Burns

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 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

Clinical Findings

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

• 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

• 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 ...