Page 92 - JSOM Summer 2022

antimicrobials for burn wounds, invasive gram-negative burn mimics the response to infection in several ways. Thus, burn
wound infection was the leading cause of death in this patient patients are often somewhat tachycardic, febrile, and have ele-
population. Appropriate wound care, to include topical anti- vated white blood cell counts even in the absence of infection.
microbial therapy, dressings, infection-control practices, and Alternate indicators of sepsis must be considered. A recent
early burn-wound excision, all promote healing by preventing study of adult burn patients identified six variables associ-
infection, maintaining a moist environment, limiting wound ated with sepsis and bacteremia: (1) heart rate > 130 beats
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progression, and protecting the wound surface. If evacuation per minute, (2) mean arterial pressure < 60mmHg, (3) base
is possible within the first 24 hours, the Prolonged Field Care deficit < −6mEq/L, (4) temperature < 36°C, (5) the use of vaso-
53
Clinical Practice Guidelines recommend covering burns with active medications, and (6) glucose > 150mg/dL. Specific risk
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clean, dry dressings and not opening intact blisters. If evac- factors that more accurately predict decreased quality of life
uation will be delayed beyond 24 hours, rapid wound care outcome scores in patients undergoing long-term burn wound
after injury is recommended. Basic wound care principles are care include urinary tract infection, venous thromboembolism,
applicable regardless of mechanism of injury. Detailed discus- renal failure, and other pulmonary complications. 54
sion of these principles can be found in the Wound Manage-
ment Prolonged Field Care Guidelines published by the Joint After initial resuscitation, special care should be taken to
Trauma System. 43 closely monitor and proactively treat issues related to pulmo-
nary, cardiovascular, and renal functioning. Acute respiratory
As part of a larger wound care strategy, topical antimicrobial distress syndrome (ARDS) occurs in about a third of intu-
therapy reduces the potential for systemic infection. Topical bated burn patients, as a result of inhalation injury, extensive
therapies allow for direct application to the burn wound of burns, pneumonia, or other factors. 55,56 ARDS is characterized
agents that would be toxic or ineffective if administered sys- by hypoxic respiratory failure secondary to diffuse alveolar
57
temically, or in concentrations well above their minimum in- damage and non-cardiogenic pulmonary edema. Accord-
44
hibitory concentrations. Additionally, hypoperfusion of the ing to the 2012 Berlin Definition, ARDS has the following
intact eschar limits tissue penetration of systemically admin- features: (1) acute onset or severe worsening of respiratory
istered antibiotics. Prior to application of topical antimicro- failure that takes place within a week of a clinical insult; (2)
bials, wounds should be thoroughly cleansed, and loose skin bilateral radiographic opacities that are not fully explained by
debrided with gauze and a chlorhexidine gluconate solution pulmonary effusions, pulmonary nodules, or pulmonary col-
in water. Once the initial wound cleaning is complete, topical lapse; and (3) not fully explained by cardiac failure or volume
antimicrobials should be applied. overload. When risk factors for ARDS are not clear, assessing
cardiac function (e.g., echocardiography) may aid in clarifying
Silver-containing topical antimicrobials, including creams the diagnostic picture. ARDS is classified as mild (PaO FiO 2
2/
and silver-impregnated dressings, are the most commonly ratio between 201 and 300mmHg), moderate (PaO /FiO ra-
2
2
used agents in the United States. Silver sulfadiazine cream is tio between 101 and 200 mmHg) and severe (PaO /FiO ratio
2
2
applied once or twice daily and covered with gauze. Silver ≤ 100mmHg). 58
45
nylon dressings are applied to clean wounds followed by a
gauze dressing, and are changed once every 3–5 days (more Acute kidney injury (AKI) may occur as a consequence of
often if needed). Mafenide acetate cream is a non-silver- burn shock or sepsis. AKI, manifested by periods of oliguria
46
47
based topical antimicrobial. Also applied once or twice daily, during burn shock and by increases in the creatinine level, is
mafenide is highly effective against gram-negative organisms. fairly common postburn even when fluid resuscitation is com-
48
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Consultation with the receiving medical treatment facility is petently performed. Recent literature has demonstrated the
recommended to determine the correct agent and duration of effective use of high-volume hemofiltration (HVHF) treatment
therapy based on patient condition, available resources, and to reverse shock and improve kidney functioning in septic
time to evacuation to a higher echelon of care. burn patients. 60
Fluid, electrolyte, and nutritional management of patients af-
Longitudinal Concerns
ter resuscitation is a complex issue. The calorie and protein
Several elements inform the long-term treatment of burn pa- requirements of burn patients are a function of burn size. In
tients. These include infection, organ failure, nutritional sup- those with burn size in excess of 30% TBSA, these require-
port, and pain and anxiety. ments are so great that Dobhoff tube feeding is almost always
required and is started as soon as the first postburn day.
Infection is the leading cause of death postburn, especially in
younger patients such as those of combatant age. 49,50,51 The Patients with burns will experience varying magnitudes of
risk of infection reflects the immunosuppression, which ac- pain and anxiety. The experience of pain varies due to multiple
companies the systemic inflammatory response to burns, and factors, including premorbid symptoms and conditions, men-
is a function of burn size. The continued presence of a large tal status, and anatomic and physiologic considerations. 61,62
open wound both drives the dysregulated immune response, The experience of pain may also impact the development of
and serves as a portal of entry for microorganisms. The pres- sequelae, such as anxiety and post-traumatic stress disorder
ence of invasive devices like central venous catheters, endo- (PTSD). A patient’s pain level must be closely monitored
63
tracheal tubes, and Foley catheters also contributes to risk. throughout the clinical course. Verbal and numerical scales or
Consequently, pneumonia, burn wound infection, and urinary charts may be used as reliable indicators of pain scales. 64
tract infection are common in these patients. 52
Moderate pain can be treated with oxycodone orally or enter-
Diagnosis of infection in patients with large burns can be par- ally as a first-line medication. Second-line interventions include
ticularly challenging because the systemic response to injury frequent, moderate IV doses of morphine or hydromorphone

90 | JSOM Volume 22, Edition 2 / Summer 2022