Prehospital Care and Interhospital Transport

Field and transport priorities begin with control of the airway, securing venous access, placement of bladder and nasogastric catheters, maintenance of body temperature, fluid administration if transport time will be more than 1 hour, documentation of the events of the injury from personnel who will not be available to the receiving facility, efforts to notify family members and to define the legal custodian of children, and clear documentation of all interventions. Hypothermia is a particular problem in burn patients because of evaporative heat losses. Transport vehicles and emergency receiving areas should be heated before the patient’s arrival. Initial burn dressing should be dry, clean sheets, rather than wetted dressings. Immediate cooling of a wound involving less than 10% of the body surface may help limit burn depth without causing systemic hypothermia. However, by the time emergency response personnel have arrived at the scene of injury, this window of opportunity has usually passed.

Phase One – Initial Evaluation and Resuscitation

A relatively rigid organized approach to initial evaluation of burn patients is useful and is described by the Advanced Burn Life Support Course of the American Burn Association.¹⁶ The primary survey is an initial pass at the patient looking for major aberrations in airway, circulatory, or neurologic status that justify urgent intervention. Intubations are done, if indicated. Clinically obvious pneumothoraces are decompressed. Emergent vascular access is obtained. A very brief neurologic assessment is made. The patient’s body is exposed for complete examination.

The secondary survey includes a detailed head-to-toe physical examination following hemodynamic normalization of the patient. Limited laboratory studies and directed imaging are done. The fundamental goal is to consider carefully the injury mechanism and to exclude all potential occult injuries before doing a detailed assessment of the burn. Computed tomography (CT) of the head, chest, abdomen, and pelvis is justified if the mechanism of injury is consistent with head or abdominal trauma. High-energy injuries such as those caused by electrical burns, motor vehicle crashes, and blasts are notorious for generating significant injuries missed during the initial evaluation.

The tertiary survey is a planned repeat physical examination 1 to 2 days after admission. Focused imaging is often a part of this process. The goal is to exclude subtle injuries that might have been overlooked initially.

An essential component of initial burn care is to find and rectify compartment syndromes before irreversible tissue ischemia occurs. Inelastic near-circumferential burns or the normal fascial envelopes of muscle groups can result in high soft tissue pressure if underlying tissues become edematous by direct injury or secondary capillary leak and edema. Extremities should be assessed for temperature, pliability, voluntary motion, pain with passive motion, named vessel pulsations, and low-pressure flow by using capillary refill and Doppler signals in the digital vessels and digital pulp. Serial compartment pressures may be valuable in selected patients, but serial clinical examination suffices to determine the need for escharotomy or fasciotomy in most situations. These extremities should be promptly decompressed via escharotomy and/or fasciotomy before the development of irreversible tissue necrosis (Fig. 37.1). Infrequently, abdominal pressures become elevated with resultant increasing airway pressures, oliguria, and hypotension. This should be promptly rectified by abdominal decompression, which can be done in the intensive care unit. Although rare, retrobulbar hypertension should be suspected in the presence of deep facial burns and responds well to lateral canthotomy, which is discussed in the following section.

Fluid resuscitation of burn patients has evolved substantially in recent years, in part as a result of lessons learned in Southwest Asia by military providers. During the first 18 to 24 hours after a serious burn, patients with larger burns manifest a diffuse capillary leak that increases with injury size, delay in initiation of resuscitation, and the presence of inhalation injury. The clinical objective is to administer adequate, but not excessive, fluid while ensuring that soft tissues are not rendered ischemic beneath inelastic eschar or tight fascial envelopes. While weight-based and burn size–based formulas have been developed over the years, none is reliably accurate in individual patients. A consensus approach is described in Box 37.2. Close physiologic monitoring with titration of infusions to meet resuscitation endpoints such as urine output, base deficit, and vital signs is required to achieve accurate, individualized resuscitation.

Capillary integrity generally normalizes at 18 to 24 hours, and fluid needs then approach approximately 150% of maintenance in most patients. Overadministration of fluid should be avoided at this phase of resuscitation.

Phase Two – Initial Excision and Biologic Closure

Phase Two focuses on identification and excision of full-thickness burns. This maneuver minimizes the occurrence of wound and systemic sepsis and should be completed before wound infection develops, generally within 5 to 7 days of injury. This phase of care often requires critical care that is generally directed by the burn team. The concept of early wound excision is important to the care of patients with significant burns and crush or other soft tissue injury that generates a burden on necrotic tissue. Excisional surgery for deep burns historically was associated with significant blood loss, but by using thoughtful technique, blood loss can be minimized and well tolerated.

Extensive burns can incite a hypercoagulable state, and burn shock is associated with splanchnic ischemia. Consequently, seriously burned patients are prone to deep venous thrombosis and pulmonary embolism. Selected use of pharmacologic and mechanical prophylaxis measures is common among burn units, although specifics will vary.

Phase Three – Definitive Wound Closure

Phase Three involves definitive wound closure; replacing temporary membranes, such as human allograft, with permanent autografts; and closing small but complex wounds such as those on hands and face. The duration of this phase varies according to injury severity but is usually complete at the time of acute hospital discharge. During this phase of care, rehabilitation efforts intensify and the patient is generally weaned from the need for intensive care.

Phase Four – Rehabilitation and Reintegration

Phase Four describes the process of reconstruction, rehabilitation, and reintegration. This phase of care frequently bridges the transition to the outpatient environment and can be lengthy, involving multiple readmissions for staged functional and aesthetic reconstruction, depending on injury pattern and severity. Continuous engagement of the burn team is ideal from the inpatient to the outpatient phases of care. Burn physical and occupational therapy is an essential component of recovery for burn patients.¹⁷ This begins with daily ranging, splinting, and antideformity positioning and progresses through active motion, strengthening, and mastery of activities of daily living. The family environment is an important therapeutic consideration.¹⁸ Family engagement and support through the process of recovery is ideal.

Burns of the Scalp

The scalp is large, representing more than 10% of the body surface in a small child. The density of deep hair follicles often results in spontaneous resurfacing of mid-dermal and deep dermal burns. This anatomy supports initial conservative treatment of most scalp burns and the use of the scalp for split-thickness donor harvest. Shaving a burned scalp will facilitate cleansing and topical wound care.

Burns of the Face

Early management of facial burns can have a major influence on ultimate facial function, appearance, and reconstructive options. The face represents only 4% of the body surface, which is nearly insignificant physiologically, opening up the option to take an initial conservative approach to all but the deepest of facial burns (Fig. 37.2). It is rare for infected facial burn wounds to be the source of overwhelming systemic sepsis. The central face is rich in sweat and sebaceous glands and when these burns are managed without acute excision, resurfacing can produce pleasing results.¹⁹ This is especially true in the bearded area of adult males.

Many topical care plans are appropriate for the treatment of facial burns. The face is richly vascular, so partial-thickness burns will quite often heal as long as desiccation and infection are avoided. A large variety of topical medications and membranes are appropriate, and none is unequivocally superior to another.²⁰ Clearly superficial burns are often treated with hygiene using bland soap and water and open application of antibiotic ointments, refreshing them every 6 to 12 hours. Deeper burns are often treated with topical silver sulfadiazine–impregnated gauze, which is cleaned and changed daily. Increasingly, membrane dressings that release silver are applied to second-degree burns, as they require less frequent changes, although this is difficult to do well on the face in many cases. Periodic gentle removal of necrotic debris and prevention of desiccation are common requirements in all successful management plans. Burns around the eyes can be dressed with topical ophthalmic antibiotic ointments. In the presence of facial burns, devices to secure oral or nasal endotracheal and enteral tubes should not place pressure on the burned nasal septum or ears (Fig. 37.3).

In all but the deepest of facial burns, it is common and prudent practice to treat the wounds topically and delay any excision and grafting until the full-thickness components are unequivocally clear.²⁰ There has been some debate over the years about grafting the face in cosmetic units. This is appropriate if it does not require the sacrifice of significant areas of healed burn or unburned skin. Areas of the face that need to be grafted are ideally resurfaced with thick split-thickness grafts of optimal color match. Optimal facial donor sites are best identified early in the course of the patient’s condition so that they can be preserved for this purpose. Facial burn excisions are done in a careful, layered fashion. Subeschar clysis with dilute epinephrine should be used liberally to minimize bleeding.²¹ The head of the operating table should be kept elevated. A critical component of the operation is to craft a dressing that absolutely protects against graft shear (Fig. 37.4). After the grafts have vascularized, massage and pressure therapy should begin. Patients with deep facial burns can have very pleasing functional and aesthetic outcomes, but it is important that they stay engaged with the burn team over time to achieve these results. The impact of small tension-relieving operations and laser-based interventions may improve results while decreasing morbidity.²² In very rare circumstances, facial transplantation may be considered.^23,24 With careful, staged reconstruction, the large majority of patients with even very destructive facial burn injuries can achieve quite acceptable long-term functional and aesthetic results (Fig. 37.5).