilation (ith hi$h ins"ired o%y$en fractions or the use of "ositi#e end' e%"iratory "ressure :,++,<. )ecause of the fre*uent "resence of atelectasis after al#eolar e%"osure to smo2e& ,++, can be useful& "ro#ided "ressures are not e%cessi#e& subse*uent to the initial use of lar$e tidal #olumes :15 to 1! m.G2$< initially in a standard #olume'control #entilator settin$. The tidal #olume should be monitored by measurin$ total res"iratory com"liance o#er a ran$e of tidal #olumes& (ith a#oidance of those #olumes associated (ith a reduction in com"liance :and increased ris2 of lun$ ru"ture<. >i$h'fre*uency "ercussi#e #entilation has been attem"ted in "atients (ith inhalation injury. This mode of #entilation "ro#ides ade*uate o%y$enation at a lo(er AiO 1& (ith lo(er "ea2 and mean air(ay "ressures. The benefit to inhalation injury is the a""arently enhanced clearance of bronchial secretions achie#ed (ith this techni*ue. Initial re"orts su$$est "otential su"eriority to standard #entilation techni*ues in "atients (ith smo2e inhalation. -echanical causes for "oor #entilation include restricted chest' (all motion from full'thic2ness burns& "neumothora% from hi$h #entilator "ressures& and mechanical difficulties (ith the endotracheal tube. +stablishin$ a tracheostomy in burn "atients is contro#ersial. If the u""er air(ay is in dan$er of imminent obstruction and endotracheal intubation attem"ts are unsuccessful& emer$ent cricothyroidotomy is indicated. The indications for nonemer$ent tracheotomy ha#e chan$ed. ;fter a "eriod in the 1945s (hen tracheostomy (as the standard method of securin$ the u""er air(ay after se#ere burn injury& se#eral re"orts associated the "rocedure (ith mortality rates ran$in$ from !1 to 155 "ercent due to a $reater incidence of o#er(helmin$ "ulmonary infection. Im"ro#ement in endotracheal tube construction resulted in s"ecific efforts to a#oid

tracheotomy in burn "atients in the 19=5s. Currently& mortality rates for burn "atients (ith tracheostomy are not different from those for "atients treated (ith endotracheal tubes& des"ite the fact that the former $rou" is more li2ely to include "atients (ho are burned so se#erely as to "reclude sur#i#al. Aor "atients re*uirin$ "rolon$ed endotracheal intubation& tracheostomy should be "erformed bet(een 9 and 95 days after intubation. ,atients (ith anterior nec2 burns (ho re*uire tracheostomy should under$o e%cision and $raftin$ of the area ! to 4 days "rior to creation of the tracheostomy. This minimi6es "ulmonary and burn (ound infectious com"lications associated (ith the tracheostomy. ,ro"hylactic antibiotics are not #aluable in burn'related chemical "neumonitis& and subse*uent burn mana$ement and treatment of e#entual bacterial "neumonia can be made more difficult if the early use of antibiotics leads to the selection of resistant or$anisms. Steroids are commonly used in "atients (ith se#ere asthma. There has been a tendency (hen dealin$ (ith smo2e "oisonin$ to use steroids for their s"asmolytic and anti' inflammatory action. In a "ros"ecti#e blind study of "atients (ith smo2e "oisonin$ and associated major burns& -oylan and Chan demonstrated that mortality and infectious com"lications (ere hi$her in the "atients treated (ith steroids. Robinson found that steroids did not alter the hos"ital course of "atients (ithout associated burns admitted to hos"ital after the -/- /rand and >ilton hotel fires in 19=1. ; trial of $enetically en$ineered surfactant in "atients (ith smo2e "oisonin$ (as unsuccessful. The decision on (hether to admit a "atient to the hos"ital& as (ell as the need for s"eciali6ed care& de"ends on the se#erity of sym"toms from the smo2e and the "resence of associated burns. ; "atient (ho has sym"toms associated (ith smo2e inhalation and (ho has more than tri#ial burns should be admitted. If the burns are $reater than 1! "ercent T)S;& the "atient should be referred to a burn center intensi#e care unit. In the absence of burns& admission de"ends on the se#erity of sym"toms& the "resence of "ree%istin$ medical "roblems& and the social circumstances of the "atient. Other(ise healthy "atients (ith mild sym"toms :only a fe( e%"iratory (hee6es& minimal s"utum "roduction& CO le#el D15& and normal blood $ases< (ho ha#e a "lace to $o and someone to stay (ith them can usually be (atched for a fe( hours and then dischar$ed. ,atients (ith "ree%istin$ cardio#ascular or "ulmonary disease should be admitted for obser#ation if they ha#e sym"toms related to the smo2e. ,atients (ith moderate sym"toms :$enerali6ed (hee6in$& mild hoarseness& moderate s"utum& CO le#els of ! to 15 "ercent< and normal blood $ases can be admitted for close obser#ation and treatment. Se#ere sym"toms :air hun$er& se#ere (hee6in$& co"ious& usually carbonaceous& s"utum<& re*uire intubation& "ossible thera"eutic bronchosco"y& #entilator su""ort& and "lacement in an intensi#e care unit. 7OUND -;N;/+-+NT +arly +%cision and /raftin$ Aor many years& burns (ere treated by daily (ashin$& remo#al of loose dead tissue& and to"ical a""lication of saline'soa2ed dressin$s until they healed by themsel#es or $ranulation tissue a""eared in the base of the (ound. Su"erficial dermal burns healed (ithin 1 (ee2s and dee" dermal burns healed o#er many (ee2s if infection (as "re#ented. Aull'thic2ness burns lost their eschar in 1 to 8 (ee2s throu$h bacterial colla$enase "roduction and daily mechanical debridement. 7hen the $ranulatin$ bed became free of debris and relati#ely uninfected& s"lit'thic2ness s2in $rafts (ere

a""lied& usually some 9 to = (ee2s after injury& and a !5 "ercent $raft ta2e (as considered acce"table. Re"eated $raftin$s e#entually closed the (ound. The "rolon$ed and intense inflammatory res"onse made hy"ertro"hic scar and contractures "art of normal burn treatment. Hi$orous "hysical thera"y& nutritional su""ort& "sycholo$ical su""ort& and "ain mana$ement (ere re*uired on a daily basis for many (ee2s to yield a satisfactory result. This is no lon$er standard "rocedure. Aor dee"er burns& rather than (aitin$ for s"ontaneous se"aration& the eschar is sur$ically remo#ed and the (ound closed& (ith $raftin$ techni*ues and "rocedures for immediate "lacement of fla"s tailored to meet "atients? indi#idual needs. Se#eral technical ad#ances ha#e made this "ossible. There is BsaferC blood& better monitorin$ e*ui"ment and methods& and a better understandin$ of the altered "hysiolo$y and increased metabolic demands of "atients (ith major burns. The ability to stabili6e the "atient (ithin a fe( days of the injury has enabled the sur$eon to remo#e dee" burn (ounds before in#asi#e infection occurs. ;n a$$ressi#e sur$ical a""roach to lar$e and small burns has "roduced a number of ad#anta$es. +arly (ound closure shortens hos"ital stay and duration of illness. +arly studies did not demonstrate dramatic differences in cosmetic and functional results& but as sur$eons ha#e become more e%"erienced& both im"ro#ed function and a""earance ha#e resulted. This is "articularly true (ith burns of the face& hands& and feet. >istorical ,ers"ecti#e The sur$ical "rinci"le that Bclean (ounds should be closedC has been a""lied since the days of >i""ocrates. Aor technical reasons& burns ha#e been the e%ce"tion to this rule. +arly in the t(entieth century& "rimary burn (ound closure (as attem"ted in "atients (ith major burns& but systemic instability& massi#e hemorrha$e& $raft loss& malnutrition& and infection resulted in such hi$h mortality rates that major burn e%cisions (ere abandoned. )ecause of their relati#ely limited e%tent& electrical burns remained an e%ce"tion. Co"e (as the first to re"ort a series of != "rimary e%cision and $raftin$s in 9= "atients after a 19 4 ni$htclub fire. Arom 1981 to 194 & Jan6e2o#ic treated 181! of 945 burned "atients (ith early tan$ential :or se*uential< e%cision and sheet auto$raftin$3 most of the burns (ere small :under 15 "ercent T)S;<. The hos"ital stay dramatically decreased& "ain (as less& need for reconstructi#e "rocedures decreased& and Baesthetic disabilityC (as $reatly reduced. The early 19=5s "roduced more clinical and e%"erimental data su$$estin$ that "rom"t (ound closure "roduced better results and im"ro#ed metabolic res"onse. It is more difficult to "ro#e that early e%cision im"ro#es mortality in "atients (ith e%tensi#e burns :$reater than 85 "ercent T)S;<. Until a useful Bartificial s2inC is a#ailable& the $oal of early com"lete (ound closure in "atients (ith massi#e burns cannot be achie#ed. In these "atients& donor sites are limited and e%cised burns must be co#ered (ith tem"orary biolo$ic dressin$s until the donor sites heal and can be recro""ed. Recent AD; a""ro#al of a "ermanent Boff the shelfC dermal substitute made of colla$en matri% combined (ith a $lycosamino$lycan :chondroitin 8'sulfate< that acts as a tem"late for endo$enous cells to re"roduce a ne( dermis is a major ste" in the de#elo"ment of a "ermanent s2in substitute. +lderly "atients "resent uni*ue "roblems. Continued stress from the burn injury results in a hi$h incidence of cardiac and cerebro#ascular catastro"hes. The atro"hic s2in of elderly "atients "resents "roblems in burn (ound and donor site healin$. No

substantial decrease in mortality for elderly "atients has occurred. The mortality rate for "atients o#er 8! years of a$e (ith burns less than or e*ual to 15 "ercent T)S; remains at a""ro%imately 15 "ercent. This increases lo$arithmically as the si6e of the burns increases& and there are fe( elderly sur#i#ors (ith burns o#er !5 "ercent T)S;. -ore burn centers are "racticin$ early e%cision and $raftin$. 7hen e%"erience has made these "rocedures routine& early e%cision and $raftin$ (ill become the treatment of choice for all dee" dermal and full'thic2ness burns. The "rocedure is still limited by difficulty in dia$nosin$ burn de"th& by limited donor sites& and the difficulties in#ol#ed in e%cision of three' dimensional areas& such as the "erineum& ears& and nose. Current Status of 7ound Care +#idence su""orts the follo(in$ conclusionsI :1< Small :less than 15 "ercent< full'thic2ness burns& and burns of indeterminate de"th :dee" "artial #ersus full thic2ness<& if treated by an e%"erienced sur$eon& can be safely e%cised and $rafted (ith a decrease in hos"ital stay& cost to the "atient& and time a(ay from (or2 or school. :1< +arly e%cision and $raftin$ dramatically decreases the number of "ainful debridements re*uired by all "atients. :9< ,atients (ith burns bet(een 15 and 5 "ercent T)S; (ill ha#e fe(er infectious (ound com"lications if treated (ith early e%cision and $raftin$. : < In animals (ith e%"erimental burns& the de"ressed immune res"onse and hy"ermetabolism associated (ith burns can be ameliorated by early burn (ound remo#al. Clinical im"ressions (ithout hard data su""ortin$ them include the follo(in$I :1< Scarrin$ is less se#ere in (ounds closed early& leadin$ to better a""earance and fe(er reconstructi#e "rocedures. There is no $ood measure of acce"table Bcosmetic a""earance C and com"arati#e studies a(ait an acce"table scale to measure results. :1< -ortality from (ound infection is lo(er in "atients (ith major burns after early e%cision. )ecause (ounds e%ceedin$ the donor sites cannot "ermanently be closed com"letely until donor sites can be rehar#ested& "roof (ill come only (hen a durable "ermanent co#er can be a""lied in a timely fashion. :9< -ortality from other com"lications of major burns may be lo(er (ith early e%cision and $raftin$. Decreasin$ stress& hy"ermetabolism& and the o#erall bacterial load of the "atients enables them to resist other com"lications. The only data to su""ort this conclusion come from animal studies. Technical Considerations +%cision of more than 15 "ercent of the total body surface should be done in a hi$hly structured en#ironment. 7ithout tourni*uets& blood loss can be massi#e. /raft loss can be catastro"hic. +%cellent monitorin$& nursin$& "hysical thera"y& nutritional

su""ort& anesthesia& and 1 'h "hysician co#era$e are mandatory. Smaller burns in im"ortant areas :hands& face& and feet< also re*uire considerable e%"erience. +%cisional "rocedures should be "erformed as early as "ossible after the "atient is stabili6ed. This allo(s the (ound to be closed before infection occurs and& in e%tensi#e burns& allo(s donor sites to be recro""ed as soon as "ossible. Cosmetic results are better if the (ound can be e%cised and $rafted before the intense inflammatory res"onse associated (ith burns becomes (ell established. ;ny burn "rojected to ta2e lon$er than 9 (ee2s to heal is a candidate for e%cision (ithin the first "ostburn (ee2. 7ound e%cision is ada"table to all a$e $rou"s& but infants& small children& and elderly "atients re*uire close "erio"erati#e monitorin$. +%cision can be "erformed to include the burn and subcutaneous fat to the le#el of the in#estin$ fascia :fascial e%cision<& or by se*uentially remo#in$ thin slices of burned tissue until a #iable bed remains :se*uential e%cision<. Aascial e%cision assures a #iable bed for $raftin$& but ta2es lon$er& sacrifices "otentially #iable fat and lym"hatics& and lea#es a "ermanent cosmetic defect. Se*uential e%cision can create massi#e blood loss and ris2s $raftin$ on a bed of uncertain #iability& but sacrifices minimal li#in$ tissue and leads to a far su"erior cosmetic result than fascial e%cision. Current "ractice reser#es fascial e%cision for "atients (ith fourth'de$ree burns and "atients (ith such massi#e burns that they can afford no $raft loss. Tan$ential :Se*uential< +%cision The "rinci"le of tan$ential e%cision is to sha#e #ery thin layers of burn eschar se*uentially until #iable tissue is reached. The burn can be remo#ed (ith a #ariety of instruments& usually "o(er' or hand'dri#en dermatomes. Relati#ely shallo( burns and some burns of moderate de"th (ill bleed bris2ly from thousands of ca"illaries after one slice. If the bed does not bleed bris2ly& another slice of the same de"th is ta2en until a #iable bed of dermis or subcutaneous fat is reached. If ins"ection of the dermal or fatty bed re#eals a surface that a""ears $ray or dull rather than (hite and shiny& or if there is e#idence of clotted #essels& the e%cision should be carried dee"er. ;ny fat that has a bro(nish discoloration& has blood stainin$& or contains clotted blood #essels (ill not su""ort a s2in $raft and must be e%cised until the bed contains uniformly yello( fat (ith bris2ly bleedin$ #essels. )leedin$ is controlled (ith s"on$es soa2ed in 1I15&555 e"ine"hrine solution a""lied to the e%cision bed for 15 min. Continued bleedin$ is then controlled (ith an electrocautery. -ajor bleedin$ is rare3 (hen bleedin$ has occurred& it has in#ariably been associated (ith inade*uate cauteri6ation of a #essel (ith "ulsatile flo(. ;reas on the e%tremities may be e%cised usin$ a tourni*uet. The cada#er' li2e a""earance of the dermis and the lac2 of bris2 bleedin$ can easily mislead the sur$eon into sacrificin$ normal tissue by carryin$ the e%cision dee"er than necessary. Aascial +%cision Aascial e%cision is reser#ed for "atients (ith #ery dee" burns :charred flame burns& "rolon$ed contact burns& molten metal burns& and electrical burns<& or for "atients (ith #ery lar$e& life'threatenin$& full'thic2ness burns. The most common techni*ue uses an electrocautery (ith cuttin$ and coa$ulatin$ ca"abilities. The ad#anta$es of fascial e%cision includeI

:1< It results in a reliable bed of 2no(n #iability. :1< Tourni*uets can be routinely used for e%tremities. :9< O"erati#e blood loss is less than (ith se*uential e%cision. : < .ess e%"erience is re*uired to ensure an o"timal bed. The disad#anta$es includeI :1< The o"erati#e time is lon$er. :1< There may be se#ere cosmetic deformity& es"ecially in obese "atients. :9< There is a hi$her incidence of distal edema (hen e%cision is circumferential. : < There is $reater dan$er of dama$e to su"erficial ner#es and tendons. :!< Cutaneous dener#ation& (hich may or may not be "ermanent& may occur. :8< S2in $raft loss from the relati#ely #ascular fascia o#er joints :elbo(& 2nee& an2le< can lead to an un$raftable bed and re*uire e#entual fla" co#era$e. +arly Reconstruction ; "otential ad#anta$e to e%cision and $raftin$ is to "ro#ide a closed (ound before the intense inflammatory res"onse be$ins. If careful attention is $i#en to sound "rinci"les of "lastic sur$ery& the ris2 that there (ill be a need for subse*uent reconstruction can be decreased. S2in $raft junctures should be a#oided o#er joints& and $rafts should be "laced trans#ersely (hen "ossible. Thic2 s2in $rafts yield a better a""earance than thin s2in $rafts. If the burn is (ell e%cised& and the s2in can be s"ared& thic2 s2in $rafts should be used on the face& nec2& and other cosmetically im"ortant areas. The resultant donor sites can be o#er$rafted (ith thin s2in $rafts to minimi6e hy"ertro"hic scarrin$ of the donor site. 7hene#er "ossible& cosmetically im"ortant areas should be $rafted (ith sheet s2in $rafts. ;lthou$h meshed s2in $rafts "ro#ide co#er (ith e%cellent function& the meshed "attern "ersists as a "ermanent reminder of the burn. ;djacent "ieces of s2in $raft should be a""ro%imated carefully. 7hile sta"les are ade*uate for areas in (hich cosmetics is not an issue& for critical areas& such as the face& suturin$ the ed$es to$ether is "referred. If the (ound can be left o"en or dressed (ith a dry banda$e after sheet s2in $raftin$& steri'stri"s can be used effecti#ely. They (ill not remain in "lace if the (ound is co#ered (ith moist dressin$s. Pee"in$ these early reconstructi#e "rinci"les in mind durin$ the first o"erations may a#ert the need for later "rocedures entirely& and (ill hel" con#ert (hat could be major reconstructi#e efforts into minor ones. Donor Sites In "re#ious years& (hen only full'thic2ness burns (ere s2in'$rafted& and "atients endured many (ee2s of daily debridement& donor sites (ere treated su"erficially.

They (ere co#ered (ith either dry fine mesh $au6e& or $au6e im"re$nated (ith a dye or other antimicrobial a$ent. They (ere left to desiccate& and the $au6e usually se"arated from the (ound in 1 to 9 (ee2s& sometimes remo#in$ substantial areas of ne( e"ithelium. ;s a$$ressi#e "ro$rams of early e%cision and $raftin$ de#elo"ed& donor sites became a "riority. 7ith early e%cision& the "atient (as s"ared the "ainful daily debridement& and (ith burn "ain diminished& "atients concentrated on donor site "ain. There are hundreds of dressin$s a#ailable for donor site and after'$raftin$ (ound care. Re"orts indicate that there is no o"timal donor dressin$. ;ll dressin$s seem to (or2& and differences in healin$ times are only 1 or 1 days. Comfort le#els and ease of care are the most si$nificant determinants. >ealed donor sites are still not free of com"lications. In addition to hy"ertro"hic scarrin$ and chan$ed "i$mentation& "atients may be troubled by blisterin$ for se#eral (ee2s. )listers are self'limitin$ and are usually treated (ith banda$es or ointments until they ree"itheliali6e. Infections occur in about ! "ercent of "atients. Infection is treated (ith systemic antibiotics and continuously moist dressin$s or sil#er sulfadia6ine. SPIN SU)STITUT+S The ne%t major ste" in burn care is li2ely to be an artificial s2in that (ill be readily a#ailable& "erform barrier function :e"idermis<& and "ro#ide the structural durability and fle%ibility of the dermis. It must be "ermanent& affordable& not susce"tible to hy"ertro"hic scarrin$& "ro#ide normal "i$mentation& and $ro( (ith de#elo"in$ children. ,ro$ress to(ard this $oal has been substantial o#er the "ast decade. Cultured +"idermal ;uto$raft In the earliest $raftin$ "rocedures& successful in #itro culturin$ of e"idermal cells :2eratinocytes< "roduced a "ermanent s2in co#er (hereby small bits of unburned s2in could "ro#ide seed 2eratinocytes that could be $ro(n to form sheets of cells and $rafted onto a burn (ound bed& closin$ massi#e (ounds (hen donor sites (ere limited. The first successful $raftin$ (as re"orted in children in 19=8. In 9 (ee2s? time& an initial s2in bio"sy could be enlar$ed 1555 times& "roducin$ hundreds of !' by !'cm sheets of e"idermis& three to ei$ht cell layers thic2. ,lacin$ these fra$ile sheets on an e%cised burn (ound could "ro#ide a "ermanent (ound co#er. Considerable e%"erience has been $ained (ith cultured e"idermal auto$rafts :C+;s<. ;reas of concern and contro#ersy remain (ith res"ect to efficacy of ta2e& durability& necessity& and cost'effecti#eness. Hariability in ta2e may be related to the bed on (hich the C+;s are a""lied& (ith nati#e or allo$enic dermis :from cada#er allo$rafts< bein$ the most successful. )acterial contamination and coloni6ation of the $rafted bed results in ra"id C+; disa""earance from the site. +n$rafted C+;s are "oorly adherent and e%tremely fra$ile for months after a""lication. Care must be ta2en to a#oid blisterin$ and $raft loss (ith mo#ement& rubbin$& scratchin$& and "hysical thera"y because of the lac2 of a dermis in e%cisions that reach fat or fascia. The histolo$ic e#ents leadin$ to C+; maturation also a""ear inconsistent. One study re"orted that (ithin 8 days Bflat e"idermis (ith all normal

strata had re$enerated& and the "rocess of de no#o dermal'e"idermal junction formation had be$unC and B(ithin three to four (ee2s& the dermal'e"idermal junction (as com"lete& but full maturation of anchorin$ fibrils re*uired more than a year.C Com"ton re"orted that Bthe subjacent connecti#e tissue initially healed to form normal scar& but it remodeled dramatically& re$enerated elastin& and resembled a true dermis (ithin four to fi#e years.C ,utland& ho(e#er& indicated that Bthe C+; interface (ith underlyin$ bed remained flat for u" to three years in three of four "atients. C+; e"idermal rete rid$es& if formed subse*uently& (ere fe(er& thinner& and shorter& (hereas e%"anded s"lit'thic2ness s2in $rafts had (ell'defined rete rid$es after one year.C It (as concluded that the "ersistent fra$ility of C+;s is related to the delayed formation of rete rid$es. 7hen the "atient is admitted& a 1'cm1 s2in bio"sy s"ecimen is usually sent to a commercial laboratory for culturin$. Three (ee2s later !' by !'cm1 sheets of cultured cells are deli#ered. C+;s are e%"ensi#e. Rue re"orted that the a#era$e cost of C+;s co#erin$ only .4 "ercent T)S; (as X 9&555. The follo(in$ conclusions can be dra(nI :1< Cultured 2eratinocytes can be $ro(n (ithin 9 (ee2s and can be $rafted successfully on a #iable& noninfected e%cised burn (ound bed. Aor a massi#e burn (ith fe( or no a#ailable donor sites& this may be life'sa#in$& es"ecially in children. :1< Ta2e #aries from "oor to fair& (ith an o"timistic ran$e of 95 to 5 "ercent. :9< )ecause e"idermal cells lac2 a dermis& in early sta$es of (ound healin$& C+;s can "ro#ide only a barrier function to "re#ent fluid e%udation and bacterial in#asion. : < The co#er is fra$ile and must be "rotected from mechanical disru"tion for months& limitin$ daily acti#ities and #i$orous "hysical and occu"ational thera"y. :!< The cost is a""ro%imately X8555 to X15&555 for each 1 "ercent T)S; co#ered. :8< C+;s are a tem"orary measure& "ermittin$ sur#i#al in the "atients (ith massi#e burns. It is unli2ely that they can e#er be a "ermanent solution because they "ro#ide only one'half of the necessary bilaminar constituent of s2in. Dermal Substitutes -any in#esti$ations ha#e loo2ed for an acce"table dermal matri% onto (hich C+; or thin e"idermal $rafts could be "laced. The only AD;'a""ro#ed synthetic dermal substitute& a material de#elo"ed by )ur2e and 0annis& is a bo#ine colla$en matri% (ith fiber si6e and distance similar to that of dermis& (ith a $round substance& chondroitin 8'sulfate& fillin$ the "ores. It "ro#ides a tem"late on (hich nati#e fibroblasts& endothelial cells& and macro"ha$es can re"lace the colla$en (ith a dermal matri% resemblin$ dermis more than disor$ani6ed scar. In a multicenter trial to determine (hether results (ith ultrathin e"idermal $rafts o#er this material could "ro#ide co#er e*ual to con#entional meshed $rafts& the results (ere e%cellent. The material is no( in use& offerin$ better cosmetic and functional results usin$ ultra'thin e"idermal $rafts so that donor sites can be recro""ed fre*uently in the treatment of lar$e burns.

NUTRITION;. SU,,ORT The nutritional effects of the hy"ermetabolic res"onse to thermal injury are manifested as e%a$$erated ener$y e%"enditure and massi#e nitro$en loss. Nutritional su""ort is directed "rimarily to(ard "ro#ision of calories to match ener$y e%"enditure and "ro#ision of nitro$en to re"lace or su""ort body "rotein stores. Chan$es in metabolism are tri$$ered by drastic chan$es in the hormonal "rofile& includin$ ele#ated le#els of catecholamines& $lucocorticosteroids& and $luca$on. These hormones& to$ether (ith other circulatin$ "e"tides& such as I.'1& TNA& and "robably I.'8& accelerate "rotein catabolism& $luconeo$enesis& and li"olysis. Insulin le#els are usually in the normal ran$e or ele#ated& but they are lo( in relation to the increased $luca$on concentrations in "lasma. Catecholamines and $lucocorticoids anta$oni6e the action of insulin& the 2ey anabolic hormone that "romotes stora$e of the metabolic fuels (ithin the cells. These metabolic and hormonal conse*uences ha#e im"ortant effects on nutritional status. Caloric Re*uirements -alnutrition in "atients (ho ha#e under$one a sur$ical "rocedure (as first characteri6ed in terms of ne$ati#e ener$y balance. >y"ermetabolism and hy"ercatabolism are uni#ersal conse*uences of injury. The cause of hy"ermetabolism seems to be dictated by the neurohumoral and cyto2ine stress res"onse. The ma$nitude of the increase in metabolic rate is directly "ro"ortional to the si6e of burn injury. The total ener$y e%"enditure may be ele#ated from 1! to 155 "ercent of basal needs& e%ceedin$ those of other injuries and directly "ro"ortional to burn si6e. +ner$y needs must be e#aluated carefully in formulatin$ a "arenteral or enteral diet thera"y "ro$ram. If the re$imen is deficient in calories& "rotein synthesis (ill not be o"timal& and nitro$en balance (ill continue to be ne$ati#e. -athematical deri#ations e%ist for the calculation of daily caloric needs in burns. The formula most used is the .on$?s modification of the >arris')enedict e*uation :Table 4'9<. The >arris')enedict e*uation estimates basal metabolic rate :)-R< (ith reasonable accuracy. .on$ "ro"osed that the )-R be multi"lied by #arious stress factors de"endin$ u"on ty"e of injury. The current re#ision for burn "atients uses a multi"lication factor of 1.9. The more se#erely ill the "atient& the less accurate standard formulas are for estimatin$ calorie e%"enditure. Routine determination of restin$ ener$y e%"enditure :R++< from the measurement of o%y$en consum"tion and carbon dio%ide "roduction is conducted at least t(ice (ee2ly on burn "atients for "ro"er adjustments of caloric needs. R++ determinations should not be construed as e*ui#alent to the 1 'h calorie re*uirement. Com"ensations must be made for daily ener$y fluctuations that occur (ith "hysical thera"y& stress& tem"erature s"i2es& dressin$ chan$es& and other influences on metabolic rate. The "atient?s calorie $oal should be calculated at 115 to 195 "ercent of the measured R++. Urinary nitro$en e%cretion is relati#ely easy to measure& but nitro$en losses in dressin$s and s2in ma2e accurate measurements of nitro$en balance difficult to obtain. Carbohydrates Carbohydrates& "rimarily in the form of $lucose& a""ear to be the best source of non"rotein calories in the thermally injured "atient. Certain tissues& includin$ the burn

(ound& neural tissues& and the formed elements of the blood& utili6e $lucose in an obli$atory fashion. ,ro#ision of $lucose to these tissues occurs at the e%"ense of lean body mass if ade*uate nutrition is not "ro#ided. In the unalimented state& the major sources of three carbon "recursors for ne( $lucose "roduction by the li#er are the (ound and s2eletal muscle. The (ound uses $lucose by anaerobic $lycolytic "ath(ays& "roducin$ lar$e amounts of lactate as an end "roduct. The (ound meets its hi$h $lucose re*uirements by means of hi$h $lucose deli#ery rates& (hich are made "ossible by the enhanced circulation to the (ound. In the li#er& lactate is e%tracted and utili6ed for ne( $lucose "roduction by the Cori cycle. Concomitantly& alanine& $lutamine& and other $lyco$enic amino acids contribute to increased $luconeo$enesis. Increased urea$enesis& (ith urea ultimately deri#ed from body "rotein stores& "arallels the rise in he"atic $lucose out"ut. ,eri"heral amino acids and (ound lactate account for a""ro%imately one'half to t(o' thirds of ne( $lucose "roduced by the li#er. The mild hy"er$lycemia obser#ed in hy"ermetabolic burn "atients is a conse*uence of accelerated $lucose flo( arisin$ from increased he"atic $lucose "roduction& not from decreased "eri"heral utili6ation. )ecause $lucose that is obtained by $luconeo$enic "ath(ays is ultimately deri#ed from "rotein stores& de"letion of body "rotein durin$ "eriods of star#ation leads to ener$y deficits and malfunctionin$ of $lucose' de"endent ener$etic "rocesses at the cellular le#el. ;cti#e trans"ort mechanisms res"onsible for maintainin$ transmembrane ionic $radients in erythrocytes are deran$ed in catabolic& thermally injured "atients. The abnormal sodium and "otassium $radients in red blood cells can be re#ersed by "ro#idin$ these "atients (ith hi$h caloric le#els of carbohydrate as $lucose. >e"atic clearance of indocyanine $reen& an ener$y'de"endent acti#e trans"ort "rocess& is decreased in se#erely injured "atients (hen ener$y normally su""lied as $lucose is re"laced by an isocaloric $lucose'free source. /lucose'insulin solutions correct the Bsic2 cell syndromeC in burned "atients (ho e%hibit a "rom"t natriuresis and nonosmotic diuresis (hen metabolic re*uirements are met by $lucose. ,rotein Combinin$ $lucose and nitro$en'containin$ nutrients im"ro#es nitro$en balance and allo(s more calories to be used for the restoration of nitro$en balance than (ould be the case if either nutrient $rou" (ere used alone. +ner$y and "rotein coo"erati#ely contribute to the im"ro#ement in "rotein conser#ation. ;fter injury& the indi#idual effects of $lucose and amino acids on nitro$en e*uilibrium o"erate by at least t(o different mechanisms. ;mino acid administration "romotes synthesis of #isceral and muscle "rotein (ithout affectin$ the rate of "rotein brea2do(n. /lucose retards (hole' body "rotein brea2do(n and decreases the total amino acid "ool& but e%erts little effect on "rotein synthesis. )oth mechanisms im"ro#e nitro$en balance& and $lucose and nitro$en should be com"onents of the nutritional re$imen for the se#erely burned catabolic "atient. The uni*ue im"ortance of $lutamine as a fuel source has been reco$ni6ed. The $astrointestinal tract uses $lutamine as a res"iratory ener$y source& and dis"oses of the majority of $lutamine as ammonia& urea& and citrulline. The alanine $enerated from $lutamine in the intestine and 2idney is used for $luconeocentesis. Durin$ critical illness& circulatin$ concentrations of $lutamine fall& and su""lemental $lutamine is re*uired to meet $astrointestinal tract ener$y re*uirements. 7hile

$lutamine is easily su""lied by the enteral route& and all a$ree on its efficacy& "arenteral "re"arations are not routinely a#ailable. There is contro#ersy as to (hether "arenterally administered $lutamine is efficacious. ;dministration of ar$inine after injury has become increasin$ly im"ortant. Increased dietary ar$inine may diminish "rotein catabolism& reducin$ urinary nitro$en secretion in trauma or stress and im"ro#in$ immune function. ;nother beneficial effect of ar$inine is its secreta$o$ue acti#ity on "ituitary and "ancreatic hormones. Dietary ar$inine su""lementation (as sho(n to increase "lasma insulin le#els after $lucose administration in "rotein'de"leted rats. Tube feedin$s desi$ned to enhance immune function ha#e demonstrated the beneficial effects of ar$inine on anabolic hormone secretion. Aat The role of fat as a source of non"rotein calories is de"endent on the e%tent of injury and the associated hy"ermetabolic res"onse. 7hen hy"ercaloric diets that do not contain nitro$en are administered& carbohydrate alone is more effecti#e in s"arin$ body "rotein than is fat alone. Aat a""ears to be a "oor calorie source for the maintenance of nitro$en e*uilibrium and lean body mass in hy"ermetabolic "atients (ith lar$e burns. ,atients (ith only moderate ele#ations of metabolic rate can use li"id calories efficiently& but these "atients rarely re*uire "arenteral nutrition3 most table foods and defined diets contain all necessary fat nutrients. .inoleic acid (as established as BessentialC in the 1995s. It cannot be synthesi6ed and has a s"ecific role in maintainin$ cellular inte$rity. Consum"tion of 1 to 9 "ercent of total calories as linoleic acid is sufficient to "re#ent deficiency in humans. Studies su$$est that fatty acids of the ome$a'9 family :"articularly a'linolenic and eicosa"entaenoic acid< are also im"ortant in dietary constituents. +icosa"entaenoic acid is the "rimary source of the triene "rosta$landins. Ome$a'9 fatty acids form a series of com"ounds similar to the ome$a'8 series& but ha#e different biolo$ic effects. These effects are less catabolic and less injurious than "rosta$landins deri#ed from the ome$a'8 fatty acids. Not only the amount of total fat& but also the structure of the fatty acids used in nutritional su""ort "ro$rams& can ha#e di#er$ent effects on metabolism& morbidity& and mortality. +nteral tube feedin$ "roducts are lar$ely de#oid of ome$a'9 fatty acids3 a'linolenic deficiency has been demonstrated in "atients on lon$'term tube feedin$s. Hitamins and -inerals Hitamin re*uirements in critically ill hy"ermetabolic burn "atients remain "oorly defined. The fat'soluble #itamins :;& D& +& and P< are stored in fat de"ots and are slo(ly de"leted durin$ "rolon$ed feedin$ of solutions that do not contain any #itamin formulations. The (ater'soluble #itamins :)' com"le% and C< are not stored in a""reciable amounts& and are de"leted ra"idly. ;ll #itamins should be su""lemented. The dosa$e $uidelines recommended by the National ;d#isory /rou"G;merican -edical ;ssociation :N;/G;-;< are reasonable for burn "atients unless sym"toms of deficiency occur. ;scorbic acid has an essential role in (ound re"air& and "lasma le#els are fre*uently de"ressed in burn "atients. It is "rudent to su""lement the N;/G;-; formulation (ith 1!5 to !55 m$ of #itamin C daily. .ar$er doses may

cause diarrhea and formation of renal stones& and (ill interfere (ith laboratory studies. +%cessi#e doses of #itamins ; and D "roduce to%ic sym"toms& and monitorin$ of serum le#els in critically ill "atients is often misleadin$& since the concentrations of the #itamin carrier "roteins are commonly decreased in these "atients. -ineral nutrients are im"ortant because of their role in metabolic "rocesses. Are*uent determinations of serum sodium& "otassium& chloride& calcium& ma$nesium& and "hos"horus are the best $uides to electrolyte re"lacement. .ess is 2no(n about trace metal re*uirements after thermal injury. Qinc is an im"ortant cofactor in en6ymatic function and (ound re"air& and 6inc deficiency has been documented in burn "atients. ;fter injury in animal models& 6inc and other trace metals seem necessary for nitro$en retention& but the le#el of these metals may merely reflect nitro$en balance and ha#e little direct im"lication. ,eriodic measurements of 6inc& co""er& man$anese& and chromium are the best (ay to determine re"lacement'dosa$e $uidelines. Trace elements are "resent in #aryin$ concentrations as contaminants in amino acid "arenteral solutions& and contribute to satisfyin$ daily re*uirements. Route of ;dministration The route of administration of nutrients is im"ortant because it seems to influence outcome. Total "arenteral nutrition is used only (hen the "atient?s needs cannot be (holly met by the enteral route. ,atients (ith burns under 1! "ercent T)S; that are not com"licated by facial injury& inhalation injury& or malnutrition& and are not associated (ith "sycholo$ical difficulties& includin$ "ossible abuse& can usually be maintained on hi$h'calorie& hi$h' "rotein diets in$ested orally. The nutritional re*uirements of "atients (ith lar$e burns cannot be met by the oral route alone& and these "atients should be fed $astrointestinally or nasoenterally. ; functionally intact alimentary tract al(ays should be used. In se#erely burned "atients& $astric ileus may limit the stomach?s role in nutritional su""ort& at least in the early "ostburn "hase& but the small bo(el usually maintains normal mobility and absor"tion. The safest route for infusion of nutrients is distal to the li$ament of Treit6. The "lacement of a small bo(el feedin$ tube& durin$ resuscitation or durin$ sur$ical treatment& can be the first ste" in "ro#idin$ nutritional su""ort. ; "rotecti#e naso$astric tube is used to measure $astric residual content. +nteral feedin$ has ad#anta$es o#er "arenteral feedin$s. +nteral nutrients seem to maintain the inte$rity of the $astrointestinal tract& and increased he"atic "rotein synthesis may reduce the incidence of bacterial translocation from the $ut. ;n oral diet "reser#es $ut mucosal mass and maintains di$esti#e en6yme content3 "arenteral feedin$ results in decreased mucosal cell turno#er. Studies ha#e #erified that oral feedin$ stimulates the $ut to elaborate tro"hic hormones& "articularly $astrin. +nteral calories initiate $reater insulin release than "arenteral nutrition& and insulin a""ears to "romote anabolism. Studies ha#e sho(n that institution of enteral feedin$ immediately after admission of "atients (ith burn trauma is beneficial. This feedin$ techni*ue blunts the intensity of the hy"ercatabolic res"onse and more effecti#ely maintains "reinjury (ei$ht. ;ssociated findin$s are decreased circulatin$ concentrations of the counterre$ulatory hormones e"ine"hrine& $luca$on& and corticosteroids.

Total "arenteral nutrition should be instituted (hen enteral feedin$s alone cannot "ro#ide ade*uate nutritional su""ort. ,rolon$ed "ostresuscitation ileus& o#eruse of narcotics& and consti"ation are fre*uently causes of failure of successful enteral alimentation. Se"sis is associated (ith ileus and se#ere $lucose intolerance& and these sym"toms may be the only e#idence of this com"lication. ,re#iously tolerated feedin$s must often be discontinued (hile hy"er$lycemia is bein$ controlled and the "atient is resuscitated. Ileus commonly "ersists& and nutrition is reinstituted by the "arenteral route& often re*uirin$ lar$e doses of insulin. If total su""ort cannot be su""lied enterally& it is useful to continue enteral nutrition e#en if the majority of nutrition is su""lied "arenterally. The benefits of enteral nutrition are reali6ed e#en (hen 15 "ercent of needs are $i#en enterally. Com"osition of +nteral Nutrition Three decades a$o& burn and trauma "atients re*uirin$ nutritional su""ort beyond that "ro#ided by a hos"ital diet recei#ed tube feedin$s consistin$ of food solutions "re"ared in a blender. These blended meals ha#e been standardi6ed& and are a#ailable in commercially "re"ared formulas. The $oal is to "ro#ide nutritional su""ort tailored to meet the needs of critically ill burn "atients. Nutritional su""ort should "ro#ide substrates in "ro"ortions based on the s"ecific metabolic deran$ements in burns. Standard meal re"lacement "roducts formulated for nonstressed or minimally stressed "atients do not meet the uni*ue nutritional re*uirements of moderately or se#erely metabolically stressed "atients. )ecause these re$imens can be $rossly incom"atible (ith needs& they are often counter"roducti#e& e%acerbatin$ nutritional inade*uacies and increasin$ the chance of he"atic& "ulmonary& and $astrointestinal tract com"lications& as (ell as other metabolic dysfunction. Studies of "atients (ith renal failure& "ulmonary insufficiency& he"atic ence"halo"athy& and burns indicate that s"eciali6ed feedin$ re$imens im"ro#e disease'related metabolic deran$ements (hile enhancin$ nutritional status. In burn "atients& si$nificant amounts of ome$a'9 fatty acids should be used. The modular tube feedin$ at the Shriners )urns Institute is a hi$h' "rotein :15 "ercent of calories<& lo('fat :1! "ercent of non"rotein 2ilocalories E2calF< nucleic acidSrestricted formulation :only enou$h to su""ly essential fatty acid<& (hich is enriched (ith ome$a'9 fatty acid :half of li"id calories<& ar$inine :1 "ercent of 2cal<& cysteine :5.! "ercent of 2cal<& histidine :5.! "ercent of 2cal<& #itamin ; :!555 IUG.<& 6inc sulfate :115 m$Gday<& and ascorbic acid :1 $Gday<. The com"osition is structured to im"ro#e immune function& o"timi6e (ound healin$& and lo(er "roduction of the "roteolytic and immunosu""ressi#e dienoic "rosta$landins. Commercially a#ailable immune functionSenhancin$ enteral feedin$s ha#e been sho(n to im"ro#e critically ill "atients. -onitorin$ enteral and tube feedin$ re$imens to determine the tolerance and effecti#eness of the dietary "ro$ram is as im"ortant as selection and initiation of the formula. Careful nutrition and metabolic assessment can hel" ensure o"timal su""ort (ith minimal com"lications. Table 4' outlines su$$ested clinical and laboratory "arameters that should be continuously monitored. The most effecti#e nutritional su""ort re$imens are effected by adherence to sound "rinci"les of early im"lementation of immune functionSenhancin$ enteral feedin$& (ith indi#idual balancin$ and continuous monitorin$. ;ncillary Nutritional Su""ort -easures

-etabolic e%"enditure can be minimi6ed by bluntin$ stressful stimuli. Thermally injured "atients& "articularly children& ha#e difficulty maintainin$ body tem"erature in cold en#ironments. )ecause of the a""arent chan$e in the hy"othalamic set "oint of thermal neutrality& burn "atients re*uire hi$her ambient tem"eratures for comfort. The tem"erature of thermoneutrality is a""ro%imately 9=.1@C :155.4@A<& de$rees hi$her than that of normal subjects. 7armin$ burn "atients to this le#el decreases the metabolic rate and corres"ondin$ ener$y re*uirements. Thermal blan2ets& radiation reflectors& and heat lam"s may be re*uired to maintain the "atient?s tem"erature abo#e 94@C :9=.8@A<. ,ain that accom"anies (ound mani"ulation and other "atient care "rocedures accentuates metabolic e%"enditure& and administration of narcotics reduces the metabolic rate. ;de*uate anal$esia and sedation should be "ro#ided so that "atients ha#e "eriods of uninterru"ted rest. >y"o#olemia& dehydration& and se"sis are "otent stimuli of catecholamine secretion& and a""ro"riate re$imens for #olume re"lacement and antibiotic administration should be follo(ed. Systemic infection e%acerbates erosion of body mass& and additional calories must be su""lied to maintain nitro$en balance at the same le#el obtained before infection. >uman $ro(th hormone increases nitro$en retention (hen administered (ith ade*uate calories and nitro$en. Im"ro#ed nitro$en balance is reflected by increased retention of "otassium& "hos"horus& and amino acids. The actions of e%o$enous $ro(th hormone a""ear to be mediated by the effects of increased insulin secretion on carbohydrate metabolism and "erha"s increased secretion of insulin'li2e $ro(th factor. .ac2 of acti#ity "romotes muscle (astin$ and atro"hy. Hi$orous "hysical thera"y "romotes "reser#ation of muscle bul2 and must be "ro#ided on a daily basis to all "atients re*uirin$ "rolon$ed hos"itali6ation. ,atients in s2eletal traction or air' fluidi6ed beds are relati#ely immobile and lose lean body mass as a result3 sim"le isometric e%ercises can usually be done by these "atients. 7ound care and e%"editious (ound closure are the most effecti#e measures for limitin$ the injury and its metabolic se*uelae. INA+CTION -ost morbidity and mortality in se#erely burned "atients are related to infection. Thermal injury causes se#ere immunosu""ression that is directly related to the si6e of the burn (ound. ; direct relationshi" bet(een s"ecific immune defects and infection has yet not been established& but it is li2ely that this $lobal immunosu""ression ma2es the burn "atient susce"tible to infection. Se"sis occurs (hen the balance of interaction bet(een the host and o""ortunistic or$anisms is altered unfa#orably. Im"ortant determinants of se"sis in burn "atients are factors such as the creation of ne( "ortals of entry& altered host defenses& and e%"osure to "otential "atho$enic and o""ortunistic or$anisms. ,redictors of Infection Reliable "redictors of infection in "atients (ith se#ere burns (ould allo( more timely inter#ention (ith sur$ical e%cision andGor anti'infecti#e a$ents. -any as"ects of the hy"ermetabolic res"onse of uninfected burn "atients are similar to those of infected and se"tic "atients (ithout lar$e inflammatory (ound surfaces. The e%tent of burn injury is one of the major demo$ra"hic "redictors of outcome. The incidence of infection and se"sis rises as burn si6e increases. Children a""ear to be more

susce"tible to systemic infection for a $i#en burn si6e. The "resence of inhalation injury correlates hi$hly (ith infection and mortality. ,atients (ith se#ere inhalation injury and no burn can ha#e a fatal outcome. )urns in#ol#in$ less than 15 to 15 "ercent T)S; in other(ise healthy burn "atients are almost ne#er associated (ith life'threatenin$ infection. The search for a laboratory study to facilitate the early dia$nosis of infection has led to intense e%amination of "ostinjury alterations of hormones& acute'"hase "roteins& and fluorescent substances in the blood and "lasma of burn "atients. -ost laboratory studies are nons"ecific and cannot distin$uish bet(een inflammation and infection. Clinical -anifestations -any of the "hysiolo$ical criteria that ha#e been claimed to reflect se"sis are noninfectious manifestations of "ostinjury hy"ermetabolism. >y"erthermia& tachycardia& increased #entilation& and hi$h cardiac out"ut are "resent routinely in other(ise healthy "atients (ith lar$e burns. )ody tem"erature in burn "atients is de"endent "artially on en#ironmental conditions. >y"erthermia :99@C E151.1@AF or $reater< occasionally re"resents a febrile res"onse to infection& "articularly in children& but e"isodic ele#ations in tem"erature are common in uninfected burn "atients. This dia$nosis remains one of e%clusion& and a definiti#e dia$nosis cannot be made (ithout a (or2u" desi$ned to detect infection. >y"othermia& ho(e#er& commonly indicates se"sis& usually due to $ram'ne$ati#e or$anisms. .eu2ocytosis is also nons"ecific. ;s lon$ as lar$e (ounds remain o"en& moderate ele#ations in leu2ocyte counts are common. Thrombocyto"enia is caused by se#eral factors& includin$ infection and se"sis. Normal to hi$h "latelet counts almost al(ays occur in burn "atients (ho are stable& and are not an indication of the imminent li2elihood of se"sis. Thrombocyto"enia is one of the major manifestations of infection. Other systemic manifestations are e#en more nons"ecific. Decreasin$ mental status can be caused by e%cessi#e sedation& histamine rece"tor bloc2in$ a$ents& and cerebro#ascular disease. >y"er$lycemia may be due to irre$ular administration of hi$h'calorie nutrient solutions or hy"o2alemia. Increased food re*uirements& hy"otension& and oli$uria may be related to underre"lacement of e#a"orati#e (ater loss or unreco$ni6ed diarrhea. The most im"ortant obser#ations are related to the tem"oral association of these "hysiolo$ical e#ents. ; "reci"itant onset of hy"er$lycemia& fall in blood "ressure& and decrease in urinary out"ut should su$$est the "ossibility that the "atient is becomin$ unstable. If these findin$s are associated (ith de#elo"ment of hy"othermia& leu2o"enia& and a fallin$ "latelet count& the "atient is "robably de#elo"in$ se"sis& and it is im"ortant to do an immediate infection e#aluation and administer the a""ro"riate antibiotics. The most common location of lethal infection is the res"iratory tract. ;(areness of the #ariety of infections commonly encountered in burn "atients allo(s an orderly e#aluation of the "otentially infected "atient. 7ound Infection ; chan$e in the "attern of burn (ound infections o#er the "ast fe( decades is "robably related to the "roliferation of broad's"ectrum antibiotics. )efore the

a#ailability of "enicillin& stre"tococci and sta"hylococci (ere the "redominant infectin$ or$anisms. )y the late 19!5s& $ram'ne$ati#e bacteria :,seudomonas s"ecies< had emer$ed as the dominant or$anism causin$ fatal (ound infections in burn "atients. ;ll burn (ounds become contaminated soon after injury (ith the "atient?s endo$enous flora or (ith resident or$anisms in the treatment facilities. -icrobial s"ecies coloni6e the surface of the (ound and may "enetrate the a#ascular eschar. This e#ent is (ithout clinical si$nificance. )acterial "roliferation may occur beneath the eschar at the #iable tissueSnon#iable tissue interface& leadin$ to subeschar se"aration. In a fe( "atients& microor$anisms may breach this barrier and in#ade the underlyin$ #iable tissue& "roducin$ systemic se"sis. The essential "atholo$ical feature of burn (ound se"sis is in#asion of the or$anisms into #iable tissue. The or$anisms then s"read to the "eri#ascular structures and directly in#ade the #essel (all& causin$ ca"illaritis and #ascular occlusion. >emorrha$ic necrosis follo(s3 subse*uently& or$anisms in#ade the bloodstream& "roducin$ metastatic lesions. ;ny or$anisms ca"able of in#adin$ tissue can "roduce burn (ound se"sis. The "redominant or$anisms causin$ burn (ound infection #ary de"endin$ on the treatment facility. )urn (ound infection can be focal& multifocal& or $enerali6ed. The li2elihood of se"ticemia increases in "ro"ortion to the si6e of the burn (ound. Since the introduction of effecti#e to"ical thera"y& fun$al burn (ound infection& "rimarily in#ol#in$ hi$hly in#asi#e ,hycomycetes and ;s"er$illus s"ecies& has increased. ,neumonia One result of the "rolon$ed sur#i#al of se#erely burned "atients in critical care units& made "ossible by modern "atient su""ort techni*ues& is that the res"iratory tract has become the most common locus of infection. )roncho"neumonia has re"laced hemato$enous "neumonia as the most common form of "ulmonary infection in burn "atients. ; dia$nosis of "neumonia is confirmed by the "resence of characteristic chest radio$ra"h "atterns& and the "resence of offendin$ or$anisms and inflammatory cells in the s"utum. ;fter inhalation injury& early infiltrates usually re"resent chemical "neumonitis and not infectious "neumonia& althou$h this dama$ed lun$ tissue may become infected. ,ro"hyla%is (ith antibiotics should not be used& as it selects resistant or$anisms and does not reduce the incidence of "neumonia. Coloni6ation of the u""er air(ay of "atients re*uirin$ intubation and mechanical #entilation should not be confused (ith a res"iratory tract infection. Aor the dia$nosis of broncho"neumonia& analysis of s"utum sam"les may be ade*uate. If there is concern about the identity of the or$anism& bronchosco"y should be used. Su""urati#e Thrombo"hlebitis Su""urati#e thrombo"hlebitis is a major cause of se"sis in burn "atients& occurrin$ in u" to ! "ercent of "atients (ith major burns. It is associated (ith the use of intra#enous catheters& es"ecially if the catheters ha#e been inserted by cut'do(n techni*ues3 the incidence increases (ith the duration of #ein cannulation. The nidus of infection is usually located in the #ein at the site of the catheter ti"& (here there is endothelial dama$e& injury& and fibrin clot formation. The fibrin mesh is subse*uently seeded durin$ e"isodes of bacteremia& (hich may occur at any time durin$ the hos"ital stay. This com"lication can be eliminated by the "lacement of catheters in

hi$h'flo( #eins& such as the femoral& subcla#ian& or internal ju$ular #eins& and by chan$in$ insertion sites e#ery = to 41 h& dislod$in$ the fibrin clot. )acterial +ndocarditis +ndocarditis is occasionally the cause of occult se"sis in burn "atients& and its incidence continues to rise (ith the increasin$ use of intra#enous catheters for hemodynamic monitorin$. +ndocarditis should be sus"ected in "atients (ith "ositi#e blood cultures and no other identifiable source of bacteremia. These "atients should be e%amined re"eatedly by bi"lanar& transthoracic& and transeso"ha$eal echocardio$ra"hy until the source of the se"ticemia is identified. -ost lesions are found on the ri$ht side of the heart& and o#er =! "ercent of "atients ha#e had central #enous or "ulmonary artery catheters "laced in the ri$ht atrium or throu$h the ri$ht #entricle. Systemic antibiotic thera"y should be instituted and continued for at least (ee2s. Urinary Tract Infections -ost "atients (ith burns $reater than 15 "ercent T)S; re*uire ind(ellin$ urinary catheters to $uide fluid resuscitation. ;se"tic techni*ues of insertion and catheter care& the use of a closed draina$e system& and the remo#al of the catheter at the earliest clinically indicated time are effecti#e measures for "re#entin$ urinary tract infections. In the absence of an inflammatory res"onse :less than 15 (hite blood cells "er hi$h'"o(er field<& the majority of "atients (ith "ositi#e urine cultures do not re*uire antimicrobial treatment. Candiduria in the absence of si$ns of systemic infection can be treated (ith bladder irri$ations (ith am"hoterin ). )urns of the "enis usually do not re*uire bladder catheter draina$e unless they are se#ere. Aull'thic2ness burns of the "enis should be treated (ith e%cision and $raftin$. Chondritis of the +ar The "inna of the ear is com"osed almost entirely of cartila$e (ith minimal blood su""ly and is #ulnerable to infection. It is a rare com"lication. 7hen chondritis does occur& a conser#ati#e a""roach (ith draina$e of the heli% centrally& in an attem"t to "reser#e the outer cartila$es& is usually successful. Treatment of Infection The definiti#e treatment of the se"tic burn (ound is the e%"editious e%cision of the (ound. -any of the other infections common to burn "atients re*uire sur$ical inter#ention. -ost infections of burn "atients ac*uired in the hos"ital in#ol#e the or$anisms that ori$inally coloni6ed the burn (ound. To"ical ;ntimicrobial Thera"y )efore the introduction of effecti#e to"ical antimicrobial a$ents& u" to 85 "ercent of the deaths in s"eciali6ed burn treatment facilities (ere caused by burn (ound se"sis. The three a$ents (ith "ro#ed (ide's"ectrum antimicrobial acti#ity (hen a""lied to the burn (ound are sil#er nitrate& mafenide acetate& and sil#er sulfadia6ine :Table 4' !<. Sil#er sulfadia6ine is the most common a$ent used in burn centers. Only mafenide acetate is able to "enetrate the eschar& and it is the only a$ent ca"able of su""ressin$ dense bacterial "roliferation beneath the eschar surface. The main disad#anta$e of mafenide acetate is the stron$ carbonic anhydrase inhibition& (hich interferes (ith renal bufferin$ mechanisms. )icarbonate is (asted& chloride is retained& and the resultin$ hy"erchloremia is com"ensated for by an increase in #entilation and

subse*uent res"iratory al2alosis. Sil#er nitrate must be used after injury before bacteria ha#e "enetrated the (ound. Its disad#anta$es are the associated electrolyte imbalances& (hich are common& and methemo$lobinemia formation& (hich is unusual. Subeschar Clysis and Sur$ical Treatment 7hen burn (ound se"sis has de#elo"ed& the "robability of sur#i#al is less than 15 "ercent. Subeschar infusion of antibiotics has been utili6ed to "re#ent or treat burn (ound in#asion in burn "atients that esca"ed to"ical chemothera"eutic control. Injection of semisynthetic "enicillins beneath the infected eschar is associated (ith mar2edly im"ro#ed sur#i#al. Subeschar clysis is best used as adju#ant thera"y in "re"aration of "atients for eschar e%cision or as "rimary treatment for "atients (ho are too unstable hemodynamically to tolerate sur$ery. /enerali6ed (ound se"sis in stable "atients should be treated by sur$ical e%cision. ;ntibiotics The number and ty"es of antibiotics used in a burn center should be restricted& and the criteria for documentin$ infections should be (ell' defined. ;n infection caused by an identified or$anism is treated by a sin$le antibiotic. Controlled trials in burn "atients ha#e not demonstrated any im"ro#ement in sur#i#al rates achie#ed by the routine use of antibiotic combinations to treat serious infection. The indiscriminate use of multi"le a$ents "romotes o#er$ro(th of Candida s"ecies& enterococci& and multi"le' antibiotic'resistant or$anisms in the "atient and in the burn center. The current "roblem of increase in sta"hylococcal and enterococcal resistance to Hancomycin em"hasi6es the im"ortance of usin$ the least com"le% antibiotic sho(n to be effecti#e a$ainst the or$anisms. Numerous studies ha#e demonstrated that altered "harmaco2inetics of antibiotics in burn "atients result in lo(ered serum dru$ le#els (hen the usual recommended dose is used. In most cases& these doses are subthera"eutic in the burn "atient& es"ecially (ith antibiotics that are "redominantly renally e%creted. Serum le#els should be monitored fre*uently and early in the course of thera"y. Ina""ro"riate "ea2 le#els should "rom"t alterations in the dosa$e& (hile inade*uate trou$h le#els should "rom"t shortenin$ of the dosa$e inter#al. +.+CTRIC;. ;ND C>+-IC;. )URNS +lectrical )urns Care at the Scene +lectrical burns are "articularly dan$erous. If the "atient remains in contact (ith the source of electricity& the rescuer must a#oid touchin$ the "atient until the current can be turned off or the (ires cut (ith "ro"erly insulated (ire cutters. Once a(ay from the source of current& the ;)Cs :air(ay& breathin$& circulation< must be chec2ed. Hentricular fibrillation& or standstill& is common3 cardio"ulmonary resuscitation should be instituted if carotid or femoral "ulses are not "al"able. If "ulses are "resent& but the "atient is a"neic& mouth'to'mouth resuscitation alone may be life'sa#in$. C,R should continue until a cardiac monitor can indicate further treatment. Once an air(ay is established and "ulses return& a careful search must be made for associated life' threatenin$ injuries. +lectrocuted "atients fre*uently fall from hei$hts and may ha#e serious head or nec2 injuries. The intense tetanic muscle contractions associated (ith electrocution can fracture #ertebra or cause major joint dislocations.

;cute and Definiti#e Care +lectrical burns are thermal burns from #ery hi$h intensity heat and from electrical disru"tion of cell membranes. ;s electric current meets the resistance of body tissues& it is con#erted to heat in direct "ro"ortion to the am"era$e of the current and the electrical resistance of the body "arts throu$h (hich it "asses. The smaller the si6e of the body "art throu$h (hich the electricity "asses& the more intense the heat and the less the heat is dissi"ated. Ain$ers& hands& forearms& feet& and lo(er le$s are fre*uently totally destroyed3 areas of lar$er #olume& li2e the trun2& usually dissi"ate enou$h current to "re#ent e%tensi#e dama$e to #iscera unless the entrance or e%it (ound is on the abdomen or chest. ;rc electrical burns are common in addition to the usual entrance and e%it (ounds. These dee" and destructi#e (ounds occur (hen current ta2es a direct "ath& often bet(een joints in close a""osition to one another at the time of injury. )urns of the #olar as"ect of the (rist& the antecubital fossa (hen the elbo( is fle%ed& and the a%illa are most common. 7hile cutaneous manifestations of electrical burns may a""ear limited& the s2in injury is only the ti" of the iceber$& and massi#e underlyin$ tissue destruction may be "resent. Resuscitation needs are usually far in e%cess of (hat (ould be e%"ected on the basis of the cutaneous burn si6e& and associated flame andGor flash burns often com"ound the "roblem. -yo$lobinuria fre*uently accom"anies se#ere electrical burns. Disru"tion of muscle cells releases cell fra$ments and myo$lobin into the circulation to be filtered by the 2idney. If this condition is untreated& the conse*uence can be "ermanent 2idney failure. Cardiac dama$e& for e%am"le& myocardial contusion or infarction& may be "resent. The conduction system may be deran$ed& and in some cases& there can be actual ru"ture of the heart (all or ru"ture of a "a"illary muscle& leadin$ to sudden #al#ular incom"etence and refractory cardiac failure. >ousehold current at 115 H either does no dama$e or induces #entricular fibrillation. If there are no cardiac abnormalities "resent in a "atient in the emer$ency room after shoc2s of 115 to 5 H& the li2elihood that they (ill a""ear later is small. +#en (ith injuries resultin$ from hi$h' #olta$e currents& normal cardiac function on admission $enerally means that subse*uent cardiac dysrhythmia is unli2ely. Studies confirm that commonly measured cardiac en6ymes bear little correlation to cardiac dysfunction& and ele#ated en6ymes may be from noncardiac muscle dama$e. -onitorin$ +C/ and isoen6ymes in an ICU settin$ for = h may be unnecessary in "atients (ith electrical burns (ho ha#e stable cardiac rhythms on admission. The ner#ous system is "articularly sensiti#e to electricity. The most se#ere brain dama$e occurs (hen current "asses throu$h the head& but s"inal cord dama$e is "ossible (hene#er current has "assed from one side of the body to the other. -yelin' "roducin$ cells are susce"tible& and delayed trans#erse myelitis can occur days or (ee2s after injury. Conduction remains normal throu$h e%istin$ myelin& but as the old myelin (ears out& it is not re"laced and conduction sto"s. Dama$e to "eri"heral ner#es is common& and may cause "ermanent functional im"airment. +#ery "atient (ith an electrical injury must ha#e a thorou$h neurolo$ical e%am as "art of the initial assessment. ,ersistent neurolo$ic sym"toms may lead to chronic "ain syndromes& and so'called "osttraumatic stress disorders are much more fre*uent after electrical burns than after thermal burns.

Cataracts are a (ell'reco$ni6ed com"lication of electrical contact burns. They occur in ! to 4 "ercent of "atients follo(ed& they are fre*uently bilateral& and they can occur e#en in the absence of contact "oints on the head. They often occur (ithin a year or t(o of injury. +lectrically burned "atients should under$o a thorou$h o"hthalmolo$ic e%amination durin$ the admissions "hase of acute care. In addition& electrical burns are fre*uently job'related& and a thorou$h baseline e%amination (ill hel"s (or2ers $et job'related insurance if they de#elo" cataracts in the future. 7ound -ana$ement There are t(o situations in (hich early sur$ical treatment is indicated for "atients (ith electrical burns. Rarely& massi#e dee" tissue necrosis (ill lead to acidosis or myo$lobinuria& (hich (ill not clear u" (ith standard resuscitation techni*ues& and major debridement andGor am"utation may be necessary on an emer$ency basis. -ore commonly& the dee" tissues under$o s(ellin$& and the ris2 of com"artment syndrome further com"romisin$ dama$ed tissue is real. Careful monitorin$& includin$ measurement of com"artment "ressures& is mandatory& and escharotomies and fasciotomies should be "erformed at the sli$htest su$$estion of "ro$ression. Routine com"artment "ressure measurements may be hel"ful& but any of the si$ns of im"endin$ com"artment syndrome :increased "ain& "allor& absence of "ulseless& decreased sensation& and tense s(ellin$< mandate "rom"t com"artment release in the o"eratin$ theater. ;ny "ro$ression of median or ulnar ner#e deficit in a hand that has been electrically burned is an indication for median and ulnar ner#e release at the (rist. If immediate decom"ression or debridement is not re*uired& definiti#e sur$ical "rocedures can be done bet(een days 9 and !& before bacterial contamination occurs and after the tissue necrosis is delineated. Hascular $rafts to re"lace clotted arteries are sometimes an o"tion. >o(e#er& they may actually increase morbidity and "rolon$ reco#ery& and am"utation and one of the ne(er "rostheses mi$ht "ro#ide better function than a hand or foot (ith "oor sensation and motor function. Chemical )urns +mer$ency Care In cases in#ol#in$ chemical burns& (hene#er "ossible& in#ol#ed clothin$ should immediately be remo#ed and the burns should be thorou$hly flushed (ith co"ious amounts of (ater at the scene of the accident. Chemicals (ill continue to burn until remo#ed& and (ashin$ for at least 1! min under a runnin$ stream of (ater may limit the o#erall se#erity of the burn. No thou$ht should be $i#en to searchin$ for a s"ecific neutrali6in$ a$ent. Delay dee"ens the burns& and neutrali6in$ a$ents may cause burns themsel#es3 they fre*uently $enerate heat (hile neutrali6in$ the offendin$ a$ent& addin$ a thermal burn to the already "otentially serious chemical burn. ,o(dered chemicals should be brushed off s2in and clothin$. Chemical burns& usually caused by stron$ acids or al2alis& are most often the result of industrial accidents& assaults& or the im"ro"er use of harsh sol#ents and drain cleaners. In contrast to a thermal burn& chemical burns cause "ro$ressi#e dama$e until the chemicals are inacti#ated by reaction (ith the tissue& or diluted by flushin$ (ith (ater. Indi#idual circumstances #ary& but acid burns may be more self'limitin$ than al2ali burns. ;cid tends to BtanC the s2in& creatin$ an im"ermeable barrier that limits further "enetration of the acid. ;l2alis combine (ith cutaneous li"ids to create soa"

and thereby continue Bdissol#in$C the s2in until they are neutrali6ed. ; full'thic2ness chemical burn may a""ear dece"ti#ely su"erficial& causin$ only a mild bro(nish discoloration of the s2in. The s2in may a""ear to remain intact durin$ the first fe( days "ostburn& and only then be$in to slou$h s"ontaneously. Chemical burns should be considered dee" dermal or full'thic2ness& until "ro#ed other(ise. Some chemicals& such as "henol& cause se#ere systemic effects& and others& such as hydrofluoric acid& may cause death from hy"ocalcemia e#en after moderate e%"osure. Unless the characteristics of the chemical are (ell 2no(n& the treatin$ "hysician is ad#ised to call the local "oison control bureau for s"ecifics in treatment. OUT,;TI+NT -;N;/+-+NT OA T>+R-;. INJURI+S -inor burns com"rise a""ro%imately 9! "ercent of all burns treated in the United States. These burns are usually su"erficial& do not e%ceed 15 to 1! "ercent of the body surface area& and rarely re*uire hos"itali6ation. -any moderate and e#en major thermal injuries& as classified by the ;merican )urn ;ssociation Injury Se#erity /radin$ System& are amenable to out"atient mana$ement after initial e#aluation and stabili6ation. ;lthou$h sur#i#al is usually not an issue and most minor burns (ill ultimately heal re$ardless of thera"y& undertreatment and :more commonly< o#ertreatment can result in infection or delay in healin$ (ith discomfort and "rolon$ed morbidity. The $oals of out"atient burn mana$ement include (ound healin$& "atient comfort& and ra"id rehabilitation. -ana$ement of -inor )urns Treatment at the Scene of the ;ccident ;fter elimination of the heat source& areas (ith minor burns should be "laced in te"id (ater rather than ice (ater. The "otential benefits of coolin$ burn (ounds are contro#ersial :Table 4'8<. It has been su$$ested that the beneficial effects& if they do e%ist& last only for the first 1 or 9 minutes after thermal injuries& and the a""lication of ice (ater after this initial "eriod may result in "rolon$ed edema and im"airment of healin$& and may con#ert a "artial'thic2ness to a full'thic2ness injury. The burn area should then be (ra""ed in a clean cloth and the #ictim ta2en to an emer$ency facility. Chemical burns should be irri$ated (ith co"ious amounts of (ater. Tar burns should be cooled (ith (ater& but the tar should not be remo#ed at the scene of the accident. Initial -edical -ana$ement ; "rotocol for immediate (ound care in the emer$ency room or out"atient facility is mandatory for efficiency in treatin$ thermal injury& (hich is too often characteri6ed by "anic& confusion& and a multi"licity of a""roaches. ; thorou$h history ta2in$ should elicit (hen and (here the accident occurred& and the burnin$ a$ent :flame& hot li*uid& electricity& etc.<. The history should also determine (hether there is any "ossibility of smo2e inhalation injury. De"endin$ u"on the circumstances of the accident& e#aluation for "ossible associated injuries is also im"ortant. ,ertinent "ast medical history& includin$ dru$ aller$ies& medication history& and history of systemic illnesses& should also be obtained. Tetanus "ro"hyla%is is the same for minor burns as for any other injury. ; tetanus to%oid booster is $i#en to any "atient (ho has not recei#ed one for ! years or (ho cannot recall the date of last immuni6ation. ,atients not "re#iously immuni6ed should

recei#e 1!5 units of tetanus human immune $lobulin& and the first of a series of acti#e immuni6ations (ith tetanus to%oid. )urn (ounds may be soa2ed in te"id (ater or co#ered (ith saline'soa2ed s"on$es that decrease the "ain until the "hysician can e#aluate the "atient. Ice (ater should not be used. The (ounds should be (ashed (ith mild soa" and (arm (ater& e%cessi#e debris trimmed& and hair sha#ed (ithin mar$ins of at least 1 in around the burn (ound. The remo#al of tar and as"halt is best accom"lished (ith the use of -edisol& a citrus and "etroleum distillate (ith hydrocarbon structure that consists of 45K "etroleum distillate :base oil<& 1! to 14K limonene :oran$e oil<& 1 to 9K lanolin& and 1K surfactant :dioctyl sodium sulfosuccinate<. This "roduct has "ro#ed to be the most efficient in remo#in$ tar (ithout dama$in$ the underlyin$ burn (ound. -ineral oil and "etroleum ointments& such as bacitracin or Neos"orin& may also be used to remo#e tar. The tar should not be "eeled off because of "otential dama$e to the hair and s2in incor"orated in the tar. Chemical burns should be irri$ated (ith (ater for 15 min if this (as not done at the scene of the accident. ; neutrali6in$ a$ent should not be a""lied& because the neutrali6in$ reaction is al(ays e%othermic :heat' "roducin$< and may result in a more se#ere injury. )listers may be mana$ed in one of three (aysI :1< The blister is left intact and the underlyin$ (ound allo(ed to heal in the blister fluid en#ironment. :1< The blister fluid is e#acuated and the o#erlyin$ s2in allo(ed to co#er the underlyin$ (ound. :9< The blister is debrided. 7hich techni*ue is used de"ends not only on the location and si6e of the blister& but also on the com"liance of the "atient. If there are *uestions concernin$ a "atient?s reliability& or there is a "otential for (ound infection& it is more "ractical and safer to debride the blister. ;fter the (ound is cleansed and debrided& the e%tent and de"th of injury and areas in#ol#ed are estimated. If the burn is minor& the "atient can be treated as an out"atient. If there is any *uestion re$ardin$ the feasibility of out"atient mana$ement& it is safer to admit the "atient to the hos"ital for 1 to =h& after (hich out"atient mana$ement is feasible if e#erythin$ is fa#orable. Aollo('u" 7ound Care The "roblems associated (ith major thermal injuryLimmunosu""ression& hy"ermetabolism& and increased susce"tibility to infectionLare not associated (ith minor burn (ounds& as it is fre*uently erroneously assumed. )asic "rinci"les include 2ee"in$ the (ound clean and in a moist en#ironment (hile the (ound heals. ,o(erful to"ical chemothera"eutic a$ents such as mafenide acetate :Sulfamylon<& or "o#idone'

iodine :)etadine< should not be a""lied to minor burn (ounds& since they ha#e been sho(n to delay (ound healin$. In addition& systemic antibiotics are rarely indicated for the treatment of small burns& and may "redis"ose the (ound to later o""ortunistic infection (ith bacteria& fun$i& or #iruses. Aollo('u" care should includeI :1< (ashin$ the (ound (ith bland soa" and (ater in a bathtub or sho(er& :1< "attin$ the (ound dry (ith a clean to(el& :9< a""lyin$ a bland ointment& such as bacitracin& and a nonstic2 "orous $au6e& such as ;da"tic or Reroform& then (ra""in$ the (ound li$htly (ith $au6e rolls :Perli%<. This re$imen is "erformed t(ice daily :see Table 4'8<. Normally& follo('u" is "erformed (ee2ly in the burn clinic. If there is some *uestion re$ardin$ the e%tent or de"th of the (ound& or the reliability of the "atient or hisGher family& initial follo('u" may be "erformed on a daily basis. The "atient (ith a minor burn should be $i#en instructions for a #i$orous "ro$ram of ran$e'of'motion e%ercises. ,rolon$ed edema& (hich retards (ound healin$& is minimi6ed (ith ade*uate "hysical thera"y. Rehabilitation time may also be decreased if an acti#e e%ercise "ro$ram is follo(ed. If the (ounds are dee" "artial' or full'thic2ness burns& the "atient can still be treated as a out"atient until "rimary e%cision and $raftin$ can be "erformed. In children& the thic2ness of the e"idermis and dermis is decreased& and thus the de"th of injury is difficult to determine. If there is any *uestion re$ardin$ de"th of injury& the (ounds are treated conser#ati#ely for 15 to 1 days before e%cision and $raftin$. If the (ound is healin$ "ro"erly& it (ill be totally e"itheliali6ed in 1 to 9 (ee2s. ; "rediction of (ound healin$ can be made by 1 days "ostinjury. If the (ounds are not healin$ (ithin this time "eriod& then "rimary e%cision and $raftin$ should be "erformed. 7aitin$ for eschar se"aration and formation of $ranulation tissue delays (ound closure& "rolon$s (ound healin$& and results in increased scarrin$ and "rolon$ed rehabilitation time. ; su"erficial "artial'thic2ness injury should be follo(ed until e"ithelial co#era$e has occurred and then e%amined at 8 (ee2s for e#idence of hy"ertro"hic scarrin$. If hy"ertro"hic scarrin$ occurs& com"ression dressin$s should be fitted and (orn until the (ound becomes *uiescent& (hich usually re*uires 11 to 1= months. ; "roblem that occurs in a healed burn is the formation of #ery thin (ater blisters& "roduced as a result of minor trauma. These blisters& (hich rarely e%ceed 1 cm& occur 1 to 8 (ee2s after (ound closure and lea#e small o"en areas that heal (ithout incident in 9 to ! days if they are 2e"t clean (ith bland soa" and (ater and co#ered (ith a bland ointment& such as bacitracin. Recently healed "artial'thic2ness burn (ounds become #ery dry. ; mild lanolin cream or lotion should be used until the natural s2in lubrication mechanisms return& usually (ithin 8 to = (ee2s. The "atient should be instructed to a#oid sun e%"osure until the (ound is com"letely healed3 e%"osure to the sun may cause hy"er"i$mentation of the (ound& (hich is fre*uently "ermanent. The use of a sun bloc2 :sun "rotection factor 95 to !5< is recommended for healed areas that must be e%"osed to direct sunli$ht.

,ruritus is a common com"laint in "atients (ith healin$ burn (ounds& and se#ere "ruritis is e%tremely difficult to treat. Di"henhydramine hydrochloride or hydro%y6ine anti"ruritics ha#e "ro#ed to be beneficial. Usin$ a moisturi6in$ cream also hel"s alle#iate itchin$. ;lternati#e -ethods of 7ound -ana$ement There are multi"le methods for mana$in$ out"atient burn (ounds. Some ad#ocate bul2y dressin$ for as lon$ as 15 to 1 days. ;lthou$h a bul2y dressin$ "re#ents "ain& there is a "otential ha6ard of bacterial o#er$ro(th in the (arm& moist dressin$& and ran$e'of'motion e%ercisin$ cannot be "erformed& (hich "rolon$s edema and interferes (ith rehabilitation. To"ical chemothera"eutic a$ents& such as sil#er sulfadia6ine& are fre*uently used in the mana$ement of minor burn injury. If this form of mana$ement is used& it is im"ortant to remember that sil#er sulfadia6ine is inacti#ated by tissue secretions and must be chan$ed at least t(ice a day. ; "seudomembrane forms o#er the "artial'thic2ness injury& (hich is fre*uently "ainful and difficult to remo#e. The use of "rosthetic s2in substitutes in the treatment of "artial'thic2ness out"atient burns has recently become "o"ular. T(o substitutes that are useful on "artial' thic2ness injury are )iobrane and O"Site. )iobrane can be used effecti#ely in "artial' thic2ness burns. It is (ell tolerated& is ca"able of com"ressin$ underlyin$ fluid collection& and does not "romote bacterial "roliferation. It may be left on until e"itheliali6ation occurs. O"Site is a synthetic barrier. Its use re*uires some e%"ertise& because fluid collections beneath the barrier fre*uently occur. The "roblem of accurate dia$nosis of de"th of injury is a dra(bac2 to the use of either of these "rosthetic s2in substitutes. If the (ound is a medium to dee" "artial'thic2ness injury& an eschar does form& necessitatin$ fre*uent dressin$ chan$es. )iolo$ical dressin$s includin$ allo$raft& %eno$raft& or amnion ha#e been used to treat out"atient burns in the "ast. The cost of cada#eric allo$raft is "rohibiti#e. Reno$rafts should not be used on su"erficial "artial' thic2ness injury because of the incor"oration of %eno$raft tissue into the healin$ donor sites& (hich occurs in as many as 9! "ercent of the "atients so treated. -ana$ement of Critical ;reas Aace Su"erficial burns of the face should be left e%"osed. The face is (ashed t(ice daily (ith a mild soa" and (ater& and a thin layer of a bland ointment :bacitracin< is a""lied to the o"en (ounds to "re#ent dryin$. +ars Su"erficial burns of the ear should be treated (ith a bland ointment. Dee"er injuries must be treated (ith to"ical antibiotics3 e%cessi#e "ressure may cause chondritis& and should be a#oided. +yes Sus"ected corneal burns should be stained (ith fluorescein for confirmation of dia$noses. Su"erficial corneal burns should be treated similarly to corneal abrasions& (ith #i$orous irri$ation& the a""lication of o"hthalmolo$ic antibiotic ointment& and

eye "atchin$. Su"erficial corneal burns not asym"tomatic by = h and more serious injuries should be e#aluated by an o"hthalmolo$ist. >ands Su"erficial burns of the hand should be ele#ated for 1 to = h to minimi6e s(ellin$. Circumferential hand burns may re*uire hos"itali6ation for obser#ation of ade*uate circulation. Ran$e'of'motion e%ercises should be$in as soon as "ossible after injury. Instructions for the e%ercise "ro$ram should be "art of the mana$ement "rotocol. Aeet ;lthou$h burns of the feet are "ainful& (al2in$ and ran$e'of'motion e%ercises should be "erformed. Crutches should not be allo(ed. To "re#ent edema& burned feet should be ele#ated (hen the "atient is not (al2in$ or e%ercisin$. ;n elastic banda$e should be a""lied o#er the (ound dressin$ (hen the "atient is (al2in$ or sittin$& but it should be remo#ed at ni$ht (hen the feet are ele#ated. ,erineum ,erineal burns fre*uently re*uire hos"itali6ation for 1 to = h for obser#ation of urinary obstruction secondary to edema. -inor "erineal burns can be treated (ith a bland ointment. +%tensi#e su"erficial "erineal burns& e.$.& "ediatric bathtub scald injuries& are best treated (ith to"ical chemothera"y :sil#er sulfadia6ine<& utili6in$ a dia"er as the (ound dressin$. Com"lications -ost com"lications in small burn injuries result from o#ertreatmentI too' #i$orous dressin$ chan$es that "ull off ne(ly formed e"ithelium& or the use of a #ariety of to"ical and systemic antibiotics that can cause secondary infection or formation of a "seudomembrane that may re*uire debridement& either of (hich may delay healin$. Treatment that is a""ro"riate for lar$er burns is o#ertreatment of small burns. In small burns& systemic antibiotics are rarely indicated and to"ical a$ents are usually not necessary. -ana$ement of -oderate or -ajor )urns ,atients (ith su"erficial "artial'thic2ness moderate and major burn injuries can also be successfully mana$ed as out"atients. In these burns& as in minor burns& sur#i#al is not an issue. The cost of burn care in the United States is a""roachin$ X1555 "er day& and out"atient mana$ement of these ty"es of burns can mar2edly decrease these costs. The "resence of endemic& dru$'resistant microor$anisms (ithin any hos"ital en#ironment& "articularly in burn centers& "oses a "otential threat to the moderately se#ere su"erficial "artial'thic2ness burn "atient& (ith fre*uent coloni6ation of the burn (ound by endemic sta"hylococcal and "seudomonas or$anisms. -edical Criteria for Out"atient -ana$ement The medical criteria for (hether a "atient is treated as an out"atient includeI :1< no e%istin$ com"lications of thermal injury& such as inhalation injury& :1< fluid resuscitation com"leted& :9< stabili6ed hos"ital course& : < ade*uate nutritional inta2e& :!< ade*uate "ain tolerance& and :8< no antici"ated se"tic com"lications. The "atient?s family must be (illin$ to "artici"ate in the care of the "atient and must be ca"able of doin$ so. Criteria for Bca"abilityC include "ersonal cleanliness& no a""arent a#ersion to burn care& an ability to "erform the dressin$ chan$es and assist in ran$e'of' motion

e%ercises& and access to trans"ortation to return the "atient for burn care and "hysical thera"y. Not all families initially meet these criteria& but (ith "ersistent education by the burn team& most families can learn ho( to conform to the $uidelines. Out"atient Treatment ,ro$ram Out"atient mana$ement of moderate and major thermal injuries in#ol#es t(o "hases of treatmentI a home'treatment "ro$ram and "hysical thera"y. ;t home& the "atients are instructed to bathe or sho(er t(ice daily& (ash the (ound (ith mild soa" and (ater& $ently debride the (ound (ith a (ashcloth& and a""ly "rescribed to"ical ointment follo(ed by a li$ht dressin$. ,atients e%ercise e#ery hour& follo(in$ a "ro$ram outlined by the "hysical thera"ist. Aamily members are instructed to encoura$e self'care and acti#e ran$e of motion at all times. 7hen the "atient is dischar$ed from the hos"ital& an a""ointment is made for out"atient "hysical thera"y. The fre*uency of treatments decreases as the (ound heals& but initially "atients are seen daily. The treatments consist of hydrothera"y& debridement of burn (ounds& and a su"er#ised e%ercise re$imen. The (ounds are e#aluated by the "hysical thera"ist and feedbac2 $i#en to the family members re$ardin$ (ound status& dressin$ chan$es& and ran$e of motion. ;ll "atients are seen (ee2ly in the burn clinic& (here the (ounds are e%amined& treatment re#ie(ed& and necessary chan$es made. ,;IN CONTRO. ;ll burn injuries are "ainful& (hether the injury is a sim"le sunburn or an e%tensi#e second' or third'de$ree burn co#erin$ a lar$e "ortion of the body. ;ttem"ts to mana$e "ain in a "atient (ith a burn injury are fre*uently frustratin$ because of the often' chan$in$ "hysiolo$ical and "sycholo$ical reactions to the injury. ; su"erficial& "artial'thic2ness injury :first'de$ree burn< dama$es the outer layers of s2in& the e"idermis& "roducin$ mild "ain and discomfort. The "ain associated (ith moderate to dee" "artial'thic2ness or second'de$ree burns #aries de"endin$ on the e%tent of destruction to the dermis. Su"erficial dermal burns initially are the most "ainful& and e#en the sli$htest chan$e in air current on the e%"osed su"erficial dermis causes the "atient to e%"erience e%cruciatin$ "ain. 7ithout the "rotecti#e co#erin$ of the e"idermis& ner#e endin$s are sensiti6ed and e%"osed to stimulation. ;reas of dee" "artial'thic2ness or full'thic2ness injury sho( little or no res"onse to shar" stimuli& yet a "atient may com"lain of a dee"& achin$ "ain& (hich is related to the inflammatory res"onse. The "hysiolo$ical effects of "ain include increase in heart rate& blood "ressure& and res"iration3 a decrease in O1saturation3 "almar s(eatin$ and facial flushin$3 and dilatation of the "u"ils. No sin$le "hysiolo$ical chan$e is an absolute indication of "ain. The burn "atient may e%"erience acute "ain from dressin$ chan$es& o"erati#e "rocedures& and rehabilitation e%ercises. The "atient may also ha#e chronic bac2$round "ain associated (ith the (ound maturation "rocess. ,ain mana$ement in#ol#es "harmacolo$ic and non"harmacolo$ic modalities. ,harmacolo$ical modalities include hy"notics and anal$esics& such as mor"hine& methadone& codeine& acetamino"hen& and nonsteroidal anti' inflammatory a$ents. ;nesthetic a$ents& such as 2etamine nitrous o%ide and fentanyl& are useful for se#erely "ainful dressin$ chan$es& such as those after s2in'$raftin$ "rocedures. ,sychotro"ic dru$s& such as antian%iety dru$s& major tran*uili6ers& and antide"ressants& may be useful in the

mana$ement of burn (ounds. Non"harmacolo$ic methods include "ro#idin$ #erbal andGor "hysical comfort& arran$in$ acti#ities that (ill distract the "atient from concentratin$ on the "ain& and rela%ation thera"y. Durin$ burn shoc2 resuscitation& "ain medication& such as mor"hine sulfate& should be $i#en s"arin$ly3 if administered& the "referred route is intra#enous. )ecause of irre$ular absor"tion& "ain medication should not be $i#en intramuscularly. -or"hine andGor methadone thera"y is be$un early on all "atients (ith acute burns admitted to the hos"ital& unless the "atient (ill be in the hos"ital only for a #ery short time. Total elimination of "ain in burn "atients is not "ossible& short of $eneral anesthesia. The major neurole"tic modalities& includin$ 2etamine nitrous o%ide and fentanyl& all com"romise res"iratory function and should be $i#en only under direct su"er#ision by "ersonnel s2illed in air(ay control and res"iratory su""ort. The concomitant use of ben6odia6e"am& hy"nosis& and "sycholo$ical su""ort reduces narcotic re*uirements. Durin$ the con#alescent "hase of burn mana$ement& a re$ular dose of an oral anal$esic such as methadone "roduces more effecti#e "ain relief than unscheduled Bas'neededC doses. R+>;)I.IT;TION ;ND C>RONIC ,RO).+-S Rehabilitation In"atient Thera"y -aintainin$ function and "re#entin$ the com"lications of "rolon$ed immobility are the s"ecific $oals of the rehabilitati#e treatment of burn "atients. Daily assessment of the "atient?s ran$e of motion& ambulation& and functional status is necessary to determine the effecti#eness of on$oin$ treatment "lans and to ma2e modifications as needed for ne( "roblems. The location of the burn in relation to the joint a%is determines (hat mo#ement (ill be limited as the burn heals. In most burns of e%tremities& the "osition of ma%imal comfort "romotes the formation of scar contractures. )ecause com"liance is a major factor in a successful rehabilitation "ro$ram& the burn thera"ist must (or2 closely (ith the entire burn team in de#elo"in$ the "atient?s trust& understandin$& and confidence. )urn teams should include "hysical and occu"ational thera"ists& and a "lay thera"ist (ho can en$a$e children in "hysical acti#ities in an en#ironment in (hich they often are not a(are of the thera"eutic nature of the e%ercises they are "erformin$. Such an a""roach commonly enables children to achie#e full ran$e of motion inde"endently. ,assi#e e%ercises must be carefully "lanned& since o#er6ealous acti#ity may lead to tendon disru"tion& muscle tears& heteroto"ic ossification& and traumatic release of scar contractures. ,hysical thera"y be$ins on the day of admission. )urned e%tremities are ele#ated and acti#ely e%ercised to minimi6e edema and reduce the need for escharotomy. Stable "atients are initially "laced in chairs3 ambulation be$ins (hen it can be tolerated. +%cessi#e use of anal$esics and antian%iety dru$s im"edes a successful mobili6ation "ro$ram. 7hen "atients $et out of bed& burned le$s are (ra""ed (ith dis"osable com"ression banda$es to "re#ent #enous stasis and edema. +#en (hen "atients are in bed& nearly all burned e%tremities de#elo" #aryin$ de$rees of edema. ;cti#e e%ercises maintain muscle mass and stren$th. ,assi#e e%ercises are most often used (ith debilitated "atients and "atients (hose state of a(areness is clouded. Continuous "assi#e motion de#ices and dynamic s"lintin$ increase function in these "atients and do not re*uire the continual "resence of rehabilitation thera"ists. Objecti#e

measurements of joint stiffness can be *uantified by "iston'dri#e dis"lacement transducers& (hich "ro#ide useful documentation of "atient "ro$ress. )urn contractures are unli2e other ty"es of contractures. )urn scars commonly en#elo" the entire circumference of sin$le joints& and the scar may in#ol#e multi"le joints. Contraction may "ull a joint in one direction and an adjacent joint in the o""osite direction. ; classic e%am"le is boutonniYre deformity of the fifth fin$er. The entire burn scar must be uniformly stretched3 com"le% s"lints or multi"le joint "in fi%ation are often re*uired. ,ositionin$ of body "arts in the antideformity "osture "re#ents (ound contracture. S"lints are also used for immobili6in$ freshly $rafted e%tremities to "re#ent inad#ertent shearin$ of the ne( auto$raft. ;ll second' and third'de$ree burns "roduce "ermanent scarrin$. Some scars in healed second'de$ree burns are barely noticeable& (hile dee"er burns& e#en (hen $rafted& may de#elo" bul2y hy"ertro"hic scar tissue. Scar hy"ertro"hy can be retarded by the use of custom'fitted "ressure $arments o#er healed scars. S"ecially fitted inserts can be used to a""ly "ressure to conca#e areas of s2in. ,atients (hose burns do not heal by the second "ostburn (ee2 should be treated (ith "ressure de#ices& first (ith a $eneric tubular elastic stoc2in$ and later& after the surface of the burn scar stabili6es& (ith custom'made com"ression $arments. ;dults usually (ear these $arments for 9 to 8 months :Ai$. 4' <& (hile small children re*uire u" to years of com"ression thera"y before scar maturation is com"lete. Out"atient Thera"y -any functional deficits "ersist after burn "atients ha#e been dischar$ed3 therefore follo('u" must be continuous for "rolon$ed "eriods. Aor many "atients& the burn center out"atient facility "ro#ides their only access to "rimary care. ,ressure $arments re*uire re$ular refittin$. ,atients usin$ com"le% "hysical trainin$ de#ices and s"ecial techni*ues for reducin$ contracture may need to #isit the rehabilitation de"artment daily. Out"atients are e#aluated 1 (ee2 after dischar$e& and the inter#al bet(een #isits is $radually len$thened& de"endin$ on indi#idual "atient needs. ;s burn scars mature& "ermanent residual deficits or deformities may be amenable to reconstructi#e sur$ical correction. Usually& multi"le small o"erations are used3 correcti#e sur$ical "rocedures may ta2e "lace o#er a "eriod as lon$ as 15 years. ,atients de#elo" follicular infection in the burn (ound se#eral months after injury. These "lu$$ed follicles usually disa""ear once hair eru"ts throu$h the o#erlyin$ e"ithelium. Se#ere itchin$ and #a$ue& but intense& neuritic "ain are lon$'lastin$ and are "oorly res"onsi#e to anti"ruritic medications and anal$esics. ,ro#idin$ detailed "rinted e%"lanations of burn care and treatment "rocedures is an essential com"onent of follo('u" care. ,sycholo$ical Su""ort )urned "atients dis"lay a #ariety of "sycholo$ical res"onses to their injury& includin$ an%iety& de"ression& denial& (ithdra(al& and re$ression. 7ithdra(al and re$ression are es"ecially common in children& (ho may refuse to "artici"ate in treatment re$imens. ,lay thera"y "ro#ides a (ay for children (ho ha#e similar cosmetic deformities or functional deficits to interact. Ra""ort bet(een team membersL"lay thera"ists& "hysical and occu"ational thera"ists& burn nurses& and "hysiciansL

"romotes com"liance amon$ the "atients and encoura$es the "ro"er use of "ressure $arments and assisti#e de#ices. Nearly half of older children and adults de#elo" "osttraumatic stress disorder after thermal injury& (hich is characteri6ed by recurrent and intrusi#e recollections of the initial injury& a#oidance of circumstances that in#o2e memories of the e#ent& loss of interest in daily acti#ities& feelin$s of isolation& hy"eralertness& memory im"airment& and slee" disturbances. Noncom"liance (ith burn thera"y is a serious out(ard manifestation of a "atient?s attem"t to a#oid recollections of the traumatic e#ent. ; "atient?s "sycholo$ical state after the burn injury& and sym"toms of "osttraumatic stress disorder durin$ acute'care hos"itali6ation& are "redicti#e of the li2elihood of chronic "osttraumatic stress disorder. The se#erity of injury does not correlate (ith the sym"toms. )oth short' and lon$'term "sychothera"eutic su""ort is fre*uently necessary in burn "atients& and a full'time "sychiatrist is an essential member of the burn team. )urn "atients rarely see2 treatment for "sycholo$ical "roblems. The fre*uency of "osttraumatic stress disorder increases (ith len$th of follo('u". Aamily su""ort $rou"s con#ene on a (ee2ly basis. The burn team "resents an u"date on the "atient?s "ro$ress& and addresses s"ecific short' and lon$'term $oals to allay an%ieties. ,sychosocial su""ort is critical for the burn "atient for the duration of the course of treatment and follo('u". Chronic ,roblems >y"ertro"hic Scar and Peloid Aormation )urn scar hy"ertro"hy ty"ically de#elo"s in dee"er "artial'thic2ness injuries and third'de$ree burns that are allo(ed to heal by "rimary intention. >y"ertro"hy of $rafted areas of e%cised burn (ounds occurs less fre*uently& and is de"endent& in "art& on the time from injury to e%cision& the site of the (ound& and the sur$ical techni*ue used. 7ith tan$ential e%cision& necrotic tissue of a "artial'thic2ness burn is remo#ed in successi#e layers until a base of "artially #iable dermis is reached3 in most circumstances& the (ound is then immediately $rafted. Se*uential e%cision e%tends to #aryin$ le#els of the s2in and subcutaneous tissue until all non#iable tissue is remo#ed. Se*uential e%cision $oes beyond tan$ential e%cision to include the com"lete e%cision of necrotic full'thic2ness injuries. Delayed tan$ential e%cision is more li2ely to result in residual scar hy"ertro"hy in $rafted burn (ounds. )ecause only a fe( e"ithelial elements& s(eat $lands& and hair follicles remain #iable in dee"& "artial'thic2ness burns& healin$ ta2es "lace from these remnants o#er a "eriod of 9 to 8 (ee2s. The resultin$ scar e"ithelium is of "oor *uality& and is "rone to hy"ertro"y. >y"ertro"hic scar should be distin$uished from a 2eloid. )oth e%hibit e%cessi#e colla$en formation& but a 2eloid o#er$ro(s the ori$inal dimensions of the initial injury and hy"ertro"hic scar de#elo"s in the bed of the injured tissue and is confined to its ori$inal anatomic boundaries. >y"ertro"hic scars fre*uently flatten (ith time and "ressure& (hereas 2eloids do not. .on$' term controlled trials ha#e not clearly demonstrated "ermanent benefits from com"ression thera"y& but com"ression $arments *uic2ly reduce the mass of hy"ertro"hic immature scars and "ro#ide "atients (ith tan$ible e#idence of the benefits of conscientious follo('u". The mechanism by (hich constant com"ression reduces scar mass is not (ell defined. It may (or2 by causin$ eschemia in the micro#asculature of hy"ertro"hic scars& (ith focal de$eneration of cells because of hy"o%ia after micro#ascular occlusion. ;nother

mechanism may in#ol#e the healin$ se*uence3 electron microsco"y has demonstrated that fibroblasts in "ressure'treated (ounds are more linearly or$ani6ed than fibroblasts in non'"ressure'treated (ounds& and colla$en is manufactured in a more or$ani6ed fashion. Other forms of thera"y for hy"ertro"hic scarrin$ include radiothera"y& cryothera"y& and ree%cision and (ound closure. Radiothera"y in doses of 1!55 to 1555 /y has been used (ith #aryin$ results. Radiation "robably reduces fibro"lasia and ca"illary buddin$. Cryothera"y is rarely used. It is associated (ith de"i$mentation and increased melanocyte sensiti#ity to subse*uent cold e%"osure. The most successful a""roach to residual hy"ertro"hic burn scars is initial "ressure thera"y until the (ound matures& follo(ed by subse*uent e%cision and a""lication of s2in $rafts. Tissue e%"ansion techni*ues ha#e been used to e%"and normal s2in and re"lace the e%cised hy"ertro"hic scar or 2eloid. Com"lication rates (ith tissue e%"ansion are as hi$h as 5 "ercent& and include infection& im"lant e%trusion& and de#ice ru"ture. These com"lications usually re*uire remo#al of the ori$inal im"lant& treatment of any infection& and re"lacement. )ecause of their mar2ed "ro"ensity to recur& 2eloids are difficult to treat. +%cision of the 2eloid and "rimary closure are effecti#e for linearly oriented 2eloids (ith a narro( base& but e%cessi#e (ound tension leads to recurrence. )road'based 2eloids may be remo#ed flush (ith the surroundin$ s2in& and a s"lit'thic2ness s2in $raft "laced o#er the base of the 2eloid to "re#ent it from recurrin$. +%cision alone has a recurrence rate of $reater than !5 "ercent. Intralesional injection of corticosteroids may reduce the bul2 of 2eloid and hy"ertro"hic scar mass& and may be used in combination (ith e%cision or s"lit'thic2ness s2in $raftin$. It is belie#ed that triamcinolone& the most commonly used steroid& acts by decreasin$ colla$en synthesis and increasin$ colla$en de$radation throu$h the colla$en inhibitors a1'macro$lobulin and a1'antitry"sin. 7hen steroid injection is used in conjunction (ith sur$ery& 2eloids should be injected for at least 1 month "rior to the o"eration. Some sur$eons inject triamcinolone in the base of the (ound and alon$ its ed$es durin$ the sur$ical "rocedure. ,osto"erati#ely& the "atient recei#es injections monthly until the (ound matures. The major side effects of intralesional injection of steroids are hy"o"i$mentation and atro"hy of the s2in surroundin$ the 2eloid. )urn scar hy"o"i$mentation and surface irre$ularity can be si$nificantly im"ro#ed by dermabrasion and thin s"lit'thic2ness $raftin$. ;de*uate "i$mentation and flat surfaces are obtained in most "atients. Tissue e%"anders are "articularly effecti#e for treatin$ burn scar alo"ecia. ;""ro%imately 15 "ercent of "atients treated in burn facilities are readmitted for reconstructi#e "rocedures. The most common areas of reconstruction in#ol#e the hand and (rist :most common<& arm and forearm& face& and nec2. Im"ro#ed in"atient burn treatment and scar mana$ement ha#e reduced the need for subse*uent reconstructi#e sur$ery. -arjolin?s Ulcer Chronic ulceration of old burn scars (as noted by -arjolin to lead fre*uently to mali$nant de$eneration. S*uamous cell carcinoma is most common& althou$h basal cell carcinomas occasionally occur. Rare tumors& includin$ mali$nant fibrous

histiocytoma& sarcoma& and neurotro"ic mali$nant melanoma& ha#e also been described. Chronic brea2do(n of a healed burn (ound scar should lead to sus"icion of mali$nant de$eneration. These lesions ty"ically a""ear decades after the ori$inal injury& but burn scar carcinoma can be encountered (ithin the first year. In the absence of cancer& most unstable burn scars should be e%cised and resurfaced. )urn scar carcinomas may metastasi6e a$$ressi#ely. -ali$nancy dictates (ide e%cision& but "ro"hylactic re$ional node dissection has not im"ro#ed mortality. ;""ro%imately 95 "ercent of burn scar carcinomas occur in the head and nec2. ;dju#ant radiothera"y im"ro#es sur#i#al. Hery dee" dermal burns that ha#e not healed by the third or fourth "ostburn (ee2 occasionally de#elo" nodules in the burn (ound bed. These lesions are sometimes erroneously inter"reted as carcinoma or lym"homa& but e%cision and $raftin$ of the nodules (ounds usually re#eals that they are "seudoe"itheliomatous hy"er"lastic lesions or 2eratoacanthomas. >eteroto"ic Ossification >eteroto"ic ossification occurs in u" to 19 "ercent of burn "atients. This com"lication may de#elo" in "atients (ith "artial'thic2ness burns and around e%tremities not in#ol#ed (ith the injury& but it most commonly in#ol#es "atients (ith full'thic2ness burns $reater than 15 "ercent T)S;& and is found adjacent to the in#ol#ed joint 1 to 9 months after injury. The elbo( is the most commonly affected joint. The dia$nosis is usually made by the "hysical or occu"ational thera"ist& (ho disco#ers increased "ain and decreased ran$e of motion of the in#ol#ed joints. .imitation of "hysical acti#ity usually "recedes radio$ra"hic e#idence of calcification& (hich is located in the muscle and surroundin$ soft tissue of the joint. ;lthou$h the mechanism causin$ heteroto"ic ossification is not 2no(n& it has been su$$ested that bleedin$ into the soft tissue& due to a$$ressi#e "hysical thera"y& is the cul"rit. ,rolon$ed immobili6ation of a joint encom"assed by a burn also a""ears to "romote heteroto"ic ossification. Restricted acti#ity "romotes mobili6ation of body calcium stores and may lead to de"osition of calcium in the soft tissues. Some su$$est sur$ical remo#al of all ossified soft tissue& but others recommend modification of rehabilitation thera"y re$imens and allo(in$ the reabsor"tion of ossified tissue. Aractures U" to 15 "ercent of burned "atients ha#e associated fractures. Aractures in "atients (ith lar$e burns are treated (ith s"lints or traction until resuscitation is com"lete. O"erati#e re"air is "referably "erformed (ithin = to 41 h of burn injury. )urn (ounds adjacent to fracture sites are usually e%cised and auto$rafted at the time of internal fi%ation. If internal fi%ation is not "ossible& e%ternal fi%ation is used& (hich "ermits access to the burn (ound and "ro#ides stability. :)iblio$ra"hy omitted in ,alm #ersion<