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

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. Labs
2. CO level
3. CN level if suspicious and/or empiric Tx (see below)
4. Work-up for associated trauma, if indicated

Treatment

1. Airway (Intubation below)
2. IVF (below)
3. Foley cath
4. Dressing (saline/tap/petroleum gauze)
5. No PPxIV Abx; topical bacitracin ok
6. Escharotomy (below)
7. H2 blocker (stress ulcer)
8. NG tube (gastroparesis)
9. Td
10. Analgesia
11. Consider Transfer

Intubation Guidelines

• Any hard signs:
  • Stridor
  • Hoarseness
  • Pharyngeal burns
• 3 or more soft signs:
  • h/o unconciousness
  • Noxious fumes at scene
  • Burn occurring in closed space
  • Facial burns
  • Carbonaceous sputum
  • CO level >15%

Fluid Resuscitation

Indicated 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

• Place Foley cath:
  • Goal:
    • Adult: UOP>30mL/hr
    • Peds: UOP >1mL/kg/hr

• Consider CVP line if h/o cardiopulmonary dz

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 Cyanide

Escharotomy

• Restriced ventilation
  • Anterior axillary line
  • 2cm below clavicle to 10th rib
  • May connect (square)
• 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
   1. Sig face/hand/feet/perineum/major joint
   2. Circumferential burns
   3. Inhalation injury
   4. Concomitant trauma
   5. Sig pre-existing dz
   6. Sig electrical/chemical burn

• For moderate burns not meeting transfer criteria may admit

Source

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