Burns: Difference between revisions
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==Background==
== Background ==
===Burn Degrees===
 
*1st
=== Burn Degrees ===
**red, tender, no blisters
 
**two point discrimination intact
*1st  
**red, tender, no blisters  
**two point discrimination intact  
**heals without scarring
**heals without scarring


*2nd
*2nd  
**Partial thickness
**Partial thickness  
**Superficial
**Superficial  
***Thin blisters
***Thin blisters  
***Heals without scarring in 2-3 wks
***Heals without scarring in 2-3 wks  
**Deep
**Deep  
***Thick blisters
***Thick blisters  
***2 point discrimination decreased
***2 point discrimination decreased  
***Can feel pressure
***Can feel pressure  
***Potential for scar/contractions
***Potential for scar/contractions  
*3rd
*3rd  
**Full thickness
**Full thickness  
**skin is white, leathery and anesthetic
**skin is white, leathery and anesthetic  
**always needs grafting
**always needs grafting  
*4th
*4th  
**3rd degree + involves muscle, bone, or other deep structures
**3rd degree + involves muscle, bone, or other deep structures


===Rule of Nines===
=== Rule of Nines ===
'''Adults'''
 
*Each area is 9% BSA:
'''Adults'''  
**Entire head and neck
 
**Right arm (including hand)
*Each area is 9% BSA:  
**Left arm (including hand)
**Entire head and neck  
**Chest
**Right arm (including hand)  
**Abdomen
**Left arm (including hand)  
**Upper back
**Chest  
**Lower back
**Abdomen  
**Right front of leg
**Upper back  
**Left front of leg
**Lower back  
**Right back of leg
**Right front of leg  
**Left back of leg
**Left front of leg  
**Right back of leg  
**Left back of leg  
*1%: Genital region
*1%: Genital region


'''Children'''
'''Children'''  
*Each area is 9% BSA:
 
**Anterior head and neck
*Each area is 9% BSA:  
**Posterior head an neck
**Anterior head and neck  
**Right arm (including hand)
**Posterior head an neck  
**Left arm (including hand)
**Right arm (including hand)  
**Chest
**Left arm (including hand)  
**Abdomen
**Chest  
**Upper back
**Abdomen  
**Lower back
**Upper back  
**Right leg (front & back)
**Lower back  
**Left leg (front & back)
**Right leg (front & back)  
**Left leg (front & back)  
*1%: Genital Region
*1%: Genital Region


<br>


{|
{|
|-
|-
||
|  
{| class="wikitable"
{| class="wikitable"
|+ '''Adults'''
|+ '''Adults'''  
! Anatomic structure
|-
! Anatomic structure  
! Surface area
! Surface area
|-
|-
| [[Anterior]] [[head]]
| [[Anterior]] [[Head]]  
| 4.5%
| 4.5%
|-
|-
| [[Posterior (anatomy)|Posterior]] [[head]]
| [[Posterior (anatomy)|Posterior]] [[Head]]  
| 4.5%
| 4.5%
|-
|-
| [[Anterior]] [[torso]]
| [[Anterior]] [[Torso]]  
| 18%
| 18%
|-
|-
| Posterior [[torso]]
| Posterior [[Torso]]  
| 18%
| 18%
|-
|-
| Each [[Anterior]] [[leg]]
| Each [[Anterior]] [[Leg]]  
| 9%
| 9%
|-
|-
| Each Posterior [[leg]]
| Each Posterior [[Leg]]  
| 9%
| 9%
|-
|-
| Each [[Anterior]] [[arm]]
| Each [[Anterior]] [[Arm]]  
| 4.5%
| 4.5%
|-
|-
| Each [[Posterior]] [[arm]]
| Each [[Posterior]] [[Arm]]  
| 4.5%
| 4.5%
|-
|-
| [[Genitalia]]/[[perineum]]
| [[Genitalia]]/[[Perineum]]  
| 1%
| 1%
|-
|-
|<ref name="O'Sullivan Fig 27.9">O'Sullivan, Susan B., Schmitz, Thomas J. Physical Rehabilitation. 5th ed. F.A. Davis Company, Philadelphia, 2007. p. 1098, Fig 27.9.</ref>
| &lt;ref name="O'Sullivan Fig 27.9"&gt;O'Sullivan, Susan B., Schmitz, Thomas J. Physical Rehabilitation. 5th ed. F.A. Davis Company, Philadelphia, 2007. p. 1098, Fig 27.9.&lt;/ref&gt;
|}
|}
||
 
 
{| class="wikitable"
{| class="wikitable"
|+ '''Children'''
|+ '''Children'''  
! Anatomic structure
|-
! Anatomic structure  
! Surface area
! Surface area
|-
|-
| [[Anterior]] [[Head]]
| [[Anterior]] [[Head]]  
| 9%
| 9%
|-
|-
| [[Posterior]] [[Head]]
| [[Posterior]] [[Head]]  
| 9%
| 9%
|-
|-
| [[Anterior]] [[torso]]
| [[Anterior]] [[Torso]]  
| 18%
| 18%
|-
|-
| [[Posterior]] [[torso]]
| [[Posterior]] [[Torso]]  
| 18%
| 18%
|-
|-
| Each [[Anterior]] [[leg]]
| Each [[Anterior]] [[Leg]]  
| 6.5%
| 6.5%
|-
|-
| Each [[Posterior]] [[leg]]
| Each [[Posterior]] [[Leg]]  
| 6.5%
| 6.5%
|-
|-
| Each [[Anterior]] [[arm]]
| Each [[Anterior]] [[Arm]]  
| 4.5%
| 4.5%
|-
|-
| Each [[Posterior]] [[arm]]
| Each [[Posterior]] [[Arm]]  
| 4.5%
| 4.5%
|-
|-
| [[Genitalia]]/[[perineum]]
| [[Genitalia]]/[[Perineum]]  
| 1%
| 1%
|-
|-
|<ref name="O'Sullivan Fig 27.9">O'Sullivan, Susan B., Schmitz, Thomas J. Physical Rehabilitation. 5th ed. F.A. Davis Company, Philadelphia, 2007. p. 1098, Fig 27.9.</ref>
| &lt;ref name="O'Sullivan Fig 27.9"&gt;O'Sullivan, Susan B., Schmitz, Thomas J. Physical Rehabilitation. 5th ed. F.A. Davis Company, Philadelphia, 2007. p. 1098, Fig 27.9.&lt;/ref&gt;
|}
|}
|}
|}


{|
|-
||
{| class="wikitable"
|+ '''Adults Obese >&nbsp;80&nbsp;kg'''
! Anatomic structure
! Surface area
|-
| [[Head]] and [[neck]]
| 2%
|-
| [[Anterior]] [[torso]]
| 25%
|-
| [[Posterior]] [[torso]]
| 25%
|-
| Each [[leg]]
| 20%
|-
| Each [[arm]]
| 5%
|-
| [[Genitalia]]/[[perineum]]
| 0%
|}
||
{| class="wikitable"
|+ '''Infants < 10&nbsp;kg'''
! Anatomic structure
! Surface area
|-
| [[Head]] and [[neck]]
| 20%
|-
| [[Anterior]] [[torso]]
| 16%
|-
| [[Posterior]] [[torso]]
| 16%
|-
| Each [[leg]]
| 16%
|-
| Each [[arm]]
| 8%
|-
| [[Genitalia]]/[[perineum]]
| 1% [but it does not add up to 100%]
|}
|}


===Rule of Palms===
 
*Pt's palm = 1%
=== Rule of Palms ===
*Use to estimate scatter burns
 
*Pt's palm = 1%  
*Use to estimate scatter burns  
*Also use for local burns up to 10% BSA
*Also use for local burns up to 10% BSA


==Pre-Hospital==
== Pre-Hospital ==
*Assess for signs of inhalational injury
 
**Start humidified O2
*Assess for signs of inhalational injury  
**Intubate if necessary (below)
**Start humidified O2  
*IVF (below)
**Intubate if necessary (below)  
*Remove all burned/burning clothing, jewelry
*IVF (below)  
*Immerse wounds in cold water (1-5˚C)
*Remove all burned/burning clothing, jewelry  
**Only effective within first 30 mins
*Immerse wounds in cold water (1-5˚C)  
**Only effective within first 30 mins  
**No direct ice to wound
**No direct ice to wound


==Workup==
== Workup ==
#Labs
 
#CO level
#Labs  
#CN level if suspicious and/or empiric Tx (see below)
#CO level  
#CN level if suspicious and/or empiric Tx (see below)  
#Work-up for associated trauma, if indicated
#Work-up for associated trauma, if indicated


==Treatment==
== Treatment ==
#Airway (Intubation below)
 
#IVF (below)
#Airway (Intubation below)  
#Foley cath
#IVF (below)  
#Dressing (saline/tap/petroleum gauze)
#Foley cath  
#No PPxIV Abx; topical bacitracin ok
#Dressing (saline/tap/petroleum gauze)  
#Escharotomy (below)
#No PPxIV Abx; topical bacitracin ok  
#H2 blocker (stress ulcer)
#Escharotomy (below)  
#NG tube (gastroparesis)
#H2 blocker (stress ulcer)  
#Td
#NG tube (gastroparesis)  
#Analgesia
#Td  
#Analgesia  
#Consider Transfer
#Consider Transfer


===Intubation Guidelines===
=== Intubation Guidelines ===
*Any hard signs:
 
**Stridor
*Any hard signs:  
**Hoarseness
**Stridor  
**Pharyngeal burns
**Hoarseness  
*3 or more soft signs:
**Pharyngeal burns  
**h/o unconciousness
*3 or more soft signs:  
**Noxious fumes at scene
**h/o unconciousness  
**Burn occurring in closed space
**Noxious fumes at scene  
**Facial burns
**Burn occurring in closed space  
**Carbonaceous sputum
**Facial burns  
**CO level >15%
**Carbonaceous sputum  
**CO level &gt;15%
 
=== Fluid Resuscitation ===
 
Indicated if:


===Fluid Resuscitation===
#&gt;20% BSA (2nd &amp; 3rd)  
Indicated if:
#>20% BSA (2nd & 3rd)
#Evidence of shock
#Evidence of shock


*Total Fluids = Parkland + maint + blood loss
*Total Fluids = Parkland + maint + blood loss  
*Parkland:
*Parkland:  
**4 x kg x %BSA (2nd&3rd)= cc NS (or LR)
**4 x kg x&nbsp;%BSA (2nd&amp;3rd)= cc NS (or LR)  
***Give 1/2 in first 8hrs, remainder in next 16hrs
***Give 1/2 in first 8hrs, remainder in next 16hrs


*Place Foley cath:
*Place Foley cath:  
**Goal:
**Goal:  
***Adult: UOP>30mL/hr
***Adult: UOP&gt;30mL/hr  
***Peds: UOP >1mL/kg/hr
***Peds: UOP &gt;1mL/kg/hr


*Consider CVP line if h/o cardiopulmonary dz
*Consider CVP line if h/o cardiopulmonary dz


===Cyanide===
=== Cyanide ===


*Consider empiric tx for smoke inhalation victims with (any):
*Consider empiric tx for smoke inhalation victims with (any):
#Hypotension
 
#Metabolic acidosis
#Hypotension  
#Metabolic acidosis  
#CV collapse
#CV collapse
*Give sodium thiosulfate (12.5 mg) alone (given possiblility of CO also)
 
*Give sodium thiosulfate (12.5 mg) alone (given possiblility of CO also)  
*See also [[Cyanide]]
*See also [[Cyanide]]


===Escharotomy===
=== Escharotomy ===
*Restriced ventilation
 
**Anterior axillary line
*Restriced ventilation  
**2cm below clavicle to 10th rib
**Anterior axillary line  
**May connect (square)
**2cm below clavicle to 10th rib  
*Restricted perfusion (focal)
**May connect (square)  
**Along long axis of hands, forearms, feet, fingers, toes if no pulse by doppler
*Restricted perfusion (focal)  
**Lateral on extremity
**Along long axis of hands, forearms, feet, fingers, toes if no pulse by doppler  
**No perfusion, add medial
**Lateral on extremity  
**No perfusion, add medial  
**Bovie or scalpel
**Bovie or scalpel
 
==Disposition==
== Disposition ==
Transfer Criteria (ABA 1994)
 
#2-3 deg >10% in pt <10 or >50yo
Transfer Criteria (ABA 1994)  
#2-3 deg >20% anyone
 
#3 deg >5% anyone
#2-3 deg &gt;10% in pt &lt;10 or &gt;50yo  
#Complicating factors
#2-3 deg &gt;20% anyone  
##Sig face/hand/feet/perineum/major joint
#3 deg &gt;5% anyone  
##Circumferential burns
#Complicating factors  
##Inhalation injury
##Sig face/hand/feet/perineum/major joint  
##Concomitant trauma
##Circumferential burns  
##Sig pre-existing dz
##Inhalation injury  
##Concomitant trauma  
##Sig pre-existing dz  
##Sig electrical/chemical burn
##Sig electrical/chemical burn


<br>


*For moderate burns not meeting transfer criteria may admit
*For moderate burns not meeting transfer criteria may admit


==Source==
== Source ==
8/07 DONALDSON (adapted from Bessen, Mistry); 3/10 DeBonis
 
8/07 DONALDSON (adapted from Bessen, Mistry); 3/10 DeBonis  


[[Category:Trauma]]
[[Category:Trauma]]

Revision as of 20:10, 16 July 2011

Background

Burn Degrees

  • 1st
    • red, tender, no blisters
    • two point discrimination intact
    • heals without scarring
  • 2nd
    • Partial thickness
    • Superficial
      • Thin blisters
      • Heals without scarring in 2-3 wks
    • Deep
      • Thick blisters
      • 2 point discrimination decreased
      • Can feel pressure
      • Potential for scar/contractions
  • 3rd
    • Full thickness
    • skin is white, leathery and anesthetic
    • always needs grafting
  • 4th
    • 3rd degree + involves muscle, bone, or other deep structures

Rule of Nines

Adults

  • Each area is 9% BSA:
    • Entire head and neck
    • Right arm (including hand)
    • Left arm (including hand)
    • Chest
    • Abdomen
    • Upper back
    • Lower back
    • Right front of leg
    • Left front of leg
    • Right back of leg
    • Left back of leg
  • 1%: Genital region

Children

  • Each area is 9% BSA:
    • Anterior head and neck
    • Posterior head an neck
    • Right arm (including hand)
    • Left arm (including hand)
    • Chest
    • Abdomen
    • Upper back
    • Lower back
    • Right leg (front & back)
    • Left leg (front & back)
  • 1%: Genital Region


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%
<ref name="O'Sullivan Fig 27.9">O'Sullivan, Susan B., Schmitz, Thomas J. Physical Rehabilitation. 5th ed. F.A. Davis Company, Philadelphia, 2007. p. 1098, Fig 27.9.</ref>


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%
<ref name="O'Sullivan Fig 27.9">O'Sullivan, Susan B., Schmitz, Thomas J. Physical Rehabilitation. 5th ed. F.A. Davis Company, Philadelphia, 2007. p. 1098, Fig 27.9.</ref>


Rule of Palms

  • Pt's palm = 1%
  • Use to estimate scatter burns
  • Also use for local burns up to 10% BSA

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

Workup

  1. Labs
  2. CO level
  3. CN level if suspicious and/or empiric Tx (see below)
  4. Work-up for associated trauma, if indicated

Treatment

  1. Airway (Intubation below)
  2. IVF (below)
  3. Foley cath
  4. Dressing (saline/tap/petroleum gauze)
  5. No PPxIV Abx; topical bacitracin ok
  6. Escharotomy (below)
  7. H2 blocker (stress ulcer)
  8. NG tube (gastroparesis)
  9. Td
  10. Analgesia
  11. Consider Transfer

Intubation Guidelines

  • Any hard signs:
    • Stridor
    • Hoarseness
    • Pharyngeal burns
  • 3 or more soft signs:
    • h/o unconciousness
    • Noxious fumes at scene
    • Burn occurring in closed space
    • Facial burns
    • Carbonaceous sputum
    • CO level >15%

Fluid Resuscitation

Indicated if:

  1. >20% BSA (2nd & 3rd)
  2. Evidence of shock
  • Total Fluids = Parkland + maint + blood loss
  • Parkland:
    • 4 x kg x %BSA (2nd&3rd)= cc NS (or LR)
      • Give 1/2 in first 8hrs, remainder in next 16hrs
  • Place Foley cath:
    • Goal:
      • Adult: UOP>30mL/hr
      • Peds: UOP >1mL/kg/hr
  • Consider CVP line if h/o cardiopulmonary dz

Cyanide

  • Consider empiric tx for smoke inhalation victims with (any):
  1. Hypotension
  2. Metabolic acidosis
  3. CV collapse
  • Give sodium thiosulfate (12.5 mg) alone (given possiblility of CO also)
  • See also Cyanide

Escharotomy

  • Restriced ventilation
    • Anterior axillary line
    • 2cm below clavicle to 10th rib
    • May connect (square)
  • Restricted perfusion (focal)
    • Along long axis of hands, forearms, feet, fingers, toes if no pulse by doppler
    • Lateral on extremity
    • No perfusion, add medial
    • Bovie or scalpel

Disposition

Transfer Criteria (ABA 1994)

  1. 2-3 deg >10% in pt <10 or >50yo
  2. 2-3 deg >20% anyone
  3. 3 deg >5% anyone
  4. Complicating factors
    1. Sig face/hand/feet/perineum/major joint
    2. Circumferential burns
    3. Inhalation injury
    4. Concomitant trauma
    5. Sig pre-existing dz
    6. Sig electrical/chemical burn


  • For moderate burns not meeting transfer criteria may admit

Source

8/07 DONALDSON (adapted from Bessen, Mistry); 3/10 DeBonis

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