Burns

Abstract

Burns are injuries to tissue caused by heat, chemicals, and/or radiation. The two factors that
influence the severity of a burn are its depth and the surface area involved. Accordingly, burns
are classified into four grades based on the depth of tissue involvement. Lund-Browder charts are
used to calculate the surface area involved. Massive tissue necrosis, which occurs with severe
burns, results in sepsis, shock, and sequential organ failure (see SOFA score for details). In the
case of severe burns, patients should be intubated, given supplemental oxygen and resuscitated
with IV fluids. Parkland's formula is commonly used to calculate initial fluid requirement, but
fluids should be adjusted to maintain clinical stability and appropriate urine output. Pulse
oximetry, blood gas analysis, and measurement of electrolyte and creatinine levels are important
diagnostic procedures for patients with severe burns. In the case of circumferential burns around
limbs, peripheral pulses and capillary refill can be used to detect perfusion. Escharotomy should
be performed in order to treat compartment syndrome and prevent acute limb ischemia. First
and second-degree burns can be treated with antiseptic ointment and dressings. Treatment of
third and fourth-degree burns involves debridement of necrotic tissue followed by skin graft or a
tissue transfer via flap. Burn wounds tend to become infected and large, severe burns tend to be
fatal injuries. The most common causes of death following burns are shock, sepsis, and
respiratory failure.

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Etiology

 Thermal injury (e.g., scalding, contact with a hot surface, fires)

 Non-thermal injury: radiation, chemical burns, electrical burns[1]

Although most cases of burns are the result of accidental injury, non-accidental injury must
always be suspected in vulnerable populations, including children and the elderly!

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Pathophysiology

Local effects
 Almost all burns are colonized by bacteria.[2]
  Common pathogens that infect burn
wounds: MRSA, Pseudomonas, Klebsiella, Acinetobacter, Candida[3]
 Eschars can cause constrictive effects.[3]
 Significant eschar on chest or neck → restricts chest excursion → asphyxia
 Circumferential eschars → loss of skin elasticity → impaired blood flow
and/or compartment syndrome (caused by an accumulation of fluids) →
acute ischemia distal to the eschar

Systemic effects
 Large (> 30% of the body surface area)[1] and/or deep burns → extensive tissue damage
→
 Release of cytokines and other inflammatory mediators (systemic inflammatory
response syndrome) →
 Increased vascular permeability → extravasation of protein and fluid from
the intravascular compartment into interstitialtissue → generalized edema, acute
respiratory distress syndrome , and hypovolemic shock with paralytic ileus[2] [2]
 Disseminated intravascular coagulation (DIC)[2]
 Evaporative fluid loss → hypothermia, dehydration
 Hemolysis, muscle damage → hemoglobinuria and/or myoglobinuria → acute tubular
necrosis
 Immunosuppression
 Hypermetabolic state with increased nutritional requirements
 Inhalation of hot smoke and/or noxious gases → inhalation injury
 Laryngeal edema → airway obstruction
 Pneumonitis
 Carbon monoxide poisoning
 Cyanide poisoning

References:[2]

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Burn severity

Depth of a burn
Burns are classified into four grades based on their depth, the degree of pain associated with
them, and other clinical features (redness, blister formation).

In cases of severe, deep burns, pain may be absent as a result of damage to sensory nerve
endings!
 Degree of burns[4] Depth of tissue Symptoms[5] Healing process
damage
1st degree (superficia
 Superficial layers Pain  Healing within 3–6
l burn) of the epidermis  Erythema days without scarring
 Swelling
 The burn
wound blanches
on applying
pressureand
refills rapidly
2ndde 2a (superficia
 Epidermis and  Pain  Healing within 1–3
gree l partial- upper layers of  Erythema weeks with hypopigmentation/h
thicknessbur the dermis; dermal Vesicles/bulla yperpigmentationbut without
n) appendages (hair e scarring
follicles, sweat,  The burn
and sebaceous wound blanches
glands) are spared. on applying
pressureand
refills slowly.
2b (deep part
 Deeper layers of  Minimal pain  Healing takes 3 weeks or longer
ial- the dermis.  Mottled skin and results in scar formation
thicknessbur with red and/or
n) white patches
 Vesicles/bulla
e
 The burn
wound does
not blanch on
applying
pressure.
3rd degree (full   No pain
Epidermis, dermis,  The burn does not heal by itself.
thickness burn) and subcutaneous Tissue necrosis
tissue. with black,
white, or
gray leather-
like skin(escha
r)
 No vesicles/bull
ae
 The burn
wound does
not blanch on
Degree of burns[4] Depth of tissue Symptoms[5] Healing process
damage
applying
pressure.
4th degree  Deeper structures Charred tissue  The tissue is dead and requires
(muscles, amputation.
fat, fascia, and
bones)
Extent of burns (surface area involved)
 Wallace's rule of nines
 A quick but reliable method for estimating the surface area covered by burns in the case
of adults.
 The rule of nines is unreliable among children.
Body surface area
Segment Adult Small child Infant
Head 9% 16% 18%
Trunk 36% (4 x 9%)
Arms 18% (2 x 9%)
Thighs 18% (2 x 9%) 13.5% 14.5%

Lower legs and feet 18% (2 x 9%) 13.5% 14.5%

Genital region 1%

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Clinical features

 Clinical features of shock (e.g., hypotension, poor urine output)

 Clinical features of ARDS (e.g., dyspnea)
 Inhalation injury should be suspected when any of the following are present:
 History of being trapped in a confined space.
 Facial burns, singed eyebrows and/or nose hair, evidence of soot on the face or in
the airway
  Stridor, dysphonia
 Extensive burns
 In case of circumferential burns around limbs → compartment syndrome: clinical
features of acute limb ischemia (e.g., weak/absent pulse, paresthesias, pallor in the
affected limb)
 In case of circumferential burns around abdomen → abdominal compartment syndrome:
impaired function fo nearly every organ system (e.g., oliguria, acute pulmonary
decompensation, hypoperfusion) and signs of increased intraabdominal pressure (jugular
venous distension, hypotension, tachycardia)

In the case of adults, shock sets in when burns involve > 15% of the body surface. Burns that
involve 50–70% of the body surface are usually lethal. In children, signs of shock appear with >
10% involvement of the body surface and 60–80% body surface involvement is
lethal!References: [1][6]

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Diagnostics

Burn severity is based upon clinical history and physical examination, but further testing is
conducted to monitor for complications and guide therapy.

 Pulse oximetry: monitor for hypoxemia

 Blood gas analysis: monitor for hypoxemia, metabolic, and/or respiratory acidosis
 Serum electrolytes: hyperkalemia and hyponatremia occurs in the acute phase
following burns; hypernatremia may occur later.[7]
 If inhalational injury is suspected, the following additional tests should be performed:[6]
 Bedside respiratory function tests to rule out airway obstruction
 Chest x-ray in order to rule out ARDS
 Carboxyhemoglobin levels
 End tidal CO2 (ETCO2), serum lactate
 Flexible fiberoptic laryngoscopy/bronchoscopy
 BUN/creatinine: monitor for acute renal injury[6]
 Hemoglobin, hematocrit : monitor for hemolysis
 Serum protein and albumin levels
 If wound infection or sepsis is suspected: wound swab and blood cultures
 In circumferential limb wounds at risk for distal ischemia/compartment syndrome, assess
perfusion with pulse oximetry (> 90%indicates adequate perfusion) and assessment
of capillary refill and peripheral pulses
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Treatment
Immediate measures in case of severe burns: Think
“ABCs”--Airway, Breathing, Circulation
 Airway management: Intubation and high flow oxygen therapy is indicated if
an inhalation injury is suspected[6] or if burns involve more than 30–40% of the body
surface. Don't delay intubation if needed, as fluid resuscitation can increase laryngeal
swelling, which will complicate intubation
 Begin initial fluid resuscitation with crystalloids, usually lactated Ringer's
solution (RL)[6]
 In adults: Parkland formula is used to guide initial fluid therapy: the volume of lactated
Ringer's solution to be administered within a period of 24 h = 4 mL/kg x % of total body
surface involved in burn x body weight (in kg)
 In children: initial fluid therapy for a 24 hour period is the Parkland formula + 24
h maintenance fluid requirements
 Note that this is an INITIAL estimate for fluid requirements: fluid therapy should be
modified to achieve a urine output of > 0.5 mL/kg/hr in adults and > 1 mL/kg/hr in
children.
 Remove any burnt clothing[6], cool the burnt area with cool running water or saline-
soaked gauzes. Do NOT use ice or ice water! Cover the wound with a sterile dressing.
 Core body temperature should be monitored for hypothermia; if body temperature <
35°C, warm IV fluids can be given
 Cool with caution or not at all in patients with burns involving >10% BSA as they are
particularly vulnerable to hypothermia.[6]

Patients with burns who cannot take fluids orally also require maintenance fluids. Parkland's
formula does not include the daily maintenance fluid requirement!

Because fluid resuscitation can worsen laryngeal edema, intubation should be performed
before fluid resuscitation![6]

Additional measures
 Tetanus prophylaxis[6]
 Analgesia (opiates often necessary)[6]
 Proton pump inhibitors or H2 antagonists: prophylaxis against Cushing's
ulcers (see stress ulcers and stress ulcer prophylaxis)[370]
 Following resuscitation, the patient should be transported to a special burn unit in the
following situations:
 2nd-degree burns involving > 10% of the body surface or 3rd-degree burns involving >
5% of the body surface
 Inhalation injury
 Burns involving specific regions (hands, feet, face, genitalia, joints)
 Electrical burns and chemical burns
  Prophylactic systemic antibiotic therapy is NOT routinely recommended.
 If burn wound infection or sepsis occurs, empirically treat for MRSA until ruled out (e.g.
with vancomycin); treat for Pseudomonas (e.g. cefepime) if suspected.

Management based on degree

 1st and 2nd-degree burns
 Irrigation
 Topical moisturizers (e.g., calamine lotion) or aloe vera-based gels: relieve symptoms
of 1st-degree burns
 Consider antiseptic ointments (e.g., silver sulfadiazine, mafenide) or
topical antibiotics (bacitractin; triple antiobitic ointments are a combination of
bactracin neomycin, polymyxin B)[6]
 For periorbital or periocular burns, topical antibiotics (e.g., bacitracin, neomycin,
or erythromycin) are preferred over silver sulfadiazine, which may be irritating and cause
ocular toxicity.
 Deroofing bullae/vesicles
 Dressing is indicated in partial thickness (2nd-degree) burns.
 3rd and 4th-degree burns
 Early debridement of burnt, necrotic tissue
 Method of tissue coverage varies depending on the specific burn characteristics. Options
include:
 Free skin grafts (split-thickness or full-thickness)
 Flap reconstruction with free or pedicled flaps. [8]
 Topical antibiotics (e.g., silver sulfadiazine, bacitracin, neomycin)

Burn eschars: specific measures

 For circumferential burn[6]
 Perform a doppler test, as well as check the capillary refill time, peripheral pulses,
sensations, and pulse oximetry in the limb hourly for 24–48 hours
 If NO impending vascular/respiratory compromise or compartment syndrome:
 Elevate the lower limb or torso
 Perform range of motion exercises as tolerated
 If vascular/respiratory compromise or compartment syndrome is impending or has
occurred:
 Escharotomy
 If compartment syndrome develops: fasciotomy
 For chest/neck eschars:
 If respiratory compromise impending or has occured → escharotomy

Small superficial and superficial partial-thickness burns may be treated on an outpatient basis
with paraffin gauze, antisepticointment, and analgesics!
Chemical burns: specific measures
 Immediate, copious irrigation of all areas of exposure with water, prior to or on the
way to the hospital.
 Once in the hospital, irrigation should be continued until the pH normalizes
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Complications

 Shock, sepsis, and respiratory failure are the most common causes of death
following burns (see “Pathophysiology” above).
 Common organisms include Staph
aureus (including MRSA), Enterococcus (including VRE), and Pseudomonas.
 Curling's ulcers (see stress ulcers)[6]
 Keloid formation, contractures[4]
 Marjolin's ulcer: squamous cell carcinoma that develops in a burn scar
 Complications of chemical burns
 Cataracts or vision loss if burn involved eyes
 Esophageal strictures if burn involved esophagus
 Systemic poisoning
 Complications of electrical burns: arrhythmias, trauma