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Burns Algorithm

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Airway

Respiratory distress

  • Consider immediate intubation/airway control

Smoke inhalation injury

  • Closed space fire
  • Hoarseness/stridor
  • Cough, dyspnea
  • Facial burns, singed nasal hair/eyebrows
  • Carbonaceous tongue/sputum
Burns Algorithm
Burns Algorithm

Major Burn

– Partial thickness: >25% TBSA (adults); >20% TBSA (<10 or >50yo)
– Full thickness > 10 %
– Burns to face, eyes, ears, hands, genitals
– Inhalation injury, major trauma
– Chemical burn, electrical injury
– High risk patients

Treatment

  • Timing
    • Early airway management is key !
    • When in doubt → intubate
    • Patient may present well appearing, in no distress → then develop massive facial tongue
    • edema minutes to hours → airway nightmare
  • RSI Medication
    • Ketamine
    • Succinylcholine (2mg/kg) permissible
Managing Burns
Managing Burns

Breathing

Oxygenation

  • Inhalation Injury
    • Thermal airway injury
    • ARDS ?
  • CO Poisoning (See Tox section)
    • Check for saturation gap (SaO2 significantly less on pulse oximetry than that calculated from the PaO2 on the arterial blood gas), COHb level

Ventilation

  • Chest wall burn
  • Pathophysiology
    • Chest wall constriction → ↓ Low Compliance → ↑ Increase PIP → Unable to ventilate
  • Treatment
    • Immediate problem: Must treat within a few minutes!
    • Chest wall escharotomy

Circulation

Resuscitation

  • Fluid resuscitation (Lactated Ringer’s)
    • Estimate burn surface area (rule of 9s, palms)
    • Increase fluid requirements when inhalation or electrical injury present
  • Place foley – should achieve a normal Urinary Output (30-50ml/h in adults)

24h Fluid requirements – Lactated Ringer’s (LR)

– Parkland: 4cc/kg x %TBSA (Total body surface area)
– Consensus: 3cc/kg x %TBSA
– Modified Brooke: 2cc/kg x %TBSA
– Galveston (Peds): 5000ml/m2 x %TBSA + 2000ml
– ALL formulas: ½ fluids in first 8 hours

Pulseless extremity ?

  • Circumferential extremity burn
  • Pathophysiology
    • Burned skin contracts + Subcutaneous swelling → venous occlusion → arterial occlusion → Ischemia
  • Treatment
    • Limb escharotomy within a few hours

Disability

Trauma

  • Trauma present ?
  • Assess patient simultaneously for trauma (fall, blast Injury, MVA) and treat (Cervical spine, pneumothorax, internal bleeding !)
  • Always attempt to obtain neurologic exam (including rectal/pupil exam) before RSI (rapid sequence intubation)

Toxic inhalation

  • CO: saturation gap, COHb level
  • CN: unexplained severe metabolic acidosis, collapse on scene
  • HS

Exposure

Secondary survey:

  • Remove clothing (operative for adherent clothing)
  • Stop burning
  • Provide first aid (avoid hypothermia with overuse of water to decontaminate wounds)
  • Asses for other injuries, asses burn severity (below), consider transfer

Burn Center Transfer (ABA criteria)

– Partial thickness >10% TBSA
– Third degree burns any age group
– Burns to face, hands, feet, genitalia, perineum, major joints
– Electrical burns (including lightning)
– Chemical burns
– Inhalation injury
– Pre-existing medical condition that could complicate management
– Traumatic injury where burn poses greatest risk

General Assessment of Burn Severity (Emerg Med Clin N Am 2007;25:13-146)

  • Severity of burn is multifactorial and depends on:
    • Depth (use partial and full thickness to describe)
      • 1° First degree – epidermal injury, no blister, red, tender, painful (sunburn)
      • 2° Second degree – Partial thickness
        • i. Superficial (no scar): involves superficial dermis→thin walled fluid blisters
        • ii. Deep (+scar): involves reticular dermis →red, blanched white, thick walled blisters
      • 3° Third degree – Full thickness: epidermis, dermis → white, leathery, numb
      • 4° Fourth degree – Skin, Subcutis, may involve fascia, muscle, bone
    • Extent (only 2nd-4th degree)
      • Rule of 9s, palms for adults, palms + fingers for children (1%)
    • Location: face, eyes, ears, hands, perineum
    • Age: mortality = age + TBSA (Total body surface area) (if over 50 yo)
    • Etiologic agent (flame, contact, scald, flash, electrical, radiation, chemical)
    • Presence of inhalation injury
    • Coexisting injury or preexisting illness
  • Classify burn according to severity (Major, Moderate, Minor) (AM Coll Surg Bull 1984;69:24)
    • Major → need burn center
    • Moderate → hospitalize for initial care, not necessarily burn center
    • Minor → Outpatient management

Minor Burns

Treatment

  • Stop the burning process → Remove clothing (operative for adherent clothing)
  • Cool the burn
    • Effective within 20 minutes of burn
    • Irrigate/immerse in tepid water (15oC) for up to 20 minutes (or soaked gauze)
    • Do not use ice
  • Analgesia: if severe, may require opioids, then NSAIDs; cover burn
  • Cleansing/debridement (Br Med J 1987;295(6591):181)
    • New burn is sterile
    • Can clean with soap/water or mild antibacterial (chlorhexidine)
    • Blisters
      • Controversial: can aspirate or de-roof large blisters and remove dead skin or leave alone
      • Small blisters should be left alone
  • Topical antibiotics
    • e.g. Silver sulfadiazene
    • Cochrane review: (Cochrane Review 2010)
      • No effect on infection
      • Slows down healing in patients with partial-thickness burns
  • Dressing Layers:
    • Layer 1: Non-adherent dressing (xeroform, vaseline gauze, Adaptec)
    • Layer 2: Consider antimicrobial layer (Silver sulfadiazene)
    • Layer 3: Antishear layer (Kerlix and Ace wrap)
  • Tetanus update; No empiric antibiotics
  • Follow up: Recheck in 24h and dressing change

Minor Burn

– Partial thickness <15% TBSA adults; <10% (elderly, children)
– Full thickness: <2% TBSA
– No cosmetic/functional risk to eyes, ears, face, hands, perineum

Special types of burns

  • Sunburns → if bad, may need IVF, H1/H2 blocker IV, NSAIDs, opiates
  • Oral commissure burns (child bites electrical cord) → delayed facial artery bleed
  • HF (Hydrofluoric) acid → need aggressive treatment with Ca (topical, IV, intra-arterial)
  • Flash burns → may look bad but usually are not (rarely have inhalation injury)
  • Electrical burns → may not look bad, but usually are (consider arrhythmias and rhabdomyolysis)
    • Usually do not have delayed presentation of Vfib/arrhythmias
    • Consider burn center transfer for electrical burns > 1000V
  • Tar burns → like dissolves like (use butter, mayo, Bacitracin to remove after cooling)
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