Principles and practice of burn surgery

TABLE 1 Members of the Burn Team Burn surgeons (general and plastic surgeons) Nurses Intensive care Acute and reconstructive wards Scrub and anesthesia nurses Case managers (acute and reconstructive) Anesthesiologists Respiratory therapists Rehabilitation therapists Dietitians Psychosocial experts Social workers Volunteers Microbiologists Research personnel Quality control personnel Support services Neurological assessment: Check Glasgow coma score. Expose the patient. At this point a rough estimate of the extent of the injury should be made and resuscitation efforts focus on physiological derangements. Initial resuscitation steps include the following: 1. Administer oxygen nasally or by mask. Intubate if patency of airway is at risk or massive edema is to be expected. 2. Insert at least two large peripheral intravenous (IV) catheters. Delays in resuscitation are costly. Therefore introduce IV catheter through burned or unburned skin. 3. Start Ringer’s lactate at 1 L/h. 4. Insert nasogastric tube. 5. Insert urinary catheter. 6. Wrap patient in thermal blanket or place under thermal panel. 7. Splint deformed extremities. The following are taken from the general Arrival Checklist at the University of Texas Medical Branch/Shriners Burns Hospital: ABCs of Trauma: Establish airway Check breathing Administer oxygen Control external bleeding Insert IVs, Foley catheter, nasogastric tube (NGT) Initiate fluid resuscitation Search for associated injuries Patient Evaluation AMPLE history (see below) Immunization status Check accompanying referral paperwork Complete physical examination Rule out occult injuries Complete laboratory evaluation (see below) Other x-ray exams if needed Clean and gently debride wounds Culture (blood, urine, wound, sputum) Photographs Burn diagrams: size and depth Fluid Requirement Calculation Measure height and weight Determine total BSA and BSA burned Resuscitation formula (see below) Circulation Assessment Escharotomies Splint and elevate Serial exams Infection Prevention Tetanus prophylaxis Streptococcus prophylaxis 48 h (children only) Major injuries: pre/perioperative systemic empirical antibiotics (based on local sensitivities) MetabolicSupport Prevent hypothermia Comfort measures: sedation, analgesics (see below) Hormonal manipulation (see Chap. 13