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Resident Orientation Manual

Produced by Galveston Shriners Burn Hospital and
The University of Texas Medical Branch Blocker Burn Unit.
Contributors:  Sally Abston MD, Patricia Blakeney PhD, Manubhai Desai MD,
Patricia Edgar RN, CIC,John P Heggers PhD, David N Herndon MD,
Marsha Hildreth RD, Ray J Nichols Jr. MD

 

EMERGENCY TREATMENT

Initial Burn Management
   Treatment of the burn injury begins at the scene of the accident.  The first priority is to stop the burning.  The patient must be separated from the burning source.  For thermal burns, immediate application of cold compress can reduce the amount of damaged tissue.  This application must be guarded in large burns and in children, as prolonged cooling can precipitate a dangerous hypothermia.  For electrical burns, the offending source should be removed from the victim with a nonconducting object made of wood or rubber.  In chemical injuries, the agent should be diluted with copious irrigation, not immersion.  A person with burning clothing should stop, drop, and roll.

   As with other forms of trauma, initial establishment of an adequate airway is vital.  Endotracheal intubation is not an essential part of management of all inhalation injuries, but may be prudent prior to patient transport or referral as airway edema will gradually increase over the first 18-24 hours post-injury.  If the patient displays evidence of airway edema and impending obstruction with hoarseness, wheezing, or stridor, then intubate the patient.  In all fire victims, administer 100% oxygen by mask or tube to reduce the likelihood of problems from pulmonary dysfunction or carbon monoxide poisoning.  If present, control external hemorrhage and stabilize fractures from concomitant trauma.  Burn wounds should be covered by a clean, dry sheet.

   Although a 20-40% BSA injury can initially appear fairly benign, burn shock can develop rapidly if fluid resuscitation is delayed.  Burns of less then15 % BSA in the conscious and cooperative patient can often be resuscitated orally.  The patient with more than 15% BSA burn on cursory assessment requires IV access.  Cut downs or central lines initially is less desirable.  Begin infusion of Ringer's lactate solution of about 1000 ml/hr in adults, 400-500 ml/mBSA/hr in children, until more accurate assessments of burn size and fluid requirements can be made.  An indwelling Foley catheter should be placed to monitor urinary output.  A nasogastric tube is inserted for gastric decompression.

   Patient evaluation should include an AMPLE history:  allergies, medications, pre-existing diseases, last meal, and events of the injury; including time, location and insults.  A history of loss of consciousness should be sought.  In adults and adolescents, burn injuries are frequently associated with alcohol or drug use, smoking, or psychiatric problems.  A complete physical exam should include a careful neurological exam, as evidence of cerebral anoxic injury can be subtle.  As in all trauma patients, occult injuries must be ruled out.  Patients with facial burns should have their corneas examined with fluorescein staining.  Routine admission labs should include CBC, serum electrolytes, glucose, BUN, creatinine, albumin, and calcium.  Pulmonary assessment should include arterial blood gases, chest x-ray, and arterial carboxyhemoglobin.  Despite a toxic level of a carbon monoxide (i.e. greater than 15%), pO and saturation values may be normal.  An EKG is especially important in patients >40 years of age or in case of electrical injuries.

   All extremities should be examined for pulses, especially with circumferential burns.  Evaluation of pulses can be assisted by use of a Doppler ultrasound flowmeter.  If pulses are absent, and fluid resuscitation is adequate, the involved limb should undergo urgent escharotomy for release of the constrictive, unyielding eschar.  In severe chest burns, escharotomy  may also be indicated to relieve chest wall restriction and improve ventilation.  Escharotomies are generally performed at the bedside under IV sedation using electrocautery.  Midaxial incisions are completed through the bleeding tissue, extending the full length of the eschar to assure adequate release, limbs should be elevated above heart level.  Pulses should be monitored for 48 hours.

   If pulses are still present but appear endangered, chemical escharotomy with sultilains ointment (e.g. Travase of Santyl) may be called for.  We prefer enzymatic escharotomies in hand burns since incisions risk superficial nerves, vessels and tendons.  Enzymatic debridement is indicated only within 24 hours of burn injury, or it otherwise increases risk of infection and sepsis.  Deep circumferential burns are coated with sutilains ointment, then wrapped with saline-soaked gauze to keep the wounds moist.  Wounds and pulses are re-evaluated in one hour.  Once capillary refill has been restored, the wounds are treated with a topical antimicrobial agent.

   Occasionally, escharotomy alone will fail to relieve intra-compartmental pressures, and a formal fasciotomy under general anesthesia is indicated.  Distal numbness and tingling are the earliest signs of ischemia, and loss of pulses is a late finding.  ~ If you consider a patient's central venous pressure is normally 8-12 cm H2O and arterial pressure is typically 80-120 mmHg, you will see that venous compromise occurs much before the loss of arterial pulsations in an affected extremity. ~
   Intra-compartment pressures can be measured with a wick catheter or inserting a spinal needle connected to a pressure catheter, such as for an arterial line, into all compartments of the affected extremity.  Compartment pressures of >20 cmH2O are significantly elevated and require immediate attention.  Fasciotomies are always indicated in high voltage electrical injuries and in severe crush injuries.  This should also include Carpal Tunnel and Guyton (Ulnar) canal releases.  An 'intrinsic-minus' hand deformity is evidence of need for deep muscle compartment decompressions.  Keep in mind that as a patient is resuscitated, new swelling and reperfusion injury can cause delayed onset of compartment syndromes.  This highlights the need for continued vigilance.

   All patients with significant burns should receive 0.5 ml of tetanus toxoid.  If prior immunization is absent or unclear, or their last booster was more than 10 years ago, 250 units of tetanus immunoglobulin is also given.


The Administration of Burn Assessment
   When cardiopulmonary assessment is complete and resuscitation underway, a more careful evaluation of the burn wounds is performed.  If the patient is adequately hydrated, appropriate doses of sedatives and narcotics may be safely administered.  Excessive narcotic doses in light of inadequate resuscitation, however, can precipitate burn shock.  The wounds are gently cleaned and loose skin and blisters debrided.  Blister fluid contains high levels of inflammatory mediators which increase burn wound ischemia.  The blister fluid is also a rich media for subsequent bacterial growth.  Deep blisters on the palms and soles are generally aspirated instead of debrided to improve patient comfort.  After burn wound assessment is complete, the wounds are covered with a topical antimicrobial agent or a biologic dressing, and an appropriate burn dressing applied.  Outer elastic compressive dressings (e.g. Ace wraps) are applied carefully, and all involved extremities are elevated.

   An estimation of burn size and depth assists in determinations of severity, prognosis and disposition of the patient.  Burn size directs the efforts of fluid resuscitation, nutritional support and surgical interventions.  Estimation of burn depth is a clinical judgment based on experience.

 

DEGREE

DEPTH

HISTORY

ETIOLOGY

SENSATION

APPEARANCE

HEALING

1st degree

superficial

momentary exposure

sunburn

sharp, uniform pain

blanches red, pink, edematous, soft, flaking, peeling

+ 7 days

2nd degree

partial thickness

exposure of limited duration to lower temperature (40-55C)

scalds, flash burn without contact, weak chemical

dull or hyperactive pain, sensitive to air/temp changes

mottled red, blanches red/pink, BLISTERS, edema, serous exudate, moist

14-21 days

3rd degree

full thickness

long duration of exposure to high temperature

immersion, flame, electrical, chemical

painless to touch and pinprick, may hurt at deep pressure

no blanching, pale white, tan charred, hard, dry, leathery, hair absent

granulates, requires grafting

4th degree

underlying structures

prolonged duration of exposure to extreme heat

electrical, flame, chemical

usually painless

charred, 'skeletonized'

amputation
fasciectomy

 

 

   Attempts at estimation of burn depth with ultrasound, temperature mapping and vital stains such as fluoroscein have not proven clinically useful.  1st degree burns are superficial and involve just the epidermis.  Typified by a sunburn, 1st degree burns are inconsequential in subsequent burn management.  Partial-thickness injuries are 2nd degree burns that involve variable amounts of dermis.  The hallmark of a partial-thickness burn is a weeping, blistering, painful wound that will potentially heal within 2 to 6 weeks.  3rd degree burns are full-thickness injuries, which require skin replacement following loss of the devitalized dermis (eschar).  Classically, full-thickness burns are identified as dry or leathery wounds that are initially insensate to light touch or pinprick. However, 3rd degree burns can still hurt.  In infants, 3rd degree burns may also appear cherry red.  Determinations of burn depth can be somewhat misleading initially, as the tissue destruction is progressive over the first 48 hours.  Burn size is based on the percentage of 2nd and 3rd degree burns as compared to total body surface area.

   Burn injuries are quantifiable, and pathophysiologic derangement is related to the size of the injury.  The surface area of a patient's palm is approximately 1% of their total body surface area and provides a quick estimate of burn size in smaller injuries.  Typically, burn size estimations are derived from the "Rule of Nines".  The body's surface is divided into areas of roughly 9% each, which includes the head and neck, the chest, the abdomen, the upper back, the lower back and buttocks, each thigh, each lower leg, and each upper extremity.  Although useful in adults, the "Rule of Nines" overestimates burn size in children.  The head and neck account for a larger proportion of the total body surface area (BSA) in children, more than 21% BSA in toddlers and babies.  For greatest accuracy and reproducibility, burn size should be determined by plotting the burn wound on Lund and Browder burn diagrams.

   A major burn injury is defined as greater than 25% BSA involvement (15% in children), or more than 10% BSA full-thickness involvement.  Major burns require aggressive resuscitation, hospitalization, and appropriate burn care.  Additional criteria for major burns include:  deep burns of the hands, feet, eyes, ears, face, or perineum;  inhalation injuries;  and electrical burns.  Moderate thermal burns of 15-25% BSA, or 3-10% BSA full-thickness, often require hospitalization for optimal patient care.  Other criteria for admission include concomitant trauma, significant pre-existing disease, and suspicion of child abuse.  Minor burns can generally be treated as outpatients.

 

Classification of Burn Injuries

 

Major Burns

Moderate Burns

Minor Burns

Burn surface involvement of 25% body surface area.
Full-thickness burns 10% body surface area.
Deep burns of the head, hands, feet, and perineum.
Inhalation injury.
Chemical or high-voltage electrical burn.
Burn area of 15-25% body surface area.
Superficial partial-thickness burns of the head, hands, feet or perineum.
Suspected child abuse.
Concomitant trauma.
Significant pre-existing disease.
15% body surface area.
Nothing involving the head, feet, hands or perineum.
 

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