Burns

Background

• Burns >60% BSA often a/w cardiac ouptut depression unresponsive to fluids

Burn Degrees

1. 1st Degree
   1. Only epidermis affected
   2. Red, tender, no blisters
   3. Heals w/o scarring in 7d
2. 2nd Degree
   1. Two types:
      1. Superficial partial thickness
         1. Epidermis + superficial dermis affected
         2. Blisters, painful
         3. Good perfusion of dermis w/ intact cap refill
         4. Heals w/o scarring in 14-21d
      2. Deep partial thickness
         1. Epidermis + deep dermis affected
         2. Blisters, painful, exposed dermis is pale white-yellow in color
         3. Burned area does not blanch (absent cap refill)
         4. May be difficult to distinguish from 3rd degree
         5. Heals w/ scarring in 3-8wk; may require skin-graft if do not heal w/in 21d
3. 3rd Degree
   1. Full thickness (epidermis + dermis)
   2. Skin is white, leathery, no pain
   3. Always requires skin grafting
4. 4th Degree
   1. 3rd degree + muscle, fat, bone involvement

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

1. Burn Center Transfer:
   1. Partial thickness >25% BSA, age 10–50y
   2. Partial thickness >20% BSA, age <10y or >50y
   3. Full thickness >10% BSA in anyone
   4. Burns involving hands, face, feet, or perineum
   5. Burns crossing major joints
   6. Circumferential burns of an extremity
   7. Burns complicated by inhalation injury
   8. Electrical burns
   9. Burns complicated by fx or other trauma (in which burn is main cause of morbidity)
   10. Burns in high-risk patients
2. Hospital admission:
   1. Partial thickness 15%–25% BSA, age 10–50y
   2. Partial thickness 10%–20% BSA, age <10y or >50y
   3. Full thickness burns <10% BSA in anyone
   4. No major burn characteristics present
3. Outpatient Treatment
   1. Partial thickness <15% BSA, age 10–50y
   2. Partial thickness <10% BSA, age <10y or >50y
   3. Full thickness <2% in anyone
   4. No major burn characteristics present

Source

Tintinalli