Chăm Sóc Và Điều Trị Bỏng Toàn Diện (Total Burn Care – Tập 5)

32  •  Critical Care in the Severely Burned: Organ Support and Management of Complications
353
associated with recovery and healing.189,190 The current
standard for diagnosis is a high index of suspicion and fre­
quent culturing of wounds, lines, blood, airways, urine, and
any other potential source. Suspicion must as well be main­
tained for invasive yeast and molds, viruses (most especially
herpetic viruses), and, of course, bacteria.
Potential does exist for elevations in procalcitonin (PCT)
to be associated with a higher risk of infection, this being
linked to pathogen infection presumably through PAMPs
rather than DAMPs. An interesting study from Iran exam­
ined the role of white blood cells, sedimentation rate,
C-reactive protein, and PCT in diagnosing sepsis in the
severely burned. The authors found that PCT was the only
test with any distinguishing capacity and accuracy.191
In a recent meta-analysis of 566 patients from nine trials
of sepsis in burn patients, PCT demonstrated a sensitivity
of 0.74 and a specificity of 0.88.192 In a subsequent study,
a protocol was instituted utilizing PCT to determine dura­
tion of antibiotic therapy in 46 burn BICU patients. Antibi­
otic duration was significantly reduced without relapse of
infection, increase in mortality or organ failure, or increase
in length of stay.193 PCT has not yet become a standard of
care; however data continue to support its utility in the
burn population.
Prevention of Organ Failure
This brief outline of the potential pathophysiology and
causes of burn-induced critical illness and MOF demon­
strates the complexity of the problem. Prevention of organ
failure is the subject of Chapter 30. Because different
cascade systems are involved in the pathogenesis, it is cur­
rently impossible to pinpoint a single mediator or system
that initiates the event. Thus because the mechanisms of
progression are not well known and specific treatments
cannot be accurately devised, it seems that prevention is the
best solution. Current recommendations are to prevent the
development of organ dysfunction and provide optimal
support to avoid the conditions that promote its onset. In
burned patients this can be accomplished most reliably
through expeditious wound closure, rapid mobilization of
the patient, and prompt identification of and treatment of
early infections.
Conclusion
Burn critical care is predicated on seven key factors: suffi­
cient goal-directed fluid resuscitation; early burn excision
and wound coverage; aggressive antimicrobial and source
control of sepsis; aggressive nutritional support; active
warming; aggressive physical, occupational, and respira­
tory therapy; and aggressive and continuous support of
organ failures until such time as the patient can heal. This
care has reduced mortality over the past three decades, in
large part through the development of specialized units for
the care of burned patients. These units are equipped with
the personnel and equipment to deliver state-of-the-art
care. Better understanding of the processes of critical illness
and MOF has led to effective prevention strategies and treat­
ment modalities. Further advances in the understanding of
find a benefit to keeping glucose in the normal range, but
rather indicated a higher range might have been even more
beneficial.181 The caveat to this analysis is that, on a post-
hoc basis, injured patients had better outcomes with a
normal glucose range rather than higher. However a
growing body of evidence has demonstrated that hypogly­
cemic episodes (<60 mg/dL) cause increased length of stay,
more infections, sepsis, MOF, and mortality.182 Interestingly
these negative outcomes and mortalities were not an acute
result of the hypoglycemia, thus indicating there are lasting
negative effects of transient and even successfully treated
hypoglycemias. As such, the Society of Critical Care Medi­
cine tolerates higher blood glucoses, in the 150–180 mg/
dL range.71 Methods to balance the benefits of euglycemia
with the risks of hypoglycemia remain an active area of
study in critical care.
In another landmark trial, cortisol levels were found to
be low in many critically ill patients, and a mortality benefit
accrued with physiologic replacement with hydrocorti­
sone.183 This study highlighted that hypocortisolemia is, at
the very least, associated with septic shock and hypoten­
sion, and that replacement with hydrocortisone at 50 mg
every 6 h improves outcomes. The same was seen in burned
patients in the ICU.184,185 This occurs despite the demon­
strated fact that burn patients are in a hyperadrenal state.186
It must be noted, however, that the benefits seem to be
limited to those with relative adrenal insufficiency assessed
by corticotropin stimulation, as seen in the follow-up COR­
TICUS trial.187 Regardless, in the case of hypotension unre­
lated to hypovolemia in burn patients, cortisol levels and
adrenal stimulation can be performed to determine whether
relative adrenal insufficiency exists.
Venet et al. performed a placebo-controlled, double-blind
RCT testing hydrocortisone in BICU patients suffering from
refractory shock, defined as greater than 0.5 μg/kg per
minute of norepinephrine. They found a significant reduc­
tion of norepinephrine treatment duration. Of note, 78% of
these patients had a negative corticotropin stimulation test.
They concluded low-dose hydrocortisone in burn patients
with refractory shock reduces vasopressor administra­
tion.188 These data thus obviate the value of cortisol stimu­
lation tests. In a subsequent study, Winter et al. demonstrated
that a hydrocortisone bolus of 100 mg followed by a
0.48 mg/kg per hour infusion improved norepinephrine
dosing in burn survivors, but not in nonsurvivors.185
Burn surgeons are typically reticent to risk the negative
wound healing and immunosuppressive complications of
glucocorticoids. However, in the setting of refractory shock,
a trial of steroids can prove diagnostic and therapeutic. Fur­
thermore high-dose vitamin A can be utilized to ameliorate
the wound-healing complications.140
INFECTIOUS DISEASE BURN CRITICAL CARE
Sepsis is a leading cause of mortality in burn patients and
is the subject of Chapter 11. Sepsis has two potential causes:
infection or inflammation without infection. Reliable detec­
tion of those patients with some component of infection is
crucial. Our difficulty in severe burns is delineating this
because traditional screening indicators for infection, such
as temperature and white blood cell count, are unreliable
because of the massive hypermetabolism and inflammation

32  •  Critical Care in the Severely Burned: Organ Support and Management of Complications
354
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MacLennan L, Moiemen N. Management of cyanide toxicity in patients
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McIntire A, Harris SA, Whitten JA, et al. Outcomes following the use of
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Ren H, Li Y, Han C, Hu H. Serum procalcitonin as a diagnostic biomarker
for sepsis in burned patients: a meta-analysis. Burns. 2015;41(3):
502-509.
Venet F, Plassais J, Textoris J, et al. Low-dose hydrocortisone reduces nor­
epinephrine duration in severe burn patients: a randomized clinical
trial. Crit Care. 2015;19:21.
Wurzer P, Branski LK, Jeschke MG, et al. Transpulmonary thermodilution
versus transthoracic echocardiography for cardiac output measure­
ments in severely burned children. Shock. 2016;46(3):249-253.
the mechanisms of the progression from SIRS to MOF might
engender new breakthroughs that can be expected to
further improve the outcomes of burned patients.
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and ventilator weaning protocol for mechanically ventilated patients in
intensive care (Awakening and Breathing Controlled trial): a randomised
controlled trial. Lancet. 2008;371(9607):126-134.

354.e1
32  •  Critical Care in the Severely Burned: Organ Support and Management of Complications
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114. Cioffi WG, Graves TA, McManus WF, et al. High-frequency percus­
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116. Chung KK, Wolf SE, Renz EM, et al. High-frequency percussive ven­
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119. Dube KM, Ditch KL, Hills L. Use of nebulized heparin, nebulized
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120. Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of
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171. CRASH-2 Collaborators, Shakur H, Roberts I, et al. Effects of
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173. Kozar RA, Peng Z, Zhang R, et al. Plasma restoration of endothelial
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174. Wahl WL, Brandt MM, Ahrns KS, et al. Venous thrombosis incidence
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175. Leyvraz PF, Richard J, Bachmann F, et al. Adjusted versus fixed-dose
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176. Faucher LD, Conlon KM. Practice guidelines for deep venous throm­
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177. Alhazzani W, Lim W, Jaeschke RZ, et al. Heparin thrombopro­
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178. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy
in critically ill patients. N Engl J Med. 2001;345(19):1359-1367.
179. Thomas SJ, Morimoto K, Herndon DN, et al. The effect of prolonged
euglycemic hyperinsulinemia on lean body mass after severe burn.
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180. Jeschke MG, Kulp GA, Kraft R, et al. Intensive insulin therapy in
severely burned pediatric patients: a prospective randomized trial.
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181. Investigators N-SS, Finfer S, Chittock DR, et al. Intensive versus
conventional glucose control in critically ill patients. N Engl J Med.
2009;360(13):1283-1297.
182. Jeschke MG, Pinto R, Herndon DN, et al. Hypoglycemia is associ­
ated with increased postburn morbidity and mortality in pediatric
patients. Crit Care Med. 2014;42(5):1221-1231.
183. Annane D, Sebille V, Bellissant E, Ger-Inf-05 Study Group. Effect
of low doses of corticosteroids in septic shock patients with or
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184. Fuchs P, Groger A, Bozkurt A, et al. Cortisol in severely burned
patients: investigations on disturbance of the hypothalamic-pitu­
itary-adrenal axis. Shock. 2007;28(6):662-667.
185. Winter W, Kamolz L, Donner A, et al. Hydrocortisone improved
haemodynamics and fluid requirement in surviving but not non-
surviving of severely burned patients. Burns. 2003;29(7):717-720.
186. Norbury WB, Herndon DN, Branski LK, et al. Urinary cortisol and
catecholamine excretion after burn injury in children. J Clin Endo­
crinol Metab. 2008;93(4):1270-1275.
187. Sprung CL, Annane D, Keh D, et al. Hydrocortisone therapy for
patients with septic shock. N Engl J Med. 2008;358(2):111-124.
188. Venet F, Plassais J, Textoris J, et al. Low-dose hydrocortisone reduces
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189. Greenhalgh DG, Saffle JR, Holmes JHT, et al. American Burn Asso­
ciation consensus conference to define sepsis and infection in burns.
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190. Murray CK, Hoffmaster RM, Schmit DR, et al. Evaluation of white
blood cell count, neutrophil percentage, and elevated temperature
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191. Barati M, Alinejad F, Bahar MA, et al. Comparison of WBC, ESR, CRP
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192. Ren H, Li Y, Han C, Hu H. Serum procalcitonin as a diagnostic
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193. Lavrentieva A, Kontou P, Soulountsi V, et al. Implementation of a
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145. Oda J, Ueyama M, Yamashita K, et al. Hypertonic lactated saline
resuscitation reduces the risk of abdominal compartment syndrome
in severely burned patients. J Trauma. 2006;60(1):64-71.
146. Latenser BA, Kowal-Vern A, Kimball D, et al. A pilot study compar­
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147. Markell KW, Renz EM, White CE, et al. Abdominal complications
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148. Wang DW, Yin YM, Yao YM. Advances in the management of acute
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149. Rivero HG, Lee JO, Herndon DN, et al. The role of acute pancreatitis
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153. Mustonen KM, Vuola J. Acute renal failure in intensive care burn
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154. Ichai C, Passeron C, Carles M, et al. Prolonged low-dose dopamine
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and soft tissue excisions: An observational study of blood product

355
Burn Nursing
DEBRA A. BENJAMIN and MARY JACO
33 
always with the patient, to monitor the patient’s vital signs
and urine output and notify the physician of changes to
ensure an adequate fluid and cardiovascular status. An
adult should maintain a urine output of 0.5 cc/kg per hour
and a child should maintain a urine output of 1.0 cc/kg per
hour. Lower urine volume rates may indicate hypovolemia,
which can lead to cardiovascular collapse. Resuscitation
fluids are to be started as soon as the patient first comes in
contact with medical personnel. This is normally accom­
plished with IV fluids using resuscitation formulas designed
for adults or children, or through oral ingestion of fluids.2
The goal is to provide adequate fluid resuscitation to main­
tain a normal cardiovascular status, perfusion of organs
and tissues, and an adequate urine output.
Inhalation injury continues to be the most serious and
life-threatening complication of burn injury. Early diagno­
sis and treatment greatly impact the outcome of care.
Impaired gas exchange is a potential problem for patients
who have face and neck burns and/or inhalation injury.
Inhalation injury may include carbon monoxide poisoning,
upper airway injury (heat injury above the glottis), lower
airway injury (chemical injury to lung parenchyma), and
restrictive defects (circumferential third-degree burn
around the chest). Upper airway edema causes respiratory
distress and is the primary concern during the initial 24- to
48-hour postburn phase. Tracheobronchitis, atelectasis,
bronchorrhea, pneumonia, and adult respiratory distress
syndrome (ARDS) may occur during the acute postburn
stage either related or unrelated to inhalation injury.
Nursing care of a patient with inhalation injury begins
with a detailed history of the accident. Inhalation injury is
suspected when the accident occurred in a closed space.
Close observation of the patient and frequent respiratory
assessments are made throughout the initial and acute
phase postburn. Initially the patient is observed for hoarse­
ness and stridor, which indicate narrowed airways. Emer­
gency equipment is placed at the bedside to facilitate
intubation if necessary. Observing an increased frequency
of cough, carbonaceous sputum, and increased inability to
handle secretions may indicate possible inhalation injury
and the potential for impaired gas exchange. Other impor­
tant observations include respiratory rate, breath sounds,
the use of accessory muscles to aid in respiratory effort,
nasal flaring, sternal retractions, increased anxiety, and
complaint of shortness of breath. Disorientation, obtunda­
tion, and coma may be due to significant exposure to smoke
toxins such as carbon monoxide or cyanide. These condi­
tions are managed emergently with 100% oxygen.
Bronchoscopy may be done early to diagnose inhalation
injury as well as to facilitate airway clearance. Humidified
oxygen should be readily available and applied to patients
who have evidence of impaired gas exchange (especially
Introduction
The bedside nurse caring for the severely burned patient is
given more responsibility than in most types of serious
illness. It is extremely important that the nurse be an inte­
gral part of the team of people caring for the burned
patient.1 This is as important when modern burn care
began as it is today. Care begins with the immediate resus­
citation of the patient in the emergency department and
continues until discharge, through rehabilitation and sur­
gical reconstruction, until the patient is completely recov­
ered and reintegrated into society. During the acute
hospitalization, the nurse caring for the burned patient
spends more time with the patient than any other member
of the burn team. Because of this, especially during the
acute hospitalization, the nurse is the best person to notice
changes in patient condition and status and must continu­
ously keep various team members updated on changes.
Physical changes can include fluid balances, cardiovascular
changes, neurological status changes, and tolerance of
nutritional feedings. The nurse may also be the best person
to act as patient advocate for psychosocial needs such as
pain control, anxiety, and the like.
Emergency Needs: Resuscitation
and Pulmonary Priorities
One of the first priorities in caring for the burn patient after
assuring that the patient’s airway is secure is to address
cardiovascular needs. After a patient receives a severe burn
injury, a leakage of fluids into the area of the burn injury
causes swelling and may prevent circulation to that and
distal areas. Circumferential burns especially need to be
monitored to ensure there that is adequate circulation to
the surrounding tissues and areas distal to the burn. Pulses
must be checked hourly, and any diminished or absent
pulses should be reported to the physician immediately.
Another complication is circumferential third-degree burns
around the chest and neck, which often cause restrictive
defects. The increased amount of edema, combined with
decreased chest excursion, may greatly decrease tidal
volume. This condition may progress and can become life
threatening, in which case chest escharotomy may be nec­
essary to release the constricting eschar. The procedure
may be done at the bedside or in the operating room. Equip­
ment includes sterile drapes, scalpel, and electrosurgical
unit (to control bleeding).
As fluids shift from the cardiovascular system to the
interstitial regions of the burn, there may be a subsequent
drop in blood pressure and organ perfusion and a decrease
in urine output. It is the responsibility of the nurse, who is

33  •  Burn Nursing
356
Wounds may consist of eschar, pseudo eschar, skin buds,
autografts, donor sites, hypermature granulating tissue,
blisters, and exposed bone and tendons. In addition to the
many kinds of possible wounds, there are many topical
antibacterial agents available for managing wounds. These
choices raise many decisions for the team to address. Topical
antimicrobial creams and ointments include mafenide
acetate, silver nitrate, silver sulfadiazine, petroleum and
mineral oil-based antibacterial products, and Mycostatin
powder. Wounds may be treated in the open fashion (topi­
cals without dressings) or closed fashion (topicals with
dressings or soaks). There are several techniques for apply­
ing dressings to different areas of the body that need to
be able to withstand exercise, ambulation, and moving
around in bed. Biological dressings, such as homografts or
heterografts, may be used as temporary wound coverage.
Dressings may also be synthetic or biosynthetic or silver-
impregnated. Selection is based on the present condition of
the wound and the expected outcome.
Secondary goals of wound care are to promote healing
and to maintain function of the affected body part. These
goals are accomplished by preventing wound infection,
treating wound infection, preventing graft loss and tissue
necrosis, providing personal hygiene, and maintaining
correct positioning and splinting throughout hospitaliza­
tion. To prevent burn wound infection, the burn nurse
must cleanse the wound with soap and water; débride
the wound of loose necrotic tissue, crusts, dried blood,
and exudate; apply topicals or dressings; and ensure that
dressing changes are ordered and done. The nurse must
inspect the wound for evidence of infection: cellulitis, odor,
increased wound exudate, and/or changes in exudate;
changes in wound appearance; and increased pain in the
wound. The physician should be notified so that changes
in wound care can be made. Cultures and biopsies may
be ordered to identify the type and count of organisms,
and infected wounds are treated with a specific systemic
antibiotic, topical dressing, soak, or a combination of all
treatments. The wound is often the source of bloodstream
sepsis. The five cardinal signs of sepsis are hyperventilation,
thrombocytopenia, hyperglycemia, disorientation, and
hypothermia.8
Preventing graft loss is another wound care challenge for
nursing. Usually the patient returns from the operating
room in a position that is maintained for 3 or 4 days. Any
interaction with the patient during this time of graft immo­
bilization requires creativity and care in order to prevent
shearing of the graft. Postoperative dressings on the thighs
and back are protected with Polysporin/polymyxin and a
fine-mesh gauze to prevent soiling by feces and to minimize
cleanup. The dressings are continuously monitored for
increased drainage and odor, which would indicate possible
wound infection. If infection is suspected, then the postop­
erative dressings may be removed early for a closer inspec­
tion of the wound.
Donor sites will also require additional care to prevent
infection. Of course, the postoperative care depends on the
coverage of the donor site. If the donor site is covered with
fine-mesh gauze, initial care is to ensure homeostasis and
adherence of the gauze to the wound. Therefore the postop
pressure dressing remains intact for 6–12 hours and is then
removed. The focus of managing the donor site is to keep
pediatric patients). Aggressive nasotracheal suction may be
indicated if the patient has difficulty managing secretions
either because of the increased amount of secretions and/
or the decreased effectiveness of the cough. In addition,
aggressive pulmonary toilet, including turning, coughing,
deep breathing, and up and out-of-bed rocking in mother’s
arms may be done regularly and frequently. Elevation of the
head of the bed, unless contraindicated, will also support
and possibly improve ventilation. Trends and changes
should be correlated with laboratory results and shared
with the team.
Intubation and mechanical ventilation may be required
to improve gas exchange. Tube placement should be checked
and documented frequently and verified daily by X-ray.
Securing the endotracheal tube requires a standard tech­
nique for stabilization and prevention of pressure necrosis.
Adequate humidity is necessary to prevent secretions from
drying and causing mucous plugging. Remember to provide
pre-/postsuctioning hyperoxygenation. Sterile technique is
used when suctioning to prevent infection. Attention to the
details of oral hygiene will provide comfort for the patient
and may reduce the occurrence of ventilator-associated
pneumonia related to colonization in the oral pharynx.3
Criteria for extubation depend on the reasons that the
tube was inserted initially, but, overall, stable vital signs and
hemodynamic parameters will support the plan for extuba­
tion. The patient should be awake and alert in order to
protect the airway; therefore pain medications may be
reduced before extubation. Ventilatory measurements and
blood gas analysis should be within normal limits.
Immediately following extubation, the nurse must be
alert for signs and symptoms of respiratory distress, admin­
ister suction as needed, monitor blood gas measurements,
and provide optimal positioning for ventilation, as well as
provide reassurance and support to decrease anxiety.
Age, burn size, and the presence of inhalation injury and
pneumonia have been identified as major contributors to
mortality.4 Thus vigilant nursing care (frequent nursing
assessments, aggressive pulmonary toilet, etc.) combined
with anticipating potential problems and being prepared to
deal with those problems will add to the team effort and
possibly improve patient outcome.
Acute Care of the Burn Wound
The primary goal for burn wound management is to close
the wound as soon as possible. Prompt surgical excisions
of the eschar and skin grafting have contributed to reduced
morbidity and mortality in severely burned patients.5–7
Wound care in the burn unit has become a specialized
art of burn nursing practice. It can be extremely challeng­
ing and complicated, and, for a new nurse, it can be the
most difficult and misunderstood part of burn nursing. The
complexity exists because of the variety of wound types,
each of which requires different interventions in relation
to time postburn or time postoperative. Wound assess­
ment and care is a learned skill that develops over time.
These skills must be taught by experienced nurses to new
burn nurses. Assessment of the burn wound takes place
in the hydrotherapy area, the operating room, and at
the bedside.

33  •  Burn Nursing
357
Surgical Care
The perioperative setting combines a number of profession­
als with different levels of experience and expertise, all
directed toward patient care. Each team member has a spe­
cialized role: the surgeon provides surgical intervention, the
surgical technician supports the surgeon, the anesthesiolo­
gist or certified registered nurse anesthetist (CRNA) pro­
vides life support functions, and the circulating nurse’s role
is to provide safe patient care by ensuring that all team
members adhere to professional standards and guidelines.
The perioperative nurse is a professional registered nurse
who provides nursing care to patients in the preoperative,
intraoperative, and postoperative phases of surgery. Periop­
erative burn nursing care can be described as hot, intense,
and demanding. Burn nursing, in fact, represents one of the
profession’s most challenging specialties.
Once surgery is completed, perioperative nurses provide
postoperative care and assessment. This phase of nursing
care can also be challenging for the nurse caring for the
patient during the immediate postoperative period. Nursing
care and plan for care depend on many factors: amount of
blood loss, surgical time, and the site(s) and extent of exci­
sion and grafting. The postanesthesia nurse caring for the
burn patient must be knowledgeable about the medications
and procedures used during surgery to provide appropriate
safe nursing care.
Many burn-injured patients will make repeated trips to
the operating room for surgical excision of the burn wound
and grafting, with grafts taken from unburned areas. These
procedures may require the patient to be anesthetized for
long periods of time. Patients are at risk for pressure ulcers
in the operating room; thus proper positioning and the use
of pressure-reducing devices is essential to reduce the risk
of pressure ulcer formation. During these operative proce­
dures the patient may lose large quantities of blood, result­
ing in decreased tissue perfusion, and the patient may
develop shock. Vasopressors and fluid resuscitation are the
usual treatments for shock. Low-flow states and the use of
vasopressors may also result in decreased tissue perfusion
and increased risk of pressure ulcer formation.
Postsurgery, the patient or surgical area is often immobi­
lized with large bulky dressings and splints to protect the
grafts. These dressings need to be applied with enough pres­
sure to stop bleeding from the grafted wound and the donor
site. But if the dressings are applied too tightly, or if edema
develops after dressing application, this may cause increased
pressure on the skin.
To prevent wound bed desiccation, antimicrobial oint­
ments or soaks are used to maintain moisture in the
grafted wound and to aid in decreasing wound coloniza­
tion with bacteria. This moisture, when in contact with
adjacent normal skin, may increase the risk of tissue
breakdown.
Inadequate nutrition prior to or after the burn injury
is potentially a significant problem. The hypermetabolic
response in the burn-injured patient leads to protein mal­
nutrition if caloric intake is compromised. To reduce the
risks of systemic infection and to promote wound healing,
enteral hyperalimentation is most frequently used and the
patient is fed by nasogastric or nasojejunal tubes.
the wound dry. If grafts/donor sites are on the back or backs
of the legs, the patient is placed in a Clinitron bed for 4–5
days to promote drying. If the donor site remains wet, addi­
tional drying techniques (hair dryers, external heaters)
may be used periodically during the day.9
If the donor site is covered with a synthetic or biological
dressing, the same principles apply. Basically, a pressure
dressing is applied to ensure adherence to the wound for a
short period of time postoperatively and then the wound is
exposed to the air to support drying. A bed cradle is used to
keep bed linen from contacting wounds. The location of the
graft, donor site, and eschar may all be on the same extrem­
ity, which again requires creativity to accomplish all three
interventions of care.
Nurses must always be vigilant when it comes to skin
assessment; early detection and prevention is the key ingre­
dient in preventing pressure ulcers in major burn patients.
Pressure ulcers are no longer treated as a burn wound.
There is evidence to support nursing practices in the pre­
vention of pressure ulcers in burn patients. Burn patients
have many risk factors that predispose them to developing
pressure ulcers. Initially hypovolemic shock with blood flow
shunted away from the skin to preserve vital organ function
is a factor. Additional injuries may increase the risk for pres­
sure ulcers, such as inhalation injury, which may require
intubation and use of paralytic agents to manage the
airway. Fluid resuscitation may contribute to massive
edema in both burned and unburned areas. The edema is
maximized at about 2–3 days postburn, which also
decreases the blood flow to the skin and adds weight to all
parts of the body.
Maintaining systemic hydration can continue to be a
problem long after the patient has received adequate resus­
citation for burn shock. Continued fluid therapy to replace
fluid loss through the burn wound is essential. If systemic
hydration is not maintained, even normal skin may be at
risk. To complicate this situation, the quantity of fluid lost
through the burn wound may increase the moisture on
normal skin adjacent to the burn wound. This moisture
may cause the normal skin to break down and predisposes
the skin to further compromise.
All patients, except those with skin grafts postoperatively,
will benefit from a bath or shower. Large acute burns are
placed on a shower cart and the wounds are gently show­
ered with warm water. The overhead heater is turned on,
and the room temperature is maintained at 85°F (29°C) or
higher. Large acute burns are not immersed in a tub of
water to prevent autocontamination and electrolyte imbal­
ance.10 Hydrotherapy can be used for careful assessment of
wounds, as well as for personal hygiene such as shampoo­
ing, mouth care, face care, and perineal care.
Hydrotherapy is an excellent opportunity for the nurse to
teach the patient and family about wound care and dress­
ing application. As the patient gets closer to discharge,
families are required to do more of the care. The trend for
earlier release from the hospital poses additional challenges
for nursing since it reduces the time available to prepare
the patient for discharge. The better the patient and family
are educated, the better the outcome. Early involvement
with patient and family helps identify potential obsta­
cles at discharge and facilitates care coordination in the
discharge process.

33  •  Burn Nursing
358
patient, leading to significant morbidity. Routine proce­
dures should be established to prevent this occurrence, and
care should include sterilization of the blender and limiting
to 4 hours the amount of time that tube feedings can be
hung at the bedside. The tubing and container should be
changed every 4 hours.
Sometimes when patients are encouraged to begin taking
food by mouth, tube feedings may be discontinued during
the day and be used only at night. Not scheduling painful
activities around meal times and providing frequent mouth
care will also contribute to improved oral intake.
Regular bowel patterns are expected in the postburn
period. Patients are given many medications during hospi­
talization that may contribute to either diarrhea or consti­
pation. Patients are expected to have at least one bowel
movement per day. If not, then a bowel evacuation regimen
should be considered. If diarrhea is the problem and the
volume exceeds 1500 mL/day, then bulking agents and/or
antidiarrhea medication may be useful to promote routine
bowel elimination.
The importance of monitoring and documenting the
many parameters of intake and output cannot be overem­
phasized. Established clinical protocols and guidelines facil­
itate the implementation and evaluation of the nutritional
program.
Other strategies to support the hypermetabolic phenom­
enon of the burn patient are to keep the room temperature
higher than 85°F (29°C) and to keep the room door closed
to prevent drafts. Also frequent rest periods must be pro­
vided during the day. Nursing generally makes the schedule
of activities for the day, so including frequent rest periods is
just as important as anything else that needs to be done
during the day. Adequate sleep during the night is also very
important: often this makes the difference between a good
day and a bad day. A quiet comfortable environment without
sensory overload (lights and noise) is essential for the
patient to sleep.
Nurses are the grand communicators of progress and/or
problems. Nurses work closely with dietitians, physicians,
patients, and families to ensure that optimal metabolic and
nutritional support is achieved during the postburn period.
Pain and Anxiety Assessment
and Management
Throughout the acute phase of care the burn patient is
predisposed to pain and anxiety. Pain in the burn wound
and fear of pain cause patients to try not to move. Careful
titration of anxiolytics and narcotics can result in an alert
patient who is relatively pain-free, but this requires intense
attention to detail from the nursing staff. The expected
outcome for pain and anxiety management is for the patient
to achieve a balance between successful participation in
activities of daily living and therapies and being comfort­
able enough to rest and sleep as needed. The ultimate goal
is for the patient to be satisfied with the pain management
plan as it is implemented. Assessment of pain and anxiety
provides a baseline for evaluation of pain and anxiety relief
measures. Pain and anxiety scales are essential to quantify
painful episodes and to evaluate effectiveness of medica­
tion. Knowing when and how much to intervene is guided
In summary, burn patients are among the high-risk pop­
ulations for pressure ulcer development. The physiology of
the burn injury combined with many of the therapies and
treatments used during hospitalization impacts the burn
patient’s risk for pressure ulcers.
Nutrition and Metabolic Changes
Hypermetabolism, or metabolic stress, is the direct response
to a burn injury. The amount of stress increases proportion­
ally to the extent of the injury and strongly influences a
patient’s nutritional requirements. This response can
magnify the normal metabolic rate by 200%. Malnutrition,
starvation, and delayed wound healing will result if calories
are not provided consistently to meet nutritional require­
ments. Children require more calorie and protein replace­
ment than do adults because they have additional nutritional
demands to support growth and development.
Managing nutritional intake and monitoring output are
among nursing’s primary responsibilities. An accurate
record of intake and output is critical to patient care because
potential problems can be detected early and alternate
options of care can be individualized to help the patient
achieve his or her goals. Accurate weights, daily or as
ordered, are also important. Remember to record whether
dressings, splints, or linens are included in the weight. Obvi­
ously, including additional elements does not reflect an
accurate weight, but trends in weight either up or down
may be identified and may be helpful in the overall manage­
ment of the patient.
Typically when patients cannot consume enough calo­
ries by mouth, then enteral feedings are begun. Sometimes
enteral feedings are started before the patient is given the
option of eating because the amount of calories is so great
and/or the condition of the patient is unstable. Parenteral
nutrition is used when enteral nutrition fails to deliver ade­
quate nutrition. The goal is to provide adequate nutrients,
calories, and protein. A nasogastric tube is inserted initially
and used to decompress the stomach until bowel sounds
return. Then tube feedings are started at a very low volume
per hour to act as a buffer against ulcer formation. The
nasogastric tube allows for checking hourly gastric residu­
als, gastric pH, and guaiac. If the gastric pH falls below 5,
or if the guaiac is positive, Maalox and Amphojel are given
every 2 hours, alternately every hour.
Aspiration of stomach contents is a potential complica­
tion and always a concern. Gastric residuals are checked
before suctioning to prevent the patient from vomiting and
possibly causing aspiration. Another precaution is to keep
the head of the bed elevated. A Dobbhoff tube is also
inserted initially, and feedings are begun as soon as 6 hours
postburn. The rate starts slowly and is advanced as toler­
ated to meet the calculated amount of nutritional replace­
ment. Tube feedings continue until the patient can take the
required amount of calories by mouth.
Another potential problem with both tubes is dislocation;
therefore it is important to check placement periodically
throughout the day. When gastric residuals start climbing,
it may be because the Dobbhoff tube has slipped into the
stomach or the patient is septic. Tube feedings may become
contaminated and become a source of infection for the

33  •  Burn Nursing
359
materials. All of these parts of the educational goal are
agreed upon by the patient, family, and educator.
Implementation of the plan is the next step, followed by
a thorough evaluation of the effectiveness of learning and/
or determination of whether the educational goal is being
accomplished. Alterations in the original plan may be
needed at any time during the educational process depend­
ing on unforeseen situations or unanticipated changes in
conditions.
The benefits are many. This process ensures communica­
tion of educational topics among the team members, pro­
vides a historical account of education, and documents
progress and/or changes in the plan. It benefits the patient
and family by making them competent in their role as care
provider when discharged from the hospital. Knowledge
allays anxiety about the unknown and aids in compliance
with recommended care after discharge, thus improving
the long-term outcomes.15 Patients and families can be
empowered to become active participants in the burn care
team early in the postburn course through a well-structured
educational plan.
Rehabilitation of the Burn Patient
A major burn is one of the most devastating injuries, both
physically and emotionally, known to man. After weeks of
being an invalid, undergoing repeated surgeries, fighting
infection, having the body ravaged by the metabolic conse­
quences of injury, and enduring pain and anxiety, the
patient now faces months of continued physical therapy to
regain the level of function that he or she had known before
the injury. Most patients who have sustained a major burn
will continue to have a higher than normal metabolic rate
for more than a year and thus find that they do not have the
stamina to easily regain their lifestyle.16 In addition to the
catabolic effects of burn injury, being hospitalized and in
bed with minimal activity for many weeks or months causes
loss of muscle and bone weakening. Children are more
prone to fractures.17 During the rehabilitation phase these
patients must continue to exercise to prevent contractures,
but they may not have the physical strength or endurance
necessary to actively participate in such programs. In addi­
tion, these patients frequently become depressed as they
face an altered self-image and a forced physical dependence
on others. They fear that they will never look normal and
that they will not be able to return to a normal life. For
adults, the concerns of whether they will be able to return
to work or have to change occupation is also a factor. What
is the role of the nurse at this phase of treatment? Although
nurses have been very involved in the care of the patient in
the early phases of care, the role of the nurse changes at
this stage. The transition from the hospital to home care is
often difficult for both the patient and family. It is important
prior to discharge that the patient and family be educated
in the care of open wounds, healed skin, itching, pain, and
anxiety before they leave the hospital. They also need infor­
mation about the normal depression that occurs posthospi­
talization and resources in their home community to which
they have access. This is where the nurse case manager
becomes an integral part of the patient care team. Hospital-
based nurse case managers can begin to work with the
by knowing the baseline pain and anxiety rating for the
individual. Patients and families should be given informa­
tion upon admission on how to use the assessment scales
and to identify an acceptable level of pain and anxiety.
Intravenous administration of opioids and anxiolytic
agents is essential to manage pain and anxiety during the
initial stage of injury due to the altered absorption and
circulation volume following a major burn injury. A patient-
controlled analgesia (PCA) pump is useful for children older
than 5 years and adults. It is important to manage back­
ground pain as well as procedural pain, for which medica­
tion should be given 15–30 minutes prior to a painful
procedure. Nursing-driven protocols for sedation and anal­
gesia have been developed for the burn ICU and were
reported to be effective in controlling pain. Nurses positively
supported the introduction of the protocol but junior nurses
seemed to be more uncomfortable with its use than more
senior nurses.11
Constipation is frequently a complication of pain man­
agement; thus a bowel management program should be
instituted at the same time.
Relaxation, guided imagery, music therapy, hypnosis, and
therapeutic touch are adjunct techniques to complement
analgesia and reduce anxiety.12 Virtual reality is a relatively
new technique used for pain control and has been quite
successful.13 It involves a computer software program with
which the patient actively interacts, thereby transferring
the patient’s attention away from the painful event. Emo­
tional support and patient and family education decrease
fear and anxiety, thereby enhancing the pain management
plan.14
Patient and Family Education
In order for nurses to be competent teachers, they must
be competent practitioners with solid theoretical founda­
tions. Continuing education to maintain competency is
key for clinical staff because of their role as educators of
patients and families. Reinforcement of the educational
process (assess, plan, implement, evaluate, and document),
characteristics of patient populations, updates on educa­
tional strategies, age-appropriate interventions, and ways
to evaluate learning are topics that will sharpen educator
competency.
Discharge planning and education begins upon admis­
sion. It begins with a thorough assessment of the patient’s
life prior to the injury. Identifying knowledge deficits and
barriers to education, prioritizing strategies for education,
and providing supplemental educational handouts and/or
classes, as well as developing a plan for evaluating the effec­
tiveness of the teaching opportunity are integral parts of
the educational process.
Assessment provides essential information for planning
an educational program to meet the specific individual
needs of each patient and family. It is also done periodically
during different stages of the educational process to deter­
mine if the plan remains valid or changes need to be made.
The assessment findings become part of the educational
plan in that the plan is tailored to meet the needs and con­
cerns of the patient and family. The plan includes the learn­
ing objectives, strategies for education, and learning

33  •  Burn Nursing
360
risk factors, the exercise program can be tailored to fit the
patient’s needs.19
Planning
What is available? Often the major issue is what is available
and who will pay for this care. When an adult is injured on
the job, this is often arranged and paid for by the compensa­
tion carrier since they have a vested interest in returning
the patient to work as soon as possible.
Implementation
Once the details are worked out, the next hurdle is to get
buy-in from the patient and family. Some programs require
the patient to be in a facility some distance from the home;
this may present issues for both the patient and family. Simi­
larly if the program is in the local community, daily visits to
the rehabilitation facility may pose transportation issues,
especially if the patient is unable to transport him- or
herself. These details can usually be worked out with coop­
eration of all caregivers and the family involved. Motivation
and determination are often the most difficult factors to
overcome. This is especially true if the patient is suffering
from depression. The nurse case manager can be very
instrumental in rallying the burn team and caregivers in
the community to help the patient and family to see this as
a way to return the patient to more normal function.
Evaluation
Success in such programs requires that all involved have the
same goals and that these goals result in measurable out­
comes. The goal of such programs is not only to increase
the patient’s tolerance to exercise but also to improve his or
her psychological and social functioning and to return the
patient to work or to the same level of functioning as before
the injury.
EXTENSIVE EXERCISE IN CHILDREN
Children may suffer from the same deconditioning as adults,
especially if they have suffered total body surface area
(TBSA) burns of 40% or greater. Cucuzzo et al. have shown
that children with greater than 40% TBSA burns have bone
demineralization.20 This deconditioning can lead to low
energy, decreased motivation, and depression. This can
make it difficult for the child to return to school, where he
or she must be alert and attentive for 6–8 hours a day.
Younger children learn much about their environment and
world through play and various activities. Limitations in
movement from burn scars or low energy may decrease
their rate of learning. Also, children learn much about
socialization through their participation in sports activities.
Physical limitations in sports may provide a type of isola­
tion from their normal group of peers. Treatment of these
patients with long-term anabolic agents and intensive exer­
cise programs to improve strength and endurance can
return the patient’s metabolic status to normal and help
with the patient’s reintegration back into his or her normal
preburn activities more quickly.
Assessment
Children and their family situation should be evaluated to
determine what exercise program is best for their burn
patient and family soon after admission to assess the
patient’s future needs and coordinate these with outside
agencies to ensure that the transition goes smoothly. Often
case managers from workmen’s compensation carriers or
health maintenance organizations (HMOs) are involved
during the early phase as well. Coordination of activities
between case managers is important to provide seamless
care. With children, it is important for the nurse case
manager to begin working with the school nurse or com­
munity health nurses to provide for this seamless transition
in care.
Although the rehabilitation therapist plays an important
role in providing referrals to community therapists and psy­
chologists, and social workers frequently make referrals to
community mental health providers, the nurse case
manager should be involved in the overall coordination of
these and other services to foster a unified approach. The
free flow of communication among all providers is neces­
sary for optimal rehabilitation of the patient.
WORK-HARDENING PROGRAMS FOR ADULTS
For adult patients, work-hardening programs have been
shown to more rapidly return the patient to his or her
optimum level of functioning.18 These programs may be
available through community rehabilitation facilities, voca­
tional rehabilitation agencies, HMOs, hospitals, or health
centers with cardiac rehabilitation programs or through
workmen’s compensation carriers. The major concern for
the nurse case manager and the burn team is early identi­
fication of which patients need these programs and at what
point the patient will benefit most from such intensive
programs.
Assessment
Burn patients, like those recovering from coronary heart
disease and surgery, find themselves deconditioned. Even 3
weeks of bedrest in a healthy subject can result in a 25%
decrease in maximal oxygen consumption. Thus burn
patients who are hospitalized for 2 or more weeks may need
to be considered for such programs. Burn patients should
be first assessed for risk factors associated with coronary
heart disease. Such risk factors include:
■ age and sex
■ elevated blood lipids
■ hypertension
■ cigarette smoking
■ physical inactivity
■ obesity
■ diabetes mellitus
■ diet
■ heredity
■ personality and behavior patterns
■ high uric acid levels
■ pulmonary function abnormalities
■ ethnic race
■ electrocardiographic abnormalities during rest and
exercise
■ tension and stress
Cardiac stress testing is usually recommended prior to
beginning an exercise program. If the patient has several

33  •  Burn Nursing
361
Thus motivating the child and parent is often difficult.
Helping the parent see this as a valuable program will
require the whole burn team to work together with the
patient and family. Alternatives may be available for older
children within the community by utilizing local gyms or
fitness centers. Communicating a prescription for exercise
to the local facility and maintaining regular follow-up of
progress can be as effective as having the patient remain
within the larger hospital system.
Evaluation
The outcome of these programs for the child can be mea­
sured in increased exercise tolerance and improved psycho­
logical and social adjustment. A major function of these
programs is to convince the child and parent that the patient
is a normal child and can succeed mentally and physically.
If the child returns home and can keep up with his or her
peers, this alone improves the child’s self-esteem.
Reconstructive Care
ASSESSMENT
The role of the nurse in the reconstructive care phase may
include clinic visit assessments, physical care associated
with surgical procedures, education related to reconstruc­
tive care and expectations, and care coordination, including
social and financial support. The nursing role of patient
advocate may be the most important for the patient and
family. Due to a lack of knowledge or understanding,
patients and families may have unrealistic expectations for
reconstructive surgery. They may have the hope that plastic
surgery can “fix” the burn scars and make the patient look
the same as before the burn. The nurse’s role in the outpa­
tient clinic or physician’s office is to listen to the patient and
family and to understand their hopes and expectations. The
nurse can take this opportunity to provide education about
the expected course of burn care and realistic expectations
for scars left from the burn injury. Often when the surgeon
discusses what should or could be done to improve the
patient’s appearance or function, the patient and family
member are reticent to ask questions or to describe what
they want. Patients’ priorities are often different from the
surgeons, and this leads to dissatisfaction. This is when the
nurse should help the patient ask questions or voice
concerns.
PLANNING
The timing of reconstructive surgeries often varies between
surgeons. Many surgeons prefer to wait until the scar has
matured to begin reconstructive surgery, but occasionally
surgery will be attempted if the scar tissue is interfering
with function. This is especially true where scar tissue may
cause bone deformity if left until it has matured. In chil­
dren, some reconstructive procedures are best postponed
until the child has matured. Surgery is often better accepted
by the child at the beginning of high school or just prior to
starting further education. The nurse case manager can be
instrumental in helping the family find the funding and
resources to provide reconstructive surgery for the patient.
injury and their family situation. Generally, children 7 years
of age and older can participate in an intensive exercise
program. This is an estimated age based on the child’s size
(ability to use exercise equipment that is manufactured for
adults) and maturity (ability to follow direction so that a
safe environment can be provided). For larger burns (60%
TBSA and greater), a 12-week exercise program is pre­
scribed. For smaller burns, a shorter period of time of about
6 weeks may be sufficient. The best time to start such a
program depends on the patient’s family situation. The
program can start immediately after discharge or can be
delayed for a few months to allow the family to return home
and prepare for the next phase of intensive exercise reha­
bilitation care. As with adults, individualized programs that
consider the pediatric patient’s current general state of
health are necessary. Because the child is under the care of
and dependent on the parent, it is important for the parent
or a responsible adult member of the family to be involved.
This may be a significant factor in when the patient is able
to start such a program. For children younger than 7 years
of age, more creative interactive play and exercise programs
have been developed utilizing music therapy as a stimulus
for children to participate in the exercise program. These
activities can include riding tricycles, playing sports games,
obstacle courses, racing, dancing, stretching, and any
activity that can be made into a game that promotes
strength and endurance. The use of activities set to music
can increase stamina, actively stretch scar tissue, and
increase joint mobility.
Planning
Although cardiac rehabilitation programs and the like may
be readily available in most major towns and cities in this
country, often they do not admit children. Children’s hospi­
tals often have rehabilitation units or outpatient programs
for children that can offer programs similar to those in adult
cardiac programs. Children’s hospitals are usually found in
major cities; thus these programs may not be as accessible
as programs for adults. In some communities, school-aged
children may be able to obtain help within the school sport
programs, especially if they have qualified athletic trainers.
Children aged 4–6 may have more difficulty finding pro­
grams outside of children’s hospitals. Some early childhood
intervention and pre-kindergarten programs may be avail­
able for younger children.
Another issue is to determine who pays for this care.
Unlike the adult with insurance or workman’s compensa­
tion insurance, children are often without funding for this
rehabilitative care. State programs for children with special
needs (e.g., Title V programs) are one avenue to explore.
Other sources of funding may come from private or public
charities, school-mandated programs, or vocational reha­
bilitation programs for the older teenager.
Implementation
Motivating the child and parent can be a major task. Often
the parent and child have spent weeks or months away from
home during the acute phase of care. If there are other
children in the home or if the parent normally works outside
the home, the parent may not feel that he or she can be
away from home an additional 2–3 months. The child may
also not want to leave the safety of the home environment.

33  •  Burn Nursing
362
whether physically or psychologically. Often burn scars
cause patients to avoid public situations where people
may gaze at them for looking different. Support should be
provided, and the patient should be encouraged to realize
that he should not be defined by his physical body. Who
they are is defined by what is in their minds, hearts, and
souls. Through family support, professional counseling,
and/or peer support the burn survivor can be taught to
accept him- or herself and set a path for life. Some choose
to cover their scars, some accept them as they are, and
some wear their scars as badges of honor for the per­
sonal war they have triumphed over. Training is avail­
able for those who are uncomfortable with being out in
public settings. Continued support from the burn team, the
family, and support groups can help with the reintegration
process.
Conclusion
Burn nursing is a unique field of practice. In the United
States, there are currently only 127 burn centers, and only
67 of those are verified burn centers. Hospital burn units
are often much different from other care units in a hospital
because they frequently house a wide range of patients,
young to old, with minor burns to critically ill patients with
major burns, to patients receiving rehabilitation or recon­
structive care. It can be difficult for the nurse to change
patient assignments from one day to the next considering
the wide range of care needed and to maintain skills in all
areas. Nursing shortages can be common among burn
units due to the general shortage of nurses and the chal­
lenging area in which they work.21 It is important that
nurses are made an active part of the burn care team to
utilize the special insights that they have concerning the
patient’s physical condition and the psychosocial needs of
the patient and family. Utilizing a nursing workload mea­
surement for burn care may help provide information on
staffing needs to ensure adequate staffing is made available
for the burn unit. Assessing patients’ daily wound care
needs and medication/IV fluid needs can be utilized to
assess nonintensive or intensive needs and then rank
patients into categories by the levels of care demanded.22
Finally it is important to give patient care nurses the oppor­
tunity to become involved in other areas of burn care. A
great way for nursing to become involved with the burn
team is for a nurse to become involved in better understand­
ing an issue or in improving burn care. This can be done
through research activities or through quality improve­
ment activities. Nurses can often identify areas for improve­
ment but may not have the resources to encourage change.
Providing education opportunities to nurses can create a
culture for change and improvement. Education can include
in-services, publications,23 and mentoring to support the
nurse who is interested in this area. Research and quality
improvement initiatives can make changes and improve­
ments in care, including improving nutritional intake,
decreasing pressure sores, decreasing infections, decreasing
pain, and improving patient satisfaction. The burn nurse is
an invaluable member of the burn care team. Her unique
insights offer important information to the successful
outcome of the burn patient. Active participation in the
If the patient is working or in school, planning the proce­
dures should accommodate the patient’s school or work
schedule as much as possible. For children, funding through
Services for Children with Special Needs may be available.
Working with insurance companies and HMOs can be com­
plicated if the surgery is presented as cosmetic rather than
corrective surgery.
IMPLEMENTATION
Preparing the patient for surgery is the responsibility of
the nurse and physician. Providing the patient with real­
istic expectations is often difficult, but educating the
patient about the surgical procedure and expected time­
lines for healing and utilizing photographs of similar burn
wounds improves understanding. Many times, immedi­
ately after the surgery, the area will look worse and the
patient may feel dissatisfied and depressed. Preoperative
preparation of the patient and family may allay some of
these issues. Surgery itself is frightening enough for the
patient and family. In children as well as adults, this can
be especially frightening because it may bring up memo­
ries of their original burn injury, hospitalization, and the
pain associated with it. Postoperatively the nurse’s role is
to teach the patient and family how to care for the wound
to prevent infection, promote healing, and prevent further
scarring. Throughout the reconstructive and rehabilita­
tion phase the nurse is supportive of the patient and family
as the scar matures. The nurse’s role during this time is
one of education, support, and encouraging the patient
to continue with exercise, splints, and pressure garments,
as ordered.
EVALUATION
Whose body is it anyway! A line from a famous play actually
sums up the evaluative process for reconstructive surgery.
As professionals, we may see great improvement in the
patient’s condition after surgery. But if the patient is not
satisfied with his or her appearance, little has been gained
by the surgery. This is the reason that the patient and family
must have realistic expectations prior to surgery. On the
other hand, the patient may be perfectly happy with his or
her scars and how they look and not desire any surgery.
And although a surgeon may have a great deal to offer with
reconstructive surgery, the patient’s decision must be
respected.
Recovery and Social
Reintegration
Nursing covers the spectrum of providing care from
health to illness and hopefully back to wellness, includ­
ing the physical, psychosocial, and spiritual realms, and
the same concept applies to burn nursing. Nursing care
must continue past the physical healing of the burn
wound. Complete healing must also include the psycho­
social and spiritual domains of the patient. Helping the
patient to accept his or her “new me” is paramount to
recovery. After any traumatic event in an individual’s
life, the person often claims to be different or changed,

33  •  Burn Nursing
363
Further Reading
Carrougher G. Burn Care and Therapy. St. Louis, MO: Mosby; 1998.
ISBI Practice Guidelines Committee. ISBI practice guidelines for burn care.
Burns. 2016;42:953-1021.
Gordon MD, Gottschlich M, Helvig EL, et al. Review of evidence-based
practice for the prevention of pressure sores in burn patients. J Burn Care
Rehabil. 2004;25:388-410.
physical care of the burn patient, attending to the psycho­
social needs of the patient and family, and continually
observing for ways to improve care are paramount to the
ultimate success of the burn team.
Complete references available online at

363.e1
33  •  Burn Nursing
References
1. Artz C, Moncrief J. Nursing care and psychological considerations. In:
The Treatment of Burns. Philadelphia: W.B. Saunders; 1969:271-287.
2. ISBI Practice Guidelines Committee. ISBI practice guidelines for burn
care. Burns. 2016;42:953-1021.
3. Hixon S, Sole M, Kir T. Nursing strategies to prevent ventilator associ­
ated pneumonia. AACN Clin Issues. 1998;9(1):1-15.
4. Shirani KZ, Pruitt BA Jr, Mason AD. The influence of inhalation injury
and pneumonia on burn mortality. Ann Surg. 1987;205:82-87.
5. Tompkins RG, Burke JF, Schoenfield DA, et al. Prompt eschar excision:
a treatment system contributing to reduced burn mortality. Ann Surg.
1986;204:272-281.
6. Herndon DN, Gore D, Cole M, et al. Determinants of mortality in pedi­
atric patients with greater than 70% full thickness total body surface
areas of thermal injury treated by early total excision and grafting.
J Trauma. 1987;27:208-212.
7. Tompkins RG, Remensnyder JP, Burke JF, et al. Significant reductions
in mortality for children with burn injuries through the use of prompt
eschar excision. Ann Surg. 1988;208:577-585.
8. Ramzy PI. Infections in burns. In: Wolf SE, Herndon DN, eds. Burn
Care. Austin, TX: Landes Bioscience; 1999:73-80.
9. Dziewulski P, Barret J. Assessment, operative planning and surgery for
burn wound closure. In: Wolf SE, Herndon DN, eds. Burn Care. Austin,
TX: Landes Bioscience; 1999:19-51.
10. Carrougher G, Gretchen G. Burn wound assessment and topical treat­
ment. In: Carrougher G, ed. Burn Care and Therapy. St. Louis: Mosby;
1998:133-165.
11. Fry C, Edelman L, Phil M, Cochran A. Response to a nursing driven
protocol for sedation and analgia in a burn-trauma ICU. J Burn Care
Res. 2009;3(1):112-118.
12. Patterson DR. Non-opioid based approaches to burn pain. J Burn Care
Rehabil. 1995;16:372-376.
13. Gonzalez M, Hoffman H, Pena R, et al. Virtual reality distraction
for children with large severe burns during repeated burn wound
debridement in the ICU. J Burn Care Res Supp. 2017;38(2):223.
14. Marvin JN. Pain assessment versus measurement. J Burn Care Rehabil.
1995;16:348-357.
15. Falvo DR, Donna R. Effective Patient Education. Gaithersburg, MD:
Aspen; 1994.
16. Hart DW, Herndon DN, Klein G, et al. Attenuation of posttraumatic
muscle catabolism and osteopenia by long-term growth hormone.
Ann Surg. 2001;233:827-834.
17. Klein GL Bone loss in children following severe burns: increase risk
for fractures in osteoporosis. Osteoporosis Update 1999. Xian, PR,
China. Proceedings of the Third International Congress on Osteoporosis.
1999:63–68.
18. Zeller J, Strum G, Cruse C. Patients with burns are successful in work
hardening programs. J Burn Care Rehabil. 1993;14:189-196.
19. Adams RB, Tribble GC, Tafel AC, et al. Cardiovascular rehabilitation
of patients with burns. J Burn Care Rehabil. 1990;11:246-255.
20. Cucuzzo N, Ferrando A, Herndon D. The effects of exercise program­
ming vs traditional outpatient therapy in the rehabilitation of severely
burned children. J Burn Care Rehabil. 2001;22:214-220.
21. Yurko L, Coffee T, Yowler C. The burn nursing shortage: a burn center
survey. J Burn Care Res. 2004;25(2):216-218.
22. De Jong A, Leeman J, Middelkoop E. Development of a nursing
workload measurement instrument in burn care. Burns. 2009;35:
942-948.
23. Olszewski A, Yanes A, Stafford J, et al. Development and implementa­
tion of an innovative burn nursing handbook for quality improve­
ment. J Burn Care Res. 2015;37(1):20-24.

364
Care of the Burned
Pregnant Patient
BERETTA CRAFT-COFFMAN, GENEVIEVE H. BITZ, DEREK M. CULNAN, KIMBERLY M.
LINTICUM, LISA W. SMITH, MAGGIE J. KUHLMANN-CAPEK, SHAWN P. FAGAN, and
ROBERT F. MULLINS
34 
Mortality Factors
A consensus in literature exists: burn size correlates most
significantly with the mortality of both mother and fetus.
Large burn size is the single most predictive indicator for
mortality.10,13,17–21 The odds of mortality of the mother rise
by 1.08 per percentage of TBSA burned (P < 0.0001).22
Furthermore, there is an association between mortality,
TBSA burned, and the incidence of intentional burns.
Women who attempt suicide via self-immolation had
greater TBSA and resultantly higher mortality rates,17 espe­
cially those with greater than 50% TBSA burned. Rode
reported a direct relationship between the size of burn and
the frequency rates of spontaneous abortion and premature
delivery.13 Rezavand et al. demonstrated that, in every tri­
mester, maternal TBSA burned positively correlated with
fetal death as well as maternal demise.12 Agarwal found
fetal loss occurred at a higher rate than maternal death
even at greater maternal TBSA burned.17
The second strongest predictor of mortality of both
mother and fetus is smoke inhalation,10 the treatment
of which remains controversial. Maternal fatalities and
mothers with fetal losses were more common in those with
concurrent inhalation injuries.10 The resultant hypoxia
strongly correlates with maternal and fetal death.23 Closed
and structural fires emit smoke potentially imbued with
cyanide (CN) and carbon monoxide (CO) gases. Upon inha­
lation, CO and CN demonstrate synergistic effects; further­
more, they concentrate at higher levels in the fetus than the
mother24 as fetal hemoglobin binds CO and CN more avidly
than maternal.5 As such, providers must treat two patients
with awareness of potential effects of CO and CN poison­
ing on both mother and child.24 Facial burns, large burns,
and self-inflicted, intentional burns all strongly associate
with inhalation injury. Significant thermal injury in the
pregnant patient population can have not only direct but
indirect effects on the pulmonary system. Unique to the
pregnant burn patient, vital lung capacity decreases while
mucosal edema,25 oxygen consumption, and minute venti­
lation increase.26 As with the severely burned nonpregnant
patient, should a pregnant burn victim be suspected of suf­
fering from inhalation injury, emergent intubation ought
to be instituted. Given the known physiologic changes of
pregnancy, which are compounded by burn edema, early
intubation in the severely burned pregnant patient should
be strongly considered. Hydroxycobalamin, the cyanide
antidote27 recommended in Chapter 32, is a pregnancy
Introduction
Approximately 8% of women experience trauma during
their pregnancies.1 Trauma in pregnancy is the most
common cause of nonobstetric-related death;2 more gen­
erally, trauma is the leading cause of death in the age
group under 40 in the United States.3–5 Women in their
reproductive years are the population at the greatest risk
of trauma.3 While it is rare to see a pregnant woman in
the burn ICU in industrialized nations, burn trauma is a
great risk to pregnant women in developing countries.
Correspondingly, recent literature regarding the care of
burned pregnant patients more commonly comes from
journals in these developing countries6 and consists mainly
of small studies and case reports. Burn injury during preg­
nancy tends to happen in the home environment.7 In
developing countries, this may be in part attributable to
the large proportion of women who attempt suicide via
self-immolation.8
Due to the particular paper paucity pertaining to preg­
nant patients, there is no great consensus on the population
of burned pregnant women, size of burn disease burden
in the population, or mortality of mother and fetus.6,9–14
However, what does exist in the literature reveals that the
maternal mortality rate exceeds 50% and has been reported
at 100% when total body surface area (TBSA) burned
exceeds 40–60%.10,12 This statistic remains unchanged
from Rode’s study in 1990 showing that when TBSA was
greater than 50%, maternal survival “was unlikely.”13
These appalling mortality data contrast a contempora­
neous study by Herndon et al. that determined the lethal
burn size for 50% (LD50) of pediatric patients reached
98% TBSA burned.15 Despite progress made in survival
rates of other burned populations, pregnant burned victims
suffer the same mortality rates as in the 1960s. In a recent
study, 60% of burned pregnant burned patients died, with
an overall 50% mortality rate of the fetus.16 As could be
predicted, fetal survival greatly depends on maternal sur­
vival, although there is a high spontaneous labor rate
among burned pregnant patients. While pregnancy does
not greatly influence treatment protocols, it might factor
into maternal outcome following thermal insult, given
the enormously high mortality rate of pregnant women
with severe burn injury when compared to the mortal­
ity rates of nonpregnant women and men with compa­
rable burn wound sizes. However, more study is obviously
necessary.

34  •  Care of the Burned Pregnant Patient
365
category C drug and should only be used if the benefits out­
weigh the risks because cyanide crosses the placenta and
will poison the fetus to a greater extent than the mother.24,28
Gestational age was also a factor reported in several
studies.16,17 Argawal found fetal survival in the third trimes­
ter correlated less to maternal survival but rather strongly
to gestational age.17 Liu determined gestational age-specific
risk of birth to be greater among the population of injured
mothers than noninjured in each gestational week until
week 38, irrespective of medical condition.29 Gestational
age is not the sole criteria for neonatologists and obstetri­
cians in determining viability of a fetus. The fetal weight
benchmark of 500 g has been adopted, which is the lower
size limit at which intubation is feasible.30,31 Given the
potentiality of obstetric intervention, it is imperative to pre­
cisely ascertain the gestational age and weight of the fetus
via fetal ultrasound and menstrual and sexual patient
history data early in the management of acute burns.
Hypovolemic shock7 and sepsis32 have also been found to
be complications resulting in maternal and fetal death.22
Recurrent septicemia is a major challenge in the manage­
ment of a severely burned obstetric patient. Intraabdominal
hypertension and abdominal compartment syndrome
develop in most severely burned patients within 48 hours
of injury.33 Intraabdominal hypertension is present when
intraabdominal pressure measures in excess of 12 mm Hg,
and abdominal compartment syndrome exists when intra­
abdominal pressure is greater than 20 mm Hg, particularly
if additional organs display dysfunction.34 Pregnancy
induces physiologic changes in all major maternal organ
systems, mimicking early perturbations seen in multisystem
organ dysfunction (MOD).35 All these complications poten­
tially lead to MOD, compounding the existing state present
in the pregnant population and further jeopardizing severely
burned obstetric patients.
Fetal Viability
Managing obstetrical complications provides an additional
challenge to the burn team. Second to death of the mother,
placental abruption is the most common cause of the death
of the fetus following trauma.3 Due to the intense kinetics
undergone by a pregnant patient postburn, the fetus often
spontaneously delivers.12 In layman’s terms, this is a mis­
carriage. Consistently studies show that fetal mortality
rates were highest during the first trimester in the setting
of major burns.16,17 However, with aggressive fetal monitor­
ing, appropriate obstetrical intervention can preserve the
life of the fetus earlier in the course of pregnancy. Studies
indicate this approach starts approximately in the 22nd
week of gestation.36 Determining the gestational age6 and
weight37,38 of the fetus enables the healthcare team to most
effectively guide this care. In a large study, Linder et al. dem­
onstrated that early preterm, low-risk deliveries increased
the risk of fetal complications with higher rates of neonatal
ICU (NICU) admission, sepsis, and antibiotic treatment as
compared to late-term neonates or the gestational control
population.39 While the study only began evaluation at ges­
tational week 37 of low-risk singleton deliveries, it did show
that neonatal morbidity risk corresponds with early term
deliveries. The burn, obstetric, and neonatal teams must
collectively weigh the risks of preterm delivery against the
risks of the fetus remaining in utero and besieged by the
expected effects of severe burn trauma.
PRACTICAL MANAGEMENT ALGORITHM
Adverse pregnancy outcomes are not associated with inci­
dents of minor trauma during pregnancy.40 However, severe
burns are major trauma. As a practical matter, manage­
ment of the pregnant burn patient can be divided into five
phases: previablity, periviability, early viability, viability, and
term (Table 34.1). Obstetrical complications (e.g., uterine
rupture and placental abruption) are potential mechanisms
of preterm delivery following acute maternal trauma.29
During the period of previability, defined as the period in the
pregnancy from conception to gestation week 22 or 2331,36,41
and a fetal weight of less than 500 g,30 the fetus cannot
survive independent of the mother.31 While the previability
stage of pregnancy is currently defined at gestational week
24 by the American College of Obstetrics and Gynecology,42
neonatologists and maternal fetal medicine specialists have
extended the gestational age of periviability to 22 weeks.36
However, this is dependent on a fetus of 500 g.30,37,38 Most
obstetricians will attempt resuscitation at 22 weeks,36 but
24 weeks and 500 g remains the benchmark for viability
because fetal mortality at 22 weeks remains incredibly
high. Providing total burn care to the mother will make her
womb the optimal incubator, thereby managing fetal care
as best as is possible. The data indicate that there is a high
spontaneous abortion rate;12 however, there is no proven
advantage to performing a termination of the pregnancy
unless maternal death seems likely otherwise.12 Effort
should be exerted to avoid medications known to be hazard­
ous to the fetus but not to the extent that the mother suc­
cumbs to shock and/or sepsis, which have very high rates
of fetal loss.
The multidisciplinary team must balance burn care
among several factors during periviability (22–26 weeks)
and early viability (26–28 weeks). Prophylactically, antena­
tal corticosteroids should be administered upon admission
in the setting of a severely burned obstetric patient. Dem­
onstrated to be the optimal interventions to reduce morbid­
ity and mortality in premature neonates, these also promote
Table 34.1  Indications for Emergent Caesarian Section
in the Setting of Severe Burns when the Fetus is
in Distress
FETAL DELIVERY IN THE SETTING OF SEVERE MATERNAL BURN
Fetal Stage
Gestational Age
Delivery Indicated
Previable
0–21 weeks
No
Periviable, weight <500 g
22–26 weeks
No
Periviable, weight ≥500 g
26–28 weeks
Yes
Early
viability
26–28 weeks
Yes
viability
28–32 weeks
Yes
Preterm
32–37 weeks
Yes
Term
37–40 weeks
Yes

34  •  Care of the Burned Pregnant Patient
366
emergency responders and the burn team may be unaware
a patient is pregnant. Thus, the first simple and requi­
site precaution in treating reproductive-age female burn
victims is to suspect pregnancy until proven otherwise.3
Immediately upon determination of pregnancy, high-risk
obstetric consultation must be sought, even before excision
of the wound. Fetal heart tones must be established and
an ultrasound performed to corroborate gestational age
obtained from patient menstrual history to determine fetal
viability. If the fetus is deemed viable, administer antenatal
corticosteroids to mature the lungs for delivery, regardless
if the fetus displays signs of distress. This also delays deliv­
ery, enlarging the time for stabilization and prep of the
mother, and it improves outcomes for the child. After these
consults and corticosteroid treatments, initiate antibiotic
therapy and coagulopathy support prior to wound excision
and/or emergent delivery.
As with nonpregnant burned patients, early wound exci­
sion is key in managing severely burned pregnant patients.
Surgical interventions include escharotomies, as indicated,
and coordination with an obstetrics team if fetal distress is
evident. The burn team must proceed with the awareness
that two patients require care. Studies have demonstrated
that maternal demise strongly correlates to fetal death.3 We
advocate early excision of abdominal eschar to prevent
abdominal compartment syndrome and decrease the risk of
infection. Should the fetus be viable and in distress, excision
of the burn wound can proceed immediately upon delivery.
However, early wound excision with fetal survival is rare in
the setting of major burns. If early wound excision is indi­
cated and the fetus is not of gestational age or sufficient
weight to support emergency caesarean section (e.g., at
least 22–24 weeks by either ultrasonographic measure­
ments and/or patient history of last menstrual period31,36
and measured fetal weight of 500 g by ultrasound36), pub­
lished data and our experience indicate that the mother will
not carry the fetus to term. The best chance of both fetal
and maternal survival is to deliver the fetus upon signs of
distress and manage the maternal burn injuries. If the fetus
shows no signs of distress, proceed with early excision and
wound coverage and monitor the fetus. In this setting,
should the fetus become distressed, perform an emergent
caesarean section. If the fetus does not display distress, the
mother remains the best incubator, but diligent monitoring
is required. Even if the fetus is not viable gestationally, the
burn team must proceed with the burn wound excisions
because the mother would be subjected to an unacceptable
risk of shock and sepsis. The care of the mother must take
precedence over that of the child.
The anatomical and physiological changes brought about
by pregnancy drastically increase the difficulty in the anes­
thetic, obstetric, and surgical management of burn patients.
“Normal” vital signs and labs in pregnant patients some­
times differ from those of nonpregnant individuals. Current
early warning system triggers used to evaluate deteriorat­
ing patients are based on nonpregnant values and thus
require refinement for the pregnant population.62 There­
fore, awareness of the differences and consultation with
appropriate specialists are fundamental to proper care. The
changing cardiovascular profile includes increases in
cardiac output, uterine blood flow, and blood volume as the
fetus matures.9 Crucially, pelvic blood flow autoregulation
organ growth43,44 and can be administered for fetuses as
young as 23 weeks.45,46 Betamethasone (two 12-mg doses
given 24 hours apart) and dexamethasone (6 mg every 12
hours in four doses) are the most commonly used antenatal
corticosteroids.43,47 There is no benefit to shorter dosing
intervals, and it is recommended that the first dose be
applied even if administration of a second dose is unlikely.43
However, antenatal corticosteroids remain contraindicated
when the risk to mother and child is greater by prolonging
the pregnancy than is emergent delivery. Effective to fore­
stall labor for up to 48 hours, tocolytic therapy is particu­
larly useful in situations needing to delay labor until after
the administration of antenatal corticosteroids or transfer
of the patient to an appropriate burn center.43,48 In the
setting of severe burns, tocolytic therapy may be indicated
prior to viability to inhibit contractions incited by intra­
abdominal surgery.47,48 Many different drug classes have
been employed (e.g., calcium channel blockers, β-mimetics,
and magnesium sulfide), but a recent study showed prosta­
glandin inhibitors to be the optimal first-line tocolytic
agents to delay labor with the lowest maternal side-effect
profile.48–50 Calcium channel blockers potentially have the
best neonatal outcomes of the tocolytic therapies.51,52 While
traditionally used to inhibit acute preterm contractions,53
predelivery administration of magnesium sulfate conveys
neuroprotection54,55 and has been shown to be ineffective
as a tocolytic agent.56 Transdermal nitroglycerin for preg­
nancies of less than 28 weeks is not recommended due to
its significant side-effect profile.57 Because these medica­
tions can exacerbate the burn shock besetting a patient,
coordination among critical care, obstetrics, neonatolo­
gists, and pharmacists is critical to guide therapy and avoid
further risk to mother and child.
The dilemma of delivery and resuscitation must be mea­
sured against the fetus’s odds of survival and chances of
leading a normal life. If the perceived risk to the child
remaining in utero exceeds the risk in the NICU, the infant
should be delivered and cared for ex utero. During in utero
critical care, the fetus must be monitored and medications
chosen to avoid fetal harm. If toxic medications must be
given, the risk should be balanced against the risk of fetal
harm. Additionally, if intrauterine fetal death results, irre­
spective of the reason, the uterus should be evacuated.
Retained stillbirth, septic abortion, and missed abortion can
lead to disseminated intravascular coagulation (DIC).58,59
Correlating with high rates of maternal morbidity and mor­
tality, DIC induced by fetal loss is best prevented by prompt
evacuation of the dead conceptus.60,61 It is ethically repre­
hensible to attempt resuscitation on a child who has or will
soon perish regardless of measures taken.
Treatment
It is widely acknowledged that burn patients suffer from
altered pharmacokinetics that make them unique among
trauma victims. While it could be presumed the treatment
protocols would alter significantly given the fetus, they do
not (Fig. 34.1). Early wound excision and coverage, aggres­
sive fluid resuscitation, antibiotic administration (though
limited in options), and sufficient nutrition are the foun­
dation of managing burned pregnant patients.17 However,

34  •  Care of the Burned Pregnant Patient
367
fetus, should that be necessitated,6 but this has yet to be
corroborated. After the 8th week of gestation, pregnant
women should present with physiological dilutional
anemia,63 which, if absent, is an early marker of hemocon­
centration (Hg > 13 g/dL)64 and hypovolemia.65 During the
third trimester, instituting an intra-abdominal bladder pres­
sure monitor for resuscitation is a necessary precaution to
monitor those patients receiving in excess of 5 mL/kg per
TBSA burned. The inability to accurately and timely assess
for intra-abdominal hypertension and compartment syn­
dromes in severely burned pregnant patients presents an
additional challenge to the burn team. Care must be taken
to ensure the pregnant patient does not develop acidemia,
hypoperfusion, hypoxia, or thromboembolic complications
stemming from high levels of coagulation factors common
to pregnant women.3 Supportive modalities include serial
electrolyte and hematologic monitoring to support normal­
ization of electrolyte levels, monitoring of hemoconcentra­
tion and fluid balance, and maintaining normothermia.
Should such complications arise, the life of the fetus could
be jeopardized. When that occurs, a review of the literature
reveals that the pregnancy will most often spontaneously
abort.6,9,18 Should obstetrical intervention be indicated,
such action must be taken expeditiously to preserve the lives
of both mother and child. However, greater study is merited
to determine the most efficacious triggers for obstetrical
is absent because pregnancy maximally dilates the uterine
vasculature. Resultantly, uterine blood flow depends solely
on maternal mean arterial pressure. Furthermore, dilu­
tional anemia of pregnancy may complicate assessments of
blood loss and sufficiency of the oxygen-carrying capacity
in burn patients.4 Aggressive fluid resuscitation is vital in
the early stages of maternal and fetal salvage. Early inter­
ventions during resuscitation include close monitoring of
hemodynamics and perfusion indices to evaluate how those
respond to initial resuscitation. We further recommend
institution of a Foley catheter, central venous catheter, and
an arterial line with advanced hemodynamic monitoring
upon admitting a severely burned obstetric patient to deter­
mine adequate volume status and perfusion. The approach
to fluid resuscitation remains the same in the pregnant
population as in the nonpregnant group, with the goal to
support fluid and plasma loss, early recognition of hypo­
perfusion, and prompt management of shock while avoid­
ing hypoxia. We use a modified Parkland formula to begin
resuscitation at 3 mL/kg per TBSA burned and titrate
accordingly, with a targeted urine output of 0.5 mg/kg per
hour. Careful monitoring of hemodynamics as well as of
blood pressure, hematocrit, and heart rate should tailor
resuscitation. Interestingly, one recent case report sug­
gested that it is optimal to decrease the infusion volume of
fluid resuscitation, especially following the delivery of the
Pregnancy associated with thermal injury
Fetal management
Determine risk versus benefit ratio of continuing maternal
gestation versus delivery & level I NICU support
Any signs of fetal distress and if gestational age > 22 weeks or
fetal weight ≥ 500 g, deliver with level I NICU support
Maternal management
Maximize profusion & hemodynamic stability
Perform early excision & grafting—avoid hemodynamic instability
Supportive modalities for electrolyte optimization, balance of
normothermia & nutritional support
Monitor fetal heart tones
Intrauterine unltrasound & determination
of fetal age, weight, and viability
Obtain Ob/Gyn consult
Consider high-risk maternal-fetal
consultation
Control of airway
Maintain adequate oxygenation
Consider early intubation to avoid distress
Initiation of fluid resuscitation
Parkland: 3 mL/kg/TBSA burned
Titration of fluids to prevent
and treat shock
Pregnancy
Optimal hemodynamics & monitor
Consider invasive monitoring to optimize
perfusion.
Fig. 34.1  Algorithm of the optimal treatment of the burned pregnant patient.

34  •  Care of the Burned Pregnant Patient
368
administered to pregnant and/or lactating women66 (Table
34.2). Animal studies showed no adverse reactions to grade
B drugs (e.g., macrolides, cephalosporins, penicillins, linco­
mycin, and clindamycin), and these are presumed safe to
treat pregnant women.6 In fact, benzylpenicillin remains
intervention as well as the optimal amount for fluid
resuscitation.
The U.S. Food and Drug Administration (FDA) classified
drug recommendations by five grades (A, B, C, D, and X)
according to the possible side effects for the fetus when
Table 34.2  Available Pharmaceuticals for Pregnant and Lactating Women and Their Recommendations
DRUG RECOMMENDATIONS FOR PREGNANCY AND/OR LACTATION IN BURN PATIENTS (*LR = LOW RISK)
Drug
Pregnancy
Category
Pregnancy Recommendations
Lactation
Recommendations
Comments
A. Topicals
Bacitracin-like
products
C
Compatible
Compatible
Limited fetal exposure would be expected
after topical use
Dakin’s solution (Na
hypochlorite
0.125%, 0.25%,
0.5%)
_
May use during pregnancy; no
human data available; risk of
fetal harm not expected based
on limited systemic absorption
Safety unknown; inadequate
literature available to
assess risk; caution advised
Mafenide
C
No human data; should not be
withheld because of pregnancy
No human data
Miconazole
C
Avoid vaginitis treatment in the 1st
trimester or application to large
areas at any time during
pregnancy
Mupirocin
B
No human data; probably
compatible
No human data; probably
compatible
Nystatin
C
Compatible
Compatible
Silver nitrate
C
None
No human data
SSD
B
No recommendations
B. Antibiotics
Aminoglycosides
D
Human data—LR
Compatible
Streptomycin linked to hearing loss in
newborns and should be avoided, unless
specific benefit established. Short-term
use of others in class acceptable with
monitoring, if benefits outweigh the risk
Penicillins
B
Compatible
Compatible
Generally safe to use
Carbapenems
(meropenem)
B
Probably compatible
Probably compatible
Use with caution only when penicillins or
cephalosporins not an option
Cephalosporins (all
generations)
B
Compatible
Compatible
Generally safe to use; use ceftriaxone with
caution at term due to risk of kernicterus
Clindamycin
B
Compatible
Compatible
Appears to be safe and effective
Daptomycin
B
Limited human data; animal
data—LR
Limited human data;
probably compatible
May use if benefits outweigh risks
Vancomycin
B
Compatible
Limited human data;
probably compatible
Safe and effective
Metronidazole
B
Human data—LR (see comments)
Hold breastfeeding (single
dose); see comments
Contraindicated 1st trimester; lactation is
potentially toxic for divided dose;
“topical” metronidazole should be
avoided
Linezolid
C
Compatible
No human data; potentially
toxic
May use if benefits outweigh risks
Sulfamethoxazole,
trimethoprim
C
Human data suggest risk in 3rd
trimester
Limited human data;
potentially toxic
Avoid in 1st trimester due to major
congenital malformations.
Sulfamethoxazole should be avoided
after 32 weeks’ gestation due to risk of
kernicterus

34  •  Care of the Burned Pregnant Patient
369
the most commonly antibiotic administered to pregnant
women.67 Categories C, D, and X have been demonstrated
to generate negative side effects in fetal development. In
cases where the benefits of treating a pregnant woman with
a grade C drug, such as quinolones and fluconazole, greatly
outweigh the risks associated with the drug or no alterna­
tive exists, they are warranted for use in pregnant women.6
Drugs belonging to class D will rarely warrant administra­
tion, and only if the risk of harm is strongly outweighed by
the benefit. Category X should only be administered in
instances where fetal loss is assured or an accepted ramifi­
cation of using the medication to preserve the life of the
mother.66 Adding to the complexity, recommendations vary
depending on trimester or for a lactating burn patient. As
part of the multidisciplinary team, the clinical pharmacist
plays an integral role in assuring safe and effective pharma­
cological therapy for each patient in the burn unit. A
pharmacist should be knowledgeable and current on the
changing recommendations of all drugs safe for adminis­
tration to pregnant and nursing patients, from antibiotics
to renal dosings. As such, the clinical pharmacist is indis­
pensible in advising the team on the optimal therapy for
burned pregnant patients.
It comes as no surprise that pregnancy increases the
mother’s metabolic requirements. Early enteral nutrition
remains key to the management of the severely burned
pregnant patient. Within 48 hours of admission to our hos­
pital, we initiate dietary consultation and estimate caloric
need. Special considerations that can develop with severely
burned pregnant patients include postoperative ileus with
caesarean delivery and surgical interventions. For those in
this patient population who may have undergone an emer­
gent caesarean section, the risk of developing acalculous
cholecystitis is elevated. Management of acalculous
Table 34.2  Available Pharmaceuticals for Pregnant and Lactating Women and Their Recommendations—cont’d
DRUG RECOMMENDATIONS FOR PREGNANCY AND/OR LACTATION IN BURN PATIENTS (*LR = LOW RISK)
Drug
Pregnancy
Category
Pregnancy Recommendations
Lactation
Recommendations
Comments
A. Topicals
Tetracyclines
D
Contraindicated in 2nd and 3rd
trimesters
Doxycycline; compatible
Should be avoided
Tigecycline
D
Contraindicated in 2nd and 3rd
trimesters
Limited human data;
probably toxic
Avoid in pregnancy unless benefits
outweigh risks
C. Antifungals
Fluconazole
D/C
Associated with fetal mortality and
congenital abnormalities
Compatible
Posaconazole
C
Animal data suggest risk of skeletal
malformations
No human data; potential
toxicity
Voriconazole
D
Animal studies have demonstrated
fetal harm
No human data; potential
toxicity
Micafungin
C
Animal data revealed embryotoxic
effects but have not been
replicated in adults
No human data; probably
compatible
Amphotericin
B
Observational data suggest rate of
human birth defects is similar to
that of the general population
Not recommended
D. Pain Medications
Codeine
C
Human data suggest risk
Limited human data;
probably compatible
Although the AAP has classified codeine as
compatible with breastfeeding, data
suggest that, for some women, codeine
can not be considered safe during
nursing, especially if therapy is >1–2
weeks
Fentanyl
C
Human data suggest risk in 3rd
trimester
Compatible
Neonatal withdrawal, respiratory
depression
Hydrocodone/APAP
C
Human data suggest risk in 3rd
trimester
Limited data; potential
toxicity
Morphine
C
Human data suggest risk in 3rd
trimester
Limited human data;
probably compatible
Oxycodone
C
Human data suggest risk in 3rd
trimester
No human data; probably
compatible
Tramadol
C
B. Antibiotics

34  •  Care of the Burned Pregnant Patient
370
Women are adversely impacted by the image-altering effects
common to burn survivors, especially from severe burns.78
Shepherd showed a positive correlation between trauma
symptoms and appearance concerns.79 Cumulatively com­
plicating recovery, mothers may also experience depres­
sion,80–82 posttraumatic stress,83 and anxiety84 following
fetal loss. These may also be experienced by any potential
partner82 in addition to the psychological distress experi­
enced by spouses and close relatives of burn and trauma
survivors,85 resulting in notable adverse sequelae for the
couple.86 All these may profoundly and detrimentally
impact any potential recovery of the mother. The inclusion
of psychiatric consultations should be a standard part of
burn care protocols, especially given the profound psycho­
logical upheaval following traumatic and unexpected fetal
loss for both the maternal survivor and any spouse or
partner. In developing countries, greater psychiatric and
social work support for expectant mothers should be made
readily accessible to better prevent suicides and suicide
attempts by self-immolation.23
In the case where the fetus survived despite maternal
complications, we observed a disassociation bond between
mother and child. Supportive modalities in keeping with
the multidisciplinary approach included recognition of
maternal signs of depression and anxiety by consequently
referring the patient to psychiatry for pharmacologic and
other therapies to address her posttraumatic and adjust­
ment stress disorders. In our experience, early family
interaction has been instrumental for a patient’s recovery
from traumatic injury, along with early initiation of infant
bonding.
Also to consider are support modalities for the multidis­
ciplinary team. Managing the care of pregnant patients,
especially those who have suffered traumatic injuries, and
fetal demise can create stressors within the critical care
medical and nursing staff that must be managed to avoid
provider burnout.87
NONSEVERE BURNS
The text of this chapter has dealt with the care of the
severely burned obstetric patient. The approach to the non­
severely burned pregnant victim is much the same (Fig.
34.1). Obtain a high-risk obstetric consult upon admission
of the pregnant burn patient. Establish and monitor fetal
heart tones. Perform an ultrasound to determine fetal via­
bility and gestational age, as well as acquire patient history
regarding last menstrual cycle. Optimize fluid resuscita­
tion and perfusion, beginning with the Parkland formula.
Utilize the multidisciplinary team to maximize manage­
ment of the burned pregnant patient. In contrast with the
treatment of the severely burned pregnant population,
early wound excision can be balanced between the risk
and benefit to both patients of surgical intervention versus
topical treatments. Protocols must be established regarding
critical care, perinatal support, lactation consultation, and
nursing monitoring should the fetus be viable and deliv­
ered; anesthetic consultation and support should surgical
intervention be indicated; nutrition optimization; clinical
pharmacist consultation regarding recommendations for
optimal medications; DVT prophylaxis initiated and aggres­
sive screening established to monitor the hypercoagulable
cholecystitis complications can be complex given a postpar­
tum surgical abdomen.
Additional Considerations
HEMATOLOGY AND COAGULOPATHY
In the severely burned patient, DIC can develop.68 DIC is
defined as an acquired syndrome characterized by the intra­
vascular activation of coagulation with loss of localization
originating from and causing damage to the microvascula­
ture, potentially leading to MOD by the Scientific and Stan­
dardization Committee of the International Society on
Thrombosis and Hemostasis.69,70 In the early, acute phase
of burn, DIC presents as the fibrinolytic phenotype; later in
the course of burn pathophysiology, DIC is often sepsis
induced.68,71–73 The syndrome is characterized by excessive
thrombosis, unchecked inflammation and MOD, insuffi­
cient anticoagulation mechanisms, and increased fibrinoly­
sis.72 Massive transfusions are common in patients with
DIC.74 Management of coagulopathy in the severely burned
pregnant patient includes transfusions of fresh frozen
plasma, packed red blood cells, cryoprecipitate, and plate­
lets while in the operative theater and for patients at risk of
significant bleeding. This is covered in greater depth in
Chapter 22 on hematology, hemostasis, thromboprophy­
laxis, and transfusion medicine.
Pregnancy normally induces a hypercoagulable state
that is compounded by thermal insult. This presents an
additional challenge for supportive and screening therapies
throughout the course of care. Prophylaxis administration
of heparin, specifically low-molecular-weight heparins, is
recommended. Routine weekly Doppler exams are sug­
gested, given the high suspicion of thrombosis in the preg­
nant population. Extensive findings of deep vein thrombosis
(DVT) in conjunction with the inability to fully anticoagu­
late a severely burned pregnant patient require the burn
team to weigh the risks versus the benefits of placing an
inferior vena cava filter device, as thrombosis is likely to
further propagate.
PSYCHOLOGICAL ISSUES
Pregnant burn prevalence is greater in developing coun­
tries. Furthermore, the etiology of traumatic injury differs
between industrialized and developing countries: a far
greater numbers of women are likely to deliberately set
themselves on fire in mostly futile suicide attempts in devel­
oping countries.12,75 However, a noted rise in self-inflicted
burns in industrialized countries exists.76 This bespeaks a
lack of psychiatric and social support for expectant mothers
that, were it better addressed, might help prevent such inci­
dences.23 Underreporting of suicide is perennially problem­
atic because no standard method exists to evaluate
pregnancy at time of death.77 The high incidence of thermal
insult found in the uneducated or illiterate populations of
obstetric patients illustrates the benefit that education
imparts in reducing burn injuries.23,75 Greater education
and access to psychological support is needed.
Perinatal loss resultant from burn injury compounds the
already traumatic psychological effects of burn patients.

34  •  Care of the Burned Pregnant Patient
371
carried to term with close monitoring. However, a very
low threshold for delivery should be maintained to avoid
fetal harm from episodes of shock, sepsis, toxins, or infec­
tions. For a fetus younger than gestational week 22, care
must focus on maintaining the mother in the hope the
fetus can survive in her womb. Between 22 and 26 weeks,
the gray period of neonatal survival, the womb is the pre­
ferred environment, but, should the fetus begin showing
signs of distress, collaboration with a high-risk obstetri­
cian and a neonatologist is imperative to attempt to pre­
serve the lives of both mother and child. The coordinated
efforts of a multidisciplinary team whose members include
burn, trauma, critical care, obstetric, neonatal, and psy­
chiatric specialists are requisite to provide the best man­
agement of the physiological and psychological challenges
presented by severely burned obstetric patients. Further
systemic research into the care of mother and fetus follow­
ing thermal insult is necessary to better refine treatment
algorithms.
Complete references available online at

Further Readings
American College of Obstetricians and Gynecologists’ Committee on Prac­
tice Bulletins-Obstetrics. Practice Bulletin No. 171: Management of
Preterm Labor. Obstet Gynecol. 2016;128(4):e155-e164.
Montagnana M, Franchi M, Danese E, et al. Disseminated intravascular
coagulation in obstetric and gynecologic disorders. Semin Thromb
Hemost. 2010;36(4):404-418.
Parikh P, Sunesara I, Lutz E, et al. Burns. During pregnancy: implications
for maternal-perinatal providers and guidelines for practice. Obstet
Gynecol Surv. 2015;70(10):633-643.
Sawyer T, Umoren RA, Gray MM. Neonatal resuscitation: advances in
training and practice. Adv Med Educ Pract. 2017;8:11-19.
state native to pregnant women; and physical therapy
regimens.
Conclusion
Given the dearth of data, the burn surgeon must respond
to the challenge presented by a pregnant burn victim by
coordinating the best practices of burn, surgical, and criti­
cal care in a team approach with a high-risk obstetrician,
neonatologist, and clinical pharmacist. What exists in lit­
erature points to the positive association between mater­
nal death and TBSA burned, that, fetal survival depends
on maternal survival, and that, despite the massive physi­
ological and anatomical changes induced by pregnancy,
the care of a burned pregnant patient is similar to that
of a nonpregnant burned victim. Indeed, the standard of
care remains as follows: aggressive fluid resuscitation, early
wound excision and coverage, empiric but class-restricted
antibiotic administration, and adequate nutrition. Patients
should be carefully resuscitated based on standard resus­
citation algorithms, titrating infusion to urine output and
hemodynamics. Burn wounds should be excised early and
wounds grafted as quickly as practical. Severely burned
pregnant women are ideally treated in burn centers spe­
cialized to handle severe burns and concurrently manage
neonatal deliveries.1 The fetus must be monitored continu­
ously for signs of distress in order to guide obstetric inter­
vention should it be warranted. Each additional week of
gestation gained corresponds to significant decreases in
neonatal morbidity and mortality.88 For burns occurring
after gestational week 28, the risk to the child from pre­
mature birth is moderate. Ideally, these children can be

371.e1
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wards. Int Nurs Rev. 2008;55(1):62-67.
88. Manuck TA, Rice MM, Bailit JL, et al. Preterm neonatal morbidity
and mortality by gestational age: a contemporary cohort. Am J Obstet
Gynecol. 2016;215(1):103 e1-e14.
54. Marret S, Ancel PY. [Neuroprotection for preterm infants with ante­
natal magnesium sulphate]. J Gynecol Obstet Biol Reprod (Paris).
2016;45(10):1418-1433.
55. Horton AL, Lai Y, Rouse DJ, et al. Effect of magnesium sulfate admin­
istration for neuroprotection on latency in women with preterm
premature rupture of membranes. Am J Perinatol. 2015;32(4):387-
392.
56. Crowther CA, Brown J, McKinlay CJ, et al. Magnesium sulphate for
preventing preterm birth in threatened preterm labour. Cochrane Data­
base Syst Rev. 2014;(8):CD001060.
57. Conde-Agudelo A, Romero R. Transdermal nitroglycerin for the
treatment of preterm labor: a systematic review and metaanalysis.
Am J Obstet Gynecol. 2013;209(6):551 e1-e18.
58. Erez O, Mastrolia SA, Thachil J. Disseminated intravascular coagula­
tion in pregnancy: insights in pathophysiology, diagnosis and man­
agement. Am J Obstet Gynecol. 2015;213(4):452-463.
59. Honda M, Matsunaga S, Era S, et al. Intrapartum anti-disseminated
intravascular coagulation therapy leading to successful vaginal deliv­
ery following intrauterine fetal death caused by placental abruption:
a case report. J Med Case Rep. 2014;8:461.
60. Montagnana M, Franchi M, Danese E, et al. Disseminated intravascu­
lar coagulation in obstetric and gynecologic disorders. Semin Thromb
Hemost. 2010;36(4):404-418.
61. Letsky EA. Disseminated intravascular coagulation. Best Pract Res Clin
Obstet Gynaecol. 2001;15(4):623-644.
62. Dennis A, Hardy L. Defining a reference range for vital signs in healthy
term pregnant women undergoing caesarean section. Anaesth Inten­
sive Care. 2016;44(6):752-757.
63. Means RT. Anemias during pregnancy and the postpartum period.
In: Greer JP, ed. Wintrobe’s Clinical Hematology. Vol. 1. 12th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2009:1239-
1246.
64. Kacmar RM, Traynor AJ. Physiologic changes of pregnancy. In:
Bucklin BA, Baysinger CL, Gambling D, eds. A Practical Approach to
Obstetric Anesthesia. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2016:3-16.
65. Campbell T, Galwankar S. Emergency medical resuscitation in preg­
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ciation of Physicians of India; 2008.
66. Food, Drug Administration HHS. Content and format of label­
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67. Heikkila A, Erkkola R. Review of beta-lactam antibiotics in pregnancy.
The need for adjustment of dosage schedules. Clin Pharmacokinet.
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68. Dobson GP, Letson HL, Sharma R, et al. Mechanisms of early trauma-
induced coagulopathy: the clot thickens or not? J Trauma Acute Care
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70. Taylor FB Jr, Toh CH, Hoots WK, et al. Towards definition, clinical and
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lar coagulation. Thromb Haemost. 2001;86(5):1327-1330.

372
Special Considerations of Age
THE PEDIATRIC BURNED PATIENT
OMAR NUNEZ LOPEZ, WILLIAM B. NORBURY, DAVID N. HERNDON, and JONG O. LEE
35 
A retrospective study involving 103 children with burns
covering more than 80% of TBSA over a 15-year period
reported an overall mortality of 33%. Mortality was signifi­
cantly higher in children under 2 years of age and in those
with more than 95% TBSA burn (Figs. 35.1 and 35.2).10
Delay in obtaining intravenous (IV) access was an addi­
tional predictor of mortality (Fig. 35.3). Aggressive fluid
resuscitation during the first hour after burn increased sur­
vival. The mortality rate also increased significantly with
inhalation injury, sepsis, and multiorgan failure.10
In addition to biological derangements, a severe burn
produces tremendous psychological challenges to a child.
Anatomical differences specific to the pediatric population
make procedures and interventions more challenging.
Initial Evaluation
First, the burn patient needs to be removed from the source
of thermal injury expeditiously and clothing and jewelry
removed immediately. Pouring cold water onto the burn
can cause hypothermia in large burns and should be
avoided. After the burning process is stopped, the patient
should be kept warm by covering with a sterile (if available)
or clean sheet or blanket. If the burn is chemical, the patient
should be removed from the chemical immediately, and the
burn should be irrigated with copious amounts of water for
at least 30 min. If the chemical is powder, it should be
brushed off first prior to irrigation.11,12
Burn patients should be assumed to be trauma patients,
and any potential life-threatening injuries should be iden­
tified and treated. The airway should be assessed first.
One-hundred percent oxygen should be administered if
inhalation injury is suspected. In addition, arterial blood
gas and carboxyhemoglobin levels should be measured:
pulse oximetry readings will be falsely normal in patients
with elevated carboxyhemoglobin levels because car­
boxyhemoglobin is read as oxyhemoglobin by the pulse
oximeter.13
Tachypnea, stridor, and hoarseness indicate an impend­
ing airway narrowing due to inhalation injury or edema,
and immediate intubation should be considered. A full-
thickness circumferential chest burn can interfere with
ventilation. Chest expansion should be observed to ensure
adequate air movement. If the patient is on a ventilator,
airway pressure and PCO2 should be monitored. If ventila­
tion is compromised, escharotomy of the chest should be
performed to improve ventilation.
Blood pressure measurement may be difficult in patients
with burned extremities. These patients may require an
arterial line to monitor their blood pressure. A radial
Introduction
According to the National Burn Repository, burn injuries
are responsible for 40,000 annual hospital admissions, of
which one third are pediatric patients.1 Despite the steady
decrease of burn injuries over the past three decades, chil­
dren continue to represent a disproportionately high pro­
portion of this population. The pattern of burn injuries
affecting children differs from the pattern observed in adult
burns.
House fires are among the leading causes of burn injuries
and burn-related deaths in the United States, with approxi­
mately 2,600 deaths and 13,000 injuries reported per
year.2 Children under 5 years of age are at a greater risk.
Deaths due to house fire among preschool children are at
a rate of more than twice the national average for all ages
(29.6 deaths/million children, or an average of 20% of all
home fire deaths).2,3 In addition, scald burns constitute the
most common mechanism of injury in the pediatric popula­
tion, representing approximately 71% of all burn injuries
nationwide.3 Scald burns are more frequently observed in
children 6 years or younger. Scald injuries may be due to
household accidents or can be deliberate abuse. More than
half of these burns are attributable to hot liquids related to
cooking, including spilling hot coffee or water, or to chil­
dren reaching up to countertops, pulling pot handles or
cords attached to cooking appliances, and spilling the con­
tents onto themselves. Other causes include unknowingly
putting body parts under a hot water faucet or climbing
into a bathtub with hot water and intentionally or uninten­
tionally being placed into or brought in contact with a hot
substance by another individual. According to epidemio­
logic studies, minorities and children living in areas with
lower incomes are disproportionately more affected by burn
injuries.4,5 Notably, flame burns are the dominant cause
in adolescents and are associated with increased severity
and increased need for hospitalization when compared to
other burns.4,6
Drastic changes in burn care over the past decades, which
include aggressive and early fluid resuscitation, prompt
excision and grafting of burn wounds, improved infection
control, modulation of the hypermetabolic response, and
management of inhalation injury, have promoted a sub­
stantial decline in in-hospital mortality after burn injury.7
This overall improvement in mortality is most perceptible in
children. For example, in 1949, a pediatric patient (aged
0–14) with a burn covering 50% of total body surface area
(TBSA) had an expected mortality rate of 50%; today, a
similar mortality rate is expected in a pediatric patient
(same age group) with a 98% TBSA burn.8,9

35  •  Special Considerations of Age
373
arterial line may not be reliable in pediatric patients with
extremity burns and may be difficult to obtain. A femoral
arterial line may be more reliable and easier to secure.
An urinary catheter is placed to monitor urine output as
a measure of successful resuscitation. Placement of a naso­
gastric tube is recommended in patients with severe burns
because they can develop gastric ileus. Persistent tachycar­
dia should alert a clinician to a missed injury or underre­
suscitation. Accurate and prompt determination of burn
size is fundamental for the proper management of burn
injury.
Resuscitation
There is a systemic capillary leak after a major burn, which
increases with burn size. Intravenous access should be
established immediately for the administration of fluids.
Delays in commencement of resuscitation of burned
patients result in worse outcome.14 Therefore it is vital that
IV access be obtained as early as possible. Due to the small
circulating volume in children, resuscitation should be
started immediately; even short delays increase the risk of
shock. Peripheral IV access is preferred, and it must go
through burned skin if necessary. IV access should be well
secured. When peripheral IV access is not available because
of severe extremity burns, a central venous line must be
placed. Children with large burns should have two large-
bore IV lines for fluid administration. The presence of two
IV lines provides a safety margin if one stops functioning.
When vascular access is unobtainable, the intraosseous
route is a viable option. Fluid volumes in excess of 100 mL/h
can be administered directly into the bone marrow.15 Intra­
medullary access can be utilized in the proximal tibia until
IV access is accomplished. A 16–18-gauge bone marrow
aspiration needle, spinal needle, or commercially available
intraosseous needle can be used to cannulate the bone
marrow compartment. Although previously advocated
only for children younger than 3 years of age, intraosseous
fluid administration can be safely performed in all pediatric
age groups.16,17 The proximal anterior tibia, medial malleo­
lus, anterior iliac crest, and distal femur are preferred sites
for intraosseous infusion. The needle should be introduced
into the bone, avoiding the epiphysis, either perpendicular
to the bone or at a 60-degree angle, with the bevel facing
the greater length of bone (Fig. 35.4). The needle has been
properly inserted when bone marrow can be freely aspi­
rated. Fluid should be allowed to infuse by gravity drip. The
use of pumps should be discouraged in case the needle
becomes dislodged from the marrow compartment.
Fluid losses are proportionally greater in children owing
to their small body weight-to-body surface area ratio.
Normal blood volume in children is approximately 80 mL/
kg body weight and in neonates 85–90 mL/kg, compared
to an adult whose normal blood volume is 70 mL/kg. The
Mortality (%)
70
60
50
40
30
20
10
0
0–2
11–18
3–10
Age (years)
Fig. 35.1  Mortality in burns of more than 80% total body surface area
for various ages.
Mortality (%)
70
80
60
50
40
30
20
10
0
80–85
86–90
91–95
96–100
Surface area burn (% of total BSA)
Fig. 35.2  Mortality for increasing burn size.
Percent receiving intravenous access
80
100
60
40
20
0
0–1
1–4
>4
Time to intravenous access (hours)
Survivors
Nonsurvivors
Fig. 35.3  Time to intravenous access in survivors and nonsurvivors.
Mortality increases with delays in starting an intravenous line and insti­
tuting volume resuscitation.

35  •  Special Considerations of Age
374
commonly used “rule of nines,” useful in adults and ade­
quate in adolescents, does not accurately reflect the burned
body surface area of children under 15 years of age (Fig.
35.5). The standard relationships between body surface
area and weight in adults do not apply to children because
infants possess a larger cranial surface area and a smaller
area in the extremities than adults. The use in children of
the most popular resuscitation formulas (initially designed
for the adult population) can easily result in suboptimal
resuscitation (Table 35.1).
Pediatric burned patients should therefore be resusci­
tated using formulas based on body surface area, which
can be calculated from height and weight using a standard
nomogram (Fig. 35.6) or formulas (Table 35.2). The com­
monly used resuscitation formula in pediatric patients calls
for the administration of 5000 mL/m2 TBSA burned plus
2000 mL/m2 TBSA for maintenance fluid given over the
first 24 hours after burn, with half the volume adminis­
tered during the initial 8 hours and the second half volume
given over the following 16 hours.18 The subsequent 24
hours, and for the rest of the time their burn wound is open,
the requirement is 3750 mL/m2 TBSA burned or remain­
ing open area plus 1500 mL/m2 TBSA for maintenance.
The fluid requirement decreases as a patient achieves more
wound coverage and healing. As in the adult patient, resus­
citation formulas offer a guidance for the amount of fluid
necessary for replacing lost volume, and the amount of
fluid should be titrated according to the patient’s response.
Resuscitation formulas have been incorporated into manual
calculators, electronic devices, and smartphone applica­
tions in order to decrease the risk of error and increase
the speed of calculation.19 Hyponatremia is a frequently
observed complication in pediatric patients after the first
A
B
Fig. 35.4  Intraosseous line placement in the proximal tibia (A) and
distal femur (B). (From Fleisher G, Ludwig S, eds. Textbook of Pediatric
Emergency Medicine, 2nd ed. Baltimore: Williams & Wilkins; 1988: 268.)
19%
15%
13%
17%
17%
18%
18%
18%
18%
10%
32%
15%
15%
9½%
9½%
9½%
32%
9½%
9½%
32%
9½%
36%
9%
9%
1–4
5–9
10–14
Adult
(Rule of nines)
Fig. 35.5  The “rule of nines” altered for the anthropomorphic differences of infancy and childhood.

35  •  Special Considerations of Age
375
extremity color, capillary refill, pulse pressure, and mental
status reflect volume status. Capillary refill is a good indica­
tor of volume status in pediatric patients. Decreased capil­
lary refill should warn a clinician of imminent cardiovascular
collapse. Measurements of arterial pH, base deficit, and
lactic acid are of particular importance in this age group,
reflecting decreased tissue perfusion. Improvements in base
deficit or lactic acid show successful resuscitation.22
Normal blood pressure range varies according to age,
with a systolic blood pressure of 100 mm Hg or less consid­
ered normal in patients younger than 9 years (Table 35.3).
Renal compensatory mechanisms for hypovolemia (e.g.,
tubular concentration) are not well-developed in young
children, contributing to hypovolemia with sustained urine
production despite reduced intravascular volume.
An indwelling urinary drainage catheter is essential for
burns of greater than 20% during resuscitation. During the
early phase of resuscitation, urine output should be assessed
hourly and the resuscitation fluid adjusted appropriately.
Fluid administration should be titrated to achieve a urine
output of 1 mL/kg/h in children and 2 mL/kg/h in infants.
Initial fluid boluses should be administered in amounts
appropriate to the size of the child and should be less than
25% of the total blood volume (20 mL/kg).
Overresuscitation must be avoided because it can lead to
congestive heart failure, pulmonary edema, abdominal and
extremity compartment syndromes, and cerebral edema in
burn patients. In children, cardiac output depends mainly
on the heart rate due to the low compliance of the heart,
which limits increase in stroke volume. In addition, the
heart is more susceptible to volume overload. Cardiac
output can be measured using transpulmonary thermodi­
lution devices, which are less invasive than a pulmonary
artery catheter and only require an arterial catheter and a
central venous line.23 Transthoracic or transesophageal
echocardiograms should be used early to assess cardiac
function in patients who are not responding to conven­
tional therapy. Children are particularly prone to the
48 hours post burn. Frequent monitoring of serum sodium
is necessary to guide appropriate electrolyte and fluid
management. Children under 1 year of age may require
more sodium supplementation because of higher urinary
sodium losses. Hypernatremia can also develop, and it has
been identified as an independent predictor of mortality in
adult burn patients.20 Potassium losses are usually replaced
with oral potassium phosphate rather than potassium
chloride, as hypophosphatemia is frequent in this popu­
lation.21 Calcium and magnesium losses also must be
supplemented.
Intravenous resuscitation fluid should be isotonic and
replace lost electrolytes. Lactated Ringer’s solution is the
most commonly used resuscitation solution for the first 24
hours post burn. Children less than 1 year of age should
also receive a separate maintenance fluid solution contain­
ing dextrose to prevent hypoglycemia because their glyco­
gen stores are limited.
Assessment of Resuscitation
The routine clinical signs of hypovolemia in adult burn
patients, such as low blood pressure and decreased urine
output, are late manifestations of shock in the pediatric
patient, and tachycardia is ubiquitous. Due to their cardio­
pulmonary physiologic reserve, pediatric patients do not
show overt signs of hypovolemia until a decrease of at least
25% of the total blood volume occurs; at this point, hemo­
dynamic decompensation occurs abruptly. Changes in distal
Table 35.1  Resuscitation by the Parkland Formula Only Compared to Maintenance Fluid Requirements Alone
CALCULATED NEEDS
REPLACEMENT BURN LOSS
Example
% Burn
Resuscitation*
Maintenance†
mL
mL/kg/%
1 year old
15
600
800
−200
−1.33
10 kg
30
1200
800
400
1.33
0.48 m2 BSA
60
2400
800
1 600
2.67
90
3600
800
2 800
3.11
4 years old
15
990
1200
−210
−0.85
16.5 kg
30
1980
1200
780
1.58
0.68 m2 BSA
60
3900
1200
2 760
2.79
90
5940
1200
4 940
3.33
12 years old
15
2400
2250
1 150
1.92
40 kg
30
4800
2550
2 550
2.12
1.13 m2 BSA
60
9600
2250
7 350
3.06
90
14,400
2250
12 150
3.38
*4 mL/kg/% burn.
†2000 mL/m2 BSA.
Table 35.2  Formulas for Calculating Body Surface Area
(BSA)
Dubois formula
BSA (m2) = ht (cm)0.725 × wt (kg)0.425 × 0.007184
Jacobson formula
BSA (m2) = [ht (cm) + wt (kg) − 60]/100

35  •  Special Considerations of Age
376
240
220
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
40
30
90
2.0
180
160
140
130
120
110
100
90
80
70
60
50
45
40
35
30
25
20
18
16
14
12
10
9
8
7
6
5
4
3
1.9
1.8
1.7
1.6
1.5
1.4
1.3
1.2
1.1
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
80
70
50
60
40
30
20
15
10
9
8
7
6
5
4
3
Weight
in pounds
Surface area
in square
meters
2
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
0.50
0.55
0.60
0.70
0.80
0.90
1.00
1.10
1.20
1.30
13
14
15
16
17
18
19
20
22
24
26
28
30
35
40
50
60
70
45
55
65
75
85
80
90
15
10
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.5
2.0
1.5
1.0
25
20
30
40
50
60
70
80
cm
in
m2
lb
kg
Height
For children of
normal height
for weight
NOMOGRAM
SA
Weight
Fig. 35.6  Standard nomogram for the determination of body surface area based on height and weight. The example depicted is for a child of 100 cm
in height and 23 kg in weight. (From Eichelberger MR, ed. Pediatric Trauma: Prevention, Acute Care and Rehabilitation. St Louis: Mosby Year Book; 1993: 572.)
Table 35.3  Normal Pediatric Vital Signs
Age
Minimum Heart
Rate (beats/min)
Systolic Blood
Pressure (mmHg)
Respirations
(breaths/min)
Minimal
Hemoglobin (g/dL)
Minimal
Hematocrit (%)
<2 years of age
100–160
86–106
30–40
11.0
33.0
2–5 years of age
80–140
89–112
20–30
11.0
33.0
6–9 years of age
70–120
97–115
18–25
11.5
34–5
9–12 years of age
70–115
102–120
18–25
11.5
34–5
>12 years of age
60–110
90
12–20
12.0
36.0

35  •  Special Considerations of Age
377
especially in a closed-space fire.33,34 The initial carboxyhe­
moglobin level should be calculated from the time the
admission level is drawn, back to the time of the burn
injury. A carboxyhemoglobin level of greater than 60% has
a greater than 50% chance of mortality. Diagnosis is made
by visualization of the airway with fiberoptic bronchoscopy
(Table 35.4).
Treatment modalities for inhalation injury include
airway maintenance, secretion clearance, and pharmaco­
logical management (Table 35.5). Further care is mainly
supportive and includes ventilator support as needed, vigor­
ous pulmonary toilet, humidification of inspired air, and
antibiotics for documented infection. A combination of
nebulized heparin and N-acetylcysteine has been shown to
decrease the duration of mechanical ventilation after inha­
lation injury.35–37
Hypermetabolism
Profound hypermetabolism is a classic feature of children
with large burn injury. No other pathological state produces
development of edema from both vasogenic and hydrostatic
sources. Vasogenic edema occurs in the early post-burn
period when vascular integrity is impaired. The mainte­
nance of intravascular osmotic pressures reduces the likeli­
hood of edema development. In difficult resuscitation,
colloids such as albumin can be used. Albumin can be
expected to remain in the intravascular space if adminis­
tered more than 8 hours after burn.
Evaluation and Management
of Airways
Airway evaluation and management must be given priority.
Children are more prone to obstruction due to the smaller
aperture of their trachea. Airway edema causes dispropor­
tionate increments in resistance with concomitant reduc­
tion of the cross-sectional area.24 Inhalation injury can lead
to delayed airway edema after administration of massive
resuscitation fluids.
Potential hemorrhage and edema make emergency intu­
bation difficult. Hence, early intubation should be consid­
ered when a long transfer is anticipated, severe inhalation
injury is present, or a patient has a large burn that likely
will develop airway edema secondary to the large amount
of fluid resuscitation. Concurrent placement of an endotra­
cheal tube (ETT) over the bronchoscope should be consid­
ered at the time of bronchoscopy. A readily available
estimate of airway diameter is the width of the patient’s
little finger, an age-based formula (age + 16)/4, or the use
of a Broselow tape.25
The ETT must be well secured. In a child, exudative
wounds and moist dressings can make this task difficult.
One successful approach is to attach the ETT with tape
around the back of the head, both above and below the ears.
An additional piece of tape over the top of the head, secured
to the tape behind the head, will prevent accidental extuba­
tion in most children.26 In addition, commercially available
endotracheal tube holders exist; however securing the tubes
with tape strips of sufficient length and width has proved
superior to two different commercial tube holders.27
Inhalation Injury
Inhalation injury is one of the main contributors to burn
mortality.28,29 The mortality rate of children with isolated
thermal burns is 1–2%, but increases to approximately 40%
in the presence of inhalation injury.30,31 Expectedly, inhala­
tion injury is associated with longer hospital stay and
increased risk of pneumonia.32 Carbon monoxide poisoning
coupled with hypoxia is the most frequent cause of death
due to inhalation injury. Any patient with a flame-related
injury, particularly if confined in a closed space, should be
evaluated for inhalation injury. If inhalation injury is sus­
pected, arterial blood gas and carboxyhemoglobin levels
should be obtained, and the patient should be placed on
100% oxygen. Signs of potential inhalation injury include
facial burns, singed nasal vibrissae, carbonaceous sputum,
abnormal mental status (agitation or stupor), respiratory
distress (dyspnea, stridor, hoarseness, wheezing), or an
elevated carboxyhemoglobin level of greater than 10%,
Table 35.4  Carbon Monoxide Poisoning
Carboxyhemoglobin
(%)
Symptoms
0–10
Normal
10–20
Headache, confusion
20–40
Disorientation, fatigue, nausea, visual
changes
40–60
Hallucination, combativeness, convulsion,
coma, shock state
60–70
Coma, convulsions, weak respiration and
pulse
70–80
Decreasing respiration and stopping
80–90
Death in less than 1 hour
90–100
Death within a few minutes
Table 35.5  Airway Maintenance, Clearance, and
Pharmacological Management
Turn side to side
q2h
Sitting or rocked in chair
As soon as physiologically
stable
Ambulation
Early
Chest physiotherapy
q2h
Suctioning and lavage (nasal/oral
tracheal)
q2h
Bronchodilators
q2h
Aerosolized heparin/acetylcysteine
q2h alternating
Heparin 5000–10,000 units with
3 mL NS
q4h
Alternated with acetylcysteine
20% 3 mL
q4h

35  •  Special Considerations of Age
378
30% of the TBSA benefit from enteral feedings to supple­
ment their diet.
Feeding tubes can be placed beyond the pylorus and
enteral nutrition initiated within a few hours of admission.
Most children will tolerate enteral feedings as early as 1–2
hours post burn. Several studies have demonstrated the effi­
cacy of early alimentation and its additional salutary
effects.57,58 Enteral feedings can be given through a flexible
nasoduodenal or nasojejunal feeding tube, bypassing the
stomach.
Several formulas are available to estimate caloric require­
ments in burn patients. Since caloric demands are related
to burn size, caloric support should be given in amounts
calculated based on total and burned body surface areas in
burned children. A series of different formulas based on
body surface areas have been developed to meet the differ­
ing requirements of the various age groups.59–61 The Curreri
formula has likewise been amended to reflect the differing
demands of the pediatric group (Table 35.6).
Growth Delay
Increased protein degradation has been reported up to 9
months after major burns. Growth delay and osteopenia
can persist up to 2 years in children.44,62,63 Despite adequate
nutritional support, children with greater than 40% TBSA
burn have a linear growth delay of height and weight and
a decrease in maximal exercise capacity during the first
year after burn, which slowly resolves to near normal dis­
tribution by post-burn year 3.64 Administration of propran­
olol and oxandrolone has been shown to ameliorate growth
delay secondary to burn injury in children.50
Management of Burn Wound
One of the most important advances in the care of burn
patients is the early surgical excision and grafting of the
burn wound. Improvements in the treatment of burn
wounds with the practice of early excision and grafting,
along with improvements in fluid resuscitation and the
general care of burn patients, have reduced the incidence
of sepsis in burn patients.65 Prior to early excision and graft­
ing, third-degree burns were treated by removing small
amounts of eschar at a time followed by grafting. Com­
monly, eschar was allowed to separate through lysis by bac­
terial enzymes, which led to a high incidence of invasive
as dramatic an effect on the metabolic rate as burn
injury.38,39 Hypermetabolism slows wound healing, pro­
longs generalized weakness, and can lead to loss of lean
body mass.
The hypermetabolic response increases with increasing
burn size. There is an upregulation of catabolic agents,
such as catecholamine, cortisol, and glucagon, which
induces a hyperdynamic cardiovascular response; elevated
oxygen consumption; increased energy expenditure; prote­
olysis, lipolysis, and glycogenolysis; loss of lean body mass;
delayed wound healing; and immune suppression.40–43
Pharmacological agents have been used to attenuate
hypermetabolism in burn injury. In order to minimize lean
body mass loss, several therapeutic agents have been used
in pediatric burned patients: anabolic hormones such as
recombinant human growth hormone, insulin, and insulin-
like growth factor-1 (IGF-1); anabolic steroids such as tes­
tosterone and synthetic analogue oxandrolone; and
adrenergic antagonists such as propranolol.44–50
THERMOREGULATION
Hypothalamic dysregulation induced by various inflamma­
tory cytokines and pain causes elevation of core body tem­
perature after a major burn even in the absence of infection.
Burn patients strive for temperatures of around 38°C. Low
temperature is more likely indicative of overwhelming
sepsis or exhausted physiological capabilities. The aug­
mented heat loss secondary to epidermal loss after a major
burn makes conventional methods of heat conservation
inappropriate in burn patients.51,52 In addition, low muscle
mass in young children and their limited shivering capacity
are factors that increase the risk of hypothermia in this
population.53
Every effort should be made to reduce heat loss.
Environmental temperature should be maintained at
30–33°C in order to reduce energy demands and evapo­
rative water losses. Bathing should be performed expedi­
tiously, with avoidance of unnecessary environmental
exposure.54
Hypothermia produces numerous consequences. The
heart is particularly sensitive to temperature, and ventricu­
lar arrhythmias are not uncommon. Hypothermia also
increases the susceptibility of the myocardium to changes
in electrolyte concentrations. The oxyhemoglobin dissocia­
tion curve is shifted to the left by decreased body tempera­
ture, impairing peripheral oxygenation. In extreme cases,
hypothermia produces central nervous system and respira­
tory depression, coagulopathy, and loss of peripheral vaso­
motor tone.41
NUTRITIONAL SUPPORT
Nutritional support becomes an essential part of treatment
of acute burn patients. Early enteral nutrition is used to
accomplish nutritional support of the hypermetabolic
response in severely burned patients. Early enteral nutrition
preserves gut mucosal integrity, improves intestinal blood
flow and motility, and can abate the hypermetabolic
response to burn.55,56 Patients with smaller burns should
receive a high-protein, high-calorie diet to support their
metabolic response. Those with burns covering more than
Table 35.6  Nutritional Requirements for Children
Galveston
Modified Curreri
Infant burn
2100 kcal/m2 +
1000 kcal/m2 burn
BMR + 15 kcal/%
Toddler burn
BMR + 25 kcal/%
Child burn
1800 kcal/m2 +
1300 kcal/m2 burn
BMR + 40 kcal/%
Adolescent burn
1500 kcal/m2 +
1500 kcal/m2 burn

35  •  Special Considerations of Age
379
Traditionally, topical antimicrobials were the most com­
monly used treatment in partial-thickness burns. One of
the drawbacks of using topical antimicrobials in burn
wounds is the pain associated with dressing changes, espe­
cially in children. Immediate application of Biobrane is one
of the treatment options for partial-thickness burns, pri­
marily scald burns covering less than 30% of the TBSA.
Biobrane can be safely used in children, including infants.
When applied within 48 h of burn, there is no difference in
infection rates between Biobrane and topical antimicrobi­
als. Furthermore, Biobrane application leads to less pain,
shorter hospitalizations, and shorter healing times com­
pared to topical antimicrobials.69–71 Other silver-based
dressings such as Acticoat, Aquacel, Silverlon, and Mepilex
Ag are available for partial-thickness burns that can be left
on for several days, thus decreasing the number of dressing
changes and the associated pain.72–74
It may be difficult clinically to determine the precise depth
of scald burns during the early post-burn period because
the wounds may be indeterminate and contain a mixture
of superficial and deep partial-thickness burns and some­
times even full-thickness burns. Indeterminate-depth scald
burns covering less than 20% of the TBSA in young chil­
dren are best managed with delayed surgical intervention
instead of early excision. Unless the wound is clearly full
thickness, the scald burn should be conservatively managed
for approximately 2 weeks to allow the wound to heal or
demarcate (Figs. 35.9 and 35.10). This delayed surgery
results in a smaller area of wound being excised and less
blood loss.75
Large scald burns can be treated with allograft or xeno­
graft, which significantly reduces the pain involved with
dressing change and wound care. Scald burns covering
more than 20% of the TBSA and of indeterminate depth
were randomized to treatment with allograft skin versus
topical antimicrobial therapy. Treatment with allograft skin
led to faster healing and less pain.76 In another study,
patients with greater than 40% TBSA burn were random­
ized to treatment with allograft skin or topical antimicrobi­
als. Patients who received allograft skin had a significantly
shorter length of hospital stay.77
Fig. 35.7  Dermal and skin substitutes can be used as temporary cover
for severe burns. Integra, a bilaminar skin substitute, can replace homo­
grafts as temporary cover. The Silastic superficial layer can be removed
after 3 weeks and a super-thin autograft then placed on top. The entire
wound can be covered with Integra, which is subsequently autografted
when donor sites are available. (From Barret J, Herndon DN, eds. Color
Atlas of Burn Care. London: WB Saunders; 2001: 107,;late 6.95.)
Fig. 35.8  The cultured epidermal autografts are ready to use 18–21
days later. Extreme care with handling is needed because of the fragil­
ity of the cultured cells. (From Barret J, Herndon DN, eds. Color Atlas of
Burn Care. London: WB Saunders; 2001: 106, plate 6.89.)
Fig. 35.9  Superficial and small areas of deep second-degree scald
burns before topical treatment: 25% total body surface area. (From
Barret J, Herndon DN, eds. Color Atlas of Burn Care. London: WB Saunders;
2001: 79, plate 5.39.)
infection, wound sepsis, increased length of hospital stay,
and increased mortality. Currently, massive excision can be
easily managed in children and contributes to shortened
length of hospital stay and reduced mortality.66,67 Early
excision of massive burns in the first 24 hours is safe and
effective.68
By using skin substitutes such as allograft, xenograft, and
Integra (Fig. 35.7), the burn wound can be covered and
protected until donor sites are available for procurement.
Cultured epidermal autografts (CEA) are available for
massive burn injuries (Fig. 35.8). Although it is an effective
way to cover large burns where donor sites are limited, it
may not be the most cost-effective approach. A group of
patients treated with CEA had greater hospital costs, a
longer hospital stay, and required more reconstructive sur­
gical admissions when compared to patients who received
conventional treatment with meshed autograft skin.66

35  •  Special Considerations of Age
380
Most
outpatients
are
treated
with
hydrocodone/
acetaminophen, and some require longer-acting narcotics
such as methadone.
Nonpharmacological methods, including hypnosis, dis­
traction techniques, and the use of virtual reality can be
used in combination with pharmacological options for the
treatment of pain and anxiety.78,95–98
Rehabilitation
One of the integral parts of successful treatment of burn
injury is rehabilitation. During the acute phase of burn
care, splints and proper positioning are used to minimize
joint deformities and contractures. Splints are fabricated
and adapted to meet individual needs and used preferably
from the first day of hospitalization. Bedside therapy, includ­
ing passive and active range of motion, is started early.
Patients with leg grafts are kept on bed rest after the opera­
tion, but on postoperative day 3 they are allowed and
encouraged to ambulate. Early physical therapy and ambu­
lation are the keys to success in the long-term rehabilitation
of burned children. When patients are discharged from
their acute-care hospitalization, they follow rigorous outpa­
tient treatment plans that include stretching, range of
motion, and strengthening exercises.
Prevention
Prevention remains the single best way to reduce pediatric
burn injuries. National prevention and education efforts
have significantly decreased the number of pediatric burns
each year. Lowering the temperature set point on water
heaters and educating families to check the bath water tem­
perature before placing a child in the bath have reduced
scald burns. Prevention groups have worked with water
heater companies and the Consumer Product Safety Com­
mission (CPSC) to provide education to raise gas water
heaters 12 inches above the ground, which significantly
reduces the risk of accidental explosions and fires.
Three-quarters of “child fire play” involves matches or
lighters. All matches and other ignition sources must be
placed out of reach of children. A positive step toward pre­
vention occurred in 1994 when the CPSC put into effect a
child-resistant lighter to protect children. The importance
of placing smoke detectors in multiple areas of the house
cannot be overstated. Current prevention education focuses
on children and especially infants who are not able to
remove themselves from a fire. Educating children as early
as possible that fire is dangerous is imperative. Providing
safe environments for children and providing appropriate
education is the responsibility of healthcare providers, the
adults who care for them, and the community.
Complete references available online at

Further Reading
Williams FN, Herndon DN, Jeschke MG. The hypermetabolic response to
burn injury and interventions to modify this response. Clin Plast Surg.
2009;36(4):583-596.
Pain Management
Therapeutic interventions such as wound care, surgical
interventions, and physical therapy cause significant
pain.78,79 Despite advances in burn care, procedural pain
continues to be severe and undertreated.80 Well-controlled
pain in the post-burn period has been associated with
improved clinical outcomes (i.e., wound healing, re-
epithelialization rates).80–82 Conversely, poorly managed
pain is associated with dysesthesias, chronic pain, and
debilitating psychological conditions.83
Pain assessment in pediatric patients must be individual­
ized to the patients’ age, clinical conditions, and prefer­
ences. Verbal pain scales that assess pain severity are the
most commonly used assessment tools.84 Published studies
report that burn patients preferred face and color scales
over visual analogs and adjective scales.85 When factors
related to the injury or the treatment limit the capacity of
the patient to communicate, the evaluation of the patient’s
behavior is a valid alternative. However it is recognized that
these patients are at increased risk for inadequate treatment
of their pain.86
The intravenous route is the preferred mode of analgesic
administration in the acute phase post-burn. Significant
changes in the metabolism of nonopioid medications
(altered volume distribution due to carrier protein changes,
alterations in receptor sensitivity) have been reported after
burn injury.87–89 Morphine sulfate and lorazepam pharma­
cokinetics seem to remain unaltered after burn injury;
however it has been reported that their clearance rates
increase after massive burns (>80% TBSA burn).90–92 Mor­
phine sulfate is one of the most commonly used analgesic
in pediatric burn patients.93 Fentanyl is another safe and
efficacious alternative. Despite enthusiasm and increased
interest, the routine use of intravenous local anesthetics is
not advocated.94
Fentanyl Oralet (10 µg/kg) has been used successfully in
the outpatient setting for dressing changes and wound care.
Fig. 35.10  Deep second-degree burns treated for 10 days with silver
sulfadiazine. Note that the edges are regenerating. Pseudo-eschar chal­
lenges the evaluation of the wounds. Foul smell, discoloration, sur­
rounding cellulitis, and eschar separation are signs of infection. (From
Barret J, Herndon DN, eds. Color Atlas of Burn Care. London: WB Saunders;
2001: 77, plate 5.31.)

380.e1
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63. Klein GL, Wolf SE, Goodman WG, Phillips WA, Herndon DN. The man­
agement of acute bone loss in severe catabolism due to burn injury.
Horm Res. 1997;48(suppl 5):83-87.
64. Rutan RL, Herndon DN. Growth delay in postburn pediatric patients.
Arch Surg. 1990;125(3):392-395.
65. Merrell SW, Saffle JR, Larson CM, Sullivan JJ. The declin­
ing incidence of fatal sepsis following thermal injury. J Trauma.
1989;29(10):1362-1366.
66. Herndon DN, Parks DH. Comparison of serial debridement and auto­
grafting and early massive excision with cadaver skin overlay in the
treatment of large burns in children. J Trauma. 1986;26(2):149-152.
67. Thompson P, Herndon DN, Abston S, Rutan T. Effect of early excision
on patients with major thermal injury. J Trauma. 1987;27(2):205-207.
68. Barret JP, Wolf SE, Desai M. Total burn wound excision of massive pae­
diatric burns in the first 24 hours post-injury. Ann Burns Fire Disasters.
1999;12(1):25-27.
69. Barret JP, Dziewulski P, Ramzy PI, et al. Biobrane versus 1% silver
sulfadiazine in second-degree pediatric burns. Plast Reconstr Surg.
2000;105(1):62-65.
70. Lal S, Barrow RE, Wolf SE, et al. Biobrane improves wound healing
in burned children without increased risk of infection. Shock.
2000;14(3):314-318, discussion 318.
71. Lang EM, Eiberg CA, Brandis M, Stark GB. Biobrane in the treat­
ment of burn and scald injuries in children. Ann Plast Surg.
2005;55(5):485-489.
72. Varas RP, O’Keeffe T, Namias N, et al. A prospective, randomized trial
of Acticoat versus silver sulfadiazine in the treatment of partial-
thickness burns: which method is less painful? J Burn Care Rehabil.
2005;26(4):344-347.
73. Caruso DM, Foster KN, Blome-Eberwein SA, et al. Randomized clini­
cal study of Hydrofiber dressing with silver or silver sulfadiazine
in the management of partial-thickness burns. J Burn Care Res.
2006;27(3):298-309.
74. Schiefer JL, Rahmanian-Schwarz A, Schaller H-E, Manoli T. A novel
hand-shaped suprathel simplifies the treatment of partial-thickness
burns. Adv Skin Wound Care. 2014;27(11):513-516.
75. Desai MH, Rutan RL, Herndon DN. Conservative treatment of
scald burns is superior to early excision. J Burn Care Rehabil.
1991;12(5):482-484.
76. Rose JK, Desai MH, Mlakar JM, Herndon DN. Allograft is superior
to topical antimicrobial therapy in the treatment of partial-

381
Care of Geriatric Patients
GABRIEL HUNDESHAGEN, JONG O. LEE, WILLIAM B. NORBURY, and
DAVID N. HERNDON
36 
Outcome
Mortality rates have diminished among all age groups in
recent decades.5,13,16 Technological progress as well as
advances in fluid resuscitation, early burn wound excision,
skin grafting, and pharmacotherapy have improved sur­
vival.17 The Baux score is calculated as a sum of age and
percent total burn surface area (TBSA) and illustrates both
the influence of age on outcome and the improvements in
burn care: When compared over time, the score at which
the survival rate reaches 0% has steadily increased from
100 in the 1940s to 130–140 in the early 2000s.18 However,
mortality and morbidity rates remain higher in geriatric
burn patients.1,2,10,13,17,19 A large registry study of Jeschke
et al. reported the LD50 (50% mortality) for 50-year-old
patients at burn sizes of 50% TBSA. This LD50 considerably
drops to 30–40% TBSA for patients older than 65 years to
only 25% for those older than 70.17 Pereira et al. have found
in a large study of mortality trends and autopsy data that
LD50 for older adults has remained steady at 35% for
decades, which is disconcerting in the light of the overall
improvement of burn care. Lung injury and sepsis were the
most common primary causes of death noted in burn
patients, and an increase in the weights of heart, lung,
spleen, and liver was noted in all age groups postmortem.16
Pomahac et al. reported that increased levels of creatinine
at the time of admission were associated with increased
mortality in older adults.20
Age, TBSA burned, and inhalation injury are associated
with increased mortality rates. The mortality rate is 7.4%
for all patients with burn injury aged 60–69 years, 12.9%
for patients aged 70–79 years, and 21% for patients older
than 80 years of age.13
Geriatric patients also experience greater long-term dis­
ability after burn injury. Only about 50% of elderly patients
with a major burn return home within the first year,7,16,21
and any loss of function, strength, or independence is more
difficult to recover than in the younger patient population.22
The unique risk factors present in this population explain
these statistics.
Risk Factors
A number of well-recognized risk factors are present in
older adults. Increased risk of infections, pulmonary dis­
eases, and sepsis as well as the variability of comorbidi­
ties present in these patients increase morbidity after a
burn. Some of the more prominent factors are shown in
Box 36.1.
Introduction
The quality of life in developed countries has improved over
the past 50 years, increasing the average lifespan by nearly
30 years.1 Individuals aged 65 years and over account for
13% of the U.S. population. This “elderly” population is pro­
jected to double from 40.2 million in 2010 to 88.5 million
by 2050. Such population aging is unprecedented.2 By
2050, the number of older adults persons in the world is
expected to exceed the number of young for the first time in
history.3 This trend presents a special challenge because
older adults will constitute an ever-growing segment of the
average surgeon’s practice and will influence clinical deci­
sions, ethical decisions, and healthcare costs.
A multicenter study conducted in Tokyo found that 25%
of burned patients were older than 65 years of age.4 A
systematic review of more than 186,500 patients in Europe
showed that 10–16% were in this age range.5 In the United
States, geriatric patients constitute about 10% of the major
burn population. The anticipated rise in the geriatric popu­
lation makes understanding age-related physiological and
metabolic changes even more important for burn care
professionals.6–8 The elderly and the very young are most
likely to die from severe burns.9–13 Adults older than 65
years old have a mortality rate from burns that is five times
the national average.9,13 Treatment of these patients
remains a greater challenge than treatment of middle-aged
and younger patients because lower physiological reserves
and higher underlying comorbidities reduce the margin for
error.
Epidemiology
Contact with flame is the main (54%) cause of burn injury.13
One third of injuries result from cooking accidents: scalds
in 22% of cases and contact with hot objects in about 6%
of cases.6–8,13,14 The latter cause is more prevalent in older
adults, reflecting increased psychological and physical dis­
ability. This fact is also reflected in the rate of fire-related
deaths in individuals older 75 years old, which is four times
the national average. The male-to-female ratio decreases
progressively as age increases, with women exceeding the
number of men in the 75 years and older group (compared
with the 5 : 1 male-to-female ratio for young adult burn
patients).13 Most burns in older adults occur at home; there­
fore, prevention must be focused in the home environ­
ment.13,15 Prevention should also focus on the fact that 30%
of geriatric patients are the victims of self-neglect, and at
least 10% are the victims of elder abuse.14

36  •  Care of Geriatric Patients
382
DECREASED CARDIOPULMONARY RESERVE
Aging reduces pulmonary reserve for both gas exchange
and lung mechanics.23 Elderly patients are more prone to
pulmonary failure, one major cause of burn-related death.
The presence of atherosclerosis, coronary artery disease,
and previous myocardial infarction is also common.
INFECTIONS
Pneumonia and urinary tract infections are the most preva­
lent complications in elderly burn patients.13 The develop­
ment of pneumonia seems to correlate with male gender,
TBSA burned, and the presence of inhalation injury and
contributes to higher mortality rates.19
MALNUTRITION AND DECREASED LEAN
BODY MASS
Aging leads to progressive decreases in lean body mass, and
some degree of protein–energy malnutrition is found in
more than 50% of elderly burn patients on admission.24–27
Any preexisting loss of lean body mass will result in
increased morbidity, early onset of immune deficiency,
organ dysfunction, weakness, and impaired wound
healing.25,28,29 Losses are caused by multiple factors, includ­
ing impaired nutrition; swallowing disorders (presbypha­
gia); reduced mobility; and age-related decreases in
endogenous anabolic hormones, human growth hormone,
and testosterone.23,25,30
Decreased anabolic activity prolongs recovery time and
greatly delays restoration of muscle. Importantly, older
adults respond to exogenous anabolic stimuli such as tes­
tosterone analogs, human growth hormone, and resistance
exercise similarly to the younger population. At the same
time, daily protein requirements are higher in older adults
than in the younger population.31 Therefore, exercise, high-
protein nutrition, and anabolic agents are essential for
recovery.32–34
AGING SKIN AND WOUND HEALING
Aging produces significant changes in the skin. Because of
these changes, burns tend to be deeper in older than in
younger patients.35–37 After the age of 65 years, the
turnover rate of the epidermis decreases by 50%. A flatten­
ing of the rete pegs and fewer epidermal-lined skin append­
ages are present. These properties significantly delay healing
of partial-thickness burns.36,37
Additionally, a progressive thinning of the dermis occurs,
along with a decrease in both collagen content and other
extracellular matrix proteins, especially glycosaminogly­
can, which lower skin turgor. There are also decreases in
vascularity, macrophages, and fibroblasts, resulting in
deeper burns, an impairment of all phases of wound healing
(Box 36.2).36,37
IMMUNE RESPONSE
It is hypothesized that aging leads to a state of “chronic
inflammation” with increased baseline levels of proinflam­
matory cytokines that increase the vulnerability of elderly
patients to negative outcomes after insults.38,39 A recent
study evaluated the unique characteristics of the inflamma­
tory and immune response in elderly burn patients. Stano­
jcic et al. were able to show an uncoordinated overactivation
of proinflammatory and antiinflammatory cytokines that
occurred delayed by 2 weeks postburn.40 This functionally
impaired “cytokine storm” is followed by a phase of deple­
tion and a dampened immune reaction in nonsurviving
patients. The study concludes that because of the delay in
the characteristic cytokine response, it cannot be used as a
predictor for mortality in older adults as opposed to adults
and children.40
Treatment
The increased complications seen in elderly burn patients
may to a certain degree result from more cautious and less
aggressive treatments. This is due to existing beliefs that
elderly burn patients cannot tolerate eschar excision as well
as their younger counterparts, resulting in a greater delay
in the excision of burn wounds.41 However, despite these
risk factors, elderly patients have repeatedly been shown to
tolerate multiple, early surgical procedures, and early
wound closure corresponds to a better outcome in these
patients.41–43 In general, elderly patients are treated identi­
cally to younger patients, and most differences in burn
management between patient groups are related to comor­
bid conditions and adversities that may arise. One unique
exception to this is that massive burns are more commonly
managed expectantly in older adults, and palliative care
may be indicated.
Box 36.1  Risk Factors in Elderly Patients
■ Chronic illness (e.g., diabetes)
■ Effects of aging (e.g., presbyphagia)
■ Cardiovascular disease (e.g., previous infarct)
■ Pulmonary reserve (decreased with age)
■ Infections (e.g., pneumonia and urinary tract infection)
■ Unintentional weight loss
■ Decrease in lean body mass
■ Impaired nutrition with presence of deficiency states in energy,
protein, and macronutrients
■ Decreased endogenous anabolic hormones
■ Skin aging (thin, decreased synthesis)
Box 36.2  Aging of Skin
■ Decreased epidermal turnover
■ Decrease in skin appendages
■ Thinning of dermis
■ Decreased vascularity
■ Decreased collagen and matrix
■ Decreased fibroblasts and macrophages

36  •  Care of Geriatric Patients
383
Fram et al. demonstrated continuous insulin infusions,
with tight euglycemic control, to restore insulin sensitivity,
improve mitochondrial oxidative capacity, and reduce
resting energy expenditure.50 Lower-dose infusions of
9–10 U/h of insulin promote substantial muscle anabolism
without the need for additional large doses of carbohy­
drate.55 Intensive insulin therapy during acute care reduces
morbidity, mortality, and complications caused by infec­
tion.51,56 Testosterone restoration is effective in both male
and female burn patients. However, the synthetic analog
oxandrolone is preferable because it possesses only 5% of
the virilizing androgenic effects of testosterone and is avail­
able in a peroral formulation. Oxandrolone restores lean
body mass and improves wound healing in burned adults,52
especially in emaciated subjects whose treatment has been
delayed.54,57 The effects of oxandrolone are independent of
age.53
Treatment of acute pediatric burn patients with oral
oxandrolone (0.1 mg/kg twice daily) enhances the effi­
ciency of protein synthesis and increases anabolic gene
expression in muscle. It also significantly increases lean
body mass at 6, 9, and 12 months after burn and bone
mineral content at 12 months after injury.58 Recombinant
human growth hormone has been successfully used in pedi­
atric patients;59,60 however, it has several adverse effects,
such as hyperglycemia.61 Its potential positive effects on the
adult and elderly burn patient population are currently
under investigation in prospective trials.
β-Adrenergic blockade with propranolol during the acute
phase and long term attenuates the effects of the burn-
induced hypermetabolic response. In severely burned sub­
jects, titration of propranolol to reduce baseline heart rate
by 15–20% improves muscle–protein balance and dimin­
ishes obligatory thermogenesis, tachycardia, cardiac work,
resting energy expenditure, and fatty infiltration of the
liver.47,62,63 However, no study has directly focused on geri­
atric patients.
Pain, Sedation, and Comfort Care
Geriatric burn patients are often undertreated for pain
because of the misconception that less pain occurs with
age.64 This can be detrimental because both pain and
anxiety further increase the levels of catecholamines.
Reduced clearance of many therapeutic agents occurs with
aging, necessitating lower dosages (Table 36.1).65 For this
reason, pain assessment using reliable tools is essential to
create an individualized treatment plan, which should also
account for any comorbid conditions that may be present
on admission. Untreated pain and incorrect sedation may
result in posttraumatic stress disorder, major depression,
and delirium.66 In addition, although the burn injury pri­
marily determines the extent of the metabolic response,
metabolic rates are also increased by physical activity, back­
ground pain, procedure-related pain, and anxiety. Judicious
narcotic support, appropriate sedation, and supportive psy­
chotherapy are mandatory to minimize these effects.67
Combination drug therapy is often required to achieve
adequate analgesia. Different approaches ranging from
patient-controlled analgesia to virtual reality have been
found to ameliorate pain in burned patients. Intravenous
INITIAL RESUSCITATION
Improved fluid resuscitation over time is one of the factors
associated with decreased mortality. Compared with
younger patients, more fluid is required to resuscitate elderly
patients with the same burn size to avoid hypovolemia.44
This is likely attributable to decreased skin turgor, which
reduces resistance to fluid accumulation or edema produc­
tion. Burn depth, inhalation injury, and delayed resuscita­
tion can influence fluid requirements.45 In addition to the
Parkland and modified Brooke formulas, Benicke et al.
developed a multifactorial resuscitation formula with a
compensating factor for advanced age (Box 36.3).46 Early
ventilatory support is more commonly required because of
decreased lung reserve.
WOUND MANAGEMENT
Early removal of the burn wound and rapid closure with
skin grafts are essential for survival.35,42,43 Because of
thinner skin, thermal injuries often create full-thickness
wounds, and skin graft procurement may create significant
donor site complications.35 Thinner skin grafts are neces­
sary, and healing time is prolonged.36
METABOLIC AND NUTRITIONAL SUPPORT
Although elderly patients do not generate the degree of
hypermetabolism seen in younger patients, the catabolic
response is comparable, necessitating a 1.5- to 2-g/kg/day
protein intake.46,47 In already malnourished patients, the
goal of nutritional support must be not only maintenance
but also replacement therapy, especially for protein and
micronutrients.25,48 Nutrient supplements are invariably
required. Most supplements are protein hydrolysates
because the gut is more capable of absorbing peptides and
amino acids than whole proteins broken down from
food.21,49
Anabolic agents are valuable adjuncts to optimal nutri­
tion.33,34,50,51 The effects of insulin and oxandrolone on
postburn hypercatabolism have been studied in the pediat­
ric population, and these anabolic agents may be used in
older adults, given that endogenous anabolic hormones are
decreased in this group after injury.51–54
Box 36.3  Parkland Formula:
Predicted volume mL
Weight in kg
TBSA nd and rd
(
) =
×
×
2
3
4 mL
Modified Brooke Formula:
Predicted volume mL
Weight in kg
TBSA nd and rd
(
) =
×
×
2
3
2mL
Benicke’s Formula:
Predicted volume mL
Weight in kg
TBSA nd and rd
(
)
(
)
(
=
×
+
×
50
300
2
3
)
(
) (
)
(
)
+
×
+
×
−
×
≥
3500
4000
3500
65
IHI
BAL
Age
years
*
TBSA, Total body surface area.
*First 24 hours; IHI (inhalation injury) present: yes = 1, no = 0; BAL
(blood alcohol level), <0.1% = 0, ≥0.1 = 1.

36  •  Care of Geriatric Patients
384
The drawback of β-blockade in older adults is that the
aging cardiovascular system is less responsive to β-receptor
stimulation. This decrease, together with anesthetic agents,
may lead to deleterious intraoperative hypotension in the
presence of prophylactic β-blockade. Further investigations
are necessary to determine the most appropriate therapeu­
tic regimen for reducing perioperative ischemia, cardiac
morbidity, and postburn hypermetabolic responses in older
adults.
Pulmonary complications are more strongly linked to
coexisting comorbidities than to chronological age.77
Because of the prevalence of chronic obstructive pulmo­
nary disease and asthma in older adults, physicians should
be alert for these conditions during perioperative evalua­
tion. With the appropriate diagnosis, aggressive pulmonary
rehabilitation including exercise training, patient educa­
tion, smoking cessation, and medication optimization is
effective in elderly patients.77 All of these aspects must be
integrated into long-term patient management. Aggressive
use of antibiotics, judicious use of bronchodilators, ade­
quate hydration and postural drainage, and chest physio­
therapy reduce the incidence of pneumonia, atelectasis,
and other pulmonary complications.
Rehabilitation
Burn rehabilitation is a long multidisciplinary process that
aims to preserve patients’ functional ability and restore
independence. Physical and occupational therapy should
begin immediately after injury. Important components of
rehabilitation include wound healing, scar prevention and
correction, splinting, casting, traction, pressure therapy,
pharmacologic therapy, exercise, and psychological support.
Older adults should be aggressively managed during reha­
bilitation to avoid any further loss of function or strength,
which are difficult to recover. Older patients are capable of
recovering muscle strength with resistance exercise and
should not be managed conservatively.22 As with children,
providing support and guidance for caretakers is essential
because these individuals will be responsible for the patient’s
well-being upon discharge.78,79
Intentional Burns in Older Adults
Identifying physical abuse by burning in older adults is dif­
ficult because no pathognomonic signs exist. Although
such abuse is relatively rare, professionals consistently
underestimate the prevalence of elder abuse. The growth in
the elderly population makes it necessary to raise awareness
among health professionals and reevaluate the clinical
approach and assessment for burn injuries inflicted inten­
tionally or negligently.80 Older adults often live alone, inter­
acting predominantly with the caregivers who enact their
abuse. These patients may keep their abuse a secret because
of shame, guilt, or fear of reprisals.81,82 Most forms of inten­
tionally inflicted burns have a higher associated morbidity
and mortality than equivalent accidental burns, in part
because of comorbidity from other physical abuse, sub­
stance abuse, or psychological problems that contributed to
or resulted from the inflicted burn. Elder mistreatment can
drug administration is preferable during the acute phase. A
proactive geriatrics consultation team may also be benefi­
cial in managing pain. Use of only comfort care measures
needs to be considered for elderly patients with burns likely
to be fatal.68
Perioperative Optimization
Aging produces many changes in the cardiovascular system
that make hemodynamic stability more difficult to achieve
and increase adverse outcomes. Coronary artery disease is
prevalent, being estimated to exceed 80% in patients older
than 80 years of age.69 Elderly patients are at higher risk for
congestive heart failure, and special considerations should
be taken during acute and long-term treatments.70 The
revised cardiac risk index stratifies patients into risk groups
and helps identify those likely to need additional cardiac
evaluation.71 Patients with minor perfusion abnormalities
undergoing low-risk surgery may not require catheteriza­
tion but should be considered for prophylactic β-blockers
and aspirin before operation. High-risk subgroups of
patients identified based on clinical risk factors and positive
noninvasive tests should undergo cardiac catheterization.
Patients with significant cardiac lesions should have defini­
tive coronary revascularization via angioplasty before large
TBSA burns are excised. The potential benefits of using
β-adrenergic blocking agents during the perioperative
period have been studied72,73 because perioperative ische­
mic events are related to an exaggerated postoperative sym­
pathetic response that leads to an increased heart rate.72,74
β-Blockade has an added advantage in burn patients:75
Severe thermal injury induces hypermetabolism that per­
sists for up to 9–12 months,63 and the resting metabolic rate
in burn patients doubles for those injuries covering greater
than 40% TBSA.62 Catecholamines are key in the initiation
of various cascades that stimulate postburn hypermetabo­
lism.76 Preventing initiation of these cascades by blocking
the action of catecholamines at the receptor level using
β-blockers such as propranolol attenuates this response and
reduces supraphysiological thermogenesis,62 tachycardia,
cardiac work, and resting energy expenditure.76
Table 36.1  Commonly Used Drugs Requiring
Decreased Doses in Elderly Patients*
Drug
Comments
Barbiturates
Should be avoided; paradoxical pharmacologic
response, often leading to restlessness,
agitation, or psychosis caused by a decreased
rate of elimination
Benzodiazepines
Increased sensitivity to pharmacologic effect;
some benzodiazepines may be metabolized
more slowly
Narcotic
analgesics
Increased sensitivity to analgesic effects:
possibly impaired clearance
Tricyclic
antidepressants
Increased incidence of cardiac and
hemodynamic adverse effects; urinary
retention and other anticholinergic effects;
decreased drug clearance
*Decreased dose due, in part, to decreased renal function in the elderly.

36  •  Care of Geriatric Patients
385
evaluation and discussion with the patient and family.
Favorable outcomes in elderly burn patients should pertain
more to relieving suffering and maintaining independence
and quality of life rather than expanding lifespan. Clear,
repeated communication between the burn team and
patients or their surrogates is critical for guiding therapy
and achieving acceptable outcomes.
Complete references available online at

Further Reading
Demling RH. The incidence and impact of pre-existing protein energy mal­
nutrition on outcome in the elderly burn patient population. J Burn Care
Rehabil. 2005;26(1):94-100.
Manktelow A, Meyer AA, et al. Analysis of life expectancy and living
status of elderly patients surviving a burn injury. J Trauma. 1989;29(2):
203-207.
McGill V, Kowal-Vern A, Gamelli RL. Outcome for older burn patients. Arch
Surg. 2000;135(3):320-325.
Pereira CT, Barrow RE, Sterns AM, et al. Age-dependent differences in
survival after severe burns: a unicentric review of 1,674 patients and
179 autopsies over 15 years. J Am Coll Surg. 2006;202(3):536-548.
Stanojcic M, Chen P, Xiu F, Jeschke MG. Impaired immune response in
elderly burn patients: new insights into the immune-senescence pheno­
type. Ann Surg. 2016;264(1):195-202.
be associated with confidentiality difficulties because they
may not want abuse reported. The priority of the examining
physician is to treat life-threatening conditions. They should
then promptly record symptoms and signs of abuse or
neglect (including photographs). Deliberately inflicted burn
injuries are best managed by a multidisciplinary team of
health care, social service, and legal professionals.80
Conclusion
Despite the remarkable reduction in mortality in burned
children over recent decades, we have not yet achieved the
same results in elderly patients. This age group still consti­
tutes a major challenge. Surgical decision making in these
patients must take into account physiological age, preburn
functional status, degree of impairment from comorbid
conditions, and clear treatment goals. No patient should be
denied an operation based on age alone because age-related
declines in organ function are predictable for the population
but not necessarily for the individual. More so, the burn
surgeon’s general mindset should be to treat geriatric
patients as aggressively as younger patients. Currently,
no “score” can improve decisions based on a thorough

385.e1
36  •  Care of Geriatric Patients
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50. Fram RY, Cree MG, Wolfe RR, et al. Intensive insulin therapy improves
insulin sensitivity and mitochondrial function in severely burned chil­
dren. Crit Care Med. 2010;38(6):1475-1483.
51. Jeschke MG, Kulp GA, Kraft R, et al. Intensive insulin therapy in
severely burned pediatric patients: a prospective randomized trial. Am
J Respir Crit Care Med. 2010;182(3):351-359.
52. Miller JT, Btaiche IF. Oxandrolone treatment in adults with severe
thermal injury. Pharmacotherapy. 2009;29(2):213-226.
53. Demling RH, DeSanti L. The rate of restoration of body weight after
burn injury, using the anabolic agent oxandrolone, is not age depen­
dent. Burns. 2001;27(1):46-51.
54. Wolf SE, Thomas SJ, Dasu MR, et al. Improved net protein balance,
lean mass, and gene expression changes with oxandrolone treatment
in the severely burned. Ann Surg. 2003;237(6):801-811.
55. Ferrando AA, Chinkes DL, Wolf SE, et al. A submaximal dose of
insulin promotes net skeletal muscle protein synthesis in patients with
severe burns. Ann Surg. 1999;229(1):11-18.
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24. Demling RH. The incidence and impact of pre-existing protein energy
malnutrition on outcome in the elderly burn patient population.
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25. Kagansky N, Berner Y, Koren-Morag N, et al. Poor nutritional habits
are predictors of poor outcome in very old hospitalized patients. Am J
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tality and cardiovascular morbidity after noncardiac surgery. N Engl J
Med. 1997;336(20):1452.
73. Wallace A, Layug B, Tateo I, et al. Prophylactic atenolol reduces post­
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75. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on
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76. Norbury WB, Herndon DN, Branski LK, Chinkes DL, Jeschke MG.
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sive insulin therapy is associated with reduced infectious complica­
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57. Demling RH, DeSanti L. Oxandrolone, an anabolic steroid, signifi­
cantly increases the rate of weight gain in the recovery phase after
major burns. J Trauma Acute Care Surg. 1997;43(1):47-51.
58. Jeschke MG, Finnerty CC, Suman OE, et al. The effect of oxandrolone
on the endocrinologic, inflammatory, and hypermetabolic responses
during the acute phase postburn. Ann Surg. 2007;246(3):351-362.
59. Branski LK, Herndon DN, Barrow RE, et al. Randomized controlled
trial to determine the efficacy of long-term growth hormone treat­
ment in severely burned children. Ann Surg. 2009;250(4):514.
60. Jeschke MG, Finnerty CC, Kulp GA, et al. Combination of recombinant
human growth hormone and propranolol decreases hypermetabolism
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386
Surgical Management of
Complications of Burn Injury
OMAR NUNEZ LOPEZ, FREDRICK J. BOHANON, RAVI S. RADHAKRISHNAN, and
DAI H. CHUNG
37 
Burns and Trauma
Although the overall incidence of combined burn and trau­
matic injury is low, the mortality is nearly twice that of
burns without associated trauma.1,2 A retrospective study
examined upward of 24,000 patients with burn, trauma,
or combined injuries and found the overall incidence of
combined burn and trauma rate to be low (3.8%),3 consis­
tent with the National Trauma Data Bank and National
Burn Repository data. There was no difference in length of
hospital stay, injury severity scores, or mortality among
burn or trauma patients alone. However, inhalational
injury, length of stay, and mortality in patients suffering
from combined injuries were significantly increased (Table
37.1). This increase in mortality was seen despite similar
burn size, demonstrating the additive effects of trauma and
burns in these patients.3 In particular, approximately 24%
of military burns are associated with concurrent traumatic
injuries, compared to the 2–7% of burn/trauma injuries
found in civilians in the same study.4 In order of frequency,
injured organ systems include musculoskeletal, head and
neck, abdominal, thoracic, and genitourinary. Industrial
accidents, attempts to escape house fires, explosions, and
electrical burns with falls account for the majority of other
victims. High-voltage electrical burns rarely occur at
ground level and are often accompanied by falls resulting
in spinal cord injuries, solid organ injury, intracerebral
hemorrhage, and multiple fractures, including vertebral,
rib, pelvic, and long bone fractures.
PRIMARY ASSESSMENT
The shocking appearance of the burn injury may unduly
shift attention away from the other seemingly underwhelm­
ing injuries in patients with combined trauma, resulting in
potential delays in diagnosis. The initial assessment of a
trauma patient, including burn victims, should focus on
airway, breathing, and circulation according to the ATLS
guidelines. With the exception of respiratory compromise
secondary to circumferential chest burns, the burn injury
itself is usually not immediately life-threatening. Inhala­
tional injury is common in burn patients. Some of the
common signs of inhalational injury include singed nasal
and facial hair, erythematous oropharynx, cough, stridor,
and carbonaceous sputum. Asphyxia can be seen with
carbon monoxide, for which pulse oximetry is an unreliable
measure of oxygenation. Intubation or a surgical airway is
Introduction
Various surgical complications can occur in burn patients
resulting from pathologic progression of the burn injury
itself or from iatrogenic etiologies. Multiple organ system
injuries can exist that require both a thorough assess­
ment and expeditious management according to advanced
trauma life support (ATLS) guidelines. Patients with large
(>30% of the total body surface area [TBSA]) burns gen­
erally require a prolonged hospital stay with numerous
debridement and skin grafting procedures that can be
complicated by wound infection and subsequent graft
failure.
Burn patients are at risk for potential surgical complica­
tions involving multiple organ systems, particularly the
gastrointestinal (GI) tract. Such complications include
stress gastritis and ulceration, acalculous cholecystitis,
superior mesenteric artery (SMA) syndrome, and acute
pancreatitis. In this patient population, the cause for occult
systemic sepsis is frequently attributed to GI sources. Nec­
rotizing enterocolitis (NEC) is a serious GI tract complica­
tion in burn patients, representing a phenomenon of
transient ischemia–reperfusion injury to the gut. It can pro­
gress to full-thickness necrosis of involved segments, perfo­
ration, and rapid clinical decline.
Abdominal compartment syndrome (ACS) can occur
during the acute phase of massive fluid resuscitation in
severely burned patients. Based on determination of
increased intra-abdominal pressures (designated as “com­
partment syndrome”) and additional physiologic parame­
ters, a decompressive laparotomy may be necessary to
prevent further end-organ damage. A major burn signifi­
cantly affects hemodynamics, and invasive monitoring may
be necessary. As a consequence, catheter-related complica­
tions, such as distal limb ischemia and catheter-associated
sepsis, can be seen with both arterial and venous vascular
access. Prolonged intravascular manipulation secondary to
the need for access predisposes to septic thrombophlebitis,
central line-associated bloodstream infections (CLABSI),
and poor outcomes.
Because of delays in diagnosis and treatment, there is a
high risk of nonthermal complications in burn patients. As
such, these secondary and sometimes fatal complications
demand immediate recognition and treatment. This chapter
reviews the frequently encountered, surgical, nonthermal
complications in burn patients with respect to diagnosis
and management.

37  •  Surgical Management of Complications of Burn Injury
387
warranted when significant respiratory distress exists. The
inhalational injury can progress rapidly over hours such
that an initial chest radiograph and arterial blood gas may
be normal. Smoke inhalation induces a multitude of physi­
ologic changes that result in increased vascular permeabil­
ity and pulmonary edema, infiltration by leukocytes, and
bronchorrhea.
Once the airway has been secured, attention should focus
on the rest of the primary assessment. Third-degree cir­
cumferential chest burns can impair respiratory mechanics
and require escharotomy to release the constrictive eschar.
This should be performed in a sterile manner with incisions
extending from the clavicle to the costal margin in the ante­
rior axillary line bilaterally and may be joined by transverse
incisions. The more common thoracic injuries, such as
pneumothorax and hemothorax, should be managed as
they would be in any other blunt or penetrating thoracic
injury. However, because burns carry such a high risk of
infection, thoracostomy tubes should be placed away from
burned skin whenever possible to reduce the risk of infec­
tious complications such as empyema. Finally, adequate
circulation should be assessed. Pericardial tamponade
resulting from a heavy impact to the anterior chest wall can
be detected by focused assessment with sonography for
trauma (FAST) examination and managed with pericardio­
centesis or a pericardial window. Myocardial dysfunction
may be encountered, especially with electrical injuries, and
dysrhythmias should be managed accordingly. If central
venous access is necessary, it should similarly be placed
away from burned tissue when possible.
ASSOCIATED INJURIES
Burn victims frequently present with concomitant trauma
injuries. Bone fractures are the most common associated
injuries; in these cases, multidisciplinary management is
mandatory. Fractures anatomically distant to the burned
area can be treated with reduction and/or casting, as indi­
cated. In addition, open fractures are preferably treated
within the first 24 hours; surgical treatment options include
irrigation, debridement of nonviable soft tissue, and inter­
nal fixation. If the injury occurs in—or the operative
incision is made through—a burned area, the wound
closure must be performed to the level of the fascia. Addi­
tional considerations in the treatment of fractures in burned
patients include characteristics of the fracture (stability,
displacement, and complexity), need of grafting of the
burned area, wound care, and prompt initiation of physical
therapy.
A complete physical evaluation is needed in all patients;
the cervical spine should be stabilized until spinal injuries
have been ruled out. When intracranial pressure (ICP)
monitoring is indicated, placement of the ICP monitor is
preferably done through a nonburned area of the scalp.
Severe burn injury may mask intra-abdominal injuries
that may have devastating complications due to the delay
in diagnosis. Furthermore, hemodynamic fluctuations sec­
ondary to intra-abdominal injuries may be overshadowed
by the massive fluid shifts and inflammatory response fol­
lowing thermal injury. If an intra-abdominal injury is sus­
pected, diagnosis and treatment modalities that are used
in nonburned trauma patients should be utilized. Lapa­
roscopy may be a useful approach for the delineation of
intra-abdominal injuries but achieving adequate peritoneal
insufflation may be difficult with the presence of signifi­
cant abdominal eschar. If laparotomy is indicated, wound
dehiscence is a known complication regardless of burn
wound location. Retention sutures or alternative methods
of abdominal wall closure should be considered when
there is increased tension when closing the abdomen. Fre­
quently, ACS may develop in the massively burned patient
that may require emergent laparotomy and temporary
wound closure.
Vascular injuries also present with a delay in diagnosis in
the presence of large burned areas, anasarca, hypotension,
and compartment syndromes. The assessment of vascular
injuries includes the routine use of Doppler ultrasound and
ankle-brachial index (ABI). Both of these modalities have
their limitations in areas of significant burned or edema­
tous skin. Computed tomography (CT) angiography is a
highly sensitive and specific method useful to diagnose vas­
cular injuries in burn patients.5
Gastrointestinal Tract
Complications
Although the superficial effects of burn injuries are often
striking, the systemic physiological response to these inju­
ries may result in significant end-organ dysfunction and
cannot be overemphasized. Burn injuries of greater than
30% TBSA produce a physiological response leading to sys­
temic shock, hypermetabolism, and widespread immuno­
suppression.6 The combination of intravascular fluid loss,
vasoactive hormone release, catabolism, and immune dys­
function results in the development of nonthermal compli­
cations associated with burn injuries.
Physiological changes in blood flow have a dramatic
effect on organ response to injury. This has been partic­
ularly well demonstrated in the GI tract, where a com­
bination of diffuse capillary leak, hypovolemia, and the
release of vasoconstrictive agents can cause a decrease
in splanchnic blood flow.7,8 Splanchnic hypoperfusion
occurs early in the post-burn period despite adequate
Table 37.1  Increased Morbidity and Mortality With
Combined Burn and Trauma3
Trauma
(n = 22,284)
Burn
(n = 1717)
B/T (n = 92)
Age
35.1 (±27.5)
31.0 (±23.2)
40.1 (±25.4)*
TBSA
N/A
17.5% (±19.7)
20.8% (±24.4)
ISS
5.5 (±10.3)
12 (±14)
23 (±16)*
LOS (days)
5.3* (±12.2)
13.7 (±16.5)
18 (±20.8)
INH
N/A
11.0%
44.5%*
Mortality
4.3%
9.8%
28.3%*
B/T, burn/trauma; TBSA, total body surface area; ISS, injury severity score;
LOS, length of stay; INH, inhalation injury.
*P < 0.05 (Age, B/T vs. Burn; ISS, B/T vs. Burn and Trauma; LOS, B/T vs.
Trauma; Mortality, B/T vs. Burn and Trauma)

37  •  Surgical Management of Complications of Burn Injury
388
PARALYTIC ILEUS
Intestinal ileus is a commonly encountered condition fol­
lowing large burns. Multiple factors contribute to the devel­
opment of ileus in burn patients, including electrolyte
imbalances, narcotic use, prolonged immobilization,
abdominal trauma, sepsis, and surgery. In addition, proin­
flammatory cytokines and proteins that are elevated as part
of the postburn systemic response, such as interleukin (IL)-
1α, IL-6, tumor necrosis factor (TNF)-α, p38 mitogen-
activated protein kinase, and endothelins have been found
to be linked to altered intestinal permeability.15,18–21 Electro­
lyte disturbances, opioids use, prolonged immobilization,
abdominal trauma, sepsis, and surgery are factors that can
result in decreased GI motility in burn patients
Cramping abdominal pain, abdominal distension, and
intolerance to enteral feedings are the most common symp­
toms. The cause of ileus should be thoroughly evaluated
because it may represent an early indicator of systemic
sepsis and can ultimately help direct care.22 Physical exami­
nation must be performed to rule out fecal impaction and
to identify signs of peritonitis associated with more serious
complications such as acute colonic pseudo-obstruction,
also known as Ogilvie’s syndrome. The treatment of ileus
involves correction of electrolyte derangements and ade­
quate hydration; implementing these basic measures in
burn patients can be difficult due to the pathophysiologic
changes that occur after severe.12,15
OGILVIE’S SYNDROME
Ogilvie’s syndrome, first described in 1948, is characterized
by massive colonic dilation without a mechanical cause for
obstruction.23,24 This entity has been well described in
burns, with a reported incidence of 0.3%.25 Clinical presen­
tation includes insidious and progressive abdominal disten­
sion. Some patients may report a history of diarrhea prior
to the onset of distension. Nausea, vomiting, and bowel
sounds are not reliable indicators of this condition. Mild
abdominal pain can develop as distension increases.23,26
Diagnosis and management of pseudo-obstruction require
that mechanical bowel obstruction be absolutely excluded.
Radiologic studies showing colonic air in all colonic seg­
ments, including the rectum, are warranted before consid­
ering pharmacologic therapy.27,28
The goal of the management is to decompress the colon
in order to minimize the risk of colonic perforation and
ischemia, which are associated with high mortality.29
Close monitoring including serial physical examinations
and plain abdominal radiographs every 12–24 hours
to evaluate colonic diameter are recommended. Initial
management is conservative in patients without signifi­
cant abdominal pain, severe colonic distension (>12 cm),
or signs of peritonitis. In patients with cecal diameter of
greater than 12 cm or who have failed 24–48 hours of
supportive management, intravenous neostigmine can
be used. In patients who fail or who have contraindica­
tions to neostigmine, colonic decompression is indicated.30
Acute colonic pseudo-obstruction secondary to opiates
can benefit from methylnaltrexone prior to decompres­
sion.31 Endoscopic decompression is the preferred method
to decompress the colon; surgical decompression (e.g.,
cardiac output and fluid resuscitation, as demonstrated
in 40% TBSA pig models that had an early reduction in
superior mesenteric blood flow associated with intesti­
nal mucosal hypoxia, acidosis, and increased bacterial
translocation.9–11
A combination of hypoperfusion and hypermetabolic
response can lead to breakdown of the gut mucosal barrier
resulting in bacterial translocation from the gut, systemic
inflammation, and ultimately, sepsis12,13 (Fig. 37.1). Several
studies have demonstrated the association between massive
cutaneous burn injury and bacterial translocation.10,14,15
Following massive burn injury, the GI tract mucosa sus­
tains immediate atrophy, resulting in significant gut barrier
dysfunction. The increase in intestinal apoptosis does not
appear to be from mesenteric hypoperfusion alone, but is
speculated to be related to proinflammatory mediators.16
An in vivo study using a 30% TBSA rat burn model con­
firmed that there was increased bacterial translocation and
permeability to macromolecules that peaked at 18 hours
post injury, lending credence to the idea that disruption of
intestinal barrier integrity in severe burns can lead to sepsis
from bacterial translocation.17 Thus, interventions aimed
at preventing splanchnic hypoperfusion and hypermetabo­
lism may circumvent complications associated with severe
burns.
Endotoxin
bacteria
Portal
circulation
Bacteria
TNF-α, IL-1,
IL-6
Mesenteric
lymph
Burn
injury
↑ Capillary leak
↑ Vasoactive hormones
↓ Mesenteric blood flow
↑ Permeability, bacterial
overgrowth
System
circulation
TNF-α
IL-1
Fig. 37.1  Schematic representation of the role of the gastrointestinal
tract in multiorgan sepsis after cutaneous burn injury. (Adapted from
Gosain A, Gamelli RL. Role of the gastrointestinal tract in burn sepsis. J Burn
Care Rehabil 2005;26: 85–91.)

37  •  Surgical Management of Complications of Burn Injury
389
intubation, feeding intolerance, compromised mental
status, oral burns, concomitant oral and/or facial trauma,
etc.). Furthermore, the oral route, in severe burns, is not the
preferred route of alimentation because it can represent a
limiting factor for the intake of the needed calories to treat
severe catabolism.53
Nutritional therapy is preferentially delivered via the
enteral route.54 Parenteral nutrition increases the risk of
complications such as intestinal atrophy, bacterial over­
growth and translocation, liver malfunction, and catheter-
related infections.53,55
Nasogastric, nasojejunal, gastric, and jejunal feeding
tubes can all deliver enteral nutrition. In the GI tract, mal­
position, coiling, or kinking of tubes can occur anywhere
along the course of the tube, including in the pharynx,
pyriform sinus, esophagus, stomach, and duodenum.56
The presence of a nasogastric or nasoenteric tube impairs
the normal function of the lower esophageal sphincter,
making the patient more susceptible to reflux of gastric
contents. which may lead to esophagitis, esophageal
stricture, gastrointestinal bleeding, or pulmonary aspira­
tion.57 Placing feeding tubes past the pylorus has become
standard practice to minimize the risk of aspiration and
complications of enteral feeding in patients with impaired
gastric emptying. However, a meta-analysis did not find
significant differences in the incidence of pneumonia,
caloric goal achieved, or mortality between gastric and
post-pyloric tube feeding.58 Nasogastric tubes can cause
gastritis or bleeding due to chronic irritation or pressure
necrosis due to suctioning of the gastrointestinal mucosa.
Patients with bloody gastric drainage require further evalu­
ation, and, whenever possible, the nasogastric tube should
be removed.59 If tubes are left in place for long periods of
time, they can be associated with nasal alar necrosis. Fre­
quent retaping of the tube to decrease pressure at any par­
ticular point or less traumatic methods of tube fixation can
prevent this complication. Patients with prior esophageal
or gastric surgery are at risk for gastrointestinal perfora­
tion, and infants, children, and patients with facial trauma
are at risk for cribriform plate perforation and intracranial
intubation.60,61
STRESS GASTRITIS
The incidence of acute gastroduodenal ulceration in burn
patients, known as Curling’s ulcer, has decreased dramati­
cally with the introduction of aggressive fluid resuscitation,
early enteral feeding, and the administration of proton pump
inhibitors (PPIs). This condition is clinically recognized in
most cases only by the onset of upper GI bleeding, and it
was once associated with mortality rates of up to 70%. For­
tunately, with the institution of the aforementioned inter­
ventions, the occurrence of clinically significant ulcers has
decreased from 15% to 3%, as has mortality.62
Although the exact pathogenesis of Curling’s remains
unknown, the hypoperfusion, hypermetabolism, and
immune dysregulation described earlier are all implicated
in ulcer formation. Specifically, intravascular depletion
leads to mucosal ischemia and disruption of the protective
mucosal barrier. Compounded by the increased acid
production, bile reflux, and direct mucosal injury due to
the presence of intraluminal tubes, the end result is
surgical cecostomy) is performed if endoscopic decompres­
sion and pharmacologic therapy fail or if there is evidence
of perforation or signs of peritonitis. Percutaneous cecos­
tomy should be reserved for patients who are not surgical
candidates.32
ABDOMINAL COMPARTMENT SYNDROME
ACS refers to the onset of new organ dysfunction caused by
increased intra-abdominal pressure.33,34 Intra-abdominal
pressure measurements have allowed grading of ACS;
however, for clinical purposes, ACS is defined as new organ
dysfunction secondary to increased intra-abdominal pres­
sure without a strict threshold.35,36 Aggressive fluid resusci­
tation, severe burns (>30% TBSA), and sepsis increase the
risk for ACS.37–40 Secondary ACS is commonly related to the
extent of volume resuscitation. For this reason, the amount
of fluid being administered and the development of early
signs of ACS should be closely monitored.41,42 Mortality for
patients who have progressed to ACS ranges from 40% to
100%.36,43
Nearly all patients have a tense and distended abdomen;
however this clinical finding is a poor predictor of ACS.44,45
Oliguria and increased ventilator requirements are common
in patients with ACS. Tachycardia, hypotension, jugular
venous distension, and peripheral edema can also be found.
Imaging studies are not helpful to diagnose ACS; however
expected findings include decreased lung volumes, atelecta­
sis, or elevated hemidiaphragms in chest radiographs. Com­
pression of the inferior vena cava, massive abdominal
distension, renal compression or displacement, bowel wall
thickening, and bilateral inguinal herniation can be dem­
onstrated in CT of the abdomen.46
Management of ACS consists of supportive care and sur­
gical abdominal decompression. However, in patients with
abdominal burns, mechanical limitations due to burn
eschars can be a significant contributing factor for increased
intra-abdominal pressure; thus early escharotomy is advo­
cated.47,48 Supportive care includes measures that can
decrease intra-abdominal pressure, such as evacuation of
intraluminal contents (e.g., nasogastric and rectal drain­
age) and improvement of abdominal wall compliance
(supine positioning without head elevation, adequate pain
control and sedation, chemical paralysis).39,49
Surgical decompression is the definitive management of
ACS; however a specific threshold for decompression has
not been defined. Several factors can be considered to decide
the need for this intervention, including progression of
organ dysfunction after supportive measures, intra-
abdominal pressure of greater than 25 mm Hg, or abdomi­
nal perfusion pressure (difference between the mean arterial
pressure and the intra-abdominal pressure) of less than
50 mm Hg.50,51 Decompression is achieved by making a
midline incision through the linea alba to open the abdomi­
nal cavity. A temporary abdominal wall closure is often used
to maintain an open abdomen.52
Complications Associated With Feeding Tubes
Adequate nutrition is one of the major determining factors
of success in the treatment of severe burns. Exclusive oral
feeding is often a nonviable option due to multiple factors
frequently observed in burn patients (e.g., endotracheal

37  •  Surgical Management of Complications of Burn Injury
390
cholecystitis. Mortality following perforation or gangrenous
emphysema is reported to be as high as 65%, but early diag­
nosis and intervention may reduce the likelihood of severe
complications significantly, as reflected by the reduction in
mortality to 7%.69
Ultrasonography is usually the first diagnostic study per­
formed when cholecystitis is suspected; gallbladder wall
thickening (>3 mm), pericholecystic fluid, mucosal slough­
ing, gallbladder distension, emphysematous gallbladder,
and frank perforation of the gallbladder with abscess forma­
tion are findings suggestive of AAC.68 When the diagnosis
is unclear despite ultrasonography, a hepato-iminodiacetic
acid (HIDA) scan can confirm the diagnosis. The specificity
of HIDA scan for AAC has been reported as high as 100%,
with a sensitivity as low as 67%.70 CT scanning can also be
used to diagnose AAC. Findings suggestive of AAC include
absence of gallstones or sludge, gallbladder wall thickening,
subserosal halo sign (intramural lucency), pericholecystic
fat infiltration, pericholecystic fluid, intramural gas, and
gallbladder distension;68 the accuracies of CT scanning and
ultrasonography are similar.71
The treatment of AAC consists of initiation of antibiotics
with Gram-negative and anaerobes coverage after collect­
ing blood cultures, and either cholecystectomy or place­
ment of a cholecystostomy tube. Prompt treatment is
needed or gallbladder gangrene can develop and result in
gallbladder perforation. Delayed treatment carries mortal­
ity rates as high as 75%.72 Cholecystectomy is the definitive
therapy for AAC, with drainage of associated abscesses
often being required. Due to the significant inflammatory
process, the laparoscopic approach is challenging, with a
higher risk of bile duct and vascular injuries. However, it is
appropriate to attempt a laparoscopic approach and convert
to open if necessary. For extremely ill patients for whom
surgical intervention is not an option, ultrasound-guided
percutaneous cholecystostomy should be considered;
success rates range from 56% to 100%. Patients treated
with a cholecystostomy tube should improve rapidly, usually
within 24 hours. Patients with AAC who fail to improve or
worsen require cholecystectomy.73-75
PANCREATITIS
Acute pancreatitis is an underrecognized complication fol­
lowing thermal injury. Increased serum pancreatic enzymes
have frequently been associated with burns, but the non­
specific symptoms, such as epigastric pain radiating to the
back, are often overlooked. Reported rates of post-burn pan­
creatitis range from 0.05% to 40%.76,77 Despite its rarity,
pancreatitis is associated with increased mortality, as sur­
vival rates were reported to be only 69% compared to 87%
in burn patients unaffected by pancreatitis. Management
for acute pancreatitis in the burn patient is similar to the
management in nonburn patients. Treatment includes sup­
portive care, bowel rest, fluid resuscitation, and parenteral
nutrition. Abdominal ultrasound should be performed to
rule out gallstone disease. Occasionally, a more detailed
workup with an abdominal CT scan is necessary to identify
complications such as pseudocyst formation, pancreatic
necrosis, or pancreatic abscess. Operative intervention is
rarely indicated.
gastroduodenal ulceration.63 Recent studies have proposed
an additional mechanism of stress ulcer formation second­
ary to the systemic production of reactive oxygen species
(ROS) in response to stress. Studies have confirmed that the
activation of ROS-producing pathways, such as p38 MAPK,
results in gastroduodenal ulcer formation.64
An effective approach in the prevention of stress gastritis
in burn patients is early enteral feeding. It has been pro­
posed that this may be because of dilutional alkalinization
or because enteral feeds provide the energy required for
mucosal cell resiliency despite ischemia. Studies have
shown that intraluminal glucose provides significant pro­
tection to ischemic cells of the small intestine and gastric
mucosa.62 Additionally, aggressive fluid resuscitation along
with H2-receptor antagonists or PPIs have proved effective
against development of stress gastritis. However, once a
stress ulcer is established, many of the same treatments just
described are initiated. Aggressive medical therapy, typi­
cally involving a high-dose continuous PPI infusion, must
be started in patients with massive burns who develop hem­
orrhage. The PPIs have been demonstrated to reduce
instances of rebleeding and the need for subsequent surgery
and/or endoscopic treatment.
Endoscopic control of bleeding is indicated as a first
approach for patients with gastric bleeding. Specific surgi­
cal indications include massive bleeding (>2.5 L in adults,
>50% blood volume in children per 24 hours), ongoing
uncontrolled blood loss, and evidence of a perforated
viscus. Operative repair of ulcers is rarely necessary, the
simplest approach consists of a long anterior gastrotomy
with oversewing of bleeding sources. In patients who are
hemodynamically stable after ligation of actively bleed­
ing ulcers, a vagotomy and pyloroplasty can be added.65
Although Curling’s ulcers are far less common than in
the past, they remain a potential risk to all burn-injured
patients.
ACALCULOUS CHOLECYSTITIS
Acute acalculous cholecystitis (AAC) is a rare complication
of burn injury found in an estimated 0.4–3.5% of burned
patients, but it may result in significant morbidity if not
quickly recognized and appropriately treated.66 Patients
with extensive burns (>40% TBSA), multiple transfusions,
sepsis, dependence on total parenteral nutrition (TPN), and
a history of narcotics use are particularly susceptible to the
development of AAC. Age, number of packed red blood cell
transfusions, and duration of ventilatory support are inde­
pendent predictive factors for the development of AAC in
severely burned patients.67 Proposed etiologies of AAC
include bile stasis, hypoperfusion causing gallbladder ische­
mia, cystic duct obstruction, and sepsis.68 Patients with
heavy narcotic use for pain control or who are dependent
on TPN tend to experience bile stasis. Hypoperfusion affects
circulating vasoactive mediators and local tissue perfusion,
leading to local ischemia of the gallbladder wall, inflamma­
tion, gangrene, and perforation.
AAC commonly presents with fever, right upper quad­
rant tenderness, leukocytosis, and elevated liver enzymes.
AAC is a surgical emergency because patients may rapidly
develop complications, including perforation or gangrenous