Burn Care

What is the first step in management of a burn victim?

Primary survey—maintain airway patency, breathing, circulation. (Just like the ABCs of any trauma.)

Secondary survey—identify associated life-threatening injuries and remove burned clothing and jewelry.

What are the ABA criteria for transfer to a specialized burn center?

1. Partial-thickness burns involving greater than 10% total body surface area (TBSA)

2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints

3. Third-degree burns in any age group

4. Electrical burns, including lightning injury

5. Chemical burns

6. Inhalation injury

7. Burn injury in patients with preexisting medical disorders that could complicate management

8. Any patients with traumatic injury in which the burn injury poses the greatest risk of morbidity or mortality

9. Any burned children if the hospital initially receiving the patient does not have qualified personnel or equipment for children

10. Any patient with burns that require special social, emotional, or long-term rehabilitative intervention

What methods are used to estimate burn size?

Lund and Brower chart—most accurate, accounts for body proportions by age group.

Wallace’s “Rule of Nines”—head and neck (9%), anterior torso (18%), posterior torso (18%), each upper extremity (9%), each lower extremity (18%), and perineum (1%).

“Patient’s Palm” method—the patient’s palm is roughly equivalent to 1% of the TBSA.

When should fluid resuscitation begin in a burn victim?

Fluid resuscitation should begin immediately. Resuscitation for burns >20% TBSA in an adult is based on the Parkland formula. Resuscitation requirements are calculated based on the time of injury, not the time of presentation.

What is the Parkland formula?

4 mL × weight (kg) × %TBSA = total volume of Lactated Ringer’s (LR) to be given over the first 24 hours.

At what rate should fluid resuscitation begin for a 70-kg man with second- and third-degree scald burns to the anterior torso and the anterior aspect of both lower extremities, now 2 hours postinjury?

This patient has about 18% TBSA to the anterior torso and 9% TBSA to each anterior lower extremity (18 + 9 + 9 = 36% TBSA).

4 mL × 70 kg × 36% = 10,080 cc of LR over first 24 hours.

Half of volume is given over the first 8 hours; the remainder is given over the next 16 hours.

10,080 ÷ 2 = 5,040 mL needed within the first 8 hours.

5,040 ÷ 6 = 840 mL/hr (the total fluid requirements for the first 8 hours will be given within 6 hours since the patient presented in a delayed fashion).

For this patient, at what rate should fluid resuscitation continue over the next 16 hours?

5,040 ÷ 16 = 315 cc/hr.

At what rate should fluid resuscitation begin for a 70-kg man now 24 hours after flash flame exposure, with an 18% area of first-degree burn to the posterior torso?

No fluid resuscitation is instituted for first-degree burns of any etiology.

How are the resuscitation requirements determined for children?

Based on body surface area:

Galveston Shriners Burns Institute formula: 5,000 mL/m²/BSA burn + 2,000 mL/m²/total BSA = total LR for first 24 hours.

What is the single best monitor of fluid resuscitation?

Urine output (0.5 mL/kg/hr for adults; 1.0–2 mL/kg/hr for children).

By what percent does inhalation injury increase fluid resuscitation requirements?

40% to 75% (~2 cc/kg/%TBSA).

What is the fluid regimen for patients with myoglobinuria or hemoglobinuria?

Discontinue LR and begin normal saline with sodium bicarbonate.

What osmotic diuretic may be added to assist in clearing the urine of these pigments?

Mannitol.

Which burn patients should receive tetanus immunization?

10% TBSA burn injury should receive 0.5 cc of tetanus toxoid; if unknown immunization history or >10 years since last booster, add 250 units of immunoglobulin.

What are the depth classifications of burn injury?

First degree—involves epidermis only.

Second degree—involves partial thickness of dermis.

Third degree—involves full thickness of dermis and all adnexal structures.

Fourth degree—involves underlying muscle, bone, or tendon.

What is the clinical appearance of a partial-thickness versus full-thickness burn wound?

A partial-thickness wound bed usually will be pink and moist underneath blisters, with intact sensation. A full-thickness injury will appear dry and insensate, and may be white, leathery, or charred depending on the depth of involvement.

In what order do different sensory modalities return in a healed burn wound?

Pain (first), light touch, temperature, vibration (last).

What are the three histologic zones of burn injury?

Zone of necrosis—area of tissue necrosis due to destruction from burn injury.

Zone of ischemia—surrounds zones of necrosis; can convert to zone of necrosis because of inadequate tissue perfusion.

Zone of hyperemia—surrounds zone of ischemia; usually reversible injury (heals).

What intervention prevents the progression of a zone of ischemia to a zone of necrosis?

Adequate fluid resuscitation with perfusion of ischemic tissue.

When should escharotomies be performed?

For deep, circumferential extremity burns with decreased or absent pulses or deep burns involving the torso that impair ventilation.

How should escharotomy incisions be planned?

Release of eschar should occur immediately at the bedside using a Bovie electrocautery.

Midaxial incisions release eschar of extremities.

Axial incisions along the flanks that connect across the midline to release the chest/torso.

Unilateral midaxial incisions on the digits on the radial surface of the small finger and thumb; escharotomy incisions on the index, long, and ring finger generally should be placed on the ulnar surface.

If perfusion to a distal extremity does not improve after an escharotomy is performed, what is the next step in management?

Fasciotomy.

What is the cardiovascular response to a burn injury?

Cardiac output (CO) initially decreases and systemic vascular resistance (SVR) increases.

After the first 24 to 48 hours, the heart rate and CO increase and SVR decreases.

How are red blood cells affected by burn injury?

Their T_1/2 is shortened.

What are some causes of early renal insufficiency in burned patients?

Hypovolemia, vasoconstriction due to catecholamine release, myoglobinuria, nephrotoxic medications.

What is the cause of Curling’s ulcer?

A decrease in splanchnic blood flow and gut motility (ileus) place burn patients at risk for Curling’s ulcer usually involving the stomach or proximal small bowel. Appropriate prophylaxis is usually instituted to prevent mucosal erosion.

Which muscle relaxant should be avoided in burned patients?

Succinylcholine—causes marked hyperkalemia.

What is the immunologic response to thermal injury?

Decreased lymphocytes, macrophages, immunoglobulins, and lysosomal enzymes.

What is the hypermetabolic response?

After an early “ebb” phase, a more prolonged period of protein catabolism, lipolysis, tachycardia, increased urinary output, increased oxygen consumption, nitrogen loss, and elevated body temperature ensues.

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