Critical Care of Burn Patients

Patients with electrical injuries or very deep tissue damage may have myoglobin in their urine, therefore they will require double the urine output to flush the kidneys of the large myoglobin cells. The amount of fluid resuscitation required is difficult to assess because you can't go by the size of the burn. If the urine is very dark, such as in the picture, increase the rate of the intravenous fluids to maintain a urine output of 100 cc/hr.Any burn greater than 10%, but this is dependent on the age and health of the patient. For instance if you are treating a healthy 20 year old with a 15 % burn, they can probably resuscitate themselves with oral fluids but nonetheless, they should be observed to make sure they take in enough fluids, is not vomiting and that they produce a satisfactory amount of urine. Anyone with an inhalation injury, associated trauma or electrical injury gets fluid resuscitation. When in doubt, over treat. Make sure they get through the first 24 hours.

Fluid replacement is the prime object of initial burn treatment. When someone gets burned, to put it very simply, their capillaries begin to leak. Instead of sticking together, keeping blood inside of the vessel, the endothelial cells separate and become very porous. Huge amounts of fluid pour out into the tissue. In small burns this fluid accumulates only in the burned areas but in very large burns fluid can accumulate everywhere in the body. These patients can develop a significant amount of edema at the expense of your vascular volume. The blood volume goes down as you become more edematous, or rather, they develop hypovolemic shock.

All of these criteria are important, but this doesn't help you very much if you are in the field. The complications of edema get worse as resuscitation proceeds. Any major burn of an extremity of the torso tends to swell very tightly. This is because the skin in third degree burns become very rigid and hard. Elasticity is drastically compromised. As you pour fluid into these patients during resuscitation, the extremity or torso will swell and the burns become tighter and tighter.This tightness can become so great that the circulation may become compromised. This happens over several hours.The patient may loose peripheral pulses, motor function and nerve function in the extremity.

People with first degree burns do not need to be hospitalized or resuscitated. The wounds will heal on their own without scarring in about 4 to 5 days. The main thing to remember about treating first degree burns is treat the symptoms. Make the patient feel better. The exception for the care of patients with first degree burns, are the very old or very young patients, for they can become seriously ill even from small first degree burns. The reason for this is due to their increased sensitivity to fluid loss and dehydration.A severe burn damages the blood vessels in the skin, causing them to leak. The leaking creates the swelling and blisters most people think of when they think of a bad burn. If too much of the skin is burned, the loss of fluids can cause serious damage to the body. Emergency care including blood transfusion and IV fluids may be required immediately to prevent the injured person’s blood pressure from dropping so low that brain damage or death results.

The procedure of choice is an escharotomy. What we have done in this man's arm is to cut through the burned tissue with a scalpel medially and laterally to ensure restoration of pulses. Notice how far apart the edges are. We did not remove any tissue. The skin simply spreads apart as a result of the tension and tightness caused by the swelling. Initially, even a badly burned extremity will feel soft. The complications of edema may also effect the ability of the chest to expand. Ventilation is mechanical. The chest needs to be able to expand during breathing. When this occurs an escharotomy may be performed to the chest in the shape of a square. It is important to connect all sides by incision.