1 Initial Assessment, Resuscitation, Wound Evaluation and Early Care	7

permeability appears to resolve in 8–12 h post-injury. Typically, colloids are not recommended in the initial 12 h phase of resuscitation (however, there is no clear evidence as to the exact timing for initiation of colloids).

The colloid of choice is albumin (5 % concentration), given as an infusion to decrease the crystalloid requirements. There is some evidence that use of colloids in the resuscitation of the thermally injured patient does normalize the I/O ratios; however, the effect on morbidity and mortality is unknown at this time [36, 37]. In critical care literature, which typically excludes the burn patients, the studies have shown that the use of colloids is safe with no overall benefit to the patient [38], and the Cochrane review in 2011 concluded that “there is no evidence that albumin reduces mortality in patients with hypovolemia, burns or hypoproteinemia. For patients with burns or hypoproteinemia, there is a suggestion that albumin administration may increase mortality” [39]. So despite the extensive of use of albumin in burn resuscitation, there is paucity of evidence for its use, and the overall benefit remains controversial.

1.2.4.2 Hypertonic Saline

The role of hypertonic saline in burn resuscitation has been studied greatly with variable results. In recent years, there has been a shift in thinking in the use of hypertonic saline. Rather than using hypertonic saline as the sole resuscitative fluid with goals of reducing fluid requirements, it has been studied in the context of decreasing the inflammatory response and bacterial translocation and therefore infectious complications [40–42].

1.2.4.3 Antioxidants: High-Dose Vitamin C

It is well documented that following thermal injury, there is an increased in capillary permeability leading to edema. The initial studies conducted by Tanaka et al. and Matsuda et al. indicated the lower water content of burn wounds with high-dose vitamin C infusion, with decreased overall resuscitation fluid requirements [43–46]. More recently, studies have demonstrated that resuscitation with high-dose vitamin C reduces the endothelial damage post-thermal injury [47, 48], with decrease in overall fluid volumes administered with no increase in morbidity or mortality [48, 49].

In summary, the resuscitation of the burn patient is complex and requires use of all tools available. It can no longer be the domain of crystalloid resuscitation without consideration for colloids, hypertonic saline, and high-dose vitamin C along with other antioxidants. All aspects of burn shock requires treatment (not just the hypovolemic component), which might require the early use of vasopressors and inotropes. Finally, the end goals of resuscitation need to be better monitored to assess the effectiveness of the resuscitation and ensure improved patient outcomes.

1.3Evaluation and Early Management of Burn Wound

1.3.1Evaluation of Burn Depth

The evaluation of the burn wound is of utmost importance, and expert clinicians have been known to be incorrect in their assessment up to 30 % of the time.

8			S. Shahrokhi
Table 1.4 Clinical appearance of dermal and full-thickness burns
Clinical appearance	Superficial dermal	Deep dermal	Full thickness
Presence of blisters	Yes	Yes	No
Dermal depth	Papillary	Reticular	Entire depth
Color of exposed	Pink	Mottled/white	White/charred/
dermis			leathery
Capillary refill	Yes	Delayed/none	None
Time to heal	<21 days	>21 days	>21 days
Moisture	Moist	Dry	Dry
Pain	Very painful	Minimal to none	Insensate
Dermal appendages	Intact	Not intact	Not intact

As previously indicated, multiple modalities have been examined to determine their efficacy and possible role in the determination of the burn depth (Table 1.3), but none has replaced the clinical examination as gold standard.

In general, first-degree burns are of minimal concern. They only involve the epidermis with erythema and no blisters and do not require medical attention. Seconddegree burns (dermal burns) and beyond are those that will require medical attention. Dermal burns are divided into superficial and deep. Their clinical characteristics are summarized in Table 1.4.

The depth of the burn determines not only the requirement for admission but also the management – operative versus conservative. The ideal treatment for all burns, which will not heal between 14 and 21 days, is to have operative excision and skin grafting. All others can be treated conservatively. The conservative management of burns includes appropriate wound care and therapy for maintenance of range of motion and overall function.

1.3.2Choice of Topical Dressings

There are various topical agents that are available for management of burns. Typically, the topical management of deep burns requires an antimicrobial agent to minimize bacterial colonization and hence infection. For superficial burns, the goal of the topical agent is to reduce environmental factors causing pain and provide the appropriate environment for wound healing. Table 1.5 summarizes some of the agents available for topical treatment of burns, and the choice of agent is dependent on their availability and the comfort and knowledge of the caregivers.

The choice of burn dressing needs to take into account the following factors:

•Eliminate the environmental factors causing pain

•Act as barrier to environmental flora

•Reduce evaporative losses

•Absorb and contain drainage

•Provide splinting to maintain position of function

The goals of topical antimicrobial therapy for deep dermal and full-thickness burns:

•To delay/minimize wound colonization

•Have the ability to penetrate eschar

1 Initial Assessment, Resuscitation, Wound Evaluation and Early Care		9
Table 1.5 Topical therapy for treatment of cutaneous burns
Agent	Description
Bacitracin/polymyxin B	Ointment for superficial burns
Mupirocin	2 % Ointment for superficial burns
	Activity against MRSA
Biobrane	Artificial skin substitute bilayer – silicone film
	with a nylon fabric outer layer and a tri-
	filament thread with collagen bound inner
	layer
	For treatment of superficial dermal burns,
	Biobrane can be left intact until wound fully
	healed
	Reduces pain and evaporative losses
Aquacel Ag	Methylcellulose dressing with ionic silver for
	superficial dermal burns
	Can be left intact until wound fully healed
	Wound base needs to be clean for dressing
	adherence
Silver sulfadiazine	1 % cream for deep dermal and full-thickness
	burns
	Has broad spectrum of activity
	Intermediate eschar penetration
Mafenide acetate	Available as 11 % water-soluble cream or 5 %
	solution for deep dermal and full-thickness
	burns
	Has broad spectrum of activity, however,
	minimal activity against staphylococcus
	species
	Excellent eschar penetration
Acticoat	Sheet of thin, flexible rayon/polyester bonded
	with silver crystal-embedded polyethylene
	mesh
	Can be left on the wound for 3–7 days
	Has broad-spectrum activity

•Have activity against common pathogens

– S. aureus, Proteus, Klebsiella, E. coli, Pseudomonas

•Should not retard wound healing

•Have low toxicity (minimal systemic absorption)

1.3.3Escharotomy

In evaluation of wounds, consideration also needs to be given for possible need for escharotomy. All deep circumferential burns to the extremity have the potential to cause neurovascular compromise and therefore benefit from escharotomies. The typical clinical signs of impaired perfusion in the burned extremity/hand include cool temperature, decreased or absent capillary refill, tense compartments, with