Overview of the management of the severely burned patient
- Gerd G Gauglitz, MMS, MD
Gerd G Gauglitz, MMS, MD
- Department of Dermatology and Allergology
- Ludwig Maximilians University, Munich, Germany
- Felicia N Williams, MD
Felicia N Williams, MD
- Assistant Professor
- Department of Surgery
- North Carolina Jaycee Burn Center
Despite major advances in therapeutic strategies for the management of patients with severe burns, including improved resuscitation, enhanced wound coverage, infection control, and management of inhalation injuries, the consequences of a severe burn are profound and result in complex metabolic changes that can adversely affect every organ system [1-3]. Management of a patient with a severe burn injury is a long-term process that addresses the local burn wound as well as the systemic, psychologic, and social consequences of the injury.
This section provides an overview of the initial care and subsequent management of patients with severe (major) burn injuries. The initial care and management of minor thermal burns are discussed separately. (See "Treatment of minor thermal burns".)
SEVERE BURN INJURY
A severe (major) burn is any burn injury that is complicated by major trauma or inhalation injury, chemical burn (table 1), high-voltage electrical burn, and in general for adults, any burn encompassing over 20 percent of the total body surface area (TBSA), excluding superficial burns (first-degree burns) such as sun burn. Those at the greatest risk for death are those at the extremes of age and burn injury in association with serious comorbidities. For elderly individuals and young children, a burn encompassing less that 20 percent of the TBSA may be considered severe. Severe burns usually require initial care in a specialized intensive care unit of a burn center. (See "Inhalation injury from heat, smoke, or chemical irritants" and "Overview and management strategies for the combined burn trauma patient".)
Although burns involving eyes, ears, face, hands, feet, or perineum that are likely to result in cosmetic or functional impairment should be cared for in a burn center (table 2), not all will require management in an intensive care unit. (See 'Criteria for intensive care' below.)
EMERGENCY CARE AND TRIAGE
Emergency care of the burn patient and triage criteria for referral to a burn center are discussed in detail elsewhere. (See "Emergency care of moderate and severe thermal burns in adults" and "Emergency care of moderate and severe thermal burns in children" and "Overview and management strategies for the combined burn trauma patient".)
- Jeschke MG, Williams FN, Gauglitz GG, Herndon DN. Burns. In: Sabiston Textbook of Surgery, Townsend M, Beauchamp RD, Evers MB, Kenneth ML (Eds), Elsevier, Philadelphia 2012. Vol 19, p.521.
- Herndon DN, Tompkins RG. Support of the metabolic response to burn injury. Lancet 2004; 363:1895.
- McCowen KC, Malhotra A, Bistrian BR. Stress-induced hyperglycemia. Crit Care Clin 2001; 17:107.
- Mlcak R, M Buffalo, C Jimenez. Pre-hospital management, transportation and emergency care. In: Total Burn Care, 4th ed, Herndon DN (Ed), 2012.
- American Burn Association: Burn center referal criteria. http://ameriburn.org/BurnCenterReferralCriteria.pdf (Accessed on July 02, 2012).
- Roberts G, Lloyd M, Parker M, et al. The Baux score is dead. Long live the Baux score: a 27-year retrospective cohort study of mortality at a regional burns service. J Trauma Acute Care Surg 2012; 72:251.
- Faucher LD, Conlon KM. Practice guidelines for deep venous thrombosis prophylaxis in burns. J Burn Care Res 2007; 28:661.
- DVT PE prophylaxis. University of Toronto Trauma Program Protocols. Sunnybrook Health Sciences Center. Department of Surgery. m.trauma.utoronto.ca (Accessed on December 06, 2012).
- Satahoo SS, Parikh PP, Naranjo D, et al. Are burn patients really at risk for thrombotic events? J Burn Care Res 2015; 36:100.
- Barajas-Nava LA, López-Alcalde J, Roqué i Figuls M, et al. Antibiotic prophylaxis for preventing burn wound infection. Cochrane Database Syst Rev 2013; :CD008738.
- Tagami T, Matsui H, Fushimi K, Yasunaga H. Prophylactic Antibiotics May Improve Outcome in Patients With Severe Burns Requiring Mechanical Ventilation: Propensity Score Analysis of a Japanese Nationwide Database. Clin Infect Dis 2016; 62:60.
- Liodaki E, Kalousis K, Schopp BE, et al. Prophylactic antibiotic therapy after inhalation injury. Burns 2014; 40:1476.
- Saffle JR, Graves C, Cochran A. Nutritional support of the burned patient. In: Total Burn Care, 4th, Herndon DN (Ed), Saunders Elsevier, Philadelphia 2012. p.333.
- Herndon DN, Stein MD, Rutan TC, et al. Failure of TPN supplementation to improve liver function, immunity, and mortality in thermally injured patients. J Trauma 1987; 27:195.
- Glas GJ, Levi M, Schultz MJ. Coagulopathy and its management in patients with severe burns. J Thromb Haemost 2016; 14:865.
- Jeschke MG, Barrow RE, Herndon DN. Extended hypermetabolic response of the liver in severely burned pediatric patients. Arch Surg 2004; 139:641.
- Jeschke MG, Chinkes DL, Finnerty CC, et al. Pathophysiologic response to severe burn injury. Ann Surg 2008; 248:387.
- Barret J. Cost-containment and outcome measures. In: Total Burn Care, 4th, Herndon DN (Ed), Saunders Elsevier, Philadepphia 2012. p.706.
- Warden GD, Warner P. Functional sequelae and disability assessment. In: Total Burn Care, 4th, Herndon DN (Ed), Saunders Elsevier, Philadelphia 2012. p.699.
- 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.
- Öster C, Willebrand M, Ekselius L. Burn-specific health 2 years to 7 years after burn injury. J Trauma Acute Care Surg 2013; 74:1119.
- Wise R, Jacobs J, Pilate S, et al. Incidence and prognosis of intra-abdominal hypertension and abdominal compartment syndrome in severely burned patients: Pilot study and review of the literature. Anaesthesiol Intensive Ther 2016; 48:95.
- Stanojcic M, Chen P, Xiu F, Jeschke MG. Impaired Immune Response in Elderly Burn Patients: New Insights Into the Immune-senescence Phenotype. Ann Surg 2016; 264:195.
- Kraft R, Herndon DN, Al-Mousawi AM, et al. Burn size and survival probability in paediatric patients in modern burn care: a prospective observational cohort study. Lancet 2012; 379:1013.
- Saffle JR. Predicting outcomes of burns. N Engl J Med 1998; 338:387.
- Ryan CM, Schoenfeld DA, Thorpe WP, et al. Objective estimates of the probability of death from burn injuries. N Engl J Med 1998; 338:362.
- Saffle JR, Davis B, Williams P. Recent outcomes in the treatment of burn injury in the United States: a report from the American Burn Association Patient Registry. J Burn Care Rehabil 1995; 16:219.
- Chung KK, Wolf SE. Critical care in the severely burned: Organ support and management of complications. In: Total Burn Care, 4th ed, Herndon DN (Ed), Saunders Elsevier, 2012. p.377.
- Bull JP, Squire JR. A Study of Mortality in a Burns Unit: Standards for the Evaluation of Alternative Methods of Treatment. Ann Surg 1949; 130:160.
- Miller SF, Bessey PQ, Schurr MJ, et al. National Burn Repository 2005: a ten-year review. J Burn Care Res 2006; 27:411.
- Lee JO, Dibildox M, Jomenez C, et al. Operative wound management. In: Total Burn Care, 4th, Herndon DN (Ed), Saunders Elsevier, Philadelphia 2012. p.1013.
- Mustonen KM, Vuola J. Acute renal failure in intensive care burn patients (ARF in burn patients). J Burn Care Res 2008; 29:227.
- Gore DC, Hawkins HK, Chinkes DL, et al. Assessment of adverse events in the demise of pediatric burn patients. J Trauma 2007; 63:814.
- Williams FN, Herndon DN, Hawkins HK, et al. The leading causes of death after burn injury in a single pediatric burn center. Crit Care 2009; 13:R183.
- Wolf SE, Rose JK, Desai MH, et al. Mortality determinants in massive pediatric burns. An analysis of 103 children with > or = 80% TBSA burns (> or = 70% full-thickness). Ann Surg 1997; 225:554.
- SEVERE BURN INJURY
- EMERGENCY CARE AND TRIAGE
- Criteria for intensive care
- Palliative care
- INTENSIVE CARE MANAGEMENT
- Initial stabilization
- Subsequent management
- - Pain control
- - Thromboprophylaxis
- - Antimicrobial therapy
- - Nutritional support
- - Coagulopathy
- - Attenuating hypermetabolism
- BURN WOUND MANAGEMENT
- Local treatment of burn wounds
- Early burn excision and coverage
- TRANSITION OF CARE
- LONG-TERM CARE
- MORBIDITY AND MORTALITY
- SUMMARY AND RECOMMENDATIONS