Burns can be caused by heat, electricity, chemicals, friction, or radiation. Skin barrier damage can lead to infection, fluid loss, and electrolyte abnormalities. Long-term consequences include permanent scarring, loss of sensation, and in severe cases loss of extremities due to inadequate circulation. Burns are assessed by determining the percentage of body surface area (BSA) involved, the depth, and the area of the body involved. A common system used to estimate BSA is following the “rule of nines.” This system breaks up the body into zones that each equate to 9% of BSA (see figure). Some clinicians use the palm of the patient’s hand as an approximate equivalent to 1% BSA.
Rule of Nines. Rule of nines is used to estimate the percentage of burn. (Reproduced with permission from Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. McGraw Hill; 2011: Fig. 210-2, p. 1375.)
First-degree burns only involve the epidermal layer. They are red, painful, and heal in approximately 1 week. Second-degree burns are subdivided into superficial or deep partial thickness. Superficial second-degree burns extend from the epidermis to the superficial dermis. Pain, skin blistering, and intact capillary refill are characteristic. Deep partial-thickness burns extend into the deep (reticular) layer of the dermis and damage hair follicles, sweat glands, and sebaceous glands. Blisters may occur, the exposed dermis is pale white to yellow in color, and capillary refill is absent. The entire thickness of the skin is compromised in third-degree burns. They appear pale (waxy), feel leathery, and are painless. Fourth-degree burns extend through the layers of the skin and involve muscle or bone.
Second-Degree Burn. This patient has sustained a second-degree burn to his hand from hot oil. (Photo contributor: Suzanne Dooley-Hash, MD.)
Management and Disposition
After resuscitation and stabilization, refer to a burn unit for partial-thickness burns that involve greater than 10% BSA, third-degree burns, or involvement of the hands, feet, face, or perineum. Electrical burns, chemical burns, inhalation injuries, and patients with significant comorbidities should also be considered for a burn unit. Clinicians should cover the burned areas with a clean, dry sheet, administer aggressive pain control, and address fluid resuscitation. The Parkland formula is commonly used to estimate fluid requirements. The patient’s weight in kilograms is multiplied by the percent BSA involved; this number is multiplied by 4 mL of lactated Ringer solution. Half of this amount is given during the first 8 hours from time of initial injury and the remaining amount is given over the next 16 hours. It is recommended to keep urine output approximately 0.5 to 1.0 mL/kg/h. To monitor for effects of cell breakdown, urinalysis, creatine kinase, ...