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Burn Triage and Treatment: Thermal Injuries

Caveat:
  • This page describes the diagnosis and treatment of skin injury due to thermal effects.
  • For skin injury due to radiation effects, see REMM's Cutaneous Radiation Syndrome page.

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General Information


  • After a radiation mass casualty incident, especially a nuclear detonation, trauma with or without thermal burns (flash burns or flame burns) will be common, especially in areas closer to the epicenter.
  • An air burst nuclear detonation will result in more burn victims than will a ground burst detonation of equal magnitude
  • Thermal burn patients will complicate the comprehensive medical response to radiological/nuclear mass casualty events, as burn care itself requires additional specialized staff, resources, and equipment for prolonged periods of time, well beyond the acute or initial phase of the medical response
    • Staff: Healthcare providers (both physicians and nurses) with significant burn care expertise are needed to optimize chances for survival and may be in short supply locally
    • Resources: Complex, expensive, resource-intensive care for the most severely burned patients will be required well beyond the acute/initial medical response phase
    • Equipment/Beds: Given the overall limited number of dedicated and available burn beds and burn specialists in any one region of the US, transfer of patients to specialized burn centers throughout the country will likely be needed. Consultation with an American Burn Association-verified burn center is recommended.
  • Thermal burns after concomitant radiation injury decrease the likelihood of survival, as do other types of combined injury.

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Diagnosis of Burns


  • Definition: A burn is the partial or complete destruction of skin caused by some form of energy, usually thermal energy.
  • Burn severity is dictated by:
    • Percent total body surface area (TBSA) involvement
      • Burns >20-25% TBSA require IV fluid resuscitation
      • Burns >30-40% TBSA may be fatal without treatment
      • In adults: "Rule of Nines" is used as a rough indicator of % TBSA

        Rule of Nines for Establishing Extent of Body Surface Burned
        Anatomic Surface% of total body surface
        Head and neck9%
        Anterior trunk18%
        Posterior trunk18%
        Arms, including hands9% each
        Legs, including feet18% each
        Genitalia1%


      • In children, adjust percents because they have proportionally larger heads (up to 20%) and smaller legs (13% in infants) than adults
        • Lund-Browder diagrams improve the accuracy of the % TBSA for children.
      • Palmar hand surface is approximately 1% TBSA

        Estimating Percent Total Body Surface Area in Children Affected by Burns
        Estimating Percent Total Body Surface Area Affected by Burns
        (A) Rule of "nines"
        (B) Lund-Browder diagram for estimating extent of burns
        (Adapted from The Treatment of Burns, edition 2, Artz CP and Moncrief JA, Philadelphia, WB Saunders Company, 1969)

    • Depth of burn injury (deeper burns are more severe)
      • Superficial burns (first-degree and superficial second-degree burns)
        • First-degree burns
          • Damage above basal layer of epidermis
          • Dry, red, painful ("sunburn")
        • Second-degree burns (partial thickness)
          • Damage into dermis
          • Skin adnexa (hair follicles, oil glands, etc,) remain
          • Heal by re-epithelialization from skin adnexa
          • The deeper the second-degree burn, the slower the healing (fewer adnexa for re-epithelialization)
          • Moist, red, blanching, blisters, extremely painful
        • Superficial burns heal by re-epithelialization and usually do not scar if healed within 2 weeks
      • Deep burns (deep second-degree to fourth-degree burns)
        • Deep second-degree burns (deep partial-thickness)
          • Damage to deeper dermis
          • Less moist, less blanching, less pain
          • Heal by scar deposition, contraction and limited re-epithelialization
          • Clinically estimated to take up to 3 weeks or longer to heal via secondary intention.
          • Deep partial thickness burns are optimally managed by autologous split thickness skin grafting to minimize hypertrophic (raised) scar formation and to improve functional mobility and aesthetic appearance.
        • Third-degree burns (full-thickness)
          • Entire thickness of skin destroyed (into fat)
          • Any color (white, black, red, brown), dry, less painful (dermal plexus of nerves destroyed)
          • Heal by contraction from wound edges and scar deposition (no epithelium left in middle of wound) over a protracted time course and subject to the following clinical sequelae if not grafted: severe scarring, wound infection and fragile repair prone to recurrent episodes of breakdown.
          • Need specialized care to attain definitive wound closure via autologous skin grafting. When surface area of full thickness injury is extensive, special techniques are employed to expand skin grafts in order to achieve maximum wound coverage.
        • Fourth-degree burns
          • Burn into muscle, tendon, bone
          • Need specialized care (skin grafting alone is generally not sufficient)
    • Age
      • Mortality for any given burn size increases with age
        • Children/young adults can survive massive burns
          • Children require more fluid per TBSA burns
          • Very young children under the age of 12 months are more at risk of burn injury complications.
        • Elderly may die from small (<15% TBSA) burns
    • Smoke inhalation injury
      • Smoke inhalation injury doubles the mortality relative to burn size
    • Associated injuries
      • Other trauma increases severity of injury
    • Delay in resuscitation
      • Delay increases fluid requirements
    • Need for escharotomies and fasciotomies
      • Increases fluid requirements
    • Use of alcohol or drugs (especially methamphetamine)
      • Makes resuscitation more difficult

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American Burn Association (ABA) Burn Unit Referral Criteria*

*Criteria not established for very large mass casualty incidents (MCI)

See ABA document with referral criteria (PDF - 11 KB) (American Burn Association)
  • A burn center may treat adults, children, or both.
  • Burn injuries that should be referred to a burn center include:
    1. Partial thickness burns greater than 10% total body surface area (TBSA).
    2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints.
    3. Third degree burns in any age group.
    4. Electrical burns, including lightning injury.
    5. Chemical burns.
    6. Inhalation injury.
    7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.
    8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols.
    9. Burned children in hospitals without qualified personnel or equipment for the care of children.
    10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention.
Excerpted from Guidelines for the Operation of Burn Centers (pp. 79-86), Resources for Optimal Care of the Injured Patient 2006, Committee on Trauma, American College of Surgeons

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Treatment


  • General information
    • All burn patients should initially be treated with the principles of Advanced Burn and/or Trauma Life Support
      • The ABC's (airway, breathing, circulation) of trauma take precedent over caring for the burn
      • Search for other signs of trauma
  • Verified Burn Centers provide advanced support for complex cases
    • Certified by the American College of Surgeons (ACS) Committee on Trauma and the American Burn Association (ABA)
    • Resources will give advice or assist with care
  • See ABA document with referral criteria (PDF - 11 KB) (American Burn Association)
  • Airway
    • Extensive burns may lead to massive edema
    • Obstruction may result from upper airway swelling
    • Risk of upper airway obstruction increases with
      • Massive burns
        • All patients with deep burns >35-40% TBSA should be endotracheally intubated
      • Burns to the head
      • Burns inside the mouth
    • Intubate early if massive burn or signs of obstruction
      • Intubate if patients require prolonged transport and any concern with potential for obstruction
      • If any concerns about the airway, it is safer to intubate earlier than when the patient is decompensating
    • Signs of airway obstruction
      • Hoarseness or change in voice
      • Use of accessory respiratory muscles
      • High anxiety
    • Tracheostomies not needed during resuscitation period
    • Remember: Intubation can lead to complications, so do not intubate if not needed
  • Breathing
    • Hypoxia
      • Fire consumes oxygen so people may suffer from hypoxia as a result of flame injuries
    • Carbon monoxide (CO)
      • Byproduct of incomplete combustion
      • Binds hemoglobin with 200 times the affinity of oxygen
      • Leads to inadequate oxygenation
      • Diagnosis of CO poisoning
        • Nondiagnostic
          • PaO2 (partial pressure of O2 dissolved in serum)
          • Oximeter (difference in oxy- and deoxyhemoglobin)
          • Patient color ("cherry red" with poisoning)
        • Diagnostic
          • Carboxyhemoglobin levels
            • <10% is normal
            • >40% is severe intoxication
      • Treatment
        • Remove source
        • 100% oxygen until CO levels are <10%
    • Smoke inhalation injury
      • Pathophysiology
        • Smoke particles settle in distal bronchioles
        • Mucosal cells die
        • Sloughing and distal atelectasis
        • Increase risk for pneumonia
      • Diagnosis
        • History of being in a smoke-filled enclosed space
        • Bronchoscopy
          • Soot beneath the glottis
          • Airway edema, erythema, ulceration
        • Nondiagnostic clinical tests
          • Early chest x-ray
          • Early blood gases
        • Nondiagnostic clinical and physical exam findings
          • Soot in sputum or saliva
          • Singed facial hair
      • Treatment
        • Supportive pulmonary management
        • Aggressive respiratory therapy
  • Circulation
    • Obtain IV access anywhere possible
      • Unburned areas preferred
      • Burned areas acceptable
      • Central access more reliable if proficient
      • Cut-downs are last resort
    • Resuscitation in burn shock (first 24 hours)
      • Massive capillary leak occurs after major burns
      • Fluids shift from intravascular space to interstitial space
      • Fluid requirements increase with greater severity of burn (larger % TBSA, increase depth, inhalation injury, associate injuries - see above)
      • Fluid requirements decrease with less severe burn (may be less than calculated rate)
      • IV fluid rate dependent on physiologic response
        • Place Foley catheter to monitor urine output
        • Goal for adults: urine output of 0.5 ml/kg/hour (or ~30-50 ml/hour)
        • Goal for children: urine output of 1 ml/kg/hour
        • If urine output below these levels, increase fluid rate
      • Preferred fluid: Lactated Ringer's Solution
        • Isotonic
        • Cheap
        • Easily stored
      • Resuscitation formulas are just a guide for initiating resuscitation
      • Resuscitation formulas:
        • Parkland formula most commonly used
          • IV fluid - Lactated Ringer's Solution
          • Fluid calculation
            • 4 x weight in kg x %TBSA burn
              • Give 1/2 of that volume in the first 8 hours
              • Give other 1/2 in next 16 hours
              • Warning: Despite the formula suggesting cutting the fluid rate in half at 8 hours, the fluid rate should be gradually reduced throughout the resuscitation to maintain the targeted urine output, i.e., do not follow the second part of the formula that says to reduce the rate at 8 hours, adjust the rate based on the urine output.
          • Example of fluid calculation
            • 100-kg man with 80% TBSA burn
            • Parkland formula:
              • 4 x 100 x 80 = 32,000 ml
              • Give 1/2 in first 8 hours = 16,000 ml in first 8 hours
              • Starting rate = 2,000 ml/hour
            • Adjust fluid rate to maintain urine output of 50 ml/hr
            • Albumin may be added toward end of 24 hours if not adequate response
      • Resuscitation endpoint: maintenance rate
        • When maintenance rate is reached (approximately 24 hours), change fluids to D50.5NS with 20 mEq KCl at maintenance level
      • Maintenance fluid rate = basal requirements + evaporative losses
        • Basal fluid rate
          • Adult basal fluid rate = 1500 x body surface area (BSA) (for 24 hrs)
          • Pediatric basal fluid rate (<20kg) = 2000 x BSA (for 24 hrs)
            • May use
              • 100 ml/kg for 1st 10 kg
              • 0 ml/kg for 2nd 10 kg
              • 20 ml/kg for remaining kg for 24 hrs
        • Evaporative fluid loss
          • Adult: (25 + % TBSA burn) x (BSA) = ml/hr
          • Pediatric (<20kg): (35 + % TBSA burn) x (BSA) = ml/hr
    • Complications of over-resuscitation
      • Compartment syndromes
        • Best dealt with at Verified Burn Centers
        • If unable to obtain assistance, compartment syndromes may require management
        • Limb compartments
          • Symptoms of severe pain (worse with movement), numbness, cool extremity, tight feeling compartments
          • Distal pulses may remain palpable despite ongoing compartment syndrome (pulse is lost when pressure > systolic pressure)
          • Compartment pressure >30 mmHg may compromise muscle/nerves
          • Measure compartment pressures with arterial line monitor (place needle into compartment)
          • Escharotomies may save limbs (high index of suspicion in completely circumferential burns)
            • Performed laterally and medially splitting eschar along entire limb
            • Performed with arms supinated
            • Hemostasis is required
          • Fasciotomies may be needed if pressure does not drop to <30 mmHg
            • Requires surgical expertise
            • Hemostasis is required
        • Chest Compartment Syndrome
          • Increased peak inspiratory pressure (PIP) due to circumferential trunk burns
          • Escharotomies through mid-axillary line, horizontally across chest/abdominal junction
        • Abdominal Compartment Syndrome
          • Pressure in peritoneal cavity > 30 mmHg
            • Measure through Foley catheter
          • Signs: increased PIP, decreased urine output despite massive fluids, hemodynamic instability, tight abdomen
          • Treatment - decompression via:
            • Abdominal escharotomy (only if abdominal surface is circumferentially burned)
            • NG tube
            • Possible placement of peritoneal catheter to drain fluid
            • Laparotomy as last resort
        • Acute Respiratory Distress Syndrome (ARDS)
          • Increased risk and severity if over-resuscitation
          • Treatment supportive
  • Wound Care
    • During initial or emergent care, wound care is of secondary importance
    • Advanced Burn Life Support recommendations
      • Cover wound with clean, dry sheet or dressing. NO WET DRESSINGS.
        • Simple dressing if being transported to burn center (they will need to see the wound)
        • Sterile dressings are preferred but not necessary
        • Covering wounds improves pain
        • Elevate burned extremities
      • Maintain patient's temperature (keep patient warm)
        • While cooling may make a small wound more comfortable, cooling any wound >5% TBSA will cool the patient
    • If providing prolonged care
      • Wash wounds with soap and water (sterility is not necessary)
      • Maintain temperature
      • Topical antimicrobials help prevent infection but do not eliminate bacteria
        • Silver sulfadiazine for deep burns
        • Bacitracin and nonsticky dressings for more superficial burns
    • Skin grafting
      • Deep burns require excision of nonviable tissue and autologous skin grafting
      • Excision and grafting generally occurs only after resuscitation and patient stabilization; it therefore may be delayed while physiologic and hemodynamic status is optimized over the first few days post injury.
      • Preferable to refer patients with need for grafting to Verified Burn Centers or, if not available, others trained in surgical techniques
        • Grafting of extensive areas may require significant amounts of blood/blood products
        • Patient's temperature must be monitored closely for risk of hypothermia
        • Anesthesia requires extra attention
  • Medications
    • All pain meds should be given IV
    • Tetanus prophylaxis should be given as appropriate
    • Prophylactic antibiotics are contraindicated
      • Systemic antibiotics are only given to treat infections

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Replacement Fluids


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Special Burns


  • General information
  • Electrical injuries
    • Extent of injury may not be apparent
      • Damage occurs deep within tissues
      • Damage frequently progresses
      • Electricity contracts muscles, so watch for associated injuries
    • Cardiac arrhythmias may occur
      • If arrhythmia present, patient needs monitoring
      • CPR may be lifesaving
    • Myoglobinuria may be present
      • Color best indicator of severity
      • If urine is dark (black, red), myoglobinuria needs to be treated
        • Increase fluids to induce urine output of 75-100 ml/hr in adults
        • In children, target urine output of 2 ml/kg/hour
        • Alkalinize urine (give NaHCOi3)
        • Check for compartment syndromes
        • Mannitol as last resort
    • Compartment syndromes are common
    • Long-term neuro-psychiatric problems may result
    • Depending upon arc of electrical impulse, internal organ injury such as pancreatitis may occur. If suspected, serum amylase should be followed.
  • Chemical Burns
    • Brush off powder
    • Prolonged irrigation required
    • Do not seek antidote
      • Delays treatment
      • May result in heat production
    • Special chemical burns require contacting a Verified Burn Center, for example:
      • Hydrofluoric acid burn
  • Radiation Burns

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American Burn Association Information


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National Burn Bed Capacity

  • Kearns R, Holmes J, Cairns B. Burn disaster preparedness and the southern region of the United States. South Med J. 2013 Jan;106(1):69-73. [PubMed Citation]
    • "According to the American Burn Association (ABA), there are 1895 burn beds in the United States28 serving a population of 308,745,538 residents,29 which equates to 1 burn bed for every 176,024 US residents. The ABA data are derived from a self-reporting system updated semiannually; however, the reports do not differentiate burn beds from those hospital beds that serve principally as 'dual use,' meaning that the beds may be distributed among multiple medical/surgical services as needed. Furthermore, the numbers reported are typically known as 'static' bed counts, based on the licensed capacity, which is typically a larger number than staffed beds. Although state burn bed definitions vary, the most common definition and most comprehensive approach of defining a burn unit is found in the ABA and American College of Surgeons' Committee on Trauma 'Resources for Optimal Care of the Injured Patient.' "30
    • "According to the American Hospital Association there are 5795 hospitals with 944,277 staffed beds. With 123 self-identified burn centers reporting 1895 beds collectively, this yields a ratio of approximately 1 burn center for every 47 hospitals or 1 burn bed for every 498 beds. In addition, these 123 burn centers typically operate near capacity. Therefore, the ability to manage a surge of burn-injured patients in most communities remains limited and relies on traditional burn bed capacity." 31

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Acknowledgement:
  • This REMM Web page was prepared originally in consultation with Dr. David Greenhalgh, President of the American Burn Association, August 2006.
  • REMM updated to sections and references since then, including the 2013 update with consultation by Dr. Suzanne Schwartz.

References


Books
  1. Handbook of Burns Volume 1: Acute Burn Care, Editors: MG Jeschke, LP Kamolz, Sjoberg, SE Wolf, SpringerWein, New York, 2012.
  2. Handbook of Burns Volume 2, Editors: JP Kamolz, JG Jeschke MG, Horch RE, Kuntscher M, Brychta P, SpringerWein, New York, 2012.
Recent Advances
  1. Wolf SE, Arnoldo BD. The year in burns 2011. Burns. 2012 Dec;38(8):1096-108. [PubMed Citation]
  2. Wolf SE, Sterling JP, Hunt JL, Arnoldo BD. The year in burns 2010. Burns. 2011 Dec;37(8):1275-87. [PubMed Citation]
  3. Wolf SE. The year in burns 2008. Burns. 2009 Dec;35(8):1057-70. [PubMed Citation]
  4. Wolf SE. The year in burns 2007. Burns. 2008 Dec;34(8):1059-71. [PubMed Citation]
  5. Ennis JL, Chung KK, Renz EM, Barillo DJ, Albrecht MC, Jones JA, Blackbourne LH, Cancio LC, Eastridge BJ, Flaherty SF, Dorlac WC, Kelleher KS, Wade CE, Wolf SE, Jenkins DH, Holcomb JB. Joint Theater Trauma System implementation of burn resuscitation guidelines improves outcomes in severely burned military casualties. J Trauma. 2008 Feb;64(2 Suppl):S146-51. [PubMed Citation]
Clinical Management: Reviews
  1. Bezuhly M, Fish JS. Acute burn care. Plast Reconstr Surg. 2012 Aug;130(2):349e-358e. [PubMed Citation]
  2. Kowalske KJ. Burn wound care. Phys Med Rehabil Clin N Am. 2011 May;22(2):213-27. [PubMed Citation]
  3. Rex S. Burn injuries. Curr Opin Crit Care. 2012 Dec;18(6):671-6. [PubMed Citation]
  4. Orgill DP. Excision and skin grafting of thermal burns. N Engl J Med. 2009 Feb 26;360(9):893-901. [PubMed Citation]
  5. Kagan RJ, Peck MD, Ahrenholz DH et al. Surgical management of the burn wound and use of skin substitutes: an expert panel white paper. J Burn Care Res 2013;34(2):60-79.
  6. Singer AJ, Dagum AB. Current management of acute cutaneous wounds. N Engl J Med. 2008 Sep 4;359(10):1037-46. [PubMed Citation]
  7. Alvarado R, Chung KK, Cancio LC, Wolf SE. Burn resuscitation. Burns. 2009 Feb;35(1):4-14. [PubMed Citation]
  8. Holmes JH 4th. Critical issues in burn care. J Burn Care Res. 2008 Nov-Dec;29(6 Suppl 2):S180-7. [PubMed Citation]
  9. White CE, Renz EM. Advances in surgical care: management of severe burn injury. Crit Care Med. 2008 Jul;36(7 Suppl):S318-24. [PubMed Citation]
Pediatrics
  1. Spies M, Herndon DN, Rosenblatt JI, Sanford AP, Wolf SE. Prediction of mortality from catastrophic burns in children. Lancet. 2003 Mar 22;361(9362):989-94. [PubMed Citation]
  2. Bohn D, Kanter RK, Burns J, Barfield WD, Kissoon N; Task Force for Pediatric Emergency Mass Critical Care. Supplies and equipment for pediatric emergency mass critical care. Pediatr Crit Care Med. 2011 Nov;12(6 Suppl):S120-7. [PubMed Citation]
Disaster incidents: planning and response
  1. Greenwood JE. Burn injury and explosions: an Australian perspective. Eplasty. 2009 Sep 16;9:e40. [PubMed Citation]
  2. Yurt RW, Lazar EJ, Leahy NE, Cagliuso NV Sr, Rabbitts AC, Akkapeddi V, Cooper A, Dajer A, Delaney J, Mineo FP, Silber SH, Soloff L, Magbitang K, Mozingo DW. Burn disaster response planning: an urban region's approach. J Burn Care Res. 2008 Jan-Feb;29(1):158-65. [PubMed Citation]
  3. Barillo DJ, Wolf S. Planning for burn disasters: lessons learned from one hundred years of history. J Burn Care Res. 2006 Sep-Oct;27(5):622-34. [PubMed Citation]
  4. Saffle JR, Gibran N, Jordan M. Defining the ratio of outcomes to resources for triage of burn patients in mass casualties. J Burn Care Rehabil, 2005 Nov-Dec;26(6):478-82 [PubMed Citation]
  5. Allison K, Porter K. Consensus on the pre-hospital approach to burns patient management. Injury. 2004 Aug;35(8):734-8. [PubMed Citation]
  6. Ahuja RB, Bhattacharya S. Burns in the developing world and burn disasters. BMJ. 2004 Aug 21;329(7463):447-9. [PubMed Citation]
  7. Abir M, Davis MM, Sankar P, Wong AC, Wang SC. Design of a model to predict surge capacity bottlenecks for burn mass casualties at a large academic medical center. Prehosp Disaster Med. 2013 Feb;28(1):23-32. [PubMed Citation]
  8. Saffle JR, Gibran N, Jordan M. Defining the ratio of outcomes to resources for triage of burn patients in mass casualties. J Burn Care Rehabil. 2005 Nov-Dec;26(6):478-82. [PubMed Citation]
  9. Ryan CM, Schoenfeld DA, Thorpe WP, Sheridan RL, Cassem EH, Tompkins RG. Objective estimates of the probability of death from burn injuries. N Engl J Med. 1998 Feb 5;338(6):362-6. [PubMed Citation]
National Burn Bed Capacity
  1. Burn care resource directory. Lists numbers of burn beds at verified centers (PDF - 87 KB) (American Burn Association)
  2. 2010 Census Briefs: Age and Sex Composition: 2010 (PDF - 2.03 MB) (US Census)
  3. Guidelines for the Operations of Burn Centers (See list of resources for optimal care of the injured patients) (PDF - 531 KB) (American Burn Association)
  4. AHA hospital statistics 2011 (American Hospital Association)
 

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