Severe burn wounds are among the most debilitating injuries because they can significantly affect the entire body.1 The body’s inflammatory response to a severe burn injury can lead to fluid loss, dangerously low blood pressure, and shock.2 The risk of infection is also elevated in patients with severe burn wounds.2 Therefore, prevention of these complications is a key component of care for these patients.3
Emergency care for patients with severe burns begins with the Advanced Trauma Life Support guidelines (ATLS) and an initial assessment to identify other life-threatening conditions.4 Before the patient is transferred to a burn care facility, respiratory and cardiovascular support, fluid resuscitation, pain management, and initial burn wound care should be provided as needed.4 To maintain adequate urine output in the patient, clinicians should begin fluid resuscitation.5 This regimen should be adjusted as needed in response to the patient’s vital signs, urine output, and concurrent illnesses or injuries.5 Pain management is essential for patients with burns.1 Although opioids are commonly used to manage pain, long-term use of these drugs can lead to opioid-induced hyperalgesia.1Alternatives to opioids include the following1:
A patient who has a severe burn injury will need a referral to a specialized burn care facility after stabilization.3 If there is a delay in transfer to a burn care facility, interim treatment should take place in an intensive care unit.4
After stabilization, a clinician may then perform a comprehensive evaluation, starting with a history and physical examination followed by an assessment of the patient’s burn wound(s), including burn depth and total body surface area (TBSA).5
Clinicians may use the following classification to characterize burn depth3:
Burn severity assessment also includes determining the extent of TBSA affected. The Rule of Nines is a common method that calculates TBSA involvement in the area of partial- and full-thickness burn injuries3:
With the Rule of Nines, if more than 15% of the body is affected, then the patient will require at least one intravenous (IV) line for fluid resuscitation.3 Another method used for TBSA burn calculation, especially in children, is the Lund and Browder Chart.5 In this method, each arm accounts for 10%, the anterior trunk and posterior trunk each account for 13%, and head and leg calculations depend on the patient's age. The Palmar Surface Method of TBSA calculation is often used for small burns. In this method, the palm of the hand accounts for 0.5%, and the entire hand surface, fingers included, accounts for 1%.5 A burn wound with a TBSA greater than 20% is considered severe.5
The clinician should ascertain the cause of the burn injury when taking the patient’s history and assessing the wound. Although more than 80% of burns are thermal (eg, from fire, steam, or hot objects),5other causes of burn wounds include the following3:
Sometime between 24 and 72 hours after the injury, debridement, wound excision, and wound coverage will likely take place in the operating room.4 Wire mesh, temporary grafts, or skin substitutes may be used for wound coverage.4 For full-thickness burns of the extremities, patients may be at risk for neurovascular compromise, such as compartment syndrome, and escharotomy or compartment release may be necessary, sometimes urgently.4 For other wounds, an escharotomy is indicated in patients with possible respiratory or vascular compromise.4
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Rehabilitation of patients with these complex injuries may take years, and optimal long-term care requires a multidisciplinary team.4Specific issues include the following:
As mentioned earlier, severe burns, or the body’s response to them, may exhibit an impact on every organ system.2,7 These effects include airway and pulmonary damage, cardiovascular dysfunction that can lead to hypovolemic shock or cardiac arrest, acute kidney injury, ileus and stress ulcer formation, and neuroendocrine disorders, including increased metabolic rate, immunosuppression, and musculoskeletal contractures.7 The often surgical nature of burn treatment can result in prolonged healing and rehabilitation needs that one must consider. Infection prevention is another challenge because the loss of the skin means loss of protection against infection.
Care of patients with severe burn wounds requires clinicians to think quickly and multitask. The stakes are very high for these critically ill patients. A holistic view, encompassing all aspects of the burn injury, its systemic effects, and the patient’s psychosocial milieu, is crucial to ensure the best possible outcome.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.