© Springer Nature Switzerland AG 2021

M. G. Jeschke et al. (eds.)Burn Care and Treatmenthttps://doi.org/10.1007/978-3-030-39193-5_1

Initial Assessment, Resuscitation, Wound Evaluation, and Early Care

Shahriar Shahrokhi¹  

(1)

Division of Plastic and Reconstructive Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

Shahriar Shahrokhi

Email: shar.shahrokhi@sunnybrook.ca

Keywords

Injured PatientAirway managementInhalation injuryBurn ResuscitationCompartment SyndromeHypertonic SalineAlbuminVitamin CFluid CreepAbdominal Compartment SyndromePrehospital Care

1 Initial Assessment and Emergency Treatment

The initial assessment and management of a burn patient begins with prehospital care. There is a great need for efficient and accurate assessment, transportation, and emergency care for these patients in order to improve their overall outcome. Once the initial evaluation has been completed, the transportation to the appropriate care facility is of outmost importance. At this juncture, it is imperative that the patient is transported to facility with the capacity to provide care for the thermally injured patient; however, at times patients would need to be transported to the nearest care facility for stabilization (i.e., airway control, establishment of IV access).

Once in the emergency room, the assessment as with any trauma patient is composed of primary and secondary surveys (Box 1). As part of the primary survey, the establishment of a secure airway is paramount. An expert in airway management should accomplish this as these patients can rapidly deteriorate from airway edema.

Even though, early and appropriate intubation is essential in the overall management of thermal injured patients, recent publication by Romanowski (2016) demonstrated that one third of patients transferred to burn centers are unnecessarily intubated [1]. In addition, the study by Ching and colleagues (2014) demonstrated that the traditional findings of singed nasal hairs, carbonaceous sputum, and facial burns are unreliable evidence for inhalation injury. Thus, they concluded that these physical findings are not absolute indicators for intubation and should be interpreted as one component of the history and physical [2].

In order to determine those that would benefit from securing an airway via intubation, one needs to consider the following:

Ability to protect their airway.

GCS level.

Presence of deep facial burns.

Inhalation injury (history of enclosed space, loss of consciousness, presence of toxic fumes).

Need for massive and ongoing resuscitation (typically reserved for TBSA >20–30%).

Once this initial assessment is complete, the disposition of the patient will be determined by the ABA criteria for burn center referral [3] (Table 1).

Table 1

ABA criteria for referral to a burn centera

aFrom Ref. [3]

In determining the percent total body surface area (%TBSA) burn, the rule of nines or the palm method (the surface area of the patient’s palm excluding the fingers = 0.5% TBSA) can be used; however, they are not as accurate as the Lund and Browder chart (Fig. 1). Attention must be paid to exclude superficial burns (First-degree burns) from the TBSA calculation.

Fig. 1

Lund and Browder chart for calculating %TBSA burn

More recently, the use of technology in the form three-dimensional software has proven to be more accurate than the conventional two-dimensional methods [4, 5].

Assessment of burn depth can be precarious even for experts in the field. There are some basics principles, which can help in evaluating the burn depth (Table 2). Always be aware that burns are dynamic and burn depth can progress or convert (due to a secondary insult) to becoming deeper. Therefore, frequent reassessment in the first 72 h is important in establishing burn depth.

Table 2

Typical clinical appearance of burn depth

Given that even burn experts are only 64–76% [6] accurate in determining burn depth, there has been an increased desire to have more objective method of determining burn depth, and therefore, technologies have been and continue to be developed and utilized in this field. Out of these various tools, laser doppler imaging (LDI) has garnered the most following. These are summarized in the following Table 3 [7]:

Table 3

Techniques used for assessment of burn deptha

aFrom Jaskille et al. [7]

Once the initial assessment and stabilization are complete, the physician needs to determine the patient’s disposition. Those that can be treated as outpatient (typically small, superficial, superficial partial-thickness burns in healthy individuals for whom outpatient care and suitable follow-up can be arranged) will need their wounds treated appropriately and discharged. There are many choices for outpatient wound therapy, and the choice will be mostly dependent on the availability of products and physician preference/knowledge/comfort with application. Table 5 summarizes some of the available products.

The thermally injured patients who are transferred to burn centers for treatment will be discussed in the next section on fluid resuscitation and early management.

Box 1 Primary and Secondary Survey

Primary survey:

Airway:

Preferably #8 ETT placed orally.

Always be prepared for possible surgical airway.

Breathing:

Ensure proper placement of ETT by auscultation/X-ray.

Bronchoscopic assessment for inhalation injury.

Circulation:

Establish adequate IV access (large bore IV placed peripherally in non-burnt tissue if possible, central access would be required but can wait).

Begin resuscitation based on the Parkland formula.

Secondary survey:

Complete head to toe assessment of patient.

Obtain information about the patient’s past medical history, mediations, allergies, tetanus status.

Determine the circumstances/mechanism of injury.

Entrapment in closed space.

Loss of consciousness.

Time since injury.

Flame, scald, grease, chemical, electrical.

Examination should include a thorough neurological assessment.

All extremities should be examined to determine possible neurovascular compromise (i.e. possible compartment syndrome) and need for escharotomies.

Burn size and depth should be determined at the end of the survey.

2 Fluid Resuscitation and Early Management

2.1 Fluid Resuscitation

As mentioned previously, patients with <10% TBSA burn do not require fluid resuscitation. However, burn encompassing >15% TBSA will require fluid resuscitation. Several formulas have been proposed for the resuscitation of the burn patient, all requiring crystalloid infusion with or without the addition of colloids. However, the mainstay of fluid resuscitation remains the Parkland formula:

While the Parkland formula provides with the total amount for 24 h and starting level for initiation of resuscitation, it is not absolute. The fluid resuscitation should be guided by physiological parameters and laboratory findings to prevent under/over-resuscitation. The goals of resuscitation should be restoration of intravascular volume, maintenance of organ perfusion and function, while preventing burn wound conversion.

In resuscitating a thermally injured patient, one must be cognizant of the three components of burn shock: cardiogenic shock, distributive shock, and hypovolemic shock. Each has a fundamental role in the pathophysiology of the burn patient and cannot be treated in a similar fashion. The myocardial depressant effects of inflammatory mediators post-burn injury has been well documented [8–12]. This typically last up to 36 h following which the patients’ cardiac function typically becomes hyper-dynamic.

Therefore, during the initial phase of burn resuscitation, the physician not only has to restore the patients’ intravascular volume but also might need to consider inotropic agents to aid the myocardial dysfunction.

2.2 Endpoint of Burn Resuscitation

Traditionally, the endpoints of resuscitation of a thermally injured patient have been determined via physiological parameters; however, the use of global end-organ functions such as urinary output, heart rate, and blood pressure is inadequate in determining the adequacy of resuscitation [13]. The addition of measurements of base deficit and lactate has become commonplace as markers of adequate resuscitation; however, it is difficult to ascertain their importance as markers of burn resuscitation, as there are multiple episodes of ischemia and reperfusion injury which result in fluctuating levels of serum lactate and base deficit [14]. In some studies, it appears that elevated lactate and base deficit levels on admission do correlate with overall organ dysfunction and mortality; however, there is no absolute number or threshold, which determines non-survivability [15–18]. Moreover, further studies have concluded that elevated lactate level is an independent risk factor for mortality [19–21].

Since at this juncture, there is no ideal method for determining the endpoints of resuscitation, some researchers have begun to adopt new techniques. Light et al. demonstrated the use of tissue pCO2 monitoring to better correlate with tissue perfusion; however, its use is not commonplace as yet [14]. Consideration should be given to use of dynamic echocardiography, pulse contour measurements, PiCCO monitor as adjuncts to overall physiological parameters for resuscitation [22–25].

Clinical assessment is outdated; the use of resuscitation markers (BD and lactate) is flawed; however, there are some which correlate well with overall risk of organ dysfunction and mortality. Newer techniques are under examination but have not gained wide acceptance for use. In conclusion, until a widely accepted method has been validated, care must be taken to incorporate as many tools as possible to determine adequate resuscitation.

2.3 Fluid Over-Resuscitation and Fluid Creep

The mainstay of fluid resuscitation remains crystalloid solutions (mainly Ringer’s lactate). However, consideration should be given to colloids if the resuscitation volumes are far exceeding those set out by the Parkland calculation as not to endure the consequences of fluid creep [26] such as:

Abdominal compartment syndrome (ACS) [26–30].

Extremity compartment syndrome [31].

Respiratory failure and prolonged intubation [32].

Pulmonary edema and pleural effusions [32].

Orbital compartment syndrome [33].

One of the more dire consequences of fluid creep is ACS, with resultant mortality of 70–100% [27–31, 34–37]. Some of the strategies that can be utilized to decrease risk of ACS or prevent intra-abdominal hypertension (IAH) progressing to ACS in a burn patient are:

Vigilant monitoring of fluid resuscitation—decrease fluid volumes as quickly as possible.

Monitor intra-abdominal pressures in all patients with ≥30% TBSA burn.

Perform escharotomies on full-thickness torso burns and proceed to a checkerboard pattern if inadequate.

Consider aggressive diuresis if evidence of over-resuscitation.

Consider neuromuscular blockade to alleviate abdominal muscle tone.

Should all the above strategies fail in lowering the intra-abdominal pressure, the definitive solution is a decompressive laparotomy with aforementioned mortality of up to 100% [27–31, 34–37]. As a result, many have looked at other modes of resuscitation beyond the use of crystalloid solutions.

2.4 Role of Colloids, Hypertonic Saline, and Antioxidants in Resuscitation

2.4.1 Colloids

As mentioned previously, the initial resuscitation is accomplished with mainly crystalloids. This is mainly as the consequence of burn pathophysiology, whereby there is a significant increase in the permeability of capillaries post-thermal injury with resultant shift of fluid into the interstitial space [38–43]. This increase permeability appears to resolve in 8–12 h post-injury. Typically, colloids are not recommended in the initial 12 h phase of resuscitation (however, there is no clear evidence as to the exact timing for initiation of colloids).

The colloid of choice has typically been albumin (5% concentration), given as an infusion to decrease the crystalloid requirements. There is some evidence that use of colloids in the resuscitation of the thermally injured patient does normalize the I/O ratios; however, the effect on morbidity and mortality is unknown at this time [44, 45]. In critical care literature, which typically excludes the burn patients, the studies have shown that the use of colloids is safe with no overall benefit to the patient [46], and the Cochrane review in 2011 concluded that there is no evidence that albumin reduces mortality in patients with hypovolemia, burns or hypoproteinemia. For patients with burns or hypoproteinemia, there is a suggestion that albumin administration may increase mortality [47]. More recent meta-analysis by Navickis and colleagues (2016) concluded that the optimal timing, dose, and patient population for albumin use remains unclear [48]. This meta-analysis demonstrated that the scope and quality of available evidence is limited, and new multicenter clinical trials should be conducted [48]. Therefore, despite the extensive of use of albumin in burn resuscitation, there is paucity of high-quality evidence for its use, and the overall benefit remains controversial.

2.4.2 Hypertonic Saline

The role of hypertonic saline in burn resuscitation has been studied greatly with variable results. In recent years, there has been a shift in thinking in the use of hypertonic saline. Rather than using hypertonic saline as the sole resuscitative fluid with goals of reducing fluid requirements, it has been studied in the context of decreasing the inflammatory response and bacterial translocation and therefore infectious complications [49–51].

2.4.3 Antioxidants: High-Dose Vitamin C

It is well documented that following thermal injury, there is an increase in capillary permeability leading to edema. The initial studies conducted by Tanaka et al. and Matsuda et al. indicated the lower water content of burn wounds with high-dose vitamin C infusion, with decreased overall resuscitation fluid requirements [52–55]. More recently, studies have demonstrated that resuscitation with high-dose vitamin C reduces the endothelial damage post-thermal injury [56, 57], with decrease in overall fluid volumes administered with no increase in morbidity or mortality [57, 58].

In summary, the resuscitation of the burn patient is complex and requires the use of all tools available. It can no longer be the domain of crystalloid resuscitation without consideration for colloids, hypertonic saline, and high-dose vitamin C along with other antioxidants. All aspects of burn shock require treatment (not just the hypovolemic component), which might require the early use of vasopressors and inotropes. Finally, the end goals of resuscitation need to be better monitored to assess the effectiveness of the resuscitation and ensure improved patient outcomes.

3 Evaluation and Early Management of Burn Wound

3.1 Evaluation of Burn Depth

The evaluation of the burn wound is of utmost importance, and expert clinicians have been known to be incorrect in their assessment up to 30% of the time. As previously indicated, multiple modalities have been examined to determine their efficacy and possible role in the determination of the burn depth (Table 3), but none has replaced the clinical examination as gold standard.

In general, superficial (first-degree) burns are of minimal concern. They only involve the epidermis with erythema and no blisters and do not require medical attention. Partial-thickness (second-degree) burns and beyond are those that will require medical attention. Partial-thickness burns are divided into superficial and deep. Their clinical characteristics are summarized in Table 4.

Table 4

Clinical appearance of dermal and full-thickness burns

The depth of the burn determines not only the requirement for admission but also the management—operative versus conservative. The ideal treatment for all burns, which will not heal between 14 and 21 days, is to have operative excision and skin grafting. All others can be treated conservatively. The conservative management of burns includes appropriate wound care and therapy for maintenance of range of motion and overall function.

3.2 Choice of Topical Dressings

There are various topical agents that are available for management of burns. Typically, the topical management of deep burns requires an antimicrobial agent to minimize bacterial colonization and hence infection. For superficial burns, the goal of the topical agent is to reduce environmental factors causing pain and provide the appropriate environment for wound healing. Table 5 summarizes some of the agents available for topical treatment of burns, and the choice of agent is dependent on their availability and the comfort and knowledge of the caregivers.

Table 5

Topical therapy for treatment of cutaneous burns

The choice of burn dressing needs to take into account the following factors:

Eliminate the environmental factors causing pain.

Act as barrier to environmental flora.

Reduce evaporative losses.

Absorb and contain drainage.

Provide splinting to maintain position of function.

Should not retard wound healing.

The goals of topical antimicrobial therapy for deep dermal and full-thickness burns:

To delay/minimize wound colonization.

Have the ability to penetrate eschar.

Have activity against common pathogens.

S. aureus, Proteus, Klebsiella, E. coli, Pseudomonas.

Have low toxicity (minimal systemic absorption).

3.3 Escharotomy

In evaluation of wounds, consideration also needs to be given for possible need for escharotomy (Fig. 2). All deep circumferential burns to the extremity have the potential to cause neurovascular compromise and therefore benefit from escharotomies. The typical clinical signs of impaired perfusion in the burned extremity/hand include cool temperature, decreased or absent capillary refill, tense compartments, with the hand held in the claw position, and the absence of pulses is a late sign [74]. On occasion, non-circumferential deep burns or circumferential partial-thickness burns might require a prophylactic escharotomy as the patient might require large resuscitation volumes due to overall injury or the inability to perform serial reassessments [74].

Fig. 2

Examples of escharotomies: (a) Checkerboard escharotomy of abdomen (b) escharotomy of the arm along medial lateral line (c) escharotomy of the hand between the second and third and fourth and fifth metacarpal bones (d) escharotomy of the leg along the medial and lateral lines

Escharotomies of the extremities are performed along the medial and lateral lines, with the extremity held in the anatomic position. For the hand, the escharotomy is performed along the second and fourth metacarpals, and for the fingers, care is taken to prevent any injury to the neurovascular bundle; therefore, escharotomies are typically not performed along the ulnar aspect of the thumb or the radial aspect of the index finger [74–76].

3.4 Operative Management

Once the thermally injured patient has been admitted, resuscitated, all wounds assessed, and managed appropriately with escharotomy and appropriate topical dressings, the surgeon needs to determine the most efficient course of action in regard to excision of burn and coverage. This needs to be undertaken as soon as the patient is fully resuscitated, usually within 72 h post-injury.

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