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

Lund and Browder Chart

• Good tool to document initial TBSA assessment

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 entire hand (palm+fingers) = about 1% TBSA
• 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)
7. Serial assessments for compartment syndrome

Treatment

• Burn Dressings

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. Consider a topical antimicrobial:
   1. Bacitracin, , neomycin, or mupirocin

      AVOID Silver Sulphadiazine as it may interfere with partial thickness healing and offers no healing advantage (inhibits keratinocytes)

4. Consider use of synthetic occlusive dressings (e.g. Tegaderm)
5. Provide followup 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. Indications based on TBSA
   1. Definite IV: Adults > 20%, Peds > 15%
   2. Perhaps IV: Adults 15-20%, Peds 10-15%
   3. Oral adequate: Adults < 15%, Peds < 10%
2. Goal is to give the least amount of fluid necessary to sustain organ perfusion (avoid "fluid creep")
3. Pts w/ inhalation injury and/or multisystem trauma often require more than Parkland amt
4. Parkland is only a guide; must titrate to pt's vitals/urine output
5. Types of fluids
   1. Many burn centers prefer LRs unless shock liver or hepatic failure suspected
   2. Colloids generally not used unless burns > 40% TBSA
   3. Do not use dextrose in adults (false uop), but children should receive small amounts due to small glycogen stores
6. Parkland:
   1. 4cc x wt (kg) x %BSA (2nd and 3rd degree 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) if age < 5 yrs old
      2. Give 1/2 in first 8 hr, remainder in next 16 hr
      3. Can consider giving D5 1/2 NS if pt < 20 kg to prevent hypoglycemia
7. Place Foley cath:
   1. Goal UOP:
      1. Adult: 0.5-1 mL/kg/hr (under or over-resuscitation [fluid creep] both decrease skin perfusion)
      2. Peds < 30 kg: 1-2 mL/kg/hr
      3. Peds > 30 kg: same as adult
         1. If UOP is greater than expected, consider glycosuria and reactive hyperglycemia as cause
      4. If myoglobinuria seen, double expected UOP until urine grossly clears (consider mannitol)
8. In burns > 40% in adults and > 30% in children < 5 yoa:
   1. Consider replacing 25% of IVF with FFP, so that total IV rate is unaltered through the 24 hrs post-burn
   2. In children, give 1/2 of total volume as FFP and 1/2 as LR throughout 24 hrs
   3. For infants < 2 yrs with > 30%, use 5% dextrose in LRs with the FFP
9. Burns > 50% or SEVERE metabolic acidosis may require 44 mEq of bicarb to each 1 L of LR in first 24 hrs, maintain bicarb > 18
10. Beyond 24 hrs:
    1. 24-48 hrs - pts require ~1/2 total volume given in first 24 hrs; change LRs to D5,1/2NS; give FFP 2 units for every liter of crystalloid
    2. 48-72 hrs - no formula; take into account TBSA/depth of burns (open partial thickness loss > full thickness with thick eschar), re-mobilization of 3rd space fluid beginning at this time

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

Burn Center Transfer

1. Partial thickness >20% BSA in 10-50
2. Partial thickness >10% BSA in <10 or > 50 yrs old
3. Full thickness >5% BSA in anyone
4. Burns involving face, eyes, ears, genitalia, joints
5. Burns complicated by confirmed inhalation injury
6. High voltage burn
7. Burns complicated by fx or other trauma (in which burn is main cause of morbidity)
8. Burns in high-risk patients

Hospital admission

1. Partial thickness 10-20% BSA 10-50 yrs old
2. Partial thickness 5-10% BSA in <10 or > 50 yrs old
3. Full thickness burns 2-5% BSA in anyone
4. High voltage injury
5. Circumferential burns of an extremity
6. Burns complicated by suspected inhalation injury
7. significant comorbidities
8. No major burn characteristics present

Outpatient Treatment

• 24-48hr

1. Partial thickness <10% BSA, age 10–50y
2. Partial thickness <15% BSA, age <10y or >50y
3. Full thickness <2% in anyone
4. No major burn characteristics present

See Also

• Electrical Injuries
• Lightning Injuries

Sources

• Pham T. et al. American Burn Association: American Burn Association Practice Guidelines burn shock resuscitation. J Burn Care Res 2008; 29:257
• Baxter C. et al. Fluid resuscitation, burn percentage, and physiologic age. J Trauma 1979; 19(11 Suppl):864-5
• Perry RJ et al. Rule of palms: Determining the approximate area of a burn: an inconsistency investigated and re-evaluated.BMJ. 1996 May 25; 312(7042): 1338.