Thermal Injury Management

Simply considering surface burns may result in gross underestimation of the extent of internal thermal injury. Prediction of the current pathway by examining entrance and exit burns allows appreciation of which internal structures may have been involved.

Adherence to traditional resuscitation formulae for thermal burns can result in insufficient fluid administration. Administration of large volumes of fluid (often much larger than initially appreciated) may be required to compensate for large internal fluid losses into damaged tissues. Haemodilution from aggressive administration of crystalloid may require blood transfusion to ensure adequate circulating haemoglobin.

Early establishment of invasive monitoring is useful to assess and guide fluid resuscitation.

Initial course of action

Analgesia is required for all patients with electrical thermal injuries. Cutaneous burns should be photographed, dressed and, where appropriate, elevated. Plastic surgical consultation is required but should not delay or interfere with ongoing resuscitation.

Compartment syndrome

Compartment syndrome should be actively sought but can be difficult to distinguish from muscle ischaemia secondary to vascular injury. Vasospasm of limb arteries may be transient, but arterial thrombosis may present with distal ischaemia and infarction. Distal pulses, limb temperature and pain should be assessed regularly. Vessel injury requires vascular surgery consultation.

Skeletal muscle damage

Skeletal muscle damage results in electrolyte derangement and myoglobin release. Serum potassium, phosphate, calcium and creatine phosphokinase measurements are necessary and should be repeated if rhabdomyolysis is a possibility.

Urine output

Hyperkalaemia poses the main threat to myocardial stability. Myoglobin release produces a brown discolouration of the urine and impairs renal tubular function. Dipstick analysis of urine will demonstrate a false positive finding for haematuria in the presence of myoglobin. Maintenance of adequate renal perfusion by restoring circulating volume and blood pressure helps to prevent renal failure. Alkalisation of the urine may also have a role. Ultimately if renal failure ensues haemofiltration may be required.

Systemic inflammatory response syndrome

Severely burned patients demonstrate evidence of a systemic inflammatory response syndrome. SIRS may develop with resulting multi organ dysfunction. Early effective resuscitation of the patient with severe electrical injury may reduce the incidence of multi organ dysfunction and failure.