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1. Project: Ghana Emergency Medicine Collaborative
Document Title: Introduction to Burns
Author(s): Robert Preston, MD
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3. Introduction to Burns
Robert Preston, MD
Division of Emergency Medicine
Division of Burn, Trauma, and Critical Care
University of Utah
Robworldwide@Gmail.com
Enlarge, Wikimedia Commons
3

4. HPI
• 9 year old with no significant medical history
• He lit his shirt on fire in his room
• He was able to extinguish the flames on his shirt,
but larger fire started in his room
• Neighbor/Ambulance staff rescued him from
bedroom, no longer on fire himself but confused
and with obvious burns to much of his body
• Initial Vitals:
• T 37.2 HR 121 BP 155/78 RR 24 S 92%ra
***
4

5. Physical
Face
Anterior thorax
Right arm, anterior
and posterior, upper
½
Left arm, anterior
aspect, entire limb
Face
Source Undetermined
5

6. ABCs
•
•
•
•
•
General: Shaking, moaning
A: Verbal, but confused.
B: Crackles at bases.
C: Thready, rapid, regular pulses
D: Opens eyes to pain; Localizes to pain
(crossing midline)
6

7. Physical
• VS: 155/78 P122 T 37.2
RR 24 Sat% 92% ra
• Gen: Shaking, moaning.
• Neuro: GCS 12; No FND
• HEENT: PERRL. Soot in
nose.
• Resp: Tachypenic.
Crackles at bases
bilaterally
• CV: Regular, rapid rate. No
r,m,g. Burns to anterior
chest
• Abd: Tender to palpation
due to burns. Not
distended.
• Skin: Burns to torso, front
and back, as well as to
upper anterior right arm,
upper anterior and
posterior left arm;
• Extremities: Pulses 2/4
throughout in all
extremities
***
7

8. LABS
• WBC: 13; Hgb: 15 Platelets: 390
141
106
8
4.0
25
0.5
101
8

9. Chest Xray
Source Undetermined
9

10. Critical Actions
ü
ü
ü
ü
ü
ü
A-B-C approach
Pain control offered, provided
Tetanus status assessed
Identify probable inhalation injury and proceed with intubation
Estimate TBSA of burn (Rule of 9s or suitable other method)
Initiate adequate initial fluid resuscitation (Parkland formula or or
suitable other method)
10

11. Webaware, Wikimedia Commons
11

12. First degree burn
Bejinhan, Wikimedia Commons
Jmh649, Wikimedia Commons
12

13. Superficial partial-thickness (2nd)
1Veertje, Wikimedia Commons
13

14. Deep partial-thickness (2nd)
Westchaser, Wikimedia Commons
14

15. Deep partial-thickness (2nd)
Source Undetermined
15

16. Full Thickness (3rd)
Source Undetermined
Source Undetermined
16

17. The initial evaluation and
management of burn injury
It’s never just a burn!
17

18. Step 1: Decontamination
• Flame and Scald injuries
– Remove clothing and use cool water/cloth to cool
• Electrical injury
– C-spine precautions
– Assess for myocardial injury
• Chemical
– Dilute, dilute, dilute
– Don’t waste time initially looking for specific antidoes*
18

19. Step 2: Primary Survey Airway
Management
• The burn patients is a multi-trauma patient
• A: Airway
– Facial and oropharyngeal swelling progresses 24
– Succinylcholine (?)
• B: Breathing
– Assess for inhalation injury
• C: Circulation
– Evaluate for circumferential burns
– Assess pulses frequently
19

20. Inhalation injury
• Responsible for most deaths from fires
• Hot gases and chemicals in the smoke
• Signs and symptoms
–
–
–
–
Burns to face or oropharynx
Singed nasal/facial hair
Carbonaceous sputum
Typical resp symptoms: cough, tachypnea, wheeze,
stridor, excessive secretion/sputum production
– Dysphonia
– Changed in mental status/LOC
20

21. Three types of Inhalation Injury
• Carbon Monoxide Poisoning
• Upper Airway
• Pulmonary
21

22. Carbon Monoxide Poisoning
• Not a pulmonary toxin – rather, a circulatory problem
– Hgb unable to transport oxygen
• Symptoms
– Progressive mental status deterioration with confusion,
somnolence, can lead to coma and seizures.
• Diagnose with ABG not pulse-ox
• Treatment – Oxygen, Oxygen, Oxygen
– FiO2 1.0 reduces T ½ from 2.5 hrs to 40 min
22

23. Upper Airway
• A THERMAL burn to the face/mouth/oropharynx.
• Symptoms primarily caused by SWELLING:
Hoarseness, stridor, airway obstruction.
• Can occur from non-flame injuries (scalds, chemicals).
• Remember that edema is PROGRESSIVE over 24
hours: re-evaluate patients frequently.
23

24. 30 minutes post-burn
Source Undetermined
24

25. 6 hours post-burn
Source Undetermined
25

26. Pulmonary Injury
• The true inhalation Injury, it is actually a CHEMICAL
injury to the tracheo-bronchial mucosa
– Loss of cilia action, sloughing, bronchiectasis, air trapping,
consolidation, infection
• NOT an indication for intubation: Oxygen!
• May be absent for 72 hours before manifesting
– Hypoxia
– ARDS-like (not really, though)
– Infection (mimic or co-existant)
• Facilitates MODF (usual cause of death)
• Confirm with bronch
26

27. Step 3: Secondary Survey
•
•
•
•
•
Head-to-toe exam looking for all injuries
De-bride burns and assess extent and depth
Document with diagrams if possible
Keep patient warm
Multiple trauma is common in burn patients
– An unconscious patient is unconscious for some
other reasons until proven otherwise
– Consider abuse/assault
– Other care as per non-burn trauma patient
• Suture lacs, stabilize fractures etc
27

28. Step 4: Fluid Resuscitation
Fluid Resuscitation is the
Primary Objective of Initial
Burn Treatment!
28

29. Step 4: Fluid Resuscitation
• Calculate Total Body Surface Area
29

30. Estimating Burn Size
Adult
Anatomic structure Surface area
Anterior head
4.5%
Posterior head
4.5%
Anterior torso
18%
Posterior torso
18%
Anterior leg
each 9%
Posterior leg
each 9%
Anterior arm
each 4.5%
Posterior arm
each 4.5%
Genitalia/perineum
1%
Child
Anatomic structure Surface area
Anterior head
9%
Posterior head
9%
Anterior torso
18%
Posterior torso
18%
Anterior leg
each 6.75%
Posterior leg
each 6.75%
Anterior arm
each 4.5%
Posterior arm
each 4.5%
Genitalia/perineum
1%
30

31. Calculating burn size
1. Best done after
debridement.
2. First-degree (nonblistered) burns
don’t count.
7mike5000, Wikimedia Commons
31

32. Step 4: Fluid Resuscitation
•
•
•
•
Calculate Total Body Surface Area
Estimate fluid requirement with formula
Don’t forget maintenance requirements
Parkland is most popular starting point
– 4 ml/kg x %BSA – ½ over first 8 hours, then over 16
– Titrate to patient response – urine output*
• If not making
– Time = 0 is time of burn, not ED arrival
32

33. Step 4: Fluid Resuscitation
• Example: 70 kg man with 40% TBSA Burns
• Parkland: 70kg x 4ml LR x 40%
= 11.2 L over 24 hours
• Give half over first 8 hours, i.e.
5.6 L / 8 = 700 ml/hr + maintenance (125/hr)
= 825 ml/hr
• Give the other half over 16 hours, i.e.
5.6 / 16 = 350 ml/hr + maintenance (125/hr)
= 475 ml/hr
• Increase or decrease hourly based on urine
output
33

34. Step 4: Fluid Resuscitation
Expect extra requirements in:
• Very young
– Average 5.8 cc/kg x %TBSA
•
•
•
•
Very deep burns
Electrical injuries (‘tip of the iceberg’)
Inhalation
Delay before ED presentation
34

35. Step 4: Fluid Resuscitation
Complications
• Facial/airway swelling
– Re-assess frequently for stridor, eyes swollen shut
• Limb swelling - Compartment Syndrome
– In both burned and unburned extremities
• Torso swelling
– Look for respiratory compromise
– Measure bladder pressures
35

36. Escharotomy Sites
• Incise to subcutaneous level
• Consider using a Bovie/cautery to
minimize bleeding
• Cut through entire length of eschar
Original Image, Sjef,
Wikimedia Commons
Altered Image, Lena Carleton,
University of Michigan
36

37. Limb Escharotomy
Wikimedia Commons ,.‫ﺁآﺭرﻡمﯼیﻥن‬
37

38. Torso Escharotomy
Source Undetermined
38

39. Torso and Abdominal Escharotomy
Source Undetermined
39

40. Step 5: Wound Care
• Debride blisters, dirt, old or non-professionallyapplied ointments. Shave adjacent hair
• Wrap fingers individually
• Avoid Occlusive dressings
• Use a non-stick gauze or leave open
• Use a non-sulfa containing silver product
• Change q12h
40

41. Burn Pearls
• Don’t soak/pack in ice/ice water:
– Frostbite and hypothermia are real risks
– Just cool – helps if performed immediately
•
•
•
•
Keep them comfortable – Pain Control is key
Make sure tetanus up to date
Consider an NG tube if 25% BSA
Outpatient therapy may be appropriate
– Less than 10% BSA
– Pain is controlled on oral meds (and tolerating POs)
– Able to perform wound care AND therapy (encourage
active range of motion)
41