A 54-year-old woman is brought to the emergency department after sustaining severe burns from a deep fryer explosion that occurred when she attempted to deep fry a frozen turkey. Temperature is 36 C (96.8 F). Blood pressure is 102/64 mm Hg and pulse is 110/min. The patient is alert but in severe pain. Examination reveals partial- to full-thickness burns of the face, neck, anterior chest and abdomen, and all 4 extremities. Intravenous access is obtained, and crystalloid resuscitation is administered, along with analgesia. The patient is brought to the burn unit, where her wounds are cleansed and dressed using topical antimicrobial ointment. During the subsequent treatment of this patient's burn injuries, which of the following is most likely to decrease the patient's risk for developing infection?
Patients with severe burn injuries have multiple risk factors for wound infection and sepsis, including disruption of the skin's protective barrier, burn-induced immunosuppression, and the presence of necrotic tissue (ie, burn eschar), which serves as an avascular, protein-rich substrate for bacterial and fungal proliferation. To control the level of bacterial colonization on burned areas, topical antimicrobial agents are typically applied during regular dressing changes. However, most topical agents cannot penetrate eschar, resulting in the eschar serving as a potential nidus for infection.
Removal of eschar through early (eg, within 5 days of injury) wound excision and grafting reduces the risk of both noninvasive and invasive burn wound infections.
In the operating room, layers of devitalized tissue are progressively removed until capillary bleeding is encountered (ie, tangential excision).
This is followed by application of split thickness skin grafts or, if graft donor sites are unavailable, other temporary coverage (eg, cadaveric skin, manufactured skin substitutes).
Due to the high blood loss caused by excision and grafting, a series of smaller procedures is typically performed in patients with large body surface area involvement.
(Choice A) Early nutritional support can offset hypermetabolism and improve overall outcomes in patients with severe burn injuries. However, parenteral (ie, intravenous) nutrition is typically avoided because it is associated with higher rates of infection and mortality compared to enteral (eg, via feeding tube) nutrition.
(Choice C) Hyperbaric oxygen therapy increases the plasma partial pressure of oxygen and is sometimes used to treat chronic, ischemic wounds (eg, diabetic foot ulcers) or as an adjuvant treatment for severe soft tissue infections (eg, necrotizing fasciitis). However, increased plasma oxygen levels cannot penetrate burn eschar because it is devascularized. Therefore, eschar removal is a better next step for both infection prevention (ie, source control) and promotion of wound healing.
(Choice D) Even for severe burns, systemic antibiotics are not used prophylactically because they do not prevent burn sepsis (ie, invasive infection) but instead may select for more aggressive, antibiotic-resistant bacteria.
(Choice E) Wound compression therapy can decrease hypertrophic scarring (rather than infection) in patients with severe burns. It is generally used only after burned areas have fully healed, whether by epithelialization or skin graft adherence.
Educational objective:
In patients with severe burn injuries, early excision of necrotic tissue and wound closure (eg, skin grafting) reduces the risk of burn wound infections.