• Admission criteria for burns
• Transfer guidelines for burns
• Wound management in burns
• Classification of burns
• 3 mechanisms of lower airway disease in an inhalational injury
• 4 preparations with regards to the respiratory management of an inhalational injury

Initial Assessment and Resuscitation

• Predictors of survival: burn size and inhalational injury
• Higher rate of burn-related comorbidities: children < 2 years, hx significant comorbidity, burn > 30% TBSA
• Pathophys:
  • burn injury causes increased capillary permeability and the release of osmotically active molecules to the interstitial space resulting in extravasation of fluid
  • protein is lost from the vascular space to the interstitium in the first 24 hrs
  • in large burns (> 20% BSA), vasoactive mediators are released to the circulation and result in systemic capillary leakage
  • edema develops in both burned and noninjured tissues
  • circulating factors depress myocardial function and decrease cardiac output
  • acute hemolysis of up to 15% of RBCs may occur from direct heat damage and from microangiopathic hemolytic process
  • can result in life-threatening shock
• Classification:
  • Superficial: epidermis injured but dermis intact
    • Red, mild inflammatory response
    • No significant edema or bulla
    • Not included in calculation of BSA
    • May be painful
    • Usually resolve in 3-5 days without scarring
  • Partial-thickness: dermis partially injured
    • Blistering often present
    • Edema due to ↑ cap permeability (direct thermal injury and local mediator release)
    • Painful because intact sensory nerve receptors are exposed
    • Pink-red color and moist appearance
    • Resolves in 2 weeks, minimal scarring
  • Deep partial-thickness: destruction of epidermis and most of dermis
    • Edema can lessen the exposure of sensory nerve receptors, making it less painful but still some intact pain sensation
    • Paler, drier appearance
    • Thrombosed vessels can give a speckled appearance
    • Can progress to full thickness if secondary damage from infection, trauma or hypoperfusion
    • Recovery takes weeks to heal, significant scarring, may need skin grafting for cosmesis
  • Full thickness: destruction of the epidermis and entire dermis
    • Pale, charred color and leathery appearance
    • Nontender due to destruction of the cutaneous nerves in the dermis (but surrounding partial thickness burns can be painful)
    • Loss of skin elasticity
    • Skin cannot expand as tissue edema develops within 24-48hr
    • Complications of circumferential: respiratory distress, abdominal compartment syndrome, vascular insufficiency of the distal extremities
    • Cannot reepithelialize, only heal from periphery, require skin grafting
• First aid:
  • Early cooling best if performed within first 60 minutes – stops ongoing thermal damage and prevents edema, reducing progression
  • No grease/butter/ointment
  • Cover with clean cloth or bandage
• Treatment priorities:
  • Prehospital care
  • Assessment
  • Resuscitation
  • Treatment of potential inhalational injury
  • Wound Care
  • Infection control
  • Appropriate admission
  • Other: potential surgical management, rehabilitation

Management:

• ABCs, removal of smoldering clothing or sources of continued burning, IV access
  • Airway: Assess for inhalational injury
    • S/S: smoke exposure in an enclosed space, burns on the face, singed nasal hairs, soot in sputum or visible in the upper airway, wheezing or rales; hoarseness
    • Edema will worsen over the first 24-48 hrs
    • Consider smaller ETT in anticipation of narrowed airway, cuffed preferred
  • Consider C-spine injury: jumped/fallen in house fire, MVA, explosions
  • Breathing:
    • CXR
    • Consider salbutamol or racemic epi if signs of inhalational injury
    • Full thickness burn of thorax may restrict ventilation → indication for escharotomy along anterior axillary lines
  • Circulation:
    • Skin color, cap refill, temp of peripheral extremities, HR, LOC, BP
  • IV access:
    • Large-bore in the upper extremity through intact skin preferred
    • Save sites for central catheter if possible
    • Avoid circumferential taping due to anticipated swelling
  • Consider potential for carbon monoxide
    • Administer 100% O2
    • Send carboxyhemoglobin level
  • Consider potential for cyanide
• Fluid resuscitation
  • Initial bolus of 20ml/kg NS or RL while assessing burns
  • Should include fluid from EMS in calculating volume in the first 24 hrs
  • Place catheter to measure U/O (most important means of monitoring fluid status) → goal 1ml/kg/hr
  • Parkland formula: 4mL/kg/% BSA in the first 24 hrs with 50% in the first 8 hrs, then 50% in the next 16 hrs
  • In children < 5 years add maintenance requirements using D5NS
  • Under resuscitation: can cause organ failure and death
  • Over resuscitation: can cause pulmonary edema, tissue edema that results in compartment syndrome
• Burn assessment
  • % Body surface area:
    • Rule of 9s in adolescent/adults: each arm is 9% TBSA, each leg is 18%, anterior & posterior torso each 18%, head is 9%, perineum 1%
    • Young children: child’s palm including the fingers is approx. 1% BSA
  • Location: Record on anatomical chart
  • Depth: Description of depth/classification (e.g. superficial, partial, etc)
• NG tube
• Temperature