Burns

Background

• Burns >60% BSA often a/w cardiac output depression unresponsive to fluids
• Inhalation injury is main cause of mortality
  • Half of pts admitted to burn centers develop ARDS

Burn Degrees

1. 1st Degree
   1. Only epidermis affected
   2. Red, tender, no blisters
   3. Heals w/o scarring in 7d
2. 2nd Degree
   1. Two types:
      1. Superficial partial thickness
         1. Epidermis + superficial dermis affected
         2. Blisters, painful
         3. Good perfusion of dermis w/ intact cap refill
         4. Heals w/o scarring in 14-21d
      2. Deep partial thickness
         1. Epidermis + deep dermis affected
         2. Blisters, painful, exposed dermis is pale white-yellow in color
         3. Burned area does not blanch (absent cap refill)
         4. May be difficult to distinguish from 3rd degree
         5. Heals w/ scarring in 3-8wk; may require skin-graft if do not heal w/in 21d
3. 3rd Degree
   1. Full thickness (epidermis + dermis)
   2. Skin is white, leathery, no pain
   3. Always requires skin grafting
4. 4th Degree
   1. 3rd degree + muscle, fat, bone involvement

Rule of Nines

Adults

Anatomic structure	Surface area
Anterior Head	4.5%
Posterior Head	4.5%
Anterior Torso	18%
Posterior Torso	18%
Each Anterior Leg	9%
Each Posterior Leg	9%
Each Anterior Arm	4.5%
Each Posterior Arm	4.5%
Genitalia/Perineum	1%

Children

Anatomic structure	Surface area
Anterior Head	9%
Posterior Head	9%
Anterior Torso	18%
Posterior Torso	18%
Each Anterior Leg	6.5%
Each Posterior Leg	6.5%
Each Anterior Arm	4.5%
Each Posterior Arm	4.5%
Genitalia/Perineum	1%

Rule of Palms

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

Pre-Hospital

• Assess for signs of inhalational injury
  • Start humidified O2
  • Intubate if necessary (below)
• IVF (below)
• Remove all burned/burning clothing, jewelry
• Immerse wounds in cold water (1-5˚C)
  • Only effective within first 30 mins
  • No direct ice to wound

Workup

1. Carboxyhemoglobin level
2. CO/CN levels
3. VBG, CBC, chem, total CK
4. CXR
5. ECG
6. UA (assess for myoglobinuria)

Treatment

Inpatient

1. Airway (see below)
2. IVF (see below)
3. Analgesia
4. Remove all rings, watches, jewelry, belts
5. Local burn care
   1. Contact burn center BEFORE applying any antiseptic dressings
   2. Small wound: moist saline-soaked dressing
   3. Large wound: sterile drape
6. Abx
   1. Topical abx but NOT IV abx is indicated
7. Foley cath
8. NGT
   1. Consider if partial-thickness burn >20% BSA (ileus frequently occurs)
9. Escharotomy (see below)
10. Tetanus vaccine

Outpatient

1. Cleanse burn w/ mild soap and water or dilute antiseptic solution
2. Debride wound as needed
3. Apply topical antimicrobial:
   1. 1% silver sulfadiazine cream (not on face or in pts w/ sulfa allergy) OR
   2. Bacitracin/triple-antibiotic ointment
4. Consider use of synthetic occlusive dressings (e.g. Tegaderm)
5. Provide f/u in 24–48hr

Intubation Guidelines

1. Full-thickness burns of the face or perioral region
2. Circumferential neck burns
3. Acute respiratory distress
4. Progressive hoarseness or air hunger
5. Respiratory depression
6. Altered mental status
7. Supraglottic edema and inflammation on bronchoscopy

Fluid Resuscitation

1. Pts w/ inhalation injury and/or multisystem trauma often require more than Parkland amt
2. Parkland is only a guide; must titrate to pt's vitals/urine output
3. Parkland:
   1. 4cc x wt (kg) x %BSA (2nd and 3rd only)= cc NS (or LR) over 24hr
      1. Give 1/2 in first 8hr, remainder in next 16hr
   2. Peds:
      1. Give Parkland + maintenance fluid (2-4cc/kg x %BSA)
      2. Give entire amount over 24hr
4. Place Foley cath:
   1. Goal UOP >1cc/kg/hr

Escharotomy

1. Indications
   1. Restricted ventilation
      1. Procedure
         1. Incise at ant axillary line from level of 2nd rib to 12th rib bilaterally
         2. Join these two incisions transversely
   2. Restricted perfusion (focal)
      1. Perform along midlateral portion of fingers/toes, extremities if no pulse by doppler

Disposition

1. Burn Center Transfer:
   1. Partial thickness >25% BSA, age 10–50y
   2. Partial thickness >20% BSA, age <10y or >50y
   3. Full thickness >10% BSA in anyone
   4. Burns involving hands, face, feet, or perineum
   5. Burns crossing major joints
   6. Circumferential burns of an extremity
   7. Burns complicated by inhalation injury
   8. Electrical burns
   9. Burns complicated by fx or other trauma (in which burn is main cause of morbidity)
   10. Burns in high-risk patients
2. Hospital admission:
   1. Partial thickness 15%–25% BSA, age 10–50y
   2. Partial thickness 10%–20% BSA, age <10y or >50y
   3. Full thickness burns <10% BSA in anyone
   4. No major burn characteristics present
3. Outpatient Treatment (w/ 24-48hr f/u)
   1. Partial thickness <15% BSA, age 10–50y
   2. Partial thickness <10% BSA, age <10y or >50y
   3. Full thickness <2% in anyone
   4. No major burn characteristics present

Source

Tintinalli