Burns
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Introduction
Causes and Risk Factors
Flame injuries are the most common in adults; splash injuries the most common in children.
Acids...
Alkalais are worse than acids...
Electric burns are almost always deeper than appearances suggest.
Pathophysiology
First degree burns leave the epidermis intact, and blisters are not present. Erythema and pain are present.
Second degree (partial thickness) burns extend into the dermis, with blistering. The skin is red and mottled, and weeping may be present
- superficial - sensation present
- deeper - lack of pain
Third degree (full thickness) burns: leathery white, brown, black, or (non-blanchable) red.
Fourth degree burns: burn extends into organs or bone
Primary Survey
Burns can be a life-threatening emergency, and a primary survey should rapidly be performed to identify immediate threats to life or limb. Stop the burning right away; this is especially important with chemical burns.
Immediately assess for signs of airway involvement, including:
- history of burn in a closed space, or presence of impaired mentation
- facial/neck burns
- singed eyebrows or nose hairs
- blackening of the mouth or nose
- coughing up black material
- oropharyngeal erythema
- hoarseness
Identification of these signs may suggest early intubation is required for management of the airway.
Breathing may be impaired by hypoxia, carbon monixide (CO) poisoning, or smoke inhalation. Assess chest expansion and sounds, and oxygen saturation. High-flow oxygen by non-rebreather should be provided if breathing appears impaired.
Assess extremities for circulation, out of concern for compartment syndrome.
Secondary Survey
- history
- physical exam
History
The history is very important. Explosions may have occurred, leading to a variety of internal damage. Injuries may have been sustained attempting to flee the fire.
Mechanism of injury
- temperature
- in an enclosed space?
Time
Treatment this far
Could this have been suicide or self-harm?
Query abuse in children, seniors, or other at-risk patients
Carbon monoxide poisoning can lead to headache, nausea, or confusion.
Physical Exam
The rule of 9's is a framework for estimating the body surface area affected by burns. It applies to 2nd or 3rd degree burns.
adults, older children
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infants, young children
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Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
In patients with major burns, labs should include the following:
- CBC
- electroytes and creatinine
- serum glucose
- pregnancy test
- type and crossmatch
With electrical burns, urinalysis for myoglobin should also be performed to assess for muscle damage.
Arterial blood gases should be done to assess respiratory function.
Carboxyhemoglobin (CoHb) levels can suggest CO poisoning.
Diagnostic Imaging
Chest X ray should be done to examine lung parenchyma if inhalation is suspected.
ECG may be done to evaluate potential cardiac irregularities, especially following major electrical burns.
Treatments
Stop the burning process by removing clothing, unless it is firmly adherent. Carefully brush away any powder. Rinse chemically burned areas with copious amounts of warm tap water.
Rescuscitation
Airway and breathing: Provide high-flow oxygen. If airway compromise is present or threatened, intubate early.
Circulation: Initiate two large-bore IVs with crystalloid (Ringer's or normal saline).
Parkland Formula
Amount of fluid required in the first 24 hours since time of injury
2-4ml x total burned surface area (TBSA%) x body weight (kg)
- + 2L D5W because patient is NPO
Give 1/2 this amount in the first 8 hours, the second half over
the next 16 hours.
Give half the above on day 2
However, the above formula is only a starting guide; fluids can be titrated to result in a urine output of 0.5 ml/kg/hr in adults, 1ml/kg/hr in children, or 2 ml/kg/hr in infants.
Fluid needs are greater in electrical burns, or if crush injury is also present. In these cases, aim for 100 ml/hr in adults, or 2ml/kg/hr in children. If you are under-resuscitating someone, increase their volume flow rate by 1/3.
Keep patients warm, as the temperature control capacity of the skin becomes seriously compromised.
Foley catheter to measure urine output (aim for 1-2 ml/kg/hr).
Arrhythmias can result from hypoxia, or electrolyte/acid-base abnormalities.
Analgesia
Opioids such as fentanyl may be required. Give small doses intravenously. Avoid opioids or sedatives before correcting hypoxia or hypotension.
Dressing
Gently cover the burns moist gauze.
Flamazine (sp) is one of the most appropriate dressings but is messy; avoid using it until the definitive providers are involved and have evaluated the burn.
Silver sulfadiazine is often used.
Indications for transfer to a burn unit
>10% TBSA for partial thickness
>20% TBSA, all ages
full thickness: >5% TBSA
electrical and chemical injuries
Surgery
For full-thickness bunrs, early excision and grafting should be carried out to save costs, minimize pain, and complications.
Escharotomy is necessary in circumferential burns to permit breathing and prevent compartment syndrome.
Other
Tetanus
Consequences and Course
Resources and References
Topic Development
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