Burn Injury: Pitfalls to Recognize

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Burn injuries can be devastating and are the leading cause of accidental death and injury in this country. The American Burn Association (ABA) reports severe burn injuries affect almost one half million Americans annually, with 3,275 deaths yearly. Hospitalizations related to burn injury number approximately 40,000 each year in the United States, with 30,000 of those admissions to verified Burn Centers. Survival of a burn injury depends on many factors: Severity of the injury, total body surface area (TBSA) damaged, co-morbidities, availability of treatment and early interventions. Survival of burn victims has improved from historical average mortality of 50% to estimated 96.8% survival rate today, due to improved treatment.

Burns are defined by the World Health Organization as injury to the skin or other organic tissue primarily caused by: Heat from radiation, radioactivity, friction, electricity, or contact with chemicals. Respiratory damage from smoke inhalation is considered a burn injury. Burns can occur secondary to product failure, improper handling of chemicals, related to medical treatment, secondary to accidents, or arson; with innumerable causes some of which may involve negligence. Burns can be as minor as a sunburn and as severe as full thickness burns with bone involvement.

The skin is the largest organ of the body and comprised of three layers, the Epidermis, Dermis and Fat layer; and performs multiple functions: Protects the internal organs, muscles, nerves and blood supply from damages, protects against ultraviolet radiation damage, body’s first defense against infections, helps maintain water and electrolyte balance, participates in vitamin D synthesis, functions as part of the immune system, regulates temperature, provides padding, and stores energy.

Early intervention in treatment of burn patients is key to improved survival and must include aggressive fluid resuscitation of burns greater than 15% TBSA. The point is to ensure perfusion of the organs (liver, kidneys, etc.) to prevent multisystem organ failure (MODS) which enhances mortality. The Parkland/Baxter Formula, or Rule of Tens, are two guides used for fluid resuscitation. Adequacy of fluid resuscitation is monitored by blood pressure readings, particularly mean arterial blood pressure (MAP), an indicator of organ perfusion and urine output greater than 0.5 ml/kg/ hr. The second key to survival is monitoring for development of sepsis; a potentially life-threatening response to infection by the body. Damage to the protective layer of skin causes an inflammatory response, which can be overwhelming in patients with burns over 20% of their body and induce MODS per the National Institute of Health. Topical antibiotics are used proactively to burned areas to mitigate risk, with frequent dressing changes and monitoring of wound condition. Guidelines for referral to a Burn Center per ABA include:

  • Partial thickness burns greater than 10% of TBSA.
  • Burns involving face, hands, feet, or genitalia.
  • Third degree burns.
  • Electrical burns including lightening injury.
  • Chemical burns.
  • Inhalation injury.
  • Pre-existing comorbidities (i.e. chronic lung disease) complicating management, prolonging recovery, and affecting mortality.
  • Burns with concomitant trauma (fractures), increasing morbidity.
  • Children in facilities unqualified to treat pediatric patients.
  • Patients with special social, emotional or rehabilitation needs.

Documentation of treatment cohesive with guidelines for care of burn patients must be found should there be an adverse outcome associated with a burn injury. The American Journal of Medical Ethics reported in 2018, referral criteria, established with the best of intentions, has led to decreased ability/willingness to treat burns outside of Burn Centers. The report noted insufficient education in U.S. medical schools regarding treatment of burn patients; resulting in lack of preparation for first line providers in the medical community. Six states do not have burn centers including: Idaho, Montana, Wyoming, South Dakota, North Dakota and Alaska, making it challenging to meet guidelines.

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Burn survivors often have long term consequences such as permanent nerve and tissue damage, disfigurement, physical disability, loss of limbs, difficulty with thermoregulation, sensitivity to sunlight, chronic pain, and sequela of organ dysfunction (i.e. dialysis).

Evaluation of burn cases requires assessment of the cause of injury; was it associated with negligence? Was the medical treatment timely and appropriate? Common errors include: Delayed or inadequate fluid resuscitation, incorrect documentation of percent burned, leading to inadequate treatment, failure to monitor, failure to appropriately intervene, and failure to recognize complications of burn injury. Burn injuries must be assessed with knowledge of treatment criteria, allowing for recognition of treatment pitfalls, critical to making a case, or refuting one. Patty Mitchell

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