Burn/Surgical

Infections/Surgical Nutrition
Dr. Ameerah S. Mantawil
1st Year Surgery Resident
Brief Background
• Burn injury historically carried a poor prognosis. With advances in
fluid resuscitation1 and the advent of early excision of the burn
wound, survival has become an expectation even for patients with
severe burns.
• Initial evaluation of the burned patient should follow the same initial
priorities of all trauma patients and involves four crucial assessments:
• airway management,
• evaluation of other injuries,
• estimation of burn size, and
• diagnosis of CO and cyanide poisoning.
• Orotracheal intubation is the preferred method for securing the airway.
• Nasotracheal intubation may be useful for patients with associated facial
trauma when experienced providers are present, but it should be avoided
if oral intubation is safe and easy.
• Burned patients are trauma patients and evaluated with a primary
survey in accordance with Advanced Trauma Life Support guidelines.
• Most burn resuscitation formulas estimate fluid requirements based on
burn size measured as a percentage of TBSA (%TBSA).
• The “rule of nines” is a crude but quick and effective method of
estimating burn size
Prognosis
• The Baux Score (mortality risk equals age plus %TBSA) was used for
many years to predict mortality in burns.
• Analysis of multiple risk factors for burn mortality has validated age
and burn size as the strongest predictors of mortality.
Resuscitation
• Parkland or Baxter formula:
• 3 to 4 mL/kg per % burn of Lactated Ringer’s, of which half is
given during the first 8 hours after burn and the remaining half is given over
the subsequent 16 hours

• The most recent American Burn Association consensus formula recommends

2 mL/kg per % burn of Lactated Ringers given the tendency toward excessive
fluid administration with the traditional formulas.
• A number of parameters are widely used to gauge burn resuscitation,
but the most common remain the simple outcomes of blood
pressure and urine output.
• MAP of 60 mmHg – ensures optimal end-organ perfusion
• Goals for urine output should be 30 mL/h in adults and 1 to 1.5
mL/kg per h in pediatric patients
• Those patients receiving higher fluid volumes were at increased risk of
complications and death.
• Common complications:
• abdominal compartment syndrome,
• extremity compartment syndrome,
• intraocular compartment syndrome, and
• pleural effusions.

Monitoring bladder pressures can provide valuable information about

development of intra-abdominal hypertension.
• The use of colloid as part of the burn resuscitation has generated much
interest over the years.
• In late resuscitation when the capillary leak has closed, colloid
administration may decrease overall fluid volumes and potentially may
decrease associated complications such as intra-abdominal hypertension.
• However, albumin use has never been shown to definitively improve
mortality in burn patients and has controversial effects on mortality in
critically ill patients. Still, many burn centers including ours continue to use
albumin as an adjunct during burn resuscitation. Attempts to minimize fluid
volumes in burn resuscitation have included study of hypertonic solutions.
Adjuncts
• High-dose ascorbic acid (vitamin C) may decrease fluid volume
requirements and ameliorate respiratory embarrassment during
resuscitation.
• Plasmapheresis has also been associated with decreased fluid
requirements and increased urine output in patients who require
higher resuscitative volumes than predicted to maintain adequate
urine output and MAP.
• Bedside ultrasound
Treatment of Burn Wound
• Silver sulfadiazine – prophylaxis rather than treating existing infection
• SSD destroys skin grafts and is contraindicated on burns or donor sites in
proximity to newly grafted areas.
• Also, silver sulfadiazine may retard epithelial migration in healing partial
thickness wounds.
• Mafenide acetate, either in cream or solution form – effective topical
antimicrobial.
• It is effective even in the presence of eschar and can be used in both treating
and preventing wound infections; the solution formulation is an excellent
antimicrobial for fresh skin grafts
Treatment of Burn Wound
• Silver nitrate – broad-spectrum antimicrobial activity as a topical
solution. The solution used must be dilute (0.5%), and prolonged
topical application leads to electrolyte extravasation with resulting
hyponatremia.
• Dakin’s solution (0.5% sodium hypochlorite solution) is an acceptable
alternative as an inexpensive topical antimicrobial
• Topical ointments such as bacitracin, neomycin, and polymyxin – for
smaller burns or larger burns that are nearly healed

• Silver-impregnated dressings are increasingly being used for donor

sites, skin grafts, and partial-thickness burns because of their potential
to avoid daily dressing changes
Surgery and Wound coverage
• Compartment Syndrome
• Escharotomies
• Early excision and grafting
• Split-thickness sheet autografts harvested with a power dermatome
• Permanent synthetic skin substitute