Derek M. Culnan

Etiology and Prevention of Multisystem Organ Failure

Abstract Anticipation, identification, and treatment of organ failure syndromes is the work of the critical care physician and is necessary for intensive care unit survival. This chapter describes organ failure syndromes during burn convalescence.

Burn Injuries of the Eye

This chapter discusses eye pathology frequently seen in the burn unit. It begins with a discussion of the relevant anatomy and histology. Eye examination in the burn unit is described, along with tips particularly applicable to critically-ill patients in the intensive care unit. The spectrum commonly-observed ocular surface disease with associated histopathological findings is described along with the predictive value of early findings such as eyelid burns and singed eyelashes. Salient features of special cases, such as electrical injury and toxic epidermal necrolysis are covered. The diagnosis and treatment of bacterial, viral and fungal corneal ulcers is discussed. Several acute and reconstructive surgical techniques that the burn surgeon may find useful for sight preservation are also described.

Treatment of Infection in Burn Patients

Abstract Burn wounds are conduits for infections. From the inciting thermal trauma to finalization of therapy, burn patients are exposed to multiple drug-resistant organisms. This chapter presents the definitions and types of infections afflicting burn patients, from cellulitis and wound infections to pneumonias and bloodstream infections. Topical and systemic antimicrobials are covered, as well as specific etiologic bacteria, fungi, and viruses. A care algorithm is elaborated, centered on source control with early surgical excision and skin grafting augmented by culture-directed antimicrobial therapy. Regardless of the etiologic organism, the best intervention for both prophylaxis and treatment of infections in the burn patient is the prompt closure of burn wounds with skin.

Significance of the Hormonal, Adrenal, and Sympathetic Responses to Burn Injury

Abstract Under cognitive stress, hormone and neurotransmitter release is conventionally thought to serve in a compensatory manner facilitating the heightened mental awareness along with metabolic and cardiovascular activity that supports rapid increases in muscular work. Thermal injury unquestionably initiates a stress response, with a magnitude proportional to the severity of the injury. However, there are important characteristics of the injury response that contrast with the fight-or-flight response. These include prolonged hormone/neurotransmitter elevation, the absence of increased muscle work limiting metabolic demand, and the presence of massive tissue injury. The second surge of stress hormones is evoked by surgical debridement and complicates the severe metabolic derangements and compromised immune capacity characteristic of the burn course during the initial 7–10 days following injury. In this chapter we present the adrenomedullary-neurotransmitter activation and actions as separate from the adrenocortical activation and actions to clarify specific responses as we currently understand them.

Care of the Burned Pregnant Patient

Abstract This chapter defines the care of severely burned obstetric patients in the rare event the burn team is faced with this complex physiologic situation. The mortality rates for severely burned pregnant women and their fetuses are the highest among the burn population. The current dearth of literature predominantly advocates treating pregnant women much as nonpregnant victims would be: early wound excision and coverage, aggressive fluid resuscitation, empiric antibiotic coverage, and adequate nutritional support. One distinction is the early administration of antenatal corticosteroids for fetal development. The lower limit of periviability is now gestational week 22 or a fetal weight of 500 g, defining the earliest viable emergent delivery stage. Optimal management requires multidisciplinary cooperation; consultation from high-risk obstetricians, neonatologists, pharmacologists, and psychiatrists ought to augment the burn team. It will be the continuous recommendation of the authors that systematic research be performed on how best to treat both patients, mother and baby.

Hematology, Hemostasis, Thromboprophylaxis, and Transfusion Medicine in Burn Patients

Abstract Severely burned patients suffer significant hematologic pathologies. Anemia develops from burn excisions and the anemia of critical illness. Fluid shifts, resuscitation, and factor consumption can cause significant coagulopathy. Transfusion of red blood cells to treat anemia, plasma to treat coagulopathy, and other blood products are critical to burn management. Critical illness, injury, immobilization, and other factors create a hypercoagulable state requiring venothromboembolic prophylaxis. Hematopoietic changes reduce red blood cell generation as well as affecting downstream immunologic function. Facile management of these hematologic pathologies is essential to the medical and surgical management of burn patients.

Acute and Reconstructive Care of the Burned Hand

Abstract Hands are commonly injured in burned patients. Optimal outcome is predicated on prompt and comprehensive action in diagnosing the depth of the burn, decompressing compartment syndromes, early and aggressive therapy, early excision and grafting, and coordinated secondary reconstructions. Rapid closure of hand burns is associated with better functional outcomes. Hand therapy is central to outcome and sufficient staff is central to care. When contractures occur, aggressive reconstruction can improve function. The most common debilitating pathology is insufficient skin coverage to allow proper range of motion. Surgical release results in a defect that can be covered with grafts or flaps. Electrical injuries commonly affect the hands. Total care of the burned hand is predicated on aggressive management and takes years to reach maximal medical benefit. Patients should be offered the full range of acute and reconstructive options in a comprehensive burn center environment.

Coronary Vasospasm After Burn Injury: First Described Case Series of a Lethal Lesion

Burn injuries generate multisystem physiological derangements. The authors present a case series of three patients developing acute coronary syndrome (ACS) stemming from coronary vasospasm (CVS) over a course of 5 months. This etiology of ACS is significant as it has previously not been described in burn patients and requires a different management algorithm than vaso-occlusive disease.All patients were admitted to a single accredited burn unit. Burn mechanisms were flash burn, chemical fire, and house fire. TBSA were 20%, 72%, and 31%, respectively. Ages were 67-, 41-, and 52-year-old men. All smoked tobacco, and one had diabetes and coronary artery disease. CVS presented with acute onset ST elevations, severe bradycardia, and cardiac arrest in all. Diagnosis was made via EKG and angiography. Treatment was undertaken with nitrates and calcium channel blockers. One of the patients died of refractory disease.The authors identified CVS in burn patients with an incidence of 2% of admissions and accounting for 17% of our burn mortality during this period. To date, there is no linkage between CVS and burns described in humans; however, there is a well-described animal model in rats. The risk factors for CVS are common among burn patients, particularly smoking and endothelial dysfunction. CVS may be a significant cause of ACS in burn patients, and it should be considered in the setting of ACS especially with a negative angiography. Knowledge of this disease state can change burn management to mitigate risk and accommodate specific cardiac treatments.