Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Updated: Dec 29 2021


  • Snapshot
    • A 42-year-old female is rescued from a burning building by firefighters and brought to the hospital. On examination, her pulse is 100/min, blood pressure is 130/60 mmHg, respirations are 34/min, and weight is 60 kg (132 lbs). She has second and third degree burns over her anterior and posterior chest and abdomen, bilateral arms and hands, and second degree burns over her face. She is coughing, spitting out carbonaceous sputum, has singed eyebrows and vibrissae (nostril hair) and a hoarse voice. Because of signs for inhalational burns, she is first intubated and ventilated. Total body surface area (BSA) involved is estimated to be 58.5%. She is given 100% oxygen, and IV lactated Ringer's (58.5% BSA x 60kg x 4ml = 14,040 ml) with 7 L administered in the first 8 hours of admission, and another 7 L in the next 16 hours. She is transferred emergently to a burn center because of facial and inhalational burns.
  • Introduction
    • Fourth leading cause of death in children
    • Types of burns include chemical (acid/alkali), electrical, radiation (UV, medical/therapeutic), thermal (scald, fire)
      • can be seasonal (e.g., fireworks)
      • can be associated with abuse
    • Most common causes
      • children: scald burns
      • adults: flame burns
    • Pathophysiology
      • three zones (from outermost to innermost): hyperemia, edema, ischemia
        • zone of hyperemia
          • vasodilation from inflammation
          • viable tissue (recovery within 7 days)
        • zone of stasis/edema
          • decreased perfusion with microvascular thrombosis
          • progressive tissue necrosis (death in 1-2 days without treatment)
          • zone where early treatment has most benefit
        • zone of ischemia
          • no blood flow
          • irreversible damage
  • Presentation
    • Classification (New)

      • Erythema/Superficial
      • 1st degree
      • Epidermis
      • + Pain
      • Blanchable
      • Superficial-partial thickness
      • 2nd degree
      • Into superficial dermis
      • + Pain
      • Blanchable
      • Blisters
      • Deep-partial thickness
      • 3rd degree
      • Into deep dermis
      • - Pain
      • NOT blanchable
      • Soft
      • Full thickness
      • 4th degree
      • Into underlying muscle/bone
      • - Pain
      • NOT blanchable
      • Hard
  • Evaluation
    • Primary and secondary survey
      • brush off gross contaminate and remove all clothing
      • if chemical burn, best next step: irrigation
        • alkali burns penetrate more deeply / rapidly than acid burns
    • Prognosis based on patient age, burn size, and evidence of inhalational injury
      • obvious skin wounds
        • evaluate locations of burns
        • estimate involvedbody surface area (% BSA)
          • each "hand width" area burned is 1% BSA
          • use Rule of 9's for adults (see above)
          • use Lund-Browder chart for children < 10 years
          • this is only for superficial and deep thickness burns (2nd/3rd degree)
            • NOT for erythemas (1st degree)
        • with electrical burns, deep tissue destruction may not be visible
      • suggestions of inhalational injury
        • facial burns and singed nasal hairs
        • hoarseness, stridor, dyspnea
        • altered mental status, headache, coma
        • cherry red skin is NOT reliable (late, post-mortem finding)
    • Investigations
      • arterial blood gas and carboxyhemoglobin level
      • CBC / electrolytes / urinalysis
      • chest radiograph
      • electrocardiogram
  • Management
    • Special considerations in ABC resuscitation
      • if inhalational injury is suspected, best next step: immediate intubation
        • impending airway edema
        • best diagnostic test: bronchoscopy
          • CXR or ABG cannot rule out inhalational injury
      • if CO poisoning is suspected, best next step: 100% O2 by facemask
        • until carboxyhemoglobin level < 10%
      • if burn eschar encircles chest, best next step: escharotomy to relieve constriction
    • Restoration of normal skin function: thermoregulation, fluid control, and infection prevention
      • thermoregulation
        • increase room temperature, cover patient with blankets, and use warmed fluids
      • fluid control
        • use Parkland formula as baseline
          • 4 ml of Lactated Ringer's per kilogram per % BSA over first 24 hours
          • first half given over first 8 hours
          • second half given over next 16 hours
        • additional fluid required if electrical burn, inhalational injury, BSA > 80%, resuscitation delayed, or 4th degree burns are present
        • monitoring
          • clear mental status
          • vitals
            • mean arterial pressure > 70 mmHg
            • pulse < 120/min
          • urine output
            • children (< 12 years): > 1.0 ml/kg/hr
            • adults: > 0.5 ml/kg/hr
      • infection prevention
        • tetanus prophylaxis
          • all patients with > 10% BSA burn or burn worse than superficial thickness need Td
        • cleanse and cover with dry sterile dressing
        • mafenide acetate
          • a topical antibiotic with broad spectrum coverage
          • can penetrate thick eschar
        • topical silver sulfadiazine
          • do NOT use in pregnant patients, children < 2 months old
          • do NOT use around eyes
        • NO benefit in prophylactic PO/IV antibiotics or corticosteroids
    • Burn surgery
      • debridement to level of bleeding capillaries
      • apply split thickness skin grafts over excised areas
      • escharotomy for circumferential burns
    • Other considerations
      • stress ulcer prophylaxis
        • H2 antagonists or proton pump inhibitors
      • nutrition
        • prepare additional supplements/tube feeds
        • basal metabolic rate increases by 2x - 3x if BSA% > 40%
    • Criteria for transfer to burn center
      • full thickness burn > 5% BSA
      • full or partial thickness burn over critical areas (face, hands, feet, genitals, perineum, major joints)
      • circumferential burns
      • chemical, electrical or lightning injury
      • electrical burns may have cardiac arrythmia or ventricular fibrillation, unexpected falls with fractures and dislocations
      • inhalational injury
      • preexisting medical problems
      • special psychosocial or rehabilitative care needs
1 of 0
1 of 7
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options