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ENVIRONMENTAL EMERGENCIES*

*The authors acknowledge the special contributions of Mark Silverberg, Teresa Bowen Spinelli, and Chaiya Laoteppitaks to prior edition.

THERMAL BURNS

Clinical Summary

The extent of burn-related injury depends on the amount of heat, the delivery medium (gas, liquid, solid, or vapor), and the duration of contact. Scald burns are most common in children. The majority of thermal injuries occur within the home, and approximately 60% of pediatric burn patients are male. In the United States, burn-related injuries in children result in approximately 300 ED visits and 2 deaths daily. Burns can be graded by depth and amount of damage.

Emergency Department Treatment and Disposition

Most thermal burns can be treated in the outpatient setting with appropriate follow-up with a burn specialist as clinically indicated. Pain should be managed as soon as possible in all patients presenting for burn management. Extent of the burn should be estimated using 1 of the following methods: Lund-Browder chart (most accurate), rule of nines (adults only; pediatric version available), or palmar surface (palm + finger tips = 1% burn surface area). Minor burns involve <10% body surface area (BSA) and do not involve the airway, hands, face, or genitalia. Minor burn management requires local wound management consisting of cooling methods (tepid water 55–65°F or 13–18°C) to reduce extension of burn, cleaning, debridement, topical antimicrobial application, and dressing. Controversy exists regarding unroofing intact blisters. The wound should be irrigated with cool saline, and necrotic skin should be debrided. A topical antimicrobial ointment such as a triple-antibiotic ointment and/or an advanced burn dressing should be applied. Silver sulfadiazine has been commonly used in the past but may lead to a delay in wound healing. A sterile dressing should then be applied and the patient should be provided adequate analgesics and close follow-up.

For significant (>10% BSA) and major (>20% BSA) thermal injuries in patients with preexisting medical conditions, the possibility of multiorgan failure needs to be anticipated, and screening labs such as a CBC, electrolytes, glucose, BUN, creatinine, creatine phosphokinase, and urinalysis should be ordered. Any history or signs of significant smoke inhalation (carbonaceous sputum, hoarse voice, singed nasal hair, or evidence of hypoxia) should prompt a CXR. All patients who were in a fire should have carboxyhemoglobin (CO-Hgb) concentration determined from a venous blood sample. A pulse oximetry level (>96%) without visual signs of oral burns and a normal venous CO-Hgb level (<5%) virtually rules out the possibility of inhalation injury. Patients with CO-Hgb levels above baseline should be placed on high-flow oxygen to help dissociate the carbon monoxide (CO) from their hemoglobin. Patients with significant CO-Hgb levels require transfer to a hyperbaric chamber. Hyperbaric oxygen has been shown to decrease the long-term neurologic sequelae associated with CO poisoning and should be employed even if the CO-Hgb level has been returned back to normal with simple high-flow oxygen. Cyanide poisoning should also be considered in fire victims. Laboratory findings will include an elevated anion gap and lactate level. Significantly, burned patients should be resuscitated in the ED and transferred to a burn center when possible. Patients with burns that meet the following American Burn Association criteria should be transferred to a burn center: partial-thickness burns >10% total BSA; burns involving face, feet, genitalia, perineum, or major joints; third-degree burns; electrical burns; chemical burns; inhalational injury; burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality; any patient with burns and concomitant trauma in which the burn injury poses the greatest risk of morbidity or mortality; burned children in hospitals without qualified personnel or equipment for the care of children; and burn injury in patients who will require special social, emotional, or rehabilitative intervention.

The Parkland formula (4 mL/kg × body weight in kilograms × percentage of BSA burned) is used for calculating the amount of Ringer’s lactate needed for initial resuscitation for burn shock. Half of this volume should be given in the first 8 hours after the burn occurred and half in the following 16 hours. Treating physicians should remember that this volume is in addition to regular maintenance fluids. Fluid resuscitation is deemed adequate if urine output is maintained at 0.5 mL/kg/h ...

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