 of all things. It can level an entire city to a smoking heap of rubble. It can consume vehicles and equipment. It can kill, maim, and scarify human beings. If and when it comes, nuclear warfare will result in many devastating fires and in a vast number of thermal casualties. Therefore, hospitals, medicine, nursing, and surgery will receive increased emphasis. This is true especially in the care and management of the thermally injured. No other form of trauma results in such extensive assaults on the human body as severe burns. The management of extensive burns calls for the utmost in professional skill and care. A knowledge of almost every principle taught in surgery is necessary for the treatment of severe burns. Most important are the procedures to be followed in the early supportive care of burned patients. Upon his arrival, a rapid assessment of the patient's condition is essential. The severity of the thermal injury is based on the percentage of body surface burned and the depth of the burn. A rapid method for estimating the percentage of body surface uses the rule of nines. Information obtained by this simplified rule is accurate enough for clinical purposes. In essence, the rule of nines divides the body surface into areas representing 9% or multiples of 9%. The head and neck represent 9% of the total body surface. The anterior trunk, 18%. The posterior trunk, 18%. Each upper extremity, 9%. Each lower extremity, 18%. And the perineum as 1% of the total body surface. For example, in this patient, it could be rapidly estimated that all areas of the legs were burned except for those around the knee and palpateal aspects of both extremities. This patient would have approximately a 14% total body surface burn on each leg. The depth of the burn, however, is often difficult to determine. Generally, second-degree burns are caused by hot liquids or by short flashes of intense heat. The affected areas appear pink or mottled red. Blister formation or weeping is typical. These second-degree burns are generally painful. This patient demonstrates a second-degree burn approximately 24 hours after injury. Notice the mottled red appearance of the skin. Third-degree burns, though, are more commonly caused by flame. They appear pearly white or charred. The wounds are generally dry and anesthetic. This area of third-degree burn is dry and anesthetic and has a characteristic pearly white appearance. Minor burns are considered to be second- degree burns, those which involve less than 15% of the total body surface or third-degree burns involving less than 2% of the total body area. Wounds of this extent may be treated on an outpatient basis. If there is minimal third-degree involvement, the patient can be later hospitalized for minor grafting procedures. Moderate burns are considered to be those with second-degree involvement of 15 to 30% of the total body surface or third-degree burns of less than 10% except for third-degree burns of the hands, face, and feet. Moderate burns can be treated in any local community hospital. Critical burns are considered to be burns that involve 30% or more of the total body surface. Third-degree burns of the face, hands, or feet. Third-degree burns involving more than 10% of the body surface. Burns complicated by respiratory tract injury, fractures, or major soft tissue injuries, and severe electrical burns. Critical burns should be treated in a general hospital. After the severity of the patient's burn has been determined, the more seriously injured will require certain immediate procedures. These include sedation as indicated, establishment of a venous lifeline, determination of the need for tracheotomy, insertion of an indwelling catheter, planning of fluid and electrolyte therapy, and initiation of antibiotic therapy and tetanus prophylaxis. Pain is not a prominent feature of extensive burns, but the sedative effect of a small dose of morphine is beneficial when given intravenously. It is safer to under sedate than to over sedate the burn patient. The establishment of a venous lifeline can be accomplished by the insertion of a needle into the vein. However, if intravenous fluids will be required over a long period of time, it is better to place a cut down in a peripheral vein. If no peripheral veins are available because of extensive burns of all extremities, a femoral catheter may be inserted as a last resort. After the femoral area has been cleaned and painted with antiseptic, it is draped as a sterile field, and a 13-gauge needle is inserted into the femoral vein. A polyethylene cannula is then threaded through the needle and passed up into the vena cava. The cannula must be inserted carefully so that it will not bend or kink. The polyethylene tubing should never be withdrawn through the needle because the tubing could be easily sheared off and lost inside the vein. The needle is then removed and the cannula permitted to remain. A smaller needle is now attached to the end of the polyethylene tubing and intravenous fluid therapy begun. Whenever respiratory damage is suspected, a tracheotomy must be performed shortly after the patient has received an extensive burn of the face. The presence of established respiratory difficulty may be diagnosed by hoarseness, coughing, or rapid respirations. Physical signs in the chest, such as ronkai or rowls, may or may not be present. A history of being burned in a closed space or the appearance of redness in the posterior pharynx may indicate respiratory damage. There are other indications for tracheotomy which present themselves after the emergency period of treatment. In fact, almost all appreciable burns of the face will require tracheotomy for the administration of anesthesia and to prevent further damage to the face by the repeated use of anesthetic masks. An indwelling urinary catheter must be inserted in all patients with burns involving more than 20% of the body surface. This assures an accurate means for measuring urinary output, a provision vital to the determination of the adequacy of initial fluid therapy. Urinary output should be maintained between 30 and 50 cubic centimeters an hour. Tentative plans must be made as to the type and amounts of replacement fluids. The BRIC fluid formula calculates the amount of fluid, electrolyte, and colloid solutions to be given after a burn during the first 24-hour period, in accordance with the weight of the patient in kilograms, and the extent and depth of the burn. The amount of colloid necessary for the first 24 hours is calculated as one half cubic centimeter per kilogram weight for each percent of burn. The calculated amount of colloid can be administered either as a plasma expander such as dextran or as whole blood when available. The amount of electrolyte solution is calculated as one and a half cubic centimeters per kilogram of weight for each percent of the total body surface burn. The electrolyte solution generally given is lactated ringers solution because it is more physiologic in its composition than normal saline. The amount of additional water to be given is relatively standard in adults, 2,000 cubic centimeters per day, being considered the normal daily requirement. This should be administered as glucose in water. During the second 24 hours post burn, patients ordinarily require one half the colloid and electrolyte requirements of the first 24 hours and approximately the same amount of additional water. It should be emphasized that any formula for estimating fluid therapy represents only the patient's probable needs and should not be followed arbitrarily. The fluid requirements for burns involving more than 50 percent of the body surface should be calculated as though only 50 percent burns were being treated. For moderate burns, much of the replacement therapy may be carried out by the oral route. A solution of 70 milli equivalents of sodium per liter can be rapidly prepared by adding one half teaspoon of soda and one half teaspoon of salt to a quart of water. The contents are then mixed thoroughly. This hypotonic solution is well tolerated when given cold. The amount of electrolyte added to the water is approximately three grams of sodium chloride and one and one half grams of sodium bicarbonate. For the larger burns, penicillin and streptomycin are added to fluids administered intravenously during the first 24 hours. Usually one million units of penicillin and one gram of streptomycin are given daily in divided doses. The broad spectrum antibiotics are generally not used initially. Tetanus toxoid or antitoxin is administered intramuscularly. Extensively burned patients continue to require intravenous therapy after the first 48 hours. Usually the patient needs very little electrolyte solution from the third to the tenth day post burn, but does require large quantities of 5% glucose in water. The serum sodium should not exceed 135 milli equivalents per liter. The amount of fluid and electrolyte therapy from the third to the tenth day post burn is determined from the patient's general condition, urinary output and blood chemistries. Frequent determinations of the serum sodium are essential in maintaining fluid and electrolyte balance during the first week post burn. The serum sodium should be kept lower than normal during the early post burn period. During this time, from the third to the tenth day post burn, frequent potassium determinations should also be made because large quantities of potassium are lost through the burn surface. Additional potassium to the extent of 80 to 120 milli equivalents a day must be administered if oral intake is inadequate. This can be accomplished by adding potassium chloride to the daily requirement of 5% glucose in water, which is to be given intravenously. During the weeks that follow an extensive burn, one or two units of blood per week will generally be required to maintain an adequate hematocrit of 45 or above. If supplemental calories and protein above and beyond those obtained from a regular diet are necessary, these needs can be met by the frequent administration of between meal drinks of high protein mixtures. Or a nasal gastric tube can be inserted and the patient fed by administration of as much high caloric and high protein supplement as his gastrointestinal tract can tolerate. By means of tube feeding, as much as 7,000 calories and 250 grams of protein can be given daily. In addition to being cared for physically, the patient must be treated emotionally as well. Throughout the early phase of burn therapy, he must be reassured as to the outcome of his injury. Relatives, however, can often be more apprehensive than the patient himself. The patient's family will also be more cooperative if they are given an accurate appraisal of his condition, as well as a clear explanation of the procedures required and the events anticipated in the management of an extensive burn. In summary, this general management in its early supportive care phase must include an accurate appraisal of the burn and an intensive adequate supportive therapy. Yes, the early supportive care of thermally injured patients is extremely vital to their eventual recovery. It is a continuing and changing procedure that should be adjusted to the fluctuating condition of the patient. As such, it demands the full-time and ability of all who are entrusted with the medical management of burn.