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Obtain a directed history from the patient and EMS personnel to determine the burning agent(s), involvement of chemicals, the duration of exposure, and if the injury was sustained in an open or enclosed space. Assess for loss of consciousness, risk of blast injury from explosion, contact with electricity, or other trauma. Assess the adequacy of, or need for, cervical immobilization. Obtain the general history, including past medical and surgical illnesses, chronic disease, allergies, medications, and tetanus immunization status.
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Quickly assess the patient's respiration and circulation and initiate stabilization (Table 216-5). Examine the patient for signs of inhalation injury, as evidenced by respiratory distress, facial burns, carbonaceous sputum, singed nasal hair, and soot in the mouth. If there is any evidence of airway compromise with swelling of the neck, burns inside the mouth, or wheezing, perform early endotracheal intubation.
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Assess the adequacy of circulation by noting the blood pressure, pulse rate, capillary refill time, mental status, and urinary output. Insert IV lines in unburned areas, but when this is not possible, a burned area can be used and resuscitation started according to a burn fluid resuscitation formula.
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During the secondary examination, perform a head-to-toe assessment, including examination of the eye for corneal burns. Estimate and record the size and depth of the burn injury. In patients with partial-thickness burns of >20% of body surface area, nasogastric tube insertion is routinely required due to frequent development of ileus. Insert a urinary catheter to measure urinary output and to prevent urinary retention in patients with perineal burns.
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Routine laboratory tests, including a CBC and measurement of electrolyte, BUN, creatinine, and glucose levels, should be performed. In patients with moderate/severe burns or suspected inhalation injury, obtain an arterial blood gas analysis, carboxyhemoglobin level, serum creatine kinase, urinalysis for myoglobin, chest radiograph, and ECG. Fiberoptic bronchoscopy is indicated in suspected inhalation injury and in intubated patients for both diagnostic and therapeutic purposes. Additional radiographs should be taken as indicated for other suspected trauma.
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Treat suspected inhalation injury with humidified 100% oxygen, intubation and ventilation, bronchodilators, and aggressive pulmonary toilet; hyperbaric oxygen may be necessary for severe carbon monoxide poisoning.
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Burn injury in the pregnant woman is associated with significant morbidity to mother and child. The outcome of the pregnancy is determined by the extent of injury to the mother. Spontaneous termination of pregnancy is common in large–body surface area burns. Resuscitation requirements may exceed those estimated using common guidelines. Fetal monitoring and early consultation with the obstetrician and burn specialist are recommended.
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The burn shock resuscitation formulas in use today are derived from laboratory studies of burn shock and resuscitation, and the utility of such formulas has been called into question.20 Although the importance of early fluid resuscitation is supported by clinical experience,20,21 no consensus exists on the appropriate assessment of resuscitation and its effect on outcome.20 Additionally, over-resuscitation is not without consequence. In general, resuscitation should be guided by monitoring cardiorespiratory status and urine output rather than strict adherence to a formula. The following formulas are a guide for fluid resuscitation of the burn-injured patient. Monitor and adjust according to individual patient response.
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The Baxter or Parkland formula is likely the most widely used thermal injury resuscitation regimen in North America.8,9 This formula calls for 4 mL of lactated Ringer's solution multiplied by the percentage of body surface area burned (partial- and full-thickness burns only) multiplied by patient body weight in kilograms. Half of the total is administered in the first 8 hours after injury and the remainder during the following 16 hours (Table 216-6). Volumes may be large, and hemodynamic monitoring techniques should be used to protect against inadvertent volume overload.
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Patients with thermal injury and concomitant multisystem trauma and those with inhalation injuries generally require fluid resuscitation in excess of calculated needs. Burn patients with preexisting cardiac or pulmonary disease require much greater attention to fluid management. Monitor fluid resuscitation closely by frequent assessment of vital signs, cerebral and skin perfusion, pulmonary status, and urinary output, as well as hemodynamic monitoring. Urine output should be 0.5 to 1.0 mL/kg/h.
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Because the ED is primarily responsible for initial fluid resuscitation, discussion with burn specialists may be helpful in avoiding early under- or over-resuscitation. Patients with major burns can quickly receive excessive IV fluid during the prehospital and ED phases, particularly if two large-bore peripheral catheters are in place with fluid infusing at a wide-open rate. Document total fluid infused and titrate infusion to the patient's response. Clear documentation of fluid resuscitation should accompany all patients transferred to burn centers.
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There are several methods of calculating fluid resuscitation for infants and children. The Parkland formula can be modified to maintain a urinary output of 1 mL/kg/h. Alternatively, a pediatric maintenance rate for 24 hours can be calculated, and an additional 2 to 4 mL/kg multiplied by percentage of body surface area burned is then added to the total. The entire amount is infused over the first 24 hours. In children weighing <25 kg, a goal urine output of 1.0 mL/kg/h is necessary. Add 5% dextrose to maintenance fluids for children weighing <20 kg due to smaller glycogen stores.8
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Two additions or modifications to isotonic crystalloid resuscitation have been studied: adjuvant colloid and hypertonic saline. However, neither improves patient outcome. Adjuvant colloid given along with isotonic crystalloid resuscitation is not beneficial and is associated with decreased glomerular filtration rate.22 Discussion of the use of adjuvant colloid continues, but it is used very little in North America and the United Kingdom,23 although Israeli investigators have reported favorable results with the addition of colloid to their burn formulas.24 Use of hypertonic saline has been associated with an increased rate of renal failure and death.25 In an effort to decrease burn edema, protein loss, and abdominal compartment syndrome, investigators have also studied the efficacy of permissive hypovolemia in reducing burn edema and the multiple organ dysfunction that follows.26 This practice necessitates invasive monitoring and is of interest, but it is not standard of care and should not be used in ED resuscitation at this time.
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Electrical injuries, incineration burns, and associated crush injuries may produce rhabdomyolysis and myoglobinuria, leading to renal failure. Acute renal failure occurs in approximately 15% of patients admitted to burn centers and is associated with severe burns (mean body surface area involvement of 48%).27 Therapy to limit renal damage from myoglobinuria should be initiated as outlined in chapter 89, "Rhabdomyolysis."
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After evaluation and resuscitation of the patient, attend to burn wounds.2 Initially, wounds are best covered with a clean, dry sheet. Later, small burns can be covered with a moist saline-soaked dressing while the patient is awaiting admission or transfer. The soothing effect of cooling on burns is most likely due to local vasoconstriction. Cooling stabilizes mast cells and reduces histamine release, kinin formation, and thromboxane B2 production. For large burns, sterile drapes are preferred, because application of saline-soaked dressings to a large area can cause hypothermia.
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Consult the admitting service or burn center early. Avoid the use of antiseptic dressings in the ED, because the admitting service will need to assess the wound. Wound care for transferred patients should be discussed with the accepting burn center. Do not delay transfer for wound debridement. For transferred patients, the referring facility should follow the accepting regional burn center's treatment protocol if available.
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Patients with circumferential deep burns of the limbs may develop compromise of the distal circulation, particularly after initiation of resuscitation. The distal vascular status of such patients must be monitored closely, including pulses, capillary refill, pulse oximetry, and skin temperature. Doppler flow testing may likewise be useful. If vascular compromise is evident, escharotomy is indicated. The eschar is incised with a scalpel to the level of the fat on the mid-lateral portion of the limb, using care to avoid incising the fascia (i.e., fasciotomy). Elevated compartment pressures can be clinically evident. The incision may be extended to the hand and fingers (Figure 216-8). Escharotomy may provoke substantial soft tissue bleeding. Consider consultation by phone with a burn surgeon.
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If there are circumferential burns of the chest and neck, eschar may restrict ventilation. An escharotomy of the chest wall should be performed to allow adequate ventilation. Incisions are made at the anterior axillary line from the level of the second rib to the level of the twelfth rib. These two incisions should be joined transversely so the chest wall can expand (Figure 216-9).
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Burn injuries are exceedingly painful, and superficial partial-thickness burns are the most painful. Burn injury not only makes an otherwise already injured area and surrounding tissue more painful, but also causes hyperalgesia, chiefly mediated by A fibers. Local cooling may be soothing but does not provide pain control and can cause hypothermia;28 additional pain management should be provided.
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During the acute phase, the preferred route for most medication is IV. Opioids (e.g., morphine, fentanyl, hydromorphone) are the mainstay of treatment, and relatively large dosages may be required. Anxiolytic agents may also be given. Ensure adequate analgesia for patients being discharged, including a regimen for both background and breakthrough pain associated with dressing changes. Achieving adequate pain control is required for patients being considered for discharge.