Critical Care of the Burn Patient
Robert L. Sheridan, MD, FAAP, FACS
Objectives
 Describe at least 3 components of a burn-specific
secondary survey
 Plan fluid resuscitation for a patient with a large burn
 List at least 3 important burn-related issues that arise
in the ICU when caring for patients with large burns
 List at least 3 nonburn conditions whose
management benefits from approaches and
resources similar to those required by burn patients
Key words: burns, critical care, resuscitation
Most patients with burns involving less than
about 25% of the body surface can be managed
without critical care. However, as burn size
increases above this point, especially in the
young, old, or medically fragile patient, mortal-
ity increases sharply unless critical care support
is provided. Patients with burns in excess of
40% of the body surface rarely survive without
skillful critical care.
Organization of Care
Patients with wounds less than about 10%
of the body surface can often be managed as
outpatients. Those with larger injuries generally
require hospital admission and often require
intensive care. The American Burn Association
has devised a set of criteria to aid in selection
of patients for transfer to dedicated burn units
(Table 1). Data demonstrate improved outcomes
and reduced costs for such patients when man-
aged in verified burn units.1,2 Care of these more
challenging patients can be organized into 4
phases, which are described in Table 2.
Epidemiological Patterns
In the United States each year, approximately
2 million people are burned; 80,000 of these
are hospitalized, and 6,500 die from the injury.
Approximately 70% of pediatric burns are
caused by hot liquid, whereas flame injuries
more often cause burns in working-age adults.
Elderly patients are at increased risk for burns
that are caused by hot liquid or by flame, often
in kitchen accidents. Young children are also at
higher risk for burn injury. Up to 20% of burns
in young children involve abuse or neglect.
Physiological Changes and Clinical
Implications
Burns over about 20% of the body surface
trigger a sequence of fairly predictable
physiological changes3 that have important
implications for ongoing care (Table 3). The
“ebb phase” is a period of hours to a few
days after injury in which there is a relative
hypodynamic state and diffuse capillary leak-
age. The basic biological factors driving these
changes are poorly understood, but they are best
addressed with individualized fluid resuscita-
tion. In successfully resuscitated patients, a
“flow phase” follows, which is a protracted
period of high cardiac output, low peripheral
vascular tone, fever, and muscle catabolism.4
These changes increase with burn size and
depth and are best addressed with individualized
nutritional support.5
The diffuse capillary leak syndrome is relatively
unique to patients suffering large burns and is
believed to be secondary to wound-released
mediators and neurohormonal changes follow-
ing injury. Formulas have been developed over
the past few decades that attempt to predict
resuscitation volume requirements based on
body weight or surface area and burn size. How-
ever, multiple other variables affect resuscitation
requirements, including time from injury to
resuscitation, the presence of inhalation injury,
and the depth and ease of liquid and vapor water
loss through the wound. No formula exists that
can accurately predict volume requirements in
all patients.6 Given the morbidity associated
with overresuscitation and underresuscitation,
burn resuscitation should be guided by hourly
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CURRENT CONCEPTS IN ADULT CRITICAL CARE

Table 1. The American Burn Association Burn Center Transfer Criteria

1. Partial thickness burns greater than 10% total body surface area.
2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints.
3. Third-degree burns in any age group.
4. Electrical burns, including lightning injury.
5. Chemical burns.
6. Inhalation injury.
7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or
affect mortality.
8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk
of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially
stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such
situations and should be in concert with the regional medical control plan and triage protocols.
9. Burned children in hospitals without qualified personnel or equipment for the care of children.
10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention.

Table 2. Phases of Burn Care

Phase Time Course Major Objectives

Initial evaluation and 0-72 hours Individualized fluid resuscitation and complete
resuscitation evaluation of injuries

Initial wound excision and Days 1-7 Accurate wound assessment with hemostatic and
biological closure minimally ablative wound excision

Definitive wound closure Days 7-30 Replacement of temporary wound membranes with
autograft and closure of high-complexity wounds

Rehabilitation, reconstruction, Day 1 to discharge Initially to maintain range and strength with
and reintegration subsequent strengthening and emotional recovery

Table 3. Predictable Physiological Changes in Burn Patients

Time Period Major Physiological Changes Clinical Implications

Day 0-3: resuscitation period Diffuse capillary leak; hypodynamic Individualized fluid resuscitation is needed.
circulation

Day 3 to bulk wound closure: Hyperdynamic hypermetabolic state Deep wounds must be excised and closed to
postresuscitation period with muscle catabolism reduce sepsis; nutritional support is important.

Bulk wound closure to 2 years Gradually tapering hypermetabolic Accurate nutritional repletion is needed for
after injury physiology up to 2 years.

re-evaluation of resuscitation endpoints; 24 hours after injury, and volume requirements

formulas only help to determine initial volume abruptly decline. Subsequently, a diffuse inflam-
infusion rates and to roughly predict overall matory state evolves that is characterized by a
requirements. In patients who are successfully hyperdynamic circulation, fever, and massively
resuscitated, capillary integrity improves 18 to increased protein catabolism.7

128

Initial Evaluation of Patients with
Large Burns
Oftentimes, the initial evaluation and manage-
ment of burn patients have not been completed
prior to their transport to the ICU. For all
patients arriving to the ICU with significant
burns, clinicians should consider the probability
of multiple trauma and incomplete initial evalua-
tion.8 Their evaluation should follow the primary
through tertiary survey format of the American
College of Surgeons Committee on Trauma,
Advanced Trauma Life Support Course.
A critical point of the primary survey of burn
patients is evaluation and control of the airway.
Unique considerations include the fact that
progressive mucosal edema may compromise
airway patency over the first few postinjury
hours. This is especially true of young children.
Edema of the tongue, face, neck, and airway can
make intubation progressively more challeng-
ing. Inhalation injury may be associated with
early upper airway edema and bronchospasm
but rarely early failure of gas exchange. If
intubation is indicated and is done before
significant edema has developed, direct laryn-
goscopy is generally safe and effective. If the
patient’s airway is already swollen, it may be
prudent to obtain help and have airway adjuncts
immediately available, such as a flexible bron-
choscope and surgical airway equipment and
personnel. Once the position of the endotracheal
tube is confirmed, properly securing the tube
is critical, since reintubation of a patient with
a swollen face may be very difficult. A harness
system using umbilical ties has proven effective,
but other methods of tube security are available.
Establishing reliable vascular access is another
important early priority. In many patients, this is
best achieved with central cannulation.
Once urgent priorities have been addressed,
a thoughtful and thorough secondary survey
should be conducted. This is especially true for
patients with large burns who may have been
transported over significant distances without a
careful and complete evaluation.9 It is common
for important issues to first be discovered during
examination on arrival in the ICU. Several
CRITICAL CARE OF THE BURN PATIENT
burn-specific additions to the trauma secondary
survey are itemized in Table 4.
Fluid Resuscitation
For perhaps as long as 1 to 3 hours after an
extensive burn, patients experience little
derangement in intravascular volume, which
explains the common observation that in the
first hours after even massive injuries, patients
can be quite alert. As wound-released mediators
are absorbed into the systemic circulation, and
as stress- and pain-triggered hormonal release
occurs, a diffuse loss of capillary integrity
occurs that results in the extravasation of fluids,
electrolytes, and even moderate-sized colloid
molecules. For reasons still unclear, this leak
abates between 18 and 24 hours later in patients
who have been well resuscitated. An increased
leak can be seen in those whose resuscitations
are delayed, thought to be due to the systemic
release of reactive oxygen species formed upon
reperfusion of marginally perfused tissues.
Increased leak and increased fluid requirements
are also common in patients with very deep
burns or inhalation injury.
A plethora of burn resuscitation formulas have
been promulgated over the past 50 years. Their
recommendations for individual patients rarely
coincide, and it is unusual for a tightly monitored
resuscitation to follow a given formula. The best
resuscitations are individualized to the specific
patient’s needs and adjusted hourly based on
resuscitation endpoints (Table 5). A reasonable
starting consensus formula is outlined in Table
6. Patients vary widely in their needs based
on duration of preresuscitation hypoperfusion,
extent and vapor transmission characteristics of
wounds, presence of inhalation injury, coincident
nonburn trauma, and individual inflammatory
response to tissue injury. Frequent monitoring
and titration of fluid resuscitation are essential
for a good outcome.10 The use of colloid in burn
resuscitation is an area of active debate, and
most current practitioners advocate the use of
colloid earlier than most classic formulas.11,12
The author’s routine fluid resuscitation practice
reflects this evolution and is outlined in Table 7.
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Table 4. Elements of the Burn-Specific Secondary Survey

Element Considerations

History 1. Important points include the mechanism of injury, closed space exposure, extrication time, delay in
seeking attention, fluid given during transport, and prior illnesses and injuries.

HEENT 1. The globes should be examined and the corneal epithelium stained with fluorescein before adnexal
swelling makes examination difficult.
2. Adnexal swelling provides excellent coverage and protection of the globe during the first days after injury.
Tarsorrhaphy is virtually never indicated acutely.
3. Corneal epithelial loss can be overt, giving a clouded appearance to the cornea, but is more often subtle,
requiring fluorescein staining for documentation. Topical ophthalmic antibiotics constitute optimal initial
treatment.
4. Signs of airway involvement include perioral and intraoral burns or carbonaceous material and progressive
hoarseness.
5. Hot liquid can be aspirated in conjunction with a facial scald injury and result in acute airway compromise
requiring urgent intubation.
6. Endotracheal tube security is crucial. An umbilical tape harness often is safer than adhesive tape if the face
is burned.

Neck 1. The radiographic evaluation is driven by the mechanism of injury.

2. Rarely, in patients with very deep circumferential neck burns, escharotomies are needed to facilitate venous
drainage of the head.

Cardiac 1. The cardiac rhythm should be monitored for 24-72 hours in patients with high-voltage electrical injury.
2. Although elderly patients may develop transient atrial fibrillation if modestly overresuscitated, significant
dysrhythmias are unusual if intravascular volume and oxygenation are adequately supported.
3. Patients with coronary disease may suffer myocardial infarction due to the hemodynamic stress associated
with the injury and should be appropriately monitored.

Pulmonary 1. C
 hest escharotomies should be performed when needed to ensure that inflating pressures are <40 cm H2O.
2. Severe inhalation injury may lead to sloughing of endobronchial mucosa and thick bronchial secretions
that can occlude the endotracheal tube; be prepared for sudden endotracheal tube occlusions.

Vascular 1. The perfusion of burned extremities should be serially monitored. Indications for escharotomy include
decreasing temperature, increasing consistency, slowed capillary refill, and diminished Doppler flow in
digital vessels.
2. Fasciotomy is indicated after electrical or deep thermal injury when distal flow is compromised on clinical
examination. Compartment pressures can be helpful, but clinically worrisome extremities should be
decompressed regardless of compartment pressure readings.

Abdomen 1. Nasogastric tubes should be placed in the patient prior to air transport in unpressurized helicopters.
2. An inappropriate resuscitative volume requirement may be a sign of an occult intra-abdominal injury.
3. Torso escharotomies may be required to facilitate ventilation in the presence of deep circumferential
abdominal wall burns.
4. Ulcer prophylaxis is indicated in all patients with serious burns.

Genitourinary 1. Bladder catheterization facilitates using urinary output as a resuscitation endpoint and is appropriate in all
who require a fluid resuscitation.
2. Ensure that the foreskin is reduced over the bladder catheter after insertion, as progressive swelling may
otherwise result in paraphimosis.
Neurological 1. An early neurological evaluation is important, as the patient’s sensorium is often progressively
compromised by medication or hemodynamic instability during the hours after injury.
2. This may require computed tomography scanning in patients with a mechanism of injury consistent with
head trauma.
3. Patients who require neuromuscular blockade for transport should also receive adequate sedation and
analgesia.

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Table 4. Elements of the Burn-Specific Secondary Survey (continued)

Element Considerations

Extremities 1. Extremities that are at risk for ischemia, particularly those with circumferential thermal burns or those
with electrical injury, should be promptly decompressed by escharotomy and/or fasciotomy when
clinical examination reveals increasing consistency, decreasing temperature, and diminished Doppler
flow in digital vessels. Limbs at risk should be dressed so they can be frequently examined.
2. The need for escharotomy usually becomes evident during the early hours of resuscitation. Many
escharotomies can be delayed until transport has been effected if transport times will not extend
beyond 6 hours after injury.
3. Burned extremities should be elevated and splinted in a position of function.

Wound 1. Wounds are often underestimated in depth and overestimated in size on initial examination.
2. Wounds should be evaluated for size, depth, and the presence of circumferential components.
3. Burn size varies in relation to patient age. A burn diagram (Figure 1) is useful for documentation.

Laboratory 1. Arterial blood gas analysis is important when airway compromise or inhalation injury is present.
2. A normal admission carboxyhemoglobin concentration does not eliminate the possibility of a
significant exposure, as the half-life of carboxyhemoglobin is 30-40 minutes in those effectively
ventilated with 100% oxygen.
3. Baseline hemoglobin and electrolytes can be helpful later during resuscitation.
4. Patients with deep thermal or electrical injuries should undergo urinalysis for occult blood.

Radiograph 1. The radiographic evaluation is driven by the mechanism of injury and the need to document
placement of lines and tubes.

Electric 1. In high-voltage exposures, cardiac rhythm should be monitored for 24 hours.

2. Low- and intermediate-voltage exposures can cause locally destructive injuries but uncommonly
result in systemic sequelae.
3. After high-voltage exposures, delayed neurological and ocular sequelae can occur, so carefully
documented neurological and eye examinations should be completed.
4. Injured extremities should be serially evaluated for intracompartmental edema and promptly
decompressed when it develops.
5. Bladder catheters should be placed in all patients suffering high-voltage exposure to document the
presence or absence of pigmenturia. This is treated adequately with volume loading in most patients.

Chemical 1. Wounds should be irrigated with tap water for at least 30 minutes. The globe should be irrigated with
isotonic crystalloid solution.
2. Blepharospasm may require ocular anesthetic administration for examination and irrigation.
3. Exposures to hydrofluoric acid may be complicated by life-threatening hypocalcemia, particularly
exposures to concentrated or anhydrous solutions. Patients should have serum calcium closely
monitored and supplemented. Subeschar injection of 10% calcium gluconate solution is appropriate
after exposure to highly concentrated or anhydrous solutions.

Tar 1. Tar should be initially cooled with tap water irrigation and later removed with a lipophilic solvent.
2. Wounds are usually quite deep and often require early decompression and later excision.

Abuse 1. All patients should be screened for abuse as the injury mechanism.
2. Approximately 20% of burns in young children are reported to state authorities for investigation,
but abuse occurs in all age groups. Often this determination is not made until the patient has been
admitted to ICU.
3. The entire team must consider the possibility of abuse and file any suspicious case with appropriate
state agencies.
4. Careful and complete documentation of the circumstances and physical characteristics of the injury is
essential.
5. Photographic documentation is ideal.

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Figure 1. A burn diagram

Image courtesy of the Sumner Redstone Burn Center of Massachusetts General Hospital.

Table 5. Resuscitation Endpoints

Endpoint Target

Examination Warm extremities, full peripheral pulses, soft abdomen

Sensorium Comfortable, arousable

Systolic pressure Infants: 60-70 mm Hg

Children: 70 to [90 + (twice age in years)] mm Hg
Adolescents and adults: 90-120 mmHg

Urine output Infants: 0.5-1 mL/kg/h

Children and adults: 0.5 mL/kg/h

Base deficit <2

Lactate level <2

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Table 6. A Consensus Formula for Starting Resuscitation—The Modified Brooke Formula

First 24 hours

Adults and children >10 kg Lactated Ringer’s solution: 2-4 mL/kg/%burn/24 h (first half in first 8 h)
Colloid: none

Children <10 kg Lactated Ringer’s solution: 2-3 mL/kg/%burn/24 h (first half in first 8 h)
Lactated Ringer’s solution with 5% dextrose: 4 mL/kg/h
Colloid: none

Second 24 hours

All patients Crystalloid: To maintain urine output. If silver nitrate is used, sodium leeching will mandate
continued isotonic crystalloid. If other topical is used, the free water requirement is significant.
Serum sodium should be monitored closely. Nutritional support should begin, ideally by the
enteral route.
Colloid (5% albumin in lactated Ringer’s solution):
0%-30% burn: none
30%-50% burn: 0.3 mL/kg/%burn/24 h
50%-70% burn: 0.4 mL/kg/%burn/24 h
>70% burn: 0.5 mL/kg/%burn/24 h

Table 7. Author’s Personal Fluid Resuscitation Practice

Burn Size LR 5% Albumin

Initial infusions

1%-20% 1.5M none

20%-50% P less 1M 1M

>50% P less 2M 2M

Abbreviation: LR, lactated Ringer’s solution; M, calculated maintenance rate; P, Parkland

calculation for crystalloid (4 mL/kg/%burn in first 24 hours, half in first 8 postinjury hours—
typically 0.25 mL/kg/%burn/h for first 8 hours).
Additional points:
• During first 24 hours, infusion rate is titrated hourly to endpoints noted in Table 5. For the
first 24 hours, LR is titrated. At 24 hours, LR and albumin are titrated in tandem. Typically,
patients require about 1.5M at 24 hours.
• If patient is a child weighing less than 20 kg, 1M of initial LR is given as D5LR, the remainder
as LR.
• If needed, boluses are given as 5% albumin.
• Goal is to be “just on the dry side of euvolemia.”
• Tube feedings can be started at trophic rate during first 24 hours in stable patients with
monitored advancement. Tube feeding rate is subtracted from LR rate.

Critical Care Issues as well as prevention of peripheral neuropathies.

A number of issues predictably arise in the burn
ICU. Critical care issues tend to crescendo at the
time of initial evaluation and resuscitation and
then in the immediate postoperative period after
major excisions.
Neurological Issues
Important neurological issues include reason-
able monitoring and control of pain and anxiety
Poorly controlled pain and anxiety have adverse
physiological and psychological consequences
and may contribute to the development of post–
intensive care syndrome.13 Burn patients often
develop some degree of tolerance to medica-
tions used to address these issues, which should
be anticipated. The role of nonbenzodiazepine
anxiolytics and antidepressants is increasing.14
Peripheral neuropathies can occasionally
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CURRENT CONCEPTS IN ADULT CRITICAL CARE
develop in burn patients because of direct
thermal damage, compression from compart-
ment syndromes or poorly fitting splints, or
the metabolic derangements that these patients
experience.15,16 Careful positioning of deeply
sedated or anesthetized patients will avoid
traction and pressure injuries.
Ocular Issues
In the weeks following acute injury, progressive
contraction of burned eyelids and periocular
skin can result in exposure of the globe. This
will cause desiccation of the globe with second-
ary keratitis, ulceration, and globe-threatening
infection.17 Lubrication of the exposed globe
with hourly application of ocular lubricants will
often effectively temporize until the contracted
lids is surgically released.
Pulmonary Issues
A number of important pulmonary issues com-
monly present in the burn unit. Airway security
is a major issue throughout the critical care
course. Endotracheal tube security should be
regularly verified, and ICU personnel should be
trained and equipped to deal with sudden airway
emergencies. Urgent reintubation in swollen
burn patients can be very challenging.
Inhalation injury is a clinical diagnosis based on
a history of closed-space exposure and the pres-
ence of singed nasal vibrissae and carbonaceous
sputum.18 Fiberoptic bronchoscopy facilitates
diagnosis in equivocal cases and may help docu-
ment laryngeal edema. The common sequelae
associated with inhalation injury include upper
airway obstruction, bronchospasm, small airway
occlusion, pulmonary infection, and respiratory
failure. Upper airway obstruction is anticipated
and managed with endotracheal intubation.
Bronchospasm (from aerosolized irritants)
generally responds to inhaled β2-adrenergic
agonists. Ventilatory strategies should be
designed to minimize auto-Positive End Expira-
tory Pressure. Small airway obstruction occurs
as necrotic endobronchial debris is sloughed and
clearance of secretions is impaired. Pulmonary
toilet and periodic therapeutic bronchoscopy
facilitate airway hygiene. Pulmonary infection
develops in 30% to 50% of patients with inhala-
134
tion injury. Differentiating between pneumonia
and tracheobronchitis (purulent infection of the
denuded tracheobronchial tree) is often difficult
but generally of little practical consequence.
A patient with purulent sputum, fever, and
impaired gas exchange should be treated with
antibiotics according to the results of cultures.
Empiric coverage should depend on time since
injury, with community acquired organisms
requiring coverage immediately after injury and
hospital acquired gram negative and positive
organisms emerging as common pathogens
subsequently. Pulmonary toilet is particularly
important in these patients, who have denuded
airways and impaired mucociliary clearance.
Fortunately, respiratory failure is fairly uncom-
mon in patients with uncomplicated inhalation
injury. It is best managed with routine pressure
and volume-limited support. Some patients,
especially those with extensive burns, may
develop acute respiratory distress syndrome
(ARDS) and should be managed with the strate-
gies developed by the ARDS Network.
Carbon Monoxide Exposure
Carbon monoxide (CO) exposure is common
in patients injured in structural fires. Impaired
mental status in such patients can occur from a
combination of CO poisoning, anoxia, drugs,
intoxicants, and hypotension. Carboxyhemoglo-
bin levels decrease rapidly after ventilation with
100% oxygen.19 Hyperbaric oxygen has been
proposed as a means of improving the prognosis
of patients with serious CO exposures, but its
use remains controversial, and it is not always
clear which patients are suffering primarily from
CO poisoning and would potentially benefit
from hyperbaric treatment.
Carbon monoxide avidly binds and inactivates
heme-containing enzymes such as hemoglobin
and the cytochromes, which are involved in
oxygen delivery and consumption, respectively.
The formation of carboxyhemoglobin results
in an acute physiological anemia, much like an
isovolemic hemodilution. A carboxyhemoglobin
concentration of 50% is physiologically similar
to a 50% isovolemic hemodilution. The routine
occurrence of unconsciousness at this level

of carboxyhemoglobin suggests that other
mechanisms may be involved in the patho-
physiological process of CO injury. Potentially,
CO binding to the cytochrome system in the
mitochondria, interfering with oxygen utiliza-
tion, is as toxic as CO binding to hemoglobin.
For unknown reasons, between 5% and 20%
of patients with serious CO exposures have
been reported to develop delayed neurological
sequelae, although this figure is debated.
Patients with significant CO exposure can be
managed with 100% normobaric oxygen for 6
hours or with hyperbaric oxygen administered
in a monoplace (single patient) or multiplace
(multiple patient) chamber. If overt neurological
impairment or a high carboxyhemoglobin level
is documented, then hyperbaric oxygen treat-
ment may be warranted if it can be administered
safely.20 Hyperbaric oxygen treatment regimens
vary, but an exposure at 3 atmospheres of 100%
oxygen for 90 minutes, with 3 ten-minute “air
breaks,” is typical. An air break refers to the
breathing of pressurized room air rather than
pressurized oxygen, which decreases the inci-
dence of seizures from acute oxygen toxicity.
Because treatment is generally in a monoplace
chamber, unstable patients are not good
candidates. Other relative contraindications are
wheezing and air trapping, which increase the
risk of pneumothorax, and high fever, which
increases the risk of seizures. Six hours of 100%
normobaric oxygen is a generally accepted
alternative. Prior to placement in the chamber,
endotracheal tube balloons should be filled
with saline to avoid balloon compression and
associated air leaks. Myringotomies are required
in intubated patients or those who cannot follow
instructions to keep the Eustachian tubes open.
Cyanide is often detectable in patients extricated
from structural fires but is rarely severe enough
to justify the risk of treatment with amyl nitrate
and sodium thiosulfate. Unexplained acidosis
is the hallmark of significant cyanide exposure.
Treatment of such patients is controversial and
tends to be program specific. Consultation with
the receiving unit is warranted when possible.
CRITICAL CARE OF THE BURN PATIENT
Gastrointestinal Issues
To the degree that they experience splanchnic
hypoperfusion early in resuscitation, burn
patients have an ulcer diathesis (“Curling’s
ulcer”). Burn patients who require resuscitation
should be treated with empirical histamine
receptor blockers, proton pump inhibitors, or
antacids until they are hemodynamically stable
and tolerating tube feedings. Ileus is often an
early sign of sepsis, so the sudden development
of ileus should prompt a search for a septic
focus. Acalculous cholecystitis is not uncom-
mon and can be addressed percutaneously in
many cases.21
Nutritional Support
Burn patients have predictable, protracted needs
for supplemental protein and calories. This
support should be carefully managed to avoid
the consequences of over- and underfeeding.22
Tube feedings at a trophic rate can often be
started during resuscitation. Initial use of an
intragastric sump tube will facilitate monitor-
ing of tolerance. Parenteral nutrition is used if
tube feedings are not tolerated for the first few
days.23 Highly catabolic burn patients tolerate
prolonged periods of fasting very poorly, espe-
cially children. Nutritional targets are debated,
but consensus holds that protein needs are about
2.5 g/kg/d and caloric goals are between 1.5 and
1.7 times the calculated basal metabolic rate,
or 1.3 to 1.5 times the measured resting energy
expenditure.24 Nutritional support needs to be
titrated to nutritional endpoints during a lengthy
burn hospitalization. Regular physical examina-
tion, quality of wound healing, nitrogen balance,
and indirect calorimetry are all useful in this
regard.25
Infectious Disease Issues
The best way to avoid wound sepsis is through
prompt excision of necrotic material with
immediate closure of resulting wounds. Topical
agents and membranes are only an adjunct to
slow bacterial growth in the presence of necrotic
material. Several topical agents and wound
membranes are in common use (Table 8).
Infection may occur beneath wound membranes
if wound debridement is incomplete.
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Table 8. Common Wound Topical Agents and Membranes

Element Characteristics

Silver sulfadiazine 1. Has broad-spectrum antimicrobial activity due to silver ion.

2. Does not cause significant metabolic or electrolyte complications.
3. Does not penetrate eschar.
4. Has been associated with neutropenia, but this is usually self-limited.

Sulfamylon (mafenide acetate 1. Penetrates eschar.

as 5% solution or 11% cream) 2. Is useful on ears to prevent suppurative chondritis.
3. Can cause metabolic acidosis due to its inhibition of carbonic anhydrase.
4. In cream form, is painful on partial-thickness burns.

Silver nitrate
Mupirocin
Porcine Xenograft (Brennan
Medical, St Paul, Minnesota)
1. Provides broad-spectrum antimicrobial coverage against gram-positive and gram-
negative bacteria.
2. Is applied as an aqueous 0.5% solution every 4 h to keep dressings moist and prevent
precipitation of silver nitrate.
3. Stains skin (and anything it contacts) black, causes hyponatremia and
hypomagnesemia.
4. Results in rare instances of methemoglobinemia, necessitating methylene blue
treatment.
1. Is effective against methicillin-resistant Staphylococcus aureus.
2. Can be used in addition to other topical agents to expand coverage.
1. Adheres to coagulum and provides excellent pain control.

Biobrane (Dow-Hickam, Sugar 1. Is a synthetic bilaminate.

Land, Texas)
Acticoat (Westaim Biomedical,
Saskatchewan, Canada)
Aquacel-Ag (Convatec,
Princeton, New Jersey)
Various semipermeable
membranes
Various hydrocolloid dressings
Various impregnated gauzes
2. Allows fibrovascular growth into inner layer.
1. Is a nonadherent dressing that delivers silver.
1. Is an absorptive hydrofiber that delivers silver.
1. Provide vapor and bacterial barrier.
1. Provide vapor and bacterial barrier.
2. Absorb exudate.
1. Provide barrier.
2. Allow drainage.

Physiological consequences of burn injury
include the routine occurrence of moderate
fever, which is not necessarily a sign of infec-
tion.26 When unexpected fever occurs, clinicians
should perform a physical examination, inspect
wounds for signs of infection, obtain any
indicated laboratory tests and radiographs, and
order cultures of blood, urine, and sputum. If
the patient appears unstable, empirical broad-
spectrum coverage is reasonable pending return
of culture data. This is sometimes a tough judg-
ment call, balancing the morbidity of untreated
infection against the morbidity of antibiotic
overuse.27 If no infectious focus is identified and
cultures remain negative, antibiotics should be
stopped. It is critically important that deteriorat-
ing burn patients be evaluated for occult foci of
infection to allow prompt treatment prior to the
development of systemic sepsis.28
Finally, the importance of vigilant infection con-
trol practices cannot be overemphasized. Burn
patients have a fairly high rate of harboring

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 CRITICAL CARE OF THE BURN PATIENT

resistant bacterial species. Outbreaks with such
organisms are best avoided by strict application
of universal precautions.
Rehabilitation Issues
Rehabilitation efforts should begin as early
as possible in patients with significant burns,
including during periods of critical illness. This
can begin with twice-daily passive ranging
of all joints and static antideformity position-
ing. These efforts will go a long way toward
preventing otherwise inevitable contractures
(Table 9). Physical and occupational therapists
should be informed of the sequence of planned
operations and the modifications of therapy that
these imply. Therapists should be encouraged to
range patients under anesthesia in conjunction
with planned operations and to fabricate custom
splints in the operating room, particularly in
children, who often poorly tolerate these activi-
ties when awake. Addressing these issues during
the period of critical illness greatly enhances the
rate of recovery when wounds are closed.29
Intraoperative Issues
Burn patients must undergo staged excision
and closure of their wounds even if they are
critically ill. Oftentimes this is the only way to
move patients out of a critically ill state. Close
communication between the ICU and operating
room teams is essential. Operating rooms must
be kept warm to minimize the occurrence of
hypothermia in exposed burn patients, as this
will cause coagulopathy and increased bleeding.
The surgical and anesthesia teams must be in
constant communication throughout the opera-
tive event to balance the physiologic stress to the
patient of a long operation against the benefits
to be gained. In patients with large burns, it is
often possible to achieve the ultimate surgical
objective in staged procedures rather than a
single operation. Planning cases so they can
be truncated in the face of unstable physiology
without compromising the overall objective is an
important part of case planning. Periodic intra-
operative collaborative patient assessment should
be done to ensure that patients are physiologi-
cally stable throughout the operative event and
opportunities for smooth staging are not missed.
Special Considerations
Burn units combine wound care, general and
plastic surgery, and critical care expertise. This
combination of resources is useful for a number

Table 9. Common Contractures Seen in Critically Ill Burn Patients and Prevention Strategies

Burn Area Common Contracture Splinting and Positioning Strategy

Neck Flexion Daily ranging and extension splinting and conformers, split
mattress

Shoulder Adduction Daily ranging and abduction splinting with axillary splints or
troughs

Elbow Flexion and extension Daily ranging and alternating extension and flexion splints

Wrist Flexion and extension Daily ranging and splinting in functional position (20E of
extension)

Metacarpophalangeal joints Extension Daily ranging and splinting in functional position

(metacarpophalangeal joints at 70-90E with IP joints in
extension)

Hips Flexion Daily ranging and extension splints and prone positioning (if
tolerated)

Knees Flexion Daily ranging and knee splints and knee immobilizers

Ankles Extension Daily ranging and neutral splints

Metatarsophalangeal joints Extension Daily ranging and splinting in functional position, rocker
bottom shoes

137
CURRENT CONCEPTS IN ADULT CRITICAL CARE
of nonburn injuries and medical illnesses, and
nonburn patients are often referred to burn units.
Important points of critical care of such patients
are mentioned next.
Electrical Injury
Patients exposed to low (approximately 0-220
V) and intermediate (approximately 220-1,000
V) voltages may have severe local wounds but
rarely suffer systemic consequences.30 Those
exposed to high voltages (>1,000 V) commonly
suffer compartment syndromes, myocardial
injury, fractures of the long bones and axial
spine, and free pigment in the plasma that may
cause renal failure if not promptly cleared.
Patients suffering high-voltage electrical injury
should undergo cardiac monitoring, serial
examination for compartment syndromes,
examination and/or radiographic clearance
of the spine, and examination of the urine
for myoglobin. Fluid resuscitation initially
is based on burn size, but this generally does
not correlate well with deep tissue injury, so
resuscitations need to be closely monitored and
adjusted. Muscle compartments at risk should
be frequently monitored by serial physical
examinations. Fasciotomy should be performed
when an evolving compartment syndrome is
suspected. Wounds are debrided and closed with
a combination of skin grafts and flaps.
Tar Injury
Hot thermoplastic road materials are the source
of occupational injury. These highly viscous
materials are heated to between 300°F and
700°F. Wounds caused by these materials
should be immediately cooled by tap water
irrigation. Resuscitation is based on burn size
and then monitored. Wounds are dressed in a
lipophilic solvent and then debrided, excised,
and grafted. The underlying wounds are gener-
ally quite deep.
Cold Injury
Soft tissue necrosis from cold injury is due
to small vessel thrombosis and is generally
managed conservatively until the extent of
irreversible soft tissue necrosis is clear, which
may require several days. Patients who present
138
with body parts that do not reperfuse after thaw-
ing, and who have had an ischemia time less
than 24 hours, may benefit from early throm-
bolytic therapy.31 When injuries are definitely
demarcated, surgical debridement, excision
and reconstruction, or closure is carried out if
needed; lesser injuries often heal without need
for surgery. Cold-injured patients may manifest
consequences of systemic hypothermia, which
should be managed accordingly.
Chemical Injury
Patients can be exposed to a wide variety of
chemicals, which in industrial settings are often
heated. Clinicians must consider the thermal,
local chemical, and systemic chemical effects of
these agents.32 Consultation with poison control
centers for guidance regarding systemic effects
can be useful. Most agents can be washed off
with tap water irrigation for 30 minutes. It is
important to protect providers from secondary
exposure. Alkaline substances may take longer
than 30 minutes to wash off, as they are not as
water-soluble as acidic agents or most other
chemicals used in industry. When the soapy feel
that alkalis usually impart to the gloved finger
is gone, or when litmus paper applied to the
wound shows a neutral pH, irrigation can be
stopped. Concentrated hydrofluoric acid expo-
sure may result in dangerous hypocalcemia, and
subeschar injection of 10% calcium gluconate
and emergent wound excision may be appropri-
ate.33 Elemental metals should be covered with
oil, and white phosphorus should be covered in
saline to prevent secondary ignition. Both agents
can react explosively with water.
Toxic Epidermal Necrolysis
Toxic epidermal necrolysis is a syndrome that
entails a diffuse epidermal-dermal bonding
derangement of both cutaneous and visceral
epithelial surfaces.34 Patients commonly present
after a drug exposure, but this is not always the
case. When the syndrome involves primarily the
face, oral mucosa, and eyes and less than 30%
of the cutaneous surfaces, it is called Steven-
Johnson syndrome. Toxic epidermal necrolysis
is similar in presentation to a very large second-
degree burn. With good wound care, in most

patients the cutaneous wound will heal without
need for surgery. Involvement of mucosa of the
lung, gut, and genitourinary tract occurs and
often leads to sepsis and organ failures.35 The
disease runs an unpredictable time course but
usually is clearly resolving by 3 weeks in most
surviving patients.
Purpura Fulminans
Purpura fulminans is a complication of sepsis
with meningococcus, pneumococcus, or other
bacterial species, causing extensive soft tissue
necrosis. It has become less common since the
meningococcal vaccination became routine.
Purpura fulminans is believed to be secondary
to a transient protein-C deficiency–related
hypercoagulable state that occurs early in the
septicemic process, triggering small vessel
thrombosis and patchy soft tissue necrosis.
These patients present with sepsis-associated
organ failures and extensive deep wounds. Both
should be managed concurrently, since the
wounds are prone to infection if not promptly
excised and closed. Early antibiotic treatment
and source control are important.
Table 10. Conflicting Priorities Presented by Patients With Burn and Polytrauma
Area of Conflict
Neurological: Patients with burns and head injuries must have
cerebral edema controlled during resuscitation; pressure
monitors increase risk of infection.
Chest: Patients with blunt chest injuries and overlying burns
may require chest tubes through burned areas, with risk of
empyema and difficulty closing the tract.
Abdomen: Blunt abdominal injuries may be hard to detect if
there is an overlying burn. There is a high incidence of wound
dehiscence operating through a burned abdominal wall.
Orthopedic: Optimal management of a fracture may be
compromised by an overlying burn.
CRITICAL CARE OF THE BURN PATIENT
Soft Tissue Infections
Patients with soft tissue infections share many
characteristics of burn patients.36 When a soft
tissue infection is suspected, patients should
be taken to the operating room for explora-
tion of involved muscle compartments with
immediate debridement of involved tissue.
Operative goals include wide exposure of the
infection so that its anatomic extent can be
accurately described and its microbiological
characteristics can be determined by culture,
Gram stain, and biopsy. Debridement under
general anesthesia is repeated until infection is
controlled. Wounds are later closed with flaps
and grafts as appropriate. Broad-spectrum and
then focused antibiotics are important adjuncts.
Some patients, particularly those with clostridial
infection, may benefit from adjunctive hyper-
baric oxygen, but prompt surgery is the primary
therapeutic modality.
Combined Burns and Trauma
Burn care priorities often conflict with orthope-
dic, neurosurgical, and other trauma priorities.37
Thoughtful resolution of these differences is
an important part of successful management
(Table 10).
Consensus Resolution
A very tightly controlled resuscitation should be
conducted, with short-term placement of indicated
pressure monitors with antibiotic coverage.
A long subcutaneous tunnel should be used to decrease
trouble closing the tract, and tubes should be removed as
soon as possible to decrease risk of empyema.
Imaging should be used liberally to detect occult
injuries. Retention sutures should be routinely used after
laparotomy.
Most such extremities are best managed with prompt
excision and grafting of the wound with external fracture
fixation.
139
CURRENT CONCEPTS IN ADULT CRITICAL CARE
Summary
Patients with large burns can present the ICU
team with very challenging problems. Wound
care and surgical procedures must go on while
the team manages sepsis and organ failures.
Pain control can be very challenging. Despite
this, seriously burned patients can do extremely
well in the long term. Skillful critical care is an
essential element of patient salvage. Thoughtful
and technically skilled critical care not only
enhances rates of survival but also directly
affects the patient’s ultimate quality of life.
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