Burns

Background

Burn Degrees

• 1st
  • red, tender, no blisters
  • two point discrimination intact
  • heals without scarring

• 2nd
  • Partial thickness
  • Superficial
    • Thin blisters
    • Heals without scarring in 2-3 wks
  • Deep
    • Thick blisters
    • 2 point discrimination decreased
    • Can feel pressure
    • Potential for scar/contractions
• 3rd
  • Full thickness
  • skin is white, leathery and anesthetic
  • always needs grafting
• 4th
  • 3rd degree + involves muscle, bone, or other deep structures

Rule of Nines

ADULTS

• Each area is 9% BSA:
  • Entire head and neck
  • Each arm including hand
  • Chest
  • Abdomen
  • Upper back
  • Lower back
  • Each front of leg
  • Each back of leg

1%: Genital region

CHILDREN

• Each area is 9% BSA:
  • Anterior head and neck
  • Posterior head an neck
  • Each arm including hand
  • Chest
  • Upper back
  • Lower back

• Each area is 13.5%:
  • Each leg (not broken up to front or back)

1%: Genital Region

Rule of Palms

• Pt's palm = 1%
• Use to estimate scatter burns
• Also use for local burns up to 10% BSA

Pre-Hospital

1) Assess for sings of inhalational injury

-Start humidified O2

-Intubation if necessary (below)

2) IVF (below)

3) Remove all burned/burning clothing, jewelry

4) Immerse wounds in cold water (1-5˚C)

-Only effective within first 30 mins)

-No direct ICE to wound

ED W/U

1) Basic labs

2) CO level

3) CN level if suspicious and/or empiric Tx (see below)

4) Work-up for associated trauma, if indicated

Management

1) Airway (Intubation below)

2) IVF (below)

3) Foley cath

4) Dress (saline/tap/petroleum gauze)

6) No IV Abx

7) Escharotomy (below)

8) H2 blocker (stress ulcer)

9) NG tube (gastroparesis)

10) No PPx abx; topical bacitracin OK

11) Td

12) Analgesia

13) Consider Transfer

I. INTUBATION GUIDELINES

1. Usual criteria

2. Hard signs

    -stridor

    -hoarseness

    -pharyngeal burns

3. Any 3 Soft Signs

    -H/O unconciousness

    -Noxious fumes at scene

    -Burn occuring in closed space

    -Facial burns

    -Carbonaceous sputum

    -CO level >15%

4. Additional

    -Need for large amnt analgesics

    -Transfer w/ potential decomp

II. FLUID RESUSITATION

If:

1) >20% BSA (2nd&3rd)

2) Evidence of shock

Total Fluids = Parkland + maint + blood loss

Parkland:

4 x kg x %BSA (2nd&3rd) = cc NS (or LR)

Give 1/2 in first 8hrs, remainder in next 16hrs

• From time of inital injury

Place Foley cath:

Goal =

Adult: UOP >30mL/hr

Peds: UOP >1mL/kg/hr

• CVP line indicated if h/o cardiopulmonary dz

IX. CYANIDE

Consider empiric tx for smoke inhalation victims with (any):

1) Hypotension

2) Metabolic acidosis

3) CV collapse

• Give sodium thiosulfate (12.5 mg) alone (given possiblility of CO also)

• • See also Tox: Cyanide/Sulfide

X. ESCHAROTOMY

1. Restriced ventilation

    -Anterior axillary line

    -2cm below clavicle to 10th rib

    -May connect (square)

2. Restricted perfusion (focal)

    -along long axis of hands, forearms, feet, fingers, toes if no pulse by doppler

    -Lateral on extremity

    -No perfusion, add medial

    *Bovie or scalpel

Disposition

TRANSFER CRITERIA (ABA 1994)

1. 2-3 deg >10% in pt <10 or >50yo

2. 2-3 deg >20% anyone

3. 3 deg >5% anyone

4. Complicating factors

    -Sig face/hand/feet/perineum/major joint

    -Circumferential burns

    -Inhalation injury

    -Concomitant trauma

    -Sig pre-existing dz

    -Sig electrical/chemical burn

• For moderate burns not meeting transfer criteria may admit

Source

8/07 DONALDSON (adapted from Bessen, Mistry); 3/10 DeBonis