Extent of 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 and the majority of thermal injuries occurring within the home; 60% of pediatric burn patients are male.
Burns can be graded by depth and amount of damage (see Table 18.1).
Table 18.1 ▪ Classification of Thermal Burns |Favorite Table|Download (.pdf)
Table 18.1 ▪ Classification of Thermal Burns
|Thickness||Tissue Affected||Clinical Manifestations|
|First degree||Partial||Epidermis||Redness, pain|
|Second degree||Partial||Epidermis/dermis||Redness, pain, fluid-filled blisters|
|Third degree||Full||Epidermis/dermis, hair follicles, sweat glands, other adnexal skin structures||Paresthesia (loss of tactile sensation)|
|Fourth degreea||Full||Cutaneous and subcutaneous structure, including muscle, fascia, bone||Paresthesia (loss of tactile sensation)|
Emergency Department Treatment and Disposition
All patients should receive analgesics as soon as possible. Minor burns involve <10% body surface area (BSA) and do not involve the airway, hands, face, or genitalia. They can be managed with local wound care in an outpatient setting. The wound should be irrigated with cool saline and patients not allergic to sulfa should apply silver sulfadiazine to burns below the clavicles while bacitracin should be substituted to burns of the head and neck to avoid potential skin discoloration cause by sulfa compounds. 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 complete blood count (CBC), electrolytes, glucose, blood urea nitrogen (BUN), creatinine, creatine phosphokinase (CPK), and urinalysis ordered. Any history or signs of significant smoke inhalation (carbonaceous sputum, hoarse voice, or evidence of hypoxia) should prompt a chest radiograph. All patients who were in a fire should have a venous determination of their carboxyhemoglobin (CO-Hgb) concentration. A good pulse oximetry level (>96%) with no 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 carboxyhemoglobin level has been returned back to normal with simple high-flow oxygen. Significantly, burned patients should be resuscitated in the emergency department (ED) and transferred to a burn center when possible. (Significant burns are burns that are greater than 10% BSA, >5% third-degree, or involve the hands, face, or genitalia.)
Figure 18.1 ▪ Electrical Burns.