A20. Critical care of severely burned patients

From greek.doctor

Burn injuries are potentially lethal injuries. Children are often affected.

Depths of burn

  • 1st degree – only the epidermis is affected
  • 2nd degree – epidermis and dermis are affected
    • 2A – upper layers of dermis affected
    • 2B – deeper layers of dermis affected
  • 3rd degree – epidermis, dermis, and subcutis affected
  • 4th degree – muscle, fat, fascia, bones affected

1st degree burns form no blisters, but the skin is oedematous, red and painful. It heals without treatment or scar formation. 2nd degree burns type 2A form vesicles and bullae, is red and painful. It heals with abnormal pigmentation but without scarring. Type 2B also form vesicles and bullae, is red and painful. It heals with scar formation.

3rd degree burns are not painful. The skin is necrotic with black or grey skin. It does not heal without intervention. 4th degree burns is unsalvageable and requires amputation.

Severity of burn

The extent of burn, the percentage of total body surface which is burnt (TBSA%), can be estimated by the Wallace rule of nines:

A severe burn is one who fulfils any of the following:

  • Any burn complicated by major trauma or inhalation injury
  • Chemical burns
  • High voltage electrical burn
  • Any burn >20% of the TBSA

Severe burns require intensive care in specialized burn centres. The patient must by haemodynamically monitored, often invasively (PiCCO). The urine output should be monitored and kept > 0,5 mL/kg/hour.

Potential complications of severe burns include:

Management

In these patients, the following interventions are important:

The amount of fluid to replace can be calculated by the Parkland formula: 4 mL/kg of bw/TBSA%. Ringer-lactate is used. Half is given in the first 8 hours, half in the next 16 hours.