Burns - Initial Management Diagnosis

Diagnosis

Degree of Burns

First-Degree Burns or Superficial Burns

Appearance: Similar to sunburn – painful, dry, swollen, erythematous without blisters & involves only the epidermis
Not included in estimates for fluid resuscitation
Hospitalization not required; pain resolves in 48-72 hours, peels off without residual scarring in 2-5 days

Second-Degree Burns or Partial-Thickness Burns

Appearance: Moist blebs, formation of vesicle & blister; underlying tissue is mottled pink & white with good capillary refill; this involves the entire epidermis & a variable portion of the dermal layer
Considered significant burns & are counted in burn size estimates
Subclassification
- Superficial:
  - Extreme pain attributed to a large number of remaining viable nerve endings exposed
  - Re-epithelialize in 7-14 days in the absence of infection
- Deep
  - Pain is less because fewer nerve endings remain viable; fluid losses & metabolic effects are similar to those of third-degree burn
  - Heals in 21-35 days if without infection; converts to full thickness burns if with wound infection, some may require grafting

Third-Degree Burns or Full-Thickness Burns

Appearance: Dry, leathery eschar, mixed white waxy, khaki, mahogany, soot-stained
Involves the entire epidermis & dermis, leaving no residual epidermis cells, may include fat, subcutaneous tissue, fascia, muscle & bone
No pain sensation & capillary filling
Wound cannot epithelialize, heals only by wound contracture or skin grafting
The difference in the growth rate of the head & extremities throughout childhood makes it necessary to use surface area charts
- The “rule of nines” used in adults is applicable only to children >14 year or as a very rough estimate to initiate therapy before transfer to a burn unit
In small burns <10%, the “rule of palm” (area from the wrist crease to finger crease in the child) may be used
- This equals 1% of the child’s body surface area (BSA)
Calculation of the fluid for resuscitation depends on the total BSA involved in the burn injury

Classification

Lund & Browder Classification

Relative percentage of body surface area affected by growth

	0 years	1 year	5 years	10 years	>15 years
A = one-half of head	9.5%	8.5%	6.5%	5.5%	4.5%
B = one-half of one thigh	2.75%	3.25%	4%	4.5%	4.5%
C = one-half of one lower leg	2.5%	2.5%	2.75%	3%	3.25%

Evaluation

A brief, accurate history must be obtained from guardian upon presentation of the patient
- Determine the time of injury, causative agent & type of burn, any first aid measures done, patient’s associated medical problems, & vaccination status
Stop the burning process by applying cold water on burned area & removing smoldering clothing or clothing saturated with hot liquid or chemicals
Assess degree, site & extent of burn

Laboratory Tests

All trauma patients will have their own specific radiologic & laboratory examinations depending on the involved organ during the injury

Routine examinations in the emergency department

General
- Complete blood count (CBC)
- Serum electrolytes
- Blood glucose
- Blood urea nitrogen (BUN)
- Creatinine (Cr)
- Clotting factor tests
- Blood typing & cross-matching
- Urinalysis
- Arterial blood gas (ABG)
Inhalational injuries
- Chest X-ray
- Carboxyhemoglobin levels
Inhalational injuries
- 12-lead electrocardiography (ECG)
- Cardiac enzymes

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