Burn InjuriesBurn InjuriesAdaobi Okobi, M.D.

Learning ObjectivesLearning ObjectivesEpidemiologyPathophysiologyClassification of burnsRed flagsTreatment

EpidemiologyEpidemiologyBurns are the 3rd leading cause of

accidental death in the U.S.>120,000 children under 20

receive care for burns in the E.D. every year

Under 5 years, scald burns cause 65% of thermal injuries

PathophysiologyPathophysiologyZone of coagulation-

maximal injury from coagulation of proteins

Zone of stasis- decreased tissue perfusion; tissue is potentially salvageable

Zone of hyperemia- increased tissue perfusion

Classification of BurnsClassification of Burns

First DegreeFirst DegreeDryNo blistersMinimal or no

edemaErythematous,

blanchesVery painfulEpidermis onlyHeals in 2-5 days

without scarring

Second Degree (Partial Second Degree (Partial Thickness)Thickness)Moist blebs, blistersUnderlying tissue is

mottled pink and white with fair cap refill

Very painful Involves epidermis

and reticular layers of dermis

Superficial: 5-21 daysDeep partial: 21-35

days with no infection; if infected converts to full thickness burn

Third Degree (Full Third Degree (Full Thickness)Thickness)

Dry, leathery escharWhite or waxy

appearanceNo blanching or

bleedingSensation: deep

pressureIncludes epidermis

and dermis and may go down to subcutaneous fat, muscle or bone

Will not heal without skin graft

Fourth DegreeFourth DegreeExtends into

muscle or boneSensation: only

deep pressureRequires skin

graft

Size of BurnSize of BurnPalm method- palm of patient’s

hand is ~1% TBSALund-Browder method (Rule of

nines)

Red Flags: AbuseRed Flags: Abuse

ResuscitationResuscitationAirwayBreathingCirculationDisabilityExposureFluids

Fluid ResuscitationFluid ResuscitationParkland formula: 4ml/kg/%TBSA (+

maintenance IVF if <5 years)Give 1st half in 8 hoursGive 2nd half over next 16 hoursD5LR is the fluid of choice in 1st 24

hoursColloids (ie albumin) may be added to

restore oncotic pressure and intravascular volume after the first 24 hours

Urine output should be >0.5-1ml/kg/hr

TreatmentTreatmentSilver sulfadiazine cream- impedes

epithelializationTopical antibiotics (Bacitracin)Chlorhexidine- antimicrobial skin cleanserMafenide acetate- carbonic anhydrase

inhibitor (treat patient with high bacterial load on wound)

Providone-iodine ointment- controversial because of cytotoxicity and delay in wound epithelialization

Bismuth-impregnated petroleum gauze (Xeroform) – helps prevent or control wound infection

Skin graft

TreatmentTreatmentPain control Clean with soap and waterDebridement (large or painful

blisters may be ruptured)Glycemic controlHigh protein dietProphylactic antibiotics-

controversialRehabilitation

Take Home PointsTake Home PointsBurns can be classified by size and

depthFirst and superficial partial second

degree burns are very painfulDeep second, third and fourth degree

burns are not painful because of damage to nerves

Be suspicious of abuse for burns that do not match the mechanism of injury, immersion burns or cigarette burns

Fluid resuscitation should be aggressive in the first 24 hours with monitoring of the urine output