Burns (The Atlas of Emergency Medicine_3rd Edition) Clinical Summary Burns can be caused by heat, electricity, chemicals, friction,

or radiation e !osure" #amage to the s$in barrier can lea%e the !atient susce!tible to infection, fluid loss, and electrolyte abnormalities" &ong'term conse(uences of burns include !ermanent scarring, loss of sensation to the affected area, and in se%ere cases loss of e tremities due to inade(uate circulation" Emergency #e!artment Treatment and #is!osition Burns are assessed by determining the !ercentage of body surface area (BSA) in%ol%ed, the de!th of the burn, and the area of the body in%ol%ed" A common system used to estimate BSA is follo)ing the *rule of nines"* This system brea$s u! the body into +ones that each e(uate to nine !ercent of BSA" Some clinicians use the !alm of their hand as an e(ui%alent to ,- BSA and measure the area in%ol%ed by using this method" .irst'degree burns only in%ol%e the e!idermal layer of s$in" These burns are red, !ainful, and heal in a!!ro imately , )ee$" Second'degree burns are subdi%ided into t)o categories, su!erficial !artial thic$ness and dee! !artial thic$ness" Su!erficial second'degree burns e tend from the e!idermis to the su!erficial dermis" /ain, s$in blistering, and intact ca!illary refill are characteristics of these burns" #ee! !artial thic$ness burns are !ainless, )hite in color, and do not blanch" At this de!th there is damage to hair follicles and s)eat glands" The entire thic$ness of the s$in is com!romised in third'degree burns" They a!!ear !ale, feel leathery, and are !ainless" .ourth'degree burns e tend through the layers of the s$in and in%ol%e muscle or bone" /ain control, ade(uate cleansing of the area, debridement of large blisters, and a!!lication of to!ical antimicrobials to minor burns are !art of emergency de!artment management" 0ne !ercent sil%er sulfadia+ine, bacitracin, or tri!le'antibiotic ointment are antimicrobial o!tions" #ressing changes should occur daily and !atients must be instructed to )atch for signs of infection" .ollo)'u! )ith a burn'care e !ert needs be arranged )ithin a fe) days of discharge for dee! !artial thic$ness or third'degree burns" /atients )ith ma1or burns must be assessed for air)ay !rotection and ade(uate circulation" Clinicians should also remember to co%er the burned areas )ith a clean, dry sheet2 administer aggressi%e !ain control to !atients2 and aggressi%ely address fluid resuscitation" The /ar$land formula is commonly used to estimate fluid re(uirements" The !atient3s )eight in $ilograms is multi!lied by the !ercent BSA in%ol%ed2 this number is multi!lied by 4 m& of lactated 5ingers solution" 6alf of this amount is gi%en during the first 7 hours and the remaining amount is gi%en o%er the ne t ,8 hours of resuscitation" 9t is recommended to $ee! urine out!ut a!!ro imately :"; to ,": m&<$g<h" 9n order to monitor for effects of cell brea$do)n, urinalysis, creatine $inase, and an E=> should be obtained" Circumferential burns of the e tremities may com!romise circulation" 9f distal !ulses are decreased, an escharotomy should be considered to !re%ent com!artment syndrome"

5eferral to a burn unit should be !lanned in cases that include !artial thic$ness burns that in%ol%e greater than ,:- BSA, third'degree burns, or in%ol%ement of the hands, feet, face, or !erineum" Electrical burns, chemical burns, inhalation in1uries, and !atients )ith significant comorbidities should also be considered for a burn unit" /earls ," E%aluation of burns includes noting the amount of BSA in%ol%ed and the de!th of the burn" ?" Minor burns can be managed in the emergency de!artment" /ain control, irrigation, debridement, antimicrobial ointments, and dressing changes are the mainstays of thera!y" 3" Adherent tar should be cooled2 mayonnaise, !olys!orin ointment, mineral oil, commercially a%ailable cream or oil'based sol%ents ha%e been suggested to aid in remo%al" 4" Cleaning of tar burns can be assisted by the use of to!ical mayonnaise or butter" Electrical 9n1ury Clinical Summary Electricity may cause harm by heat generated through tissue resistance or directly by the current on cells" S$in, ner%es, %essels, and muscles usually sustain the greatest damage" Many factors affect the se%erity of in1ury@ ty!e of current (#C or AC), current intensity, contact duration, tissue resistance, and current !ath)ay through the body" Those at high ris$ for electrical in1ury are toddlers, and !eo!le )ho )or$ )ith electricity" Ahen electricity tra%erses the tissues, it may cause a host of in1uries@ contact burns, thermal in1ury, arc burns, muscular tetany, or blunt trauma due to se%ere muscle contraction" Sudden death (asystole, res!iratory arrest, %entricular fibrillation), myocardial damage, cerebral edema, neuro!athies, disseminated intra%ascular coagulation, myoglobinuria, com!artment syndrome, and %arious metabolic disorders ha%e been described" 6igh'%oltage #C or AC current ty!ically causes a single %iolent muscular contraction that thro)s the %ictim from the source" As a result, blunt trauma and blast in1uries may occur" &o)'%oltage AC currents (as from a household outlet) ty!ically cause muscular tetany, forcing the %ictim to continue contact )ith the source" Emergency #e!artment Treatment and #is!osition After initial stabili+ation, consider cer%ical s!ine immobili+ation, o ygen administration, cardiac monitoring, and intra%enous crystalloid infusion" A .oley catheter )ill hel! monitor urine out!ut and is es!ecially im!ortant if rhabdomyolysis is sus!ected" #iagnostic testing to consider includes@ EC>, CBC, urinalysis, C/=, C/='MB, electrolytes, BBC, creatinine, and coagulation !rofile" 5adiogra!hic assessment is im!ortant for those )ith a sus!icion of trauma"

Se%ere or high'ris$ in1uries should be admitted to a burn unit, or trauma center )ith burn consultation" /atients )ith minor, brief, lo)'intensity e !osures, )ith a normal EC>, normal urinalysis, and no significant burns or trauma may be considered for discharge after 8 to 7 hours of obser%ation" /earls ," The lo) resistance of )ater ma$es its association )ith electricity !articularly dangerous" ?" 6igh'ris$ features include high'%oltage e !osure (D8:: E), dee! burns, neurologic in1ury, dysrhythmias, abnormal electrocardiogram, e%idence of rhabdomyolysis, suicidal intent, or significant associated trauma"

Burns: Introduction (Schwartz's Principles of Surgery8e)

Thermal burns and related in1uries are a ma1or cause of death and disability in the Bnited States" The introduction of burn centers in the ,F8:s and ,FG:s !ro%ided the basis for regional s!ecialty'treatment centers, )hich )ere the first to !ro%ide a truly multidisci!linary a!!roach to care" The interacti%e multidisci!linary team has !ro%en to be the least e !ensi%e and most efficient method of treating ma1or burn in1ury, of )hich the initial acute care is only a small !art of the total treatment" Burn !atients often re(uire years of su!er%ised rehabilitation, reconstruction, and !sychosocial su!!ort" 0mission of any ste! in the treatment regimen by any of the burn team members, including the burn surgeon, nurses, thera!ists, nutritionists, or !sychosocial su!!ort staff, can result in less than o!timal outcomes" E!idemiology 9n the Bnited States, a!!ro imately ,", million indi%iduals annually are burned seriously enough to see$ health care2 about 4;,::: of these re(uire hos!itali+ation, and about 4;:: die" More than F:- of burns are !re%entable2 nearly one half are smo$ing related or due to substance abuse" ,,? Ahile !re%ention of burns is still the long'term solution to burn care, ad%ances in the care of burned !atients during the !ast 3: years are among the most dramatic in medicine" The annual federal e !enditure for research on cancer, heart disease, and stro$e %astly e ceeds that for trauma and burns, des!ite the fact that trauma and burns account for a loss of !roducti%e !erson'years from in1ury that is greater than that of cancer, heart disease, and stro$e combined" The annual number of burn deaths in the Bnited States has decreased from a!!ro imately ,;,::: in ,FG: to around 4;:: currently" 0%er the same !eriod, the burn si+e associated )ith a ;:- mortality rate (i"e", the &#;:) has increased from 3:- of the total body surface area (TBSA) to greater than 7:- TBSA in other)ise healthy young adults" 3,4 The duration of hos!ital stay has been cut in half" Almost F;- of the !atients admitted to burn centers in the B"S" no) sur%i%e, and o%er one half of them return to !reburn le%els of !hysical and social functioning )ithin ,? to ?4 months follo)ing in1ury" ;,8 The (uality of burn care is no longer measured only by sur%i%al, but also by long'term function and a!!earance" Although small burns are not usually life threatening, they need the same attention as larger burns to achie%e o!timal outcomes" E%en in the largest burn centers, the a%erage burn si+e re(uiring admission is less than ,;- TBSA" The surgeon3s goal for any

burn is )ell'healed, durable s$in )ith normal function and near'normal a!!earance" Scarring, a %irtual certainty )ith dee! burns, can be minimi+ed by a!!ro!riate early surgical inter%ention and long'term scar management" These goals re(uire indi%iduali+ed !atient care !lans based on burn characteristics and host factors" As )ith other forms of trauma, burns fre(uently affect children and young adults" 9n children under 7 years of age, the most common burns are scalds, usually from the s!illing of hot li(uids" G 9n older children and adults, the most common burns are flame'related, usually the result of house fires, the ill'ad%ised use of flammable li(uids as accelerants, or are smo$ing' or alcohol'related" 7 Chemicals or hot li(uids, follo)ed by electricity, and then molten or hot metals most often cause )or$'related burns" F The hos!ital e !enses and the societal costs related to time a)ay from )or$ or school are staggering" ,: Most burns are limited in e tent, but a significant burn of the hand or foot may $ee! manual )or$ers a)ay from )or$ for a year or more, or e%en !ermanently" The e%entual outcome for the burned !atient is related to in1ury se%erity, indi%idual !hysical characteristics of the !atient, moti%ation of the !atient, (uality of the treatment, and after'care su!!ort" Etiology Cutaneous burns are caused by the a!!lication of heat, cold, or caustic chemicals to the s$in" Ahen heat is a!!lied to the s$in, the de!th of in1ury is !ro!ortional to the tem!erature a!!lied, duration of contact, and thic$ness of the s$in" Scald Burns Scalds, usually from hot )ater, are the most common cause of burns in ci%ilian !ractice" Aater at ,4:H. (8:HC) creates a dee! !artial'thic$ness or full'thic$ness burn in 3 seconds" At ,;8H. (8FHC), the same burn occurs in , second" ,, As a reference !oint, freshly bre)ed coffee generally is about ,7:H. (7?HC)" Boiling )ater al)ays causes dee! burns2 li$e)ise, thic$ sou!s and sauces, )hich remain in contact )ith the s$in longer, in%ariably cause dee! burns" E !osed areas of s$in tend to be burned less dee!ly than clothed areas, as the clothing retains the heat and $ee!s the hot li(uid in contact )ith the s$in for a longer !eriod of time" 9mmersion scalds are al)ays dee!, se%ere burns" ,? The li(uid causing an immersion scald may not be as hot as )ith a s!ill scald2 ho)e%er, the duration of contact )ith the s$in is longer during immersion, and these burns fre(uently occur in small children or elderly !atients )ho ha%e thinner s$in" #eliberate scalds are a common form of re!orted child abuse and are res!onsible for about ;- of the !ediatric admissions to burn centers" The !hysician should note any discre!ancy bet)een the history !ro%ided by the caregi%er and the distribution or !robable cause of a burn" ,3 Any sus!icious burn re(uires in'!atient admission and must be re!orted !rom!tly to the a!!ro!riate authorities" Scald burns from grease or hot oil are usually dee! !artial'thic$ness or full'thic$ness burns, as the oil or grease may be in the range of 4::H. (?::HC)" ,4 Tar and as!halt burns are a s!ecial $ind of scald" ,; The *mother !ot* at the bac$ of a roofing truc$ maintains tar at a tem!erature of 4:: to ;::H. (?:: to ?8:HC)" Burns caused by tar directly from the mother !ot are in%ariably full'thic$ness burns" 6o)e%er, by the time the tar has been s!read on a roof or street, its tem!erature has been lo)ered to the !oint )here most burns caused by it are

!artial'thic$ness in de!th" The tar should be remo%ed by a!!lication of a !etroleum'based ointment or a nonto ic sol%ent (e"g", Medisol or sunflo)er oil) under a dressing" The dressing may be remo%ed and the ointment or sol%ent rea!!lied fre(uently until the tar has dissol%ed" 0nly then can the e tent of the in1ury and the de!th of the burn be estimated accurately" ,8,,G .lame Burns .lame burns are the second most common mechanism of thermal in1ury" Although the incidence of in1uries caused by house fires has decreased )ith the use of smo$e detectors, smo$ing'related fires, im!ro!er use of flammable li(uids, motor %ehicle collisions, and ignition of clothing by sto%es or s!ace heaters also are res!onsible for flame burns" /atients )hose bedding or clothes ha%e been on fire rarely esca!e )ithout some full'thic$ness burns" .lash Burns .lash burns are ne t in fre(uency" E !losions of natural gas, !ro!ane, butane, !etroleum distillates, alcohols, and other combustible li(uids, as )ell as electrical arcs cause intense heat for a brief time !eriod" ,7,,F Clothing, unless it ignites, is !rotecti%e against flash burns" .lash burns generally ha%e a distribution o%er all e !osed s$in, )ith the dee!est areas facing the source of ignition" ?: .lash burns are ty!ically e!idermal or !artial thic$ness, their de!th de!ending on the amount and $ind of fuel that e !lodes" 6o)e%er, electrical arc burns and those from gasoline are often full'thic$ness and re(uire grafting" At least some areas of flash burns often heal )ithout re(uiring e tensi%e s$in grafting, but the burns generally co%er a large TBSA, and in an e !losi%e en%ironment may be associated )ith significant thermal damage to the u!!er air)ay" Contact Burns Contact burns result from contact )ith hot metals, !lastic, glass, or hot coals" They are usually limited in e tent, but are in%ariably dee!" Toddlers )ho touch or fall )ith outstretched hands against irons, o%ens, and )ood'burning sto%es are li$ely to suffer dee! burns of the !alms" ?,I?3 9t is common for !atients in%ol%ed in industrial accidents to ha%e associated crush in1uries because these accidents are commonly caused by contact )ith !resses or other hot, hea%y ob1ects" ?4 Motor %ehicle and motorcycle collisions may lea%e %ictims in contact )ith hot engine !arts" ?; The e haust !i!es of motorcycles cause a characteristic burn of the medial lo)er leg, that although small, usually re(uires e cision and grafting" Contact burns are often fourth'degree burns, es!ecially those in unconscious or !ostictal !atients, and those caused by molten materials" ?8I?7 Burn /re%ention More than F:- of all burns are !re%entable, and ongoing !re%ention and education efforts seem to be the most effecti%e means to im!act burn incidence" 0%er the !ast ?: years se%eral critical legislati%e actions, such as that mandating flame'resistant slee!)ear for children, ha%e decreased burns and burn mortality" ?F Smo$e detectors, re(uired in all residential rental units and ne) construction, ha%e li$ely contributed to decreased burn se%erity and mortality" 3: Many states ha%e initiated legislation mandating that the ma imum tem!erature for home and !ublic hot )ater heaters be set to belo) ,4:H. (8:HC), )ith !ositi%e results" 3,

9ndi%idual burn centers, the American Burn Association (ABA), and the 9nternational Society for Burn 9n1ury (9SB9) ha%e all !roduced multi!le !ublic ser%ice announcements regarding hot )ater, carburetor flashes, grilling'related burns, scalds, and other $inds of burn in1ury" Cumerous !rograms are directed at school'aged children2 for e am!le, the *Sto!, #ro!, and 5oll* se(uence" A national !rogram aimed at $ee!ing smo$e detector batteries fresh uses the slogan *Change your cloc$, change your smo$e detector battery*" 6os!ital Admission and Burn Center 5eferral The se%erity of sym!toms from smo$e inhalation and the magnitude of associated burns dictate the need for hos!ital admission and s!eciali+ed care" Any !atient )ho has a sym!tomatic inhalation in1ury or more than tri%ial burns should be admitted to a hos!ital" As a rule of thumb, if the burns co%er more than ; to ,:- TBSA, the !atient should be referred to a designated burn center" 9n the absence of burns, admission de!ends on the se%erity of res!iratory sym!toms, !resence of !remorbid medical !roblems, and the social circumstances of the !atient" 0ther)ise healthy !atients )ith mild res!iratory sym!toms Ji"e", only a fe) e !iratory )hee+es )ith minimal s!utum !roduction, normal carbo yhemoglobin (C06b), and normal blood gas %aluesK )ho ha%e a !lace to go and someone to stay )ith them can be obser%ed for , to ? hours and then discharged from the emergency de!artment" /atients )ith !remorbid cardio%ascular or !ulmonary disease )ho ha%e any sym!toms related to smo$e inhalation should be admitted for obser%ation" /atients )ith moderate sym!toms (i"e", generali+ed )hee+ing )ith mild hoarseness and moderate s!utum !roduction, but normal C06b and blood gas %alues) are admitted to a medical'surgical unit for close obser%ation and sym!tomatic treatment" /atients )ith se%ere sym!toms (e"g", air hunger, se%ere )hee+ing, and co!ious s!utum !roduction )ith ty!ically abnormal blood gas %alues, regardless of C06b le%els) should be intubated and admitted to an intensi%e care unit, or !referably a burn unit" Burn Center 5eferral Criteria The ABA has identified the follo)ing in1uries as those re(uiring referral to a burn center after initial assessment and stabili+ation at an emergency de!artment@ ," /artial'thic$ness and full'thic$ness burns totaling greater than ,:- TBSA in !atients under ,: or o%er ;: years of age" ?" /artial'thic$ness and full'thic$ness burns totaling greater than ?:- TBSA in other age grou!s" 3" /artial'thic$ness and full'thic$ness burns in%ol%ing the face, hands, feet, genitalia, !erineum, or ma1or 1oints" 4" .ull'thic$ness burns greater than ;- TBSA in any age grou!" ;" Electrical burns, including lightning in1ury" 8" Chemical burns" G" 9nhalation in1ury" 7" Burn in1ury in !atients )ith !ree isting medical disorders that could com!licate management, !rolong the reco%ery !eriod, or affect mortality" F" Any burn )ith concomitant trauma (e"g", fractures) in )hich the burn in1ury !oses the greatest ris$ of morbidity or mortality" 9f the trauma !oses the greater immediate ris$, the !atient may be treated initially in a trauma center until stable, before being transferred to a burn center" The !hysician3s decisions should be made )ith the regional medical control !lan and triage !rotocols in mind" ,:" Burn in1ury in children admitted to a hos!ital )ithout (ualified !ersonnel or e(ui!ment

for !ediatric care" ,," Burn in1ury in !atients re(uiring s!ecial social, emotional, and<or long'term rehabilitati%e su!!ort, including cases in%ol%ing sus!ected child abuse" Burn Center Eerification and a Cational Burn 5egistry 9n ,FF;, in con1unction )ith the American College of Surgeons Committee on Trauma (ACS' C0T), the ABA initiated a !rogram of Burn Center Eerification" A detailed document outlines the resources and !rocesses necessary to !ro%ide o!timal care of the burn !atient" 3? The !rogram is %oluntary, and burn centers may be re%ie)ed to %erify that they !ro%ide state' of'the'art care for burn !atients" This !rocess in%ol%es a lengthy (uestionnaire, a site %isit, a )ritten re!ort, and a!!ro%al by the 1oint %erification committees" By ?::3, about 8: centers had undergone this %erification !rocess" A national burn registry is $e!t by B"S" and Canadian burn centers to !ro%ide national statistics regarding incidence, e!idemiology, and outcome of burn cases" Emergency Care Care at the Scene Air)ay 0nce flames are e tinguished, initial attention must be directed to the air)ay" 9mmediate cardio!ulmonary resuscitation is rarely necessary, e ce!t in electrical in1uries or in !atients )ith se%ere carbon mono ide !oisoning" .or these unfortunate !atients, cardio!ulmonary resuscitation (C/5) should be !erformed !er Ad%anced Cardiac &ife Su!!ort (AC&S) guidelines" Any !atient rescued from a burning building or e !osed to a smo$y fire should be !laced on ,::- o ygen %ia a nonrebreather mas$ if there is any sus!icion of smo$e inhalation" 9f the !atient is unconscious or in res!iratory distress, endotracheal intubation should be !erformed by a!!ro!riately trained !ersonnel" 0ther 9n1uries and Trans!ort 0nce an air)ay is secured, the !atient is assessed for other in1uries and then trans!orted to the nearest hos!ital" 9f a burn center is )ithin a 3:'minute trans!ort time and the burn is se%ere )ithout associated trauma, the !atient may be ta$en directly to that facility" /atients should be $e!t flat and )arm and be gi%en nothing by mouth" The emergency medical !ersonnel should !lace an intra%enous line and begin fluid administration )ith lactated 5inger3s (&5) solution at a rate of a!!ro imately , &<h in the case of a se%ere burn2 other)ise, a maintenance rate is a!!ro!riate assuming no concomitant, nonthermal trauma" .or trans!ort, the !atient should be )ra!!ed in a clean sheet and blan$et" Sterility is not re(uired" Before or during trans!ort, constricting clothing and 1e)elry should be remo%ed from burned !arts, because local s)elling begins almost immediately" Cold A!!lication Small burns, !articularly scalds, may be treated )ith immediate a!!lication of cool )ater" 9t has been mathematically demonstrated that cooling cannot reduce s$in tem!erature enough to !re%ent further tissue damage, but there is e%idence in animals that cooling delays edema formation, !robably by reducing initial thrombo ane !roduction" 33I3; After se%eral minutes ha%e ela!sed, further cooling does not alter the !athologic !rocess" 9ced )ater should ne%er

be used, e%en on the smallest of burns" 38 9f ice or cold )ater is used on larger burns, systemic hy!othermia often follo)s, and the associated cutaneous %asoconstriction can e tend the thermal damage" Emergency 5oom Care The !rimary rule for the emergency !hysician is to ignore the burn" As )ith any form of trauma, the air)ay, breathing, and circulation !rotocol (ABC) must be strictly follo)ed" Although a burn is a dramatic in1ury, a careful search for other life'threatening in1uries is the first !riority" 0nly after ma$ing an o%erall assessment of the !atient3s condition should attention be directed to the burn" Emergency Assessment of 9nhalation 9n1ury The !atient3s history is an im!ortant !art of assessing the e tent of their in1uries" 9nhalation in1ury should be sus!ected in anyone )ith a flame burn, and assumed until !ro%en other)ise in anyone burned in an enclosed s!ace" The acrid smell of smo$e on a %ictim3s clothes should raise sus!icion" The rescuers are the most im!ortant historians and should be (uestioned carefully before they lea%e the recei%ing facility" Careful ins!ection of the mouth and !haryn should be done early" 6oarseness and e !iratory )hee+es are signs of !otentially serious air)ay edema or inhalation in1ury" Co!ious mucus !roduction and carbonaceous s!utum (i"e", e !ectorated s!utum and not 1ust blac$ flec$s in the sali%a) are !ositi%e signs, but their absence does not rule out air)ay in1ury" Carbo yhemoglobin le%els should be obtained, and ele%ated le%els or any sym!toms of C0 !oisoning are !resum!ti%e e%idence of associated inhalation in1ury" A decreased /@. ratio, the ratio of arterial o ygen !ressure (/a0?) to the !ercentage of ins!ired o ygen (.90?), is one of the earliest indicators of smo$e inhalation" A ratio of 4:: to ;:: is normal2 !atients )ith im!ending !ulmonary !roblems ha%e a ratio of less than 3::" A ratio of less than ?;: is an indication for endotracheal intubation rather than for increasing the ins!ired o ygen concentration" .ibero!tic bronchosco!y is ine !ensi%e, is (uic$ly !erformed in e !erienced hands, and is useful for accurately assessing edema of the u!!er air)ay" Although bronchosco!y documents tracheal erythema, it does not materially influence the treatment of !ulmonary in1ury" 3G .luid 5esuscitation in the Emergency 5oom As burns a!!roach ?:- TBSA, local !roinflammatory cyto$ines enter the circulation and result in a systemic inflammatory res!onse" 37 The micro%ascular lea$, !ermitting loss of fluid and !rotein from the intra%ascular com!artment into the e tra%ascular com!artment, becomes generali+ed" Cardiac out!ut decreases as a result of burn shoc$ and myocardial in1ury" 3F The resulting intense sym!athetic res!onse leads to increased systemic %ascular resistance and decreased !erfusion to the s$in and %iscera" #ecreased flo) to the s$in may con%ert a +one of stasis to one of coagulation, thereby increasing the de!th of burn" #ecreased cardiac out!ut may de!ress central ner%ous system (CCS) function, and in e treme cases, ultimately lead to cardiac failure in healthy !atients or to myocardial

infarction in !atients )ith !remorbid coronary artery atherosclerosis" 9m!airment in CCS function manifests as restlessness, follo)ed by lethargy, and finally by coma" 9f resuscitation is inade(uate, burns of 3:- TBSA fre(uently lead to acute renal failure, )hich in the case of a se%ere burn almost in%ariably results in a fatal outcome" 5esuscitation begins by starting intra%enous &5 solution at a rate of ,::: m&<h in adults and ?: m&<$g !er hour in young children" Burn !atients re(uiring intra%enous resuscitation (i"e", generally those )ith burns greater than ?:- TBSA) should ha%e a .oley catheter !laced and urine out!ut monitored hourly, the goal being 3: m&<h in adults and ,": m&<$g !er hour in young children" 0nce the e tent of the burn is ascertained, resuscitation should be tailored to the in1ury using the /ar$land formula (Table G',), as both o%er' and underresuscitation are deleterious" Table G', .ormulas for Estimating Adult Burn /atient 5esuscitation .luid Ceeds Electrolyte Colloid for#ulas E%ans Broo$e Slater Crystalloid for#ulas /ar$land Modified Broo$e $ypertonic saline for#ulas 6y!ertonic saline solution (Monafo)LEolume to maintain urine out!ut at 3: m&<h2 fluid contains ?; mE( Ca<& Modified hy!ertonic (Aarden)L&actated 5inger3s M ;: mE( Ca6C03 (,7: mE( Ca<&) for 7 h to maintain urine out!ut at 3:I;: m&<h2 lactated 5inger3s to maintain urine out!ut at 3:I ;: m&<h beginning 7 h !ostburn e%tran for#ula ( e#ling)L#e tran 4: in saline@ ? m&<$g<h for 7 h2 lactated 5inger3s@ %olume to maintain out!ut at 3: m&<h2 fresh fro+en !lasma@ :"; m&<$g<h for ,7 h beginning 7 h !ostburn 5e!roduced )ith !ermission from Aarden >#@ Burn shoc$ resuscitation" World J Surg ,8@,8, ,FF?"
S0B5CE@

Colloid

"

Cormal saline ,": m&<$g<- ,": m&<$g<- burn burn &actated 5inger3s ,"; m&<$g<- burn &actated 5inger3s ? &<?4 h :"; m&<$g .resh fro+en !lasma G; m&<$g<?4 h 4 m&<$g<- burn ? m&<$g<- burn

?::: m& ?::: m&

&actated 5inger3s &actated 5inger3s

/atients )ith burns co%ering less than ;:- TBSA usually can begin resuscitation %ia t)o large'bore !eri!heral intra%enous lines" Because of the high incidence of se!tic

thrombo!hlebitis, lo)er e tremities should not be used as !ortals for !eri!heral intra%enous lines" B!!er e tremities are !referable, e%en if the intra%enous line must !ass through burned s$in or eschar" /atients )ith burns greater than ;:- TBSA, or those )ho ha%e associated medical !roblems, are at the e tremes of age, or ha%e concomitant inhalation in1uries should ha%e additional central %enous access established )ith in%asi%e hemodynamic monitoring" Because of the hemodynamic instability in !atients )ith burns greater than 8;- TBSA, these !atients should be transferred as (uic$ly as !ossible to a burn center so they can be monitored in an intensi%e care setting" Tetanus /ro!hyla is Burns are tetanus'!rone )ounds" The need for tetanus !ro!hyla is is determined by the !atient3s current immuni+ation status" /re%ious immuni+ation )ithin ; years re(uires no treatment, immuni+ation )ithin ,: years re(uires a tetanus to oid booster, and un$no)n immuni+ation status re(uires hy!erimmune serum (i"e", 6y!er'Tet)" >astric #ecom!ression Many burn centers begin enteral feeding on admission to reduce the ris$ of gastric ulceration (Curling3s ulcer), !re%ent ileus, and blunt catabolism" 4: 9f !atient trans!ort is %ia air ambulance or is going to ta$e more than a fe) hours, the safest course is usually to decom!ress the stomach )ith a nasogastric tube" /ain Control #uring the shoc$ !hase of burn care, medications should be gi%en intra%enously" Subcutaneous and intramuscular in1ections are %ariably absorbed de!ending on !erfusion and should be a%oided" /ain control is best managed )ith small intra%enous doses of an o!iate until analgesia is ade(uate )ithout inducing hy!otension" /sychosocial Care /sychosocial care should begin immediately" The !atient and family must be comforted and gi%en a realistic assessment regarding the !rognosis of the burns" 9n house fires, !atients3 lo%ed ones, !ets, and !ossessions may ha%e been lost" 9f the family is not a%ailable, some member of the team, usually the social )or$er, should determine the e tent of !ersonal loss" 9f the !atient is a child, and if the circumstances of the burn are sus!icious, !hysicians in all states are re(uired by la) to re!ort any sus!ected case of child abuse to local authorities" Care of the Burn Aound After all other assessments ha%e been com!leted, attention should be directed to the burn" 9f the !atient is to be transferred during the first !ostburn day, )hich is almost al)ays the case, the burn )ounds can be minimally dressed in gau+e" 6o)e%er, the si+e of the burn should be calculated to establish the !ro!er le%el of fluid resuscitation, and !ulses distal to circumferential dee! burns should be monitored" The !atient can be )ra!!ed in a clean sheet and $e!t )arm until arri%ing at the definiti%e care center"

Escharotomy Thoracic Escharotomy The ade(uacy of res!iration must be monitored continuously throughout the resuscitation !eriod" Early res!iratory distress may be due to the com!romise of %entilation caused by chest )all inelasticity related to a dee! circumferential burn )ound of the thora " /ressures re(uired for %entilation increase and arterial /C0? rises" 9nhalation in1ury, !neumothora , or other causes can also result in res!iratory distress and should be a!!ro!riately treated" Thoracic escharotomy is seldom re(uired, e%en )ith a circumferential chest )all burn" Ahen re(uired, escharotomies are !erformed bilaterally in the anterior a illary lines" 9f there is significant e tension of the burn onto the ad1acent abdominal )all, the escharotomy incisions should be e tended to this area by a trans%erse incision along the costal margins (.ig" G',)" .9>" G',"

&ocations for escharotomies" The incisions are !laced along the mid'medial and mid'lateral lines of the e tremities and the thora (dashed lines)" The s$in is es!ecially tight along ma1or 1oints, and decom!ression at these sites must be com!lete (solid lines)" Cec$ and digital escharotomies are rarely necessary" Escharotomy of the E tremities Edema formation in the tissues under the tight, unyielding eschar of a circumferential burn on an e tremity may !roduce significant %ascular com!romise that, if left unrecogni+ed and untreated, )ill lead to !ermanent, serious neuromuscular and %ascular deficits" All 1e)elry must be remo%ed from the e tremities to a%oid distal ischemia" S$in color, sensation, ca!illary refill, and !eri!heral !ulses must be assessed hourly in any e tremity )ith a circumferential burn" The occurrence of any of the follo)ing signs or sym!toms may indicate !oor !erfusion of a distal e tremity )arranting escharotomy@ cyanosis, dee! tissue !ain, !rogressi%e !aresthesia, !rogressi%e decrease or absence of !ulses, or the sensation of cold e tremities" An ultrasonic flo)meter (#o!!ler) is a reliable means for assessing arterial blood flo), the need for an escharotomy, and also can be used to assess ade(uacy of circulation after an escharotomy" 4, Transfers to a burn center )ithin 8 hours of in1ury should not re(uire escharotomy at the referring hos!ital" Ahen necessary, escharotomies may be done as bedside !rocedures )ith a sterile field and scal!el or electrocautery" &ocal anesthesia is unnecessary because full' thic$ness eschar is insensate2 ho)e%er, intra%enous o!iates or an iolytics should be utili+ed" The incision, )hich must a%oid ma1or neuro%ascular and musculotendinous structures, should be !laced along the mid'medial or mid'lateral as!ect of the e tremity" To !ermit ade(uate se!aration of the cut edges for decom!ression, the incision should be carried do)n through the eschar, )hich includes de%itali+ed dermis, to the subcutaneous fat" The incision should e tend the length of the constricting full'thic$ness burn and across in%ol%ed 1oints (see .ig" G',)" Ahen a single escharotomy incision does not result in restoring ade(uate distal

!erfusion, a second escharotomy incision on the contralateral as!ect of the e tremity should be !erformed" A digital escharotomy is ne%er re(uired" Because burn !atients are at ris$ for de%elo!ing a com!artment syndrome u! to G? hours follo)ing in1ury, any in%ol%ed e tremity should be continually reassessed for signs of increased com!artment !ressures that can occur after initial decom!ression" A com!artment syndrome follo)ing initially ade(uate escharotomy, albeit rare, re(uires urgent o!erati%e fasciotomy" As !rimary release or decom!ression maneu%ers, fasciotomies are %irtually ne%er indicated e ce!t )ith ma1or electrical burns" Burn Se%erity The se%erity of any burn in1ury is related to the si+e and de!th of the burn, and to the !art of the body that has been burned" Burns are the only truly (uantifiable form of trauma" The single most im!ortant factor in !redicting burn'related mortality, need for s!eciali+ed care, and the ty!e and li$elihood of com!lications is the o%erall si+e of the burn as a !ro!ortion of the !atient3s TBSA" Treatment !lans, including initial resuscitation and subse(uent nutritional re(uirements, are directly related to the si+e of burn" Burn Si+e A general idea of the burn si+e can be made by using the rule of nines. Each u!!er e tremity accounts for F- of the TBSA, each lo)er e tremity accounts for ,7-, the anterior and !osterior trun$ each account for ,7-, the head and nec$ account for F-, and the !erineum accounts for ,-" Although the rule of nines is reasonably accurate for adults, a number of more !recise charts ha%e been de%elo!ed that are !articularly hel!ful in assessing !ediatric burns" Most emergency rooms ha%e such a chart" A diagram of the burn can be dra)n on the chart, and more !recise calculations of the burn si+e made from the accom!anying TBSA estimates gi%en" Children under 4 years of age ha%e much larger heads and smaller thighs in !ro!ortion to total body si+e than do adults" 9n infants the head accounts for nearly ?:- of the TBSA2 a child3s body !ro!ortions do not fully reach adult !ercentages until adolescence" E%en )hen using !recise diagrams, interobser%er %ariation may %ary by as much as N?:-" 4? An obser%er3s e !erience )ith burned !atients, rather than educational le%el, a!!ears to be the best !redictor of the accuracy of burn si+e estimation" .or smaller burns, an accurate assessment of si+e can be made by using the !atient3s !almar hand surface, including the digits, )hich amounts to a!!ro imately ,- of TBSA" Burn #e!th Along )ith burn si+e and !atient age, the de!th of the burn is a !rimary determinant of mortality" Burn de!th is also the !rimary determinant of the !atient3s long'term a!!earance and functional outcome" Burns not e tending all the )ay through the dermis lea%e behind e!ithelium'lined s$in a!!endages, including s)eat glands and hair follicles )ith attached sebaceous glands" Ahen dead dermal tissue is remo%ed, e!ithelial cells s)arm from the surface of each a!!endage to meet s)arming cells from neighboring a!!endages, forming a ne), fragile e!idermis on to! of a thinned and scarred dermal bed" S$in a!!endages %ary in de!th, and the dee!er the burn,

the fe)er the a!!endages that contribute to healing, and the longer the burn ta$es to heal" The longer the burn ta$es to heal, the less dermis remains, the greater the inflammatory res!onse, and the more se%ere the scarring" Ahen nono!erati%e treatment is the norm, as it is in many de%elo!ing countries, an accurate assessment of burn de!th is of little im!ortance e ce!t for !redicting mortality" 0n the other hand, )ith aggressi%e surgical treatment, an accurate estimation of burn de!th is crucial" Burns that heal )ithin 3 )ee$s usually do so )ithout hy!ertro!hic scarring or functional im!airment, although long'term !igmentary changes are common" Burns that ta$e longer than 3 )ee$s to heal often !roduce unsightly hy!ertro!hic scars, fre(uently lead to functional im!airment, and !ro%ide only a thin, fragile e!ithelial co%ering for many )ee$s or months" State'of'the'art burn care in%ol%es early e cision and grafting of all burns that )ill not heal )ithin 3 )ee$s" The challenge is to determine )hich burns will heal )ithin 3 )ee$s, and are thus better treated by nono!erati%e )ound care" An understanding of burn de!th re(uires an understanding of s$in thic$ness" The dee!est layer of e!idermal cells (basal layer) is an intensely acti%e layer of e!ithelial cells under layers of dead $eratini+ed cells, and is su!erficial to the acti%e structural frame)or$ of the s$in, the dermis" The thic$ness of s$in %aries )ith the age and se of the indi%idual and the area of the body" The thic$ness of the li%ing e!idermis is relati%ely constant, but $eratini+ed (dead and cornified) e!idermal cells may reach a thic$ness of :"; cm on the !alms and soles" The thic$ness of the dermis %aries from less than , mm on the eyelids and genitalia to more than ; mm on the !osterior trun$" The !ro!ortional thic$ness of s$in in each body area in children is similar to that in adults, but infant s$in thic$ness in each s!ecific area may be less than one half that of adult s$in" The s$in does not reach adult thic$ness until !uberty" Similarly, in !atients o%er ;: years of age, dermal atro!hy has begun2 all areas of s$in become thin in elderly !atients, and the s$in a!!endages are far less acti%e" Burn de!th is de!endent u!on the tem!erature of the burn source, the thic$ness of the s$in, the duration of contact, and the heat'dissi!ating ca!ability of the s$in (i"e", blood flo))" A scald in an infant or elderly !atient )ill be dee!er than an identical scald in a young adult" A diabetic )ith im!aired sensation or an into icated !atient )ith an im!aired sensorium )ho lies on a heating !ad all night may sustain full'thic$ness burns, because of the long duration of contact )ith the !ad and the !ressure of the body )eight that occludes cutaneous blood flo) and !re%ents heat dissi!ation" Burns are classified according to increasing de!th as e!idermal (first'degree), su!erficial and dee! !artial'thic$ness (second'degree), full'thic$ness (third'degree), and fourth'degree" Because most dee! burns are e cised and grafted, such a !recise characteri+ation is not necessary for nonIlife'threatening burns" A more !ertinent classification might be *shallo) burns* and *dee! burns"* Ce%ertheless, distinguishing bet)een dee! burns that are best treated by early e cision and grafting, and shallo) burns that heal s!ontaneously, is not al)ays straightfor)ard, and many burns ha%e a mi ture of clinical characteristics, ma$ing !recise classification difficult" Shallo) Burns E!idermal Burns (.irst'#egree)

As im!lied, these burns in%ol%e only the e!idermis" They do not blister, but become erythematous because of dermal %asodilation, and are (uite !ainful" 0%er ? to 3 days the erythema and !ain subside" By about the fourth day, the in1ured e!ithelium des(uamates in the !henomenon of !eeling, )hich is )ell $no)n after sunburn" Su!erficial /artial'Thic$ness (Second'#egree) Su!erficial !artial'thic$ness burns include the u!!er layers of dermis, and characteristically form blisters )ith fluid collection at the interface of the e!idermis and dermis" Blistering may not occur until some hours after in1ury, and burns originally a!!earing to be e!idermal may subse(uently be diagnosed as su!erficial !artial'thic$ness burns after ,? to ?4 hours" Ahen blisters are remo%ed, the )ound is !in$ and )et2 currents of air !assing o%er it cause !ain" The )ound is hy!ersensiti%e, and the burns blanch )ith !ressure" 9f infection is !re%ented, su!erficial !artial'thic$ness burns heal s!ontaneously in less than 3)ee$s, and do so )ithout functional im!airment" They rarely cause hy!ertro!hic scarring, but in !igmented indi%iduals the healed burn may ne%er com!letely match the color of the surrounding normal s$in" #ee! Burns #ee! /artial'Thic$ness (Second'#egree) #ee! !artial'thic$ness burns e tend into the reticular layers of the dermis" They also blister, but the )ound surface is usually a mottled !in$'and')hite color immediately after the in1ury because of the %arying blood su!!ly to the dermis ()hite areas ha%e little to no blood flo) and !in$ areas ha%e some blood flo))" The !atient com!lains of discomfort rather than !ain" Ahen !ressure is a!!lied to the burn, ca!illary refill occurs slo)ly or may be absent" The )ound is often less sensiti%e to !in!ric$ than the surrounding normal s$in" By the second day, the )ound may be )hite and is usually fairly dry" 9f not e cised and grafted, and if infection is !re%ented, these burns )ill heal in 3 to F )ee$s, but in%ariably do so )ith considerable scar formation" Bnless acti%e !hysical thera!y is continued throughout the healing !rocess, 1oint function can be im!aired, and hy!ertro!hic scarring is common" .ull'Thic$ness (Third'#egree) .ull'thic$ness burns in%ol%e all layers of the dermis and can heal only by )ound contracture, e!itheliali+ation from the )ound margin, or s$in grafting" They a!!ear )hite, cherry red, or blac$, and may or may not ha%e dee! blisters" .ull'thic$ness burns are described as being leathery, firm, and de!ressed )hen com!ared )ith ad1oining normal s$in, and they are insensate" The difference in de!th bet)een a dee! !artial'thic$ness burn and a full'thic$ness burn may be less than , mm" The clinical a!!earance of full'thic$ness burns can resemble that of dee! !artial'thic$ness burns" They may be mottled in a!!earance, rarely blanch on !ressure, and may ha%e a dry, )hite a!!earance" 9n some cases, the burn is translucent, )ith clotted %essels %isible in the de!ths" Some full'thic$ness burns, !articularly immersion scalds, ha%e a red a!!earance and initially may be confused )ith su!erficial !artial'thic$ness burns" 6o)e%er, they can be distinguished because they do not blanch )ith !ressure" .ull'thic$ness burns de%elo! a classic burn eschar, a structurally intact but dead and denatured dermis that if left in situ o%er days and )ee$s, se!arates from the underlying %iable tissue"

.ourth'#egree .ourth'degree burns in%ol%e not only all layers of the s$in, but also subcutaneous fat and dee!er structures" These burns almost al)ays ha%e a charred a!!earance, and fre(uently only the cause of the burn gi%es a clue to the amount of underlying tissue destruction" Electrical burns, contact burns, some immersion burns, and burns sustained by !atients )ho are unconscious at the time of burning may all be fourth'degree" Assessment of Burn #e!th The standard techni(ue for determining burn de!th has been clinical obser%ation of the )ound" The difference in de!th bet)een a shallo) burn that heals in 3 )ee$s, a dee! !artial' thic$ness burn that heals only after many )ee$s, and a full'thic$ness burn that )ill not heal at all, may be only a matter of a fe) tenths of a millimeter" A burn is a dynamic !rocess for the first fe) days2 a burn a!!earing shallo) on day , may a!!ear considerably dee!er by day 3" .urthermore, the $ind of to!ical )ound care used can dramatically change the a!!earance of the burn" .or these reasons, and because of the increasing im!ortance of an accurate assessment of burn de!th for !lanning definiti%e care of burn )ounds, there is considerable interest in technology that )ill hel! determine burn de!th more !recisely and more (uic$ly than clinical obser%ation" E%aluation by an e !erienced surgeon as to )hether a !artial'thic$ness burn )ill heal in 3 )ee$s is about G:- accurate" 43 9n e !erienced hands, ho)e%er, early e cision and grafting !ro%ides better results than nono!erati%e care for such indeterminate burns" 44 0ther techni(ues to (uantify burn de!th in%ol%e (,) the ability to detect dead cells or denatured collagen (e"g", bio!sy, ultrasound, and %ital dyes), (?) assessment of changes in blood flo) (e"g", fluorometry, laser #o!!ler, and thermogra!hy), (3) analysis of the color of the )ound (e"g", light reflectance methods), and (4) e%aluation of !hysical changes, such as edema (e"g", nuclear magnetic resonance imaging)" 4;I;; Conetheless, the most common modality of burn de!th estimation used in state'of'the'art burn care today is still clinical obser%ation" To date, machines ha%e !ro%en to be significantly more cumbersome and only slightly more accurate than humans in assessing burn de!th, and so remain only research instruments" The /hysiologic 5es!onse to Burn 9n1ury Burn !atients )ith or )ithout inhalation in1ury commonly manifest an inflammatory !rocess in%ol%ing the entire organism2 the term systemic inflammatory response syndrome (S95S) summari+es that condition" S95S )ith infection (i"e", se!sis syndrome) is a ma1or factor determining morbidity and mortality in thermally in1ured !atients" /athologic alterations of the metabolic, cardio%ascular, gastrointestinal, and coagulation systems occur, )ith resulting hy!ermetabolism2 increased cellular, endothelial, and e!ithelial !ermeability2 classic hemodynamic alterations2 and often e tensi%e microthrombosis" The cardio%ascular manifestations of S95S largely disa!!ear )ithin ?4 to G? hours, but the !atient remains in a hy!ermetabolic state until )ound co%erage is achie%ed" Burn Shoc$ Burn shoc$ is a com!le !rocess of circulatory and microcirculatory dysfunction that is not

easily or fully re!aired by fluid resuscitation" Tissue trauma and hy!o%olemic shoc$ result in the formation and release of local and systemic mediators, )hich !roduce an increase in %ascular !ermeability and micro%ascular hydrostatic !ressure" ;8 Most mediators act to increase !ermeability by altering %enular endothelial integrity" The early !hase of burn edema, lasting from minutes to an hour, is attributed to mediators such as histamine, !roducts of !latelet acti%ation, eicosanoids, and !roteolytic !roducts of the coagulation, fibrinolytic, and $inin cascades" Easoacti%e amines may also act by increasing micro%ascular blood flo) or %ascular !ressures, accentuating the burn edema" 6istamine is !robably res!onsible for the early !hase of increased %ascular !ermeability after burn in1ury, because it is released in large (uantities from mast cells in burned s$in immediately after in1ury" ;G 9t !redominantly disru!ts %enular endothelial tight 1unctions, !ermitting egress of fluid and !roteins" Serum histamine !ea$s in the first se%eral hours follo)ing a burn, suggesting that histamine is in%ol%ed only in the %ery early increase in micro%ascular !ermeability" Serotonin is released immediately !ostburn %ia !latelet aggregation, and acts directly to increase !ulmonary %ascular resistance, and indirectly to am!lify the %asoconstricti%e effects of nore!ine!hrine, histamine, angiotensin 99, and select eicosanoids at the micro%ascular le%el" ;7 Eicosanoids, %asoacti%e !roducts of arachidonic acid metabolism, are released in burn tissue and contribute to the formation of burn edema" These substances do not directly alter %ascular !ermeability, but increased le%els of the %asodilator !rostaglandins (/>), such as />E?, and !rostacyclin (/>9?), result in arterial dilatation in burn tissue that increases blood flo) and hydrostatic !ressure in the in1ured microcirculation and accentuates edema formation" 9ncreased concentrations of />9? and the %asoconstrictor thrombo ane (TO) A? ha%e been demonstrated in burn tissue, burn blister fluid, lym!h, and )ound sera" ;F The acti%ation of multi!le !roteolytic cascades occurs immediately after burn in1ury" =inins, s!ecifically the brady$inins, increase %ascular !ermeability, !rimarily in the %enule" 8: /latelet'acti%ating factor is released after burn in1ury and increases ca!illary !ermeability" 8, Concomitant )ith the systemic micro%ascular lea$ early after a burn, a hy!ercoagulable and hy!erfibrinolytic state e ists" As hematologically measured, it resembles disseminated intra%ascular coagulation (#9C) and may correlate )ith organ failure and outcome" 8? 9n addition to the loss of micro%ascular integrity, thermal in1ury also causes changes at the cellular le%el" The reduction in cardiac out!ut after burn in1ury is a result of cellular shoc$, hy!o%olemic shoc$, and increased systemic %ascular resistance (SE5) due to sym!athetic stimulation from the release of multi!le mediators" The cardiac myocyte shoc$ state is a result of im!aired calcium homeostasis and subse(uent intracellular signaling dysregulation" 83,84 Effecti%e !harmacologic inter%entions to re%erse this burn's!ecific form of cardiogenic shoc$ are still in the e !erimental stages" .ollo)ing successful resuscitation, cardiac out!ut normali+es )ithin ?4 to G? hours, and then increases to su!ranormal le%els during the )ound healing !hase of burn management" Metabolic 5es!onse to Burn 9n1ury

6y!ermetabolism 5esting energy e !enditure (5EE) after burn in1ury can be as much as ,::- abo%e !redictions based on standard calculations for si+e, age, se , and )eight" Some debate !ersists regarding the genesis of this !henomenon, but increased heat loss from the burn )ound and increased beta'adrenergic stimulation are !robably !rimary factors" 8;,88 5adiant heat loss is increased from the burn )ound secondary to increased blood flo) and integumentary loss" Measurement of 5EE is hel!ful in assessing nutritional status" 0n a%erage, the 5EE is a!!ro imately ,"3 times the !redicted basal metabolic rate (BM5) obtained using the 6arris'Benedict e(uation" >lucose metabolism is ele%ated in almost all critically'ill !atients, including those )ith burn in1uries" Studies ha%e focused !articularly on burn !atients because their relati%ely stable !hysiologic condition allo)s re!roducible e !erimental conditions" >luconeogenesis and glycogenolysis are increased in burn !atients" 9n addition, !lasma insulin le%els ty!ically are ele%ated in burn !atients" The basal rate of glucose !roduction is ele%ated des!ite this hy!erinsulinemic state, )hich can be defined as he!atic insulin resistance" 6ence, hy!erglycemia com!licates the acute management of many significant burns and may be related to !oor outcomes, s!ecifically increased mortality and decreased graft ta$e" 8G .urther, hy!erglycemia may e acerbate muscle catabolism in burn !atients )hile not influencing 5EE" 87 E ogenous insulin administration to achie%e euglycemia has been sho)n to decrease donor site healing time and decrease length of stay, )hile ameliorating s$eletal muscle catabolism" 8F,G: &i!olysis occurs at a rate in e cess of the re(uirements for fatty acids as an energy source due to alterations in substrate cycling" 9n burn !atients, the ma1ority of released fatty acids are not o idi+ed, but rather re'esterified into triglycerides, resulting in fat accumulation in the li%er" The acute and long'term conse(uences of this he!atic steatosis are unclear" 6o)e%er, in a !ediatric auto!sy study, 7:- of the fatalities o%er ,: years had he!atic steatosis, and it a!!eared to correlate )ith se!sis" G, Beta'bloc$ade using !ro!ranolol a!!ears !romising as a means to mani!ulate !eri!heral li!olysis and !otentially !re%ent he!atic steatosis, although clinical outcome data )ith res!ect to fatty acid metabolism are still lac$ing" G? /roteolysis is increased in burn !atients as com!ared to normal indi%iduals )ho are fed isonitrogenous, isocaloric diets" .ollo)ing utili+ation, !rotein is e creted !rimarily in the urine as urea" This results in an increased efflu of amino acids from the s$eletal muscle !ool, including gluconeogenic amino acids" 9n !articular, alanine and glutamine (>ln) are released at an increased rate" Muscle !rotein brea$do)n is accelerated )hile acute !hase !roteins are !roduced at an increased rate in the li%er" Aound healing re(uires enhanced !rotein synthesis and increased immunologic acti%ity" /rotein inta$e greater than , g<$g !er day has been recommended for all thermally in1ured !atients, and for burn !atients )ith normal renal function, the recommended !rotein inta$e is ? g<$g !er day" The im!ortance of >ln inta$e or its metabolic !recursors has been in%estigated in critically'ill burn !atients" Current standard nutritional formulations ha%e largely omitted >ln or its !recursors2 ho)e%er, beneficial effects ha%e been found )ith >ln and ornithine '$etoglutarate (0=>) su!!lementation" 9n !articular, gram'negati%e bacteremia and !ossibly mortality )ere reduced )ith !arenteral >ln su!!lementation, )hile inflammation )as blunted and nutritional !arameters )ere im!ro%ed" G3 Similarly, enteral 0=> su!!lementation )as associated )ith increased !lasma

>ln le%els, enhanced )ound healing, and im!ro%ed nitrogen metabolism" G4,G; The !recise mechanisms by )hich direct and indirect >ln su!!lementation im!ro%es outcome remain unclear and are a fertile area of metabolism research" The anabolic steroid o androlone also has been sho)n to im!ro%e donor'site healing time, diminish )eight loss, and blunt !rotein catabolism during the acute !hase of burn )ound healing" G8 Ceuroendocrine 5es!onse Catecholamines are massi%ely ele%ated follo)ing burn in1ury, and a!!ear to be the ma1or endocrine mediators of the hy!ermetabolic res!onse in thermally in1ured !atients" /harmacologic beta'bloc$ade utili+ing !ro!ranolol diminishes the intensity of !ostburn hy!ermetabolism in !ediatric !atients as demonstrated by im!ro%ed s$eletal muscle !rotein $inetics )ith diminished 5EE and o ygen consum!tion2 ho)e%er, clinical outcome data are still lac$ing, and these results ha%e yet to be demonstrated in adult burn !atients" GG Con%ersely, gro)th hormone (>6) le%els are attenuated follo)ing thermal in1ury" Although early studies of e ogenous >6 as an anticatabolic agent )ere !romising in the !ediatric !o!ulation, ultimately its use has been su!!lanted by less e !ensi%e, safer, and e(ually effecti%e !harmacothera!ies" G7 /ro!ranolol has been sho)n to be su!erior to >6, )hile o androlone is e(ually as effecti%e as >6 in ameliorating catabolism" GF,7: Both !ro!ranolol and o androlone ha%e fe)er significant side effects than >6, and o androlone a!!ears to be e(ually effecti%e in adults and children" Thyroid hormone serum concentrations are altered in !atients )ith large burns" Total thyronine (T3) and thyro ine (T4) concentrations are reduced, and re%erse T3 concentrations are ele%ated, )hile cellular concentrations are li$ely normal" Concentrations of free T3 and T4 fall mar$edly in the !resence of se!sis in burned !atients" 7, Burn in1uries abolish the normal diurnal %ariation in glucocorticoid secretion, !roducing !ersistent hy!ercortisolemia" Although catabolic, cortisol does not a!!ear to a!!reciably influence metabolic acti%ity alone, but acts additi%ely and synergistically )ith the catecholamines and glucagon" >lucagon concentrations are related directly to metabolic rate and a!!ear to e ert effects %ia insulin and insulin'li$e gro)th factor', modulation" 7? 9mmunologic 5es!onse to Burn 9n1ury The immune status of the burn !atient has a !rofound im!act on outcome in terms of sur%i%al and ma1or morbidity" Many mediators are released from both in1ured and unin1ured tissues at the )ound site )here they e ert local and systemic effects" The timetable of induction<su!!ression and !hysiologic se(uela are similar in !atients suffering thermal and non'thermal trauma (see Cha!" ,, *Systemic 5es!onse to 9n1ury and Metabolic Su!!ort*)" The greatest difficulty in attem!ting to deci!her the body3s res!onse to in1ury is the com!le interaction bet)een the multi!le, redundant inflammatory cascades and the immune system" .luid Management /ro!er fluid management is critical to sur%i%al follo)ing ma1or thermal in1ury" /rior to Aorld Aar 99, hy!o%olemic shoc$ )ith conse(uent acute renal failure )as the leading cause of death from burns" Mortality related to burn'induced hy!o%olemia has decreased considerably )ith increased understanding of the massi%e fluid shifts and hemodynamic changes that occur during burn shoc$" Much of the early $no)ledge about burn shoc$ resuscitation dates to t)o B"S" disasters@ the 5ialto Theater fire in Ce) 6a%en, Connecticut, in ,F?,, and the Coconut

>ro%e fire in Boston, Massachusetts, in ,F4?" An aggressi%e a!!roach to fluid thera!y has subse(uently led to reduced mortality rates in the first 47 hours !ostburn2 nonetheless, a!!ro imately ;:- of the deaths still occur )ithin the first ,: days after burn in1ury, o)ing to multi!le organ failure syndrome (M0.S) and o%er)helming se!sis" 0ne of the !rinci!al causes, !articularly of M0.S, is inade(uate fluid resuscitation and maintenance" .luid management follo)ing successful resuscitation from burn shoc$ is e(ually as im!ortant" /atho!hysiology of Burn Shoc$ Burn shoc$ is both hy!o%olemic and cellular in etiology" 9t is characteri+ed by s!ecific hemodynamic changes including decreased cardiac out!ut, increased e tracellular fluid, decreased !lasma %olume, and oliguria" As )ith treating other forms of shoc$, the !rimary goal is to restore and !reser%e tissue and end'organ !erfusion" 9n burn shoc$, resuscitation is com!licated by obligatory burn edema" The %oluminous e tra%ascular fluid shifts that result from a ma1or burn are uni(ue to thermal trauma" A ma1or com!onent of burn shoc$ is the increase in systemic micro%ascular !ermeability" #irect thermal in1ury results in significant changes in the microcirculation, both systemically and locally" Ma imal edema formation occurs bet)een 7 and ,? hours follo)ing in1ury in smaller burns, and bet)een ,? and ?4 hours in ma1or thermal in1uries" The rate of !rogression of tissue edema is de!endent on the ade(uacy of resuscitation" As !re%iously described, multi!le mediators ha%e been im!licated in causing the micro%ascular changes %ia a direct increase in %ascular !ermeability or an increase in intra%ascular hydrostatic !ressure" The end result of these changes in the micro%asculature due to thermal in1ury is disru!tion of the normal barriers se!arating the intra%ascular and interstitial com!artments, )ith ra!id e(uilibrium bet)een the t)o com!artments" 6ence, !lasma %olume is se%erely de!leted (hy!o%olemia), )hile there is a mar$ed increase in e tracellular fluid (edema)" Thermal in1ury also causes changes at the cellular le%el" Ba ter originally demonstrated that in burns co%ering more than 3:- TBSA, there is a systemic decrease in cell transmembrane !otential" This decrease in !otential, defined by the Cernst e(uation, results from an increase in intracellular CaM concentrations secondary to a decrease in CaM'=M'AT/ase acti%ity res!onsible for maintaining the transcellular ionic gradient" This has subse(uently been confirmed in modern animal models" 73 5esuscitation only !artially restores the transmembrane !otential and intracellular CaM concentrations to normal, im!lying that hy!o%olemia is not solely res!onsible for the cellular defects seen )ith burn shoc$" The aforementioned animal models ha%e also im!licated defecti%e adenosine tri!hos!hate (AT/) metabolism as a cause" Membrane !otential may not return to normal for many days follo)ing thermal in1ury, des!ite ade(uate resuscitation" 9f resuscitation is inade(uate, cellular transmembrane !otential !rogressi%ely decreases, and ultimately results in cell death" Burn Shoc$ 5esuscitation The !rimary goal of fluid resuscitation is to ensure end'organ !erfusion by re!lacing fluid that is se(uestered as a result of the thermal in1ury" Su!!ort of the burned !atient in this manner is !rinci!ally aimed at the first ?4 to 47 hours after in1ury, )hen the rate of de%elo!ment of hy!o%olemia is ma imal" A critical conce!t to understanding burn shoc$ is that massi%e fluid shifts occur e%en though total body )ater initially remains unchanged" Ahat actually changes is the %olume of each fluid com!artment, )ith intracellular and

interstitial %olumes increasing at the e !ense of intra%ascular %olume" Edema formation is ine%itable and is undoubtedly accentuated by the resuscitation !rocess" 74 Many careers and lifetimes ha%e been de%oted to studying burn shoc$ resuscitation, resulting in un(uestionably significant ad%ancements in burn care" Multi!le resuscitation formulas, em!loying %arious solutions at different %olumes and rates, ha%e e%ol%ed from that research (see Table G',)" 6o)e%er, neither the Cational 9nstitutes of 6ealth (C96) in ,FG7 nor ABA in ?::, has been able to !ro%ide consensus or e%idence'based guidelines demonstrating the su!eriority of one formula o%er another for burn shoc$ resuscitation" Conetheless, acce!ted recommendations continue to be that resuscitation should !roceed in a manner sufficient to maintain end'organ !erfusion and abrogate electrolyte disturbances, )hile being fle ible and amenable to indi%idual !atient differences, regardless of the com!osition, %olume, or infusion rate of the solution em!loyed" 7; Crystalloid 5esuscitation Crystalloid, in !articular lactated 5inger3s solution (&5) )ith a sodium concentration of ,3: mE(<&, is by far the most e tensi%ely used resuscitation fluid" 78 9t is the recommended resuscitation solution of both the ACS'C0T and the ABA" /ro!onents of crystalloid resuscitation argue that colloids are no better, and are certainly more e !ensi%e, than crystalloid for maintaining intra%ascular %olume initially after thermal in1ury" This argument is !redicated u!on the obser%ation that e%en large !roteins, on the order of 3:: $d, lea$ from ca!illaries for a!!ro imately ?4 hours after thermal in1ury2 7G hence any theoretical ad%antage of colloids is negated" This is su!!orted by the lac$ of clinical effect, and !otential detriment, found )hen using colloid in the only !ros!ecti%e randomi+ed clinical trial of crystalloid %s" colloid in burn resuscitation" 77 The (uantity of crystalloid needed for ade(uate resuscitation is de!endent on the monitoring !arameters" 9f a urinary out!ut of :"; m&<$g of body )eight !er hour re!resents ade(uate end'organ !erfusion, a!!ro imately 3 m&<$g for each !ercent TBSA burned )ill be needed in the first ?4 hours" 6o)e%er, if , m&<$g or more body )eight !er hour is o!timal, considerably more fluid )ill be needed, )ith more edema resulting" The /ar$land formula recommends 4 m& &5<$g for each !ercent TBSA burned o%er the first ?4 hours, )ith one half of that amount administered in the first 7 hours, and the remaining half o%er the ne t ,8 hours 7F (see Table G',)" The modified Broo$e Army 6os!ital formula recommends ? m& &5<$g !er !ercent TBSA burned o%er the first ?4 hours (see Table G',)" 9n ma1or burns, hy!o!roteinemia, and in !articular hy!oalbuminemia, in%ariably de%elo!s as a conse(uence of the acute !hase res!onse" Ahether crystalloid resuscitation e acerbates hy!oalbuminemia, and the clinical rele%ance thereof, remains to be elucidated" Conetheless, it a!!ears that crystalloid resuscitation may lead to greater edema formation than other regimens, but again the clinical rele%ance of this is uncertain" Colloid 5esuscitation /lasma !roteins generate the in)ard oncotic force that counteracts the out)ard intra%ascular hydrostatic force, as dictated by Starling3s la) of the ca!illaries" Aithout !rotein, intra%ascular %olume could not be maintained" /rotein re!lacement )as an integral com!onent of early formulas for burn resuscitation" The E%ans formula uses , m&<$g body )eight !er !ercent TBSA burned each for colloid and crystalloid o%er the first ?4 hours (see

Table G',)" 9n the original Broo$e Army 6os!ital formula, :"; m&<$g !er !ercent TBSA burned )as administered as colloid and ,"; m&<$g !er !ercent TBSA burned as crystalloid (see Table G',)" Considerable confusion and some contro%ersy e ist concerning the role of !rotein, s!ecifically albumin, in burn shoc$ resuscitation" There are three a!!roaches@ ," /rotein solutions are not gi%en in the first ?4 hours because during this !eriod they are no more effecti%e than crystalloid in maintaining intra%ascular %olume" ?" /roteins, s!ecifically albumin, should be gi%en from the beginning of resuscitation )ith crystalloid" 3" /rotein should not be gi%en bet)een 7 to ,? hours !ostburn because of the massi%e fluid shifts during this !eriod, after )hich they should be used" Multi!le colloid solutions are a%ailable, each )ith s!ecific effects, ris$s, and benefits" 6eat' fi ed !lasma !rotein solutions (e"g", /lasmanate) contain denatured and aggregated !rotein fractions, )hich diminish their o%erall oncotic effect" Albumin solutions and hetastarch, a synthetic !olysaccharide colloid, are similar in their oncotic acti%ity" .resh fro+en !lasma (../) contains all the !rotein fractions that e ert oncotic and nononcotic functions" The o!timal amount of !rotein<colloid for burn shoc$ resuscitation, if any, remains undefined" Albumin is the !rinci!al colloid used clinically and re!orted in studies" More recently, ../ (G; m&<$g !er ?4 hours) combined )ith &5 solution (? &<?4 h) )as studied during burn shoc$ F: (see Table G',)" The estimated %olume of ../ is calculated, but the actual %olume infused is titrated to maintain an ade(uate urine out!ut" The authors es!ouse the use of ../ to decrease resuscitation %olumes, limit )eight gain, and reduce edema2 ho)e%er, no clinically meaningful benefit or difference )as reali+ed )ith the use of ../" Many burn centers use some form of colloid at some !oint during burn shoc$ resuscitation, but )ithout su!!orting le%el 9 data" 9n fact, as mentioned !re%iously, le%el 9 data e ist to the contrary" Conetheless, it does a!!ear that albumin is not associated )ith increased mortality )hen used in burn resuscitation" F, 6y!ertonic Saline The resuscitation of burn !atients )ith a salt solution of ?4: to 3:: mE(<& of sodium, rather than &5, )as concei%ed as a means to reduce edema (o)ing to the smaller total fluid re(uirements) )hile ensuring !erfusion" Earious a!!roaches using hy!ertonic solutions ha%e been !ro!osed (see Table G',)" /hysiologically, a shift of intracellular )ater into the e tracellular s!ace occurs as the result of the hy!ertonic'hy!erosmolar solution" Thus, e tracellular fluid increases as intracellular fluid decreases, gi%ing the a!!earance of less edema" Se%eral studies ha%e re!orted that this intracellular )ater de!letion is a!!arently not detrimental, but the conce!t remains contro%ersial" Current recommendations are that the serum sodium le%els should not e ceed ,8: mE(<d&" 9nitial animal models and nonrandomi+ed clinical trials a!!eared to substantiate this a!!roach" 6o)e%er, t)o recent !ros!ecti%e randomi+ed clinical trials and a systematic re%ie) failed to demonstrate any benefit to hy!ertonic saline resuscitation" F?IF4 9n fact, Bortolani and Barisoni found increased mortality )ith hy!ertonic saline in the more se%erely burned !atients they studied" F3 6y!ertonic resuscitation may !ro%e beneficial to selected burn !atients2 ho)e%er, this subset of !atients has not been defined, and currently hy!ertonic saline resuscitation remains

e !erimental" #e tran #e tran is a colloid consisting of glucose molecules that ha%e been !olymeri+ed into chains to form high'molecular')eight !olysaccharides" This com!ound is a%ailable commercially in a number of molecular si+es" #e tran )ith an a%erage molecular )eight of 4: $d is referred to as lo) molecular )eight de tran (&MA#)" #e tran is e creted by the $idneys, )ith a!!ro imately 4:- being remo%ed )ithin ?4 hours and the remainder slo)ly metaboli+ed" #emling and associates used de tran G: and &MA# in o%ine models to limit edema in nonburned tissues" F;,F8 #e tran G: !re%ented edema formation, but )as associated )ith increased !rotein losses from burned tissue" &MA# im!ro%ed microcirculatory flo) by decreasing red blood cell aggregation, and the net fluid re(uirements )ith &MA# )ere about half those noted )ith &5 solution alone" Thus, they !ro!osed a resuscitation formula em!loying &MA# in saline, &5, and ../ as outlined in Table G'," .inally, in a !ros!ecti%e randomi+ed trial, de tran G: offered no benefit o%er crystalloid resuscitation )ith &5" FG #e tran is not currently used for burn resuscitation" S!ecial Considerations in Burn Shoc$ 5esuscitation /ediatric .luid 5esuscitation The burned child re!resents a s!ecial challenge, as resuscitation must be much more !recise than that for an adult )ith a similar burn" F7 Children )eighing less than ?: $g ha%e limited !hysiologic reser%es, es!ecially )ith res!ect to glucose" As such, most smaller children, and !articularly those )eighing less than ?: $g, re(uire the addition of glucose'based maintenance fluids to the calculated resuscitation %olumes, or !rofound hy!oglycemia )ill ensue o)ing to minimal glycogen reser%es" Maintenance fluids may be administered intra%enously using a de trose'balanced salt solution or as enteral feeds" Children re(uire relati%ely more fluid on a !er $ilogram basis for burn shoc$ resuscitation than adults, )ith resuscitation fluid re(uirements for children a%eraging a!!ro imately 8 m&<$g !er !ercent TBSA of burn" FF This is most li$ely reflecti%e of the near t)ofold increase in urine out!ut (,": to ,"; m&<$g body )eight !er hour) re(uired to ensure ade(uate end'organ !erfusion in children" Conetheless, general resuscitation formulas, e cluding maintenance fluid thera!y, are similar for children and adults, but children commonly re(uire formal resuscitation for relati%ely small burns of ,: to ?:- TBSA" Thus, the TBSA threshold for burn center referral of children is lo)er than that for adults" 9nhalation 9n1ury 9nhalation in1ury undoubtedly increases the fluid re(uirements for successful resuscitation follo)ing thermal in1ury" /atients )ith documented inhalation in1ury re(uire a!!ro imately ,"; times the resuscitation %olumes com!ared to !atients )ithout inhalation in1ury" ,:: 9nhalation in1ury accom!anying thermal trauma increases the magnitude of the total body in1ury %ia dis!ro!ortionate increases in systemic inflammation" 9n%asi%e 6emodynamic Monitoring The use of !ulmonary artery catheters (/ACs), )ith or )ithout goal'directed thera!y, has not

ty!ically been !art of burn shoc$ resuscitation" Conetheless, certain !atients may benefit from in%asi%e hemodynamic monitoring to try and !recisely direct their resuscitation" 9t is generally acce!ted that !atients )ith $no)n significant !remorbid cardiac or !ulmonary disease, associated inhalation in1ury, or concomitant nonthermal trauma, as )ell as the elderly might re(uire /AC monitoring during burn resuscitation" >oal'directed, hemodynamic resuscitation in burn !atients has met )ith mi ed results" ,:,,,:? As in trauma and surgical critical care !atients, it is li$ely that attainment of hemodynamic goals merely re!resents sufficient !hysiologic reser%e to sur%i%e the in1ury, and not s!ecific salutary effects of the thera!y" ,:3 9n fact, hemodynamic resuscitation of burn shoc$ is uni%ersally associated )ith substantially increased fluid %olumes and !redis!oses to com!lications of o%erresuscitation" 0%erresuscitation .ailure to institute a!!ro!riate early fluid resuscitation follo)ing thermal in1ury is associated )ith substantially )orse outcomes" Aith modern burn care in the Bnited States, this has become the rare e ce!tion, e cluding international transfers from de%elo!ing countries" 9n fact, many burn !atients may actually be o%erresuscitated" ,:4 S!ecific com!lications ha%e emerged that a!!ear to only be attributable to e cessi%e resuscitation" /rior to the early ,FF:s, abdominal com!artment syndrome (ACS) )as %irtually unheard of follo)ing thermal in1ury" 5e!orts and studies of ACS ha%e increasingly a!!eared in the literature since that time, and it is no) discussed as if it is an uncommon, but )ell recogni+ed and acce!ted, conse(uence of thermal trauma" ,:;I,:7 6o)e%er, this begs the (uestion, *9f ACS is a ty!ical conse(uence of ma1or thermal in1ury resuscitation, then )hy )as it not described !rior to the ,FF:sP* ACS is !re%entable and iatrogenic in the %ast ma1ority of !atients, o)ing to in1udicious resuscitation" 6o)e%er, there is a small minority of !atients in )hom o%er)helming %olumes (D,"; times !redicted %olume) are re(uired, for as yet unclear reasons, to ensure successful resuscitation" 9n our e !erience )ith these select !atients, !lasma!heresis (i"e", !lasma e change thera!y) has emerged as a useful resuscitation ad1unct to minimi+e further fluid re(uirements once a !atient has demonstrated refractoriness to standard resuscitation" Tana$a and colleagues re!orted the successful use of high'dose (88 mg<$g !er hour for ?4 hours) intra%enous %itamin C to reduce resuscitation %olumes in !atients sustaining ma1or burns, )ith an a!!arent decrease in edema'related com!lications and mechanical %entilation times" ,:F Early and appropriate resuscitation follo)ing ma1or thermal in1ury is of !aramount im!ortance to ensure a good outcome2 ho)e%er, o%erresuscitation may !roduce com!lications that nullify the gains" Choice of .luids and 5ate of Administration All of the solutions re%ie)ed are effecti%e in restoring tissue !erfusion" Most !atients can be resuscitated )ith crystalloid, s!ecifically lactated 5inger3s solution" Cormal saline should be a%oided, as the %olumes re(uired for resuscitation in%ariably lead to a com!licating hy!erchloremic metabolic acidosis" 9n !atients )ith massi%e burns, young children, and burns com!licated by se%ere inhalation in1ury, a combination of fluids can be used to achie%e the desired goal of end'organ !erfusion )hile minimi+ing edema" 5esuscitation formulas should only be considered general guidelines for burn shoc$ resuscitation" The /ar$land formula, for instance, decreases the %olume administered by ;:at 7 hours !ostburn" The relationshi! bet)een %olume re(uired and time !ostburn, de!icted

by the smooth cur%e in .ig" G'? re!resents the influence of tem!oral changes in micro%ascular !ermeability and edema formation on fluid re(uirements" The gentle changes de!icted by the cur%e are in shar! contrast )ith the abru!t changes in the fluid infusion rate !rescribed by the /ar$land formula" Bltimately, the %olume and rate of infused fluid should maintain a urine out!ut of 3: m&<h in adults ( :"; m&<$g !er hour), )ith lo)er limits acce!table in the face of $no)n renal insufficiency, and ,": to ,"; m&<$g !er hour in children" .9>" G'?"

/hysiologic cur%e of fluid re(uirements com!ared )ith the /ar$land formula for calculating !ostburn fluid re!lacement" 5esuscitation is considered successful )hen there is no further accumulation of edema, usually bet)een ,7 and ?4 hours !ostburn, and the %olume of infused fluid re(uired to maintain ade(uate urine out!ut a!!ro imates the !atient3s maintenance fluid %olume, )hich is normal maintenance %olume !lus e%a!orati%e )ater loss" .luid 5e!lacement .ollo)ing Burn Shoc$ 5esuscitation The in1ured micro%asculature may manifest increased !ermeability for se%eral days follo)ing successful resuscitation, but the rate of fluid loss is considerably less than that seen in the first ?4 hours" ,,: Burn edema formation at ?4 hours !ostburn is nearly ma imal, and the interstitial s!ace may )ell be saturated" Additional fluid re(uirements de!end on the ty!e of fluid used during the initial resuscitation" 9f hy!ertonic saline resuscitation )as used, a hy!erosmolar state results, and the addition of free )ater is re(uired to restore isosmolarity" 9f colloid )as not used during resuscitation and the serum oncotic !ressure is lo) because of intra%ascular !rotein de!letion<dilution, su!!lementation may be needed" /rotein su!!lementation re(uirements %ary )ith the resuscitation used" The Broo$e formula !ro!oses :"3 to :"; m&<$g !er !ercent TBSA burned of ;- albumin during the second ?4 hours !ostburn" The /ar$land formula re!laces the remaining !lasma %olume deficit, )hich %aries from ?: to 8:- of the total circulating !lasma %olume, )ith colloid" Colloid re!lacement should be used s!aringly, in the form of albumin, and only after ?4 hours !ostburn" 5egardless of )hether colloid is used or not, !atients should recei%e a!!ro!riate maintenance fluids" The total daily maintenance fluid re(uirement in the adult !atient is calculated by the follo)ing formula, )here m? is s(uare meters of TBSA@

This fluid may be gi%en intra%enously or enterally" A general guideline is that a !atient )ill re(uire a!!ro imately ,"; times their normal maintenance fluids follo)ing successful resuscitation from a ma1or thermal in1ury" The solution infused intra%enously should be one

half normal saline )ith !otassium su!!lements" Because of the loss of intracellular !otassium during burn shoc$, the !otassium re(uirement in adults )ith normal renal function is a!!ro imately ,?: mE(<d" After initial resuscitation, urine out!ut alone is an unreliable guide to sufficient hydration" 5es!iratory )ater losses, osmotic diuresis secondary to hy!erglycemia, high'!rotein<high' calorie enteral nutrition, and derangements in antidiuretic hormone (A#6) mechanisms contribute to increased fluid losses des!ite a!!arently ade(uate urine out!ut" Adult !atients )ith ma1or thermal in1uries re(uire a urine out!ut of a!!ro imately ,::: to ,;:: m&<?4 h2 children re(uire a!!ro imately 3 to 4 m&<$g !er hour a%eraged o%er ?4 hours" The measurement of serum sodium concentration is not only a means of diagnosing dehydration, but is a good guide for estimating and managing ongoing fluid re!lacement" 0ther useful indices of the state of hydration include body )eight change, fractional e cretion of sodium (.ECa), serum and urine nitrogen concentrations, serum and urine glucose concentrations, the inta$e and out!ut record, and clinical e amination" Serum electrolytes, calcium, magnesium, and !hos!hate le%els should also be monitored and maintained )ithin normal limits" 9nhalation 9n1ury 0f some 4;,::: fire %ictims admitted to hos!itals each year, a!!ro imately 3:- sustain smo$e or thermal damage to the res!iratory tree" Carbon mono ide (C0) !oisoning, thermal in1ury, and smo$e inhalation are three distinct as!ects of clinical inhalation in1ury" Although the sym!toms and treatment of each %ary, the distinct in1uries may coe ist and re(uire concomitant treatment" Carbon Mono ide /oisoning The ma1ority of house fire deaths can be attributed to C0 !oisoning" C0 is a colorless, odorless, and tasteless gas )ith an affinity for hemoglobin (6b) a!!ro imately ?:: times that of o ygen" Ahen inhaled and absorbed, C0 binds to 6b to form carbo yhemoglobin (C06b)" C06b interferes )ith o ygen deli%ery to the tissues by at least fi%e mechanisms" .irst, it !re%ents re%ersible dis!lacement of o ygen on the 6b molecule" Second, C06b shifts the o ygen'6b dissociation cur%e to the left, thereby decreasing o ygen unloading from normal hemoglobin at the tissue le%el" ,,, Third, C0 binds to reduced cytochrome a3, resulting in less effecti%e intracellular res!iration" ,,? .ourth, C0 can bind to cardiac and s$eletal muscle, resulting in direct to icity" ,,3 .inally, C0 can act in the central ner%ous system in a !oorly understood fashion, causing demyelination and associated neurologic sym!toms" ,,4 &e%els of C06b are easily measured, but the degree of im!airment may not directly correlate )ith blood le%els of C06b" ,,; &e%els less than ,:- ty!ically do not cause sym!toms" At a C06b le%el of a!!ro imately ?:-, healthy !ersons com!lain of headache, nausea, %omiting, and loss of manual de terity" At a!!ro imately 3:-, !atients become )ea$, confused, and lethargic" 9n a fire, this le%el can be fatal because the %ictim loses the desire and ability to flee" At le%els of 4: to 8:-, the !atient la!ses into a coma, and le%els greater than 8:- are usually fatal" 9n %ery smo$y fires, C06b le%els of 4: to ;:- can be reached after only a fe) minutes of e !osure" C0 is re%ersibly bound to the heme molecules of 6b, and des!ite intense affinity, readily

dissociates according to the la)s of mass action" The half'life (t,<?) of C06b )hen breathing room air is a!!ro imately 4 hours" 0n ,::- o ygen, the t,<? is reduced to 4; to 8: minutes" ,,8 9n a hy!erbaric o ygen chamber at ? atm, it is a!!ro imately 3: minutes, and at 3 atm it is about ,; to ?: minutes" The im!ortance of C0 !oisoning in %ictims of inhalation in1ury )as dramatically demonstrated in the ,FGF M>M >rand 6otel and ,F7, 6ilton 6otel fires in &as Eegas, Ce%ada" Although only a small number of thermal in1uries occurred, ,?3 !eo!le died at the scene, !rimarily from C0 !oisoning" At the same time, the efficacy of !rom!t assessment and treatment of inhalation in1ury )as demonstrated" 0f more than 4:: indi%iduals )ho recei%ed hos!ital e%aluation for inhalation in1ury, mortality )as less than ,-, )hile the rate of significant com!lications including myocardial infarction, res!iratory failure, and !neumonia )as ,- each" #iagnosis and Treatment /atients burned in an enclosed s!ace or ha%ing any signs or sym!toms of neurologic im!airment should be !laced on ,::- o ygen %ia a nonrebreather face mas$ )hile )aiting for measurement of C06b le%els" The use of !ulse o imetry (S!0?) to assess arterial o ygenation in the C0'!oisoned !atient is contraindicated, as the C06b results in erroneously ele%ated S!0? measurements" ,,G 9f intubation is re(uired, then hy!er%entilation )ith ,::- o ygen should be instituted" The use of hy!erbaric o ygen (6B0) thera!y remains contro%ersial" Early human studies of 6B0 thera!y in acute C0 !oisoning !roduced mi ed results" ,,7 T)o recent )ell'designed, !ros!ecti%e, randomi+ed clinical trials com!ared normobaric o ygen thera!y to 6B0 thera!y in !atients suffering C0 !oisoning without concomitant burns. ,,F,,?: Schein$estel and associates from Australia demonstrated no benefit, and !ossible ad%erse conse(uences, of 6B0 on neuro!sychologic outcomes follo)ing acute, se%ere C0 !oisoning" ,,F Con%ersely, Aea%er and colleagues from Salt &a$e City, Btah, sho)ed a significant im!ro%ement in cogniti%e outcomes )ith the use of 6B0" 9t should be noted that the inclusion criteria, and !articularly the 6B0 !rotocols, )ere different bet)een these t)o studies, ma$ing com!arison difficult" The (uestion remains as to )ho )arrants 6B0 thera!y, under )hat !rotocol, and )hat )ill be the antici!ated outcome" ,?, Ahile 6B0 thera!y may be innocuous in isolated C0 !oisoning, in the !resence of concomitant burns and smo$e inhalation, the rate of catastro!hic com!lications during treatment in the hy!erbaric chamber is !otentially (uite high" ,?? 5esuscitation and early enteral nutrition efforts )ith close monitoring, so instrumental to a good outcome )ith modern burn care, can be se%erely ham!ered or im!ossible )hile a !atient is in the chamber" .urthermore, interfacility trans!ort of a critically burned !atient sub1ects them to many !otential com!romises in care" To date, no !ros!ecti%e randomi+ed trial in !atients )ith C0 !oisoning and thermal in1ury has been conducted" Thus, 6B0 thera!y in burn !atients )ith C0 !oisoning is of un$no)n thera!eutic %alue or efficacy, and should only be utili+ed )hen@ (,) the C06b is greater than ?;-, (?) a neurologic deficit e ists, (3) no formal burn resuscitation is re(uired (ty!ically TBSA Q,: to ,;-), (4) !ulmonary function is stable )ith an intact air)ay, and (;) interfacility transfer does not com!romise burn care" ,?3 Thermal Air)ay 9n1ury

The term *!ulmonary burn* is a misnomer" True thermal damage to the lo)er res!iratory tact and !ulmonary !arenchyma is e tremely rare, unless li%e steam or e !loding gases are inhaled" The air tem!erature near the ceiling of a burning room may reach ;4:HC (,:::H.) or more, but air has such !oor heat'carrying ca!acity that most of the heat is dissi!ated in the oro!haryn , naso!haryn , and u!!er air)ay" Thus the heat dissi!ation in the u!!er air)ay can cause significant thermal in1ury to the !ro imal tracheobronchial tree" Thermal in1ury to the res!iratory tract is usually immediate and manifests as mucosal and submucosal erythema, edema, hemorrhage, and ulceration" ,?4 Thermal in1ury is usually limited to the u!!er air)ay (abo%e the %ocal cords) and !ro imal trachea for t)o reasons@ (,) the oro!haryn and naso!haryn !ro%ide an effecti%e mechanism for heat e change because of their relati%ely large surface area, associated air turbulence, and mucosal fluid lining that acts as a heat reser%oir2 and (?) sudden e !osure to hot air ty!ically triggers refle closure of the %ocal cords, reducing the !otential for lo)er air)ay in1ury" Animal models ha%e demonstrated that significant heat e change also occurs in the subglottic air)ay bet)een the %ocal cords and the tracheal bifurcation, )ith !rotection and s!aring of the distal air)ays" Thus the lo)er tracheobronchial tree is rarely e !osed to hot, ambient gas at a fire scene" An e ce!tion is the inhalation of su!er'heated steam, )here because of heat dissi!ation in the res!iratory tract as the steam condenses into )ater, se%ere in1ury has been re!orted in the distal air)ays )ith measurable in1ury in the al%eoli" 9n these !atients the lo)er tracheobronchial tree is ra!idly obstructed, and they usually die from untreatable as!hy iation" /atients )ith the greatest ris$ of u!!er air)ay obstruction are those in1ured in an e !losion, )ith burns of the face and u!!er thora , and those )ho ha%e been unconscious in a fire" Mucosal burns of the mouth, oro!haryn , naso!haryn , and laryn result in edema formation and may lead to u!!er air)ay obstruction at any time follo)ing the in1ury, but !articularly during the first ?4 hours !ostburn" Any !atient )ith burns of the face should ha%e a careful e amination of the mouth and !haryn , and if these are abnormal, the laryn should also be %isuali+ed immediately" 5ed, dry mucosa or small mucosal blisters raise the !ossibility of direct thermal in1ury and !otential air)ay obstruction" The !resence of significant intraoral and !haryngeal burns is a clear indication for immediate endotracheal intubation, as !rogressi%e edema can ma$e later intubation e tremely ha+ardous, if not im!ossible" Mucosal burns are rarely full'thic$ness, and can be successfully managed )ith good oral hygiene" 0nce the !atient is intubated, the tube should remain in !lace until the edema subsides, as manifested by a %igorous cuff lea$ u!on deflation in adults" Steroids ha%e no !lace in the management of u!!er air)ay edema resulting from thermal in1ury" Smo$e 9nhalation A nightclub fire in #ublin, 9reland, in ,F7, added a great deal to the understanding of smo$e inhalation in1ury because the disaster site )as meticulously reconstructed and the e%ent reenacted for scientific analysis" Aithin minutes, %isibility )as reduced to less than , m and ambient tem!eratures reached ,,8:HC" Cear the fire, dramatic changes in inhaled gas concentrations )ere noted@ o ygen )as reduced to less than ?-, C0 increased to greater than 3-, hydrogen cyanide )as measured at ?;: !!m (it is lethal at D,:: !!m), and hydrogen chloride )as measured at 7;:: !!m" 6ydrogen cyanide, a common !roduct of the combustion of !olyurethane and nitrogen'

containing !olymers, is an e%en more effecti%e inhibitor of cellular res!iration than C0, and also interferes )ith o ygen utili+ation at the tissue le%el" By inhibiting the final ste! of o idati%e !hos!horylation %ia re%ersible inhibition of cytochrome o idase, cyanide halts aerobic metabolism, inducing lactic acidosis and cellular ano ia" Cyanide is e (uisitely in1urious to tissues )ith minimal anaerobic reser%e e"g", the CCS" Combined e !osure to cyanide and C0 results in a ra!idly fatal synergistic decrease in tissue o ygen utili+ation" 6undreds of to ic !roducts are released during combustion (flaming) or !yrolysis (smoldering), de!ending on the ty!e of fuel burned, the o ygen content of the en%ironment, and the actual tem!erature of burning" Some ?7: to ic substances ha%e been identified in )ood smo$e alone" /etrochemical science has !roduced a )ealth of !lastic materials used in homes and automobiles, that )hen burned, !roduce nearly all of these substances, and many other !roducts not yet characteri+ed" /rominent by'!roducts of incom!lete combustion are o ides and hydrogenated moieties of sulfur and nitrogen, as )ell as numerous aldehydes" 0ne aldehyde, acrolein (from acrylics, !oly!ro!ylene, and cellulose), causes se%ere !ulmonary edema in atmos!heric concentrations of ,: !!m or less" After inhalation, highly soluble acidic and basic com!ounds ra!idly dissol%e in the )ater lining the mucosa of the res!iratory tract, causing direct e!ithelial in1ury, manifested as e!ithelial edema, submucosal hemorrhage, and necrosis" E!ithelial in1ury can occur at all le%els of the res!iratory tract, from oro!haryn to al%eolus" The anatomic le%el at )hich the damage occurs is de!endent on the %entilatory !attern, the smo$e com!osition (i"e", !articulate concentration, !article si+e, and chemical com!onents), and the distribution of !article de!osition" .at'soluble com!ounds tend to do more damage in the distal air)ay and al%eolus" Although the chemical mechanisms of in1ury may be different among to ic !roducts, the o%erall end'organ res!onse is relati%ely homogeneous and reasonably )ell defined" ,?;,,?8 There is an immediate loss of bronchial e!ithelial cilia and decreased al%eolar surfactant le%els" Atelectasis results, com!ounded by small'air)ay edema, and is only slo)ly re%ersed by normal %entilation" This regional hy!o%entilation results in )orsening atelectasis, intra!ulmonary shunt, and subse(uent hy!o emia" Chemical irritation of the res!iratory tract incites a locali+ed acute inflammatory res!onse" The initial res!onse is an a!!ro imate ,:'fold increase in bronchial blood flo)" Concurrently, al%eolar macro!hages are stimulated and release cyto$ines, )hich acti%ate circulating neutro!hils that locali+e to the site of in1ury and release reacti%e o ygen s!ecies and !roteases, resulting in increased !ulmonary micro%ascular !ermeability" The de%elo!ment of air)ay edema, combined )ith the sloughing of necrotic e!ithelium and im!airment of the mucociliary clearance of secretions, !roduces air)ay obstruction in small and large air)ays" The result is heterogeneous %entilation, and the mismatch bet)een %entilation and !erfusion leads to hy!o emia" Ahee+ing and air hunger are common early manifestations of inhalation in1ury" The !ulmonary !arenchymal damage associated )ith inhalation in1ury a!!ears to be dose de!endent" ,?G Aithin a fe) hours, tracheobronchial e!ithelium sloughs, and a hemorrhagic tracheobronchitis de%elo!s" 0ngoing neutro!hil acti%ation leads to further !ulmonary endothelial disru!tion2 concomitantly, !ulmonary lym!h flo) increases, )ith both enhancing !ulmonary edema" 9n se%ere cases, the hemorrhagic tracheobronchitis and air)ay !lugging result in e treme %entilation deficits, and !atients succumb to a se%ere res!iratory acidosis because of their inability to clear C0?" 9n other cases, !articularly those associated )ith

thermal in1ury, interstitial edema becomes most !rominent, resulting in acute res!iratory distress syndrome (A5#S) and o ygenation difficulties" Concomitant cutaneous thermal in1ury results in the systemic release of inflammatory mediators, including !rostaglandins and reacti%e o ygen intermediates (509s) that can aggra%ate !ulmonary in1ury inde!endent of smo$e inhalation" ,?7 9n !articular, thrombo ane'A? released from burned tissue causes a %ariety of changes in the lung, including !ulmonary hy!ertension, reduced dynamic com!liance, and increased li!id !ero idation" 509s generated as a conse(uence of neutro!hil acti%ation and increases in anthine o idase contribute to lung in1ury" #ecreased !lasma oncotic !ressure, from the loss of !lasma !roteins %ia increased micro%ascular !ermeability in both burned and unburned tissue, creates an abnormal !ressure gradient in the !ulmonary circulation that results in !ulmonary edema" These changes hel! e !lain the degree of synergy in cases of combined inhalation and burn in1uries" Early in the course of inhalation in1ury, !ulmonary function is %ariable" ,?F Classically, decreased functional residual ca!acity (.5C), decreased %ital ca!acity, and e%idence of obstructi%e disease )ith reduction in flo) rates, an increase in dead s!ace, and a ra!id decrease in com!liance occur" Much of the %ariability in !ulmonary res!onse a!!ears to be related more to the se%erity of the associated cutaneous burn than to the degree of smo$e inhalation" Aithout associated cutaneous thermal in1ury, the mortality from isolated inhalation in1ury is (uite lo)" The disease rarely !rogresses to A5#S, and sym!tomatic treatment usually leads to com!lete resolution of sym!toms in a fe) days" 6o)e%er, in the !resence of burns, inhalation in1ury a!!ro imately doubles the mortality rate from burns of any si+e" /ulmonary sym!toms are usually !resent on admission, but they may be delayed for ,? to ?4 hours follo)ing in1ury" #iagnosis The incidence of smo$e inhalation in1ury in %ictims of fire %aries )ith diagnostic criteria" ,3: The incidence may be as lo) as ? to ,;- )hen single or restricti%e criteria based on history and !hysical e amination are used, but as high as 3:- )hen based on ob1ecti%e tests such as fibero!tic bronchosco!y (.0B)" The o%erall incidence of smo$e inhalation in the Bnited States has fallen o%er the !ast 3 decades, !rimarily because of the use of home smo$e detectors" Anyone )ith a flame burn sustained in an enclosed s!ace should be assumed to ha%e an inhalation in1ury until !ro%ed other)ise" The acrid smell of smo$e on the %ictim3s clothes should raise immediate sus!icion" 9n obtaining a history, em!hasis should be !laced on findings s!ecific to the smo$e e !osure and to the ty!e of thera!y instituted !rior to hos!itali+ation" Ahen e !osure occurs in a closed s!ace, such as a building or an automobile, the smo$e is less diluted by ambient air, resulting in greater !ulmonary e !osure to C0 and other smo$e constituents than in an o!en's!ace e !osure" The duration of e !osure correlates )ith the se%erity of lung in1ury" A thorough e amination should be !erformed and include e%aluation of the face and oro!haryngeal air)ay for hoarseness, stridor, edema, or soot im!action suggesting in1ury2

chest auscultation for )hee+ing or rhonchi suggesting in1ury to distal air)ays2 le%el of consciousness associated )ith decreased )ith hy!o emia, C0 !oisoning, or cyanide !oisoning2 and testing for the !resence of neurologic deficits associated )ith C0" Co!ious mucus !roduction and carbonaceous expectorated s!utum are hard signs of inhalation in1ury, but their absence does not rule out in1ury" C06b le%els should be obtained2 an ele%ated C06b or any sym!toms of C0 !oisoning are !resum!ti%e e%idence of associated smo$e inhalation" Anyone sus!ected of smo$e inhalation should ha%e an arterial bloodgas dra)n" 0ne of the earliest indicators of in1ury is a decreased /@. ratio, the ratio of arterial o ygen !ressure (/a0?) to ins!ired o ygen as assessed by !ulse o imetry (.90?)" A ratio of about 4:: is normal2 !atients )ith im!ending !ulmonary !roblems ha%e a ratio of less than 3:: (e"g", a /a0? of Q,;: )ith an .90? of :";:)" A /@. ratio less than ?;: is an indication for %igorous !ulmonary thera!y and intubation, not an indication for merely increasing the .90?" A /@. ratio less than ?:: defines A5#S" The early need for bronchosco!ic e%aluation and diagnosis remains contro%ersial" Some recommend the routine use of .0B, noting that it is ine !ensi%e, (uic$ly !erformed in e !erienced hands, and is highly useful in assessing air)ay in1ury, if not the gold standard" ,3:,,3, " ,3? 6o)e%er, aside from documenting the !resence of edema, tracheal erythema, and<or carbon de!osits, .0B does not materially influence the treatment of smo$e inhalation" 9t is o!erator'de!endent and not ris$'free" 9n addition, yield )ith .0B a!!ears to be strongly de!endent u!on clinical sus!icion (i"e", !retest !robability) of inhalation in1ury" >i%en these limitations, it is recommended that a history, !hysical e amination, and laboratory studies be used to ma$e the diagnosis of inhalation in1ury, and the use of .0B be reser%ed for e ce!tional cases re(uiring thera!eutic .0B (e"g", e !ansion of lobar colla!se or remo%al of obstructing intrabronchial secretions or casts)" Treatment B!!er Air)ay Co standard treatment has e%ol%ed to ensure sur%i%al after smo$e inhalation" 9n the !resence of increasing oro!haryngeal and laryngeal edema, ra!id endotracheal intubation is indicated" A tracheostomy is ne%er an emergency !rocedure and should not be used as the initial ste! in air)ay management, es!ecially in !atients )ith burns to the face and nec$" 9nstead, a soft' cuffed endotracheal tube should be inserted and left in !lace until the edema subsides" An adult !atient3s ability to breathe around the tube )ith the cuff deflated is an indication for remo%al of the tube" This assessment is difficult in children due to their smaller anatomy, the use of uncuffed endotracheal tubes, the increased incidence of !oste tubation stridor, and the fre(uent need for reintubation" ,33 The incidence of !oste tubation stridor in burn %ictims is as high as 4G-, com!ared to 4- in electi%e surgical !atients" The treatment of !oste tubation stridor includes the administration of nebuli+ed racemic e!ine!hrine and helium'o ygen (helio ) mi tures" ,34 Steroids are ne%er used" &o)er Air)ay and Al%eoli Tracheobronchitis, commonly seen )ith inhalation in1ury, !roduces )hee+ing, coughing, and retained secretions" The %entilation'!erfusion mismatch !resent in these !atients can result in

mild to moderate hy!o emia, %arying )ith the degree of !remorbid lung disease2 therefore su!!lemental o ygen should be administered routinely" 9ncreased air)ay resistance is more often the result of edema and retained secretions than true bronchos!asm" Although a trial of bronchodilators is indicated in those !atients )ith !remorbid bronchos!astic disease, the o%erall efficacy is (uestionable" 9nhaled beta? agonists, racemic e!ine!hrine, terbutaline, or theo!hylline are used most commonly" The usual !resenting sign of distal air)ay in1ury is hy!o emia, diagnosed by !ulse o imetry or arterial blood gas" Because most inhalation %ictims recei%e su!!lemental o ygen, significant al%eolar'arterial o ygen gradients can be missed by !ulse o imetry2 an S!0? less than F;- does not occur until the /a0? is less than 7: mm 6g" Arterial blood gas analysis is the monitoring modality of choice in assessing o ygenation after inhalation in1ury" 5emember that C06b can erroneously ele%ate S!0?" 9nitial thera!y should al)ays include the administration of high'flo) o ygen, to augment systemic o ygenation and reduce C06b in cases of C0 !oisoning" B!!er air)ay !atency absolutely must be assured, and air)ay resistance minimi+ed )ith chest !hysiothera!y and<or bronchodilators" Central hy!o%entilation caused by C0 or cyanide !oisoning should be treated immediately as !re%iously described" 0%erall treatment for smo$e inhalation is su!!orti%e, )ith the goal being maintenance of ade(uate o ygenation and %entilation until the lungs heal" Mild cases are treated )ith humidified o ygen, %igorous !ulmonary toilet, and bronchodilators as needed" The need for mechanical %entilation is determined by re!eated blood gas measurements demonstrating refractory hy!o emia" Because of the fre(uent !resence of atelectasis after al%eolar e !osure to smo$e, !ositi%e end'e !iratory !ressure (/EE/) can be (uite useful in recruiting atelectatic regions and increasing .5C, thus increasing o ygenation" Eentilator tidal %olumes should be chosen so that !lateau !ressures are consistently less than 3; cm 6?0, ty!ically achie%ed )ith about 8 m&<$g ideal body )eight, in order to limit barotrauma" The !recise mode of initial mechanical %entilation a!!ears less im!ortant than ensuring a lung !rotecti%e strategy" 6igh'fre(uency !ercussi%e %entilation (6./E) has been utili+ed in burn !atients )ith inhalation in1ury" 6./E a!!ears to !ro%ide su!erior o ygenation at a lo)er .90?, )ith lo)er air)ay !ressures than con%entional mechanical %entilation (CME)" 9nitial small cohort studies of 6./E in both adults and children a!!eared !romising, )ith decreased !neumonia and mortality rates, im!ro%ed gas e change and !ulmonary mechanics, and minimal barotrauma )ith %irtually no re!orted ad%erse effects" ,3,,,3;I,37 Many hy!othesi+ed that the benefits of 6./E )ere a!!arently due to enhanced clearance of bronchial secretions" 6o)e%er, in the only !ros!ecti%e randomi+ed controlled trial of 6./E com!ared to CME in inhalation in1ury, 6./E only im!ro%ed the /@. ratio during the first 3 days, )ithout any difference in the other %ariables measured, including !neumonia and mortality" ,3F The management and outcome of inhalation in1ury need to be !ros!ecti%ely e amined using modern lung !rotecti%e %entilation strategies2 )here 6./E )ill fit into a modern a!!roach remains to be seen" 0ther re!orted ad1uncts to a!!ro!riate mechanical %entilation for inhalation in1ury are@ intrabronchial surfactant administration, aerosoli+ed he!arin<acetylcysteine, and e tracor!oreal membrane o ygenation )hen all else fails" ,4:I,44 5esults are encouraging, but the treatments remain e !erimental at this time"

Electi%e tracheostomy in burn !atients remains contro%ersial" Conetheless, if the u!!er air)ay is in danger of imminent obstruction and endotracheal intubation attem!ts are unsuccessful, emergent cricothyroidotomy is indicated, )ith con%ersion to a formal tracheostomy soon thereafter" The indications for nonemergent tracheostomy ha%e changed o%er the last ? decades" After a !eriod in the ,FG:s, )hen tracheostomy )as the standard method of securing the u!!er air)ay after se%ere burn in1ury, se%eral re!orts associated the !rocedure )ith mortality rates ranging from ;: to ,::-, due to a greater incidence of o%er)helming !ulmonary infection" 9m!ro%ements in endotracheal tube construction resulted in s!ecific efforts to a%oid tracheostomy in burn !atients during the ,F7:s" Currently, mortality rates, infectious com!lications, and air)ay se(uelae in adult and !ediatric burn !atients )ith tracheostomy are no different from !atients treated )ith long'term endotracheal tubes" ,4;I,4F .or !atients re(uiring !rolonged endotracheal intubation, tracheostomy should be !erformed at the discretion of the managing burn surgeon" There is no outcome benefit to early tracheostomy in burn !atients" ,;: /atients )ith anterior nec$ burns )ho re(uire tracheostomy should undergo successful e cision and grafting of the area !rior to creation of the stoma" This minimi+es !ulmonary and burn )ound infectious com!lications associated )ith the tracheostomy" /ro!hylactic antibiotics are not indicated )ith inhalation in1ury, )hich is a chemical !neumonitis" ,3: Subse(uent burn )ound management and treatment of e%entual bacterial !neumonia may be made more difficult )ith the early use of antibiotics, as it ra!idly leads to the selection of resistant organisms" ,;, &i$e)ise, steroids are contraindicated )ith inhalation in1ury, although their anti'inflammatory actions )ere originally thought to be hel!ful" 9n a !ros!ecti%e, randomi+ed, controlled, blinded study of !atients )ith inhalation in1ury and ma1or burns, those treated )ith steroids e !erienced a higher mortality rate and more se!tic com!lications than controls not treated )ith steroids" ,;? Aound Management Early E cision and >rafting .or many years, burns )ere treated by daily )ashing (tan$ing), remo%al of loose dead tissue, and to!ical a!!lication of saline'soa$ed dressings until the burns healed !rimarily or granulation tissue a!!eared in the base of the )ound" E!idermal and su!erficial !artial' thic$ness burns healed )ithin 3 )ee$s, and full'thic$ness burns healed o%er many )ee$s if infection )as !re%ented" .ull'thic$ness burns lost their eschar in ? to 8 )ee$s %ia bacterial collagenase !roduction and daily mechanical dRbridements" Ahen the granulating bed became free of debris and relati%ely uninfected, s!lit'thic$ness s$in grafts (STS>s) )ere a!!lied, usually some 3 to 7 )ee$s after in1ury" A ;:- graft ta$e )as considered acce!table" 5e!eated graftings e%entually closed the )ound" The !rolonged and intense inflammatory res!onse )ith this method made hy!ertro!hic scarring and contractures !art of normal burn treatment" Eigorous !hysical thera!y, nutritional su!!ort, !sychologic su!!ort, and !ain management )ere re(uired daily for many )ee$s to yield a satisfactory result" .ortunately, this is no longer standard !rocedure" .or dee!er burns (i"e", dee! !artial' thic$ness and full'thic$ness burns), rather than )aiting for s!ontaneous se!aration, the eschar is surgically remo%ed and the )ound closed %ia grafting techni(ues and<or immediate fla! !rocedures tailored to the indi%idual !atient" This aggressi%e surgical a!!roach to burn )ound management has become $no)n as early e cision and grafting (ES>)" Se%eral technical ad%ances ha%e made this !ossible, including a safer autologous blood su!!ly, better

monitoring e(ui!ment and methods, and a better understanding of the deranged !hysiology of !atients )ith ma1or burns" The ability to stabili+e the !atient )ithin a fe) days of the in1ury has enabled the surgeon to remo%e dee! burn )ounds before in%asi%e infection occurs" The o!timal timing of early ES> has yet to be definiti%ely determined2 ho)e%er, ES> )ithin 3 to G days, and certainly by ,: days, follo)ing in1ury a!!ears !rudent" An aggressi%e surgical a!!roach to large and small burns has !roduced a number of ma1or ad%ancements" 9n fact, early ES> has reduced burn mortality more than any other inter%ention (.ig" G'3)" Early )ound closure also reduces hos!ital stay, duration of illness, se!tic com!lications, and the need for ma1or reconstruction, )hile decreasing hos!ital costs" 44,,;3I,;; Early studies did not demonstrate dramatic differences in cosmetic or functional results, but as surgeons ha%e become more e !erienced )ith early ES>, both im!ro%ed function and a!!earance ha%e resulted" This is !articularly true )ith burns of the face, hands, and feet" ,;8I,8; .9>" G'3"

Effects of %arious inter%entions u!on ;:- mortality rate (&#;:) in burn !atients o%er time" Current Status of Aound Care Solid clinical and e !erimental e%idence su!!ort the follo)ing conclusions@ ," Small (i"e", Q?:-) full'thic$ness burns and burns of indeterminate de!th, if treated by an e !erienced surgeon, can be safely e cised and grafted )ith a decrease in hos!ital stay, costs, and time a)ay from )or$ or school" ?" Early ES> dramatically decreases the number of !ainful dRbridements re(uired" 3" /atients )ith burns of ?: to 4:- TBSA )ill ha%e fe)er infectious )ound com!lications if treated )ith early ES>" 4" 9n animal models, the immunosu!!ression and hy!ermetabolism associated )ith burns can be ameliorated by early burn )ound remo%al" Clinical im!ressions, )ithout hard data su!!orting them, include the follo)ing@ ," Scarring is less se%ere in )ounds closed early, leading to better a!!earance and fe)er reconstructi%e !rocedures" There is no good measure of *acce!table* cosmetic a!!earance, and com!arati%e studies a)ait a consistent scale to measure results" ?" Mortality from )ound infection is lo)er in !atients )ith ma1or burns after early e cision" Because )ounds e ceeding donor s$in a%ailability cannot be closed com!letely until donor sites can be rehar%ested, definiti%e !roof )ill come only )hen a durable !ermanent co%ering (i"e", s$in substitute) can be a!!lied in a timely fashion" 3" Mortality from other com!lications of ma1or burns may be lo)er )ith early ES>" Ameliorating the stress, hy!ermetabolism, and o%erall bacterial load of the !atients enables them to resist other com!lications" The only data to su!!ort this conclusion come from animal studies"

Technical Considerations E cision of greater than ,:- of TBSA should be done in a highly structured en%ironment, !referably a dedicated burn center" Aithout tourni(uets and<or to!ical hemostatic agents, blood loss can be massi%e, and graft loss can be catastro!hic" E cellent monitoring, nursing, !hysical thera!y, nutritional su!!ort, anesthesia, and ?4'hour !hysician co%erage are mandatory" Smaller burns in im!ortant areas (e"g", hands, face, and feet) also re(uire considerable e !erience" E cisional !rocedures should be !erformed as early as !ossible after the !atient is stabili+ed, usually )ithin a )ee$ of in1ury" This allo)s the )ound to be closed before infection occurs, and in e tensi%e burns, allo)s donor sites to be re'cro!!ed as soon as !ossible" Cosmetic results are better if the )ound can be e cised and grafted before the intense inflammatory res!onse becomes )ell established" Any burn !ro1ected to ta$e longer than 3 )ee$s to heal is a candidate for e cision )ithin the first !ostburn )ee$" Aound e cision is ada!table to all age grou!s, but infants, small children, and elderly !atients re(uire close !erio!erati%e monitoring" E cision can be !erformed to include the burn and subcutaneous fat to the le%el of the in%esting fascia (fascial e cision), or by tangentially remo%ing thin slices of burned tissue until a %iable bed remains (tangential e cision)" .ascial e cision assures a %iable bed for grafting, but ta$es longer, sacrifices !otentially %iable tissue, and lea%es a !ermanent cosmetic defect" Tangential e cision can create massi%e blood loss and ris$s grafting on a bed of uncertain %iability, but sacrifices minimal li%ing tissue, and leads to a su!erior cosmetic result" .ascial e cisions are ty!ically reser%ed for dee!er burns2 ho)e%er, they can be useful in selected !atients )ith large full'thic$ness burns in%ol%ing only the su!erficial subcutaneous fat" Subcutaneous fat in older burn !atients (i"e", age D8: years) does not readily su!!ort s$in grafts )ell" Therefore, in these authors3 e !erience, more fascial e cisions are being !erformed )ith the immediate a!!lication of 9CTE>5A and subse(uent grafting in such !atients" ,88 Tangential (Se(uential) E cision The !rinci!le of tangential e cision is to e cise layers of eschar at a tangential angle to the surface until %iable tissue is reached" The burn can be remo%ed )ith a %ariety of instruments, usually hand dermatomes (.ig" G'4)" 5elati%ely shallo) burns and some burns of moderate de!th )ill bleed bris$ly from thousands of ca!illaries after one slice" 9f the bed does not bleed bris$ly, another slice of the same de!th is ta$en until a %iable bed of dermis or subcutaneous fat is reached )ith resultant bris$ bleeding (.ig" G';)" 9f ins!ection of the dermal bed re%eals a surface that a!!ears gray or dull rather than )hite and shiny, or if there are thrombosed %essels, the e cision should be carried dee!er" Any fat that has a bro)nish discoloration, !etechial a!!earance, or contains thrombosed blood %essels )ill not su!!ort a graft, and must be e cised until the bed contains uniformly yello) fat )ith bris$ly bleeding %essels" Bleeding is controlled )ith s!onges soa$ed in ,@,:,::: e!ine!hrine solution a!!lied to the e cision bed" Continued bleeding is then controlled )ith 1udicious electrocautery" Ma1or bleeding is rare, and )hen it occurs, it in%ariably is associated )ith inade(uate cauteri+ation of a %essel )ith !ulsatile flo)" .9>" G'4"

Tangential e cisions using (A) Aatson, and (B) >oulian $ni%es" .9>" G';"

6ealthy, %iable )ound bed )ith bris$ bleeding follo)ing tangential e cision" Areas on the e tremities may be e cised under tourni(uet2 ho)e%er, this re(uires e !erience" The cada%eric a!!earance of the dermis and the lac$ of bris$ bleeding )ith the tourni(uet inflated can easily mislead the surgeon into sacrificing normal tissue by carrying the e cision dee!er than necessary" .ascial E cision .ascial e cision is ty!ically reser%ed for !atients )ith dee! full'thic$ness burns, or )ith large, life'threatening full'thic$ness burns (.ig" G'8)" The most common techni(ue uses electrocautery )ith cutting and coagulating ca!abilities" .9>" G'8"

.ascial e cision )ound bed" Cote tac$ing sutures along the edges to minimi+e the a!!earance of the defect" The ad%antages of fascial e cision include@ ," ?" 3" 4" 9t results in a reliable bed of $no)n %iability" Tourni(uets can routinely be used for e tremities" 0!erati%e blood loss is less than )ith tangential e cision" &ess e !erience is re(uired to ensure an o!timal bed"

The disad%antages include@ ," ?" 3" 4" ;" &onger o!erati%e times" The !ossibility of se%ere cosmetic deformity, es!ecially in obese !atients" There is a higher incidence of distal edema )hen the e cision is circumferential" There is greater danger of damage to su!erficial neuromuscular structures" Cutaneous dener%ation, )hich may or may not be !ermanent, occurs"

8" S$in graft loss from the relati%ely less %ascular fascia o%er 1oints (es!ecially the elbo), $nee, or an$le) can lead to an ungraftable bed and re(uire e%entual fla! co%erage" Early 5econstruction A !otential ad%antage to ES> is to !ro%ide a closed )ound before the locali+ed intense cutaneous, and subse(uently systemic, inflammatory res!onse is ma imal" 9f careful attention is gi%en to sound !rinci!les of !lastic surgery, the ris$ that there )ill be a need for subse(uent reconstruction can be decreased" >raft 1unctures should be a%oided o%er 1oints, and grafts should be !laced trans%ersely )hen !ossible" Thic$ STS>s (e"g", D:":,; inch) ty!ically yield a better a!!earance than do thin grafts (e"g", :":,: inch)" 9f the burn is )ell e cised, and the s$in can be s!ared, thic$ grafts should be used on the face, nec$, and other cosmetically im!ortant areas, )ith hands being an e ce!tion" ,8: The resultant donor sites from the thic$ STS>s can be o%ergrafted )ith %ery thin STS>s (e"g", :"::7 inch) if needed, to minimi+e hy!ertro!hic scarring of the donor site" Ty!ically in larger burns (D?:- TBSA), STS>s are meshed to allo) greater )ound co%erage !er graft (.ig" G'G)" This is !articularly im!ortant )hen donor sites are limited" 6o)e%er, if at all !ossible, cosmetically im!ortant areas should be grafted )ith a single sheet of STS> (.ig" G'7)" Although meshed STS>s !ro%ide co%erage )ith e cellent function, the meshed !attern )ill !ersist as a !ermanent reminder of the burn (.ig" G'F)" .9>" G'G"

Ty!ical a!!earance of meshed s!lit'thic$ness s$in graft secured )ith sta!les" .9>" G'7"

E cised face burn )ith single sheet s!lit'thic$ness s$in graft secured )ith sutures" .9>" G'F"

Ty!ical scarring associated )ith )idely meshed s!lit'thic$ness s$in grafts !rior to the a%ailability of dermal substitutes"

Ad1acent !ieces of STS> should be a!!ro imated carefully )ith a small amount of o%erla!" Ahile sta!les are ade(uate for securing most grafts, cosmetically critical areas, such as the face, should be sutured" 6y!afi , a !orous, elastic, and adherent dressing material, is another

o!tion for securing STS>s (.ig" G',:)" Commercially'a%ailable fibrin glues are another atraumatic means to affi STS>s" 9nitial studies are !romising, and the !ossibility for enhanced healing )ith im!ro%ed cosmesis a)aits %alidation in an ongoing multicenter trial" 9f the )ound can be left o!en or !laced in a dry dressing after sheet grafting, Steri'Stri!s can be used effecti%ely" They )ill not remain in !lace if the )ound is co%ered )ith moist dressings" .9>" G',:"

Sheet s!lit'thic$ness s$in graft of right arm secured )ith 6y!afi " =ee!ing these early reconstructi%e !rinci!les in mind during the first o!erations may a%ert the need for later !rocedures entirely, and )ill hel! con%ert )hat could be ma1or reconstructi%e efforts into minor ones" #onor Sites 9n the !ast, )hen only full'thic$ness burns )ere grafted and !atients endured many )ee$s of daily dRbridements, donor sites )ere treated ca%alierly" They )ere co%ered )ith either dry fine mesh gau+e, or gau+e im!regnated )ith a dye or other antimicrobial agent" They )ere left to desiccate, and the gau+e usually se!arated from the )ound in ? to 3 )ee$s" As aggressi%e !rograms of early ES> de%elo!ed, care and healing of donor sites became a !riority" Aith early e cision, the !atient )as s!ared the !ainful daily dRbridement, and )ith burn !ain diminished, !atients focused on donor site !ain" #onor sites are (uite !ainful as they are a su!erficial !artial'thic$ness in1ury" A!!ro!riate dressings diminish donor site !ain" There are numerous dressings a%ailable for donor site )ound care" 5e!orts indicate that there is no o!timal donor site dressing2 ho)e%er, moist )ound healing is su!erior to dry )ound healing" All dressings seem to )or$, and differences in healing times are minimal among the moist )ound healing modalities" Comfort le%els and ease of care are the most significant determinants" 6ealed donor sites are still not free of com!lications" 9n addition to hy!ertro!hic scarring and !igmentation changes, blistering for se%eral )ee$s may trouble !atients" Blisters are self' limiting and treated )ith bandages or ointments until they re'e!itheliali+e" #onor site infections occur in a!!ro imately ;- of !atients and can be de%astating, )ith con%ersion of a !artial'thic$ness to a full'thic$ness )ound re(uiring a STS> for closure" 9nfection is treated aggressi%ely )ith systemic and to!ical antibiotics" ,8G S$in Substitutes The ne t ma1or ste! in burn care is li$ely to be an artificial s$in that )ill be readily a%ailable, !erform a barrier function (e!idermis), and !ro%ide the structural durability and fle ibility of the dermis" 9t must be !ermanent, affordable, resist hy!ertro!hic scarring, !ro%ide normal !igmentation, and gro) )ith de%elo!ing children" /rogress to)ard this goal has been substantial o%er the !ast decade2 ho)e%er, the ideal artificial s$in has yet to be de%elo!ed"

,87 #ermal Substitutes The de%elo!ment of dermal substitutes has added greatly to the ca!abilities of the burn surgeon, es!ecially )hen faced )ith a large burn and limited donor sites" They readily facilitate com!lete e cision of the entire burn )ith )ound closure" #e!ending on the !roduct, grafting )ith STS> may be immediate or delayed until the dermal substitute has engrafted" Currently three dermal substitutes are a%ailable in the Bnited States@ 9CTE>5A, Allo#erm, and #ermagraft" These !roducts are fundamentally similar in that they allo) for the creation of a *neo'dermis* !o!ulated by the !atient3s o)n mesenchymal cells u!on )hich a thin STS> is !laced" The use of thinner STS> allo)s for earlier re'cro!!ing of donor sites, (uic$er closure of the com!lete burn, and less donor site scarring" Successful use of any one of the a%ailable dermal substitutes is techni(ue'de!endent and associated )ith a learning cur%e" Allo#erm is a cryo!reser%ed allogeneic dermis from )hich the e!ithelial elements ha%e been remo%ed )ith hy!ertonic saline !rior to free+e'drying" 9t is treated in a detergent to $ill any %iruses" The result is a theoretically antigen'free, com!lete dermal scaffolding )ith intact e!idermal basement membrane !roteins" 9mmediately follo)ing e cision to %iable tissue, Allo#erm is rehydrated, treated according to the manufacturer3s s!ecifications, and a!!lied to the )ound bed" 9t is designed to be immediately autografted )ith a thin STS> (e"g", Q:":,: inch)" Early results of clinical trials a!!ear fa%orable com!ared to standard grafting techni(ues" ,8F,,G: #ermagraft consists of human neonatal fibroblasts cultured on Biobrane" Biobrane is a biosynthetic dressing com!osed of a silicone membrane coated on one side )ith !orcine collagen and imbedded )ith nylon mesh" The neonatal fibroblasts are seeded into the nylon mesh" .ollo)ing e cision, #ermagraft is !re!ared according to the manufacturer3s recommendations and affi ed to the )ound" A!!ro imately ? )ee$s after a!!lication, the silicone membrane is remo%ed and the )ound bed grafted )ith a STS>" Early clinical trials also a!!ear encouraging" ,G,,,G? #ermagraft, ho)e%er, is a dressing, and does not !ro%ide full dermal scaffolding, thus re(uiring standard thic$ness s$in grafts" 9CTE>5A )as de%elo!ed by Bur$e and Tannas in the ,F7:s and became commercially a%ailable in ,FF8" ,G3 0f all the dermal substitutes, the greatest e !erience has been gained )ith 9CTE>5A, both )orld)ide and in the Bnited States 9t is a bilaminate membrane consisting of a !orous collagen'chondroitin 8'sulfate fibrillar layer (dermal analogue) bonded to a thin silicone layer (tem!orary e!idermis)" 9CTE>5A is a!!lied to a freshly e cised burn )ound and allo)ed to %asculari+e for ,4 days or longer (.ig" G',,)" An ultra'thin (:"::8 to :"::7 inch) STS> is !laced after remo%al of the silicone layer from the %asculari+ed *neo' dermis* (see .ig" G',,C)" The ultra'thin donor sites allo) for faster total )ound closure by early re'cro!!ing of donor sites and more ra!id donor site healing, )hile cosmesis is im!ro%ed" ,G4 .9>" G',,"

9CTE>5A" (A) .ull'thic$ness burn !re!ared for fascial e cision" (B) 9ntegra a!!lied to the freshly e cised )ound bed and secured )ith sta!les" (C) 6ealthy, %asculari+ed 9CTE>5A *neo'dermis* )hich is ready for grafting follo)ing silicone membrane remo%al" (D) 5esults at 3 years )ith full range of motion of the right shoulder" Cote su!erior cosmesis obtained )ith 9CTE>5A" 9CTE>5A is !re!ared in the o!erating room according to the manufacturer3s s!ecifications, including ,@, meshing, and affi ed )ith sta!les to freshly e cised burn )ounds (see .ig" G' ,,B)" An integral as!ect of 9CTE>5A )ound co%erage is the )idely e !anded elastic net dressing that must be sta!led o%er the 9CTE>5A to !re%ent shearing" After at least ,4 days in to!ical antibioticIsoa$ed dressings, a :"::8'inch STS> is a!!lied to the e tent that a%ailable donor sites allo)" The grafts are dressed a!!ro!riately and $e!t moist )ith to!ical antibiotic solution until acce!table ta$e is e%ident" #onor sites can be re'cro!!ed until com!lete co%erage of the 9CTE>5A is obtained" 0f note, the silicone layer should not be remo%ed until the time of grafting, regardless of the time since initial a!!lication" /remature remo%al of the silicone layer leads to gro)th of granulation tissue that increases the ris$ of hy!ertro!hic scar formation" 6o)e%er, fluid collections in or belo) the 9CTE>5A should be drained or *)indo)ed* if they a!!ear !urulent or are large enough to threaten engraftment" A recent re%ie) of these authors3 e !erience )ith 9CTE>5A from ,FF8 to ?::, at the Bni%ersity of Aashington Burn Center indicates that outcomes correlate )ith e !erience )ith the !roduct and meticulous attention to details" ,G4a .or com!arison and to assess technical im!ro%ement, !atients )ere di%ided into t)o grou!s@ ,FF8 to ,FFF (grou! 9) and ?::: to ?::, (grou! 99)" >rou! 9 had ;G !atients )ith burns a%eraging 3F- TBSA and an a%erage age of 4: years" The a%erage !ercentage ta$e of 9CTE>5A )as G8-" >rou! 99 consisted of 3F !atients )ith burns a%eraging 3G- TBSA and an a%erage age of 3; years" 9n star$ contrast, the a%erage !ercentage ta$e of 9CTE>5A )as FG-" Co differences )ere obser%ed bet)een the grou!s )ith res!ect to number of o!erations re(uired, length of stay, or mortality" The outcomes im!ro%ed )ith increasing e !erience, underscoring the learning cur%e associated )ith the use of dermal substitutes" Ahile no change in mortality associated )ith use of 9CTE>5A has been obser%ed, there has been less hy!ertro!hic scarring (see .ig" G',,#)" The safety and efficacy of 9CTE>5A has been further %alidated in a multicenter, !osta!!ro%al, clinical trial" ,G; 9CTE>5A and STS> ta$es )ere e cellent, and associated infectious com!lications )ere minimal" Cultured S$in A!ligraf is an .#A'a!!ro%ed biologic dressing com!osed of cultured neonatal $eratinocytes and fibroblasts" This allograft bioengineered !roduct has been a!!ro%ed for use in chronic nonhealing ulcers, but has not yet been )idely mar$eted for the burn !atient" 0ne indication

for use of this !roduct might be in an elderly !atient at significant ris$ for a nonhealing donor site, )ho has a small dee! burn that has started to granulate" 9t can be used as a biologic dressing to enhance !rimary healing, or e%en as a STS> substitute, but only in small burns" ,G8 A!ligraf may also im!ro%e the cosmetic outcome of meshed STS>s )hen it is used as an o%erlay dressing on the STS>" ,GG Ad%ances in tissue culture techni(ues ha%e led to the de%elo!ment, and ultimate commercial a%ailability, of cultured e!ithelial autografts (CEAs)" E!icel is currently the only .#A' a!!ro%ed CEA !roduct a%ailable" These grafts are created from a full'thic$ness bio!sy of the !atient3s o)n s$in and re(uire 3 )ee$s to gro)" They are (uite e !ensi%e at a!!ro imately U,4,;:: for G;: cm?" Early small series and case re!orts of massi%ely burned !atients )ere !romising" 6o)e%er, this enthusiasm )as tem!ered by subse(uent concerns about CEA durability and graft ta$e" ,G7 Cost also has limited the use of CEAs by many burn centers" Conetheless, )hen cou!led )ith standard burn thera!y, CEAs may be !otentially life sa%ing for the massi%ely burned !atient" CEA combined )ith a dermal substitute is a logical e tension of these ad%ancements, and initial results are encouraging" ,GF .urther in%estigation of this ne t ste! is under)ay" Cutritional Su!!ort The nutritional effects of the hy!ermetabolic res!onse to thermal in1ury are manifested as e aggerated energy e !enditure and massi%e nitrogen loss" Cutritional su!!ort is aimed at !ro%ision of calories to match energy e !enditure, )hile !ro%iding enough nitrogen to re!lace or su!!ort body !rotein stores" The changes in metabolism are triggered by drastic alterations in the neuroendocrine and cyto$ine !rofiles, resulting in !rotein catabolism, gluconeogenesis, and li!olysis" /lasma insulin le%els are normal to ele%ated, but are lo) relati%e to increased glucagon concentrations" Catecholamines and glucocorticoids also antagoni+e the action of insulin" These metabolic and hormonal derangements ha%e im!ortant conse(uences for nutritional status" Caloric 5e(uirements 6y!ermetabolism and catabolism are uni%ersal conse(uences of in1ury, regardless of the etiology" The magnitude of increase in the metabolic rate follo)ing thermal in1ury is directly !ro!ortional to the TBSA of the burn" The total energy e !enditure may be ele%ated any)here from ,; to ,::- abo%e basal needs, significantly e ceeding the metabolic increases of other in1uries" Energy needs must be e%aluated carefully in formulating a nutritional !lan" 9f the regimen is deficient in calories, anabolism )ill be subo!timal, and the nitrogen balance )ill continue to be negati%e" Mathematical formulas e ist for the calculation of daily caloric re(uirements in burn !atients" The formula most )idely used is &ong3s modification of the 6arris'Benedict e(uation" (Table G'?) The original 6arris'Benedict e(uation estimates BM5 )ith reasonable accuracy" &ong !ro!osed that the BM5 be multi!lied by %arious stress factors de!ending u!on the ty!e of in1ury" The modification for burn !atients uses a factor of ,";" The more se%erely ill the !atient, the less accurate standard formulas are for estimating calorie e !enditure" Table G'? &ong Modification of the 6arris'Benedict E(uation

&en BM5 V (88"4G N ,3"G; )eight N ;": height V 8"G8 age) (acti%ity factor) (in1ury factor) "o#en BM5 V (8;;",: N F";8 )eight M ,"7; height V 4"87 age) (acti%ity factor) (in1ury factor) 'cti(ity factor Confined to bed@ ,"? 0ut of bed@ ,"3 In)ury factor Minor o!eration@ ,"?: S$eletal trauma@ ,"3; Ma1or se!sis@ ,"8: Se%ere thermal burn@ ,"; BM5 V basal metabolic rate" /eriodic determination of 5EE %ia indirect calorimetry may be utili+ed to allo) more accurate ad1ustments of caloric !ro%ision" 5EE determinations should not be construed as e(ui%alent to the ?4'hour calorie re(uirement" Com!ensations must be made for daily energy fluctuations that occur )ith !hysical thera!y, stress, tem!erature ele%ations, dressing changes, and other influences on metabolic rate" ,7: Total urine nitrogen (TBC) e cretion is easy to measure, and accurately reflects the degree of catabolism2 )hereas calculated nitrogen e cretion using the urine urea nitrogen (BBC) underestimates catabolism and nitrogen losses in burned !atients" ,7, The TBC should be monitored regularly, )ith the goal being a !ersistently !ositi%e nitrogen balance" Earious %isceral !roteins are commonly measured, ty!ically as !art of a *nutrition !anel,* to assess ongoing nutritional status" Analysis of these %alues is !recarious, and instead of !eriodic static assessment, !ositi%e trends o%er time should be sought" ,7?,,73 Carbohydrates Carbohydrates, in the form of glucose, a!!ear to be the best source of non!rotein calories in the thermally'in1ured !atient" ,74 Certain tissues, including the burn )ound, neural tissues, and the formed elements of the blood, utili+e glucose in an obligatory fashion" /ro%ision of glucose to these tissues occurs at the e !ense of lean body mass (i"e", s$eletal muscle) if ade(uate nutrition is not !ro%ided" 9n the unfed state, the ma1or sources for he!atic gluconeogenesis are the burn )ound and s$eletal muscle" The )ound utili+es glucose by anaerobic glycolytic !ath)ays, !roducing large amounts of lactate as an end !roduct" The )ound meets its high glucose re(uirements %ia increased glucose deli%ery, )hich is made !ossible by the enhanced circulation to the )ound" 9n the li%er, lactate is e tracted and utili+ed for gluconeogenesis %ia the Cori cycle" Concomitantly, alanine, glutamine (>ln), and other amino acids contribute to the increased gluconeogenesis" 9ncreased ureagenesis, )ith urea deri%ed from body !rotein stores, !arallels the rise in he!atic glucose !roduction" /eri!heral amino acids and )ound lactate account for a!!ro imately ;: to 8:- of the ne) glucose !roduced by the li%er" The hy!erglycemia

obser%ed in hy!ermetabolic burn !atients is a conse(uence of accelerated glucose flu , not decreased !eri!heral utili+ation" Because glucose that is obtained %ia gluconeogenic !ath)ays ultimately deri%es from !rotein stores, de!letion of body !rotein during burn hy!ermetabolism leads to energy deficits, malfunctioning of glucose'de!endent energetic !rocesses, and s$eletal muscle )asting" 6igh' carbohydrate enteral nutrition formulations a!!ear to blunt the catabolism, resulting in s$eletal muscle s!aring" ,7; 0!timal glucose o idation during burn hy!ermetabolism occurs at inta$es of a!!ro imately ; mg<$g !er minute2 e ogenous su!!ly at rates abo%e this result in its use by nono idati%e !ath)ays, )ithout contributing to energy balance" ,78 /rotein Combining glucose and !rotein'containing nutrients im!ro%es nitrogen balance and allo)s more calories to be used for the restoration of nitrogen balance than )ould be !ossible if either nutrient )ere used alone" After thermal in1ury, carbohydrate and !rotein nutrients coo!erati%ely contribute to the im!ro%ement in nitrogen e(uilibrium by at least t)o distinct mechanisms" /rotein administration !romotes synthesis of %isceral and muscle !rotein, )ithout a!!reciably affecting the rate of catabolism" ,7G E ogenous glucose retards catabolism, but e erts little effect on !rotein synthesis" Both mechanisms im!ro%e nitrogen balance, and sufficient glucose (i"e", G g<$g !er day) and !rotein (i"e", ? g<$g !er day) should be com!onents of the nutritional regimen for the se%erely'burned catabolic !atient" The im!ortance of >ln as a metabolic fuel source has been recogni+ed, and it is considered a conditionally'essential amino acid" ,77 The gastrointestinal tract !referentially uses >ln as an energy source, and dis!oses of the ma1ority of it as ammonia, urea, and citrulline" The alanine generated from >ln is used for gluconeogenesis" #uring critical illness, circulating concentrations of >ln fall, and su!!lemental e ogenous >ln is necessary to meet re(uirements" As noted earlier, >ln su!!lementation has been associated )ith im!ro%ed outcomes follo)ing thermal in1ury" .at The role of fat as a source of non!rotein calories is de!endent on the e tent of in1ury and associated hy!ermetabolism" 5ecall that follo)ing significant thermal in1ury, there are alterations in substrate cycling and fatty acid o idation that fa%or re'esterification and he!atic de!osition of triglycerides" .at a!!ears to be a !oor caloric source o%erall, and es!ecially for the maintenance of nitrogen e(uilibrium and lean body mass, in burn'induced hy!ermetabolism" ,7F /atients )ith only moderate ele%ations in metabolic rate can use li!id calories efficiently, but these !atients rarely re(uire nutritional su!!ort" E%en more im!ortant than their energy inefficiency, fats a!!ear to affect outcome follo)ing thermal in1ury" Cot only the total %olume of fat administered, but also the !articular fatty acid moiety, is im!ortant" /atients fed lo)'fat enteral diets ( ,;- of non!rotein calories as fat) had fe)er infectious com!lications, im!ro%ed )ound healing, shorter lengths of stay, and a!!arently reduced mortality com!ared to controls fed standard, relati%ely high'fat, enteral

diets" ,F:,,F, 0mega'3 fatty acid su!!lementation a!!ears to confer some outcome benefit2 ho)e%er, this is more definiti%e in animal models than in humans" Eitamins and Minerals Eitamin re(uirements in critically'ill, hy!ermetabolic burn !atients remain !oorly defined" The fat'soluble %itamins (A, #, E, and =) are e tensi%ely stored in fat de!ots and are only slo)ly de!leted during !rolonged feeding of %itamin'free solutions" The )ater'soluble %itamins (B com!le and C) are not stored in a!!reciable amounts, and are ra!idly de!leted" All %itamins should be su!!lemented" The dosage guidelines of the Cational Ad%isory >rou!<American Medical Association (CA><AMA) are reasonable for burn !atients unless sym!toms of deficiency occur" 0f note, all commercially'a%ailable enteral feeding formulations meet CA><AMA recommendations for %itamins and minerals" Eitamin C (ascorbic acid) has an essential role in )ound re!air %ia !artici!ation in collagen synthesis, and !lasma le%els are fre(uently lo) in burn !atients" 9t is !rudent to su!!lement the CA><AMA recommended dose )ith a!!ro imately ,::: mg of %itamin C daily" &arger doses may cause diarrhea or ne!hrolithiasis, )ill interfere )ith laboratory studies, and are e creted unchanged" E cessi%e doses of %itamins A and # !roduce to icity2 monitoring of serum le%els is often misleading in burn !atients, since the concentrations of the %itamin carrier !roteins are commonly decreased" Minerals and trace elements are essential because of their role in metabolic !rocesses" .re(uent determinations of serum sodium, !otassium, chloride, calcium, magnesium, and !hos!horus are the best guides to electrolyte re!lacement" &ess is $no)n about trace element re(uirements after thermal in1ury" Winc is an im!ortant cofactor in en+ymatic function and )ound re!air, and +inc deficiency has been documented in burn !atients" ,F? Thus, em!iric +inc su!!lementation is )arranted follo)ing ma1or burns" /eriodic measurements of serum and !lasma +inc, co!!er, manganese, and chromium are the best )ay to determine re!lacement dosages" Conetheless, a recent study demonstrated reduced !neumonia rates )hen trace elements )ere administered as su!!lemental doses abo%e the CA><AMA recommendations, raising the !ossibility of o%erall increased re(uirements in the thermally in1ured" ,F3 5oute of Administration The route of nutritional su!!ort is im!ortant because it directly influences outcome" Total enteral nutrition (TEC) is the o%er)helmingly fa%ored mode of alimentation in the se%erely burned" Total !arenteral nutrition (T/C) is used only )hen com!lete enteral failure is encountered, as T/C is associated )ith increased mortality" ,F4 /atients )ith burns co%ering less than ?:- of their TBSA )ho are not com!licated by facial in1ury, inhalation in1ury, malnutrition, or !sychologic disturbances can ty!ically be maintained on high'calorie, high'!rotein, oral diets" 6o)e%er, the oral route alone cannot meet the nutritional re(uirements of !atients )ith ma1or burns, and these !atients should be fed enterally %ia a gastric or duodenal feeding tube regardless of their moti%ation to eat" A functioning gastrointestinal (>9) tract should al)ays be used" 9n se%erely'burned !atients, gastro!aresis may limit intragastric nutritional su!!ort, !articularly in the early !ostburn !eriod" 6o)e%er, immediate intragastric feeding a!!ears to

limit gastro!aresis and is un(uestionably safe" ,F;,,F8 E%en in the face of intragastric feeding intolerance, TEC should not be abandoned" /ost!yloric feeding tends to )or$ )ell in the burn !atient )ith gastro!aresis" ,FG /ro$inetics should be used as needed" The !recise >9 tract location (i"e", intragastric %s" !ost!yloric) for o!timal TEC !ro%ision is contro%ersial and a matter of !reference2 the location is !robably less im!ortant than sim!ly ensuring ade(uate TEC" TEC has significant ad%antages o%er T/C that translate into reduced morbidity and im!ro%ed mortality" 4: Enteral nutrients maintain the integrity of the >9 tract %ia !reser%ation of gut mucosal mass and immunity, )hich a!!ears to reduce bacterial translocation and the incidence of gut'deri%ed infection" ,F7 Con%ersely, the absence of intraluminal nutrients leads to increased a!o!tosis and decreased mucosal mass" ,FF TEC enhances s!lanchnic !erfusion )ith an im!ro%ement in gut o ygen balance, e%en during resuscitation from burn shoc$" ?:: 6istorically, Curling3s ulcers and >9 hemorrhage )ere common burn'related com!lications, )hich !rom!ted aggressi%e !harmacologic gastric acid su!!ression" Aggressi%e, early, intragastric TEC alone has !ro%en to be ade(uate ulcer !ro!hyla is, and %irtually eliminated Curling3s ulcers" ?:, TEC is also less e !ensi%e than T/C" Studies ha%e sho)n that institution of TEC immediately u!on admission is safe and beneficial" ?:?,?:3 This early nutritional regimen a!!ears to blunt the intensity of hy!ermetabolism and more effecti%ely maintains !rein1ury )eight )ithout significant com!lications" 6o)e%er, the o!timal timing of early TEC has yet to be defined" ?:4 TEC should not be )ithheld during !erio!erati%e !eriods, as this only leads to energy deficits and increased catabolism2 !erio!erati%e TEC, including intrao!erati%e infusion, has been !ro%en to be safe" ?:; T/C should be instituted only u!on com!lete enteral failure" /rotracted ileus and the o%eruse of narcotics )ith resultant consti!ation are fre(uent causes of TEC failures" Se!sis is associated )ith ileus and hy!erglycemia2 these signs may be the only e%idence of this com!lication" ?:8 Aggressi%e bo)el regimens )ith la ati%es and fiber su!!lements, not 1ust stool softeners, should be routine !roacti%e measures to a%ert consti!ation" 9f T/C has to be administered, it is useful to continue some enteral nutrition, !articularly >ln su!!lementation" The benefits of enteral nutrition are reali+ed, e%en )ith lo) %olumes" Com!osition of Enteral Cutrition Cumerous commercially a%ailable formulations e ist to choose from today" The ultimate goal is to !ro%ide nutritional su!!ort tailored to meet the needs of critically'ill burn !atients" Standard meal re!lacement !roducts or su!!lements formulated for nonstressed or minimally'stressed !atients do not meet the uni(ue nutritional re(uirements of moderately' or se%erely'stressed burn !atients" Cumerous studies indicate that s!eciali+ed feeding regimens im!ro%e burn'related metabolic derangements )hile enhancing nutritional status" 9n burn !atients, a high'!rotein, high'carbohydrate, lo)'fat diet )ith fiber is o!timal" As noted earlier, a!!ro!riate su!!lements to include >ln, %itamins, minerals, and trace elements are indicated, and add to the benefits of TEC" 9mmune'enhancing diets (e"g", 9M/ACT) offer no clear ad%antage o%er standard high'!rotein formulas in the burn !o!ulation" ?:G Monitoring of TEC to assess tolerance and effecti%eness is as im!ortant as the selection of the formula or timing of initiation" Careful nutrition and metabolic assessment can hel!

ensure o!timal su!!ort )ith minimal com!lications" Although su!erior to T/C, TEC still has associated com!lications, and any e%idence of feeding intolerance should be acti%ely in%estigated" ?:7 9nfection 9nfectious mortality follo)ing thermal in1ury has significantly declined o%er the !ast ? decades, )ith the greatest reduction attributed to early ES>" 6o)e%er, follo)ing successful resuscitation, most acute morbidity and %irtually all mortality in se%erely burned !atients are still related to infection" Thermal in1ury causes !rofound immunosu!!ression that is !ro!ortional to the TBSA of the burn )ound" A direct relationshi! bet)een s!ecific immunologic defects and infection has yet to be definiti%ely established in humans2 nonetheless, the resultant in%ariable, global immunosu!!ression ma$es the burn !atient e (uisitely susce!tible to infection" Se!sis de%elo!s )hen the balance bet)een host factors and !athogenic or o!!ortunistic organisms is unfa%orably altered" Conetheless, !ro!hylactic systemic antibiotics are not !art of modern burn care, as they do not reduce se!tic com!lications and only lead to increased bacterial resistance" 5is$ .actors for 9nfection The e tent of burn in1ury (i"e", TBSA) is one of the ma1or determinants of o%erall outcome, and the incidence of infection correlates )ith burn se%erity" ?:F Children a!!ear to be more susce!tible to systemic infection than adults for any gi%en si+e burn" ?,: 6o)e%er, burns in%ol%ing less than ?:- TBSA in other)ise healthy indi%iduals are rarely associated )ith life'threatening infection" The !resence of an inhalation in1ury strongly correlates )ith infection, !articularly !neumonia" /remorbid diabetes significantly increases infection rates follo)ing thermal in1ury, es!ecially )hen cou!led )ith !oor glycemic control" ?,, Age !er se is not an inde!endent ris$ factor for infection follo)ing thermal in1ury, although it has a significant im!act on o%erall outcome" Clinical Manifestations and #iagnosis Many of the !hysiologic criteria defining se!sis are noninfectious se(uelae of !ostin1ury hy!ermetabolism" 6y!erthermia, tachycardia, increased %entilation, and high cardiac out!ut, indicati%e of se!sis as )ell as a hy!erdynamic'hy!ermetabolic state, are !art of the normal res!onse to ma1or burns in other)ise healthy !atients" Body tem!erature regulation is altered in burn !atients, and is !artially de!endent u!on en%ironmental conditions" 6y!erthermia ( 37";HC) is routinely !resent follo)ing thermal in1ury, !articularly in children, and is a !oor indicator of infection" ?,?,?,3 Con%ersely, hy!othermia commonly heralds se!sis, usually due to gram'negati%e organisms" &eu$ocytosis in the burn !atient is also nons!ecific" As long as large )ounds remain o!en, %ariable ele%ations in leu$ocyte counts are common" Thrombocytosis is in%ariable follo)ing ma1or thermal in1ury, )hereas thrombocyto!enia is a fairly reliable manifestation of se!sis" &i$e)ise, sudden feeding intolerance is commonly associated )ith significant infection" 0ther traditional manifestations of se!sis are !otentially e%en more nons!ecific in the burn !atient" An altered mental status can be caused by %arious medications commonly used in modern burn care, !articularly o!ioids" 6y!erglycemia may be !reci!itated by administration of the necessary high'calorie, high'carbohydrate diet, as )ell as being a conse(uence of the

neuroendocrine res!onse to thermal in1ury" 9ncreased fluid re(uirements, hy!otension, and oliguria may be related to inade(uate ongoing fluid re!lacement follo)ing successful resuscitation" The most im!ortant obser%ations are related to the tem!oral association of the aforementioned !hysiologic e%ents" Abru!t onset of hy!erglycemia, fall in blood !ressure, and decrease in urinary out!ut should suggest the !ossibility that the !atient is becoming unstable" 9f these findings are associated )ith de%elo!ment of hy!othermia, feeding intolerance, and<or a falling !latelet count, the !atient is !robably de%elo!ing se!sis" 9t is im!ortant to do an immediate infection )or$'u! and administer the a!!ro!riate antimicrobials" E%en )ith firm clinical e%idence of se!sis, a definiti%e microbiologic diagnosis of infection can sometimes be difficult to obtain" Blood cultures ha%e a relati%ely lo) yield in the burn !o!ulation, and other anatomic sites of !otential infection (e"g", )ounds, res!iratory tract, and urine) should !referentially be cultured" ?,4 5ecently, serum !rocalcitonin has been sho)n to be a sensiti%e mar$er of significant infection in burn !atients" ?,;,?,8 6o)e%er, further %alidation is re(uired !rior to its )ides!read clinical use in the diagnosis of infection" A thorough !hysical e am and a)areness of the infections commonly encountered in burn !atients allo)s an orderly e%aluation of the !otentially infected !atient" S!ecific 9nfections Aound 9nfection A change in the flora of burn )ound infections o%er the !ast fe) decades is !robably related to the !roliferation of broad's!ectrum !arenteral and to!ical antibiotics" Before the a%ailability of !enicillin, stre!tococci and sta!hylococci )ere the !redominant infecting organisms" By the late ,F;:s, gram'negati%e bacteria, es!ecially Pseudomonas s!ecies, had emerged as the dominant organisms causing fatal )ound infections in burn !atients" ?,G All burn )ounds become coloni+ed by G? hours after in1ury )ith the !atient3s o)n flora or )ith endemic organisms from the treatment facility" Bacteria coloni+e the surface of the )ound and may !enetrate the a%ascular eschar" This coloni+ation is in%ariable and )ithout clinical significance2 hence, routine early )ound cultures are not efficacious and only increase costs" ?,7 Bacterial !roliferation may occur beneath the eschar at the %iable' non%iable tissue interface, leading to eschar se!aration if early ES> is not !racticed" 9n a fe) !atients, microorganisms may breach this barrier and in%ade the dee!er underlying %iable tissue, !roducing )ound se!sis" The essential !athologic feature of burn )ound se!sis is in%asion of organisms into %iable tissue, )hich is diagnosed %ia bio!sy and (uantitati%e tissue culture demonstrating greater than ,:; organisms !er gram of tissue" The organisms s!read to the !eri%ascular structures, )ith direct %essel )all in%asion, causing a %asculitis and thrombosis" 6emorrhagic necrosis follo)s" Subse(uently, organisms in%ade the bloodstream, !roducing se!sis )ith !otential metastatic lesions" Any organisms ca!able of in%ading tissue can !roduce burn )ound se!sis" The !redominant organisms causing burn )ound infection %ary de!ending on the treatment facility flora" Burn )ound infection can be focal, multifocal, or generali+ed" The li$elihood of se!sis increases in !ro!ortion to the si+e of the )ound" Su!erficial )ound s)ab cultures

should ne%er be used to e%aluate !otential in%asi%e burn )ound infection" 0nce the diagnosis of burn )ound se!sis is confirmed, a!!ro!riate !arenteral antibiotics should be administered and the )ound !rom!tly e cised" Before the introduction of effecti%e to!ical antimicrobial agents, u! to 8:- of the deaths in burn centers )ere caused by burn )ound se!sis" The three agents )ith !ro%en broad' s!ectrum antimicrobial acti%ity )hen a!!lied to the burn )ound are sil%er sulfadia+ine (SS#), mafenide acetate, and sil%er nitrate (Table G'3)" SS# is the most common agent used in burn centers and has antifungal !ro!erties in addition to good bacterial co%erage" 6o)e%er, SS# does not !enetrate eschar" 0nly mafenide acetate is able to !enetrate eschar, and it is the only agent ca!able of su!!ressing dense subeschar bacterial !roliferation" The main disad%antage of mafenide acetate is its carbonic anhydrase inhibition, )hich may interfere )ith renal buffering mechanisms" Bicarbonate is consumed, chloride is retained, and the resulting hy!erchloremic metabolic acidosis is com!ensated for by an increase in %entilation and subse(uent res!iratory al$alosis" 6o)e%er, this is ty!ically of little clinical conse(uence" Sil%er nitrate must be used before bacteria ha%e !enetrated the )ound" 9ts disad%antages are the associated electrolyte imbalances (e"g", hy!onatremia), )hich are common, and methemoglobinemia, )hich is unusual" Since the introduction of effecti%e to!ical thera!y, fungal burn )ound infections, !rimarily in%ol%ing highly in%asi%e /hycomycetes and Aspergillus organisms, has increased"

Table G'3 To!ical Antimicrobial Agents for Burn Aound Care Sil(er *itrate 'cti(e co#ponent :";- in a(ueous solution Spectru# of anti#icro+ial acti(ity >ram'negati%eLgood >ram'!ositi%eLgood TeastLgood &ethod of "ound care 0cclusi%e dressings 'd(antages /ainless Co hy!ersensiti%ity reaction Co gram'negati%e resistance #ressings reduce /enetrates eschar Aound a!!earance readily monitored Xoint motion unrestricted Co gram'negati%e /ainless Aound a!!earance readily monitored )hen e !osure method used Easily a!!lied E !osure E !osure or single'layer dressings >ram'negati%eLgood >ram'!ositi%eLgood TeastL!oor >ram'negati%eL%ariable >ram'!ositi%eLgood TeastLgood ,,",- in )ater'miscible base ,":- in )ater'miscible base &afenide 'cetate Sil(er Sulfadiazine

Sil(er *itrate e%a!orati%e heat loss >reater effecti%eness against yeasts

&afenide 'cetate resistance

Sil(er Sulfadiazine Xoint motion unrestricted )hen e !osure method used >reater effecti%eness against yeast Ceutro!enia and thrombocyto!enia 6y!ersensiti%ityL infre(uent &imited eschar !enetration

isad(antages #eficits of sodium, !otassium, calcium, and chloride Co eschar !enetration &imitation of 1oint motion by dressings MethemoglobinemiaL rare ArgyriaLrare Staining of en%ironment and e(ui!ment /ainful on !artial' thic$ness burns Susce!tibility to acidosis as a result of carbonic anhydrase inhibition 6y!ersensiti%ity reactions in G- of !atients

A ne)ly emerging %ariant of burn )ound infection, the *melting graft')ound syndrome,* )as recently re!orted from the authors3 burn center, and in%ol%es !rogressi%e e!ithelial loss (melting) from a !re%iously )ell'ta$en graft, healed burn )ound, or healed donor site" 6istorically, such e!ithelial loss )as attributed to the gro)th of Streptococcus s!ecies2 ho)e%er, *melting* )ithout significant stre!tococcal coloni+ation or infection )as encountered" Aound cultures from affected !atients mainly gre) Staphylococcusaureus (including methicillin'resistant S. aureus), and none gre) Streptococcus s!ecies" These infections ha%e !otentially de%astating conse(uences" As such, a!!ro!riate systemic antibiotics, to!ical antibiotics, and aggressi%e )ound care are mandatory for effecti%e treatment" 5ee cision and grafting rarely are re(uired for sal%age" /neumonia 0ne result of the !rolonged and im!ro%ed sur%i%al of se%erely burned !atients is that the res!iratory tract has become the most common source of infection" 9t is generally agreed that inhalation in1ury increases the ris$ of de%elo!ing !neumonia" 6o)e%er, this may be more related to endotracheal intubation than the actual inhalation in1ury" ?,F The diagnosis of !neumonia is confirmed by the !resence of characteristic infiltrates on chest radiogra!hs and !ositi%e s!utum cultures" .ollo)ing inhalation in1ury, early infiltrates usually re!resent chemical !neumonitis and not infection, although this in1ured !ulmonary tissue may become infected" The most efficacious and sensiti%e method of obtaining tracheobronchial s!ecimens for microbiologic analysis remains contro%ersial" 5egardless of s!ecimen collection methodology, coloni+ation of the u!!er air)ay in !atients re(uiring mechanical %entilation should not be confused )ith a res!iratory tract infection" Ahen !neumonia is clinically sus!ected, broad's!ectrum antibiotics a!!ro!riate for the endemic bacterial flora should be !rom!tly instituted, and subse(uently narro)ed according to culture results" Single'agent thera!y is generally a!!ro!riate and efficacious regardless of

the !athogen, including Pseudomonas aeruginosa" /neumonia still carries a significant mortality rate of a!!ro imately ?;- in mechanically'%entilated burn !atients" ??: /ro!hylactic antibiotics should not be used, as they only select for resistant organisms and do not reduce the incidence of !neumonia" &i$e)ise, early tracheostomy does not lo)er !neumonia rates in either children or adults suffering ma1or thermal in1ury" ,48,,4G Consistent infection control !ractices and timely e tubation seem to be the only effecti%e means to lo)er the incidence of !neumonia" Eascular Catheter'5elated 9nfections Aith e%ol%ing technology and a trend to)ard in%asi%e hemodynamic monitoring, central %enous catheteri+ation is common!lace in many burn centers" This !ractice is (uite a!!ro!riate in !atients )ith cardio!ulmonary !athology or concomitant nonthermal trauma, )hich mandate central monitoring" 6o)e%er, burn shoc$ resuscitation does not re(uire central %enous access, and can be (uite successfully accom!lished em!loying only !eri!heral access" All %ascular access modalities carry ris$, in !articular infectious com!lications, and central line com!lications can be life threatening" The incidence of !eri!heral su!!urati%e thrombo!hlebitis follo)ing thermal in1ury is miniscule in the modern era, as sa!henous %enous cutdo)ns ha%e been abandoned and standard line care is routine" ??: The true incidence of central line se!sis in burn !atients is un$no)n" Technologic ad%ancements and %arious inter%entions ha%e been directed at reducing catheter'related bloodstream infections (C5BS9s) in at'ris$ !atient !o!ulations" ??, Antimicrobial'im!regnated central lines are (uite efficacious in reducing C5BS9s in surgical !atients, and in all li$elihood are also effecti%e in burn !atients, although they ha%e not been thoroughly studied in the burned !o!ulation" &i$e)ise, routine central %enous catheter changes )ithout e%idence of infection are !robably un)arranted and only increase com!lication rates2 there are no conclusi%e data in the burn literature to su!!ort routine catheter changes" Contrary to !o!ular belief, the s!ecific central line site does not a!!ear to influence infection rates in the burn !atient" ??? 6o)e%er, the distance from the burn )ound does a!!ear to correlate in%ersely )ith C5BS9, and e%ery effort should be made to !lace intra%enous lines as far from the burn as !ossible" ??3 As )ith !neumonia, the most effecti%e measures to reduce C5BS9s are infection control !ractices and timely remo%al of the de%ice" Ahen diagnosed, C5BS9 should be a!!ro!riately treated )ith systemic antimicrobials and immediate remo%al of the catheter" Electrical 9n1ury and Burns Electrical in1uries are !articularly dangerous, as they can be instantaneously fatal and also !ut rescuers in significant danger" 9n1ury se%erity de!ends on the am!erage of the current (determined by the %oltage of the source and the resistance of the %ictim), the !ath)ay of current through the %ictim3s body, and the duration of contact )ith the source" Electrical current sources are ty!ically classified as either lo)' or high'%oltage, )ith ,::: %olts (E) being the di%iding line, and distinct in1uries are associated )ith each ty!e" ??4 0%er F;- of all electrical in1uries and electrical burns are caused by lo)'%oltage commercial alternating current in the range of : to ??: E" An electrical burn !otentially has three different com!onents@ (,) the true electrical in1ury from current flo), (?) an arc or flash flame in1ury !roduced by current arcing at a tem!erature of a!!ro imately 4:::HC from its source to ground, and (3) a flame in1ury from the ignition of clothing or surroundings"

Care at the Scene 9f the %ictim remains in contact )ith the electrical source, the rescuer must absolutely a%oid touching the %ictim until the current is shut off" 0nce a)ay from the source of current, the standard ABCs (air)ay, breathing, and circulation) must be ra!idly e%aluated and su!!orted if necessary" 5es!iratory arrest secondary to !aralysis of the central res!iratory control system or due to !aralysis of the res!iratory muscles can occur2 thus an air)ay should al)ays be established and maintained" Eentricular fibrillation or asystole are not uncommon, and cardio!ulmonary resuscitation according to Basic &ife Su!!ort<Ad%anced Cardiac &ife Su!!ort<Ad%anced Trauma &ife Su!!ort !rotocols should be instituted if !ulses are not !al!able" 0nce an air)ay is established and !ulses return, a careful search must be made for associated life'threatening in1uries" Electrically in1ured !atients fre(uently fall from heights and may ha%e serious head or s!ine in1uries, as )ell as long bone fractures" The intense tetanic contractions associated )ith electrical in1ury alone can cause fractures or 1oint dislocations" All significant electrical burns should be referred to a dedicated burn center" Acute Management and Multisystem 9n%ol%ement Electrical burns are thermal in1uries from %ery intense heat and from electrical disru!tion of cell membranes" ??; As electrical current meets tissue, it is con%erted to heat in direct !ro!ortion to the am!erage of the current and the resistance of the tissues through )hich it !asses" The smaller the si+e of the body !art through )hich the electricity !asses, the more intense the heat and the less the heat is dissi!ated into surrounding tissue" .ingers, hands, forearms, feet, and lo)er legs are fre(uently totally destroyed by high'%oltage in1uries" Areas of larger %olume, li$e the trun$, usually dissi!ate enough current to !re%ent e tensi%e damage to %iscera unless the contact !oint(s) are on the abdomen or chest" ??8 Ahile cutaneous manifestations of electrical burns may a!!ear limited, burned s$in should not be considered the only in1ury, as massi%e underlying tissue destruction may be !resent" 5esuscitation needs are usually far in e cess of )hat )ould be e !ected on the basis of the cutaneous burn si+e, and associated flame and<or flash burns often com!ound the !roblem" Myoglobinuria fre(uently accom!anies electrical burns, but the clinical significance a!!ears to be tri%ial" ??G #isru!tion of muscle cells releases cellular debris and myoglobin into the circulation to be filtered by the $idney" 9f this condition is untreated, the conse(uence can be irre%ersible renal failure" 6o)e%er, modern burn resuscitation !rotocols alone a!!ear to be sufficient treatment for myoglobinuria" Cardiac damage, such as myocardial contusion or infarction, may be !resent" More li$ely, the conduction system may be deranged" 6ousehold current at ,,: E either does no damage or induces %entricular fibrillation" 9f there are no electrocardiogra!hic rhythm abnormalities !resent u!on initial emergency de!artment e%aluation, the li$elihood that they )ill a!!ear later is minuscule" E%en )ith high'%oltage in1uries, a normal cardiac rhythm on admission generally means that subse(uent dysrhythmia is unli$ely" Studies confirm that commonly measured cardiac en+ymes bear little correlation to cardiac dysfunction, and ele%ated en+ymes may be from s$eletal muscle damage" ??7,??F Mandatory electrocardiogram (EC>) monitoring and cardiac en+yme analysis in an 9CB setting for ?4 hours follo)ing in1ury is unnecessary in !atients )ith electrical burns, e%en those resulting from high'%oltage current, in !atients )ho ha%e stable cardiac rhythms on admission" ?3:

The ner%ous system is e (uisitely sensiti%e to electricity" The most de%astating in1ury )ith fre(uent brain damage occurs )hen current !asses through the head, but s!inal cord damage is !ossible )hene%er current has !assed from one side of the body to the other" Sch)ann cells are (uite susce!tible, and delayed trans%erse myelitis can occur days or )ee$s after in1ury" ?3,,?3? Conduction initially remains normal through e isting myelin, but as myelin )ears out, it is not re!laced and conduction ceases" Anterior s!inal artery syndrome from %ascular dysregulation can also !reci!itate s!inal cord dysfunction" #amage to !eri!heral ner%es is common and may cause !ermanent functional im!airment" ?33,?34 E%ery !atient )ith an electrical in1ury must ha%e a thorough neurologic e am as !art of the initial assessment" /ersistent neurologic sym!toms may lead to chronic !ain syndromes, and !osttraumatic stress disorders are a!!arently more common after electrical burns than thermal burns" Cataracts are a )ell'recogni+ed se(uela of high'%oltage electrical burns" ?3;,?38 They occur in ; to G- of !atients, fre(uently are bilateral, occur e%en in the absence of contact !oints on the head, and ty!ically manifest )ithin , to ? years of in1ury" Electrically in1ured !atients should undergo a thorough o!hthalmologic e amination early during their acute care" Aound Management There are t)o uni(ue situations in )hich immediate surgical treatment is indicated for !atients )ith electrical burns" 5arely, massi%e dee! tissue necrosis )ill lead to acidosis or myoglobinuria that )ill not resol%e )ith standard resuscitation techni(ues2 ma1or dRbridement and<or am!utation may be necessary as an emergency !rocedure" More commonly, in1ured dee! tissues undergo significant s)elling, increasing the ris$ of com!artment syndrome, and !otentially leading to further tissue loss" Careful monitoring as !re%iously described, including measurement of com!artment !ressures, is mandatory" Escharotomies and fasciotomies should be !erformed at com!artment !ressures of 3: mm 6g or more, or )ith clinical indications of com!artment syndrome" Any !rogression of median or ulnar ner%e deficit in a hand that has been electrically burned is an indication for immediate median and ulnar ner%e release at the )rist" 9t a!!ears that selecti%e decom!ression of electrically burned u!!er e tremities, as guided by clinical findings, is su!erior to mandatory decom!ression in !reser%ing o%erall tissue %iability" ?3G 9f immediate decom!ression or dRbridement is not re(uired, definiti%e surgical !rocedures can be done in the usual time frame, bet)een days 3 and ;" This !re%ents in%asi%e bacterial infection and allo)s for clear delineation of tissue %iability" Chemical Burns Strong acids or al$alis cause most chemical burns" They ty!ically are associated )ith industrial accidents, assaults, or the im!ro!er use of harsh household sol%ents and cleaners" 9n contrast to thermal in1ury, chemical burns cause !rogressi%e damage and in1ury until the chemicals are inacti%ated by reaction )ith tissues or diluted by thera!eutic irrigation" 9ndi%idual circumstances can %ary, but acid burns ty!ically are more self'limiting than al$ali burns" Acids tend to *tan* the s$in, creating an im!ermeable barrier of coagulation necrosis debris along the leading edge of the chemical burn that limits further !enetration" Al$alis combine )ith cutaneous li!ids to create a soa!, and are thus able to continue dissol%ing the s$in until they are neutrali+ed" 9nitial Care

All in%ol%ed clothing should be remo%ed, and unli$e thermal in1ury, the burns should be irrigated )ith co!ious amounts of te!id )ater at the accident scene follo)ing chemical e !osures" Chemicals )ill continue to burn until !hysically remo%ed" 9rrigating for at least ,; minutes under a running stream of te!id )ater may limit the o%erall se%erity of the burn2 ho)e%er, care should be ta$en to a%oid hy!othermia" Ceutrali+ing agents or antidotes are contraindicated, e ce!t )ith hydrofluoric acid burns" #elay dee!ens the chemical burn, and neutrali+ing agents may e%en !roduce thermal burns, as they fre(uently generate substantial heat u!on neutrali+ation of the offending agent" ?37 /o)dered chemicals should be brushed off s$in and clothing" All significant chemical burns should be referred to a dedicated burn center" Aound Management A full'thic$ness chemical burn may a!!ear dece!ti%ely su!erficial, causing only a mild bro)nish discoloration of the s$in" The s$in may remain intact during the first fe) days !ostburn, and only then begin to slough s!ontaneously" Chemical burns should be considered dee! !artial'thic$ness or full'thic$ness until !ro%en other)ise" As such, they are best treated by early ES> after full demarcation of in1ury" Some chemicals, such as !henol, cause se%ere systemic effects, )hile hydrofluoric acid may cause death from hy!ocalcemia e%en after moderate e !osure" 6ydrofluoric acid burns are uni(ue chemical burns in that they should be acutely treated )ith an antidote, calcium" Calcium gluconate should be administered intra'arterially as )ell as to!ically, and all electrolyte abnormalities aggressi%ely corrected" ?3F /ain Control All burn in1uries are !ainful, )hether the in1ury is sim!ly sunburn or an e tensi%e !artial' thic$ness or full'thic$ness burn co%ering a large !ortion of the body" Attem!ts to manage !ain in the thermally in1ured are fre(uently frustrating because of the un!redictable !hysiologic and !sychologic reactions to the burn" ?4: An e!idermal burn damages the outer layers of s$in, the e!idermis, !roducing mild !ain and discomfort" Aithout the !rotecti%e co%ering of the e!idermis, ner%e endings are sensiti+ed and e !osed to stimulation" The !ain associated )ith !artial'thic$ness burns %aries de!ending on the e tent of dermal destruction" Su!erficial !artial'thic$ness burns initially are the most !ainful2 e%en the slightest air current blo)ing across the e !osed dermis causes the !atient e cruciating !ain" Areas of dee! !artial'thic$ness or full'thic$ness in1ury sho) little or no res!onse to shar! stimuli, yet a !atient may com!lain of a dee! aching !ain, )hich is related to the inflammatory res!onse" The !hysiologic effects of !ain are !rimarily res!onses to catecholamines, and include increased heart rate, blood !ressure, and res!iration2 decreased 0? saturation2 !almar s)eating2 facial flushing2 and !u!illary dilation" Total elimination of !ain in burn !atients is not !ossible, short of general anesthesia" The burn !atient may e !erience acute !ain from dressing changes, o!erati%e !rocedures, and rehabilitation thera!y e ercises" /atients may also ha%e chronic bac$ground !ain associated )ith the )ound maturation !rocess" There is a )ide degree of intra' and interindi%idual %ariation )ith res!ect to the e !erience of burn'related !ain" ?4, /ain management in%ol%es both !harmacologic and non!harmacologic modalities" The mainstays of !harmacologic !ain control are analgesics, !rinci!ally o!ioids and nonsteroidal anti'inflammatory drugs" Anesthetic agents, namely $etamine and nitrous o ide, are (uite useful for e tremely !ainful

!rocedures such as dressing changes" /sychotro!ic drugs (e"g", an iolytics, tran(uili+ers, and<or antide!ressants) also can be useful in the management of burn )ounds" The concomitant use of ben+odia+e!ines )ith o!ioids a!!ears to be additi%e and reduces o!iate re(uirements" ?4? Con!harmacologic methods ha%e become more !re%alent o%er the !ast decade, as efficacious techni(ues ha%e e%ol%ed" ?43,?44 Eirtual reality thera!y as an ad1unct to analgesics a!!ears !articularly !romising" ?4; Chronic /roblems 6y!ertro!hic Scar .ormation 6y!ertro!hic scarring is a !otentially de%astating conse(uence of thermal in1uries and is unfortunately all too common" The etiology and !atho!hysiology of hy!ertro!hic scars are still incom!letely understood" Burn scar hy!ertro!hy classically de%elo!s in dee!er !artial' thic$ness and full'thic$ness in1uries that are allo)ed to heal by !rimary intention" 6y!ertro!hy of e cised and grafted burn )ounds occurs less fre(uently, and is !artly de!endent on the time from in1ury to e cision, the site of the )ound, and the !atient3s race or ethnicity" ?48,?4G #elayed e cision is more li$ely to result in hy!ertro!hic scarring, and !igmented indi%iduals are at an increased ris$" #onor sites also can become hy!ertro!hic, and this !ro!ensity a!!ears to be related to graft thic$ness, donor site infection, and !atient characteristics" Cumerous etiologies for hy!ertro!hic scarring, ranging from cellular and histologic to biochemical, ha%e been !ro!osed" B!regulation and o%er!roduction of transforming gro)th factor' (T>.' ) a!!ears to be a !romising !ossibility, )ith !otential thera!ies already clinically a%ailable" ?47 6o)e%er, gene array technology has sho)n that the etiology is li$ely (uite com!le , )ith multi!le gene alterations being in%ol%ed" ?4F 6y!ertro!hic scarring should be distinguished from a $eloid" Both e hibit e cessi%e collagen formation2 ho)e%er, a $eloid gro)s beyond the original dimensions of the in1ury, )hile a hy!ertro!hic scar is confined to its original anatomic boundaries" 6y!ertro!hic scars fre(uently flatten )ith time and !ressure, )hereas $eloids do not" Cumerous treatments ha%e been !ostulated for hy!ertro!hic scarring2 ho)e%er, fe) ha%e !ro%en to be efficacious" ?;:I?;? /ressure a!!lied directly to a hy!ertro!hic scar %ia %arious %ehicles has been the most )idely used treatment modality" Elastici+ed, custom'fitted, com!ression garments and silicone dressings are the most )idely used and acce!ted !ressure thera!ies" &ong'term controlled trials ha%e not clearly demonstrated permanent benefits from com!ression thera!y, but com!ression garments (uic$ly reduce the mass of hy!ertro!hic immature scars, and !ro%ide !atients )ith tangible e%idence of the benefits of conscientious follo)'u!" The mechanism by )hich com!ression<!ressure reduces scar mass is not )ell defined, but histologic remodeling occurs" ?;3 The most successful a!!roach to residual hy!ertro!hic burn scars is initial !ressure thera!y until the )ound matures, follo)ed by subse(uent e cision and grafting if necessary" 9ntralesional in1ection of corticosteroids may reduce the bul$ of the hy!ertro!hic scar mass, and may be used in combination )ith other treatment modalities" 9t is belie%ed that triamcinolone, the most commonly used steroid, acts by decreasing collagen synthesis and increasing collagen degradation" Classically, a!!ro imately ?:- of the !atients treated in burn facilities )ere readmitted for reconstructi%e !rocedures" The most common areas of reconstruction in%ol%e the hand and

)rist, arm and forearm, face, and nec$" 9m!ro%ed in!atient burn treatment and scar management ha%e reduced the need for subse(uent reconstructi%e surgery to around ; to ,:in the authors3 burn center" Mar1olin3s Blcer Chronic ulceration of old burn scars )as noted by Mar1olin to !redis!ose to malignant degeneration" S(uamous cell carcinoma is most common, although basal cell carcinomas occasionally occur, and rare tumors such as malignant fibrous histiocytoma, sarcoma, and melanoma ha%e been re!orted" Chronic brea$do)n of a healed burn scar should lead to the sus!icion of malignant degeneration" ?;4 These lesions ty!ically a!!ear decades after the original in1ury in )ounds that healed !rimarily, but acute cases arising )ithin a year of in1ury ha%e been re!orted" They also can arise in grafted areas and a!!ear to ha%e an e%en longer time to occurrence )hen they do" ?;; The !recise incidence of burn scar carcinoma is un$no)n, but a!!ears to be lo)er in countries )here early e cision and grafting ha%e been ado!ted" Malignancy mandates )ide e cision, )ith !otential am!utation if the lesion is on an e tremity" Burn scar carcinomas can metastasi+e, ty!ically to regional nodal basins" /ro!hylactic regional lym!h node dissection has not im!ro%ed sur%i%al, but sentinel lym!h node bio!sy is a !romising modality to direct thera!eutic node dissection and a)aits %alidation in this !o!ulation" 0n a selected basis, ad1u%ant radiation may be )arranted" >enerally, outcome is good )ith !rom!t diagnosis and resection" 6eteroto!ic 0ssification 6eteroto!ic ossification (60) is a rare com!lication of thermal in1ury, but is associated )ith significant morbidity" ?;8 9t most commonly occurs in !atients )ith ma1or full'thic$ness burns and is found ad1acent to an in%ol%ed 1oint , to 3 months after in1ury" The u!!er e tremity is most commonly affected" The thera!ist, )ho disco%ers increased !ain and decreased range of motion of in%ol%ed 1oints, usually ma$es the diagnosis" &imitation of !hysical acti%ity usually !recedes radiogra!hic e%idence of calcification, )hich is located in the muscle and surrounding soft tissue of the 1oint" Although the mechanism causing 60 is not $no)n, it has been suggested that bleeding into the soft tissue due to aggressi%e !hysical thera!y is the cul!rit" ?;G /rolonged immobili+ation of a 1oint encom!assed by a burn also a!!ears to !romote 60" ?;7 5estricted acti%ity !romotes mobili+ation of body calcium stores and may lead to de!osition of calcium in the soft tissues" Some !ro!ose resection of all ossified soft tissue, but others recommend modification of rehabilitation thera!y regimens and allo)ing the reabsor!tion of ossified tissue" Surgical inter%ention is certainly )arranted )ith e%idence of neuromuscular com!romise" Bis!hos!honates and e ternal beam radiation ha%e been ad%ocated as !ro!hylactic measures in high'ris$ !atients2 ho)e%er, solid !ros!ecti%e data su!!orting these recommendations is lac$ing"