Abstract

ABSRACT:The estimated 32,600,000 fires that occur annually in the United States produce over 300,000 injuries and 7,500 deaths. Ten percent of hospitalized burn victims die as a direct result of the burn. Initial evaluation and management of the burn patient are critical. The history should include the burn source, time of injury, burn environment, and combustible products. The burn size is best estimated by the Lund and Browder chart, and the burn depth is determined by clinical criteria. Pulmonary involvement and circumferential thoracic or extremity burns require detection and aggressive treatment to maintain organ viability. Hospitalization is usually necessary for adults with burns larger than 10% of the total body surface area (TBSA) or children with burns larger than 5% of TBSA. Major burns, those of 25% or more of TBSA or of 10% or more of full thickness, should be considered for treatment at a burn center, as well as children or elderly victims with burns of greater than 10% TBSA. Lactated Ringers solution, infused at 4 ml/kg/% TBSA, is generally advocated for initial fluid restoration. After the acute phase (48 hours), replacement of evaporative and hypermetabolic fluid loss is necessary. These losses may constitute 3 to 5 liters per day for a 40% to 70% TBSA burn. Blood transfusion is often required because of persistent loss of red blood cells (8% per day for about ten days). Many electrolyte abnormalities may occur in the first two weeks. Pulmonary injury commonly is lethal. Gircumoral burns, oropharyngeal burns, and carbonaceous sputum are indicative of inhalation injury, but arterial blood gas determinations, fiberoptic bronchoscopy, and xenon lung scans are useful for confirming the diagnosis. Humidified oxygen, intubation, positive-pressure ventilation, and pulmonary toilet are the mainstays of therapy for inhalation injury. Wound care is initially directed at preservation of vital function by escharotomy, if restrictive eschar impairs ventilatory or circulatory function. Antibacterial agents may be applied to the burn, but invasive sepsis, defined as > 105 organisms per gram of tissue with invasion of subjacent viable tissue, requires systemic antibiotic therapy. Wound debridement is done by daily hydrotherapy, tangential excision, chemicals, primary excision, and grafting, tailoring the technique to the individual burn. Nutritional supplementation aimed at prevention of weight loss and maintenance of nitrogen balance should begin by 48 hours after the injury and should meet nutritional requirements by the end of the first week.