Burns

Background

• Types of burn includes chemical (acid/alkali), electrical, radiation (UV, medical/therapeutic), thermal (scald, fire), and can be associated with abuse
• Most common causes in children are scald burns, while most common causes in adults are flame burns
• Early treatment for major burns include airway management, supplemental oxygen and large volumes of IV fluids
• All burns are initially managed with pain management, topical ointments and non-adherent dressing (major burns require debridement)
• Shock, sepsis and respiratory failure are among the most common cause of death after a burn injury

Etiology

• Thermal burns
  • Most common type of burn
  • Flame burns (fire)
  • Contact burns (hot surfaces)
  • Scalding (hot liquids or steam)
• Nonthermal burns
  • Chemical burns
    • Acids such as sulfuric acid, nitric acid, hydrofluoric acid, phenol, and acetic acid
    • Alkalis such as calcium oxide, sodium hydroxide, and potassium hydroxide
  • Electrical burns
    • Low voltage sources: electrical cords, outlets in the households
    • High voltage sources: power lines, lightening
  • Radiation burns
    • UV radiation (sunlight, phototherapy)
    • High-energy particles (from radiotherapy, nuclear accidents)
  • Friction burns
    • Skin injury caused by abrasion against a hard surface

Clinical presentation

Burn Degrees

• 1st degree burn: superficial dermis
  • Blanches on pressure and refills
  • Healing within 3 to 6 days without scarring
• 2nd degree burn: dermis
  • 2A blanches on pressure and refills
  • 2B does not blanch on pressure
  • Both have vesicles/bullae
  • Healing takes 3 weeks or more, with hypopigmentation/hyperpigmentation
  • 2B has scarring
• 3rd degree burn: subcutaneous tissue
  • No pain
  • Black, white, leather like skin lesion (eschar)
  • Does not heal by itself
• 4th degree burn: reaches muscle, fat, bone
  • Charred tissue
  • Dead tissue needs to be removed (amputation)

Rule of 9

• A clinical tool used to rapidly assess the TBSA affected by burns in adults
• The adult body is divided into regions (not children)

Diagnosis

• Pulse oximetry or pulse CO-oximetry (to monitor for progressive hypoxemia, CO poisoning)
• Bronchoscopy (direct evaluation for possible airway injury that include mucosal edema, inhaled soot)
• Blood gas analysis
• Serum electrolytes
• ECG (to assess for arrhythmias for electrical injuries)
• Inhalational injury (respiratory function tests, chest X-ray, carboxyhemoglobin levels)
• Urinalysis (to distinguish myoglobinuria from hematuria)
• BUN/creatinine
• Hemoglobin and hematocrit
• Serum protein and albumin
• Wound swab and blood cultures
• Assessment of capillary refill and peripheral pulses if circumferential wounds

Treatment

• ABCDE
• Fluid resuscitations
  • Establish IV access
  • Use lactated Ringer’s solution (to avoid hyperchloremic metabolic acidosis)
  • Parkland formula (fluid resuscitation protocol for patients with burn injuries)
    • 4 mL * Body weight (kg) * % of TBSA for the first 24 hours
• Local burn wound care (minor wounds)
  • Acute pain management (acetaminophen or NSAIDs)
  • Irrigate the wound to cool the area and remove the debris
  • Clean the wound with soap or diluted
  • Consider applying a topical antibiotics
  • Consider non-adherent wound dressing if the skin is broken
• Local burn wound care (major wounds)
  • Acute pain management (small frequent doses of IV opioids)
  • Consider immediate escharotomy or fasciotomy if the limb perfusion is compromised
  • Irrigate the wound to cool the area and remove the debris
  • Clean the wound with soap or diluted
  • Apply a topical antibiotics (bacitracin is used for partial-thickness burns, silver sulfadiazine is used for full thickness burns)
  • Applying a wound dressing (occlusive dressing, hydrocolloid dressing, biosynthetic dressing)
• Definitive management
  • Early debridement of necrotic tissue
  • Wet-to-dry dressings for infected wounds or wounds with devitalized tissue
  • Free skin grafts (eg, split thickness or full thickness skin graft)
  • Burn reconstruction (eg, flap reconstruction with free or pedicled flaps)

Complications

• Shock, sepsis and respiratory failure
  • Most common causes of death from burns
  • Common organisms of sepsis include MRSA, enterococcus and Pseudomonas
• Circumferential burns may lead to
  • Compartment syndrome
  • Acute limb ischemia
• Curling ulcers
• Keloid formation, contractures
• Marjolin ulcer
• Complications of chemical burns
  • Cataracts or vision loss (if the burn involves the eyes)
  • Esophageal strictures (if the burn involves the esophagus)
• Complications of electrical burns
  • Arrhythmias

Mind maps