Burns injury - PACT - ESICM

Removal of the burned tissue and wound closure as soon as possible is vital.
Burned tissue is an ideal culture medium for bacteria and fungi, but even if not
infected, the presence of burn tissue is a significant source of inflammatory
mediators that support an ongoing systemic inflammatory response.
Wound grafting
The aim of the treatment is complete closure of the wound with autogenous split
thickness skin grafts. If enough viable skin is available, skin grafting can be
performed in the same operation after necrosectomy. In large burns, many surgeons
prefer to do the necrosectomy and grafting in two procedures during two sequential
days to make sure that necrosectomy is complete before grafting. Temporary
coverage with cadaver skin or biological dressing as above may be necessary in larger
burn wounds.
In burns exceeding 40–50% TBSA, autologous cell cultures (keratinocytes, fibroblasts)
may provide good coverage of the burned surface. The definitive role of this therapy
is still to be confirmed.
American Burn Association White Paper. Surgical Management of the Burn
Wound and Use of Skin Substitutes
Herndon DN, editor. Total Burn Care. 3rd edition. Edinburgh: Saunders-Elsevier;
2007. ISBN 978-1416032748
Wood FM, Kolybaba ML, Allen P. The use of cultured epithelial autograft in the
treatment of major burn injuries: a critical review of the literature.
Burns 2006; 32(4): 395–401. PMID 16621307
Complications of fluid management (‘fluid creep’)
The Parkland formulae (2-4 mL/kg/%TBSA) for burn injury
resuscitation was launched in the late sixties, and has been the
cornerstone for fluid management in burns ever since. In later years
there has been a tendency to give larger volumes of resuscitation
fluid for a number of reasons:
Fluid creep is the term
created by Pruitt to
describe fluid
resuscitation in excess
of that predicted by
the Parkland formula
and which is associated
with compartment
syndromes
First, and possibly most important, is the use of central circulation surveillance
techniques (pulse contour measurement and echocardiography) to assess fluid status
of the patients in parallel to using the endpoints suggested by the Parkland formulae
(urine output and mean arterial pressure). It is then evident that in the normal
patient there is central circulation hypovolaemia if the Parkland formulae is adhered
to, especially at 12 hrs post burn. Thus, conventional burn fluid resuscitation
(Parkland formula) is a permissive ‘hypovolaemia’ strategy. Secondly, it is claimed
that patients are currently more likely to be intubated and sedated with large doses
of sedatives and analgesics. This practice leads indirectly to larger fluid volume
needs to maintain blood pressure and urine output. Thirdly, as mortality for patients
with the largest injuries is declining, resuscitative measures are more often
16