Basics
Description
Burns represent an acute injury to the flesh.
Etiology
Burns can be classified into 7 categories
- Scalds: Hot liquids, grease, or steam
- Contact: Hot or cold surfaces
- Thermal: Fire or flames
- Radiation burns
- Chemical burns
- Electrical burns
- Friction burns: Road rash, rope burns
Diagnosis
Signs and Symptoms
- Most burns will have external signs of trauma to the skin
- Inhalation injury
- Facial burns, pharyngeal injection
- Singed nasal hair/eyelashes
- Carbonaceous sputum
- Change in respiratory mechanics (wheezing, coughing, tachypnea)
- Electrical and chemical burns may have minimal external findings (entry/exit wounds)
History
- AMPLE history, source of fire (plastic, wood, chemical, etc.), the location and surroundings, any explosions
- Medical/surgical/social history, medications, allergies, tetanus immunization status
- Carbon monoxide (CO) poisoning (most common cause of death in fires) from exposure to wood-based fires/combustion:
- Pulse oximetry unreliable in CO poisoning
- Cyanide poisoning from burning wool, silk, nylon, and polyurethane found in furniture/paper
Physical Exam
- Focus on airway 1st, then secondary survey for concurrent injuries
- Evaluate the face, oropharynx, and nares for signs of inhalation injury
- Assess need for immobilization of cervical spine (explosion or falls)
- Eye exam for corneal burns
- Estimate severity of partial- and full-thickness burns by assessing size/depth of burn
Specific patterns of injury may indicate nonaccidental injury (immersion wounds, cigarette burns, etc.)
Essential Workup
- Severity of the burn should be assessed by determining the size and depth of the burn
- Size is reported as percent involvement of total body surface area (TBSA) in 1 of 3 ways:
- 1: Rule of nines (applies only to adults)
- TBSA of body parts is estimated by multiples of 9%
- Adult estimates of percentage of TBSA
- Head and neck: 9
- Arms: Right, 9; left, 9
- Legs: Right, 18; left, 18
- Trunk: Front, 18; back, 18
- Perineum, palms: 1
- In infants and children, the head contributes more to the percentage of TBSA and legs contribute less.
- Infants/children
- Head and neck: 18
- Arms: Right, 9; left, 9
- Legs: Right, 14; left, 14
- Trunk: Front, 18; back, 18
- 2: Lund and Browder chart; divides body into areas and assigns percentage of BSA based on age; produces more reliable results than rule of 9s
- 3: Palm surface area; patients palm and fingers represent ~1% of TBSA
- Helpful in assessing irregular/scattered burns
- Superficial or 1st-degree (epidermis only) when: Local erythema, minimal swelling/pain, no initial blisters (may occur in 2-3 days); healing occurs in several days, no scar
- Partial-thickness or 2nd-degree burns (epidermis and dermis): Superficial partial-thickness or deep partial-thickness burns:
- Superficial partial-thickness burns (epidermis and superficial dermis)
- Often seen in scald burns
- Generally with blister formation, underlying skin is pink, moist, painful, good capillary refill, sensation intact
- Heals in 14-21 days, generally no scars
- Deep partial-thickness burns (epidermis and deep dermis)
- Skin may be blistered, with white to yellow dermis; absent capillary refill/pain sensation
- Heals via epithelialization within 3-12 wk, although may cause severe scaring and contractures requiring surgery
- Full-thickness or 3rd-degree burns (through epidermis and dermis)
- Skin is charred, leathery, and pale, no blisters, sensation is absent
- Will not heal spontaneously; will require surgical repair and skin grafting
- Full-thickness burns or 4th-degree burns (damage to underlying structures)
- Full-thickness + involvement of underlying fascia, muscle, bone, and other tissues
- Requires extensive d ©bridement/grafting
- Resultant disability
Diagnosis Tests & Interpretation
Lab
- Severe burns: CBC, serum electrolytes, glucose, BUN, creatinine, PT/PTT, type and crossmatch, and pregnancy test (if indicated)
- Blood gas with CO level for closed space or suspected inhalation exposures
- Cyanide level (if indicated)
Imaging
CXR
Diagnostic Procedures/Surgery
- Bronchoscopy to assess for inhalation injury
- ECG, especially in electrical burns, elderly patients
Differential Diagnosis
- Electrical injury
- Chemical injury
- Associated trauma or intoxication
Treatment
Pre-Hospital
- Stop the burning process, remove smoldering/contaminated clothes/jewelry
- Keep patient warm, cool affected areas
- Establish patent airway, frequent reassessment, start 100% oxygen
- Early intubation for respiratory distress
- Early IV fluid therapy, especially if >20% TBSA
- Institute pain relief, with narcotics if possible
- Protect the wound with clean sheets
- Transport to burn center (for major burns) if transport time <30 min
- Spinal immobilization if mechanism is concerning
Initial Stabilization/Therapy
- Airway control is paramount
- Early intubation for patients with signs of upper airway involvement, significant nasolabial burns, or circumferential neck burns
- IV access, supplemental 100% oxygen, monitor, pulse oximetry
- Evaluation for concurrent injuries
- Provide adequate analgesia
- Early fluid resuscitation is essential
Ed Treatment/Procedures
- Fluid resuscitation: Partial- and full-thickness burns (>20% TBSA)
- Parkland formula (not for pediatric patients): 4 mL of lactated Ringer solution (preferred) or normal saline (NS) per kilogram per percentage of BSA burned
- 1/2 in the 1st 8 hr and the remaining 1/2 over the next 16 hr
- Example: 70-kg patient with a 40% TBSA burn requires 4 mL — 70 kg — 40% = 11,200 mL over 24 hr, with 5,600 mL over 1st 8 hr or 700 mL/hr
- After the initial resuscitation, burns with >20% TBSA should have IV fluid therapy guided by invasive hemodynamic monitoring or urine output
- Maintain urine output of 0.5 mL/kg/hr for adults and 1 mL/kg/hr for children
- Escharotomy
- Circumferential burn eschar may lead to vascular or respiratory compromise
- Indications: Circulatory compromise of limb that does not improve with elevation, or respiratory compromise in circumferential chest wall burn
- Extremities: Incisions on extremities should be made medially and laterally along the long axis of the limb just superficial to the subcutaneous fat layer through the entire length of the burn eschar
- Chest wall: Make longitudinal incisions at anterior axillary line from the 2nd rib to the level of the 12th rib; connect with 2 transverse incisions across the chest
- Wound care:
- Cover the wounds with Polysporin or bacitracin ointment and nonadherent dressings
- Use silver sulfadiazine in contaminated/dirty wounds (avoid if transferring to burn center as interferes with later assessment of burn)
- Do not delay transfer to burn unit for wound care
- Prophylactic antibiotics not indicated
- Outpatient management of minor burns
- Sterile technique for cleansing and d ©bridement
- Pain control is almost always needed
- Remove loose, necrotic skin; d ©bride broken, tense, or infected blisters
- Topical antibacterial agents (e.g., silver sulfadiazine, bacitracin, mafenide acetate) recommended in deep partial-thickness or full-thickness burns only
- Consider collagenase (Santyl) in partial thickness wounds with eschar present; no need in 3rd-degree wounds; this lacks antibiotic properties
- 3-layer burn dressings should keep the wound moist and absorb exudate
- Inner layer should be nonadherent porous mesh gauze saturated with nonpetroleum-based lubricant, or a mild ointment (bacitracin or Polysporin) under a nonadherent porous gauze
- 2nd layer should be fluffed coarse-mesh gauze
- Outer wrap should keep the dressing in place without constricting
- Dressings should be changed at least daily
- Silver wound dressings (Silverlon and Acticoat)
- Thin coating of metallic silver applied to knitted fabric backing
- Requires dressing to remain moist
- May leave in place for up to 3 days
- Even minor burns need tetanus if indicated
- Parkland formula underestimates fluid requirements in children; the Galveston formula is more accurate
- 5,000 mL/m2 BSA burned + 2,000 mL/m2
- Use 5% dextrose in lactated Ringer solution IV over the 1st 24 hr; give 1/2 in the 1st 8 hr and the other 1/2 over the next 16 hr
- Titrate to goal urine output of 1 mL/kg/hr
- Consider nonaccidental trauma, particularly with burns on the back of hands or feet, buttocks, perineum, or legs
- Avoid hypothermia
- Children have greater body surface area/mass ratio and lose heat more rapidly
- Avoid hypoglycemia
- Children are more prone to hypoglycemia due to limited glycogen stores
- Significant morbidity to mother and child
- Fluid requirements may exceed estimations
- Fetal monitoring and early obstetric consultation recommended
Medication
- Bacitracin ointment: Apply 1-4 times per day
- Mafenide (Sulfamylon) acetate cream: Apply 1 or 2 times per day
- Narcotics, especially for d ©bridement of blisters and larger, severe burns
- Silverlon and Acticoat: Cut sheet to size of burn; moisten with sterile water
- Silver sulfadiazine cream: Apply 1-2 times per day
- Tetanus toxoid or immunoglobulin: 0.5 mL IM; 250 U IM once along with toxoid
- Santyl: apply to eschar/wound bed once daily
Follow-Up
Disposition
Admission Criteria
- Injuries requiring admission
- Partial-thickness burns of noncritical areas (excludes eyes, ears, face, hands, feet, or perineum) involving 10-20% of BSA in adults (>10 yr and <50 yr)
- Partial-thickness burns of noncritical areas involving 5-10% of BSA in children <10 yr
- Suspicion of nonaccidental trauma
- Patients unable to care for wounds in outpatient setting (e.g., homeless patients)
- Injuries requiring transfer/admission to a burn center
- Partial-thickness or full-thickness burns involving ≥10% of BSA
- Full-thickness burns involving >5% of BSA
- Partial-thickness and full-thickness of face, hands, feet, genitalia, perineum, or major joints
- Electrical burns, including lightning injury
- Significant chemical burns
- Inhalation injury
- Patients with pre-existing illness that could complicate management
- Patients with concomitant trauma or social barriers
Discharge Criteria
Partial-thickness burns of <10% of BSA in adults (<5% in children or the elderly) involving noncritical areas only. Patients must be reliable, able to manage wounds as outpatients and obtain follow-up.
Issues for Referral
Maintain low threshold for referral to burn specialist whenever there is raised concern regarding cosmesis, involvement of hands/face/eyes/perineum, or if burn is overlying a joint.
Followup Recommendations
1-2 days after the injury to assess for early infection, saturation of dressings, pain control
Pearls and Pitfalls
- Early IV fluid rehydration is essential
- Intubate early for signs of respiratory distress; must recognize potential for airway involvement
- Early pain control in all burns
- Monitor for hypoglycemia in children
Additional Reading
- Committee on Trauma, American College of Surgeons. Guidelines for the operation of burn units. Resources for Optimal Care of the Injured Patient; 2006:79-86.
- Pham TN, Cancio LC, Gibran NS. American Burn Association practice guidelines burn shock resuscitation. J Burn Care Res. 2008;29(1):257-266.
- Toon MH, Maybauer MO, Greenwood JE, et al. Management of acute smoke inhalation injury. Crit Care Resusc. 2010;12:53-61.
- Cancio LC, Lundy JB, Sheridan RL. Evolving changes in the management of burns and environmental injuries. Surg Clin North Am. 2012;92(4):959-986.
Codes
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]
- 949.4 Deep necrosis of underlying tissue [deep third degree] without mention of loss of a body part, unspecified
- 949.5 Deep necrosis of underlying tissues [deep third degree] with loss of a body part, unspecified
- 949 Burn, unspecified site
ICD10
- T20.00XA Burn of unsp degree of head, face, and neck, unsp site, init
- T30.0 Burn of unspecified body region, unspecified degree
- T30.4 Corrosion of unspecified body region, unspecified degree
- T21.00XA Burn of unsp degree of trunk, unspecified site, init encntr
- T22.00XA Burn unsp deg of shldr/up lmb, ex wrs/hnd, unsp site, init
- T24.009A Burn unsp deg of unsp site unsp lower limb, ex ank/ft, init
- T30 Burn and corrosion, body region 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)
- 314534006 Thermal burn (disorder)
- 423123007 Burn by fire (disorder)
- 423858006 scald of skin (disorder)
- 425656005 radiation burn (disorder)
- 426284001 Chemical burn (disorder)