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burns%20-%20initial%20management
BURNS - INITIAL MANAGEMENT
Treatment Guideline Chart
Thermal burns are burns due to external heat sources that raises skin and tissue temperature causing tissue cell death or charring. Flame is the most common type of burn. Inhalation injury is found in 30% of victims of major flame burns.
Chemical burns are due to strong acids, alkalis, detergents or solvents coming into contact with the skin. Tissues are damaged by protein coagulation or liquefaction rather than hyperthermic activity.
Electrical burns are due to electrical current or lightning coming in contact with the body.
First degree burns or superficial burns appears similar to sunburn that is painful, dry, swollen, erythematous without blisters and involves only the epidermis.
Second degree burns or partial-thickness burns has appearance of moist blebs, formation of vesicle and blister; underlying tissue is mottled pink and white with good capillary refill; this involves the entire epidermis and a variable portion of the dermal layer.
Third degree burns or full-thickness burns appears dry, leathery eschar, mixed white waxy, khaki, mahogany and soot stained. It involves the entire epidermis and dermis, leaving no residual epidermis cells, may include fat, subcutaneous tissue, fascia, muscle and bone.

Burns%20-%20initial%20management Diagnosis

Diagnosis

Depths 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 and blister; underlying tissue is mottled pink and white with good capillary refill which may bleed
  • Involves the entire epidermis and a variable portion of the dermis (papillary and reticular layer)
  • Considered significant burns and 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 and 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 and may require grafting

Third-Degree Burns or Full-Thickness Burns

  • Appearance: Dry, leathery eschar, mixed white waxy, khaki, mahogany, soot-stained without blanching or bleeding
  • Involves the entire epidermis and dermis, leaving no residual epidermis cells; may include fat, subcutaneous tissue, fascia, muscle and bone
  • No pain sensation and capillary filling due to loss of nerves and capillary elements
  • Wound cannot epithelialize and heals only by wound contracture or skin grafting
  • The difference in the growth rate of the head and extremities throughout childhood makes it necessary to use surface area charts
    • The “rule of nines” used in adults is applicable only to children >14 years old or as a very rough estimate to initiate therapy before transfer to a burn unit
  • In small burns <10% of BSA, 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 BSA
  • Calculation of the fluid for resuscitation depends on the total BSA involved in the burn injury

Classification

Lund and Browder Classification

Relative percentage of BSA affected by growth

Body Part 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 and type of burn, any first aid measures done, patient’s associated medical problems, and vaccination status
  • Stop the burning process by applying cold water on burned area and removing smoldering clothing or clothing saturated with hot liquid or chemicals
  • Assess degree, site and extent (size and depth) of burn

Laboratory Tests

  • All trauma patients will have their own specific radiologic and 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 
    • Clotting factor tests
    • Blood typing and cross-matching
    • Urinalysis
    • Arterial blood gas (ABG)
  • Inhalational injuries
    • Chest X-ray
    • Carboxyhemoglobin (HbCO) levels
  • Inhalational injuries
    • 12-lead electrocardiography (ECG)
    • Cardiac enzymes

Other Imaging Tests

Laser Doppler Imaging

  • Produces a color map of the affected tissue to assess burn depth and may be used 2-5 days after the burn

Reflectance Confocal Microscopy (RCM)

  • Combined with optical coherence tomography (OCT), may visualize morphologic changes in the skin and cell damage up to a depth of 1 mm
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