37-10: Thermal Burns

Worldwide, burns are a common cause of injury and potential morbidity and mortality. Burn prognosis is affected by the type of environment where the burn occurred. Low-resource settings (wilderness or low-income areas) are associated with delays in and suboptimal access to standard burn treatments.

Epidemiologic data on thermal burn injury show that the incidence and severity have been declining for both burn-related hospitalizations and deaths. Related injuries include smoke inhalation, fractures, and blast injuries. Subsequent problems include bacterial superinfection, sepsis, respiratory damage, and multiorgan failure; during later stages, problems include scar contractures and disfigurement.

The first 48 hours after thermal burn injury offer the greatest opportunity to impact the survival of the patient. Early surgical intervention, wound care, enteral feeding, glucose control and metabolic management, infection control, and prevention of hypothermia and compartment syndrome have contributed to significantly lower mortality rates and shorter hospitalizations. Research utilizing several different well-established burn severity scores has shown the importance of patient comorbidities to the prognosis of patients with severe burn injuries.

GENERAL CONSIDERATIONS

A. Classification

Burns are classified by extent, depth, patient age, and associated illness or injury. Accurate estimation of burn size and depth is necessary to quantify the parameters of resuscitation.

1. Extent

In adults, the “rule of nines” (Figure 37–2) is useful for rapidly assessing the extent of a burn. More detailed charts based on age are available when the patient reaches the burn unit. It is important to view the entire patient to make an accurate assessment of skin findings on initial and subsequent examinations (eFigure 37–3). This may prevent overutilization of transport to burn centers in patients with only minor burn injuries. One rule of thumb is that the palm of an open hand in adult patients constitutes 1% of total body surface area (TBSA). TBSA is calculated for partial- and full-thickness burns. Superficial (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.