Management of the Burn Patient
A 58-year-old female patient was activated as a Level 1 trauma alert after being involved in a house explosion with resultant fire. She was awake and alert with no loss of consciousness at the scene but sustained significant thermal injuries per EMS report. She was intubated pre-hospital for “airway protection” out of concern for inhalation injury with facial burns. Initial evaluation revealed an older woman, orally intubated with bilateral breath sounds, mildly tachycardic in the 100s, moderately hypertensive in the 160s/90s, with readily apparent full-thickness burns to the face, neck, anterior torso, bilateral arms, and bilateral legs (Photos 1 and 2). Secondary survey and imaging revealed no further injuries. At this juncture, it’s important to remember and remind the non-burn or trauma center practitioner that a thermally-injured patient is still a “trauma” patient. While a large, third degree burn certainly elicits a significant morbid response in many observers, spending significant time managing the burn wounds while neglecting potential internal hemorrhage will invariably lead to a delay in treatment and worse outcomes.
The patient was immediately taken to our specialized Burn Operating Room once other injuries were ruled out and both non- and -excisional debridement of her burn wounds occurred, with resultant wound dressing application. Her upper body burns were debrided and dressed with antimicrobial dressings. She then resuscitated for the next 48 hours, ultimately receiving approximately 3.3 mL/kg/%TBSA in the first 24 hours post-injury based on a TBSA of 63%, primarily full-thickness (third degree). Resuscitation continued over the first 48 hours, and the patient underwent serial excisional debridement and wound preparation procedures over the next few weeks. Given the size of her burns, we opted to utilize cultured epidermal autografts for assistance with skin/wound coverage. It is important to note that during the entirety of our patient’s two-month hospitalization she received attentive multidisciplinary care including efforts from nutrition services, therapy services, social work, as well as the nursing and physician teams. After continued local wound and graft care the patient was discharged on HD61 to a rehabilitation facility, where she stayed for approximately three weeks until discharge home, where she now lives independently and is continuing to improve.
Jeffrey S. Litt, DO, FACS, is Assistant Professor of Surgery, Burn Director, Division of Acute Care Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, MissouriCorresponding author.