Management of Acute Thermal Injury
Thermal injury is a common cause of trauma that results in significant costs to both the individual and to society. The mechanism of injury whether it is flash or flame burns, scald injury, or electrical burn provides important prognostic information, and
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Kavitha Ranganathan, Stewart C. Wang, and Benjamin Levi
Case Presentation A 35 year old male with a history of alcohol and drug abuse is brought to the Emergency Department after sustaining partial and full thickness burns to his bilateral anterior upper extremities, chest, face, and neck. On physical exam, the patient has singed nasal hairs as well as soot in the perioral region. His extremities appear well perfused. He is mildly sedated but appropriately oriented (Fig. 83.1). Question What is the most important first step in management? Answer In the setting of thermal injury, a complete primary survey must be performed in accordance with ACLS guidelines to assess the exact nature of injuries [1, 2]. On presentation, the airway must be secured, breathing must be assessed and large bore IV access must be placed to facilitate aggressive fluid resuscitation [3]. Though it is preferred to obtain IV access in non-burned tissues, sometimes this is necessary. Despite higher
K. Ranganathan (*) • B. Levi Department of Surgery, University of Michigan Health Systems, Ann Arbor, MI, USA e-mail: [email protected] S.C. Wang Burn Surgery, Department of Surgery, University of Michigan Health Systems, Ann Arbor, MI, USA
infectious risk, central access might still be required. Prior to presentation, it is of utmost importance to isolate the patient from the cause of the injury, using aggressive irrigation of the tissues if necessary in the setting of chemical injury. This patient presents with facial burns, and it is critical to assess airway patency immediately on arrival. Bronchoscopy is the definitive form of airway assessment. Although it is also important to take note of physical exam findings that can indicate potential injury to the airway such as singed nasal hairs or soot in the airway, these exam findings are not always accurate, and early protection of the airway is critical to the immediate survival of patients presenting with thermal injuries [4]. If there is even minor concern for inhalation injury, immediate intubation is required. Chest X-ray can be performed at this time to ensure appropriate placement of the endotracheal tube and to serve as a baseline given that pneumonia is the most common inpatient complication and cause of death for patients with burns. Importantly, succinyl choline must be avoided on induction of anesthesia in patients with long-standing thermal injury given the high risk for hyperkalemia due to upregulation of acetylcholine receptors post-injury. Once the airway has been secured and the patient is hemodynamically stable, the extent of burn injury must be quantified. Total body surface area (TBSA) is a critical factor in this process (Table 83.1). TBSA impacts survival.
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_83
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K. Ranganathan et al.
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Patients with greater than 10 % TBSA burns are commonly admitted to an intensive care unit for monitoring. Importantly, only deep partial and
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