After evaluation and resuscitation, the burn wounds are addressed.14 Initially in the ED, the wound is best covered with a clean, dry sheet. Later, small burns can be covered with a moist saline-soaked dressing while the patient is awaiting admission or transfer. The soothing effect of cooling on burns is most likely due to local vasoconstriction. Studies have shown that cooling stabilizes mast cells and reduces histamine release, kinin formation, and thromboxane B 2 production. In large burns, sterile drapes are better, as saline-soaked dressings applied to a large area can cause hypothermia. The admitting service should be consulted early. The use of antiseptic dressing should be avoided in the ED as the admitting service will need to assess the wound. If the patient is going to be transferred, the accepting burn unit should be contacted for specific instructions regarding burn care. Do not delay transfer for debridement of the wound. The transferring facility should utilize the regional burn center's treatment protocol.
Patients with circumferential deep burns of the limbs may develop compromise of the distal circulation. Distal pulses need to be monitored closely; a Doppler flow probe may be very helpful. If there is compromise to the circulation, escharotomy will be needed. The eschar needs to be incised on the midlateral side of the limb, allowing the fat to bulge through. This may be extended to the hand and fingers ( Fig 194-3). Escharotomy may provoke substantial soft tissue bleeding, often calling for electrocautery.
If there are circumferential burns of the chest and neck, the eschar may cause mechanical restriction to ventilation. An escharotomy of the chest wall needs to be done to allow adequate ventilation. Incisions need to be made at the anterior axillary line from the level of the second rib to the level of the twelfth rib. These two incisions should be joined transversely so that the chest wall can expand ( Fig 194-4).
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