A major burn is a horrifying injury, requiring painful treatment and a long period of rehabilitation. Burns can be fatal, permanently disfiguring, and incapacitating, both emotionally and physically.
In the United States, more than 2 million people are burned each year. Of these, up to 70,000 are hospitalized and 20,000 require admission into specialized burn units. Infections are a major cause of morbidity and mortality in the seriously burned patient; as many as 10,000 patients in the United States die each year due to burn-related infections.
Thermal burns, the most common type, frequently result from residential fires, motor vehicle crashes, playing with matches, improperly stored gasoline, space heater or electrical malfunctions, and arson. Other causes include improper handling of firecrackers, scalding accidents, and kitchen accidents (such as a child climbing on top of a stove or grabbing a hot iron). Sometimes burns are traced to child or elder abuse.
Chemical burns result from the contact, ingestion, inhalation, or injection of acids, alkali, or vesicants. Electrical burns commonly occur after contact with faulty electrical wiring or high-voltage power lines, or when electric cords are chewed (by young children). Friction, or abrasion, burns happen when the skin is rubbed harshly against a coarse surface. Sunburn follows excessive exposure to sunlight and improper use of tanning lights.
Routine blood work for a patient with a burn injury includes a complete blood count, platelet count, clotting studies, liver function studies, and carboxyhemoglobin, electrolyte, blood urea nitrogen, glucose, and creatinine levels. Urinalysis may reveal myoglobinuria and hemoglobinuria. If the patient is age 35 or over, he'll also need an electrocardiogram. Chest X-ray films and arterial blood gas levels allow the evaluation of alveolar function. Fiberoptic bronchoscopy shows the condition of the trachea and bronchi.
The priority in burn treatment is securing an airway, especially for a patient with severe facial burns or suspected pulmonary injury. Initial treatment though to prevent hypoxia includes endotracheal intubation, administration of high concentrations of oxygen, and positive-pressure ventilation.
Treatment for moderate or severe burns includes administering lactated Ringer's solution through a large-bore I.V. line to expand vascular volume. The volume to infuse is calculated according to the extent of the area burned and the amount of time that has elapsed since the burn injury occurred. Several formulas are used as general guidelines for fluid replacement in the first 24 hours after a burn. The specific infusion varies according to the patient's response, especially urine output. Central I.V. lines and arterial lines are inserted as necessary. An adult patient also needs I.V. fluids sufficient to maintain a urine output of 30 to 50 ml/hour; the output of a child under 66 lb (30 kg) should be maintained at I ml/kg/hour. An indwelling urinary catheter permits accurate monitoring of urine output.
I.V. morphine (2 to 4 mg) alleviates pain and anxiety. The patient also will need an NG tube to prevent gastric distention and accompanying ileus from hypovolemic shock.
All burn patients need a booster of 0.5 ml of tetanus toxoid administered I.M. Most burn centers don't recommend administering prophylactic antibiotics because overuse of antibiotics fosters the development of resistant bacteria.
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