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Burns 217
Table 33.2: Wallace’s “rule of nines” for estimating % TBSA involved in burns. or a hospital with an ICU. Guidelines include:
Anatomic area % TBSA • children with burns >10% BSA require IV resuscitation;
Head and neck 9 • children with burns >30% BSA require central line placement;
Anterior trunk 18
• resuscitate crystalloids initially, with possible subsequent inclusion
Posterior trunk 18 of colloids; and
Right upper extremity 9 +
• kaliuresis is common, and K losses must be supplemented; how-
Left upper extremity 9 ever, this should be done with care because the damaged tissue may
Right lower extremity 18 release large amounts of potassium.
Left lower extremity 18 Nutrition
Perineum & external genitalia 1 During days 2 and 3 following thermal injury, treatment is directed
toward fluid resuscitation and maintenance of haemodynamic stability
and electrolyte balance. Starting on postburn days 3 to 5, metabolic
um, genitalia, and joints are considered primary areas. They must be expenditure in the thermally injured patient begins to increase and is
given appropriate care to optimise wound healing and prevent cosmetic paralleled by an accompanying increase in nutritional demands. This
and functional problems. increased metabolic drive is directed toward support of the healing burn
Investigation wound by both local and systemic hormonal mechanisms. Due to the
Burn patients presenting acutely should be resuscitated as described catabolic effect of catecholamines and increased energy expenditure, a
above. The initial therapy aims at restoring normal physiologic param- high-calorie and high-protein diet or nutritional supplementation should
eters and the prevention of life-threatening complications. It is guided be initiated as soon as possible after injury.
by the weight of the patient and the % TBSA injured. The goals of nutritional support are to maintain and improve
Initial blood samples should be drawn for blood grouping and organ function, prevent malnutrition, and improve overall outcomes.
cross-match, total blood count, electrolytes, glucose, and urea nitrogen. Nutritional support is not without potential complications, which may
Arterial blood gases and pH are obtained whenever inhalation injury include sepsis, glucose, and osmolar intolerance, and the mechanical
is suspected. hazards of the administration techniques.
Radiological investigations are generally not necessary except A number of different formulae that may be used to calculate caloric
where inhalation injury is suspected or in the multiple trauma patient. needs for burn patients exist. The Curreri formula is one example:
Where possible, an initial baseline chest radiograph is useful for later Calories/day = (wt in kg) (25) + (40) (% BSA)
comparisons.
Hospital Care This formula probably overestimates caloric needs, and needs
periodic recalculation as healing occurs.
An assessment of the severity of the burn (Table 33.3) should be estab-
Hypermetabolism is a characteristic physiological response to
lished early, as it gives a useful guide of the prognosis and the amount
major injury, and there is a direct relationship between the magnitude
of resources that will be required to care for the child. The following
and duration of the hypermetabolic response and the severity of the
steps should be initiated once the child has been resuscitated
sustained trauma. The hypermetabolic response to burn injury is not
Table 33.3: Classification of burn severity. temperature dependent, and has been postulated to be mediated through
the hypothalamic temperature centre. The reset hypothalamus triggers
Moderately Major
Minor burns an increased metabolic rate by elevating the plasma levels of three
severe burns burns
hormones: catecholamines, glucagon, and cortisol. Because the skin
BSA <5% 5–15% >15%
plays a large part in thermoregulation, extensive damage due to burns
Special areas involved No No Yes impairs the body’s thermoregulatory capacity.
Full thickness burns None None Present There is also a marked catabolic response that accompanies severe
burns; it is associated with weight loss; poor wound healing; and
Comorbidities present
(medical or trauma) None None or present Present negative nitrogen, potassium, sulfur, and phosphorus balance. It is also
associated with increased levels of glucagon and catecholamines in
Electrical or chemical injury None None Present
plasma as well as depressed levels of insulin.
Management Outpatient Hospital Hospital The increased metabolic expenditure persists for several weeks until
the burn wound either spontaneously heals or is closed by skin grafting.
However, even wound closure does not immediately return metabolic
1. Clean the burns with normal saline and dress with saline gauzes, or expenditure to normal, and thus increased nutritional support must
cover with gauze dressing. continue even after closure of the wound surface.
2. Adequate anaelgesia must be administered. Adequate nutritional support is best monitored by daily
3. Administer tetanus prophylaxis. measurement of body weight. Postburn weight loss of up to 10% is
well tolerated, provided the patient was not nutritionally compromised
4. Prophylactic antibiotics, oral or intravenous, are not indicated. Their before the burn. Weight loss exceeding 10% of the preburn weight is
use, prophylactically, is indicated only in the following three scenarios:
associated with increased morbidity. A progressive physical therapy
- early administration of antistreptococcal drugs in a high-risk programme enhances the deposition of protein into lean muscle
patient to prevent burn wound cellulitis;
mass, allowing the performance of kinetic work required for the
- perioperative administration of antibiotics; and maintenance of normal function.
- administration of broad-spectrum antibiotics pending return of Enteral feedings are recommended over parenteral feedings in
culture information in febrile or hypotensive patients. burn patients because they are more physiological and less costly,
Ideally, children with severe burns should be managed in a burn centre and they help to preserve gut structure and function, thereby reducing