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Key Features

Essentials of Diagnosis

  • Estimates of the burn location, size and depth greatly determine treatment plan

  • The first 48 hours of burn care offers the greatest impact on morbidity and mortality of a burn victim

General Considerations

  • Burns are classified by extent, depth, patient age, and associated illness or injury

  • Accurate estimation of burn size and depth is important, since these estimations will quantify the parameters of resuscitation

  • In adults, the "rule of nines" is useful for rapidly assessing the extent of a burn (Figure 37–2)

  • One rule of thumb is that the palm of an open hand of the patient constitutes 1% total body surface area (TBSA) in adults

    • Partial- and full-thickness burns are included in calculating the TBSA

    • Superficial burns (formerly called first-degree burns) usually do not represent significant injury in terms of fluid and electrolyte management or prognosis

  • However, superficial or partial-thickness burns may convert to deeper burns, especially if treatment is delayed or bacterial colonization or superinfection occurs

Figure 37–2.

Estimation of body surface area in burns.

Clinical Findings

Symptoms and Signs

  • Superficial burns (previously referred to as first-degree burns)

    • May be red or gray

    • Demonstrate excellent capillary refill

    • Are not blistered initially

  • Partial-thickness burns (previously second-degree) can be subdivided into superficial and deep

    • Superficial partial-thickness burn

      • Blistered

      • Appears pink and wet

    • Deep partial-thickness burns

      • Appear white and wet

      • Bleed if poked

      • Cutaneous sensation is maintained

  • Full-thickness burns (previously third-degree)

    • Result in a loss of adnexal structures

    • May appear white-yellow in color

    • May have a black charred appearance

    • The stiff, dry skin does not bleed when poked

    • Cutaneous sensation is lost


  • When burns exceeding approximately 20% of TBSA are present, systemic metabolic derangements may occur and require intensive support

  • The inflammatory cascade can result in shock and coagulopathy

  • Chest radiographs, usually normal initially, may show acute respiratory distress syndrome in 24–48 h with severe inhalation injury


  • Deep partial-thickness and full-thickness burns are treated in a similar fashion

    • Neither will heal appropriately without early debridement and grafting

    • Without such treatment, the resultant skin is thin and scarred

  • Telemedicine evaluation of acute burns offers accurate, cost-effective access to a burn specialist during the crucial 48 hours after the burn injury


  • Nonsteroidal anti-inflammatories (NSAIDs) and opioids are used in pain management

  • Evidence is increasing that ketamine is a good analgesic for burn patient

  • Fluid resuscitation: may be instituted simultaneously with initial resuscitation

    • Parkland formula for fluid requirement in first 24 h: lactated Ringer injection (4 mL/kg body weight per percent TBSA)

    • Electrical burns and inhalation injury increase fluid requirement

    • Adequacy of resuscitation determined clinically: urinary output and specific ...

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