Chapter 57: Managing Burn Injury

Burn severity is determined by factors including the patient’s age (older adults having heightened mortality risk), the extent of the total body surface area (TBSA) affected, burn depth (classified from superficial first-degree to full-thickness fourth-degree), and the presence of inhalation injury. The assessment of TBSA utilizes methods such as the Rule of Nines and the more precise Lund and Browder chart to guide critical interventions like fluid resuscitation. Pathophysiologically, burn wounds create three zones of tissue damage—coagulation, stasis, and hyperemia—while major burns (greater than 20% TBSA) trigger a systemic inflammatory response, leading rapidly to hypovolemic burn shock due to massive plasma leakage and increased capillary permeability. Cardiovascular stability is compromised by decreased cardiac output and hypovolemia, necessitating careful fluid and electrolyte monitoring to prevent issues like acute kidney injury caused by free hemoglobin or myoglobin in the urine, often seen with electrical burns. Inhalation injuries, particularly from carbon monoxide (CO) poisoning, pose a significant mortality threat and require prompt treatment with high-flow oxygen. Care in the emergent phase focuses on establishing airway patency, breathing, and circulation (ABCDE), utilizing individualized fluid resuscitation formulas based on patient weight and TBSA to maintain adequate tissue perfusion. The acute phase shifts focus to infection prevention and wound management, emphasizing early surgical excision of necrotic tissue (débridement) to reduce the systemic hypermetabolic state and facilitate wound closure. Temporary biologic dressings (homografts, xenografts) or definitive autografts (split-thickness or cultured epithelial autografts) are essential for wound coverage. Pain management is complex, requiring multimodal approaches for background, breakthrough, and procedural pain, complemented by strategies to modulate hypermetabolism through early, high-calorie, high-protein nutrition. The final rehabilitation phase is protracted, focusing on mobility, the prevention of complications like contractures and hypertrophic scarring through pressure garments, and crucial psychological support to aid the patient's long-term social and functional reintegration, addressing common issues such as posttraumatic stress disorder (PTSD) and altered body image.