Burn injuries affect over 1.25 million people per year in the United States. Thermal burns can be caused by fire, scalding liquids, or electricity and result in damage to the epidermis and dermis layers of the skin. Chemical and electrical burns involve additional injury mechanisms. Burn severity is classified by depth and total body surface area affected. Minor burns involve less than 10% total body surface area, while critical burns involve over 20% or burns of special areas like hands or face. Initial management of burns focuses on the ABCs - airway, breathing, and circulation. Fluid resuscitation is initiated for larger burns to prevent hypovolemic shock. Wound care and infection prevention are also important in treatment

1. Epidemiology
 Tissue injury caused by thermal, electrical,
or chemical agents
 Can be fatal, disfiguring, or incapacitating
 ~ 1.25 million burn injuries per year
• 45,000 hospitalized per year
• 4500 die per year (3750 from housefires)
 3rd largest cause of accidental death

2. Risk Factors
 Fire/Combustion
• Firefighter
• Industrial Worker
• Occupant of burning structures
 Chemical Exposure
• Industrial Worker
 Electrical Exposure
• Electrician
• Electrical Power Distribution Worker

3. Anatomy and Physiology of Skin

4. Skin
 Largest body organ. Much more than a
passive organ.
• Protects underlying tissues from injury
• Temperature regulation
• Acts as water tight seal, keeping body fluids in
• Sensory organ

5. Skin
 Injuries to skin which result in loss, have
problems with:
• Infection
• Inability to maintain normal water balance
• Inability to maintain body temperature

6. Skin
 Two layers
• Epidermis
• Dermis
 Epidermis
• Outer cells are dead
• Act as protection and
form water tight seal

7. Skin
 Epidermis
• Deeper layers divide to produce the stratum
corneum and also contain pigment to protect
against UV radiation
 Dermis
• Consists of tough, elastic connective tissue
which contains specialized structures

8. Skin
 Dermis - Specialized Structures
• Nerve endings
• Blood vessels
• Sweat glands
• Oil glands - keep skin waterproof, usually
discharges around hair shafts
• Hair follicles - produce hair from hair root or
papilla
– Each follicle has a small muscle (arrectus pillorum) which can
pull the hair upright and cause goose flesh

9. Pathophysiology of Burns:
 Potential complications
• Fluid and Electrolyte loss  Hypovolemia
• Hypothermia, Infection, Acidosis
•  catecholamine release, vasoconstriction
• Renal or hepatic failure

10. Assessment of Burn Injury:
 An important step in management is to
determine depth and extent of damage to
determine where and how the patient
should be treated

11. Types of Burn Injuries
 Thermal burn
• Flame
• Scalding
 Chemical burn
• Acid
• Alkali
 Electrical burn
• Lightning
 Radiation burn

12. Depth Classification
 Superficial ( 1st Degree)
 Partial thickness (2nd Degree)
 Full thickness (3rd Degree)

13. Burn Classifications
 1st degree (Superficial burn)
• Involves the epidermis
• Characterized by reddening
• Tenderness and Pain
• Increased warmth
• Edema may occur, but no blistering
• Burn blanches under pressure
• Example - sunburn
• Usually heal in ~ 7 days

14. Burn Classifications
 First Degree Burn
(Superficial Burn)

15. Burn Classifications
 2nd degree (Partial Thickness)
• Damage extends through the epidermis and
involves the dermis.
• Not enough to interfere with regeneration of the
epithelium
• Moist, shiny appearance
• Salmon pink to red color
• Painful
• Does not have to blister to be 2nd degree
• Usually heal in ~7-21 days

16. Burn Classifications
 2nd Degree
Burn
(Partial
Thickness Burn)

17. Burn Classifications
 3rd degree (Full Thickness)
• Both epidermis and dermis are destroyed with
burning into SQ fat
• Thick, dry appearance
• Pearly gray or charred black color
• Painless - nerve endings are destroyed
• Pain is due to intermixing of 2nd degree
• May be minor bleeding
• Cannot heal and require grafting

18. Burn Classifications
 3rd Degree Burn
(Full Thickness burn)

19. Body Surface Area Estimation
 Rule of
Nines
• Adult
 Palm Rule

20. Body Surface Area Estimation
 Rule of Nines
• Peds
– For each yr
over 1 yoa,
subtract 1%
from head and
add equally to
legs
 Palm Rule

22. Pediatric Burns
 Thin skin
• increases severity of burning relative to adults
 Large surface/volume ratio
• rapid fluid loss
• increased heat loss  hypothermia
 Delicate balance between dehydration and
overhydration
 Immature immunological response  sepsis
 Always consider possibility of child abuse

23. Burn Patient Severity
 Factors to Consider
• Depth or Classification
• Body Surface area burned
• Age: Adult vs Pediatric
• Preexisting medical conditions
• Associated Trauma
– blast injury
– fall injury
– airway compromise
– child abuse

24. Burn Patient Severity
 Patient age
• Less than 2 or greater than 55
• Have increased incidence of complication
 Burn configuration
• Circumferential burns can cause total occlusion
of circulation to an area due to edema
• Restrict ventilation if encircle the chest
• Burns on joint area can cause disability due to
scar formation

25. Minor Burn Criteria
 30 < 2% BSA
 20 < 15% BSA
• <10% pediatric
 10 < 20% BSA

26. Moderate Burn Criteria
 30 2-10% BSA
 20 15-30% BSA
• 10-20% pediatric
 Excluding hands, face, feet, or genitalia
 Without complicating factors

27. Critical Burn Criteria
 30 > 10% BSA
 20 > 30% BSA
• >20% pediatric
 Burns with respiratory injury
 Hands, face, feet, or genitalia
 Burns complicated by other trauma
 Underlying health problems
 Electrical and deep chemical burns

28. Thermal Burn Injury
Pathophysiology
 Emergent phase
• Response to pain  catecholamine release
 Fluid shift phase
• massive shift of fluid - intravascular 
extravascular
 Hypermetabolic phase
•  demand for nutrients  repair tissue damage
 Resolution phase
• scar tissue and remodeling of tissue

29. Thermal Burn Injury
Pathophysiology
 Eschar formation
• Skin denaturing
– hard and leathery
• Skin constricts over wound
– increased pressure underneath
– restricts blood flow
• Respiratory compromise
– secondary to circumferential eschar around the thorax
• Circulatory compromise
– secondary to circumferential eschar around extremity

30. Assessment & Management -
Thermal Injury
 Airway and Breathing
• Assess for potential airway involvement
– soot or singing involving mouth, nose, hair, face, facial hair
– coughing, black sputum
– enclosed fire environment
• Assist ventilations as needed
• 100% oxygen via NRB if:
– Moderate or critical burn
– Patient unconscious
– Signs of possible airway burn/inhalation injury
– History of exposure to carbon monoxide or smoke

31. Assessment & Management -
Thermal Injury
 Airway and Breathing (cont)
• Respiratory rates are unreliable due to toxic
combustion product’s
– May cause depressant effects
• Be prepared to intubate early if patient has
inhalation injuries
– Prep early for RSI

32. Assessment & Management -
Thermal Injury
 Circulatory Status
• Burns do not cause rapid onset of hypovolemic
shock
• If shock is present, look for other injuries
• Circumferential burns may cause decreased
perfusion to extremity

33. Assessment & Management -
Thermal Injury
 Consider Fluid Therapy for
• >10% BSA 30
• >15% BSA 20
• >30-50% BSA 10 with accompanying 20
 LR using Parkland Burn Formula
• 4 (2-4) cc/kg/% burn
• 1/2 in first 8 hours
• 1/2 over 2nd 16 hours

34. Management - Thermal Injury
 Fluid therapy
• Objective
– HR < 110/minute
– Normal sensorium (awake, alert, oriented)
– Urine output - 30-50 cc/hour (adult); 0.5-1 cc/kg/hr (pedi)
– Resuscitation formula’s provide estimates, adjust to individual
patient responses
• Start through burn if necessary, upper
extremities preferred
• Monitor for Pulmonary Edema

35. IV fluid Computation:
 70 kg. person with 60% BSB
4 cc./kg./BSB (Parkland Formula)
4 x 70 x 60 = 16800 cc. of Plain LR
Give ½ in 8 hrs. (16800/2 = 8400 cc in 8 hrs.)
or 1050 cc/hr. x 8 hrs.
Give ½ in the next 16 hours:
8400/16 = 525 cc. x 16 hrs.

36. Management - Thermal Injury
 Analgesia
• Morphine Sulfate
– 2-3 mg repeated q 10 minutes titrated to adequate ventilations
and blood pressure
– 0.1 mg/kg for pediatric
– May require large but tolerable total doses
–Tetanus Prophylaxis
–Prevention of Curling’s Ulcer
–Antibiotics

37. Management - Thermal Injury
 Treat Burn Wound
• Low priority - After ABC’s and initiation of IV’s
• Do not rupture blisters
• Cover with sterile dressings

38. Inhalation Injury
 Anticipate respiratory problems:
• Head, Face, Neck or Chest
• Nasal or eyebrow hairs are singed
• Hoarseness, tachypnea, drooling present
• Loss of consciousness in burned area
• Nasal/Oral mucosa red or dry
• Soot in mouth or nose
• Coughing up black sputum
• In enclosed burning area (e.g. small apartment)

39. Inhalation Injury
 Burned or exposed to products of
combustion in closed space
 Cough present, especially if productive of
carbonaceous sputum
 Any patient in fire has potential of hypoxia
and Carbon monoxide poisoning

40. Inhalation Injury
 Supraglottic Injury
• Susceptible to injury from high temperatures
• May result in immediate edema of pharynx and
larynx
– Brassy cough
– Stridor
– Hoarseness
– Carbonaceous sputum
– Facial burns

41. Inhalation Injury
 Subglottic Injury
• Rare injury
• Injury to Lung parenchyma
• Usually due to superheated steam, aspiration of
scalding liquid, or inhalation of toxic chemicals
• May be immediate but usually delayed
– Wheezing or Crackles
– Productive cough
– Bronchospasm

42. Inhalation injury
 Other Considerations
• Toxic gas inhalation
• Smoke inhalation
• Carbon Monoxide poisoning
• Thiocyanate poisoning
• Thermal burns
• Chemical burns

43. Inhalation Injury Management
 Airway, Oxygenation and Ventilation
• Assess for airway edema early and often
• Consider early intubation, RSI
• When in doubt oxygenate and ventilate
• High flow oxygen
• Bronchodilators may be considered if
bronchospasm present
• Diuretics not appropriate for pulmonary edema

44. Chemical Burns
 Usually associated with industrial exposure
 First Consideration: Should you be here?
• Does the patient need decontamination before
treatment?
 Burning will continue as long as the
chemical is on the skin

45. Chemical Burns
 Acids
• Immediate coagulation-type necrosis creating an
eschar though self-limiting injury
– coagulation of protein results in necrosis in which affected
cells or tissue are converted into a dry, dull, homogeneous
eosinophilic mass without nuclei

46. Chemical Burns
 Bases (Alkali)
• Liquefactive necrosis with continued penetration
into deeper tissue resulting in extensive injury
– characterized by dull, opaque, partly or completely fluid
remains of tissue
 Dry Chemicals
• Exothermic reaction with water

47. Chemical Burn Management
 Definitive treatment is to get the chemical
off!
 Begin washing immediately - removal the
patient’s clothing as you wash
• Watch for the socks and shoes, they trap
chemicals

48. Chemical Burn Management
 Liquid Chemicals
• wash off with copious amounts of fluid
 Dry Chemicals
• brush away as much of the chemicals as possible
• then wash off with large quantities of water
 Flush for 20-30 minutes to remove all
chemicals

49. Chemical Burn Management
 Do not attempt neutralization
• can cause additional chemical or thermal burns
from the heat of neutralization
 Assess and Deliver secondary care as with
other thermal and inhalation burns

50. Electrical Burns
 Usually follows accidental contact with
exposed object conducting electricity
• Electrically powered devices
• Electrical wiring
• Power transmission lines
 Can also result from Lightning
 Damage depends on intensity of current

51. Electrical Burns
 Current kills, voltage simply determines
whether current can enter the body
• Ohm’s law: I=V/R
 Electrical follows shortest path to ground
 Low Voltage
• usually cannot enter body unless:
– Skin is broken or moist
– Low Resistance (follows blood vessels/nerves)
 High Voltage
• easily overcomes resistance

52. Electrical Burns
 Severity depends upon:
• what tissue current passes through
• width or extent of the current pathway
• AC or DC
• duration of current contact

53. Electrical Burns
 Alternating Current (AC)
• Tetanic muscle contraction may occur resulting
in:
– Muscle injury
– Tendon Rupture
– Joint Dislocation
– Fractures
• Spasms may keep patient from freeing oneself
from current

54. Electrical Burns
 Contact with Alternating Current can also
result in:
• Cardiac arrhythmias
• Apnea
• Seizures

55. Electrical Burns
 In addition to contact burns, patients can
also develop flash burns when the current
arcs near them
• Flame burns may occur when clothing ignites
after exposure to electrical current

56. Electrical Burns
 Pathophysiology of Injuries
• External Burn
• Internal Burn
• Musculoskeletal injury
• Cardiovascular injury
• Respiratory injury
• Neurologic injury
• Rhabdomyolysis and Renal injury

57. Electrical Burn Management
 Make sure current is off
• Lightning hazards
• Do not go near patient until current is off
 ABC’s
• Ventilate and perform CPR as needed
• Oxygen
• ECG monitoring
– Treat dysrhythmias

58. Electrical Burn Management
Any patient with an electrical burn regardless
of how trivial it looks needs to go to the
hospital. There is no way to tell how bad the
burn is on the inside by the way it looks on
the outside.

59. THANK YOU