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hemoglobin A1 The remaining HbA1 species contain fructose1,6 diphosphate (HbA1a1); glucose-6-phosphate (HbA1a2); and unknown carbohydrate moiety (HbA1b) The hemoglobin A1c fraction is abnormally elevated in diabetic persons with chronic hyperglycemia Methods for measuring HbA1c include electrophoresis, cation-exchange chromatography, boronate affinity chromatography, and immunoassays Office-based immunoassays using capillary blood give a result in about 9 minutes and this allows for immediate feedback to the patients regarding their glycemic control Since glycohemoglobins circulate within red blood cells whose life span lasts up to 120 days, they generally reflect the state of glycemia over the preceding 8 12 weeks, thereby providing an improved method of assessing diabetic control The HbA1c value, however, is weighted to more recent glucose levels (previous month) and this explains why significant changes in HbA1c are observed with short-term (1 month) changes in mean plasma glucose levels Measurements should be made in patients with either type of diabetes mellitus at 3to 4-month intervals so that adjustments in therapy can be made if HbA1c is either subnormal or if it is more than 2% above the upper limits of normal for a particular laboratory In patients monitoring their own blood glucose levels, HbA1c values provide a valuable check on the accuracy of monitoring In patients who do not monitor their own blood glucose levels, HbA1c values are essential for adjusting therapy Data from the Diabetes Control and Complications Trial (DCCT) showed that there is a linear relationship between the HbA1c and the mean of seven-point capillary blood glucose profiles (preprandial, postprandial, and bedtime) Thus, mean plasma glucose levels of 170, 205, 240, and 275 mg/dL approximately correlate with HbA1c values of 7%, 8%, 9%, and 10%, respectively Use of HbA1c for screening is controversial Sensitivity in detecting known diabetes cases by HbA1c measurements is only 85%, indicating that diabetes cannot be excluded by a normal value On the other hand, elevated HbA1c assays are fairly specific (91%) in identifying the presence of diabetes The accuracy of HbA1c values can be affected by hemoglobin variants or derivatives; the effect depends on the specific hemoglobin variant or derivative and the specific assay used.

Burns are classified by extent, depth, patient age, and associated illness or injury Accurate estimation of burn size and depth will determine the adequacy of resuscitation

The rule of nines (Figure 37 2) is useful for rapidly assessing the extent of a burn More detailed charts based on age are available when the patient reaches the burn unit Therefore, it is important to view the entire patient after cleaning soot to make an accurate assessment, both initially and on subsequent examinations Only second- and third-degree burns are included in calculating the total burn surface area, since first-degree burns usually do not

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The survival from major burn injury has dramatically increased in the last 20 years Consistently, the three major risk factors for mortality were age greater than 60 years, burn area greater than 40% of total body surface area, and inhalation injury A good rule of thumb for predicting mortality after severe burn injury is still the Baux Score (age + percent burn, eg, age 50 years + 20% burn = 70% mortality), although this is obviously quite variable depending on associated medical factors Burn size, age, history of electrical injury, history of concomitant trauma (especially penetrating) and female sex as well as duration of stay in the ICU and the presence of mechanical ventilation presage a poorer outcome In ICU patients, low tidal volume ventilation improves ventilationperfusion mismatch and aggressive diagnosis of pneumonia facilitates targeted antibiotic therapy

Entire head and neck = 9% Posterior surface of upper trunk = 9%

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9% Entire arm = 9%

An injury commonly associated with burns is smoke inhalation (see 9) Suspicion of inhalation injury is aroused when the nasal hairs are singed, the mechanism of burn involves closed spaces, the sputum is carbonaceous, or the carboxyhemoglobin level exceeds 5% in nonsmokers This suspicion should lead the clinician to institute early intubation before airway edema supervenes The products of combustion, not heat, are responsible for lower airway injury Electrical injury that causes burns may also produce cardiac arrhythmias that require immediate attention Pancreatitis occurs in severe burns Prior alcohol exposure may exacerbate the pulmonary components of burn injury Toxic epidermal necrolysis (TEN) occasionally occurs following sulfonamide or phenytoin administration (see 6) If TEN is severe, patients are best transferred to a burn unit and treated as having severe burn injury Corticosteroid therapy should be avoided

Posterior surface of lower trunk = 9%

Posterior surface of each leg = 9%

9% 9%

and subclavian vein laceration when such a line is placed in a volume-depleted patient Femoral lines provide good temporary access during resuscitation Venous access catheters placed in the emergency department should be changed within 24 hours because of the high risk of nonsterile placement Distal saphenous cutdown is occasionally necessary An arterial line is useful for monitoring mean arterial pressure and drawing blood

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