Case Report: Burns
Reid Sadoway
PGY1
Emergency Medicine, Dalhousie
History
3 yo boy, presents to pediatric ED with mother
Child can be heard crying inside waiting/patient room,
has both hands bandaged and wrapped
According to mother, unwitnessed event but child
likely grabbed grates on an old wood burning stove.
Child immediately screamed out, parents grabbed him,
and flushed hands under cool water.
Wrapped child’s hands in towels and brought to ED
No other injuries noted
Case cont’d
PMHx: Had orchidopexy for an undescended testicle at
15 months of age, otherwise healthy.
Meds: None
Allergies: Penicillin – Rash
Immunizations: UTD
Development: All normal for fine motor, gross motor,
and speech
Vitals
Temp: 36.4
HR: 154
RR: 28
O2: 99% on RA
BP: 96/52
Weight: 14.5 kg
Glucose: Not Done
Physical Exam
H+N: Normal, no obvious burns or singe to
oropharynx or nares
Cardiac: N S1S2, no murmurs noted
Resp: AE=AE, no wheeze, no stridor, no obvious
increased work of breathing
Abdo: Soft, non tender with N bowel sounds
Hands look as follows……
Hand exam
CR: 1-2 seconds in all digits
Radial pulses: N
Still moving all fingers and wrists
Mom able to convince child to give a thumbs up
Disposition
Child’s hands covered in ointment containing
lidocaine/tetracaine + vaseline
Wrapped in gauze, mother advised to change daily with
daily application of ointment
Given follow up appointment with plastics because of
location of burn
Child happy and eating popsicle on way out of the
department.
Introduction to Burns
Relatively common injuries caused by direct or indirect
contact with heat, electrical current, radiation, or
chemical agents
With thermal burns, the severity of injury is dependent
on length of exposure, the temp, and the intrinsic
tissue structure leading to heat conductivity
Common denominator in burn injuries is protein
denaturation and cell death (either by necrosis or
apoptosis)
Epidemiology
In the U.S. there are approx 450 000 medical visits per year
related to burns, with 3500 deaths and 45 000 admissions.
The majority of burns occur from fire or flame (44%), scalds
(33%), contact with hot objects (9%), electricity (4%), or
chemical agents (3%)
More than 1/3 of admissions have >10% TBSA affected.
Other admission typically involve severe burns to vital areas
such as the hands, face, or feet, or there has been other
trauma involved
Half of patients are between 19 and 44 years of age. Most
commonly affected are the upper extremities (44%), lower
ext (26%) and H & N (17%)
Pathophysiology
Unique, dynamic injuries in that there tends to be
progression in depth and size occurring AFTER the
time of injury.
Temperatures below 440 C are generally tolerated
without injury. However as temperature rises there is
an exponential decrease in the time to injury.
Traditionally burns are separated into 3 concentric
zones: Coagulation, Stasis/Ischemia, and Hyperemia
Pathophysiology Cont’d
The cont’d progression of burn injuries is
multifactorial and not completely understood at this
time.
The initial inflammatory response triggers a cascade
that seems to cause further injury
There is an occlusion of the dermal microcirculation
with a combination of red blood cells, neutrophils, and
microthrombi that results in reduced perfusion.
Pathophysiology Cont’d
Inhalation injury: Exposure to heat can cause rapid
and extensive upper airway edema in burn patients.
Components of smoke such as incomplete combustion
materials (ie CO, cyanide, aldehydes, and oxides) can
result in further pulmonary edema and V/Q mismatch
Necrosis in the airway leads to de-epitheliazation and
formation of pseudomembranous casts that cause
further airway obstruction
Reduced ability to clear secretions causing further
exacerbation
Classification of Burns
Burns are classified by mechanism of injury, depth,
extent, and associated injuries and comorbidities.
First Degree: Limited to the epidermis, characterized
by erythema and pain
Second Degree/Partial Thickness: Can be further
subdivided into superficial and deep. Superficial
thickness burns are limited to the papillary dermis
while Deep extend to the reticular dermis
Important to distinguish between the two as Deep
partial thickness burns will often will not heal in 2-3
weeks and can lead to scarring and contractures.
Classification of Burns
Third Degree: Also referred to as full thickness burns
Appear thick, white, or tan. Also appear dry with
possible charred appearance.
Non-blanching, and because of nerve destruction are
not painful
Fourth Degree: Extend through the skin into muscle
and bone.
Appear stiff, charred, with visibly thrombosed vessels
1 st Degree Burn
2 nd Degree Burn
2nd Degree Burns
3 rd Degree Burn
4 th Degree Burn
Burn Assessment
Various tools and modalities to assess the depth and
healing capacity of burns. In the emergency
department however one must use clinical assessment
and estimation, which can be unreliable.
The extent of the burned area or total body surface
area (TBSA) burned is also critical in assessment.
Helps guide the fluid resuscitation management in the
patients. Also helps convey criteria for admittance to
the hospital/burn ward.
Only second degree or deeper burns are used when
assessing TBSA affected.
Burn Assessment
A useful tool for assessment of smaller burns or
scattered areas of burn is that the area of a patient’s
palm and fingers is approximately 1% TBSA
For larger burns the “rule of 9’s” is frequently
employed.
The rule of nines should not be used for children as
their head is larger and, in proportion, their extremities
are smaller than those of adults.
Finally, burns are classified by severity into minor,
moderate, and severe based on the TBSA burned, the
percentage of full-thickness injury, and the involvement
of specific areas such as the face, hands, feet, or
perineum.
Burn Assessment
Burn Assessment
Burn Assessment
Pre-Hospital Management
First priority is to stop the burning process and prevent
further injury
Following this, one should assess the airway, cardiac,
and peripheral perfusion status
Prehospital administration of fluids is warranted in
extensive burns if IV access can be established
effectively and expeditiously in non-burned skin
Ringers Lactate is the fluid of choice as it reduces the
chance of developing hyperchloremeic acidosis
compared to NS. Parkland formula can be used for
dosing
Burn should be covered with a clean sterile dressing.
Minimize hypothermia
ER Management
People tend to focus on the burns when patients come
in, it is important to look for other injuries and do
proper ABC assessment.
Airway injury and compromise warrants intubation,
possibly fiberoptically. If RSI isn’t possible, consider
surgical airway
If IV hasn’t been established then do so. May need
central line if peripheral line not possible. Humidified
O2 should be done to keep sats high (>92%)
Full monitors should be in place, and a catheter may be
placed in order to monitor U/O
Inhalation Injury
Smoke inhalation affects 5-35% of burn patients. Presence
of inhalation injury more than doubles the mortality rate in
adults.
Traditional methods for assessment of inhalational injury
were/are external physical exam, however now it is felt that
direct visualization via laryngoscopy (fiberoptic) or
bronchoscopy is best.
Mechanical ventilation helps provide support, can help with
secretion control and help in the recruitment of alveoli.
Aerosolized NAC and Heparin can help with breakdown of
thick secretions while suctioning and chest physio augment
their removal
Inhalational Injury
Fluid Resuscitation
Prior to WWII many burn patients died of
hypovolemic shock and renal failure. Following combat
as well as other fires there began to be fluid regimens.
The massive amounts of inflammatory mediators lead
to increased permeability of the local and systemic
vasculature and extravasation of intravascular fluids
Patients with small burns can usually be treated with
oral fluids (if they can tolerate oral fluids).
Patients with severe burns require IV fluids in order to
prevent shock and increase intravascular volume
Fluid Resuscitation
Parkland Formula: TBSA x weight (kg) x 4 (ml)
Gives the amount of fluid to give in 24 hours. First ½
should be given in the first 8 hours while the second ½
should be given over the following 16.
Other formulas can also be used including “rule of 10”
This formula states that the estimated burn size
(percent of TBSA) is multiplied by 10 to derive the
initial fluid rate in milliliters per hour. For every 10 kg
above 80 kg, 100 mL is added to this rate
These regimens are guidelines and fluids should be
adjusted according to tissue/organ perfusion
Fluid Resuscitation
Fluid Resuscitation
Special Considerations:
Children have a larger TBSA relative to weight when
compared with adults and therefore have larger fluid
requirements
Fluid needs often calculated on TBSA rather than weight,
using things such as the Galveston Formula.
Colloids: Since leakage of proteins through capillaries lasts
12-24 hours, colloids are not generally recommended in the
initial resuscitation unless the burn is very deep.
ABA guidelines consider the possible addition of colloids
AFTER the 12-24 hr mark to decrease fluid requirements
Local Wound Care
Burns should be considered contaminated and have
gentle cleansing with soap and cool water. Necrotic
tissue should be carefully removed as needed (analgesia
will most likely be warranted in these scenarios)
Tetanus booster should be given if patient has not had
booster in the last 5 years.
Ice water should generally be avoided as it has been
associated with increased tissue injury and hypothermia
Local Wound Care
Burn Blister Management: Remains a topic of debate.
Some evidence that there is less infection with intact
blisters, however tends to be less pain with ruptured
blisters.
With blisters that have already ruptured, any necrotic
epidermis should be gently removed while adherent
epidermis is left intact. With large or tense blisters, the
unruptured blister may be aspirated with a sterile
needle
Burn Dressings
Purpose is to protect the wound, to reduce pain, to
absorb wound exudate, and to reduce evaporative heat
loss
First degree wounds can generally be managed with
topical anesthetics, aloe vera gels, and NSAIDS
Second degree wounds can be managed with dressings
with the main principle being CLEAN AND GREASY!
Burn Dressings
Open: Appropriate for large, contaminated burns with
exudate.
The wound can then be covered by a non-occlusive
dressing with daily cleansing and dressing changes.
Closed: Use of occlusive dressings for a moist
environment in a wound that has little to mild exudate.
Saran Wrap can be used as it seals in heat, acts as a
barrier and also allows you to visualize the wound.
Pain Management
Burn injuries are among the most painful experienced
and pain control should be among the highest
priorities for physicians
Pain, especially in the emergent phase can be divided
into three categories: background, breakthrough, and
procedural.
Pharmacologic agents used to treat burn pain include
opioid analgesics, nonopioid analgesics, anxiolytics,
and anesthetics. The type of medication used is
determined by the severity of pain, the anticipated
duration of pain, and intravenous (IV) access
Pain Management
Minor burns can be managed with Tylenol and NSAIDS
In the emergent setting moderate to severe burn pain is
generally managed with parenteral opioids titrated to effect.
Fentanyl (with a short half life) can be used for short
breakthrough and procedural pain for things like
debridement and dressing changes
Intravenous infusion of lidocaine (1 mg/kg followed by 40
μg/kg/min infusion) has also been shown to reduce the
pain in burn patients.
In large severe burns or pediatric burns consider sedation
and regional nerve blocks
Thank You!!
References:
Rosen’s Guide to Emergency Medicine
UpToDate
American Burn Association Guidelines
