Intensive care management and control of infection
Authors: Mark Ansermino, Carolyn Hemsley
Journal: BMJ (2004)

Intensive care managementThe goal in management of an acute burn is to limit the extent of the systemic insult.Intensive care management should not be seen as rescue for failed initial treatment but as a preventive measure in patients at high risk of organ failure.Intensive care units have the resources for improved monitoring and expertise in managing acute physiological changes.Intensive care management should not, however, become an obstacle to early aggressive surgical excision of the burn wound, which is associated with improved outcome. Airway burnsThe term "inhalational injury" has been used to describe the aspiration of toxic products of combustion, but also more generally any pulmonary insult associated with a burn injury.Patients with cutaneous burns are two to three times more likely to die if they also have lower airway burns.Death may be a direct result of lung injury but is usually due to the systemic consequences of such injury.It may be impossible to distinguish lung injury caused at the time of the burn directly to the lungs by a burn from injury due to the systemic consequences of the burn.Diagnosis of lower airway burns is largely based on the patient's history and clinical examination.Clinicians should have a high index of suspicion of airway burns in patients with one or more of the warning signs.Special investigations will support clinical suspicion.However, severity of injury or prediction of outcome is not aided by additional tests.The pathophysiology of airway burns is highly variable, depending on the environment of the burn and the incomplete products of combustion.The clinical manifestations are often delayed for the first few hours but are usually apparent by 24 hours.Airway debris-including secretions, mucosal slough, and smoke residue-can seriously compromise pulmonary function.There is no specific treatment for airway burns other than ensuring adequate oxygenation and minimising iatrogenic lung insult.Prophylactic corticosteroids or antibiotics have no role in treatment.Control of the airway, by endotracheal intubation, is essential before transporting any patient with suspected airway burn.Rapid fluid administration, with inevitable formation of oedema, may lead to life threatening airway compromise if control of the airway is delayed.Endotracheal intubation before oedema formation is far safer and simpler.Oxygen (100%) should be given until the risk of carbon monoxide toxicity has been excluded, since high concentrations of oxygen will clear carbon monoxide from the body more rapidly than atmospheric concentrations.Importantly, carbon monoxide toxicity may result in a falsely elevated pulse oximetry saturation.Airway burns are associated with a substantially increased requirement for fluid resuscitation.Reducing the fluid volume administered, to avoid fluid accumulation in the lung, results in a worse outcome.Invasive monitoring may be required to guide fluid administration, especially with failure to respond to increasing volumes of fluid.Adequate oxygen delivery to all the tissues of the body is essential to prevent multi-organ failure.