Re Burns,
Burns as a clinical enity are complex. I offer the following as a Cliff Notes brief explanation of burns and their treatment. There will be a lot left out.
Burns are classified as chemical, electrical, or thermal. Since thermal are the most common and the other two are special cases, we will stick to thermal. Burns are also classified by depth of injury from 1st degree (superficial) to third degree in which the entire thickness of the skin is involved. The important distinction between first and second vs third is that third degree burns require coverage by skin grafting. We will stick to third degree burns (this doesnt mean 2nd degree cant be problematic). The severity of burns and survival rates depend on the percent surface area of skin involved. Excluding critical areas ie. hands, feet, genitalia, face usually burns over 30% would be considered critical.
Burns can be associated with respiratory injury (smoke or toxic inhalation) particularly when the burn occurs inside an inclosure. Wood smoke contains aldehydes (including formaldehyde) and fires in nightclubs may release toxic fumes and carbon monoxide which kill very quickly. The presence of signs inflation of the upper respiratory system is a bad prognostic indicator.
The initial problem severe burns present is in fluid and electrolite management this is related to inflamation and loss of skin coverage which normally slows evaportive water loss from the body. Infection is surprisingly unusal even in 90% burn before the fifth day. The usual regimen calls for lo dose Penicillin to prevent Strep infections which can come early
The real trouble with extensive body burns is that it takes longer to graft a 90% burn than it does a 30% burn. Burn pts must use areas of their bodies which have not been burned to graft the burned areas. If thin split thickness grafts are used, the donor areas may be re-harvested after three weeks. As you can see a patient with 90% burns can only graft from a 10% area so total grafting takes many reharvestings.
Burn patients go into a hypermetabolic state in which they have tremendous caloric requirements. They are similar to advanced cancer pts in that they enter a negative nitrogen balance. It is very hard to keep up with these demands. This altered metabolic state persists until the patient gets coverage. The most serious consequence of this is on the immune system. The combination of large areas of exposed flesh and an impaired immune is the real problem in extensive burn survival because of the suseptability to all kinds of micro organisms.
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