## Systemic Complications and Management of Severe Burns ### Inhalation Injury: Recognition and Management **Key Point:** Inhalation injury is present in 20–30% of hospitalized burn patients and significantly increases mortality (up to 60% with severe inhalation injury). **High-Yield:** Signs requiring early intubation: - Stridor (laryngeal edema) - Hoarseness - Singed nasal hairs - Carbonaceous sputum - Altered mental status - Enclosed space fire exposure **Clinical Pearl:** Early intubation (within 6–12 hours) is safer than delayed intubation once severe edema develops. Inhalation injury is a TRUE statement. ### Acute Kidney Injury in Burns **Key Point:** AKI in severe burns results from: 1. **Myoglobinuria** — from deep muscle necrosis (rhabdomyolysis) 2. **Hemoglobinuria** — from hemolysis 3. **Hypovolemia** — if resuscitation is inadequate **Mnemonic:** "BURN-AKI" — Burn-induced Acute Kidney Injury - **B**urns cause rhabdomyolysis - **U**rine becomes dark (cola-colored) - **R**igorous fluid resuscitation needed (target urine output 200–300 mL/hr if myoglobinuria present) - **N**ephrotoxic pigments (myoglobin, hemoglobin) - **A**cute tubular necrosis if untreated - **K**idney function monitored via creatinine, BUN - **I**ncreased mortality if AKI develops **Clinical Pearl:** Aggressive fluid resuscitation is the PRIMARY treatment — it dilutes urine and maintains renal perfusion. This statement is TRUE. ### Curling's Ulcer Prophylaxis **Key Point:** Curling's ulcer is a stress ulcer that occurs in severe burns (typically >20% TBSA) due to: - Splanchnic hypoperfusion - Increased gastric acid secretion - Mucosal ischemia **High-Yield:** Prophylaxis is indicated with: - **H2 blockers** (e.g., famotidine) - **Proton pump inhibitors** (e.g., omeprazole) — preferred in many centers - Early enteral nutrition (protective effect) **Clinical Pearl:** Incidence has decreased with modern resuscitation and early nutrition, but prophylaxis remains standard of care. This statement is TRUE. ### Escharotomy Timing: The Critical Error **Key Point:** Escharotomy is a surgical incision through the eschar (dead tissue) to relieve circumferential burn-induced compartment syndrome. **Warning:** The statement "Escharotomy should be performed immediately upon admission before fluid resuscitation" is INCORRECT. **Clinical Pearl:** Correct timing of escharotomy: - Performed **DURING or AFTER fluid resuscitation** has begun - Indicated when: - Circumferential burns of the chest restrict respiration - Circumferential burns of limbs cause vascular compromise (loss of pulses, cyanosis, pain) - Compartment pressures exceed perfusion pressure - **Timing:** Usually within 6–12 hours of admission, once resuscitation is underway - Performing escharotomy BEFORE resuscitation risks inadequate perfusion and worsening tissue damage **Mnemonic:** "ESCHAR-AFTER" — Escharotomy is performed AFTER (or during) resuscitation starts, not before. ### Table: Burn Complications and Management | Complication | Mechanism | Management | Timing | | --- | --- | --- | --- | | **Inhalation injury** | Thermal/chemical airway injury | Early intubation if stridor/hoarseness | Within 6–12 hrs | | **AKI/Myoglobinuria** | Rhabdomyolysis, hemolysis | Aggressive LR resuscitation, urine output 200–300 mL/hr | Immediate | | **Curling's ulcer** | Splanchnic ischemia, acid hypersecretion | PPI/H2 blocker prophylaxis, early nutrition | From admission | | **Compartment syndrome** | Circumferential eschar, fluid accumulation | Escharotomy during/after resuscitation | 6–12 hrs post-injury |
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