Documentation of resuscitation throughout the continuum of care is lifesaving. Providers must document resuscitation!
Prophylactic systemic antibiotics are not indicated for burn injury in the absence of infection. Penetrating wounds or open fractures should be treated with antibiotics according to respective guidelines. See the Wound Care section for discussion of topical antimicrobials.
Smoke inhalation injury is mediated by inhaled toxic gases and carbonaceous particles (soot).
Carbon monoxide (CO) toxicity include those exposed to smoke from burning hydrocarbons (e.g., vehicle or generator exhaust) or cellulose-containing materials (wood, paper, charcoal).
Cyanide is encountered in fires involving certain nitrogen-containing materials such as polyurethane. Initial symptoms include dizziness, headache, nausea, and anxiety.
Hydrogen fluoride (HF) is a byproduct of standard fire-suppression systems. Exposure to HF may result in rapidly progressive or fatal respiratory failure despite minimal external evidence of injury. Symptoms include shortness of breath, cough, hypoxia, and hypocalcemia; there must be a high level of suspicion for HF inhalation.10
Refer to the Inhalation Injury and Toxic Industrial Chemical Exposure CPG for additional information.4
Refer to Eye Trauma: Initial Care CPG for additional information.4
CIRCUMFERENTIAL BURNS, ESCHAROTOMY, & EXTREMITY COMPARTMENT SYNDROME
Escharotomy is normally performed for circumferential full thickness burns.
Check pulses (preferably using a Doppler flowmeter if available). If pulse is decreased or absent:
Escharotomy incises the skin only, not the fascia and is usually sufficient for limb ischemia caused by burns unless there is underlying muscle damage, over-resuscitation, or combined injury. The requirement for escharotomy or fasciotomy usually presents in the first 48 hours following injury. If the need for either procedure has not been identified within the first 24-48 hours, then circulation is likely to remain adequate without surgical intervention.
Elevation of the burned extremities (especially the upper extremities) above the level of the heart is required to decrease edema and prevent compartment syndrome.
CLINICAL INDICATIONS:
Deep partial-thickness or full-thickness circumferential burns to arms or legs.
Circumferential, full thickness burns to the chest wall.
CONTRAINIDICATIONS: No contraindications
Fasciotomy
Optimal fluid resuscitation and prompt escharotomy usually mitigates the need for fasciotomy. Consider fasciotomy in the operating room (OR) if pulses remain undetectable after complete escharotomy.
Due to the frequency of extremity injuries seen among combat casualties, fasciotomies on burned extremities may be required for those with:
Following escharotomy or fasciotomy, late bleeding may occur as circulation is restored. Examine the surgical site every few minutes for up to 30 minutes for signs of new bleeding, which is usually easily controlled with electrocautery.
Refer to Acute Extremity Compartment Syndrome and the Role of Fasciotomy in Extremity War Wounds CPG for additional information. 23
Abdominal Compartment Syndrome
Massive fluid replacement (> 250 mL/kg within 24 hours) is a risk factor for abdominal compartment syndrome (ACS), a clinical diagnosis which includes increased bladder pressure, increased airway pressure, oliguria, and hypotension.24,25 Bladder pressure > 20 mmHg warrants consideration of therapeutic paracentesis which may provide partial relief. A bladder pressure > 30 mmHg, when measured accurately, is a serious finding that mandates immediate assessment and treatment.
Decompressive laparotomy, when performed for ACS in patients with massive burns, almost always indicates a nonsurvivable situation. The decision to pursue decompressive laparotomy must consider this fact.24
PLEASE CALL THE BURN CENTER PRIOR TO PROCEDURE! Avoiding over resuscitation is key to avoiding ACS.
If the patient requires a decompressive laparotomy, perform a standard midline incision followed by temporary abdominal closure. If the abdominal wall skin is burned, adhesive drapes for negative pressure wound dressings will not adhere to the skin edges. Use of Stomahesive paste or another barrier is recommended.
a. Fragments embedded in the skin and soft tissue should be irrigated out if possible or kept covered with soaking wet dressings. Note that if the dressings dry the white phosphorus may ignite them.
b. Urgently retrieve deeply embedded fragments in the OR.
c. Use a Wood’s lamp to help locate the fragments. Monitor calcium levels closely and treat hypocalcemia with IV replacement.
d. Plan a second-look operation within the day to identify missed fragments.
Refer to Inhalation Injury and Toxic Industrial Chemical Exposure CPG for additional information.4
Special considerations for electrical injury: