Determine the Severity of Injury
Once initial resuscitation efforts have begun, additional information is often required to determine the disposition of the burn patient. Ask the patient, witnesses, and family about the mechanism of injury (eg, explosion, spilled liquid, house fire) and about the possible presence of combustibles known to be toxic. Find out whether the patient was burned in an open or enclosed space; the latter increases the risk of inhalation injury and should prompt consideration of early intubation. Also ask about underlying medical problems, tetanus immunization status, and medication allergies.
An accurate estimate of the severity of injury is crucial in determining the need for hospital admission or referral to a burn center and in guiding initial fluid resuscitation and establishing a prognosis. In general, patients with minor burns may be managed as outpatients, patients with moderate uncomplicated burns should be hospitalized, and patients with major burns should be transferred to a burn center. Even in the absence of major burn criteria, if the hospital does not have facilities or expertise in caring for burn patients, victims with moderate or major burns should be referred to a burn center. The following factors are used to determine burn severity.
Accurate measurement of the burned area, expressed as a percentage of body surface area, should be performed in all burn patients. Burn size may be quickly estimated by using an age-adjusted surface area chart (see Figure 45–2) or by using the “rule of nines” as mentioned earlier in this chapter. The size of scattered small burns can be estimated by comparing them with the size of the patient's hand, which constitutes about 1.25% of body surface area. The extent of all burns should be recorded on a drawing (front and back views) on the patient's chart.
Burns are typically described as first, second, third, or fourth degree. A more useful description, based on the wound's ability to heal, is partial thickness (heals spontaneously) and full thickness (requires skin grafting). Deep partial-thickness burns usually require grafting to expedite healing and decrease contractures and hypertrophic scar. Figure 45–3 shows the level of skin involved with each type of burn. Table 45–2 outlines the physical findings usually associated with each type of burn. The depth of burn should be recorded accurately on a drawing (front and back views) on the patient's chart.
Layers of the skin, showing depth of first-, second-, and third-degree burns. (Reproduced, with permission, from Way LW, ed. Current Surgical Diagnosis and Treatment, 11th ed. New York, NY: McGraw-Hill; 2003.)
Table 45–2. Characteristics of Burn Depth. |Favorite Table|Download (.pdf)
Table 45–2. Characteristics of Burn Depth.
|Depth of Burn||Color and Appearance||Skin Texture||Capillary Refill||Pain/Pinprick||Healing|
|1st degree||Superficial epidermis||Red||Normal||Yes||Yes||5–10 days; no scar|
|2nd degree||Superficial partial thickness||Red; may be blistered||Edematous||Yes||Yes||10–21 days; no or minimal scar|
|Deep partial thickness||Pink to white||Thick||Possibly||Possibly||25–60 days; dense scar|
|3rd degree||Full thickness||White, black, or brown||Leathery||No||No||No spontaneous healing|
|4th degree||Involves underlying subcutaneous tissue, tendon, or bone||Variable||Variable||No||No||No spontaneous healing|
Several principles must be kept in mind when considering burn depth. First, because it is difficult to distinguish deep partial-thickness burns from full-thickness burns, these burns should be assumed to be full-thickness injuries and should be treated accordingly. Second, burn wounds change over 48–72 hours, and what may appear to be superficial injury on initial examination may progress to a deeper-level injury, especially if the patient has poor perfusion or the wound becomes desiccated or infected.
Burns in the following areas are considered major injuries:
Deep burns of the hands or feet cause scarring and may produce permanent disability.
Partial- or full-thickness facial burns may cause severe scarring, with profound physical and emotional impact. They are also often associated with inhalation injury and compromised airway.
Burns of the eyes may cause corneal scarring and eyelid dysfunction that may ultimately lead to blindness. Note: Patients with possible eye burns should be examined as quickly as possible, preferably in the emergency department, because massive periorbital edema often develops and hinders later examination. Further discussion of eye injury is detailed later in this chapter.
Deep burns of the ears predispose to development of pressure deformity and infection. Examine the tympanic membrane in patients with external ear injuries caused by hot liquids or chemicals. Burns associated with electrical injury, including lightning strikes, also require examination of the tympanic membrane. A high incidence of rupture occurs with this mechanism of injury.
Burns of the perineum are difficult to manage on an outpatient basis and are more susceptible to infection than are other types of burns.
Presence of Circumferential Burns
Any deep circumferential burn is a potential major injury. Circumferential deep burns of the neck may cause lymphatic and venous obstruction that leads to laryngeal edema and airway obstruction. Circumferential burns of the extremities may restrict blood flow, causing an increase in tissue pressure and ischemia. Circumferential chest wall injuries may impede chest wall movement and lead to respiratory failure.
Inhalation injury signifies a major burn. Signs and symptoms suggestive of inhalational injury include burns sustained in a confined space, singed nasal nares, soot around the nares, carbonaceous sputum, hoarseness, stridor, respiratory distress, and a carboxyhemoglobin level >10%. Diagnosis and management of inhalation injuries are discussed below.
Damage from electrical injury may be extensive, even though the outward signs of injury are minimal. Cardiac arrhythmias and renal failure from myoglobinuria are possible complications. Electrical currents as little as 100 milliamps can cause ventricular fibrillation. All electrical injuries should be considered major injuries.
The mortality rate from burn injury is increased in very young or very old patients; these are also the age groups in which burns most commonly occur. Burns in a child younger than 5 years or in an adult older than 55 years are more likely to be serious than are burns in other age groups.
Burns may occur in patients with other injuries, such as fractures or internal injuries due to vehicular accidents, falls, or explosions. The associated injuries often place the patient at increased risk of serious complications or death, even though the burns themselves are small.
Major Underlying Medical Problems
Major pre-existing medical problems in a burn patient are associated with an increased rate of serious complications and death. Any pre-existing condition that prevents normal healing puts a patient with even minor burns at risk for complication. Patients with a history of myocardial infarction, angina, significant pulmonary disease, diabetes mellitus, or renal failure are considered poor-risk patients even if their burns are not serious. Burned patients with a history of alcohol or other drug abuse are also at higher risk for complications following burn injury.
Oral, subcutaneous, or intramuscular administration of narcotic analgesics may provide adequate pain relief for outpatients; however, in patients with moderate or major burn injuries an intravenous opiate such as morphine should be carefully titrated to control pain. Ventilator support may be required in some patients to permit adequate pain control. Recent studies evaluating pain control in burn patients have shown that large amounts of opiates increase the fluid requirements for adequate resuscitation. Fluid volumes should be monitored and adjusted accordingly.
Provide Appropriate Wound Care
Gently remove clothing, dirt, and other foreign material adhering to the burn; irrigation with sterile saline (at room temperature) may be helpful. Do not scrub wounds or use harsh detergents or chemical disinfectants (eg, benzalkonium chloride, povidone–iodine). Little or no debridement of moderate or major wounds should be performed in the emergency department. Redundant skin from ruptured blisters of minor superficial partial-thickness burns may be removed. The wounds of patients with moderate or major burns, especially those who will be transferred to a burn facility, should not be treated with topical ointments or complex dressings in the emergency department, because these will have to be removed for evaluation upon arrival at the receiving facility. A simple nonadherent dressing such as petrolatum-impregnated gauze or sterile saline-soaked dressings should be applied instead. Administer tetanus prophylaxis if indicated. Direct communication with the accepting physician at the burn center can provide specific and individualized instructions for wound care prior to transfer.
Transfer the Patient to a Burn Center
All major burns and many moderate burn injuries are best treated in a burn center, which has the personnel, equipment, and expertise needed to treat major burns effectively. When a patient with a serious burn is first evaluated, the closest burn center should be contacted immediately, so that recommendations for care can be obtained and plans made for transfer, if indicated. If transfer can be carried out quickly, escharotomy may be performed at the receiving facility in patients with circumferential burns of the extremities, chest, or neck and who do not have signs of respiratory compromise or tissue ischemia. Fluid resuscitation and all other supportive measures should be continued during transport, and the patient should be kept warm. See Table 45–3 for treatment and transfer criteria.
Table 45–3. Summary of American Burn Association Classification of Burn Severity. |Favorite Table|Download (.pdf)
Table 45–3. Summary of American Burn Association Classification of Burn Severity.
- <10% TBSA in adults
- <5% TBSA in children or elderly
- No 3rd degree burns
- 10–20% TBSA superficial burns in adults
- 5–10% TBSA superficial burns in children or elderly
- No 3rd degree burns
- Suspected inhalation injury
- Circumferential burn
- Concomitant medical problems
- >20% TBSA partial thickness burns in adults
- >10% TBSA partial thickness burns in children or the elderly
- 3rd degree burns in any age group
- High voltage burns, including lightening
- Burns that involve the face, hands, feet, genitalia, perineum, or major joints
- Chemical burns
- Inhalation injury
- Concomitant trauma
- Inability to provided appropriate care at current facility
|Disposition||Outpatient Management||Hospital Admission||Referral to Burn Center|