Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 37-10: Thermal Burns + Key Features Download Section PDF Listen +++ +++ 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 are necessary to 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, particularly in cases of treatment delays, bacterial colonization, or superinfection ++ Figure 37–2. Estimation of body surface area in burns. Graphic Jump LocationView Full Size||Download Slide (.ppt) + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Superficial burns May be red or gray Demonstrate excellent capillary refill Are not blistered initially Partial-thickness burns 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 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 + Diagnosis Download Section PDF Listen +++ ++ Burns greater than approximately 20% of TBSA may lead to systemic metabolic derangements requiring 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 + Treatment Download Section PDF Listen +++ ++ Deep partial-thickness and full-thickness burns are treated in a similar fashion Both require early debridement and grafting to heal properly Without such treatment, the skin becomes 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 +++ Medications ++ Nonsteroidal anti-inflammatories (NSAIDs) and opioids are used in pain management Evidence is increasing that ketamine is a good analgesic for burn patients 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 is determined clinically: urinary output and specific gravity, blood pressure, pulse, temperature, and central venous catheter Half of calculated fluid is given in first 8-h period (measured from hour of injury); remaining fluid, split in half, delivered over next 16 h Very large volume of fluid may be needed Avoid overly aggressive crystalloid administration in patients with pulmonary injury or cardiac dysfunction Colloid administration is not warranted in routine burn resuscitation in view of its deleterious effect on glomerular filtration and its association with pulmonary edema +++ Surgery ++ Because full-thickness circumferential burn may develop ischemia under constricting eschar, escharotomy incisions can save life and limb Early excision and grafting of burned areas are critical, as soon as 24 h after injury or when patient will hemodynamically tolerate the procedures Wounds that do not heal in 7–10 days (ie, deep partial-thickness or full-thickness burns) are best treated by excision and autograft +++ Therapeutic Procedures ++ Establish airway; evaluate for other injuries Administer supplemental oxygen Intubate if smoke inhalation injury suspected Establish vascular access Large bore peripheral venous catheter access is established Subclavian lines must be avoided in emergency setting in volume-depleted patients because of the risk of pneumothorax and subclavian vein laceration Femoral lines provide good temporary access during resuscitation if central venous access is needed Venous access catheters placed in the emergency department should be changed within 24 hours because of the high risk of nonsterile placement An arterial line is useful for monitoring mean arterial pressure and for drawing blood in critically ill patients Fasciotomy is indicated to prevent further soft tissue, vascular, and nerve damage when soft tissue edema produces high pressures in the deep tissue compartments in the arms and legs Tetanus status should be verified and updated in all burn patients Clean burned areas thoroughly daily Topical antibiotics may be applied after wound cleansing Silver nylon dressings have been shown to be beneficial in decreasing length of stay, controlling pain and preventing infection Transparent film or biosynthetic dressings can be reserved for clean superficial and partial thickness burns An indwelling urinary catheter is essential for monitoring urinary output Monitor smoke inhalation injuries with serial blood gas determination and bronchoscopy Burn patients require extensive support Maintain normal core body temperature (by maintaining environmental temperature at or above 30 °C) in patients with burns over more than 20% of total body surface area Enteral feedings may be started once the ileus of the resuscitation period has resolved, usually the day after the injury If the patient does not tolerate low-residue tube feedings, total parenteral nutrition should be started without delay through a central venous catheter Most patients can be fed adequately with energy equal to 100% to 120% of estimated basal energy expenditure A useful guide is to provide 25 kcal/kg body weight plus 40 kcal per percent of burn surface area Early aggressive enteral nutrition reduces infections, noninfectious complications, length of hospital stay, impaired healing, and mortality + Outcome Download Section PDF Listen +++ +++ Complications ++ Consider comorbid conditions Suspect smoke inhalation injury when nasal hairs are singed, mechanism of burn involves closed spaces, sputum is carbonaceous, or carboxyhemoglobin level is > 5% in nonsmokers Electrical injury May cause deep tissue burns without significant superficial skin findings May also produce cardiac arrhythmias that require immediate attention Pancreatitis and stress ulcers occur in severe burns Abdominal compartment syndrome is a potentially lethal condition in severely burned patients Multiorgan system failure Nearly all burn patients have one or more septicemic episodes during hospital course; gram-positive infections initially, Pseudomonas infections later +++ Prognosis ++ The Prognostic Burn Index Determined by the sum of the patient's age and percentage of full thickness or deep partial thickness burn Most useful at the extremes of age An additional 20% mortality is added if inhalation injury is present The following factors have significantly reduced mortality rates and shortened hospitalizations: Recent treatment advances, including improvements in wound care and treatment of infection Early surgical intervention, including early burn excision and skin substitute usage Early nutritional support through parenteral or enteral feeding Glucose control and metabolic management Prevention of hypothermia and compartment syndrome +++ When to Refer ++ Transfer to a burn unit is indicated for Large burn size (for partial-thickness burns, > 10% of TBSA or for full-thickness burns, > 5% of TBSA) Circumferential burn Inhalation injury Burn involving a joint or high-risk body part (face, hands, feet, genitalia) Patients with comorbidities +++ When to Admit ++ All severe burn patients require extensive supportive care, both physiologically and psychologically Significant burns (based on location and extent), comorbidities, or suboptimal home situations Burn center consultation can advise which patients require transfer and which can be managed via telemedicine/telephone consultation Monitoring includes vital signs, wound care and observation for potential complications of electrolyte abnormalities, acute kidney injury, liver failure, cardiopulmonary compromise, hyperglycemia, and infection + References Download Section PDF Listen +++ + +Chao KY et al. Respiratory management in smoke inhalation injury. J Burn Care Res. 2019 Jun 21;40(4):507–12. [PubMed: 30893426] + +Jayawardena A et al. Early surgical management of thermal airway injury: a case series. J Burn Care Res. 2019 Feb 20;40(2):189–95. [PubMed: 30445620] + +Otterness K et al. Emergency department management of smoke inhalation injury in adults. Emerg Med Pract. 2018 Mar;20(3):1–24. [PubMed: 29489306] + +Pham CH et al. The role of collagenase ointment in acute burns: a systematic review and meta-analysis. J Wound Care. 2019 Feb 1;28(Sup2):S9–15. [PubMed: 30767636] + +Reid A et al. Inhalational injury and the larynx: a review. Burns. 2019 Sep;45(6):1266–74. [PubMed: 30529118] + +Smith RR et al. Analysis of factors impacting length of stay in thermal and inhalation injury. Burns. 2019 Nov;45(7):1593–9. [PubMed: 31130323]