Burns

Background

• Burns >60% BSA often associated with cardiac output depression unresponsive to fluids
• Inhalation injury is main cause of mortality
  • Half of patients admitted to burn centers develop ARDS

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

Clinical Features

1st Degree

• Only epidermis affected
• Red, tender, no blisters
• Heals without scarring in 7d

2nd Degree

Two types:

• Superficial partial thickness
  • Epidermis + superficial dermis affected
  • Blisters, painful
  • Good perfusion of dermis with intact cap refill
  • Heals without scarring in 14-21d
• Deep partial thickness
  • Epidermis + deep dermis affected
  • Blisters, painful, exposed dermis is pale white-yellow in color
  • Burned area does not blanch (absent cap refill)
  • Sensation diminished to light touch and pinprick but normal pressure sensation
  • May be difficult to distinguish from 3rd degree
  • Heals with scarring in 3-8wk; may require skin-graft if do not heal within 21d

3rd Degree

• Full thickness: epidermis + dermis + hypodermis
• Skin is white, leathery, no pain
• Always requires skin grafting

4th Degree

• 3rd degree + muscle, fat, bone involvement

Differential Diagnosis

Burns

• Burn
  • First degree
  • Second degree
  • Third degree
  • Fourth degree
• Smoke inhalation injury (airway compromise)
• Chemical injury
  • Acrolein
  • Hydrochloric acid
  • Tuolene diisocyanate
  • Nitrogen dioxide
• Systemic chemical injury
  • Carbon monoxide toxicity
  • Cyanide toxicity
• Electrical injury

Vesiculobullous rashes

Febrile

• Diffuse distribution
  • Varicella
  • Smallpox
  • Disseminated gonococcal disease
  • DIC
  • Purpural fulminans
• Localized distribution
  • Necrotizing fasciitis
  • Hand-foot-and-mouth disease

Afebrile

• Diffuse distribution
  • Bullous pemphigoid
  • Drug-Induced bullous disorders
  • Pemphigus vulgaris
  • Phytophotodermatitis
  • Erythema multiforme major
• Localized distribution
  • Contact dermatitis
  • Herpes zoster
  • Dyshidrotic eczema
  • Burn
  • Dermatitis herpetiformis
  • Erythema multiforme minor
  • Poison Oak, Ivy, Sumac dermatitis
  • Bullosis diabeticorum

Evaluation

Lund Browder Chart to document initial TBSA assessment.

Workup

• Carboxyhemoglobin level
• Carbonmonoxide/cyanide levels
• VBG, CBC, chem, total CK
• CXR
• ECG
• Urinalysis (assess for myoglobinuria)
• Serial assessments for compartment syndrome

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

• Patient's entire hand (palm+fingers) = about 1% TBSA
• Use to estimate scatter burns
• Also use for local burns up to 10% BSA

Lund-Browder Classification

Children

Anatomic structure	0 Yr	1 Yr	5 Yrs	10 Yrs	15 Yrs
Anterior Head	9.5%	8.5%	6.5%	5.5%	4.5%
Posterior Head	9.5%	8.5%	6.5%	5.5%	4.5%
Anterior Torso	1%	1%	1%	1%	1%
Posterior Neck	1%	1%	1%	1%	1%
Anterior Torso	13%	13%	13%	13%	13%
Posterior Torso	13%	13%	13%	13%	13%
Each Anterior Upper Leg	2.75%	3.25%	4%	4.25%	4.5%
Each Posterior Upper Leg	2.75%	3.25%	4%	4.25%	4.5%
Each Anterior Lower Leg	2.5%	2.5%	2.75%	3%	3.25%
Each Posterior Lower Leg	2.5%	2.5%	2.75%	3%	3.25%
Each Anterior Upper Arm	2%	2%	2%	2%	2%
Each Posterior Upper Arm	2%	2%	2%	2%	2%
Each Anterior Lower Arm	1.5%	1.5%	1.5%	1.5%	1.5%
Each Posterior Lower Arm	1.5%	1.5%	1.5%	1.5%	1.5%
Each Anterior Hand	1.5%	1.5%	1.5%	1.5%	1.5%
Each Posterior Hand	1.5%	1.5%	1.5%	1.5%	1.5%
Each Anterior Foot/Ankle	1.75%	1.75%	1.75%	1.75%	1.75%
Each Posterior Foot/Ankle	1.75%	1.75%	1.75%	1.75%	1.75%
Each Buttock	2.5%	2.5%	2.5%	2.5%	2.5%
Genitalia/Perineum	1%	1%	1%	1%	1%

Management

• Consider empirically treating for cyanide toxicity

Not Severe (Outpatient)

• Cleanse burn with mild soap and water or dilute antiseptic solution
• Debride wound as needed
• Consider a topical antimicrobial:
  • Bacitracin, neomycin, or mupirocin
  • AVOID Silver Sulfadiazine as it may interfere with partial thickness healing and offers no healing advantage (inhibits keratinocytes)
• Consider use of synthetic occlusive dressings (see burn dressings)
• Blisters
  • Leave blisters intact unless they cross a joint or if a large blisters precludes application of a dressing

Severe (Inpatient)

• IVF (see below)
• Analgesia
• Remove all rings, watches, jewelry, belts
• Local burn care (burn dressing)
  • Contact burn center BEFORE applying any antiseptic dressings
  • Small wound: moist saline-soaked dressing
  • Large wound: sterile drape
• Antibiotics
  • Administer in coordination with burn physician
  • Prophylactic antibiotics have been abandoned - debridement is paramount to prevent infection
  • Maintain glucose control to prevent infection
  • Core temperature is usually "reset" to 38-39°C, so fever in the absence of other symptoms of sepsis does not indicate infection
  • If septic, start broad spectrum antimicrobials - be sure to assess for need for antifungals in addition to antibiotics
• Nasogastric Tube
  • Consider if partial-thickness burn >20% BSA (ileus frequently occurs)
  • Definite NG tubes in burns > 30% in adults and 25% in children
• Early GI prophylaxis (PPI/H2 blocker)
  • evidence of stress ulceration even within hours after major burns
• Tetanus vaccine

Fluid Resuscitation

• Give least amount of fluid necessary to sustain organ perfusion (avoid "fluid creep")
• Patients with inhalation injury and/or multi-system trauma often require more than Parkland amount.
• The Parkland is only a guide; must titrate to patient's urine output, clear sensorium, and HR less than 110
• The Lund-Browder chart is another alternative method of estimate burn surface area in addition to the rule of nines
• Goal directed therapy with Swan-Ganz catheters, inotropes, and fluid support have shown no superiority to standard clinical parameters, and have increased over-resuscitation and incidence of abdominal compartment syndrome (see below)

Indications based on TBSA

• Definite IV: Adults > 20%, Peds > 15%
• Perhaps IV: Adults 15-20%, Peds 10-15%
• Oral adequate: Adults < 15%, Peds < 10%

Types of fluids

• Many burn centers prefer lactated ringers unless shock liver or hepatic failure suspected
• Colloids generally not used unless burns > 40% TBSA
• Do not use dextrose in adults (false uop), but children should receive small amounts due to small glycogen stores

Parkland

• 4cc x wt (kg) x %BSA (2nd and 3rd degree only)= cc NS (or LR) over 24hr
• Give 1/2 in first 8hr, remainder in next 16hr

Peds

• Give Parkland + maintenance fluid (2-4cc/kg x %BSA) if age < 5 yrs old
• Give 1/2 in first 8 hr, remainder in next 16 hr
• Can consider giving D5 1/2 NS if patient < 20 kg to prevent hypoglycemia

Goal UOP

• If UOP is greater than expected, consider glycosuria and reactive hyperglycemia as cause.
• Maintain urine output of 0.5 mL/kg/hr urine in adults and 0.5–1.0 mL/kg/hr in children weighing < 30 kg
• If myoglobinuria seen, double expected UOP until urine grossly clears (consider mannitol diuresis)

Intubation Guidelines

• Full-thickness burns of the face or perioral region
• Circumferential neck burns
• Acute respiratory distress
• Progressive hoarseness or air hunger
• Respiratory depression
• Altered mental status
• Supraglottic edema and inflammation on bronchoscopy

Escharotomy Burn Indications

• Circumferential eschar with one of the following:
  • Circumferential torso - restricted ventilation
  • Circumferential extremities - vascular compromise
• Immediate escharotomy if compartment pressure > 30 mmHg
• Elevate limb and optimize fluid status

Special Cases

• In burns > 40% in adults and > 30% in children < 5 yo, consider colloids which reduce abdominal compartment syndrome
  • Consider replacing 25% of IVF with FFP, so that total IV rate is unaltered through the 24 hrs post-burn
  • In children, give 1/2 of total volume as FFP and 1/2 as LR throughout 24 hrs
  • For infants < 2 yrs with > 30%, use 5% dextrose in LRs with the FFP
• Burns > 50% or SEVERE metabolic acidosis may require 44 mEq of bicarb to each 1 L of LR in first 24 hrs, maintain bicarb > 18
• Beyond 24 hrs:
  • 24-48 hrs - patients require ~1/2 total volume given in first 24 hrs; change LRs to D5,1/2NS; give FFP 2 units for every liter of crystalloid
  • 48-72 hrs - no formula; take into account TBSA/depth of burns (open partial thickness loss > full thickness with thick eschar), re-mobilization of 3rd space fluid beginning at this time

Disposition

Outpatient Treatment

24-48hr

• Partial thickness <10% BSA, age 10–50y
• Partial thickness <15% BSA, age <10y or >50y
• Full thickness <2% in anyone
• No major burn characteristics present

Hospital admission

• Partial thickness 10-20% BSA 10-50 yrs old
• Partial thickness 5-10% BSA in <10 or > 50 yrs old
• Full thickness burns 2-5% BSA in anyone
• High voltage injury
• Circumferential burns of an extremity
• Burns complicated by suspected inhalation injury
• significant comorbidities
• No major burn characteristics present

Burn Center Transfer Criteria

• Partial thickness >20% BSA in 10-50
• Partial thickness >10% BSA in <10 or > 50 yrs old
• Full thickness >5% BSA in anyone
• Burns involving face, eyes, ears, genitalia, joints, hands, feet
• Burns complicated by confirmed inhalation injury
• High voltage burn
• Burns complicated by fracture or other trauma (in which burn is main cause of morbidity)
• Burns in high-risk patients

See Also

• Caustic burns
• Electrical Injuries
• Lightning Injuries
• Burn dressings

References

Authors

Ross Donaldson