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Laboratory evaluation may reveal dehydration; leukocytosis; elevated BUN; hyperuricemia; hemoconcentration; acid-base abnormalities (eg, lactic acidosis, respiratory alkalosis); and decreased serum potassium, sodium, calcium, and phosphorus Urine is concentrated, with elevated protein, tubular casts, and myoglobinuria Thrombocytopenia, fibrinolysis, and disseminated intravascular coagulopathy (DIC) may occur; coagulopathy is likely Rhabdomyolysis and myocardial, hepatic, or renal damage may be identified by elevated serum creatine kinase and aminotransferase levels and BUN and by the presence of anuria, proteinuria, and hematuria ECG findings may include ST T changes consistent with myocardial ischemia PCO2 may be less than 20 mm Hg

Treatment is aimed at reducing the core temperature rapidly (within 1 hour) while supporting organ system function Immersion in an ice-water bath (1 5 C) is the most effective cooling method but may not be practical due to its physical requirements and patient access limitations Evaporative cooling is a rapid and effective alternative and is easily performed in most emergency settings The patient s clothing should be removed and the entire body sprayed with water (20 C) while ambient or slightly warmed (45 C) air is passed across the patient s body with large fans or other means at high velocity (100 ft/min) The patient should be in the lateral recumbent position or supported in a hands-and-knees position to expose as much skin surface as possible to the air Also effective are use of cold wet sheets accompanied by fanning, immersion in chilled water, and localized ice or ice slush application Skin massage is recommended to prevent cutaneous vasoconstriction Intravascular heat exchange catheter

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The incidence and severity of burn injuries has been declining, with both deaths and acute hospitalizations attributable to burns down about 50% Over three-fourths of burns involve less than 10% of total body surface area Aggressive, early excision (24 72 hours postburn) of deeply burned tissues and skin grafting, early enteral feeding, and improved infection control have contributed to significantly lower mortality rates

and shorter hospitalizations Nonetheless, an estimated 125 million burn injuries and 51,000 acute hospitalizations of burn victims occur each year in the United States Serious burn injuries in children occur most frequently in those younger than 5 years As terror attacks increase around the world, a new population of multiply injured patients is emerging, fully 10% of them with pure burn wounds Severe burns cause problems in the initial phase from hemodynamic compromise, related injuries such as smoke inhalation or fractures, and associated microbacterial superinfection, sepsis and multiorgan failure Later, secondary scarring and constrictive wounds occur Significant quality of life and social functionality can be expected even for severely burned patients, although postdischarge wound care is necessary in a large number of patients, particulary the elderly

represent significant injury in terms of prognosis or fluid and electrolyte management However, first- or seconddegree burns may convert to deeper burns, especially if treatment is delayed or bacterial colonization or superinfection occurs

Judgment of depth of injury is difficult The first-degree burn may be red or gray but will demonstrate excellent capillary refill First-degree burns are not blistered initially If the wound is blistered, this represents a partial-thickness injury to the dermis, or a second-degree burn As the degree of burn is progressively deeper, there is a progressive loss of adnexal structures Hairs can be easily extracted or are absent, sweat glands become less visible, and the skin appears smoother Deep second- and third-degree burns are treated in a similar fashion, since neither will heal appropriately without early debridement and grafting; the resultant skin is thin and scarred The benefits of hyperbaric oxygen for treatment of acute burns remain unproven and anecdotal

FIGURE 10-12

Table 27 5 The Diabetes Expert Committee criteria for evaluating the standard oral glucose tolerance test1

Normal Glucose Tolerance Fasting plasma glucose (mg/dL) Two hours after glucose load (mg/dL) < 100 Impaired Glucose Tolerance 100 125 Diabetes Mellitus2 126

< 140

140 199

200

1 Give 75 g of glucose dissolved in 300 mL of water after an overnight fast in persons who have been receiving at least 150 200 g of carbohydrate daily for 3 days before the test 2 A fasting plasma glucose 126 mg/dL is diagnostic of diabetes if confirmed on a subsequent day

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