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Burns

- Transfer to burn center for (3)[C] - 2nd- and 3rd-degree burns >10% of BSA in patients <10 years and >50 years of age - 2nd-degree burns >20% of BSA and full-thickness burns >5% BSA in any age range - 3rd-degree burns in any age group - Burns of hands, feet, face, or perineum - Electrical or lightning burns - Inhalation injury - Chemical burns - Circumferential burn - Burns in patients with additional trauma (fractures, etc.) in which the burn is the more severe injury; otherwise, send to trauma center for stabilization. - Burn injuries in patients with preexisting medical conditions that could affect management, mortality, or recovery

- Inhalation injury - Intubation, ventilation with positive end-expiratory pressure assistance - Hyperbaric oxygen treatment may be useful in patients with carbon monoxide levels >25%, patients with coma, focal neurologic deficit, ischemic ECG changes, and pregnant patients (1)[C].

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Pediatric Considerations

Consider child abuse or neglect when dealing with hot water burns in children; abuse accounts for 15% of pediatric burns. Special concerns are sharply demarcated wounds, immersion injuries, and suspect stories. Involve child welfare services early.

EPIDEMIOLOGY

  • Predominant age: 30 years; 13% infants; 11% >60 years of age
  • Predominant gender: males account for 70%

Incidence

Per year in the United States

  • 1.2 to 2 million burns; 700,000 emergency room visits; 45,000 to 50,000 hospitalizations; 3,900 deaths owing to burn-related complications
  • In children: 250,000 burns; 15,000 hospitalizations; 1,100 deaths
  • Estimated total cost of $2 billion annually for burn care
  • House fires cause 75% of deaths.
  • Burn deaths decreasing nationally due to improved prevention and treatment
  • Increase in burns from the illegal production of methamphetamines. Patients can present with a combination of chemical burn, thermal burn, and explosion injury.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Open flame and hot liquid are the most common causes of burns (heat usually ≥45 °C): flame burns more common in adults; scald burns are more common in children.
  • Caustic chemicals or acids (may show little signs or symptoms for the first few days)
  • Electricity (may have significant injury with very little damage to overlying skin)
  • Excess sun exposure

RISK FACTORS

  • Water heaters set too high
  • Workplace exposure to chemicals, electricity, or irradiation
  • Young children and older adults with thin skin are more susceptible to injury.
  • Carelessness with burning cigarettes: related to 18% of fatal fires in 2006
  • Inadequate or faulty electrical wiring
  • Lack of smoke detectors: Lacking or nonfunctioning smoke alarms are implicated in 63% of residential fires.
  • Arson: cause of 12.4% of fires that resulted in fatalities in 2012

GENERAL PREVENTION

Home safety education should be a key mechanism for injury prevention.

  • Families educated on home safety were more likely to have safe hot water temperatures.
  • Safety education results in more families having functioning smoke alarms and increased use of fireguards.

COMMONLY ASSOCIATED CONDITIONS

Smoke inhalation syndrome

  • May involve thermal burn to respiratory mucosa (e.g., trachea, bronchi) as well as carbon monoxide inhalation
  • Occurs within 72 hours of burn
  • Should be suspected in all burns occurring in an enclosed space or exposure to explosions

DIAGNOSIS

HISTORY

  • History of source of burn
  • In children or elderly: Check for consistency between the history and the burn's physical characteristics.

PHYSICAL EXAM

  • 1st degree: Erythema of involved tissue, skin blanches with pressure, skin may be tender.
  • 2nd degree: Skin is red and blistered, skin is very tender.
  • 3rd degree: Burned skin is tough and leathery; skin is nontender.
  • Rule of 9s (1)[C]Each upper extremity: adult and child 9%Each lower extremity: adult 18%; child 14%Anterior trunk: adult and child 18%Posterior trunk: adult and child 18%Head and neck: adult 10%; child 18%
  • Quick estimate: The surface area of the patient's hand (palmar surface plus fingers) is 1% of the body surface area (BSA).
  • Careful documentation of extent of burn and the estimated depth of burn
  • Check for any signs suggestive of potential airway involvement: singed nasal hair, facial burns, carbonaceous sputum, progressive hoarseness, inflamed oropharynx, circumferential burns around the neck, tachypnea

DIAGNOSTIC TESTS & INTERPRETATION

  • Children: glucose (hypoglycemia may occur in children because of limited glycogen storage)
  • Smoke inhalation: arterial blood gas, carboxyhemoglobin
  • Electrical burns: ECG, urine myoglobin, creatine kinase isoenzymes

Initial Tests (lab, imaging)

  • Labs: hematocrit; type and crossmatching; electrolytes, including BUN and creatinine; urinalysis
  • Imaging: Chest radiograph; Xenon scan is useful in suspected smoke inhalation.

Diagnostic Procedures/Other

Bronchoscopy may be necessary in smoke inhalation to evaluate lower respiratory tract (2)[A].

TREATMENT

  • Prehospital care (1)[C]Remove the patient from the source of burn.Extinguish and remove all burning clothing.Room-temperature water may be poured onto burn but only in the first 15 minutes following burn exposure.Wrap patient to prevent hypothermia.All patients to receive 100% oxygen via face mask
  • Hospitalization for all serious burns2nd-degree burns >10% of BSAAny 3rd-degree burnBurns of hands, feet, face, or perineumElectrical or lightning burnsInhalation injuryChemical burnsCircumferential burn
  • Transfer to burn center for (3)[C]2nd- and 3rd-degree burns >10% of BSA in patients <10 years and >50 years of age2nd-degree burns >20% of BSA and full-thickness burns >5% BSA in any age range3rd-degree burns in any age groupBurns of hands, feet, face, or perineumElectrical or lightning burnsInhalation injuryChemical burnsCircumferential burnBurns in patients with additional trauma (fractures, etc.) in which the burn is the more severe injury; otherwise, send to trauma center for stabilization.Burn injuries in patients with preexisting medical conditions that could affect management, mortality, or recovery

GENERAL MEASURES

  • Based on depth of burns and accurate estimate of total BSA involved (rule of 9s)
  • Tetanus prophylaxis (if not current)
  • Remove all rings, watches, and other items from injured extremities to avoid tourniquet effect.
  • Remove clothing and cover all burned areas with dry sheets.
  • Flush area of chemical burn (for ~2 hours).
  • For all major burns, use 100% oxygen administration; consider early intubation.
  • Do not apply ice to burn site.
  • Nasogastric tube (high risk of paralytic ileus)
  • Foley catheter
  • Analgesia
  • ECG monitoring in first 24 hours following electrical burn
  • Whirlpool hydrotherapy followed by silver sulfadiazine (Silvadene) occlusive dressings in severe burns
  • Daily or BID cleansing with dressing changes
  • Burn fluid resuscitation (1)[C]Calculate fluid resuscitation from time of burn, not from time treatment begins.2 to 4 mL lactated Ringer — body weight (kg) — % BSA burn (1/2 given in first 8 hours, in second 8 hours, and in third 8 hours); in children, this is given in addition to maintenance fluids and is adjusted according to urine output and vital signs. Protocol-based resuscitation leads to superior outcomes.Colloid solutions are not recommended during the first 12 to 24 hours of resuscitation (1)[C],(4)[A].Other: Use of biologic membranes or skin substitutes may be indicated for burn coverage.
  • Inhalation injuryIntubation, ventilation with positive end-expiratory pressure assistanceHyperbaric oxygen treatment may be useful in patients with carbon monoxide levels >25%, patients with coma, focal neurologic deficit, ischemic ECG changes, and pregnant patients (1)[C].

MEDICATION

First Line

  • IV morphine or hydromorphone (Dilaudid) for severe pain
  • Oral analgesics, such as acetaminophen (Tylenol) with codeine, acetaminophen with oxycodone (Percocet), or acetaminophen with hydrocodone (Lortab) for moderate pain
  • Silver sulfadiazine (Silvadene): Apply topically to burn site (can cause leukopenia). Do not use in sulfa-allergic patients, women who are pregnant/breastfeeding, or infants < 2 months)
  • Neosporin or bacitracin ointment: Apply to facial burns.
  • Mupirocin: has potent inhibitory activity against methicillin-resistant Staphylococcus aureus (MRSA) (5)[B]
  • Acticoat A.B. (a dressing consisting of 2 sheets of high-density polyethylene mesh coated with nanocrystalline silver) has a more controlled, prolonged release of silver, allowing less frequent dressing changes (5)[B].
  • Electrical burn with myoglobinuria will require alkalinization of urine and mannitol.
  • Consider H2 blockers (e.g., famotidine) or proton pump inhibitors (e.g., lansoprazole, pantoprazole) for stress ulcer prophylaxis in severely burned patients.
  • Tetanus toxoid/tetanus immunoglobulin
  • There is no clear indication for prophylactic systemic antibiotics (5)[B].
  • Use of negative pressure wound therapy may result in a low-protease environment with higher levels of angiogenic factor (vascular endothelial growth factor [VEGF]) during wound healing, leading to more chaotic, hyperkeratinized, thickened epidermis when compared with a standard hydrocolloid dressing (6)[C].

Second Line

  • Mafenide (Sulfamylon) for full-thickness burn, best against Pseudomonas (Caution: metabolic acidosis, painful)
  • Silver nitrate 0.5% (messy, leeches electrolytes from burn, causes water toxicity)
  • Povidone-iodine (Betadine) may result in iodine absorption from burn and "tan eschar,"ť makes d ©bridement more difficult.
  • Travase (enzymatic debridement)

SURGERY/OTHER PROCEDURES

  • Escharotomy may be necessary in constricting circumferential burns of extremities or chest due to compartment syndrome.
  • Tangential excision with split-thickness skin grafts: Early excision of burns results in a significant reduction in mortality (excluding patients with inhalational injury) and a significant decrease in hospital length of stay (7)[B].
  • Various dressings (e.g., biosynthetic, biologic) are available to help reduce the number of dressing changes and promote healing.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Early mobilization is the goal.

DIET

  • High-protein, high-calorie diet when bowel function resumes
  • Nasogastric tube feedings may be required in early postburn period.
  • Total parenteral nutrition if NPO is expected for >5 days
  • Early initiation of enteral nutrition in the first 24 hours of admission results in shorter intensive care unit (ICU) stay and lower wound infection rates

PATIENT EDUCATION

  • Use of sunscreen: Skin grafts or newly epithelialized skin is highly sensitive to sun exposure and thermal extremes.
  • Prevent access to electrical cords/outlets.
  • Isolate household chemicals.
  • Use low-temperature setting for water heater (<54 °C).
  • Household smoke detectors with special emphasis on maintenance
  • Family/household evacuation plan
  • Proper storage and use of flammable substances
  • Burn management: http://www.aafp.org/afp/2000/1101/p2029.html
  • Burn prevention: http://www.aafp.org/afp/2000/1101/p2032.html

PROGNOSIS

  • 1st-degree burn: complete resolution
  • 2nd-degree burn: epithelialization in 10 to 14 days (deep 2nd-degree burns probably will require skin graft)
  • 3rd-degree burn: no potential for reepithelialization; skin graft is required.
  • Baux score (sum of age and TBSA burned) and Denver 2 score (pulmonary score ranging 0 to 3, using PaO2/FiO2 cutoffs of 100, 175, and 250), renal score (0 to 3, using creatinine cutoffs of 1.8, 2.5, and 5.0 mg/dL), hepatic score (0 to 3, using bilirubin cutoffs of 2, 4, and 8 mg/dL), and cardiac score (0 to 3, based on number and dosage of inotropes) can be used to estimate mortality (8)[B].
  • Length of hospital stay and need for ICU care depend on extent of burn, smoke inhalation, comorbidities, and age.
  • Burn size is correlated to complications; >60% TBSA burned in children and >40% in adults are at increased risk for mortality and morbidity (8)[B].
  • A 50% survival rate can be expected with a 62% burn in patients aged 0 to 14 years, 63% burn in patients aged 15 to 40 years, 38% burn in patients aged 40 to 65 years, and 25% burn in patients >65 years of age (1)[C].
  • 90% of survivors can be expected to return to an occupation comparable to their preburn employment.

COMPLICATIONS

  • Gastroduodenal ulceration (Curling ulcer)
  • Marjolin ulcer: malignant squamous cell carcinoma developing in old burn site
  • Signs of infection: discoloration, green fat, edema, eschar separation, and conversion of 2nd-degree to 3rd-degree wound
  • Biopsy is the best way to diagnose wound infection.
  • Burn wound sepsis: most commonly S. aureus (including MRSA), vancomycin-resistant enterococci, and gram-negative organisms (5)[B].
  • Pneumonia
  • Decreased mobility with possibility of future flexion contractures
  • Hypertrophic scarring common with burns.

REFERENCES

11 Teague H, Swencki SA, Tang A. The burned patient: assessment, diagnosis, and management in the ED. Trauma Reports. 2005;6(2):1-12.22 Dries DJ, Endorf FW. Inhalation injury: epidemiology, pathology, treatment strategies. Scand J Trauma Resusc Emerg Med. 2013;21:31.33 Bezuhly M, Fish JS. Acute burn care. Plast Reconstr Surg. 2012;130(2):349e-358e.44 Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2013;(2):CD000567.55 Church D, Elsayed S, Reid O, et al. Burn wound infections. Clin Microbiol Rev. 2006;19(2):403-434.-66 Caulfield RH, Tyler MP, Austyn JM, et al. The relationship between protease/anti-protease profile, angiogenesis and re-epithelialisation in acute burn wounds. Burns. 2008;34(4):474-486.77 Ong YS, Samuel M, Song C. Meta-analysis of early excision of burns. Burns. 2006;32(2):145-150.88 Jeschke MG, Pinto R, Kraft R, et al. Morbidity and survival probability in burn patients in modern burn care. Crit Care Med. 2015;43(4):808-815.

CODES

ICD10

  • T30.0 Burn of unspecified body region, unspecified degree
  • T30.4 Corrosion of unspecified body region, unspecified degree

ICD9

  • 949.0 Burn of unspecified site, unspecified degree
  • 949.1 Erythema [first degree], unspecified site
  • 949.2 Blisters, epidermal loss [second degree], unspecified site
  • 949.3 Full-thickness skin loss [third degree nos]
  • 949.5 Deep necrosis of underlying tissues [deep third degree] with loss of a body part, unspecified
  • 949.4 Deep necrosis of underlying tissue [deep third degree] without mention of loss of a body part, unspecified

SNOMED

  • 125666000 Burn (disorder)
  • 403190006 First degree burn (disorder)
  • 403191005 Second degree burn (disorder)
  • 403192003 Third degree burn (disorder)
  • 284196006 burn of skin (disorder)

CLINICAL PEARLS

  • 1st degree: erythema of involved tissue; skin blanches with pressure. Skin may be tender.
  • 2nd degree: Skin is red and blistered. Skin is very tender.
  • 3rd degree: Burned skin is tough and leathery. Skin is not tender.