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Chapter 8: Burns

Jonathan Friedstat; Fred W. Endorf; Nicole S. Gibran

KEY POINTS

  1. Follow American Burn Association criteria for transfer of a patient to a regional burn center.

  2. Never administer prophylactic antibiotics other than tetanus vaccination.

  3. Early excision and grafting of full-thickness and deep partial-thickness burns improve outcomes.

  4. Intravenous fluid resuscitation for patients with burns greater than 20% of total body surface area (children with burns >15% of total body surface area) should be titrated to mean arterial pressure (MAP) greater than 60 mmHg and urine output greater than 30 mL/h.

INTRODUCTION

Surgical care of the burned patient has evolved into a specialized field incorporating the interdisciplinary skills of burn surgeons, nurses, therapists, and other healthcare specialists. However, recent mass casualty events have been a reminder that healthcare systems may be rapidly pressed to care for large numbers of burn patients. Naturally, general surgeons may be at the forefront in these events, so it is crucial that they are comfortable with the care of burned patients and well equipped to provide standard of care.

BACKGROUND

Burn injury historically carried a poor prognosis. With advances in fluid resuscitation1 and the advent of early excision of the burn wound,2 survival has become an expectation even for patients with severe burns. Continued improvements in critical care and progress in skin bioengineering herald a future in which functional and psychological outcomes are equally important as survival alone. With this shift in priority, the American Burn Association (ABA) has emphasized referral to specialized burn centers after early stabilization. Specific criteria should guide transfer of patients with more complex injuries or other medical needs to a burn center (Table 8-1). The ABA has published standards of care3 and created a verification process to ensure that burn centers meet those standards.4 Because of increased prehospital safety measures, burn patients are being transferred longer distances to receive definitive care at regional burn centers5; recent data from one burn center with a particularly wide catchment area confirmed that even transport times averaging 7 hours did not affect the long-term outcomes of burn patients.6

Table 8-1Guidelines for referral to a burn center
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Table 8-1 Guidelines for referral to a burn center

Partial-thickness burns greater than 10% TBSA

Burns involving the face, hands, feet, genitalia, perineum, or major joints

Third-degree burns in any age group

Electrical burns, including lightning injury

Chemical burns

Inhalation injury

Burn injury in patients with complicated pre-existing medical disorders

Patients with burns and concomitant trauma in which the burn is the greatest risk. If the trauma is the greater immediate risk, the patient may be stabilized in a trauma center before transfer to a burn center.

Burned children in hospitals without qualified personnel for the care of children

Burn injury in patients who will require special social, emotional, or rehabilitative intervention

TBSA ...

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