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".)
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- 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