BURNS

I. Classification of burns

  1. Classification by depth--Traditional classification as 1st, 2nd, 3rd degree is no longer much used; Estimation of thickness may need to be revised after initial assessment
  1. Superficial
    1. Dry, red, blanches with pressure
    2. Painful
    3. Heals in 3-6d
    4. Doesn't scar
    5. Less likely on thin skin (medial thigh, perineum, ears, children & > 55yo)
  1. Superficial partial thickness
    1. Blistering, blanch with pressure, typically moist & weeping
    2. Painful
    3. Heals in 7-20d
    4. Rarely scars; can cause pigmentary changes
  1. Deep partial thickness
    1. Blisters, easily unroofed, with waxy appearance underneath, don't blanch with pressure, variable color (cheesy white to red)
    2. Usually not painful; can sense pressure
    3. Heals in 21d+
    4. Risk of contracture
  1. Full thickness
    1. Waxy white/leathery gray to charred/black, dry & inelastic, nonblanching
    2. May be red after a scald injury, may have blisters
    3. Usually not painful; can sense deep pressure
    4. Does not heal spontaneously if > 2% BSA
    5. Risk of contracture
  1. Classification by extent--Usually expressed as % of Body Surface Area
  1. "Rule of Nines"--Less accurate than:
  1. Lund & Browder method (Mertens DM, Jenkins ME, Warden GD. Outpatient burn management. Nurs Clin North Am 1997;32:343-64, and Lund C, Browder N. The estimation of areas of burns. Surg Gynecol Obstet 1944;79:352-8):
Area Birth to1 year 1 to 4 years 5 to 9 years 10 to 14 years 15 years Adult 2nd* 3rd* TBSA
Head 19 17 13 11 9 7      
Neck 2 2 2 2 2 2      
Anterior trunk 13 13 13 13 13 13      
Posterior trunk 13 13 13 13 13 13      
Right buttock 2.5 2.5 2.5 2.5 2.5 2.5      
Left buttock 2.5 2.5 2.5 2.5 2.5 2.5      
Genitalia 1 1 1 1 1 1      
Right upper arm 4 4 4 4 4 4      
Left upper arm 4 4 4 4 4 4      
Right lower arm 3 3 3 3 3 3      
Left lower arm 3 3 3 3 3 3      
Right hand 2.5 2.5 2.5 2.5 2.5 2.5      
Left hand 2.5 2.5 2.5 2.5 2.5 2.5      
Right thigh 5.5 6.5 8 8.5 9 9.5      
Left thigh 5.5 6.5 8 8.5 9 9.5      
Right leg 5 5 5.5 6 6.5 7      
Left leg 5 5 5.5 6 6.5 7      
Right foot 3.5 3.5 3.5 3.5 3.5 3.5      
Left foot 3.5 3.5 3.5 3.5 3.5 3.5      
            Total:      
  1. American Burn Association Grading System for Burn Severity--ALL criteria refer to partial- or full-thickness burns (J. Burn Care Rehab. 11:98, 1990--cited in AFP review)
    1. MINOR--OK for outpatient mgmt
      1. < 10% BSA in adult, < 5% if < 10yo or > 50yo
      2. < 2% full-thickness
    2. MODERATE--Admit
      1. 10-20% in adult, 5-10% if < 10yo or > 50yo
      2. 2-5% full-thickness
      3. High-voltage, suspected inhalation, circumferential, or susceptibility to infection
    3. MAJOR--Admit to burn center
      1. > 20% BSA in adult, > 10% if < 10yo or > 50yo
      2. > 5% full-thickness
      3. Any sig. burn to face, eyes, ears, genitalia, or joints
      4. Sig. associated injuries (e.g. fracture)

II. Acute management of burns-See under "Follow-up management" for reccs re: seeking referral

  1. Admit for IV hydration and surgical care according to ABA criteria above:
  1. Consider risk of smoke inhalation
    1. Suspect if cough, wheeze, dyspnea, facial burns, sooty mucus, laryngeal edema
    2. If suspected, observe for 12-24h b/c of possibility of delayed airway edemac
    3. To confirm dx--bronchosopy, V-Q scanning
    4. Check carboxyhemoglobin if suspect inhalation injury to r/o CO poisoning
  1. High-voltage electrical injury--Can have cardiac arrhythmias up to 72h afterward! Monitor x 72 or until ECG is normal, whichever happens LAST; nonspecific ST-T wave changes common
  2. Consider possibility of child abuse in all burns in kids--Particularly if looks like immersion injury (sharp demarcation between burned & normal skin)
  3. Ambulatory management of burns--the "Six C's"
    1. Clothing--Remove any hot or burned clothing or clothing exposed to chemicals
    2. Cooling
      1. Even after several hours, may decrease the pain
      2. Sterile saline-soaked gauze colled to around 12'C
    3. Cleaning
      1. Consider local or regional anesthesia if necessary; don't apply topically or inject directly into a burn
      2. Wash only with mild soap & tap water; disinfectants can impede healing
      3. Remove tar & asphalt residues with mixture of cool water & mineral oil, & residual by application of antibiotic ointment over several days
      4. Debride necrotic tissue
      5. Remove ruptured blisters; consider rupturing blisters if contain cloudy fluid or are likely to rupture imminentsl (e.g. over joints)
    4. Chemoprophylaxis
      1. Update Tetanus immunization if indicated
      2. Topical abx, e.g. Silver sulfadiazine or Bacitracin, for all but superficial burns (DON'T use silver sulfadiazine on face, in pregnant women, in nursing moms with babies < 2yo, or in newborns)
      3. Alternatives to topical abx--Dressings that only need to be applied once, e.g. biologics (pigskin, human allograft), bismuth-impregnated petroleum gauze, Bioprane dressings.
    5. Covering--Various sterile dressings appropriate; no need for superficial burns
    6. Comforting--Pain control

III. Follow-up management of burns

  1. Consider first f/u visit day after the injury, to assess pain control and ability to manage dressing changes
  2. Consider weekly visits after that until burn is fully epithelialized
  3. See 4-6wks after completing epithelialization to assess for hypertriphic scarring and contractures.
  4. Moisturizers & sunblock for several months after burn heals
  5. CONSIDER REFERRAL to a burn specialist if pt is at risk for hypertrophic scarring/contractures:
    1. Not healing in 10d for dark-skinned pts, 14d for other pts
    2. Full-thickness burn > 2cm in diameter
    3. Deep Partial Thickness or worse of > 3% BSA (because can be difficult to differentiate from full-thickness)

Source: AFP 62:2015, 2000