Overview and management strategies for the combined burn trauma patient
- Steven E Wolf, MD
Steven E Wolf, MD
- Professor and Vice-Chairman for Research, Department of Surgery
- University of Texas – Southwestern Medical Center
Burns complicate the management and outcomes of trauma patients . As with injuries sustained but not associated with burns, the initial management of a combined burn/trauma patient is stabilization and resuscitation of the patient. Management of the burn wounds is a secondary priority.
The prevalence, management strategies, and outcomes for the combined burn/trauma patient will be discussed here. The resuscitation and stabilization of multitrauma patients and the emergency management of burn patients are reviewed separately. (See "Initial management of trauma in adults" and "Trauma management: Approach to the unstable child" and "Emergency care of moderate and severe thermal burns in adults" and "Emergency care of moderate and severe thermal burns in children".)
The prevalence of combined burn/trauma ranges from 0.4 to 5.8 percent . Approximately 1 to 5 percent of patients who sustain burn injuries incur penetrating and/or blunt trauma [1-4]. Approximately 25 to 30 percent of those injured in a mass disaster or terrorist attack will sustain a moderate to severe burn injury . (See "Management principles for burns resulting from mass disasters and war casualties".)
ETIOLOGY AND TYPES OF INJURIES
Combined burn/trauma results from motor vehicle accidents with explosions, fires with structural collapse, falls while escaping a fire, electrical injuries and falls, scald burns during assaults, plane crashes, and explosions with airborne fragments and flames in civilian and combat settings [2-4,6,7].
The most common injuries associated with burns and the frequency in which they occur include [1,3,4]:
- Shamir MY, Rivkind A, Weissman C, et al. Conventional terrorist bomb incidents and the intensive care unit. Curr Opin Crit Care 2005; 11:580.
- Santaniello JM, Luchette FA, Esposito TJ, et al. Ten year experience of burn, trauma, and combined burn/trauma injuries comparing outcomes. J Trauma 2004; 57:696.
- Brandt CP, Yowler CJ, Fratianne RB. Burns with multiple trauma. Am Surg 2002; 68:240.
- Rosenkranz KM, Sheridan R. Management of the burned trauma patient: balancing conflicting priorities. Burns 2002; 28:665.
- ABA Board of Trustees, Committee on Organization and Delivery of Burn Care. Disaster management and the ABA Plan. J Burn Care Rehabil 2005; 26:102.
- Hawkins A, Maclennan PA, McGwin G Jr, et al. The impact of combined trauma and burns on patient mortality. J Trauma 2005; 58:284.
- Kauvar DS, Wolf SE, Wade CE, et al. Burns sustained in combat explosions in Operations Iraqi and Enduring Freedom (OIF/OEF explosion burns). Burns 2006; 32:853.
- Glas GJ, Levi M, Schultz MJ. Coagulopathy and its management in patients with severe burns. J Thromb Haemost 2016; 14:865.
- American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 9th ed, American College of Surgeons, Chicago 2012.
- Nahm NJ, Vallier HA. Timing of definitive treatment of femoral shaft fractures in patients with multiple injuries: a systematic review of randomized and nonrandomized trials. J Trauma Acute Care Surg 2012; 73:1046.
- Pape HC, Tornetta P 3rd, Tarkin I, et al. Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery. J Am Acad Orthop Surg 2009; 17:541.
- Caba-Doussoux P, Leon-Baltasar JL, Garcia-Fuentes C, Resines-Erasun C. Damage control orthopaedics in severe polytrauma with femur fracture. Injury 2012; 43 Suppl 2:S42.
- Hart DW, Wolf SE, Beauford RB, et al. Determinants of blood loss during primary burn excision. Surgery 2001; 130:396.
- Hart DW, Wolf SE, Mlcak R, et al. Persistence of muscle catabolism after severe burn. Surgery 2000; 128:312.
- Murray CK, Hoffmaster RM, Schmit DR, et al. Evaluation of white blood cell count, neutrophil percentage, and elevated temperature as predictors of bloodstream infection in burn patients. Arch Surg 2007; 142:639.
- Wolf SE, Jeschke MG, Rose JK, et al. Enteral feeding intolerance: an indicator of sepsis-associated mortality in burned children. Arch Surg 1997; 132:1310.
- Greenhalgh DG, Saffle JR, Holmes JH 4th, et al. American Burn Association consensus conference to define sepsis and infection in burns. J Burn Care Res 2007; 28:776.
- Jeschke MG, Mlcak RP, Finnerty CC, et al. Burn size determines the inflammatory and hypermetabolic response. Crit Care 2007; 11:R90.
- Williams FN, Jeschke MG, Chinkes DL, et al. Modulation of the hypermetabolic response to trauma: temperature, nutrition, and drugs. J Am Coll Surg 2009; 208:489.
- Millham FH, LaMorte WW. Factors associated with mortality in trauma: re-evaluation of the TRISS method using the National Trauma Data Bank. J Trauma 2004; 56:1090.
- Wolf SE, Kauvar DS, Wade CE, et al. Comparison between civilian burns and combat burns from Operation Iraqi Freedom and Operation Enduring Freedom. Ann Surg 2006; 243:786.
- Moreau AR, Westfall PH, Cancio LC, Mason AD Jr. Development and validation of an age-risk score for mortality predication after thermal injury. J Trauma 2005; 58:967.
- Chawda MN, Hildebrand F, Pape HC, Giannoudis PV. Predicting outcome after multiple trauma: which scoring system? Injury 2004; 35:347.
- Rutledge R, Osler T, Emery S, Kromhout-Schiro S. The end of the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS): ICISS, an International Classification of Diseases, ninth revision-based prediction tool, outperforms both ISS and TRISS as predictors of trauma patient survival, hospital charges, and hospital length of stay. J Trauma 1998; 44:41.
- Champion HR, Copes WS, Sacco WJ, et al. Improved predictions from a severity characterization of trauma (ASCOT) over Trauma and Injury Severity Score (TRISS): results of an independent evaluation. J Trauma 1996; 40:42.
- Champion HR, Sacco WJ, Copes WS, et al. A revision of the Trauma Score. J Trauma 1989; 29:623.
- Markell KW, Renz EM, White CE, et al. Abdominal complications after severe burns. J Am Coll Surg 2009; 208:940.
- ETIOLOGY AND TYPES OF INJURIES
- STABILIZATION AND EARLY MANAGEMENT STRATEGIES
- IMMEDIATE BURN WOUND MANAGEMENT
- Eschar management
- Transfer guidelines
- MANAGEMENT STRATEGIES FOR COMPLICATED SETTINGS
- Closed head injury
- Open and closed fractures
- Venous thromboembolism prophylaxis
- Hypermetabolism and nutrition
- SUMMARY AND RECOMMENDATIONS