A 25-year-old with burns to the face, torso and upper extremities

• Extremes of age
• Alcohol or substance abuse
• Smoking
• Violence
• Low socioeconomic status (method of cooking, size of the house, and ventilation)
• Convulsion disorder

• Children and the elderly

• More than 40% non-superficial TBSA
• Inhalational injury

• The types of burn and parts of the body burned: scald, flame, electrical, acid burn, alkali burn, contact burn
• Duration of contact with the flame, wire, or hot object
• The temperature of the burning object or the voltage of the wire
• Features suggestive of inhalational injury
• Features of compartment syndrome
• Features of burn shock
• Other injuries

Scald burns are common in children.

Alkali burns cause more damage since they penetrate tissue more deeply (via liquefaction necrosis). Acid burns cause coagulative necrosis.

Electrical burns are common in electricians. DC electrocution e.g. lightning can cause asystole. AC electrocution e.g. wall socket can cause ventricular fibrillation. Cataracts are a long-term complication of electrical injury.

• Burning in an enclosed area e.g. a single room, house fire
• Coughing up greyish or blackish sputum (soot-stained sputum)
• Loss of consciousness or confusion
• Immersion in boiling water
• Difficulty in breathing

Calculating the Total Body Surface Area (TBSA) affected by second- or -third-degree burns (approximated by the rule of 9s, or 1% rule of palms for patchy areas)

Indicates possible inhalational injury

• Burns within enclosed areas
• Significant facial burns
• Change in voice quality
• Singed nasal hairs

• Upper airway edema
• Acute respiratory failure (due to chemical pneumonitis from the products of combustion)
• Carbon monoxide poisoning

• The classic sign of carbon monoxide poisoning in patients exposed to smoke from house fires, exhaust, or gas heaters.

Patients initially present with headache, nausea, and dizziness. If severe or untreated it progresses to seizures, coma, multi-organ failure, and death.

• Second-degree burns to the face and bilateral upper extremities
• Third-degree burns to the chest and back.
• Inhalational injuries (singed nasal hairs, carbonaceous sputum, low oxygen saturation)
• Carbon monoxide poisoning (confusion, history of being trapped in a house fire, cherry-red skin)
• Burn shock

• Circumferential burns in the extremities increase the risk of compartment syndrome

Keep the limb elevated.

Watch out for limb swelling, excruciating limb pain, purple/blue/black skin discoloration, loss of sensation or weakness, weak pulse, and decreased cap refill. A fasciotomy may be necessary to relieve pressure.

• Circumferential burns to the chest limit ventilation due to the inflexible eschar and underlying tissue edema

Escharotomy may be necessary

• 2nd or 3rd degree burns 10% TBSA in patients < 10 or > 50 years of age
• 2nd or 3rd degree burns > 15% in all patients
• 2nd and 3rd degree burns to the face, hand, feet, genitalia, perineum, or skin overlying major joints
• Significant electrical and chemical burns
• Inhalational injury
• Circumferential burns
• Significant pre-existing illness
• Suspected child abuse or neglect

• Primary survey and a full history/physical examination as in all trauma patients
• Secure the airway via endotracheal tube since this patient has signs of inhalational injury

• Fiberoptic bronchoscopy

Clinical diagnosis is through observing signs of inhalational injury (facial burns, singed nasal hairs, carbonaceous sputum, and burn in an enclosed area)

Other diagnostic features include carboxyhemoglobin >10%, SpO2 < 90%, or a high probability V/Q scan.

Chest X-rays have no value in diagnosing inhalational injury

• Carbon monoxide pulse oximetry

This is not always readily available. A standard pulse oximeter cannot tell the difference between oxygen and carbon monoxide bound to hemoglobin. ABGs can show normal PaO2 and decreased SaO2. Hemoglobin concentration would not change since CO poisoning is not a consumptive or destructive process.

• Punch biopsy + wound features + systemic manifestations (fever, tachycardia, etc..)

Punch biopsy demonstrates >10^5 bacteria/g of burned tissue

• Early intubation

There is a risk of upper airway obstruction due to thermal injury and edema

• Parkland formula

Total fluid volume for resuscitation = 4cc x weight(kg) x TBSA (%)

Total fluid volume for resuscitation in children = 3cc x weight(kg) x TBSA (%)

Calculate from the time of injury. 1/2 of the total volume is given in the first 8 hours. The second half is given in the subsequent 16 hours.

The rate of fluid administration is titrated to a urine output of 0.5ml/kg/h in adults and 1ml/kg/h in children.

100% oxygen via a non-rebreather face mask

• Ringer’s Lactate

Colloids increase the risk of pulmonary complications within the first 24 hours of burns.

Large volumes of normal saline (as required by burns patients) can lead to hyperchloremic metabolic acidosis.

• Sodium and potassium

Hyponatremia is often iatrogenic and can lead to seizures in burn patients

Hyperkalemia is due to the destruction of cells and tissues and can lead to arrhythmia

• Chest escharotomy

Extremity escharotomy is considered in patients with full-thickness circumferential burns with evidence of circulatory impairment (weak pulse, decreased cap refill, weakness and decreased sensation)

Unlike fasciotomy, escharotomy is performed by incising only the eschar and not the deeper underlying tissues.

Escharotomy is a painless procedure since the nerve endings are burned.

• Cleaning and debridement
• Antimicrobial agents

Options include exposure method (open), occlusive method (closed with dressing), continuously wet with saline, plastic bag method for hands and feet, and early excision and grafting,

• No

Prophylactic antibiotics do not reduce burn infections. Instead, they select for resistant organisms and contribute towards antimicrobial resistance

Proton pump inhibitors or H2 blockers

• Enteral route

There is controversy regarding the benefits of early versus late initiation of nutrition.

Parenteral nutrition can be used in patients who cannot tolerate enteral feeding.

• Protect others from exposure and remove the casualty from the area of exposure
• Remove all clothing
• Brush dry chemicals from the casualty
• Copious irrigation with tap water

The longer the chemical is in contact with the patient’s body, the worse the prognosis

Phenol burns can be neutralized with polyethylglutamate

HCl burns can be neutralized with calcium gluconate in petroleum jelly

• Cardiac monitoring for 12-24 hours for arrhythmia
• Diuresis (there may be myoglobinuria)

Particularly when high-voltage injury (>1000 V is suspected)

Fasciotomy may be required since compartment syndrome can develop rapidly

• Hyperglycaemia
• Decreased plasma volume
• Increased Systemic vascular resistance
• 40-60% decrease in cardiac output
• Decrease in central venous pressure
• Decrease in hematocrit

Burn wound sepsis.

• Discolored burn
• Eschar with green pigment
• Black necrotic skin
• Skin separation
• Other signs of sepsis

Note that fever is not always reliable since the skin (the body’s primary temperature regulator) is compromised in burn victims. The diagnosis of burn wound sepsis is made on bacterial concentration per gram of tissue in the burn wound or eschar. A finding of >10^5 bacteria/g of tissue is highly suggestive of burn wound sepsis

• Pseudomonas aeruginosa
• Staphylococcus aureus
• Streptococcus pyogenes

Infections delay wound healing, encourage scarring, and can result in burn wound sepsis with bacteremia.

Fungal infections occur later during recovery and are mostly caused by Candida albicans.

• Reduced intravascular volume causes decreased perfusion to the gastrointestinal tract. This leads to ischemic necrosis of the gastric mucosa and an increased risk of ulcer formation. Gastroduodenal Ulcers in patients with severe burns are known as Curling’s ulcers

The skin is compromised and unable to regulate body temperature or prevent fluid from seeping out of the body. If enough intravascular volume is lost the patient can enter hypovolemic shock.