E-MED 1.3
Evaluation and Management of Burns
Reading: Tintinalli Chapters 216 & 217
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Skin function
o Semipermeable barrier to prevent evaporate water loss*
o Environmental protection
o Control body temp
* This is why partial/full thickness burns can result in disruption
of the barrier function and contribute to free water deficits
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1.
Thermal Injury
o Cause range of hemostatic disruption (ex sunburn, spilled coffee)  burn shock
o Fluid and electrolyte abnormalities seen in burn shock are result of alterations of cell membrane
potentials
 Intracellular influx water and sodium
 Extracellular migration of potassium
o Burns >60% body surface area (BSA) associated with decreased cardiac output  non responsive to fluid
resuscitation
Define the rule of nines and be able to calculate burn percentages.
BURN SIZE
 Quantified as the percentage of the BSA
(Body Surface Area) involved
 ***THE RULE OF NINES***
o Standard percentages for adults
o (Modifications for pediatric patients)
2.
Describe, define, identify, and recognize the following.
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1st  BURN
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Epidermal layer ONLY
Skin is red, painful, tender, NO blister formation
o Sunburn
Heal within 7 days with no scarring
Require only symptomatic treatment
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Extend into the dermis
Two types:
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2nd  BURN
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3rd  BURN
4th  BURN
I.
Superficial partial-thickness
Epidermis & superficial dermis (papillary layer) are
damaged.
Blistering of skin, exposed dermis is red and moist at
blister base
o EX: Hot water burn
Very painful to touch, good profusion (cap refill intact)
Heal in 14-21 days, scarring minimal, full return of
function
II.
Deep partial-thickness
Extends deep into dermis (reticular layer)
o Damage to hair follicles, sweat and sebaceous
glands
Skin blistered, exposed dermis is pale white to yellow in
color, burned area does not blanch, absent cap refill,
absent pain sensation
May be hard to to distinguish from 3rd degree burn
Heals 3 weeks – 2 months, scarring is common, may
need surgical debridement, skin graft to return to
normal function
Causes: hot liquid, steam, grease, flame
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Full-thickness Burns
Involve entire thickness of skin
All epidermal and dermal structures are destroyed
Skin is charred, pale, painless and leathery
Cause: flame, hot oil, steam, contact with hot objects
Will NOT heal spontaneously. Need surgical repair,
grafting, significant scarring
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Extend through skin to the subq, fat, muscle, and even
bone.
Life threating injuries
Need amputation, extensive reconstruction
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3.
4.
Identify and recognize the necessary considerations regarding the initial evaluation, stabilization, and management of a burn patient.
Identify, list and recognize the specific and important components of the history and physical exam for a burn patient initial
management in the emergency room.
TREATMENT
MINOR
Localized burn treatment
MODERATE-MAJOR
1. Prehospital care (EMS, paramedic, FD)
EMS/Paramedic care:
 Stop the burning process
 Establish airway
 Initiate fluid resuscitation
 Relieve pain
 Protect burn wound
 Transport to appropriate facility
2. ED resuscitation and stabilization
3. Admission to hospital or transfer to burn center
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MINOR BURN = 1st , superficial 2nd 
i.
ii.
iii.
iv.
Tx Plan:
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ED Management:
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Isolated (one burn area)
Not involved hands, feet, perineum
Not across major joints (hip, knee, shoulder)
Not be circumferential (ex DIP joint)
Provide appropriate analgesics
Clean with mild soap and water
Debride as needed
Apply topical antimicrobial:
o 1% SSD (silver sulfadiazine, Silvadene)
cream
 NOT for face, NOT for sulfa
allergies
o Bacitracin ointment
o Triple antibiotic ointment
o Aquaphor
Consider use of synthetic occlusive dressings
Tetanus immunization updated
o Esp if deeper than superficial partialthickness burn (20)
Provide detailed burn care instructions
Direct History
o What was burning agent?
o Were chemicals involved?
o Duration of exposure?
o Fire: open vs enclosed space (carbon
monoxide)?
o Explosion? Blast injury (ex shrapnel)?
o Contact with electricity?
o Other trauma?
o LOC (loss of consciousness)?
ABCs:
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Airway
o Re-evaluation of airway
o Early intubation
 Signs of airway burn (mouth, nose),
swelling, inhalation injury
Breathing
o Continuous pulse ox monitor with
supplemental O2
o Determine carboxyhemoglobin level
 Carbon Monoxide
o Bronchoscopy if inhalation injury is concern
Circulation
o Establish TWO large bore (16, 14 gauge IV
needle…) access lines (IV/IO-intraosseous) in
UNBURNED skin
o IV administration of Lactacted Ringer’s (LR)
solution using Parkland formula
o Cardiac monitoring
ADDITIONAL CARE: IN ALL PATIENTS
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Pulses
o ESPECIALLY in those with circumferential/deep burns of the limbs
 Compartment syndrome!!!!
o May need doppler flow testing
Escharotomy
o For compromise of circulation
PAIN CONTROL
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During emergent treatment, preferred route is IV
o Morphine, fentanyl
o May need large or frequent doses
o Anxiolytic agents used along with pain meds
Ongoing treatment:
o Codeine, hydrocodone, oxycodone, NSAIDs
WOUND CARE
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5.
6.
Small wounds can be covered with moist-saline soaked dressing
Large wounds use (dry) sterile surgical drapes just to cover/protect
o Application of saline soaked could cause hypothermia
o Avoid sterile dressings in ED as admitting team/transfer facility will have to undress to eval wound
Identify and recognize the criteria for admission and transfer for a burn patient.
Define and outline the emergency room management and disposition of minor burns.
DISPO: Transfer to Burn Unit
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>20% Partial thickness(>50yo <10yo)
>25% Partial thickness (ages 10-50)
Full thickness burn >10%, any age
Electrical burns
Chemical burns
Inhalation injury
Burn in patients with high risk pre-existing
medical conditions
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Burns with trauma
Circumferential limb burns
Burns of hands, face, feet, perineum
Burns crossing major joints
Burns in patients needing social, emotional,
long term rehab needs
DISPO: Hospitalization
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Partial thickness 15%-25%, age 10-50
Partial thickness 10%-20%, age <10/>50
Full thickness <10% anyone
DISPO: Outpatient
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Partial thickness <15%, age 10-50
Partial thickness <10% age <10/>50
Full thickness <2%, anyone
7.
Identify and recognize the fluid of choice for fluid resuscitation in burn patients.
FLUID RESUSITATION
 Parkland Formula
o Adults:
 LR (lactated ringers) 4mL x weight (kg) x BSA burned over initial 24h
 Half over first 8 hrs from time of burn
 Other half over subsequent 16 hrs
Example: 154 lb, 40% 2nd and 3rd degree burns
4mL x 70kg x 40* = 11,200 mL over 24 hours
5600mL in the first 8 hours
*PERCENTAGE IS NOT CONVERTED TO A DECIMAL, JUST USE THE NUMBER
(If pt received fluids (normal saline or LR) before arriving to ED, that amount can be deducted from calculation results)
LRs are slightly hypotonic (130 mEq/L sodium), helping to further correct hypovolemia and extracellular sodium
deficits. Also contains other electrolytes similar to plasma.
• Plasma infusion: tremendous ability to restore intravascular volume
8.
9.
Identify, recognize the history and clinical presentation needed to make the diagnosis of smoke inhalation injury.
Identify, list and recognize the emergency room treatment for a patient with and/or suspected of having a smoke inhalation injury.
INHALATION INJURY
 Main cause of mortality in burn patients
 ½ of all fire deaths due to smoke inhalation
o Carbon monoxide poisoning (cells can’t get O2)
o Edematous airways
 Thermal injuries below vocal cords only due to steam inhalation
o Direct thermal injury limited to upper airway
 Smoke inhalation will cause mucosal edema
o Signs/symptoms (hoarseness, singed nasal hair, soot in mouth, nose)
o Early ET (endotracheal) intubation
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BC the longer you wait  the more swelling occurs  the harder it is to intubate
Indication for ET intubation
o Full-thickness burns of the face or peri-oral region
o Circumferential neck burns
o Acute respiratory distress
o Progressive hoarseness
o Respiratory depression
o Altered mental status
o Supraglottic edema and inflammation on bronchoscopy
10. Identify, list and recognize the initial (baseline) diagnostic lab studies which should be obtained for a burn patient.
11. Identify and recognize diagnostic labs which may be indicated in the evaluation of inhalation injury.
SECONDARY EXAM
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Head to Toe assessment
o Eyes for corneal burns
o Size of burns, depths
Routine labs
o CBC, BMP (electrolytes, BUN/Cr, glucose)
If inhalation suspected:
o ABG, carboxyhemoglobin, CXR, EKG, Bronchoscopy
Other tests ordered as indicated (ie., trauma)
12. List, identify and recognize the aspects which determine tissue damage in a chemical burn.
CHEMICAL BURNS
 Over 25,000 products are capable of causing chemical burns
 5-10% of all US Burn center admissions
 Deaths rare (<1%) but are usually from result of ingestion
 Face, eyes, extremities
 Burns are caused by acids or alkalis
ABSORPTION OF CHEMICALS
 Body Site
o Skin folds, surface exposed, mucus membranes
 Integrity of Skin
o Skin breaks, elderly
 Nature of the Chemical
o Acid vs Alkali
 Occlusion
o Clothing, dressing
13. Identify and recognize the substance properties which cause the majority of chemical burns.
14. Briefly identify the general characteristics of an acid burn in contrast to an alkali burn.
ACID
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MOA: coagulation necrosis
Less tissue damage
Leathery eschar forms which prevents deep
penetration of substance
Ex: Hydrochloric acid, Sulphuric acid, Nitric acid
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ALKALI
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MOA: liquefaction necrosis
More tissue damage
Deep penetration of substance
Ex: Bleach, Sodium hydroxide, Calcium hydroxide,
Ammonium hydroxide
15. Identify and recognize the general approach and goals of treatment for chemical burns.
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Immediately remove any particles/solution / saturated clothing
o Contact time with the skin is the most important chemical burn feature that health care professionals
may alter
o *The amount of time it takes to initiate dilution / removal of chemical agent directly relates to the
severity of the injury
 Wounds irrigated 3 minutes after some exposures have a 2-fold increase in becoming fullthickness burns than those irrigated after 1 minute of exposure.
Topical abx
Tetanus
Morgan Lens – irrigates the eye
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MSDS (Material Safety Data Sheet)
o
Contains information on the potential hazards of chemical products.
 Use, storage, handling, contents
16. Identify and recognize the general characteristics and ED management of other burn considerations including:
a. Tar burns
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Roofing, Asphalt
Heated to temps 500F
o Burns tend to be more thermal than chemical
If hot, tar should be cooled to prevent further thermal injury
Use emulsifying agent to remove tar from skin
b.
Sunburn
c.
d.
Facial burns
Circumferential burns