Dr. Brandon Bruns is an Assistant Professor of Surgery here at the University of Maryland and did a large amount of his training at University of Texas Southwestern, home of Parkland Memorial Hospital and the Parkland formula. Â Who better to ask to come talk to us about Burn Management in the ICU? Â If you don’t work at a burn center, don’t think that you’ll never see a burn patient. In the critically ill, poly-trauma patient you may actually be faced with the challenge soon… So learn from one of our experts and be prepared for the next burn patient that shows up in your ICU!
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Pearls
- The Parkland formula is just a starting point for volume resuscitation
- It was meant for patients with a > 20% total body surface area burn
- Concept that is founded upon the capillary leak syndrome that occurs in the first 24 hours post-burn
- IV fluid therapy should be titrated on an hourly basis to maintain adequate urine output > 0.5mL/kg/hour
- Don’t be afraid to place an IV through burned skin – it is not a contraindication!
- In clinical practice, it is nearly impossible to identify compartment syndromes due to circumferential burns in the intubated patient. As a result, just do the escarotomy at the bedside.
- If signs of hypoperfusion or a metabolic acidosis persists, the patient needs to go to the OR for a true fasciotomy to relieve the excessive compartment pressure.
- Upper extremity escarotomies should be performed with the patient in anatomic position, along medial & lateral lines.
- PITFALL: Â Failure to have the patient in anatomical position can lead to “barber poling” which can lead to chronic contractures and even worse long-term disability.
- Sulfamylon (a commonly used topical agent to penetrate burn eschar) is a potent carbonic anhydrase inhibitor that will routinely cause a metabolic acidosis.
- Start enteral nutrition early! It has been proven time and time again to reduce both morbidity and mortality in the burn patient.
- Toxic Epidermal Necrolysis: One of the true dermatologic emergencies
- Most commonly caused by medications
- Antiretrovirals and sulfonamides are two of the most common offending agents.
Suggested Reading
- Roberts G, Lloyd M, Parker M, et al. The Baux score is dead. Long live the Baux score: a 27-year retrospective cohort study of mortality at a regional burns service. J Trauma Acute Care Surg. 2012;72(1):251-6.
- White CE, Renz EM. Advances in surgical care: management of severe burn injury. Crit Care Med. 2008;36(7 Suppl):S318-24.
- Tricklebank S. Modern trends in fluid therapy for burns. Burns. 2009;35(6):757-67.
- Roderique EJ, Gebre-giorgis AA, Stewart DH, Feldman MJ, Pozez AL. Smoke inhalation injury in a pregnant patient: a literature review of the evidence and current best practices in the setting of a classic case. J Burn Care Res. 2012;33(5):624-33.
