Trauma

Burns: General Information

Background

1. Definition
   • Flame, scald, and contact burns from a heat or fire source
2. Synopsis
   • Approximately 1.25 million burns/year in the United States
   • Burn history and physical exam are essential for governing treatment/disposition
     • Early management and subsequent advances in care have reduced morbidity and mortality significantly

Pathophysiology

1. Mechanism
   • 6 Burn Mechanisms: Fire, Scald, Contact, Chemical, Electrical, and Radiation
     • Flame, scald, and contact burns induce cellular damage via transfer of energy that induces coagulative necrosis
     • Chemical and electrical burns cause direct injury to cellular membranes
   • Exposure causes a zone of tissue necrosis (closest to burn), ischemia or stasis, and hyperemia (farthest away)
     • Necrosis is irreversible, ischemia potentially reversible, and hyperemia reversible
   • Superficial burns damage epithelium, partial thickness burns damage the dermis, full thickness burns damage deeper structures
     • Large area burns result in increased fluid loss that is proportionate to % BSA burned
   • Circumferential deep burns may act as a tourniquet when an extremity or digit swells, resulting in distal ischemia
   • Airway burns may result in delayed loss of airway as inflammation progresses
   • Additional systemic complications include
     • Electrolyte abnormalities
     • Decreased cardiac output, decreased renal blood flow
     • Increased metabolic demands
     • Hepatic steatosis
     • Increased infection risk secondary to widespread release of inflammatory mediators, increased fluid loss, and other factors
2. Etiology/Risk Factors
   • Alcohol consumption contributes to a large number of burns
   • Holiday decorations (e.g., Christmas lights, Christmas tree, candles, etc.)
   • Children are at increased risk due to lack of awareness
   • Select vocations (e.g., firefighter, electrician, police) carry increased risk
3. Epidemiology
   • Incidence/Prevalence
     • Approximately 1.25 million burns/year in the United States
       • 60,000-80,000 hospitalizations
     • Bimodal peak (ages 0-2 and 20-29)
   • Mortality/Morbidity
     • Extremes of age are at greater risk for unfavorable outcomes
     • 50% mortality for ages 0-14 with 98% TBSA burns
     • 50% mortality for ages 65+ with 35% TBSA burns
     • 5,500 deaths/year

Diagnostics

1. History/Symptoms
   • History is essential to determining subsequent management
   • Time burn occurred
     • Important for the Parkland formula
     • Useful in gauging the evolution of the injury
   • Burn mechanism
     • Chemical: Determine specific substance; some are highly destructive
     • Electric: Must consider additional injuries
     • Flash Burns: Potential Airway concern
     • Contact: Specific substance important (tar/oil worse than water)
   • Location of burns
     • Airway concern if face
     • Cosmetically sensitive/functionally important if face, hands, genitals
   • Rule out associated injury
     • Toxic inhalations from house fires (CO, CN)
     • Jump or fall from height (Fractures)
   • Verify tetanus status in addition to routine medical history
2. Physical Exam/Signs
   • General Appearance, Vitals
     • Tachycardia may be secondary to pain or fluid loss
     • Hypoxia and Tachypnea may suggest airway involvement
   • Airway Assessment
     • Facial burns, singed nasal hairs/facial hair, carbonaceous sputum suggest airway involvement
     • Patient with airway involvement may be talking and without respiratory distress
     • Secure airway or further evaluate with NP scope if concern
   • Burn assessment (View Video)
     • Assess overall Total Body Surface Area (TBSA) involvement
       • Rule of 9s useful for larger burns (View image)
         • 9% for head, each upper extremity, and side of a lower extremity
         • 18% anterior trunk
         • 18% posterior trunk/buttocks
         • 1% perineum
       • Patient's palm = 1% TBSA for smaller burns
     • Assess each burned area separately to determine depth
       • 1st degree: Superficial partial thickness; red, painful, no blisters
       • 2nd degree: Partial thickness; some blisters, painful, normal sensation and texture
       • 3rd degree: Full thickness; white appearance, insensate, leathery
     • Extremities require the following to be assessed
       • Circumferential or non-circumferential
       • If circumferential does patient have distal perfusion and sensation
     • Other specific areas to evaluate carefully
       • Airway assessment
       • Chest: extensive burns make ventilation difficult due to decreased compliance
       • Abdomen: extensive burns can create abdominal compartment syndrome resulting in high intraabdominal pressures and organ ischemia
       • Genitourinary: burns can result in urinary obstruction
   • Specific Burn Types
     • Electrical burns
       • May have small entrance/exit sites but cause massive tissue injury
       • Can result in rhabdomyolysis, delayed swelling and limb loss
     • Super-heated air inhalation
       • Closed-space exposures (i.e., house fires)
       • May develop severe, delayed airway edema & airway compromise, especially in children
     • Chemical burns
       • Hydrofluoric acid dissociates subcuticularly causing intense pain but minimal or no skin surface changes
3. Labs/Tests
   • Labs are rarely beneficial in evaluating burn patients
   • Simple burns with anticipated discharge generally do not need labs
   • Burn patients requiring admission generally have routine trauma labs sent (e.g., extensive or severe burns, concomitant trauma, etc.)
4. Imaging
   • Bedside NP scope useful if suspecting airway burns (versus intubation)
   • Tomography, Ultrasound, and X-Rays only useful if concomitant trauma
5. Other Tests/Criteria
   • Rule of 9s (Open Calc)

Treatment Overview

1. Prehospital Care
   • Assess for signs of inhalational injury
     • Start humidified oxygen if suspected
     • Intubate early
   • Begin IVF resuscitation with Lactated Ringers if transport time > 30 minutes
   • Remove all burned clothing, jewelry
   • Immerse all wounds in cold water (1-5°C)
     • Immediate cooling only effective in first 30 minutes
     • DO NOT apply ice to wound
     • Local cooling may be continued if total BSA < 9%
   • Tar injuries
     • Cool tar immediately with cold water to prevent ongoing injury
       • Cool until tar is hardened
     • After cooled, remove tar to prevent bacterial overgrowth
       • Can use antibiotic ointments, butter, mayonnaise, baby oil, sunflower oil to soften tar
         • Softening of tar may take up to 90 minutes
     • Rest of care as per usual burn care
2. Emergency Department Care
   • Initial/Prep/Goals
     • Cool saline moistened gauze to burn areas to remove residual heat (no ice = hypothermia)
       • Tap water is equally safe and effective as sterile NS
     • IV for fluid replacement and pain control
     • IV fluids: multiple equations in use to calculate
       • Parkland: (4 mL) x (body weight in kg) x (% BSA burn) = total fluid for first 24 hrs
       • Give 1/2 in first 8 hrs from time of burn, rest over next 16 hrs
         • If patient presents 2 hrs after burn, must give initial fluid over 6 hrs (*Note: 8 hrs - 2 hrs = 6 hrs)
       • Adjust fluid volume to maintain adequate urine (50-75 mL/hr)
         • Elderly patients with heart disease may not be able to handle this volume
     • Foley catheter for monitoring urine output
     • Escharotomy along long axis sides of digits, extremities, trunk if full thickness burn, and decreased distal pulses (View Video)
     • No prophylactic IV antibiotics
     • Topical antibiotics with silvadene or bacitracin
     • Cover burns with sterile gauze
     • IV narcotics for pain control (major burns)
     • PO analgesics with hydrocodone for minor-moderate burns
     • Tetanus prophylaxis, based on history
   • See Treatment by burn severity
     • Minor-Moderate Burn Treatment (Partial thickness, no high-risk areas, BSA < 5%)
     • Major Burn Treatment (Partial-Full thickness, high-risk areas, BSA > 5%)

Disposition

1. Admission criteria
   • 2nd and 3rd degree burns > 10% TBSA
     • Consider if 2nd degree burns < 10% TBSA
   • Full thickness burns in any age group
   • Any burn involving the face, hands, feet, eyes, ears, or perineum that may result in a cosmetic or functional deficit
   • Electrical injuries, Inhalational injuries, Chemical burns
   • Burns in patients with significant comorbid conditions (e.g., DM, COPD)
2. Consultation
   • Burn, Trauma unit
3. Discharge/Follow-up instructions
   • Minor burns can be discharged
   • Close follow-up
   • Adequate analgesia
   • Prognosis
     • Depth of burn determines tissue destruction and healing
       • Superficial: rapid healing and no scarring
       • Partial: heal possible scarring, heal from deeper layers first
       • Full Thickness: severe scarring, large infection risk, generally need grafting

References

1. Papini R. Management of burn injuries of various depths. BMJ Jul 17, 2004;329(7458):158-160
2. Stander M, Wallis LA. The emergency management and treatment of severe burns. Emerg Med Int. 2011;2011:161375
3. DuBose JA, O'Connor JV, Scalea TM. Lung, Trachea, and Esophagus. In: Mattox KL, Moore, EE, Feliciano DV; (eds). Trauma, 7th ed., McGraw-Hill, Inc, 2013;Chapter 25
4. Pham TN, Cancio LC, Gibran NS. American Burn Association Practice Guidelines: Burn Shock Resuscitation. J of Burn Care and Research Jan-Feb 2008;29(1):257-266
5. Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Academic Emerg Med. May 2007;14(5):404-409

Contributor(s)

• Latham, Douglas E., MD

Updated/Reviewed: May 2019