Once diuresis begins the emergent phase is over, and the burn patient stops dying of shock and starts dying of infection and catabolism. Recognise burn sepsis when the temperature is low rather than high, match the topical to the wound, calculate the protein that actually closes a burn, and position the patient against the contracture that comfort would give them.
Day 6 · 45 percent TBSA flame burnYou are handed a stable-looking patient. Tick every finding that is present on your assessment. Three of these are reassuring and the rest are not — and in a burn patient the usual signs of infection are unreliable, so the picture you build here is the whole diagnosis.
The wound
The patient
Which topical, and why?
The most extreme hypermetabolic state in medicineResting energy expenditure can approach twice normal, peaking around days 5–7 and persisting for months after the wounds close. Catecholamines, cortisol and glucagon drive gluconeogenesis, insulin resistance and relentless skeletal-muscle catabolism. If you do not feed this patient, they will burn their own diaphragm.
When does feeding start?
The position of comfort is the position of contractureBurned tissue contracts into flexion, and a patient left comfortable will fuse into a useless posture. Rehabilitation begins on day one, not at discharge. For each burned area, choose the position you splint into.
How do you position and splint it?
0
findings of burn sepsiswaiting for a fever loses hours
Topical antimicrobials — and what each one does to your patient
Agent
Penetration
Nursing implications
Prophylactic systemic antibiotics are not given. They select resistant organisms without reducing wound infection. Control is topical, plus early excision and grafting — taking full-thickness eschar to a viable bed within the first several days is the single biggest advance in burn survival, because it removes the culture medium.
Protein per day
105–140 g
1.5–2 g/kg/day — collagen is protein
Calories per day
1,750–2,450
25–35 kcal/kg/day, plus a burn factor
Curreri estimate
3,550 kcal
25 kcal/kg + 40 kcal per %TBSA — the older formula, kept because it still shows the magnitude
Route
Enteral
early feeding preserves gut mucosal integrity and reduces bacterial translocation