Management of the Burned Patient

Pathophysiology & Assessment - Flames & First Response

• Etiology: Flames, scalds, chemical, electrical.
• First Response (ABCDE):
  • Stop burning; remove constrictions.
  • Airway (check for inhalation injury: soot, facial burns).
  • Breathing; Circulation (IV access).
• Assessment:
  • Depth: Superficial, Partial, Full-thickness.
  • TBSA: Rule of Nines (Adults), Lund-Browder (Peds).
    • 📌 Rule of Nines: Head/Arm 9% each, Leg/Trunk (front/back) 18% each, Perineum 1%.
• Pathophysiology: Mediator release → ↑capillary permeability → edema, hypovolemia → shock.
• Fluids: Parkland: $4mL \times \text{wt (kg)} \times %TBSA$.

⭐ Administer half of total 24-hr resuscitation fluid in first 8 hrs post-burn.

Airway & Respiratory - Breathing Through Fire

• Inhalation Injury Assessment:
  • Signs: Facial burns, singed nasal hairs, soot, hoarseness, stridor.
  • History: Enclosed space fire.
• Early Intubation Criteria:
  • Stridor, respiratory distress, hypoxia ($PaO_2$ <60 mmHg), hypercapnia ($PaCO_2$ >50 mmHg).
  • GCS <8, extensive facial/neck burns, circumferential neck burns.
  • Use larger ETT (edema).
• Management:
  • 100% humidified O₂.
  • Bronchodilators.
  • Lung protective ventilation (ARDS).
  • Monitor COHb (>10% = CO poisoning).
  • Consider cyanide poisoning.
  • Chest escharotomy for circumferential chest burns.

⭐ Early prophylactic intubation is critical in suspected airway burns as edema can rapidly progress, making later intubation difficult or impossible.

Fluid Resuscitation - Quenching the Inferno

• Goal: Combat shock, maintain perfusion.
• Fluid of Choice: Ringer's Lactate (RL).
• Parkland Formula: $4 \text{ mL} \times \text{Wt (kg)} \times % \text{TBSA (2nd/3rd°)}$.
  • Administer:
    • ½ in first 8 hrs (from burn).
    • ½ in next 16 hrs.
• Monitoring & Endpoints:
  • Urine Output (UOP):
    • Adults: 0.5-1 mL/kg/hr.
    • Children (<30kg): 1-2 mL/kg/hr.
    • Electrical burns: Target 75-100 mL/hr (or 1-1.5 mL/kg/hr for myoglobinuria).
  • Mean Arterial Pressure (MAP) > 65 mmHg.
  • Lactate < 2 mmol/L.
  • Improved sensorium.

⭐ The "first 8 hours" for Parkland formula fluid administration starts from the time of burn injury, not from hospital arrival.

Intraoperative Anesthesia - Navigating Burn Surgery

• Agents: Ketamine (induction); Volatiles/TIVA (maintenance). Non-depolarizers: ↑ dose, monitor blockade.
• Monitoring: Standard + Arterial line, CVP. Core temp (esophageal/bladder). Urine output > 0.5-1 mL/kg/hr.
• Fluids & Blood: Aggressive resuscitation. Anticipate major blood loss; transfuse for Hb > 7-8 g/dL.
• Temperature: Maintain normothermia: Warm OR (>28°C), fluid warmers, forced air warmers.
• Analgesia: Multimodal approach (opioids, ketamine).

⭐ Succinylcholine is contraindicated 24 hours to 2 years post-burn due to severe hyperkalemia risk from extrajunctional receptor upregulation. )

Post‑Op & Complications - Aftermath & Alerts

• Pain Control: Multimodal analgesia (opioids, ketamine, regional).
• Infection: Major risk. Monitor for sepsis (fever, ↑HR, ↑RR, WBC changes). Wound care crucial.
  • Antibiotic stewardship.
• Fluid Balance: Titrate to UO (>0.5-1 mL/kg/hr adults, >1 mL/kg/hr children).
• Nutrition: High protein, high calorie. Early enteral feeding.
• Key Complications:
  • Hypothermia: Aggressive warming.
  • ARDS, VAP.
  • AKI (rhabdomyolysis).
  • Curling's ulcer (PPI prophylaxis).
  • Contractures: Early PT/OT. ⭐ > Sepsis is the leading cause of late mortality in burn patients.

High‑Yield Points - ⚡ Biggest Takeaways

• Prioritize airway management, especially with inhalational injury; early intubation is key.
• Aggressive fluid resuscitation (Parkland: 4mL x %TBSA x kg) is crucial; target urine output 0.5-1 mL/kg/hr.
• Avoid succinylcholine >24 hrs post-burn due to severe hyperkalemia risk.
• Expect resistance to NDMRs; higher doses may be needed.
• Actively prevent hypothermia due to significant heat loss.
• Utilize multimodal analgesia for comprehensive pain relief.
• Consider CO poisoning in smoke inhalation; give 100% oxygen immediately_._