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Burns
Caleb J. Mentzer, DO
James R. Yon, MD
image BASICS
DESCRIPTION
  • Tissue injuries caused by application of heat, chemicals, electricity, or irradiation
  • Extent of injury (depth of burn) is a result of intensity and duration of exposure.
    • 1st degree involves superficial layers of epidermis.
    • 2nd degree involves varying amounts of epidermis (with blister formation) and part of the dermis.
    • 3rd degree involves destruction of all skin elements (full thickness) with coagulation of subdermal plexus.
  • System(s) affected: endocrine/metabolic, pulmonary, skin/exocrine
Geriatric Considerations
  • Prognosis is worse for severe burns.
  • Patients >60 years of age account for 11% all of burns.
Pediatric Considerations
Consider child abuse or neglect when dealing with hot water burns in children; abuse accounts for 15% of pediatric burns. Special concerns are sharply demarcated wounds, immersion injuries, and suspect stories. Involve child welfare services early.
EPIDEMIOLOGY
  • Predominant age: 30 years; 13% infants; 11% >60 years of age
  • Predominant gender: males account for 70%
Incidence
Per year in the United States
  • 1.2 to 2 million burns; 700,000 emergency room visits; 45,000 to 50,000 hospitalizations; 3,900 deaths owing to burn-related complications
  • In children: 250,000 burns; 15,000 hospitalizations; 1,100 deaths
  • Estimated total cost of $2 billion annually for burn care
  • House fires cause 75% of deaths.
  • Burn deaths decreasing nationally due to improved prevention and treatment
  • Increase in burns from the illegal production of methamphetamines. Patients can present with a combination of chemical burn, thermal burn, and explosion injury.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Open flame and hot liquid are the most common causes of burns (heat usually ≥45°C): Flame burns are more common in adults; scald burns are more common in children.
  • Caustic chemicals or acids (may show little signs or symptoms for the first few days)
  • Electricity (may have significant injury with very little damage to overlying skin)
  • Excess sun exposure
RISK FACTORS
  • Water heaters set too high
  • Workplace exposure to chemicals, electricity, or irradiation
  • Young children and older adults with thin skin are more susceptible to injury.
  • Carelessness with burning cigarettes: related to 18% of fatal fires in 2006
  • Inadequate or faulty electrical wiring
  • Lack of smoke detectors: Lacking or nonfunctioning smoke alarms are implicated in 63% of residential fires.
  • Arson: cause of 12.4% of fires that resulted in fatalities in 2012
GENERAL PREVENTION
Home safety education should be a key mechanism for injury prevention.
  • Families educated on home safety were more likely to have safe hot water temperatures.
  • Safety education results in more families having functioning smoke alarms and increased use of fireguards.
COMMONLY ASSOCIATED CONDITIONS
Smoke inhalation syndrome
  • May involve thermal burn to respiratory mucosa (e.g., trachea, bronchi) as well as carbon monoxide inhalation
  • Occurs within 72 hours of burn
  • Should be suspected in all burns occurring in an enclosed space or exposure to explosions
image DIAGNOSIS
PHYSICAL EXAM
  • 1st degree: Erythema of involved tissue, skin blanches with pressure, skin may be tender.
  • 2nd degree: Skin is red and blistered, skin is very tender.
  • 3rd degree: Burned skin is tough and leathery; skin is nontender.
  • Rule of 9s (1)[C]
    • Each upper extremity: adult and child 9%
    • Each lower extremity: adult 18%; child 14%
    • Anterior trunk: adult and child 18%
    • Posterior trunk: adult and child 18%
    • Head and neck: adult 10%; child 18%
  • Quick estimate: The surface area of the patient's hand (palmar surface plus fingers) is 1% of the body surface area (BSA).
  • Careful documentation of extent of burn and the estimated depth of burn
  • Check for any signs suggestive of potential airway involvement: singed nasal hair, facial burns, carbonaceous sputum, progressive hoarseness, inflamed oropharynx, circumferential burns around the neck, tachypnea
DIAGNOSTIC TESTS & INTERPRETATION
  • Children: glucose (hypoglycemia may occur in children because of limited glycogen storage)
  • Smoke inhalation: arterial blood gas, carboxyhemoglobin
  • Electrical burns: ECG, urine myoglobin, creatine kinase isoenzymes
Initial Tests (lab, imaging)
  • Labs: hematocrit; type and crossmatching; electrolytes, including BUN and creatinine; urinalysis
  • Imaging: Chest radiograph; Xenon scan is useful in suspected smoke inhalation.
Diagnostic Procedures/Other
Bronchoscopy may be necessary in smoke inhalation to evaluate lower respiratory tract (2)[A].
image TREATMENT
  • Prehospital care (1)[C]
    • Remove the patient from the source of burn.
    • Extinguish and remove all burning clothing.
    • Room-temperature water may be poured onto burn but only in the first 15 minutes following burn exposure.
    • Wrap patient to prevent hypothermia.
    • All patients to receive 100% oxygen via face mask
  • Hospitalization for all serious burns
    • 2nd-degree burns > 10% of BSA
    • Any 3rd-degree burn
    • Burns of hands, feet, face, or perineum
    • Electrical or lightning burns
    • Inhalation injury
    • Chemical burns
    • Circumferential burn
  • Transfer to burn center for (3)[C]
    • 2nd- and 3rd-degree burns > 10% of BSA in patients <10 years and >50 years of age
    • 2nd-degree burns >20% of BSA and full-thickness burns >5% BSA in any age range
    • 3rd-degree burns in any age group
    • Burns of hands, feet, face, or perineum
    • Electrical or lightning burns
    • Inhalation injury
    • Chemical burns
    • Circumferential burn
    • Burns in patients with additional trauma (fractures, etc.) in which the burn is the more severe injury; otherwise, send to trauma center for stabilization.
    • Burn injuries in patients with preexisting medical conditions that could affect management, mortality, or recovery
GENERAL MEASURES
  • Based on depth of burns and accurate estimate of total BSA involved (rule of 9s)
  • Tetanus prophylaxis (if not current)
  • Remove all rings, watches, and other items from injured extremities to avoid tourniquet effect.
  • Remove clothing and cover all burned areas with dry sheets.
  • Flush area of chemical burn (for ˜2 hours).
  • For all major burns, use 100% oxygen administration; consider early intubation.
  • Do not apply ice to burn site.
  • Nasogastric tube (high risk of paralytic ileus)
  • Foley catheter
  • Analgesia
  • ECG monitoring in the first 24 hours following electrical burn
  • Whirlpool hydrotherapy followed by silver sulfadiazine (Silvadene) occlusive dressings in severe burns
  • Daily or BID cleansing with dressing changes
  • Burn fluid resuscitation (1)[C]
    • Calculate fluid resuscitation from time of burn, not from time treatment begins.
    • 2 to 4 mL lactated Ringer × body weight (kg) × % BSA burn (1/2 given in first 8 hours, in second
      P.153

      8 hours, and in third 8 hours); in children, this is given in addition to maintenance fluids and is adjusted according to urine output and vital signs. Protocol-based resuscitation leads to superior outcomes.
    • Colloid solutions are not recommended during the first 12 to 24 hours of resuscitation (1)[C],(4)[A].
    • Other: Use of biologic membranes or skin substitutes may be indicated for burn coverage.
  • Inhalation injury
    • Intubation, ventilation with positive end-expiratory pressure assistance
    • Hyperbaric oxygen treatment may be useful in patients with carbon monoxide levels >25%, patients with coma, focal neurologic deficit, ischemic ECG changes, and pregnant patients (1)[C].
MEDICATION
First Line
  • IV morphine or hydromorphone (Dilaudid) for severe pain
  • Oral analgesics, such as acetaminophen (Tylenol) with codeine, acetaminophen with oxycodone (Percocet), or acetaminophen with hydrocodone (Lortab) for moderate pain
  • Silver sulfadiazine (Silvadene): Apply topically to burn site (can cause leukopenia). Do not use in sulfa-allergic patients, women who are pregnant/breastfeeding, or infants <2 months)
  • Neosporin or bacitracin ointment: Apply to facial burns.
  • Mupirocin: has potent inhibitory activity against methicillin-resistant Staphylococcus aureus (MRSA) (5)[B]
  • Acticoat A.B. (a dressing consisting of two sheets of high-density polyethylene mesh coated with nano-crystalline silver) has a more controlled, prolonged release of silver, allowing less frequent dressing changes (5)[B].
  • Electrical burn with myoglobinuria will require alkalinization of urine and mannitol.
  • Consider H2 blockers (e.g., famotidine) or proton pump inhibitors (e.g., lansoprazole, pantoprazole) for stress ulcer prophylaxis in severely burned patients.
  • Tetanus toxoid/tetanus immunoglobulin
  • There is no clear indication for prophylactic systemic antibiotics (5)[B].
  • Use of negative pressure wound therapy may result in a low-protease environment with higher levels of angiogenic factor (vascular endothelial growth factor [VEGF]) during wound healing, leading to more chaotic, hyperkeratinized, thickened epidermis when compared with a standard hydrocolloid dressing (6)[C].
Second Line
  • Mafenide (Sulfamylon) for full-thickness burn, best against Pseudomonas (Caution: metabolic acidosis, painful)
  • Silver nitrate 0.5% (messy, leeches electrolytes from burn, causes water toxicity)
  • Povidone-iodine (Betadine) may result in iodine absorption from burn and “tan eschar,” makes débridement more difficult.
  • Travase (enzymatic debridement)
SURGERY/OTHER PROCEDURES
  • Escharotomy may be necessary in constricting circumferential burns of extremities or chest due to compartment syndrome.
  • Tangential excision with split-thickness skin grafts: Early excision of burns results in a significant reduction in mortality (excluding patients with inhalational injury) and a significant decrease in hospital length of stay (7)[B].
  • Various dressings (e.g., biosynthetic, biologic) are available to help reduce the number of dressing changes and promote healing.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Early mobilization is the goal.
DIET
  • High-protein, high-calorie diet when bowel function resumes
  • Nasogastric tube feedings may be required in early postburn period.
  • Total parenteral nutrition if NPO is expected for >5 days
  • Early initiation of enteral nutrition in the first 24 hours of admission results in shorter intensive care unit (ICU) stay and lower wound infection rates
PATIENT EDUCATION
  • Use of sunscreen: Skin grafts or newly epithelialized skin is highly sensitive to sun exposure and thermal extremes.
  • Prevent access to electrical cords/outlets.
  • Isolate household chemicals.
  • Use low-temperature setting for water heater (<54°C).
  • Household smoke detectors with special emphasis on maintenance
  • Family/household evacuation plan
  • Proper storage and use of flammable substances
  • Burn management: http://www.aafp.org/afp/2000/1101/p2029.html
  • Burn prevention: http://www.aafp.org/afp/2000/1101/p2032.html
PROGNOSIS
  • 1st-degree burn: complete resolution
  • 2nd-degree burn: epithelialization in 10 to 14 days (deep 2nd-degree burns probably will require skin graft)
  • 3rd-degree burn: no potential for reepithelialization; skin graft is required.
  • Baux score (sum of age and TBSA burned) and Denver 2 score (pulmonary score ranging 0 to 3, using PaO2/FiO2 cutoffs of 100, 175, and 250), renal score (0 to 3, using creatinine cutoffs of 1.8, 2.5, and 5.0 mg/dL), hepatic score (0 to 3, using bilirubin cutoffs of 2, 4, and 8 mg/dL), and cardiac score (0 to 3, based on number and dosage of inotropes) can be used to estimate mortality (8)[B].
  • Length of hospital stay and need for ICU care depend on extent of burn, smoke inhalation, comorbidities, and age.
  • Burn size is correlated to complications; >60% TBSA burned in children and >40% in adults are at increased risk for mortality and morbidity (8)[B].
  • A 50% survival rate can be expected with a 62% burn in patients aged 0 to 14 years, 63% burn in patients aged 15 to 40 years, 38% burn in patients aged 40 to 65 years, and 25% burn in patients >65 years of age (1)[C].
  • 90% of survivors can be expected to return to an occupation comparable to their preburn employment.
REFERENCES
1. Teague H, Swencki SA, Tang A. The burned patient: assessment, diagnosis, and management in the ED. Trauma Reports. 2005;6(2):1-12.
2. Dries DJ, Endorf FW. Inhalation injury: epidemiology, pathology, treatment strategies. Scand J Trauma Resusc Emerg Med. 2013;21:31.
3. Bezuhly M, Fish JS. Acute burn care. Plast Reconstr Surg. 2012;130(2):349e-358e.
4. Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2013;(2):CD000567.
5. Church D, Elsayed S, Reid O, et al. Burn wound infections. Clin Microbiol Rev. 2006;19(2):403-434.
6. Caulfield RH, Tyler MP, Austyn JM, et al. The relationship between protease/anti-protease profile, angiogenesis and re-epithelialisation in acute burn wounds. Burns. 2008;34(4):474-486.
7. Ong YS, Samuel M, Song C. Meta-analysis of early excision of burns. Burns. 2006;32(2):145-150.
8. Jeschke MG, Pinto R, Kraft R, et al. Morbidity and survival probability in burn patients in modern burn care. Crit Care Med. 2015;43(4):808-815.
Codes
ICD10
  • T30.0 Burn of unspecified body region, unspecified degree
  • T30.4 Corrosion of unspecified body region, unspecified degree
Clinical Pearls
  • 1st degree: erythema of involved tissue; skin blanches with pressure. Skin may be tender.
  • 2nd degree: Skin is red and blistered. Skin is very tender.
  • 3rd degree: Burned skin is tough and leathery. Skin is not tender.