Burns

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

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

• 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 Guidelines below)
2. IVF (below)
3. Analgesia
4. Dressing (saline/tap/petroleum gauze)
5. Abx
   1. Topical bacitracin OK
   2. Prophylactic IV abx not indicated
6. Foley cath
7. Escharotomy (below)
8. H2 blocker (stress ulcer)
9. NG tube (gastroparesis)
10. Tetanus vaccine
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

1. 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

1. Indications
   1. Restricted ventilation
      1. Procedure
         1. Anterior axillary line
         2. 2cm below clavicle to 10th rib
         3. May connect (square)
   2. Restricted perfusion (focal)
      1. Perform along long axis of hands, forearms, feet, fingers, toes if no pulse by doppler
      2. Lateral on extremity
      3. No perfusion, add medial

Disposition

For moderate burns not meeting transfer criteria may admit

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

Source

Tintinalli