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resistant staphylococci are fortunately still rare in burn patients Increasingly, sterile multiple organ failure is regarded as a leading cause of death among severely burned patients
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The goal of therapy after fluid resuscitation is rapid and stable closure of the wound Wounds that will not heal spontaneously in 7 10 days (ie, deep second-degree or third-degree burns) are best treated by excision and autograft; otherwise, granulation and infection may develop, and the quality of the skin in regenerated deep partial thickness burns is marginal because of the very thin dermis that emerges Biosynthetic skin replacements, especially Integra, a dermal replacement template consisting of bovine collagen, chondroitin-6-sulfate, and a silastic sheet, are routinely used when autologous skin grafts are in short supply (usually when total burn area exceeds 40%) Even in the case of contaminated fields with high bacterial counts, Integra has found a clinical niche, although graft survival is less than that with autologous grafts Cultured allogeneic keratinocyte grafts for more superficial injuries, have provided alternatives With severe burns, skin substitution with cultured grafts can be lifesaving However, although the replaced dermis does have nearly normal histologic dermal elements, there are no adnexal structures present and very few, if any, elastic fibers
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As edema fluid accumulates, ischemia may develop under any constricting eschar of an extremity, neck, or trunk if the fullthickness burn is circumferential Escharotomy incisions through the anesthetic eschar can save life and limb and can be performed in the emergency department or operating room
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When high-voltage electrical injury occurs, extensive deep tissue necrosis should be suspected Deep tissue necrosis leads to profound tissue swelling Because deep tissue compartments in the arms and legs are contained by unyielding fascia, these compartments must be opened by surgical fasciotomy to prevent further soft tissue, vascular, and nerve death Electrical burn injuries remain the most devastating and underrecognized burn injuries, causing amputations (often because of unrecognized compartment syndromes) and acute renal failure, resulting in part from rhabdomyolysis Creatine kinase levels are usually elevated in patients with severe electrical burns (and constitute a negative prognostic indicator) Severe (often underrecognized) muscle necrosis due to electrical burns may occur in the absence of significant skin burns
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Burn patients require extensive support An attempt must be made to maintain normal core body temperature (by maintaining environmental temperature at or above 30 C) in patients with burns over more than 20% of total body surface area, since the hypermetabolic state of burns is exacerbated by subnormal temperatures Respiratory injury, sepsis, and multiorgan failure are common Enteral feedings may be started once the ileus of the resuscitation period has resolved, usually the day after the injury There is often a markedly increased metabolic rate after burn injury, due in large part to whole body synthesis and increased fatty acid substrate cycles If the patient does not tolerate low-residue tube feedings, total parenteral nutrition should be started without delay through a central venous catheter Contrary to conventional teachings, data indicate that most patients can be fed adequately with energy equal to 100% to 120% of estimated basal energy expenditure (BEE) A useful guide is to provide 25 kcal/kg body weight plus 40 kcal per percent of burn surface area Early aggressive enteral nutrition reduces infections, noninfectious complications, length of hospital stay, impaired healing, and mortality Anticatabolic treatments such as blockade, growth hormone, insulin, oxandrolone, and synthetic testosterone have been advocated Occasionally, acute respiratory distress syndrome or respiratory failure unresponsive to maximal ventilatory support may develop in burn patients In addition, the incidence of venous thromboembolism in the lower extremities is high among burn patients Duplex ultrasonography is the best method for identifying venous thromboembolism Early pulmonary dysfunction after severe burn injury is widely recognized It is now appar-
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