BURNS

Contents

Definition, Description, Types, Etiology

Anatomy of Integumentary System
Determining Severity of Burn
Assessment
Pathophysiology
Management

Definition
Burns are a result of the effects of thermal
injury on the skin and other tissues
Human skin can tolerate temperatures up to
42-440 C (107-1110 F) but above these, the
higher the temperature the more severe the
tissue destruction
Below 450 C (1130 F), resulting changes are
reversible but >450 C, protein damage
exceeds the capacity of the cell to repair

Anatomy of the Skin

Anatomy of the Skin

Depth of Burns
Superfacial (First-degree) burns

Involve only top skin layer

Epidermis only damaged
Painful to touch
Area initially erythematous
due to vasodilatation
Epidermis sloughed off in 7
days with complete scarless
healing

Depth of Burns
Partial-thickness
Superfacial(Seconddegree) burns
*Involve epidermis and
some portion of dermis
*Can be either
superficial or deep

Partial thickness- Superfacial Second

degree burn

Partial thickness
Deep Second degree burns
Epidermis & deeper degrees of dermis
destroyed
Are pink to cherry red, wet, shiny with
serous exudate
Very painful when touched or exposed to air
Heal in 14- 28 days with scarring
May need early excision and grafting

Partial thickness
Deep Second degree burns

Depth of Burns
Fullthickness(Thirddegree) burns
Extend through
all layers of skin

Need better
phtls

Full-thickness(Third-degree)
burns
Will appear as thick, dry, leathery, waxy
white to dark brown regardless of race or
skin color
May have a charred appearance with visible
thrombosis of blood vessels
Will have little to no sensation because
nerve endings have been destroyed except
in surrounding tissues with partial thickness
burns

Full-thickness(Third-degree)
burns

Depth of Burns
Fourth-degree burns
Extend through all
layers of skin as well
as extending to
underlying fat,
muscle, bone or
internal organs

Burn Photos
2nd degree Burn 1 day

Mild Burn
2nd degree Burn 2 days

2nd degree Burn 1 hr

Burn Size Estimation

Critical to providing adequate resuscitation

3 common guidelines used

Rule of Nines
Lund-Browder Chart
Palmer Method

Rule of Nines
In the adult, most areas of the body can be
divided roughly into portions of 9% or
multiples of 9.
In the child, similar portions are assigned
This division is useful in estimating the
percentage of body surface damage an
individual has sustained in burn.

Rule of Nines

Lund-Browder Chart

Palmer Method
The palmer surface
of the patients hand
from crease at
wrist to tip of
extended fingersequals ~ 1% of the
patients total body
surface area

Extent of Burns

Classification According to Extent

Mild: 10%
Moderate:
10-30%
Severe: > 30%
Hospitalization for >
10% of body surface
area

Infant Rule of Nines

(for quick assessment of
total body surface area
affected by burns)
Anatomic
structure

Surface
area

Head

18%

Anterior Torso

18%

Posterior Torso

18%

Each Leg

14%

Each Arm

9%

Perineum

1%

Kinds of Burns
Flame Burn: due
to gasoline,
kerosene, liquified
petroleum gas
(LPG) or burning
houses

Kinds of Burns
Scald Burn: most
frequent in home
injuries; hot
water, liquids and
foods are most
common causes;
above 65o C, cell
death

Kinds of Burns
Chemical Burns
2 types of chemical burns

acids-can be neutralized

alkaline- adheres to tissue,

causing protein hydrolyses and
liquefaction
examples: industrial or
agricultural sites, highways and
battlefields > cleaning agents,
drain cleaners, lyes, and
military grade agents, etc.
Chemical (Acid) Burns

Chemical Burns
With chemical burns, tissue destruction may
continue for up to 72 hours afterwards.
It is important to remove the person from
the burning agent or vice versa.
Chemicals, heat, and light rays can burn the
eye.

Kinds of Burns

Radiation Burns
from X-ray,
radioactive
radiation and
nuclear bomb
explosions

Kinds of Burns
Electrical Burns
worse than the other types; with entrance
and exit wounds; may stop the heart and
depress the respiratory center; may cause
thrombosis and cataracts

Electrical Burns

Injury from electrical burns results from

coagulation necrosis that is caused by intense
heat generated from an electric current.
Can cause tissue anoxia and death
The severity depends on amount of voltage,
tissue resistance, current pathways, and
surface area in contact with the current and
length of time the current flow was sustained.

External signs of an electrical burn may be

deceiving.
Entrance may be small, while deeper tissue
damage may be massive.

Burn Photos
Electrical Burns
Exit Wounds

Severe swelling
peaks 24-72 hrs after

Electrical burns mummified

1st 2 fingers later removed

Electrical Burns
Entrance Wounds

Entrance wound of electrical

burns from an overheated tool

Smoke and Inhalation Injury

Can damage the
tissues of the
respiratory tract
Although damage to
the respiratory
mucosa can occur, it
seldom happens
because the vocal
cords and glottis
closes as a
protective
mechanisms.

The glottis (1) is the opening in the epiglottis (2). It is the

dark slit in the center of the epiglottis and is evident when the
tongue is pulled down toward the chest cavity.

Inhalation injury
Airway edema & Carbon deposits

3 types of smoke and inhalation

injuries

1. Carbon monoxide poisoning (CO poisoning and asphyxiation count for majority of
deaths)

Treatment- 100% humidified oxygen-draw carboxyhemoglobin level- can occur without any
burn injury to the skin

3 types of smoke and inhalation

injuries (cont)
2. Inhalation injury above the glottis (caused
by inhaling hot air, steam, or smoke.)
Mechanical obstruction can occur quicklyTrue ER! Watch for facial burns, signed nasal
hair, hoarseness, painful swallowing, and
darkened oral or nasal membranes

3 types of smoke and inhalation

injuries (cont)
3. Inhalation injury below glottis
(above glottis-injury is thermally produced)
below glottis-it is usually chemically
produced.
Amount of damage related to length of
exposure to smoke or toxic fumes
Can appear 12-24 hours after burn

3 Phases of Burn Management

Emergent (resuscitation)
0 48 hours, can be up to days later
Acute (definitive care)
day 3 until wounds heal
Rehabilitation
Begins during resuscitation and continues
throughout lifespan

Emergent Phase
(Resuscitative Phase)
Lasts from onset to 5 or more days but
usually lasts 24-48 hours
Begins with fluid loss and edema formation
and continues until fluid motorization and
diuresis begins
Greatest initial threat is hypovolemic shock
to a major burn patient

Emergent Phase
Initial Management/Care
MAKE SURE YOU ARE SAFE !!!
Remove patient from area! Stop the burn!
Airway-check for patency, soot around nares,
or signed nasal hair. 100% O2 via NRM @
15L. Watch for early upper airway edema
>intubate is in doubt.
Breathing- check for adequacy of ventilation,
consider need for early intubation or early
escharotomy if ventilation is impaired

Emergent Phase Initial

Management/Care
Circulation-check for presence and regularity of
pulses, consider early escharotomy if circulation to a
limb is impaired
Disability- AVPU, altered mental status in burn
patient is not normal >think carbon monoxide
poisoning. Check pupils. Check for movement in all
extremities.
Expose- Remove clothing and jewelry. Do not pull
on clothing stuck to skin > Cut away clothing or soak
it off. Cover with dry sterile sheet and tuck in sides.

Emergent Phase Initial

Management/Care
Fluid Resuscitation- estimate TBSA burn percentage and
weight then calculate fluids for first 24 hour period using
Parkland formula
Foley catheter- to monitor urine output
Secondary survey starting with a good scene and patient
history then head to toe exam
Pain Management- early and often based on patients
hemodynamic status and pain scale
Psychosocial issues- consider need for religious
intervention, legal consult for family affairs, etc for
patients with life-threatening burns

Secondary Survey History

Flame
How did the burn occur?
Did the burn occur outside or inside?
Did the clothes catch on fire?
How long did it take to extinguish the flames?
How were the flames extinguished?
Was gasoline or another fuel involved?
Was there an explosion?
Was there a building/house fire?
Was the patient found in a smoke-filled room?

Secondary Survey History

How did the patient escape?
If the patient jumped out a window, from what
floor?
Were others killed at the scene?
Was there a motor vehicle crash?
How badly was the vehicle damaged?
Was there a motor vehicle fire?
Are there other injuries?
Are the purported circumstances of the injury
consistent with the burn characteristics?

Secondary Survey History

Chemical
What was the agent?
How did the exposure occur?
What was the duration of contact?
What decontamination occurred?
Was there an explosion?

Secondary Survey History

Electrical
What kind of electricity was involved?
What was the duration of contact?
Did the patient fall?
What was the estimated voltage?
Was there loss of consciousness?
Was cardiopulmonary resuscitation
administered at the scene?

Specific burn Treatment notes

Care for Thermal Burn
For <10% TBSA burn-apply moist cool
sterile dressings to small burn
For larger-cover area with dry sterile
dressings or sheet

Specific burn Treatment notes

Care for Chemical Burn (1 of 2)
Remove the chemical
from the patient.
If it is a powder
chemical, brush off
first.
Remove all
contaminated
clothing.

Care for Chemical Burn (2 of 2)

Flush burned area
with large amounts
of water for 30
minutes or more.
Transport quickly.

Chemical Burn- Eyes

Occur whenever a toxic
substance contacts the
body
Eyes are particularly
vulnerable.
Fumes can cause burns.
To prevent exposure,
wear appropriate gloves
and eye protection.

Chemical Burn- Eyes

For chemicals, flush eye with saline
solution or clean water.
You may have to force eye open to get
enough irrigation to eye.
With an alkali or strong acid burn, irrigate
eye for about 20 minutes.
Bandage eye with dry dressing.

Irrigating the Eye

Specific burn Treatment notes

Care for Electrical Burn
Cardiac Monitor
Fluids -Ringers Lactate or other fluids to
flush kidneys if myoglobinuria is present
Assess for bone fractures and treat
appropriately if found

Complications during emergent

phase of burn injury may occur
in 3 major

Cardiovascular
Respiratory
Renal

Cardiovascular System
Arrhythmias, hypovolemic shock which may
lead to irreversible shock
Circulation to limbs can be impaired by
circumferential burns and then the edema
formation
Causes: occluded blood supply thus causing
ischemia, necrosis, and eventually gangrene
Escharotomies (incisions through eschar)
done to restore circulation to compromised
extremities

Respiratory System
Vulnerable to 2 types of injury
1. Upper airway burns that cause edema formation &
obstruction of the airway
2. Inhalation injury can show up 24 hrs later-watch for
respiratory distress such as increased agitation or change
in rate or character of respirations
preexisting problem (ex. COPD) more prone to get
respiratory infection
Pneumonia is common complication of major burns
Is possible to overload with fluids--leading to pulmonary
edema

Renal System
Most common renal complication of burns
in the emergent phase is Acute Tubular
Necrosis (ATN) (muscle destruction >
myoglobulin release > protein leak clogs
kidney cells >ischemia) Because of
hypovolemic state, blood flow decreases,
causing renal ischemia. If it continues,
acute renal failure may develop.

U.S. Statistics
About 2.4 million people suffer
burns annually
Account for an estimated
700,000 ER visits per year and
45,000 require hospitalizations
Between 8,000-12,000 burn
patients die, and approximately
one million will sustain
substantial or permanent
disabilities
Fires kill about 500 children
<14 years annually and injure
40,000 others
Fire ranks 5th among accidental
injuries, after motor accidents,
poisoning, falls and drowning

The majority of children <4

years hospitalized for
burn-related injuries suffer
from scald burns (65%) or
contact burns (20%)

Lab studies
Severe burns:
CBC
Chemistry profile
ABG with
carboxyhemoglobin
Coagulation profile

U/A
CPK and urine
myoglobin (with
electrical injuries)
12 Lead EKG

Imaging studies
CXR
Plain Films / CT scan: Dependent upon
history and physical findings

Physiological Response

Typically, biphasic response

The initial period of hypofunction manifests as: (a) Hypotension, (b)
Low cardiac output, (c) Metabolic acidosis, (d) Ileus, (e)
Hypoventilation, (f) Hyperglycemia, (g) Low oxygen consumption and
(h) Inability to thermoregulate
This ebb phase occurs usually in the first 24 hours and responds to
fluid resuscitation
The flow phase, resuscitation, follows and is characterized by gradual
increases in (a) Cardiac output, (b) Heart rate, (c) Oxygen
consumption and (d) Supranormal increases of temperature
This hypermetabolic hyperdynamic response peaks in 10-14 days after
the injury after which condition slowly recedes to normal as the burn
wounds heal naturally or surgically closed by applying skin grafting

Pathologic Features

Zone of coagulation (necrosis): Superficial area of coagulation

necrosis and cell death on exposure to temperatures >450
(primary injury)
Zone of stasis (vascular thrombosis): Local capillary circulation
is sluggish, depending on the adequacy of the resuscitation,
can either remain viable or proceed to cell death (secondary
injury)
Zone of hyperemia (increased capillary permeability)

Pathophysiology

Increased capillary leak, with protein and intravascular volume loss

Hypermetabolic response, similar to SIRS

loss of lean body mass, protein catabolism

Cardiac output decreased initially, then normalizes

depressed contractility/increased SVR/afterload

anticipate, identify, & treat low ionized calcium

Pathophysiology

Usual indices (BP, CVP) of volume status unreliable in burn patients; urine output best
surrogate marker of volume resuscitation

ADH secretion may be confounding variable

ARF rare unless prolonged hypotension

exception: soft tissue injury with pigmenturia

kaliuresis may require brisk K+ replacement
hypertension (with encephalopathy) may occur

Pathophysiology

Pulmonary dysfunction results from multiple etiologies

shock, aspiration, trauma, thoracic restriction

inhalation injury; increases mortality 35-60%
diffuse capillary leak reflected at alveolar level

CNS dysfunction may result from hypovolemia/hypoperfusion, hypoxia, or CO exposure

Pathophysiology

High risk of gastric stress ulceration

Increased gut permeability, with increased potential for bacterial translocation

protective role of early enteral feeding

Gut dysmotility due to drugs, or disuse

Early, mild hepatic dysfunction common; late or severe dysfunction heralds increased
morbidity

Pathophysiology

Anemia is common

initially due to increased hemolytic tendency

later due to depressed erythropoietin levels, and
ongoing acute phase iron sequestration
may be exacerbated by occult bleeding, or
iatrogenicity related to fluid management

Thrombocytopenia early; thrombocytosis then supervenes as acute phase response

Pathophysiology

Immunologic dysfunction is pleiotropic

normal barrier, immune functions of skin lost

immunoglobulin levels depressed, B-cell
response to new antigens blunted
complement components activated, consumed
normal T4/T8 ratios inverted
impaired phagocyte function
immunologic dissonance

Complications of Burns
Burn Shock
Pulmonary complications due to inhalation
injury
Acute Renal Failure
Infections and Sepsis
Curlings ulcer in large burns over 30%
usually after 9th day
Extensive and disabling scarring
Psychological trauma
Cancer called Marjolins ulcer, may take 21
years to develop

First Aid Measures in Burns

1.
2.
3.
4.

5.

Extinguish flames by rolling in the ground, cover child with

blanket, coat or carpet
After determining airway is patent, remove smoldering clothes
and constricting accessories during edema phase in the 1st 2472 hours after
Brush off remaining chemical if powdered or solid then wash
or irrigate abundantly with water
Cover burn wounds with clean, dry sheet and apply cold (not
iced) wet compresses to small injuries; significant burns (>1520% BSA) decreases body temperature which contraindicates
use of cold compress dressings
If burn caused by hot tar, mineral oil to remove it

Initial Management: ABCDEs

Airway
Breathing
Circulation
Depth of Burn
Extent of Injury(s)

Pediatric (special) issues

Initial Airway Management

Evaluate, and ensure airway patency
Determine the need for an artificial airway
intact airway reflexes?
risk factors for airway burns/edema?
Perioral burns, carbonaceous sputum subjective
dysphagia, hoarseness or changes in phonation

erythema to edema transition may be rapid

Ensure adequate air exchange, thoracic

excursion with tidal breaths

Breathing Assessment/Support
Ensure adequate oxygenation
ABG with carboxyhemoglobin level preferred
humidified 100% FiO2 emperically

Assess for possible inhalation injury

history of an enclosed space, carbonaceous
sputum, respiratory symptoms, altered LOC
younger children at greater risk

NMB for intubation: avoid succinylcholine

Breathing Assessment/Support
NG tube placement
thoracic decompression; reduce aspiration risk

Ventilatory support recommended for

circulatory insufficiency, or GCS<8
decreased airway protective reflexes
risk of inhalation injury/CO exposure
risk of concomitant injury/trauma requiring
evaluation/support

Initial Management:
Circulatory

Assess capillary refill, pulses, hydration

Evaluate sensorium
Place foley to assess urine output
Achieve hemostasis at sites of bleeding
Venous access, depending upon BSA
involvement; avoid burn sites if possible
Begin emperic volume resuscitation

Initial Depth Assessment

Assess depth of injuries:
First degree burn
restricted to superficial epithelium
pain, erythema, blistering
treatment rarely required (IV hydration)

Second degree (partial thickness, dermal) burn

through epidermis into a variable portion of dermis
infection, malnutrition, hypoperfusion may cause
conversion to full thickness (3rd degree) burn

Initial Depth Assessment

Assess depth of injuries:
Third degree (full thickness)
full thickness injury extending through all layers into
subcutaneous fat
typically requires some degree of surgical closure

Fourth degree
third degree with extension into bone/joint/muscle

Note circumferential burns, compartment

syndrome risk; consider escharotomy need

Initial Management: Extent

Expressed as percentage of total BSA
Only 2nd & 3rd degree burns mapped

Once adult proportions attained (~15 yo),

rule of nines may be used
For children less than 15 years of age, age
adjusted proportions must be used
fluid replacement is based upon BSA estimates

Must rule out concomitant other injuries

Management: Pediatric Issues

Hypothermia
increased insensible fluid loss from burn

Hypoglycemia
stress response; smaller glycogen stores

Vaccination
adequate tetanus prophylaxis mandatory

If injury pattern not consistent with history,

consider possibility of child abuse

Recommendations for Hospitalization

1. Total burns >10% BSA or >2% full thickness,
halved for <2 or >40 yr
2. Hands, face, feet or genitalia involved
3. Evidence or suspicion of inhalation injury
4. Associated injuries present
5. Suspicion that burn inflicted
6. Burn is infected
7. Burn circumferential
8. History of prior medical illness
9. Patient is comatose
10. Patient or family unable to cope with situation

Hospital Management
1. General assessment and cardiopulmonary
stabilization
2. Resuscitation
3. Establishment of IV lines and blood studies
4. Wound care and infection control
5. Pain relief and psychological support
6. Nutritional support
7. Physical Therapy/Occupational Therapy

Airway compromise?
Respiratory distress?
Circulatory compromise?
Yes
Intubation, 100% O2
IV access, fluids

No

Multiple trauma?
Yes

No

Evaluate & treat

injuries

Burns >15% or
complicated burns?
No

Yes
IV access;
fluid replacement

Circumferential full
thickness burns?
Yes
Escharotomy

No
Burn care, tetanus prophylaxis,
analgesia

Initial Procedures
Fluid infusion must be started immediately
NGT insertion to prevent gastric dilatation, vomiting
and aspiration
Urinary catheter to measure urine output
Weight important and has to be taken daily
Local treatment delayed till respiratory distress and
shock controlled
Hematocrit and bacterial cultures necessary

Fluid Resuscitation
For most, Parkland formula a suitable starting
guide (4 ml Ringers Lactate/kg body weight/%
BSA burned), to be given over 1st 8 hr from
time of onset while remaining over the next 16 hr
During 2nd 24 hr, of 1st day fluid requirement to
be infused as D5LR
Oral supplementation may start 48 hr after as
homogenized milk or soy-based products given
by bolus or constant infusion via NGT
Albumin 5% may be used to maintain serum
albumin levels at 2 g/dl
Packed RBC recommended if hematocrit falls
below 24% (Hgb <8 g/dl)
Sodium supplementation may be needed if burns
greater than 20% BSA

Inhalation Injury

Three syndromes:
1. Early CO poisoning, airway obstruction & pulmonary
edema major concerns
2. ARDS usually at 24-48 hrs or much later
3. Pneumonia and pulmonary emboli as late
complications (days to weeks)
Assessment:
1. Observation (swelling or carbonaceous material in
nasal passages
2. Laboratory determination of carboxyhemoglobin and
ABGs
Treatment:
1. Maintain patent airway by early ET intubation,
adequate ventilation and oxygenation
2. Aggressive pulmonary toilet and chest physiotherapy

Infection Control
Tetanus prophylaxis: 250-500 IU TIG or 3000 units equine
ATS ANST IM; Toxoid also
Antibiotic of choice is one that will include Pseudomonas in its
spectrum; most frequent pathogens in burns are
Staphylococcus aureus, Pseudomonas aeruginosa and the
Klebsiella-Enterobacter species
Topical therapy:
0.5% Silver nitrate dressing
Mafenide acetate or Sulfacetamide acetate cream
Silver sulfadiazine cream
Povidone-iodine ointment
Gentamicin cream or ointment

Pain Relief and Adjustment

Important to provide adequate analgesia,

anxiolytics and psychological support to:
a) Reduce early metabolic stress
b) Decrease potential for posttraumatic stress
syndrome
c) Allow future stabilization and rehabilitation
Family support patient through grieving
process and help accept long-term changes in
appearance

Nutritional Support
Shriners Burn Institute at Galveston,
Texas Guidelines for Caloric Intake
1000 kcal/m2 BSA burned +
Infants
2100 kcal/m2 total BSA
2-15 years

1300 kcal/m2 BSA burned +

1800 kcal/m2 total BSA

Adolescents

1500 kcal/m2 BSA burned +

1500 kcal/m2 total BSA

Burn Injury: Prevention

Pre-emptive counseling of families essential

water heater temperature from 54oC to 49oC (130120oF) es time for full thick-ness scald
from <30 seconds to 10 minutes
Cigarette misuse responsible for >30% of house fires
Smoke detector installation/maintenance

Burn Injury: Prevention

Burn prevention has far greater impact on public health than
refinements in burn care
Burn risks related to age:
infancy: bathing related scalds; child abuse
toddlers: hot liquid spills
school age children: flame injury from matches
teenagers: volatile agents, electricity, cigarettes
introduction of flame retardant pajamas

B.U.R.N.S.

B - Breathing
Body image
U - Urine output
R - Rule of nines
Resuscitation of fluid
N - Nutrition
S - Shock
Silvadene
Support

B.U.R.N.S.

B- BreathingKeep airway open.

Facial burns, singed nasal hair, hoarseness, sooty sputum, bloody sputum and
labored
respiration indicate TROUBLE!
- Body Image- assist patient in coping by encouraging expression of thoughts and feelings.

B.U.R.N.S.

U- URINE OUTPUTAdult 30-70 cc per hour

Child 20-50 cc per hour
Infant 10-20 cc per hour
Watch the K+ to keep it between 3.5-5.0 mEq/l Keep the CVP around 12 cm water pressure

B.U.R.N.S.

R- RESUSCITATION OF FLUID
Salt & electrolyte solutions are essential over the
1st 24 hrs -First 24 hour calculation starts at the
time of injury

- of the fluid for the first 24 hrs should be

administered over the first 8 hour period
- the remainder is administered over the next 16
hours.

Maintain B/P at 90-100 systolic.

- RULE OF NINES-

B.U.R.N.S.
N -NUTRITIONProtein & Calories are components of the
diet
Supplemental gastric tube feedings or
hyperalimentation may be used in pts with
large burned areas.
Daily weights will assist in evaluating the
nutritional needs

B.U.R.N.S.

S-SHOCK- Watch the B/P, CVP, and renal function.

REMEMBER THESE PATIENTS ARE AFRAID AND NEED SUPPORT !

- SILVADENE- topical antibiotic

Thank You!