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Surgery_Schwartz. even for patients with severe burns.3 Continued improvements in critical care and progress in skin bioengineering herald a future in which func-tional and psychologic outcomes are equally important as sur-vival alone. With this shift in priority, the American Burn Association (ABA) has emphasized referral to specialized burn centers after early stabilization. Specific criteria should guide transfer of patients with more complex injuries or other medical needs to a burn center (Table 8-1). The ABA has published stan-dards of care4 and created a verification process to ensure that burn centers meet those standards.5 Because of increased prehospital safety measures, burn patients are trans-ferred longer distances for definitive care at regional burn centers6; data from one burn center with a particularly wide catch-ment area confirmed that even transport times averaging several hours did not affect the long-term outcomes of burn patients.7INITIAL EVALUATIONInitial evaluation of the


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Surgery_Schwartz. a particularly wide catch-ment area confirmed that even transport times averaging several hours did not affect the long-term outcomes of burn patients.7INITIAL EVALUATIONInitial evaluation of the burned patient should follow the same initial priorities of all trauma patients and involves four crucial assessments: airway management, evaluation of other injuries, 1estimation of burn size, and diagnosis of CO and cyanide poi-soning. With direct thermal injury to the upper airway or smoke inhalation, rapid and severe airway edema is potentially lethal. Anticipating the need for intubation and establishing an early airway are critical. Signs of impending respiratory compromise include a hoarse voice, wheezing, or stridor; subjective dyspnea is a particularly concerning symptom and should trigger prompt elective endotracheal intubation. Perioral burns and singed nasal hairs alone do not indicate an upper airway injury, but are signs that the oral cavity and pharynx should be further


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Surgery_Schwartz. trigger prompt elective endotracheal intubation. Perioral burns and singed nasal hairs alone do not indicate an upper airway injury, but are signs that the oral cavity and pharynx should be further evaluated for mucosal injury. Orotracheal intubation is the preferred method for securing the airway. Nasotracheal intubation may be use-ful for patients with associated facial trauma when experienced providers are present, but it should be avoided if oral intubation is safe and easy.Burned patients are trauma patients and evaluated with a primary survey in accordance with Advanced Trauma Life Sup-port guidelines. Concurrently with the primary survey, large-bore peripheral intravenous (IV) catheters should be placed and fluid resuscitation should be initiated; for a burn larger than 40% total body surface area (TBSA), two large-bore IVs are ideal. IV place-ment through burned skin is safe and effective but requires atten-tion to securing the catheters. Central venous access and intraosseous


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Surgery_Schwartz. surface area (TBSA), two large-bore IVs are ideal. IV place-ment through burned skin is safe and effective but requires atten-tion to securing the catheters. Central venous access and intraosseous (IO) access should be considered when peripheral access cannot be easily obtained. Rarely, IV resuscitation is indi-cated in patients with burns smaller than 15% who can usually hydrate orally. Pediatric patients with burns larger than 15% may require IO access in emergent situations if venous access cannot be attained. An early and comprehensive secondary survey must be performed on all burn patients, but especially those with a his-tory of associated mechanical trauma such as a motor vehicle collision. Also, patients from structural fires in which the manner of egress is not known should be carefully evaluated for injuries from a possible jump or fall. Urgent radiology studies, such as a chest X-ray, should be performed in the emergency department, but nonurgent skeletal evaluation (i.e.,


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Surgery_Schwartz. evaluated for injuries from a possible jump or fall. Urgent radiology studies, such as a chest X-ray, should be performed in the emergency department, but nonurgent skeletal evaluation (i.e., extremity X-rays) can be Background 251Initial Evaluation 251Burn Classification 252Burn Depth 253Prognosis 254Resuscitation 254Inhalation Injury and Ventilator Management 255Treatment of The Burn Wound 257Nutrition 257Complications in Burn Care 258Surgery 259Wound Coverage 259Rehabilitation 260Late Complications: Hypertrophic Scar, Contractures, and Heterotopic Ossification 260Psychological Recovery 261Prevention 261Burn Disasters 261Future Areas of Study 262Brunicardi_Ch08_p0251-p0270.indd 25128/12/18 11:51 AM 252Table 8-1Guidelines for referral to a burn centerPartial-thickness burns greater than 10% TBSABurns involving the face, hands, feet, genitalia, perineum, or major jointsThird-degree burns in any age groupElectrical burns, including lightning injuryChemical burnsInhalation


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Surgery_Schwartz. greater than 10% TBSABurns involving the face, hands, feet, genitalia, perineum, or major jointsThird-degree burns in any age groupElectrical burns, including lightning injuryChemical burnsInhalation injuryBurn injury in patients with complicated preexisting medical disordersPatients with burns and concomitant trauma in which the burn is the greatest risk. If the trauma is the greater immediate risk, the patient may be stabilized in a trauma center before transfer to a burn center.Burned children in hospitals without qualified personnel for the care of childrenBurn injury in patients who will require special social, emotional, or rehabilitative interventionTBSA = total body surface area.done in the intensive care unit (ICU) to avoid hypothermia and delayed resuscitation. Hypothermia is a common prehospital complication that contributes to resuscitation failure. Patients should be wrapped with clean blankets in transport. Cooling should be avoided in patients with moderate or large


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Surgery_Schwartz. a common prehospital complication that contributes to resuscitation failure. Patients should be wrapped with clean blankets in transport. Cooling should be avoided in patients with moderate or large (>20% TBSA) burns. Patients with acute burn injuries should never receive prophylactic antibiotics. This intervention has been clearly demonstrated to promote development of fungal infections and resistant organisms and was abandoned in the mid-1980s.8 A tetanus booster should be administered in the emergency department depending on patient immunization status.The importance of pain management for these patients has been widely recognized over the past 25 years. While pain man-agement is a priority for burn patients, it is important to acknowl-edge the opioid crisis and the recent push toward decreasing opiate use in general.9 In order to limit opiate-related morbidity, we recommend responsible opiate use in conjunction with mul-timodal pain control and development of a weaning plan


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Surgery_Schwartz. decreasing opiate use in general.9 In order to limit opiate-related morbidity, we recommend responsible opiate use in conjunction with mul-timodal pain control and development of a weaning plan start-ing at opioid commencement. Clear expectations around pain medication use should be set with patients. Anxiety is another component of the psychological response of burn patients, seen with both wound care and general postinjury hospital course. Benzodiazepines are a staple in the treatment of acute anxiety; however, they can contribute significantly to hospital delirium.10 We recommend conservative benzodiazepine use to mitigate the effects of anxiety while minimizing deliriogenic effects of benzodiazepines.2Most burn resuscitation formulas estimate fluid require-ments based on burn size measured as a percentage of TBSA (%TBSA). The “rule of nines” is a crude but quick and effec-tive method of estimating burn size (Fig. 8-1). In adults, the anterior and posterior trunk each account for


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Surgery_Schwartz. as a percentage of TBSA (%TBSA). The “rule of nines” is a crude but quick and effec-tive method of estimating burn size (Fig. 8-1). In adults, the anterior and posterior trunk each account for 18%, each lower extremity is 18%, each upper extremity is 9%, and the head is 9%. In children under 3 years old, the head accounts for a larger relative surface area and should be taken into account when esti-mating burn size. For smaller or odd-shaped burns, the “rule of the palm” where the palmar surface of the hand, including the digits, is 1% TBSA is useful. Diagrams such as the Lund and Browder chart give a more accurate accounting of the true burn size in children and adults. The importance of an accurate burn size assessment cannot be overemphasized. Superficial or first-degree burns should not be included when calculating burn size, and thorough cleaning of soot and debris is mandatory to avoid confusing soiled skin with burns. Examination of referral data suggests that physicians


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Surgery_Schwartz. not be included when calculating burn size, and thorough cleaning of soot and debris is mandatory to avoid confusing soiled skin with burns. Examination of referral data suggests that physicians inexperienced with burns tend to overestimate the size of small burns and underestimate the size of large burns, with potentially detrimental effects on pretrans-fer resuscitation.11BURN CLASSIFICATIONBurns are commonly classified as thermal, electrical, or chemi-cal burns, with thermal burns consisting of flame, contact, or scald burns. Flame burns are the most common cause for hos-pital admission of burns, and have the highest mortality. This is primarily related to their association with structural fires and the accompanying inhalation injury and/or CO poisoning.12Electrical burns make up 3% of U.S. hospital admissions but have special concerns,12 including cardiac arrhythmia and compartment syndrome with concurrent rhabdomyolysis. A baseline ECG is recommended in all patients with an


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Surgery_Schwartz. 3% of U.S. hospital admissions but have special concerns,12 including cardiac arrhythmia and compartment syndrome with concurrent rhabdomyolysis. A baseline ECG is recommended in all patients with an electrical injury, and a normal ECG in a low-voltage injury (<1000 V) may preclude hospital admission. Because compartment syn-drome and rhabdomyolysis are common in high-voltage elec-trical injuries, vigilance must be maintained for neurologic or vascular compromise, and fasciotomies should be performed even in cases of moderate clinical suspicion. Long-term neuro-logic symptoms13 and cataract development14 are not uncommon with high-voltage electrical injuries, and neurologic and oph-thalmologic consultation should be obtained to define baseline patient function.15Chemical burns also comprise 3% of admitted burn patients12 and result in potentially severe burns. Typically, acid chemical burns result in coagulation necrosis and alkali chemical burns cause liquefactive necrosis (with an


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Surgery_Schwartz. 3% of admitted burn patients12 and result in potentially severe burns. Typically, acid chemical burns result in coagulation necrosis and alkali chemical burns cause liquefactive necrosis (with an exception of hydrofluoric acid, which also causes liquefactive necrosis).16,17 Key Points1 Follow American Burn Association criteria for referral of a patient to a regional burn center.2 Never administer prophylactic antibiotics other than tetanus vaccination.3 Early excision and grafting of full-thickness and deep partial-thickness burns improve outcomes.4 Intravenous fluid resuscitation for patients with burns >20% of total body surface area (children with burns >15% of total body surface area) should be titrated to mean arterial pres-sure (MAP) >60 mmHg and appropriate urine output.Brunicardi_Ch08_p0251-p0270.indd 25228/12/18 11:51 AM 253BURNSCHAPTER 8The most important components of initial therapy are careful removal of the toxic substance from the patient and irrigation of the


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Surgery_Schwartz. 25228/12/18 11:51 AM 253BURNSCHAPTER 8The most important components of initial therapy are careful removal of the toxic substance from the patient and irrigation of the affected area with water for a minimum of 30 minutes. In cases of exposure to dry chemicals, such as concrete or pow-dered forms of lye, the substance should be swept from the patient to avoid a thermal reaction with water. The offending agents in chemical burns can be systemically absorbed and may cause specific metabolic derangements. Formic acid has been known to cause hemolysis and hemoglobinuria, and hydroflu-oric acid causes hypocalcemia. Hydrofluoric acid is a particu-larly common offender due to its widespread industrial uses. Calcium-based therapies are the mainstay of treating hydroflu-oric acid burns, with topical application of calcium gluconate onto wounds18 and IV administration of calcium gluconate for systemic hypocalcemia symptoms. Intra-arterial calcium gluco-nate infusion provides effective


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Surgery_Schwartz. topical application of calcium gluconate onto wounds18 and IV administration of calcium gluconate for systemic hypocalcemia symptoms. Intra-arterial calcium gluco-nate infusion provides effective treatment of progressive tissue injury and intense pain.19,20 Patients undergoing intra-arterial therapy need continuous cardiac monitoring. Persistent refrac-tory hypocalcemia with electrocardiac abnormalities may signal the need for emergent excision of the burned areas.21BURN DEPTHBased on the original burn depth classification by Dupuytren in 1832,22 burn wounds are commonly classified as superficial (first-degree), partial-thickness (second-degree), full-thickness (third-degree), and fourth-degree burns, which affect underlying soft tissue. Fifth-degree burns (through muscle to bone) and sixth degree burns (charring bone) were also described although are less common. Partial-thickness burns are classified as either superficial or deep partial-thickness burns by depth of involved dermis.


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Surgery_Schwartz. degree burns (charring bone) were also described although are less common. Partial-thickness burns are classified as either superficial or deep partial-thickness burns by depth of involved dermis. Clinically, first-degree burns are painful but do not blis-ter, second-degree burns have dermal involvement and are extremely painful with weeping and blisters, and third-degree burns are leathery, painless, and nonblanching. Jackson described three zones of tissue injury following burn injury.23 The zone of coagulation is the most severely burned portion and is typically in the center of the wound. As the name implies, the affected tissue is coagulated and sometimes frankly necrotic, much like a full thickness burn, and will need excision and graft-ing. Peripheral to that is a zone of stasis, with variable degrees of vasoconstriction and resultant ischemia, much like a second-degree burn. Appropriate resuscitation and wound care may pre-vent conversion to a deeper wound, but infection or


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Surgery_Schwartz. with variable degrees of vasoconstriction and resultant ischemia, much like a second-degree burn. Appropriate resuscitation and wound care may pre-vent conversion to a deeper wound, but infection or suboptimal perfusion may result in an increase in burn depth. This is clini-cally relevant because many superficial partial-thickness burns will heal with nonoperative management, and the majority of deep partial-thickness burns benefit from excision and skin grafting. The outermost area of a burn is called the zone of hyperemia, which will heal with minimal or no scarring and is most like a superficial partial thickness burn or first-degree burn.Unfortunately, even experienced burn surgeons have lim-ited ability to accurately predict the healing potential of partial-thickness burns soon after injury; one reason is that burn wounds evolve over the 48 to 72 hours after injury. Numerous burn depth assessment tools have been developed with the idea that


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Surgery_Schwartz. of partial-thickness burns soon after injury; one reason is that burn wounds evolve over the 48 to 72 hours after injury. Numerous burn depth assessment tools have been developed with the idea that 39%4.5%4.5%9%9%18%1%1%18%18%18%FrontBackFigure 8-1. The “rule of nines” can be used as a quick reference for estimating a patient’s burn size by dividing the body into regions to which total body surface area is allocated in multiples of nine.Brunicardi_Ch08_p0251-p0270.indd 25328/12/18 11:51 AM 254BASIC CONSIDERATIONSPART Iearlier burn depth definition will expedite appropriate surgical decision-making. One of the most effective ways to determine burn depth is full-thickness biopsy, but this has several limita-tions; not only is the procedure painful and potentially scar-ring, but accurate interpretation of the histopathology requires a specialized pathologist and may have slow turnaround times.24 Laser Doppler can measure skin perfusion to predict burn depth with sensitivities and


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Surgery_Schwartz. interpretation of the histopathology requires a specialized pathologist and may have slow turnaround times.24 Laser Doppler can measure skin perfusion to predict burn depth with sensitivities and specificity of up to 83% and 97%, respectively.25 Noncontact ultrasound has been postulated as a painless modality to predict nonhealing wounds and has the advantage of easily performed serial measurements.26 Unfortu-nately, none of these newer therapies have proven adequately superior to justify their cost and as yet have not substituted serial examination by experienced burn surgeons.PROGNOSISThe Baux score (mortality risk equals age plus %TBSA) was used for many years to predict mortality in burns. Analysis of multiple risk factors for burn mortality has validated age and burn size as the strongest predictors of mortality.27 Advance-ments in burn care have lowered overall mortality to the point that the original Baux score may no longer be accurate. How-ever, the Revised Baux Score, which


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Surgery_Schwartz. predictors of mortality.27 Advance-ments in burn care have lowered overall mortality to the point that the original Baux score may no longer be accurate. How-ever, the Revised Baux Score, which accounts for age, burn size, and inhalation injury, has been found to be independently associated with mortality.28 As such, age, burn size, and inhala-tion injury continue to be the most robust indicators for burn mortality.29 Age even as a single variable strongly predicts mortality in burns,30 and in-hospital mortality in elderly burn patients is a function of age regardless of other comorbidities.31 In nonelderly patients, comorbidities such as preinjury human immunodeficiency virus (HIV), metastatic cancer, and kidney or liver disease may influence mortality and length of stay.32 A large database study of 68,661 burn patients found that the vari-ables with the highest predictive value for mortality were age, %TBSA, inhalation injury, coexistent trauma, and pneumonia.33 A more recent study


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Surgery_Schwartz. study of 68,661 burn patients found that the vari-ables with the highest predictive value for mortality were age, %TBSA, inhalation injury, coexistent trauma, and pneumonia.33 A more recent study analyzing 506,628 burn inpatients between 1998 and 2008 demonstrated an association between burn size, age, inhalation injury, and mortality. Other factors associated with mortality included African American race, female gender, and treatment in urban private hospitals (as opposed to urban academic hospitals).34Mortality is not the only outcome of interest in the burn population. Burn injury can significantly impact the subsequent quality of life for survivors, including but not limited to appear-ance, mobility, functional status, and ability to work. One study found that burn injury reduces short term quality of life by 30% and long-term quality of life by approximately 11%.35 Predic-tors of poorer physical and mental health 12 months removed from burn injury include older age, female


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Surgery_Schwartz. short term quality of life by 30% and long-term quality of life by approximately 11%.35 Predic-tors of poorer physical and mental health 12 months removed from burn injury include older age, female gender, and greater %TBSA burn size.36 One factor impacting quality of life is itching—a late and bothersome consequence of burn injury that affects both adult and pediatric population.37,38 Other factors dis-cussed later in this chapter include hypertrophic scarring, con-tracture, and heterotopic ossification. Finally, return to work or school has been a useful tool to evaluate recovery and prognosis. A recent meta-analysis found that approximately 28% of burn survivors never return to work.39 A recent study using an inter-ventional bundle involving the patient, the employee, worker’s compensation, and burn clinic staff demonstrated a return to work rate of 93%.40 The return to school for pediatric patients is actually very prompt, averaging about 10 days after discharge. However, further


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Surgery_Schwartz. and burn clinic staff demonstrated a return to work rate of 93%.40 The return to school for pediatric patients is actually very prompt, averaging about 10 days after discharge. However, further study is needed to determine whether atten-dance and performance suffer despite early reentry to school.41 It is important to recognize these potential quality-of-life issues in burn patients and take necessary steps to diminish the impact that burn injury has on quality of life both in the hospital and following discharge.RESUSCITATIONA myriad of formulas exist for calculating fluid needs during burn resuscitation, suggesting that no one formula benefits all patients. The most commonly used formula, the Parkland or Baxter formula, consists of 3 to 4 mL/kg per % burn of Lac-tated Ringer’s, of which half is given during the first 8 hours after burn and the remaining half is given over the subsequent 16 hours.1 The most recent American Burn Association con-sensus formula recommends 2 mL/kg per %


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Surgery_Schwartz. half is given during the first 8 hours after burn and the remaining half is given over the subsequent 16 hours.1 The most recent American Burn Association con-sensus formula recommends 2 mL/kg per % burn of Lactated Ringers given the tendency toward excessive fluid administra-tion with the traditional formulas.42 The concept behind continu-ous fluid requirements is simple. The burn (and/or inhalation injury) drives an inflammatory response that leads to capillary leak; as plasma leaks into the extravascular space, crystalloid administration maintains the intravascular volume. Therefore, if a patient receives a large fluid bolus in a prehospital setting or emergency department, the fluid has likely leaked into the interstitium, and the patient still requires ongoing burn resusci-tation according to the estimates. Continuation of fluid volumes should depend on the time since injury, urine output, and mean arterial pressure (MAP). As the capillary leak closes, the patient will require


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Surgery_Schwartz. to the estimates. Continuation of fluid volumes should depend on the time since injury, urine output, and mean arterial pressure (MAP). As the capillary leak closes, the patient will require less volume to maintain these two resuscitation endpoints. Children under 20 kg have the additional require-ment that they do not have sufficient glycogen stores to main-tain an adequate glucose level in response to the inflammatory response. Specific pediatric formulas have been described, but the simplest approach is to deliver a weight-based maintenance IV fluid with glucose supplementation in addition to the calcu-lated resuscitation with lactated Ringer’s.It is important to remember that any formula for burn resuscitation is merely a guideline, and fluid must be titrated based on appropriate response to therapy. A number of parame-ters are widely used to gauge burn resuscitation, but the most common remain the simple outcomes of blood pressure and urine output. As in any critically ill


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Surgery_Schwartz. response to therapy. A number of parame-ters are widely used to gauge burn resuscitation, but the most common remain the simple outcomes of blood pressure and urine output. As in any critically ill patient, a target MAP of 60 mmHg ensures optimal end-organ perfusion. Goals for urine out-put should be 30 mL/h in adults and 1 to 1.5 mL/kg per h in pediatric patients. Because blood pressure and urine output may not correlate perfectly with true tissue perfusion, the search continues for other adjunctive parameters that may more accu-rately reflect adequate resuscitation. Some centers have found serum lactate to be a better predictor of mortality in severe burns,43,44 and others have found that base deficit predicts even-tual organ dysfunction and mortality.45,46 Because burned patients with normal blood pressure and serum lactate levels may have compromised gastric mucosal perfusion, continuous measurement of mucosal pH with its logistical difficulties has garnered limited


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Surgery_Schwartz. patients with normal blood pressure and serum lactate levels may have compromised gastric mucosal perfusion, continuous measurement of mucosal pH with its logistical difficulties has garnered limited popularity.47,48 Invasive monitoring with pul-monary artery catheters typically results in significant excessive fluid administration without improved cardiac output or preload measurements; use of invasive monitoring seems to have vari-able effects on long-term outcomes.49Actual administrated fluid volumes typically exceed vol-umes predicted by standard formulas.50 One survey of burn 4Brunicardi_Ch08_p0251-p0270.indd 25428/12/18 11:51 AM 255BURNSCHAPTER 8centers showed that 58% of patients end up getting more fluids than would be predicted by Baxter’s formula.51 Comparison of modern-day patients with historical controls shows that over-resuscitation may be a relatively recent trend.52 One theory is that increased opioid analgesic use results in peripheral vaso-dilation and


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Surgery_Schwartz. patients with historical controls shows that over-resuscitation may be a relatively recent trend.52 One theory is that increased opioid analgesic use results in peripheral vaso-dilation and hypotension and the need for greater volumes of bolused resuscitative fluids.53 A classic study by Navar et al showed that burned patients with inhalation injury required an average of 5.76 mL/kg per % burn, vs. 3.98 mL/kg per % burn for patients without inhalation injury, and this has been corroborated by subsequent studies.54,55 Prolonged mechanical ventilation may also play a role in increased fluid needs.56 A multicenter study found that age, weight, %TBSA, and intu-bation on admission were significant predictors of more fluid delivery during the resuscitation period. Those patients receiv-ing higher fluid volumes were at increased risk of complications and death.57 Common complications include abdominal com-partment syndrome, extremity compartment syndrome, intraoc-ular compartment syndrome,


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Surgery_Schwartz. fluid volumes were at increased risk of complications and death.57 Common complications include abdominal com-partment syndrome, extremity compartment syndrome, intraoc-ular compartment syndrome, and pleural effusions. Monitoring bladder pressures can provide valuable information about devel-opment of intra-abdominal hypertension.The use of colloid as part of the burn resuscitation has gen-erated much interest over the years. In late resuscitation when the capillary leak has closed, colloid administration may decrease overall fluid volumes and potentially may decrease associated complications such as intra-abdominal hypertension.58 A recent meta-analysis accounting for statistical heterogeneity among studies included demonstrated a trend toward mortality ben-efit for patients receiving albumin.59 However, albumin use has never been shown to definitively improve mortality in burn patients and has controversial effects on mortality in critically ill patients.60-63 Still, many burn


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Surgery_Schwartz. albumin.59 However, albumin use has never been shown to definitively improve mortality in burn patients and has controversial effects on mortality in critically ill patients.60-63 Still, many burn centers including ours continue to use albumin as an adjunct during burn resuscitation.64 Attempts to minimize fluid volumes in burn resuscitation have included study of hypertonic solutions. A recent meta-analysis evaluating hyperosmotic vs. isoosmotic fluid resuscitation demonstrates decreased total fluid load (vol/%TBSA per weight) over the first 24 hours with use of hyperosmotic fluid with no difference in total fluid, urine output, creatinine, or mortality.65 A described downside of hypertonic fluid administration is hyperchloremic acidosis.66Other adjuncts are being increasingly used during initial burn resuscitation. High-dose ascorbic acid (vitamin C) may decrease fluid volume requirements and ameliorate respira-tory embarrassment during resuscitation, although no mortality benefit


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Surgery_Schwartz. initial burn resuscitation. High-dose ascorbic acid (vitamin C) may decrease fluid volume requirements and ameliorate respira-tory embarrassment during resuscitation, although no mortality benefit has been noted thus far in two trials.67,68 Plasmapheresis has also been associated with decreased fluid requirements and increased urine output in patients who require higher resuscita-tive volumes than predicted to maintain adequate urine output and MAP.69 It is postulated that plasmapheresis may filter out inflammatory mediators, thus decreasing ongoing vasodilation and capillary leak.70One adjunct that has found increasing utility in surgi-cal ICUs has been the application of bedside ultrasound.71 Ultrasound offers the potential to make rapid, noninvasive assessments during acute changes in clinical condition. For burn patients, bedside ultrasonography may be indicated for evalu-ation of volume status, gross assessment of cardiac function, and diagnosis of pneumothorax. Determining


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Surgery_Schwartz. in clinical condition. For burn patients, bedside ultrasonography may be indicated for evalu-ation of volume status, gross assessment of cardiac function, and diagnosis of pneumothorax. Determining patient cardiac function and volume status may guide fluid resuscitation. Car-diac function can be evaluated with three common heart views: the parasternal long axis, parasternal short axis, and apical four-chamber views.72 Whereas no study has used ultrasound to guide fluid resuscitation in burn patients, volume status can be estimated by examination of cardiac function and evaluation of the inferior vena cava (IVC) diameter with changes in respira-tion, as has been done in patients with hemorrhage and shock.73 Ultrasound also allows timely diagnosis of pneumothorax.74 A high-frequency probe with an adequate window between ribs permits identification of lung parenchyma against the chest well. A pneumothorax appears as a transition on ultrasound between lung parenchyma, which has a


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Surgery_Schwartz. probe with an adequate window between ribs permits identification of lung parenchyma against the chest well. A pneumothorax appears as a transition on ultrasound between lung parenchyma, which has a heterogeneous appear-ance, and air, which has a hypoechoic appearance. Further stud-ies are warranted to identify indications for the use of ultrasound in burned patients.Machine learning and bedside computer decision support are other adjuncts gaining traction in caring for burn patients. These modalities can enhance patient care and aid in diagnosis, treatment, and research.75 The use of bedside computer decision support has been particularly appealing for resuscitation of burn patients in the first 48 hours and has been shown to improve fluid management during initial resuscitation.76The role of blood transfusion in critically injured patients has undergone a reevaluation in recent years.77,78 Blood transfu-sions are considered to be immunomodulatory and potentially immunosuppressive,


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Surgery_Schwartz. of blood transfusion in critically injured patients has undergone a reevaluation in recent years.77,78 Blood transfu-sions are considered to be immunomodulatory and potentially immunosuppressive, which is one explanation to the links between blood transfusions and increased infection and shorter time to recurrence after oncologic surgery.79,80 A large multi-center study of blood transfusions in burn patients found that increased numbers of transfusions were associated with increased infections and higher mortality in burn patients, even when cor-recting for burn severity.81 A follow-up study implementing a restrictive transfusion policy in burned children showed that a hemoglobin threshold of 7 g/dL had no more adverse outcomes vs. a traditional transfusion trigger of 10 g/dL. In addition, costs incurred to the institution were significantly less.82 A recent ran-domized control trial in patients with >20% TBSA compared outcomes of a restrictive to a liberal red blood cell transfusion


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Surgery_Schwartz. costs incurred to the institution were significantly less.82 A recent ran-domized control trial in patients with >20% TBSA compared outcomes of a restrictive to a liberal red blood cell transfusion strategy (hemoglobin 7–8 vs. 10–11, respectively). There were no differences in blood stream infection, organ dysfunction, ven-tilator days, time to wound healing, or 30-day mortality between both groups.83 These data, in concert with other reported compli-cations such as transfusion-related lung injury,84 have led to rec-ommendations that blood transfusions be used only when there is an apparent physiologic need. Attempts to minimize blood transfusion in nonburned critically ill patients have led to use of erythropoietin by some centers. However, burn patients often have elevated erythropoietin levels, and a randomized study in burn patients showed that recombinant human erythropoietin did not effectively prevent anemia or decrease the number of transfusions given.85 Promising animal


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Surgery_Schwartz. levels, and a randomized study in burn patients showed that recombinant human erythropoietin did not effectively prevent anemia or decrease the number of transfusions given.85 Promising animal studies demonstrating erythropoietin-mediated prevention of secondary burn progres-sion have yet to be validated in humans.86INHALATION INJURY AND VENTILATOR MANAGEMENTInhalation injuries are commonly seen in tandem with burn inju-ries and are known to increase mortality in burned patients.87,88 Smoke inhalation is present in as many as 35% of hospital-ized burn patients and may triple the hospital stay compared to isolated burn injuries.89 Mortality for inhalation injury has been reported to be as high as 25%, with this increasing to 50% in patients with ≥20% TBSA burns.90 The pneumonia rate in Brunicardi_Ch08_p0251-p0270.indd 25528/12/18 11:51 AM 256BASIC CONSIDERATIONSPART Ipatients with inhalation injury has been reported to be three times higher than those without inhalation injury, and


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Surgery_Schwartz. 25528/12/18 11:51 AM 256BASIC CONSIDERATIONSPART Ipatients with inhalation injury has been reported to be three times higher than those without inhalation injury, and it has been associated with increased length of stay, increased ven-tilator days, and need for tracheostomy.91,92 The combination of burns, inhalation injury, and pneumonia increases mortal-ity by up to 60% over burns alone.93 Subsequent development of the adult respiratory distress syndrome (ARDS) is common in these patients and may be caused in part by recruitment of alveolar leukocytes with an enhanced endotoxin-activated cyto-kine response.94 When ARDS complicates burns and inhalation injury, mortality approaches 66%; in one study, patients with burns ≥60% TBSA in combination with inhalation injury and ARDS had 100% mortality.95Smoke inhalation causes injury in two ways: by direct heat injury to the upper airways and inhalation of combustion prod-ucts into the lower airways. Direct injury to the upper airway


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Surgery_Schwartz. mortality.95Smoke inhalation causes injury in two ways: by direct heat injury to the upper airways and inhalation of combustion prod-ucts into the lower airways. Direct injury to the upper airway causes airway swelling that typically leads to maximal edema in the first 24 to 48 hours after injury and often requires a short course of endotracheal intubation for airway protection. Com-bustion products found in smoke, most commonly from syn-thetic substances in structural fires, cause lower airway injury. These irritants cause direct mucosal injury, which in turn leads to mucosal sloughing, edema, reactive bronchoconstriction, and finally obstruction of the lower airways. Injury to both the epi-thelium and pulmonary alveolar macrophages causes release of prostaglandins, chemokines, and other inflammatory mediators; neutrophil migration; increased tracheobronchial blood flow; and, finally, increased capillary permeability. All of these com-ponents of acute lung injury increase the risk of


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Surgery_Schwartz. inflammatory mediators; neutrophil migration; increased tracheobronchial blood flow; and, finally, increased capillary permeability. All of these com-ponents of acute lung injury increase the risk of pneumonia and ARDS following an inhalation injury.The physiologic effects of smoke inhalation are numerous. Inhalation injury decreases lung compliance96 and increases air-way resistance work of breathing.97 Inhalation injury in the pres-ence of burns also increases overall metabolic demands.98 The most common physiologic derangement seen with inhalation injury is increased fluid requirement during resuscitation. Since severe inhalation injury may result in mucosal sloughing with obstruction of smaller airways, bronchoscopy findings including carbon deposits, erythema, edema, bronchorrhea, and a hemor-rhagic appearance may be useful for staging inhalation injury. The Abbreviated Injury Score—a scale from 0 to 4, with 0 representing no injury and 4 representing massive injury—is commonly


Surgery_Schwartz

Surgery_Schwartz. a hemor-rhagic appearance may be useful for staging inhalation injury. The Abbreviated Injury Score—a scale from 0 to 4, with 0 representing no injury and 4 representing massive injury—is commonly used for grading inhalation injury. Higher grades of bronchoscopic inhalation injury have been associated with increased incidence of ARDS, increased ventilator days, higher rate of multiple organ dysfunction syndrome, and higher mortality.99 Bronchoscopic evaluation can also help isolate organisms early in the course of a potential pneumonia. Bronchoalveolar lavage (BAL) within 24 hours after an inhalation injury demonstrates a high rate of positive quantitative cultures,100 suggesting that pneumonia develops soon after the acute lung injury. Bacterial contamina-tion from urgent intubation may contribute to early development of pneumonia in patients with inhalation injury.100 Early evalu-ation with bronchoscopy can identify causative organisms and guide appropriate antibiotic


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Surgery_Schwartz. may contribute to early development of pneumonia in patients with inhalation injury.100 Early evalu-ation with bronchoscopy can identify causative organisms and guide appropriate antibiotic therapy.Because bronchoscopy is an invasive test, attempts have been made to utilize other diagnostic modalities, such as tho-racic computed tomography (CT) scans101 and xenon ventilationperfusion scanning.102,103 However, these are generally not uti-lized unless otherwise indicated, and the best tools available for diagnosing inhalation injury remain clinical presentation and bronchoscopic evaluation. Decreased PaO2:FiO2 ratio (<350) on admission may not only predict inhalation injury but also indi-cate increased fluid needs more accurately than bronchoscopic grading of the severity of inhalation.104Treatment of inhalation injury consists primarily of support-ive care. Aggressive pulmonary toilet and routine use of nebulized bronchodilators such as albuterol are recommended. Nebulized


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Surgery_Schwartz. of inhalation injury consists primarily of support-ive care. Aggressive pulmonary toilet and routine use of nebulized bronchodilators such as albuterol are recommended. Nebulized N-acetylcysteine is an antioxidant free radical scavenger designed to decrease the toxicity of high oxygen concentrations. Aero-solized heparin aims to prevent formation of fibrin plugs and decrease the formation of airway casts and has been associated with increased number of ventilator-free days.105 A recent meta-analysis demonstrated improved mortality with the use of inhaled anticoagulation regimens.106 Aerosolized tissue plasminogen activator107 and recombinant human antithrombin108 have shown promise in sheep models but have not yet seen widespread clinical use. Administration of intrabronchial surfactant has been used as a salvage therapy in patients with severe burns and inhalation injury.109 Inhaled nitric oxide may also be useful as a last effort in burn patients with severe lung injury who are


Surgery_Schwartz

Surgery_Schwartz. has been used as a salvage therapy in patients with severe burns and inhalation injury.109 Inhaled nitric oxide may also be useful as a last effort in burn patients with severe lung injury who are failing other means of ventilator support.110 The use of steroids has traditionally been avoided due to the worse outcomes in burn patients111; however, some data demonstrate selectively improved outcomes with septic shock requiring vasopressor circulatory.112An important contributor to early mortality in burn patients and often seen in patients with inhalation injury is carbon mon-oxide (CO) poisoning. This clear, odorless gas has an affinity for hemoglobin is approximately 200 to 250 times more than that of oxygen. Carboxyhemoglobin decreases the levels of nor-mal oxygenated hemoglobin and can quickly lead to anoxia and death.113 CO also causes uncoupling of oxidative phosphory-lation in mitochondria, free radical generation, and increased systemic inflammatory response via platelet


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Surgery_Schwartz. can quickly lead to anoxia and death.113 CO also causes uncoupling of oxidative phosphory-lation in mitochondria, free radical generation, and increased systemic inflammatory response via platelet activation—all of which may increase cardiac and neurologic morbidity and mortality in CO toxicity.114 Unexpected neurologic or cardiac symptoms should raise the level of suspicion, and an arterial carboxyhemoglobin level must be obtained because pulse oxim-etry can be falsely elevated. Administration of 100% normo-baric oxygen is the gold standard for treating CO poisoning and reduces the half-life of CO from 250 minutes in room air to 40 to 60 minutes.115 Some authors have proposed hyperbaric oxygen as an adjunctive therapy for CO poisoning.116 However, a recent meta-analysis offers mixed results regarding the suc-cess and long-term outcomes of hyperbaric oxygen, and its asso-ciated logistical difficulties and complications have limited its usefulness for patients with moderate or large


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Surgery_Schwartz. regarding the suc-cess and long-term outcomes of hyperbaric oxygen, and its asso-ciated logistical difficulties and complications have limited its usefulness for patients with moderate or large burns.117 Patients who sustain a cardiac arrest as a result of their CO poisoning have an extremely poor prognosis regardless of the success of initial resuscitation attempts.118Hydrogen cyanide toxicity may also be a component of an overwhelming smoke inhalation injury. Cyanide inhibits cyto-chrome oxidase, which is required for oxidative phosphorylation.119 Afflicted patients may have a persistent, severe lactic acidosis, neurologic symptoms, pulmonary edema, or cardiac sequelae (ST elevation on electrocardiogram).120,121 Classic signs of cya-nide poisoning—including bitter almond breath and cherry-red skin changes—are rare and should not be used as the sole diagnostic criteria. Treatment consists of sodium thiosulfate, hydroxocobalamin, and 100% oxygen. Sodium thiosulfate works as a


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Surgery_Schwartz. and cherry-red skin changes—are rare and should not be used as the sole diagnostic criteria. Treatment consists of sodium thiosulfate, hydroxocobalamin, and 100% oxygen. Sodium thiosulfate works as a substrate for the metabolism cyanide into a nontoxic deriva-tive, but it works slowly and is not effective for acute therapy.121 Hydroxocobalamin—a vitamin B12 precursor—quickly Brunicardi_Ch08_p0251-p0270.indd 25628/12/18 11:51 AM 257BURNSCHAPTER 8complexes with cyanide, is excreted by the kidney, and is rec-ommended for immediate therapy.122 In the majority of patients, lactic acidosis will resolve with ventilation, and sodium thio-sulfate treatment becomes unnecessary.123 Given the unknown side-effects of hydroxocobalamin administration, it should be reserved only for patients with a strong suspicion of cyanide poisoning.New ventilator strategies have contributed to the improved mortality with ARDS. Although ARDS still contributes to mor-tality in burn patients, treatments have


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Surgery_Schwartz. a strong suspicion of cyanide poisoning.New ventilator strategies have contributed to the improved mortality with ARDS. Although ARDS still contributes to mor-tality in burn patients, treatments have improved so that mor-tality is primarily from multisystem organ failure rather than isolated respiratory causes.124 The ARDS Network Study find-ing that low tidal volume (6 cc/kg) or “lung-protective ventila-tion” had a 22% lower mortality than patients with traditional tidal volumes (12 cc/kg)124 has dramatically changed the man-agement of patients with acute lung injury. A similar approach had previously been shown to improve outcomes in pediatric burn patients.125 In patients with refractory hypoxemia despite lung-protective ventilation, prone positioning may improve oxygenation and mortality.126,127 No specific studies have exam-ined prone positioning in burned patients, and in fact exclusion criteria from a large prone positioning trial included patients with ≥20% TBSA.127 Select


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Surgery_Schwartz. No specific studies have exam-ined prone positioning in burned patients, and in fact exclusion criteria from a large prone positioning trial included patients with ≥20% TBSA.127 Select reports demonstrate the feasibility of prone positioning in burn patients,128 although they pres-ent logistical challenges and caution must be used in patients with frontal and facial burns who are already at risk for loss of the grafts, invasive catheters, and the endotracheal tube. Highfrequency percussive ventilation (HFPV) has shown early promise in patients with inhalation injury.129 One study showed notable decreases in both morbidity and mortality with HFPV, especially in patients with burns <40% TBSA and inhalation injury.130 A randomized controlled trial between low-tidal vol-ume ventilation and HFPV in burn patients requiring mechani-cal ventilation demonstrated no significant difference in primary clinical outcomes.131 A related technique is high-frequency oscillatory ventilation (HFOV),


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Surgery_Schwartz. HFPV in burn patients requiring mechani-cal ventilation demonstrated no significant difference in primary clinical outcomes.131 A related technique is high-frequency oscillatory ventilation (HFOV), which has been used primarily as a salvage modality in patients refractory to more conventional measures.132 However, two recent studies and a recent metaanalysis have concluded that HFOV yields no mortality benefit and in fact may actually increase patient mortality in patients with ARDS.133-135 Extracorporeal membrane oxygenation (ECMO) is typically reserved for salvage situations, although utilization of ECMO for burn patients is increasing and out-comes have been shown to be similar to other ECMO patients.136TREATMENT OF THE BURN WOUNDMultitudes of topical therapies exist for the treatment of burn wounds, many of which contain antimicrobial properties. A recent Cochrane Database Review nicely summarizes the data surrounding antisepsis for burns; however, much of the data is


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Surgery_Schwartz. treatment of burn wounds, many of which contain antimicrobial properties. A recent Cochrane Database Review nicely summarizes the data surrounding antisepsis for burns; however, much of the data is inconclusive.137 Silver sulfadiazine is one of the most widely used in clinical practice. Silver sulfadiazine has a wide range of antimicrobial activity, primarily as prophylaxis against burn wound infections rather than treatment of existing infec-tions. It has the added benefits of being inexpensive, being easily applied, and having soothing qualities. It is not signifi-cantly absorbed systemically and thus has minimal metabolic derangements. Silver sulfadiazine has a reputation for causing neutropenia, but this association is more likely due to neutro-phil margination from the inflammatory response following burn injury. True allergic reactions to the sulfa component of silver sulfadiazine are rare, and at-risk patients can have a small test patch applied to identify a burning sensation


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Surgery_Schwartz. following burn injury. True allergic reactions to the sulfa component of silver sulfadiazine are rare, and at-risk patients can have a small test patch applied to identify a burning sensation or rash. Silver sulfadiazine destroys skin grafts and is contraindicated on burns or donor sites in proximity to newly grafted areas. Also, silver sulfadiazine may retard epithelial migration in healing partial-thickness wounds.Mafenide acetate, either in cream or solution form, is an effective topical antimicrobial. It is effective even in the pres-ence of eschar and can be used in both treating and prevent-ing wound infections; the solution formulation is an excellent antimicrobial for fresh skin grafts. Use of mafenide acetate may be limited by pain with application to partial-thickness burns. As mafenide is a carbonic anhydrase inhibitor, a his-torically described side effect is metabolic acidosis. However, multiple studies have been performed using mafenide to treat burn wounds without any


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Surgery_Schwartz. mafenide is a carbonic anhydrase inhibitor, a his-torically described side effect is metabolic acidosis. However, multiple studies have been performed using mafenide to treat burn wounds without any significant incidence of metabolic acidosis.138,139Silver nitrate has broad-spectrum antimicrobial activity as a topical solution. The solution used must be dilute (0.5%), and prolonged topical application leads to electrolyte extravasation with resulting hyponatremia. A rare complication is methemo-globinemia.140 Although inexpensive, silver nitrate solution causes black stains, and laundry costs may offset any fiscal benefit to the hospital. Although there is no definitive evidence regarding use in the burn population, Dakin’s solution (0.5% sodium hypochlorite solution) is an acceptable alternative as an inexpensive topical antimicrobial.For smaller burns or larger burns that are nearly healed, topical ointments such as bacitracin, neomycin, and polymyxin B can be used. These are also


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Surgery_Schwartz. as an inexpensive topical antimicrobial.For smaller burns or larger burns that are nearly healed, topical ointments such as bacitracin, neomycin, and polymyxin B can be used. These are also useful for superficial partial-thickness facial burns as they can be applied and left open to air without dressing coverage. Meshed skin grafts in which the interstices are nearly closed are another indication for use of these agents, preferably with greasy gauze to help retain the ointment in the affected area. All three have been reported to cause nephrotoxicity and should be used sparingly in large burns. Recent media coverage of methicillin-resistant Staphy-lococcus aureus (MRSA) has led to widespread use by commu-nity practitioners of mupirocin for new burns. Unless the patient has known risk factors for MRSA, mupirocin should only be used in culture-positive burn wound infections to prevent emer-gence of further resistance.Silver-impregnated dressings are increasingly being used for donor


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Surgery_Schwartz. for MRSA, mupirocin should only be used in culture-positive burn wound infections to prevent emer-gence of further resistance.Silver-impregnated dressings are increasingly being used for donor sites, skin grafts, and partial-thickness burns because of their potential to avoid daily dressing changes. These may be more comfortable for the patient, reduce the number of dressing changes, and shorten hospital length of stay, but they limit serial wound examinations. Biologic membranes such as Biobrane (Smith & Nephew Global Products) provide a prolonged barrier under which wounds may heal. Because of the occlusive nature of these dressings, these are typically used only on fresh, super-ficial, partial-thickness burns that are clearly not contaminated.NUTRITIONNutritional support may be more important in patients with large burns than in any other patient population. Not only does adequate nutrition play a role in acute issues such as immune responsiveness, but the hypermetabolic response


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Surgery_Schwartz. in patients with large burns than in any other patient population. Not only does adequate nutrition play a role in acute issues such as immune responsiveness, but the hypermetabolic response in burn injury may raise baseline metabolic rates by as much as 200%.141 This can lead to catabolism of muscle proteins and decreased lean body mass that may delay functional recovery.142 Early enteral Brunicardi_Ch08_p0251-p0270.indd 25728/12/18 11:51 AM 258BASIC CONSIDERATIONSPART Ifeeding for patients with burns >20% TBSA is safe and may reduce loss of lean body mass,143 slow the hypermetabolic response,144 and result in more efficient protein metabolism.145,146 Early enteral feeds have also been associated with shorter dura-tion of ICU stay and decreased rates of wound infection.147 If the enteral feeds are started within the first few hours after admis-sion, gastric ileus may be avoided. Adjuncts such as metoclo-pramide promote gastrointestinal motility; if other measures for gastric


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Surgery_Schwartz. enteral feeds are started within the first few hours after admis-sion, gastric ileus may be avoided. Adjuncts such as metoclo-pramide promote gastrointestinal motility; if other measures for gastric feeding are unsuccessful, advancing the tube into the small bowel with nasojejunal feeding can be attempted.148 In endotracheally intubated patients, trips to the operating room do not necessitate holding enteral feedings.149 Immune-modulating supplements such as glutamine may decrease infectious com-plications in burn patients,150,151 although the effect on mortality and wound closure remains unknown. One proposed mechanism for glutamine’s immune modulating properties is via preven-tion of T-cell suppression in mesenteric lymph nodes.152 There is currently a multicenter randomized control trial recruiting to determine the effect of glutamine on mortality, blood stream infections, and health-related quality of life (https://clinicaltri-als.gov/ct2/show/NCT00985205). Micronutrient


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Surgery_Schwartz. trial recruiting to determine the effect of glutamine on mortality, blood stream infections, and health-related quality of life (https://clinicaltri-als.gov/ct2/show/NCT00985205). Micronutrient supplementa-tion with antioxidant vitamins (vitamin E and ascorbic acid) and trace minerals (selenium, zinc, and copper) optimizes wound healing, enhances immune function, and fights oxida-tive stress.153Calculating the appropriate caloric needs of the burn patient can be challenging. A commonly used formula in non-burned patients is the Harris-Benedict equation, which calcu-lates caloric needs using factors such as gender, age, height, and weight. This formula uses an activity factor for specific inju-ries, and for burns, the basal energy expenditure is multiplied by two. The Harris-Benedict equation may be inaccurate in burns of <40% TBSA, and in these patients, the Curreri formula may be more appropriate. This formula estimates caloric needs to be 25 kcal/kg per d plus 40 kcal/%TBSA per d.


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Surgery_Schwartz. may be inaccurate in burns of <40% TBSA, and in these patients, the Curreri formula may be more appropriate. This formula estimates caloric needs to be 25 kcal/kg per d plus 40 kcal/%TBSA per d. Indirect calorim-etry can also be used to calculate resting energy expenditure, but in burn patients, a “metabolic cart” has not been documented to be more beneficial than the predictive equations.154 Titrating caloric needs closely is important because overfeeding patients will lead to storage of fat instead of muscle anabolism.155Modifying the hypermetabolic response is an area of intense study. β-Blocker use in pediatric patients decreases heart rate and resting energy expenditure and abrogates protein catabolism, even in long-term use.156 There may be benefits to β-blockade in adult patients,157 and many centers use β-blockers routinely in the adult population with limited safety and efficacy data.158 Some data suggests that β-blocker use in the adult burn population has a greater


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Surgery_Schwartz. and many centers use β-blockers routinely in the adult population with limited safety and efficacy data.158 Some data suggests that β-blocker use in the adult burn population has a greater incidence of iatrogenic hypotension and bradycardia. As such, it is important to monitor hemodynamic status when starting β-blockers in these populations.159The anabolic steroid oxandrolone has been extensively studied in burn patients as well and has demonstrated improve-ments in lean body mass and bone density in severely burned children.160 The weight gain and functional improvements seen with oxandrolone may persist even after stopping administration of the drug.161,162 A double-blind, randomized study of oxandro-lone showed decreased length of stay, improved hepatic pro-tein synthesis, and no adverse effects on endocrine function, although the authors noted a rise in transaminases with unclear clinical significance.163 Oxandrolone therapy has also been asso-ciated with overall decreased


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Surgery_Schwartz. adverse effects on endocrine function, although the authors noted a rise in transaminases with unclear clinical significance.163 Oxandrolone therapy has also been asso-ciated with overall decreased mortality in patients with large burns.164Hyperglycemia has been associated with increased mortal-ity after burn injury,165 and intensive insulin therapy in critically ill patients has shown benefit, presumably from avoidance of hyperglycemia.166 However, in burn patients, the insulin itself may have a metabolic benefit, with improvements in lean body mass and amelioration of the inflammatory response to burn injury.167,168 Oral hypoglycemic agents such as metformin also help to avoid hyperglycemia and may contribute to prevention of muscle catabolism.169COMPLICATIONS IN BURN CAREThere are several complications commonly associated with treatment of burn patients. Though not always avoidable, main-taining vigilance for typical complications and using appro-priate techniques for prevention


Surgery_Schwartz

Surgery_Schwartz. complications commonly associated with treatment of burn patients. Though not always avoidable, main-taining vigilance for typical complications and using appro-priate techniques for prevention may limit the frequency and severity of complications. Ventilator-associated pneumonia, as in all critically ill patients, is a significant problem in burned patients. However, it is so common in patients with inhalation injury that a better nomenclature may be postinjury pneumonia. Unfortunately, commonly used scores in critical illness such as the Clinical Pulmonary Infection Score (CPIS) have not been shown to be reliable in burn patients. Quantitative broncho-scopic cultures in the setting of clinical suspicion of pneumo-nia should guide treatment of pneumonia.170 Simple measures such as elevating the head of the bed and maintaining excel-lent oral hygiene and pulmonary toilet are recommended to help decrease the risk of postinjury pneumonia. There is some question as to whether early


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Surgery_Schwartz. the head of the bed and maintaining excel-lent oral hygiene and pulmonary toilet are recommended to help decrease the risk of postinjury pneumonia. There is some question as to whether early tracheostomy decreases infectious morbidity in burn patients and whether it improves long-term outcomes. There do not seem to be any major differences in the rates of pneumonia with early tracheostomy, though there may be reduced development of subglottic stenosis compared with prolonged endotracheal intubation.171,172 Practical consid-erations such as protection of facial skin grafts may influence the decision for tracheostomy placement. One major consider-ation in deciding whether to perform a tracheostomy has been the presence of eschar at the insertion site, which complicates tracheostomy site care and increases the risk of airway infec-tion. Bedside percutaneous dilatational tracheostomy is a facile method for performing tracheostomy and is reported to be as safe as open tracheostomy in the


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Surgery_Schwartz. and increases the risk of airway infec-tion. Bedside percutaneous dilatational tracheostomy is a facile method for performing tracheostomy and is reported to be as safe as open tracheostomy in the burn population.173Massive resuscitation of burned patients may lead to an abdominal compartment syndrome characterized by increased airway pressures with hypoventilation and decreased urine output and hemodynamic compromise. Decompressive lapa-rotomy is the standard of care for refractory abdominal com-partment syndrome but carries an especially poor prognosis in burn patients.174 Adjunctive measures such as minimizing fluid, performing torso escharotomies, decreasing tidal volumes, and chemical paralysis should be initiated before resorting to decompressive laparotomy. Patients undergoing massive resus-citation also develop elevated intraocular pressures and may require lateral canthotomy.175Deep vein thrombosis (DVT) and prophylaxis in the burn population has received increasing attention


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Surgery_Schwartz. resus-citation also develop elevated intraocular pressures and may require lateral canthotomy.175Deep vein thrombosis (DVT) and prophylaxis in the burn population has received increasing attention in the literature recently. Up to 25% of burn patients develop DVT, and fatal pulmonary emboli have been reported in burn patients.176,177 A recent prospective trial demonstrated an 8% incidence of DVT in patients with 30% to 60% TBSA burns not receiving low molecular weight heparin prophylaxis with no evidence of DVT in patients receiving prophylaxis. There were no complications Brunicardi_Ch08_p0251-p0270.indd 25828/12/18 11:51 AM 259BURNSCHAPTER 8from low molecular weight heparin prophylaxis.178 Thus, it appears that heparin prophylaxis is safe in burn patients and may help prevent thrombotic complications.Unfortunately, the use of both prophylactic and therapeu-tic heparin may be associated with heparin-associated throm-bocytopenia (HIT). One study of HIT in burn patients showed an


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Surgery_Schwartz. complications.Unfortunately, the use of both prophylactic and therapeu-tic heparin may be associated with heparin-associated throm-bocytopenia (HIT). One study of HIT in burn patients showed an incidence of 1.6% in heparinized burn patients. Thrombotic complications included DVT, pulmonary embolus, and even arterial thrombosis requiring limb amputation. Nonheparin anticoagulation for HIT commonly caused bleeding complica-tions requiring transfusion.179 Although rare, a high index of suspicion for HIT should be maintained in thrombocytopenic burn patients, particularly if the platelet counts drop at hospital days 7 to 10.Burn patients often require central venous access for fluid resuscitation and hemodynamic monitoring. Because of the ana-tomic relation of their burns to commonly used access sites, burn patients may be at higher risk for catheter-related blood-stream infections. The 2012 Centers for Disease Control and Prevention National Healthcare Safety Network report indicates


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Surgery_Schwartz. access sites, burn patients may be at higher risk for catheter-related blood-stream infections. The 2012 Centers for Disease Control and Prevention National Healthcare Safety Network report indicates that American burn centers have higher infectious complica-tion rates than any other ICUs.180 Because burn patients may commonly exhibit leukocytosis with a documented bloodstream infection, practice has been to rewire lines over a guide wire and to culture the catheter tip. However, this may increase the risk of catheter-related infections in burned patients, and a new site should be used if at all possible.181SURGERYFull-thickness burns with a rigid eschar can form a tourniquet effect as the edema progresses, leading to compromised venous outflow and eventually arterial inflow. The resulting compart-ment syndrome is most common in circumferential extremity burns, but abdominal and thoracic compartment syndromes also occur. Warning signs of impending compartment syndrome may include


Surgery_Schwartz

Surgery_Schwartz. compart-ment syndrome is most common in circumferential extremity burns, but abdominal and thoracic compartment syndromes also occur. Warning signs of impending compartment syndrome may include paresthesias, pain, decreased capillary refill, and progression to loss of distal pulses; in an intubated patient, the surgeon should anticipate the compartment syndrome and perform frequent neurovascular evaluations. Abdominal com-partment syndrome should be suspected with decreased urine output, increased ventilator airway pressures, and hypotension. Hypoventilation, increased airway pressures, and hypotension may also characterize thoracic compartment syndrome. Escha-rotomies are rarely needed within the first 8 hours following injury and should not be performed unless indicated because of the terrible aesthetic sequelae. When indicated, they are usu-ally performed at the bedside, preferably with electrocautery to minimize blood loss. Extremity incisions are made on the lateral and medial


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Surgery_Schwartz. terrible aesthetic sequelae. When indicated, they are usu-ally performed at the bedside, preferably with electrocautery to minimize blood loss. Extremity incisions are made on the lateral and medial aspects of the limbs in an anatomic position and may extend onto thenar and hypothenar eminences of the hand. Digital escharotomies do not usually result in any meaningful salvage of functional tissue and are not recommended. Inad-equate perfusion despite proper escharotomies may indicate the need for fasciotomy, but this procedure should not be routinely performed as part of the eschar release. Thoracic escharotomies should be placed along the anterior axillary lines with bilateral subcostal and subclavicular extensions. Extension of the ante-rior axillary incisions down the lateral abdomen typically will allow adequate release of abdominal eschar.The strategy of early excision and grafting in burned patients revolutionized survival outcomes in burn care. Not only did it improve


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Surgery_Schwartz. abdomen typically will allow adequate release of abdominal eschar.The strategy of early excision and grafting in burned patients revolutionized survival outcomes in burn care. Not only did it improve mortality, but early excision also decreased reconstruction surgery, hospital length of stay, and costs of care.182-184 Once the initial resuscitation is complete and the patient is hemodynamically stable, attention should be turned to excising the burn wound. Burn excision and wound coverage should ideally start within the first several days, and in larger burns, serial excisions can be performed as patient condition allows. Excision is performed with repeated tangential slices using a Watson or Goulian blade until viable, diffusely bleeding tissue remains. It is appropriate to leave healthy dermis, which will appear white with punctate areas of bleeding. Excision to fat or fascia may be necessary in deeper burns. The downside of tangential excision is a high blood loss, though this may


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Surgery_Schwartz. dermis, which will appear white with punctate areas of bleeding. Excision to fat or fascia may be necessary in deeper burns. The downside of tangential excision is a high blood loss, though this may be ame-liorated using techniques such as instillation of an epinephrine tumescence solution underneath the burn. Pneumatic tourni-quets are helpful in extremity burns, and compresses soaked in a dilute epinephrine solution are necessary adjuncts after excision. A fibrinogen and thrombin spray sealant (Tisseel Fibrin Sealant; Baxter, Deerfield, IL) also has beneficial effects on both hemo-stasis and graft adherence to the wound bed. The use of these techniques has markedly decreased the number of blood trans-fusions given during burn surgery.185 For patients with clearly deep burns and concern for excessive blood loss, fascial exci-sion may be employed. In this technique, electrocautery is used to excise the burned tissue and the underlying subcutaneous tis-sue down to muscle fascia. This


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Surgery_Schwartz. for excessive blood loss, fascial exci-sion may be employed. In this technique, electrocautery is used to excise the burned tissue and the underlying subcutaneous tis-sue down to muscle fascia. This technique markedly decreases blood loss but results in a cosmetically inferior appearance due to the loss of subcutaneous tissue. For excision of burns in dif-ficult anatomic areas, such as the face, eyelids, or hands, a pres-surized water dissector may offer more precision but is time consuming, has a steep learning curve, and is expensive.186WOUND COVERAGESince full-thickness burns are impractical for most burn wounds, split-thickness sheet autografts harvested with a power dermatome make the most durable wound coverings and have a decent cosmetic appearance. In larger burns, meshed auto-grafted skin provides a larger area of wound coverage. This also allows drainage of blood and serous fluid to prevent accumula-tion under the skin graft with subsequent graft loss. Areas of cosmetic


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Surgery_Schwartz. skin provides a larger area of wound coverage. This also allows drainage of blood and serous fluid to prevent accumula-tion under the skin graft with subsequent graft loss. Areas of cosmetic importance such as the face, neck, and hands should be grafted with nonmeshed sheet grafts to ensure optimal appear-ance and function. Unfortunately, even extensive meshing of skin grafts in patients with limited donor sites may not provide adequate amounts of skin. One emerging technique for large burns with limited donor sites is the Meek micrografting tech-nique, or “postage-stamp” technique, where expansion ratios of up to 9:1 are able to be achieved. This technique has a con-siderable learning curve and requires further investigation to determine whether it is the optimal technique for large surface area burns with limited donor sites.187 Options for temporary wound coverage include human cadaveric allograft, which is incorporated into the wound but is rejected by the immune sys-tem and must


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Surgery_Schwartz. area burns with limited donor sites.187 Options for temporary wound coverage include human cadaveric allograft, which is incorporated into the wound but is rejected by the immune sys-tem and must be eventually replaced. This allows temporary biologic wound coverage until donor sites heal enough so that they may be reharvested. Xenograft appears to function as well as allograft for temporary wound coverage and is considerably less expensive.The search for a perfect permanent synthetic skin sub-stitute remains elusive. Integra (Integra LifeSciences Cor-poration, Plainsboro, NJ) is a bilayer product with a porous Brunicardi_Ch08_p0251-p0270.indd 25928/12/18 11:51 AM 260BASIC CONSIDERATIONSPART Icollagen-chondroitin 6-sulphate inner layer that is attached to an outer silastic sheet, which helps prevent fluid loss and infection as the inner layer becomes vascularized, creating an artificial neodermis. At approximately 2 weeks after placement, the silas-tic layer can be removed and a


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Surgery_Schwartz. helps prevent fluid loss and infection as the inner layer becomes vascularized, creating an artificial neodermis. At approximately 2 weeks after placement, the silas-tic layer can be removed and a thin autograft can be placed over the neodermis. This results in faster healing of the more superfi-cial donor sites and has been increasingly utilized for treatment of complex wounds and injuries.188 Alloderm (LifeCell Corpo-ration, The Woodlands, TX) is a dermal substitute consisting of cryopreserved acellular human dermis. NovoSorb™ Biode-gradable Temporizing Matrix (PolyNovo Limited, Melbourne, Australia) is a biodegradable polyurethane dermal substitute newly available and recently approved by the United States Food and Drug Administration (FDA). These dermal substitutes should also be used in combination with thin split-thickness skin grafts for final wound coverage.189Epidermal skin substitutes such as cultured epithelial auto-grafts are an option in patients with massive burns and


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Surgery_Schwartz. in combination with thin split-thickness skin grafts for final wound coverage.189Epidermal skin substitutes such as cultured epithelial auto-grafts are an option in patients with massive burns and very limited donor sites.190,191 Their clinical use has been limited by a long turnaround time for culturing, as well as the fragility of the cultured skin, which creates great difficulty with intraopera-tive handling and graft take. There are promising developments in skin culturing techniques and engineered skin development, but no other products are FDA approved and commercially available.188Thighs make convenient anatomic donor sites; they are eas-ily harvested and relatively hidden from an aesthetic standpoint. The thicker skin of the back is useful in older patients, who have thinner skin elsewhere and may have difficulty with healing of donor sites. The buttocks are an excellent donor site in infants and toddlers; silver sulfadiazine can be applied to the donor site with a diaper as


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Surgery_Schwartz. elsewhere and may have difficulty with healing of donor sites. The buttocks are an excellent donor site in infants and toddlers; silver sulfadiazine can be applied to the donor site with a diaper as coverage. The scalp is also an excellent donor site; the skin is thick and the many hair follicles allow rapid heal-ing, with the added advantage of being completely hidden once hair regrows. Epinephrine tumescence is necessary for harvest-ing the scalp, for both hemostasis of this hypervascular area and also to create a smooth contoured surface for harvesting.The list of commonly used donor site dressings is long and includes simple transparent films to hydrocolloids, petrolatum gauzes, and silver-impregnated dressings. Donor sites close to fresh grafts may be dressed with a porous nonadherent gauze, and both the donors and grafts are soaked with an antimicrobial solution. Principles behind choosing a dressing should balance ease of care, comfort, infection control, and cost. The choice


Surgery_Schwartz

Surgery_Schwartz. gauze, and both the donors and grafts are soaked with an antimicrobial solution. Principles behind choosing a dressing should balance ease of care, comfort, infection control, and cost. The choice of donor site dressing is largely institution dependent, and few data support the clear superiority of any single treatment plan.REHABILITATIONRehabilitation is an integral part of the clinical care plan for the burn patient and should be initiated on admission. Immediate and ongoing physical and occupational therapy is mandatory to prevent functional loss. Patients who are unable to actively participate should have passive range-of-motion exercises done at least twice a day. This includes patients with burns over joints, such as with hand burns. Patients should be taught exer-cises they can do themselves to maintain full range of motion. Patients with foot and extremity burns should be instructed to walk independently without crutches or other assistive devices to prevent extremity


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Surgery_Schwartz. can do themselves to maintain full range of motion. Patients with foot and extremity burns should be instructed to walk independently without crutches or other assistive devices to prevent extremity swelling, desensitize the burned areas, and prevent disuse atrophy; when patients are not ambulating, they must elevate the affected extremity to minimize swelling. If postoperative immobilization is used for graft protection, the graft should be evaluated early and at frequent intervals so that active exercise can be resumed at the earliest possible occasion. The transition to outpatient care should also include physical and occupational therapy, with introduction of exercises designed to accelerate return to activities of daily living as well as specific job-related tasks. Tight-fitting pressure garments provide vascu-lar support in burns that are further along in the healing process. Whether they prevent hypertrophic scar formation has been long debated. However, they do provide


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Surgery_Schwartz. pressure garments provide vascu-lar support in burns that are further along in the healing process. Whether they prevent hypertrophic scar formation has been long debated. However, they do provide vascular support that many patients find more comfortable.LATE COMPLICATIONS: HYPERTROPHIC SCAR, CONTRACTURES, AND HETEROTOPIC OSSIFICATIONOnce patients have recovered from their acute burns, many face management of the hypertrophic burn scars. In patients with healed burns or donor sites, hypertrophic scar-related morbid-ity includes pruritus, erythema, pain, thickened tight skin, and even contractures. Within these scars, there is believed to be an increased inflammatory response, irregular neovascularization, aberrant cytokine and Toll-like receptor expression, abundant collagen production, and abnormal extracellular matrix struc-ture. Treatment for these scars has included nonsurgical therapies such as compression garments, silicone gel sheeting, massage, physical therapy, and


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Surgery_Schwartz. and abnormal extracellular matrix struc-ture. Treatment for these scars has included nonsurgical therapies such as compression garments, silicone gel sheeting, massage, physical therapy, and corticosteroid. Surgical excision and scar revision represent more invasive scar management approaches that are often necessary for functional and aesthetic recovery.192Laser-based therapies provide additional treatment options for symptomatic hypertrophic scars. Two of the most common ones are the pulsed dye laser (PDL) and the ablative carbon dioxide (CO2) laser. The PDL causes photothermolysis of hemoglobin, resulting in coagulative necrosis.193 It obliterates small capillaries close to the skin and has had success treating congenital, cutaneous vascular malformations. The CO2 laser has been used for treatment of acne and recently has been gain-ing acceptance for its use to treat hypertrophic burn scars.194 It works by ablating microscopic columns of tissue to flatten scars and is also believed


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Surgery_Schwartz. treatment of acne and recently has been gain-ing acceptance for its use to treat hypertrophic burn scars.194 It works by ablating microscopic columns of tissue to flatten scars and is also believed to stimulate matrix metalloproteinases and other signaling pathways to induce collagen reorganization. Lasers are ultimately believed to help with scar remodeling and collagen reorganization. CO2 laser therapy has been shown to decrease symptoms associated with hypertrophic scarring, including scar appearance, pliability, contracture, neuropathic pain, and pruritus. A recent prospective study utilizing PDL and CO2 laser therapy demonstrated improved signs and symptoms of hypertrophic scars based on the Vancouver Scar Scale and the University of North Carolina 4P Scar Scale.195 Outpatient and office-based treatment sessions are tolerated well by most patients. There is wide practice variation on when to start ther-apy and the number of treatments, but the literature has general support for


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Surgery_Schwartz. treatment sessions are tolerated well by most patients. There is wide practice variation on when to start ther-apy and the number of treatments, but the literature has general support for starting treatment at 6 to 12 months and offering three treatments. More research is needed to determine the full potential of laser therapy to provide burn survivors a less inva-sive treatment of hypertrophic scars with improved symptoms and quality of life.Contractures are another long-term complication of burn injury that can result in significant morbidity. Contractures result from both wound contracture and scar contracture and prevents range of motion of a particular joint. Factors influenc-ing contracture development include burn depth and activation Brunicardi_Ch08_p0251-p0270.indd 26028/12/18 11:51 AM 261BURNSCHAPTER 8of dermal fibroblasts, myofibroblasts, fibrocytes, and helper T cells.196 Despite aggressive physiotherapy, contractures have been reported to develop in as many as


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Surgery_Schwartz. 11:51 AM 261BURNSCHAPTER 8of dermal fibroblasts, myofibroblasts, fibrocytes, and helper T cells.196 Despite aggressive physiotherapy, contractures have been reported to develop in as many as one-third of burn patients. A recent study of 1865 patients demonstrated that the shoulder is the most affected joint, followed by the elbow, wrist, ankle, and knee.197 A similar study in the pediatric population yielded similar results. Gender, race, and %TBSA were associated with contracture development in the adult population. Age and length of stay in the ICU were associated with contracture develop-ment, severity of contracture, and total number of contractures in the pediatric population. Treatment of contractures includes both nonsurgical and surgical options, ranging from pressure garments and splints to laser therapy and contracture excision.Heterotopic ossification (HO) is another long-term mor-bidity associated with burn injury. HO is the pathologic devel-opment of lamellar bone in


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Surgery_Schwartz. and splints to laser therapy and contracture excision.Heterotopic ossification (HO) is another long-term mor-bidity associated with burn injury. HO is the pathologic devel-opment of lamellar bone in peripheral tissue. Its incidence has been reported to be between 1% and 3% of burn patients.198 Symptoms include decreased range of motion, pain, and swell-ing overlying the affected joints. Often times, the pathologic bone formation can be visualized radiographically with plain X-rays. Risk factors include >30% TBSA, arm burns, arm grafts, ventilator days, and number of trips to the operat-ing room.199 Treatment includes aggressive physiotherapy, NSAIDs, bisphosphonates, radiation therapy, and rarely surgi-cal excision. A risk scoring system has been developed to pre-dict which burn patients are at risk of developing HO based on admission criteria; however, further validation is warranted.200PSYCHOLOGICAL RECOVERYPsychological rehabilitation is equally important in the burn patient.


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Surgery_Schwartz. are at risk of developing HO based on admission criteria; however, further validation is warranted.200PSYCHOLOGICAL RECOVERYPsychological rehabilitation is equally important in the burn patient. Depression, posttraumatic stress disorder (PTSD), concerns about image, and anxiety about returning to society constitute predictable barriers to progress in both the inpa-tient and outpatient setting. Psychological distress occurs in as many as 38% of burn patients and persists in severity long after discharge.201 Rates of depression vary between 4% and 54% following injury, although these numbers vary dramatically based on the methodology used to diagnose depression.202 Still, depressive symptoms have been documented in up to 43% of patients 2 years following injury and have been associated with the female gender. Factors such as gender, extraversion, capac-ity for forgiveness, the event as a disaster or nondisaster, alcohol use, and peritraumatic emotional response have been identified as


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Surgery_Schwartz. the female gender. Factors such as gender, extraversion, capac-ity for forgiveness, the event as a disaster or nondisaster, alcohol use, and peritraumatic emotional response have been identified as contributing factors to PTSD.203 Despite the psychological impact of burn injury, many patients will be able to quickly return to work or school, and goals should be set accordingly. The involvement of clinical psychologists and psychiatrists is invaluable in providing guidance and coping techniques to lessen the significant psychological burden of burn injury.PREVENTIONDespite many areas of progress in prevention over the past cen-tury, burns continue to be a common source of injury. The cor-nerstone for burn prevention programs has been “The Five Step Process,” a systematic method of assessing, implementing, and evaluating burn hazards and subsequent intervention impact, and The Five E’s—engineering/environment, enforcement, education, emergency response, and economic initiative.204 It


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Surgery_Schwartz. implementing, and evaluating burn hazards and subsequent intervention impact, and The Five E’s—engineering/environment, enforcement, education, emergency response, and economic initiative.204 It has been shown that patients who live in environments opti-mal for sustaining burn injury have decreased knowledge of burn prevention strategies.205 Some successful initiatives have included school-based education and community-based inter-ventions targeting simple home safety measures. A 6-year study of second-graders demonstrated both shortand long-term retainment of information related to burn, fire, and life safety following multiple educational sessions. Smoke alarms are known to decrease mortality from structural fires, but not all homes are equipped with proper smoke alarms, particularly in low-income households. Mandatory smoke alarm installa-tion via community initiatives can be successful but seems to be contingent on close, long-term follow-up to ensure proper maintenance and


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Surgery_Schwartz. in low-income households. Mandatory smoke alarm installa-tion via community initiatives can be successful but seems to be contingent on close, long-term follow-up to ensure proper maintenance and function.206,207 Regulation of hot water heater temperatures has had some success and may be even more effec-tive in conjunction with community-based programs emphasiz-ing education and in-home inspections.208,209 A recent systematic review of prevention in lowand middle-income countries iden-tified multiple successful prevention programs.210 Burn profes-sionals have also demonstrated incomplete knowledge on best practices for fire safety and burn prevention.211 As such, appro-priate education of burn professionals participating in preven-tion programs is necessary.BURN DISASTERSAlthough rare, burn disasters can be devastating to those involved due to the sudden nature of the event, the difficulty of managing personnel and resources,212 a deficit of staff expe-rience in burn management, and


Surgery_Schwartz

Surgery_Schwartz. disasters can be devastating to those involved due to the sudden nature of the event, the difficulty of managing personnel and resources,212 a deficit of staff expe-rience in burn management, and relatively small resource availability for a potentially large number of patients.213 The American Burn Association has estimated that up to 30% of patients in mass casualty incidents suffer from burn injury.214 A recent review of the literature between 1990 and 2016 identi-fied 752 burn disasters world-wide, defined as an incident with ≥50 burn injuries and/or ≥30 burn-related deaths. The major-ity occurred in Asia and the Middle East and are thought to be secondary to rapid industrialization, inadequate fire-prevention strategies, and poor building codes. There was a significant increase in terrorist-related incidences from 2000 to 2015. Finally, the authors demonstrated that international adoption of the U.S. Health and Human Services guidelines on bed avail-ability for burns and trauma


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Surgery_Schwartz. incidences from 2000 to 2015. Finally, the authors demonstrated that international adoption of the U.S. Health and Human Services guidelines on bed avail-ability for burns and trauma dramatically underestimated the number of beds needed for burn disasters.215Preparedness is paramount for reacting quickly, efficiently, and effectively to a burn disaster. General surgeons not trained in burn care may feel uncomfortable longitudinally caring for severely burned patients following a burn disaster. However, due to resource limitations, they should be prepared to care for burn patients for the first 72 hours of resuscitation or until the patients can be transferred to a center that specializes in burn care. This will involve initial evaluation, resuscitation, and potential inter-ventions including central line placement, intubation, and escha-rotomies. Coordination for burn disasters should take place at three levels: institutional/intrafacility, interfacility/intrastate, and


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Surgery_Schwartz. including central line placement, intubation, and escha-rotomies. Coordination for burn disasters should take place at three levels: institutional/intrafacility, interfacility/intrastate, and interstate/regional. It is important to have multiple stakeholders involved in the development of a disaster plan, from the burn surgeons to the emergency department personnel to the emer-gency medical personnel who are first responders.216 Resource utilization can be guided by The American Burn Association Age/TBSA survival grid, which stratifies patients into benefit-to-resource categories (outpatient, high, low, and expectant) based on age and %TBSA.3 This allows providers to allocate resources during burn disasters based on the severity of injury Brunicardi_Ch08_p0251-p0270.indd 26128/12/18 11:51 AM 262BASIC CONSIDERATIONSPART Iand expected survival.214 Another important consideration is the involvement of nonburn hospitals in the planning for burn disas-ters as burn centers do not


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Surgery_Schwartz. 11:51 AM 262BASIC CONSIDERATIONSPART Iand expected survival.214 Another important consideration is the involvement of nonburn hospitals in the planning for burn disas-ters as burn centers do not possess enough resources to be sole providers in these events. Multiple strategies have been adopted by local burn centers, including the development of a consortium of hospitals surrounding one burn center in New Jersey to allow transfer of patients when resource capacity is in jeopardy.217Interest in mass burn casualty disaster planning invariably includes a discussion of radiation burns. Radioactive material results in both acute injury from immediate exposure and more prolonged injury from delayed exposure to radioactive fallout or contamination. When a 10-kiloton nuclear bomb is deto-nated, people at a distance 0.7 miles from ground zero absorb 4.5 Gy. At 60 days, the median lethal radiation dose (LD50) is 3.5 Sv; with aggressive medical care, this dose might be doubled to nearly 7 Sv.


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Surgery_Schwartz. people at a distance 0.7 miles from ground zero absorb 4.5 Gy. At 60 days, the median lethal radiation dose (LD50) is 3.5 Sv; with aggressive medical care, this dose might be doubled to nearly 7 Sv. To put this in context, radiation expo-sure from a diagnostic CT of the chest or abdomen is 5 mSv, and the average annual background absorbed radiation dose is 3.6 mSv. Radiation is known to impact several organ systems and result in several syndromes based on increasing exposure doses. These syndromes include hematologic (1–8 Sv expo-sure), gastrointestinal (8–30 Sv exposure), and cardiovascular/neurologic syndromes (>30 Sv exposure), with the latter two being nonsurvivable.218-220After initial evaluation and decontamination by removing clothing, a useful way to estimate exposure is by determining the time to emesis. Patients who do not experience emesis within 4 hours of exposure are unlikely to have severe clinical effects. Emesis within 2 hours suggests a dose of at least 3 Sv, and


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Surgery_Schwartz. the time to emesis. Patients who do not experience emesis within 4 hours of exposure are unlikely to have severe clinical effects. Emesis within 2 hours suggests a dose of at least 3 Sv, and emesis within 1 hour suggests at least 4 Sv. The hematologic system follows a similar dose-dependent temporal pattern for predicting radiation exposure, mortality, and treatment. These have been determined based on the Armed Forces Radiobiology Research Institute’s Biodosimetry Assessment Tool, which can be downloaded from www.afrri.usuhs.mil.The combination of radiation exposure and burn wounds has the potential to increase mortality compared with traditional burns. Early closure of wounds before radiation depletes circu-lating lymphocytes may be needed for wound healing (which occurs within 48 hours). Also, in radiation injuries combined with burn or trauma, laboratory lymphocyte counts may be unreliable.218-221 A significant difference between burn/traumatic injuries and radiation injures is


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Surgery_Schwartz. Also, in radiation injuries combined with burn or trauma, laboratory lymphocyte counts may be unreliable.218-221 A significant difference between burn/traumatic injuries and radiation injures is that burn/traumatic injuries can result in higher mortality when not treated within hours.Decontamination and triage are vital to maximize the num-ber of survivors. Initial decontamination requires removal of clothing and washing wounds with water. Irrigation fluid should be collected to prevent radiation spread into the water supply. Work by many professional organizations, including the ABA, has focused on nationwide triage for disasters and will be vital to save as many lives as possible. Yet, it is likely that expectant or comfort care could be offered to more patients than typically seen in civilian hospitals, due to resource availability after the disaster.Finally, agents used in warfare—including white phos-phorus and sulfur mustard—can cause significant morbidity and mortality. White


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Surgery_Schwartz. civilian hospitals, due to resource availability after the disaster.Finally, agents used in warfare—including white phos-phorus and sulfur mustard—can cause significant morbidity and mortality. White phosphorus oxidizes when exposed to the atmosphere, creating the highly corrosive phosphorus pentox-ide. Absorption of even small amounts of white phosphorus can result in hypocalcemia and hyperphosphatemia and their subse-quent cardiac side effects. Treatment consists of removal of all clothing, irrigation with cool liquid (as phosphorus pentoxide liquidizes above 44°C), application of saline soaked gauze to prevent drying out and reignition, and potential surgical excision.222,223 Sulfur mustard, more commonly known as mus-tard gas, is another chemical warfare agent that can cause lesions similar to burn lesions. The gas infiltrates the skin surface, caus-ing degranulation of mast cells, leukocyte invasion, and sub-sequent blistering of the skin. Treatment includes scrubbing to


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Surgery_Schwartz. similar to burn lesions. The gas infiltrates the skin surface, caus-ing degranulation of mast cells, leukocyte invasion, and sub-sequent blistering of the skin. Treatment includes scrubbing to relieve the remaining skin of sulfur mustard, irrigation, and traditional burn therapy depending on the depth of the lesion.FUTURE AREAS OF STUDYIt has long been anecdotally noted that two patients of simi-lar ages and burn size may have very divergent responses to their burn injuries. Attention is being increasingly turned to identifying genetic differences among burn patients and how they affect response to injury. Specific allele variants have been linked with increased mortality in burned patients.224 It may be that genetic differences may predispose burn patients to severe sepsis,225 perhaps by downregulating the immune response.226 The Inflammation and the Host Response to Injury trial was a prospective, multicenter, federally funded study that aimed to define specific genetic pathways