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1180 PART 10: The Surgical Patient

producing skeletal deformities in children are frequent long-term Critical Care
sequelae. There are also late sequelae of electrical trauma in which the CHAPTER
etiology is unknown. Cataracts occur in 1% to 2% of victims even though of the Burn Patient
the current path did not necessarily involve the head and neck. 123
Rehabilitation into society and gainful employment are the ultimate Barbara A. Latenser
objectives of the care of these patients. Subtle mental status and person-
ality changes may severely affect the patient’s motivation and participa-
tion in rehabilitation programs that are crucial to optimal function.
38
Rehabilitation for such patients is often emphasized, as amputation KEY POINTS
is often the only management option for patients with extensive soft- • Focusing burn care in centers with an entire team dedicated to the
tissue injury as a result of high-voltage electrical injuries. Workforce burn patient has resulted in burn research that has led to improved
reentry represents a significant postinjury patient rehabilitation mile- physical and psychosocial outcomes, fewer complications, better
stone and should be guided by consultation with the employer, patient, pain management strategies, and shorter lengths of hospital stay.
coworkers, and experienced occupational medicine and rehabilitation • Airway evaluation and management strategies in patients with inhala-
teams. There is a paucity of studies which measure the successful rate tion injury and/or a large thermal injury differ from nonburn patients.
of electrical injury patients’ reentry into their premorbid jobs, and
the rates of return to work varies from 5.3% to 56%. 39,40-43 Although • Ventilator management strategies for burn patients must include
one study evaluating postinjury quality of life for electrical injury the same ventilator-associated pneumonia (VAP) bundle and the
patients found that patients were generally successful in returning daily sedation vacation to assess readiness for extubation that is
to their previous employment after injuries, the majority of studies used in nonburn patients. In addition, specific assessment of air-
42
suggests that patients sustaining either high- or low-voltage injuries way edema must be performed.
have quite poor long-term outcomes with high levels of emotional • Burn shock is a physiologic insult combining hypovolemic and
distress, persistent neuropsychological and cognitive changes, and distributive shock. The optimal patient outcome is provided by
physical complaints. 23,41,43 proper fluid resuscitation using large bore peripheral intravenous
access and urine output monitored by a Foley catheter.
• Prophylactic systemic antibiotic therapy does not prevent systemic
KEY REFERENCES infection but daily wound cleansing with soap and water followed
by topical antimicrobial therapy is efficacious.
• Ahrenholz DH, Schubert W, Solem LD. Creatine kinase as a prog- • Patients with burns >20% total body surface area who have a
nostic indicator in electrical injury. Surgery. 1988:104(4):741. transpyloric feeding tube placed on admission and high-protein
• Arnoldo BD, Purdue GF, Kowalske K, et al. Electrical injuries: a feedings continued throughout operative procedures have better
20-year review. J Burn Care Rehabil. 2004;25:479-484. wound healing and shorter length of hospital stay.
• Better OS, Stein JH. Early management of shock and prophylaxis • The primary goal for wound care is wound closure. Full-thickness
of acute renal failure in traumatic rhabdomyolysis. N Engl J Med. burns should be excised within the first 7 days, and treated with auto-
1990;322:825. grafting if appropriate or allografting/xenografting/dermal replace-
• Brown CV, Rhee P, Chan L, et al. Preventing renal failure in ment therapy if the burn size is too great for immediate autografting.
patients with rhabdomyolysis: do bicarbonate and mannitol make • Burn pain is best treated with intravenous opioids and longer acting
a difference? J Trauma. 2004;56:1191-1196. analgesic agents. Anxiolytics should also be used to decrease pain
• Chudasama S, Goverman J Donaldson JH, van Aalst J, Cairns BA, and for procedures such as hydrotherapy.
Hultman CS. Does voltage predict return to work and neuropsy- • Rehabilitation therapy begins at admission for optimal outcomes,
chiatric sequelae following electrical burn injury? Ann Plast Surg. including positioning, splinting, early mobilization even while on
2010;64:522-525. the ventilator, and strengthening to promote healing.
• Gottlieb LJ, Saunders J, Krizek TJ. Surgical technique for salvage
of electrically damaged tissue. In: Lee RC, Cravalho EG, Burke JF,
eds. Electrical Trauma: Pathophysiology. Cambridge, England:
Cambridge University Press; 1990. INTRODUCTION
• Holliman CJ, Saffle JF, Kravitz M, et al. Early surgical decom- The goal of this review is to provide an overview of some of the most
pression in the management of electrical injuries. Am J Surg. important critical care issues and approaches that are unique to burn
December 1982;144(6):733-739. patients when compared to the general intensive care unit population.
• Lee RC, Cravalho EG, Burke JF. Electrical Trauma: The The critically burned patient differs from other critically ill patients in
Pathophysiology, Manifestations, and Clinical Management. many ways, the most important being the necessity of a team approach
Cambridge, England: Cambridge University Press; 1991. to patient care. The burn patient is best cared for in a dedicated burn
• Monafo WW, Freedman BM. Electrical and lightning injury. In: center where resuscitation and monitoring concentrate on the patho-
Boswick JA Jr, ed. The Art and Science of Burn Care. Baltimore, physiology of burns, inhalation injury, edema formation, and potential
University Park Press, 1988. complications associated with burn and inhalation injuries. Early opera-
• Robinson NM, Chamberlain DA. Electrical injury to the heart tive intervention and wound closure, metabolic interventions, early
may cause long-term damage to conducting tissue: a hypothesis enteral nutrition, and glucose control have led to continued improve-
and review of the literature. Int J Cardiol. 1996;53:273. ments in outcome. Prevention of complications such as hypothermia,
compartment syndromes, and contractures is part of burn critical care.
While expert opinion may have been the driving force behind current
burn care standards and guidelines, continuing research driven by level
REFERENCES I data is the wave of the future in the care of the burn patient.
Major strides in understanding the principles of burn care over
Complete references available online at www.mhprofessional.com/hall the last half century have resulted in improved survival rates, shorter

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