Complications Post Burns

Original Editor - Name

Top Contributors - Naomi O'Reilly, Manisha Shrestha, Abdulazeez Arowolo, Jess Bell and Chelsea Mclene  

Introduction

Burn injuries are under-appreciated injuries that are associated with substantial morbidity and mortality. The injuries can be caused by friction, cold, heat, radiation, chemical or electric sources, but the majority of burn injuries are caused by heat from hot liquids, solids or fire. Burn injuries are a significant problem with more than 500,000 people seeking medical treatment, 40,000 resultant hospitalizations, and 4000 deaths per year in the United States. The annual cost of treating these burns is estimated to be in excess of U.S. $ 1 billion, not including the indirect costs of disability and rehabilitation.

Burn injuries can have devastating sequelae that can cause long term morbidity. The best way to minimize complications is to manage burns in a dedicated burns center with immediate full multi-disciplinary involvement. Complications can be early or long-term, and local or systemic.

Systemic Complications

Systemic complications will arise secondary to the large inflammatory response produced by the body in response to the burn injury. Following a burn, there is an enormous production of reactive oxygen species (ROS) which is harmful and implicated in inflammation, systemic inflammatory response syndrome, immunosuppression, infection and sepsis, tissue damage, and multiple organ failure.Systemic effects will typically manifest in patients with burns of >25% total body surface area (TBSA) or often smaller proportions in children.

Burn Shock

Burn shock is a medical emergency that occurs when the body's tissues and organs are deprived of adequate oxygenated blood, which includes decreased cardiac output, increased vascular resistance, hypovolaemia and hypoperfusion that occur after severe burn injuries have been sustained.Inflammatory and vasoactive mediators such as histamines, prostaglandins, and cytokines are released causing a systemic capillary leak, intravascular fluid loss, and large fluid shifts. These responses occur mostly over the first 24 hours peaking at around six to eight hours after injury.

Infection

Burn wound infection is a common cause of morbidity and mortality in burn patients, particularly within disaster and conflict settings. Sepsis, or multiple organ dysfunction syndrome are the leading causes of late morbidity and mortality in traumatic brain injury. The catecholamine surge that follows a systemic insult is directly involved in the regulation of cytokine expression in situations of acute stress producing a worsening clinical condition and, ultimately, a poor outcome. The trauma-induced catecholamine surge affects systemic organs and contributes to organ damage.

Multisystem Organ Dysfunction

Multisystem Organ Dysfunction, a progressive disorder that commonly occurs in acutely ill patients, exists in a continuum with the systemic inflammatory response syndrome (SIRS) that affects most patients with severe burns, with or without an infection with increased risk seen with burn wounds >20 percent total body surface area, increasing age, male gender, sepsis, hypoperfusion, and under-resuscitation.

Specific organ injuries

• Acute lung injury – caused by a combination of burn and smoke inhalation, which can eventually lead to acute respiratory distress syndrome (ARDS)
• Acute kidney injury – multifactorial from a combination of SIRS, hypotension, myoglobinuria, and any iatrogenic nephrotoxic agents

• Endocrine complications – Direct fluid loss from the burns, third space losses, and kidney injury can lead to electrolyte imbalance, commonly results in initial hypernatraemia; subsequent hypokalaemia, hypomagnesaemia, hypocalcaemia, and hypophosphataemia
• Gastrointestinal complications – these include paralytic ileus, Curling’s ulcer, and bacterial translocation
  • Early enteral feeding often mitigates complications, aiming to maintain body weight and endocrine homeostasis

Compartment Syndrome

Compartment Syndrome, common both following burns or crush injuries, is a condition in which there is increased pressure within a closed osteofascial compartment, resulting in impaired local circulation. Without prompt treatment, acute compartment syndrome can lead to ischemia and eventually, necrosis, often resulting in the need for amputation if not adequately managed.

Orthopedic Complications

Heterotrophic Ossification

Heterotophic Ossification, also referred to as ectopic ossification and myositis ossificans, is the formation of pathological bone in muscle or soft tissue, which if severe can lead to ankylosis and impaired function. It usually presents around the joint, predominantly in the hip, with the first signs including swelling around the joint, reduced range of motion, with or without fever, spasticity and pain, which are similar clinical signs to those of fracture and deep venous thrombosis. Ultrasound, CT Scan or Bone Scan are used to provide a definitive diagnosis of heterotopic ossification, although blood tests may also give some indication.

Skin Complications

Hypertrophic Scarring, Keloid Formation and Contractures are unfortunately quite common following burn injury, and occur more frequently within low resource, disaster and conflict settings where access to ongoing treatment may be impacted.

Respiratory Complications

Respiratory complications, particularly those related to inhalation injury, occur as a result of direct cellular damage, alterations in regional blood circulation and perfusion, obstruction of the airways, and the release of pro-inflammatory cytokine and toxin release. This may cause reduced functionality of mucociliary clearance and weakening of alveolar macrophages, which places the patient at a high risk of bacterial infection, especially pneumonia.

Resources

Complications of Burn Injury

Rehabilitation of Burns Casualties