Author
Brady Pregerson, MD
Attending Physician
Department of Emergency Medicine
Cedars-Sinai Medical Center
Los Angeles, California
Disclosure: Brady Pregerson, MD, has disclosed no relevant financial relationships.
Editor
Mark P. Brady, PA-C
Adjunct Faculty and Preceptor
Physician Assistant Program
University of New England
Physician Assistant
Department of Emergency Medicine
Cambridge Hospital, Cambridge Health Alliance
Cambridge, Massachusetts
Disclosure: Mark P. Brady, PA-C, has disclosed no relevant financial relationships.
Reviewer
Andrea B. Lese, MD
Staff Physician
Section of Emergency Medicine
Yale-New Haven Hospital
New Haven, Connecticut
Disclosure: Andrea B. Lese, MD, has disclosed no relevant financial relationships.
In terms of human life, suffering, disability, and financial loss, severe burn injuries can have catastrophic consequences and are characterized by profound morbidity and mortality. This patient presented with a deep partial-thickness burn. In 2011, approximately 450,000 patients in the United States suffered burn-related injuries requiring medical treatment. Of these, 45,000 required hospitalization, with 3,500 injuries resulting in burn- or fire-related deaths.[1]
Despite significant advances in burn management and critical care, including early excision and grafting, aggressive resuscitation, and advances in antimicrobial therapy, there continues to be many common errors, misconceptions, and controversies in the initial emergency management of burn injuries, including (but not limited to) those shown here. Burn victims rarely die immediately as a result of thermal injury; immediate death is typically the result of coexisting trauma, toxin or smoke inhalation, or airway compromise.
Superficial or first-degree burns (such as the sunburn shown) result in injury to the top layer of skin (epidermis) and cause the lower levels of the skin below the epidermis (dermis) to become red and swollen. Treatment may include a cool towel, cortisone, topical aloe vera, nonsteroidal anti-inflammatory drugs, and/or antihistamines. If the patient appears ill, consider intravenous fluids and steroids. If the total body surface area is extensive, even superficial burns can result in dehydration and hypothermia through loss of the normal skin function.
Patients with superficial partial-thickness burns (superficial second-degree burns) present with blistering (shown) as a result of injury to the top layer of skin (epidermis). A small area of the dermis may also be injured. Debridement of burn blisters is a common controversy. Blisters are actually damaged skin, which does not technically act as a protective barrier. Blister fluid can promote bacterial growth and contains prostaglandins that promote inflammation and increase pain. Debridement of a blister removes a mass lesion that may impede function, especially if on the hand or foot. Debridement also allows topical medication to reach the burn base.
Sometimes, blisters obscure full-thickness wounds, as shown here. Usually, however, wounds underlying blisters are partial-thickness wounds. The literature does not support or refute the practice of debriding blisters. One review states that evidence actually speaks against debriding the blister because it increases the chance of infection.[2] Another review has formulated clinical practice guidelines based on blister size (<6 mm leave intact, >6 mm debride), blister type (debride thin-walled, leave thick-walled blisters intact), and infection prevention strategies (debride blisters to remove nonviable tissue, to improve visualization of wound bed and estimation of depth, and to evacuate blister fluid that may suppress local and systemic immune function), among other considerations.[3] Image courtesy of Wikipedia Commons.
Deep partial-thickness second-degree burns (shown) injure the epidermis and the dermis. Deep second-degree burns are often caused by oil, grease burns, and fires. These burns are treated initially similarly to superficial second-degree burns, although they may require skin grafting, splints, and compression bandage. These patients may require referral for long-term care or admission to a burn center. Image courtesy of Wikimedia Commons.
This figure shows how a burn affects the skin in layers: the zone of coagulation (devitalized, necrotic, white, no circulation), zone of stasis (circulation sluggish, may covert to full thickness, mottled red) and zone of hyperemia (outer rim, good blood flow, red). The use of ice to cool a burn may aid in patient comfort, but it can cause additional tissue damage to already vulnerable skin due to a cold thermal injury. Ice may actually decrease blood flow to the vulnerable zone of stasis, creating a larger zone of coagulation and increasing the amount of tissue damage. Instead of ice, cool tap water should be used to avoid hypothermia and a cold thermal injury to already-damaged tissues.
Full-thickness or third-degree burns (shown) injure the epidermis, the dermis, and the subcutaneous fatty tissue under the skin, and often cause significant muscle tissue damage. There is a common misconception that full-thickness burns are not painful. Although the area of tissue with full-thickness burns is usually insensate, these burns will often have very painful partial thickness burns (second-degree burns) surrounding them. Image courtesy of Wikipedia Commons.
The first step in assessing a burn and planning resuscitation involves a careful examination of all body surfaces. A common clinician error is to underestimate the percentage of affected total body surface area (TBSA). To estimate the TBSA, use a standard Lund-Browder chart or the “rule of nines” (shown). A useful tool for estimating TBSA of spotty burns is the close approximation of just less than 1% body surface area to the patient's palm size. Only second-degree burns or greater should be included in the TBSA determination for burn fluid calculations, although very extensive first-degree burns can lead to hypovolemia as well.
This image shows a child with extensive partial- and full-thickness burns covering a large percentage of TBSA. One study found TBSA and patient age to be the most important factors in predicting mortality from burn injuries. Although inhalation injury was significantly associated with mortality after thermal injury, it added little to the prediction of mortality using TBSA and age alone.[4] It is often difficult to accurately predict the severity (partial versus full thickness) and TBSA percentage in the acute phase after the injury.
This child has extensive superficial and partial thickness burns to the face, upper chest, and arms. In addition to underestimating TBSA, underestimating burn depth can be a critical error. It can take several days for the full extent of the injury to declare itself; therefore, reassessment of these patients is critical. In outpatient management, wound checks in 2 days are recommended for wounds with cellulitic changes. Wound checks in 2 weeks can assess need for referral for treatment of contractures and possible skin grafts.[4]
Electrical burns (shown) can have devastating effects on nerve and muscle tissue and are frequently associated with other blunt trauma (ie, fall from ladder). Electric injury accounts for 1,000 deaths each year in the United States, with a mortality rate of 3-15%.[5,6] In electrical burns, the majority of the burned damaged tissue is below the surface. The visible burn is only the “tip of the iceberg,” so the severity of electrical burns may be underestimated and associated trauma missed. Consider and look for fractures and dislocations and monitor cardiac activity. Most patients with electrical injuries should be admitted for monitoring and intravenous fluids.
This image shows the grounded site of a low-voltage injury after a suicide attempt. Underresuscitation of patients with electrical burn injuries can become an issue; clinicians cannot use TBSA to estimate fluid needs because most damaged tissue is unseen. Patients with electrical injuries are also at risk for developing compartment syndrome and rhabdomyolysis. Rhabdomyolysis can cause myoglobinuria and subsequent renal failure. Titrate fluids to urine output of 1-2 mL/kg/hr and consider intravenous sodium bicarbonate infusion if rhabdomyolysis develops.
A high level of suspicion should be maintained for compartment syndrome, which can be difficult to ascertain in an intubated and sedated patient. Soft tissues under the skin always swell with burns due to capillary leak of fluids in the first days. In circumferential burns, the thorax or limb is burned all the way around and there is a loss of skin expansion from the loss of turgor/elasticity in burned tissue. This loss of elasticity can result in severe respiratory distress, as the chest is unable to expand. In a limb, the pressure gradually increases. Eventually, pressure inside a limb exceeds arterial pressure, causing compartment syndrome and requiring an escharotomy (arrows) to relieve the pressure. It is critical to recognize the emergent need for an escharotomy of the chest if the burn is affecting respiration or the limb if there are signs of neurovascular compromise.
A major error in the acute management of the burn patient is not securing the airway promptly. Thermal injuries can cause rapid onset of edema of the airway (shown), making airway management difficult or impossible. Intubate early, or call an ENT specialist or anesthesiologist if unsure. Indications for securing the airway early include stridor, cough, enclosed space fire, hoarse voice, carbonaceous sputum, facial burn, or loss of consciousness. Image courtesy of Wikimedia Commons.
Clinicians managing the airway of a burn patient may not recognize carbon monoxide (CO) poisoning. Symptoms of carbon monoxide poisoning include headache, malaise, nausea and vomiting, weakness, dyspnea, ataxia, seizure, chest pain, and coma. Oxygen saturation is often normal. Treatment includes oxygen for 5 hours or until CO level is less than 5-10 parts per million (PPM). Hyperbaric chamber indications include a CO level >25-40 PPM, altered mental status, acidosis, chest pain, and pregnancy. Neonates should also be treated in the hyperbaric chamber. Cyanide poisoning should also be considered in fire victims.
Inadequate fluid resuscitation is another critical error in burn care management. When performing fluid resuscitation of a patient with thermal burns, the Parkland Formula is used to calculate the volume of fluid needed in the first 24 hours: 4 × TBSA × kg in the first 24 hours after injury, with half in the first 8 hours. A simplified guideline for the first 8 hours is 1 L/h for a 75-kg patient with 50% TBSA (this does not apply to electrical burns). Use Ringer’s lactate (shown) instead of normal saline. Urine output will better optimize fluid resuscitation, with a goal of 1-2 mL/kg/hr for urine output.
Finally, it is crucial to consider early transfer to an appropriate tertiary burn center; this table lists the burn center transfer criteria as provided by the American Burn Society. When transferring patients to a burn center, use dry dressings to prevent hypothermia in patients with burn TBSA >10%. There is no need to apply silvadene if transferring a patient to a burn center, as this will just necessitate removal on arrival at the burn center to enable evaluation of the burns.
Author
Brady Pregerson, MD
Attending Physician
Department of Emergency Medicine
Cedars-Sinai Medical Center
Los Angeles, California
Disclosure: Brady Pregerson, MD, has disclosed no relevant financial relationships.
Editor
Mark P. Brady, PA-C
Adjunct Faculty and Preceptor
Physician Assistant Program
University of New England
Physician Assistant
Department of Emergency Medicine
Cambridge Hospital, Cambridge Health Alliance
Cambridge, Massachusetts
Disclosure: Mark P. Brady, PA-C, has disclosed no relevant financial relationships.
Reviewer
Andrea B. Lese, MD
Staff Physician
Section of Emergency Medicine
Yale-New Haven Hospital
New Haven, Connecticut
Disclosure: Andrea B. Lese, MD, has disclosed no relevant financial relationships.
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