Burn Triage and Treatment: Thermal Injuries

• General Information

• Diagnosis of Burns

• American Burn Association Burn Unit Referral Criteria

• Treatment

• Special Burns

• American Burn Association Information

Caveat:

• This page describes the diagnosis and treatment of skin injury due to thermal
effects.

• For skin injury due to radiation effects, see REMM's Cutaneous Radiation Syndrome
page.
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General Information

• After a radiation mass casualty incident, especially a nuclear detonation, trauma with
or without thermal burns (flash burns or flame burns) will be common, especially in
areas closer to the epicenter.

• An air burst nuclear detonation will result in more burn victims than will a ground
burst detonation of equal magnitude

• Thermal burn patients will complicate the comprehensive medical response to

radiological/nuclear mass casualty events, as burn care itself requires additional
specialized staff, resources, and equipment for prolonged periods of time, well beyond
the acute or initial phase of the medical response

○ Staff: Healthcare providers (both physicians and nurses) with significant burn
care expertise are needed to optimize chances for survival and may be in
short supply locally

○ Resources: Complex, expensive, resource-intensive care for the most severely

burned patients will be required well beyond the acute/initial medical response
 phase

○ Equipment/Beds: Given the overall limited number of dedicated and available

burn beds and burn specialists in any one region of the US, transfer of
patients to specialized burn centers throughout the country will likely be
needed. Consultation with an American Burn Association-verified burn center
is recommended.

• Thermal burns after concomitant radiation injury decrease the likelihood of survival,
as do other types of combined injury.
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Diagnosis of Burns

• Definition: A burn is the partial or complete destruction of skin caused by some form
of energy, usually thermal energy.

• Burn severity is dictated by:

○ Percent total body surface area (TBSA) involvement

 Burns >20-25% TBSA require IV fluid resuscitation

 Burns >30-40% TBSA may be fatal without treatment

 In adults: "Rule of Nines" is used as a rough indicator of % TBSA

Rule of Nines for Establishing Extent of Body Surface Burned

Anatomic Surface % of total body surface

Head and neck 9%

Anterior trunk 18%

Posterior trunk 18%

Arms, including hands 9% each

Legs, including feet 18% each

Genitalia 1%

 In children, adjust percents because they have proportionally larger

 heads (up to 20%) and smaller legs (13% in infants) than adults

 Lund-Browder diagrams improve the accuracy of the % TBSA

for children.

 Palmar hand surface is approximately 1% TBSA

Estimating Percent Total Body Surface Area in Children Affected

by Burns

(A) Rule of "nines"

(B) Lund-Browder diagram for estimating extent of burns
(Adapted from The Treatment of Burns, edition 2, Artz CP and Moncrief
JA, Philadelphia, WB Saunders Company, 1969)

○ Depth of burn injury (deeper burns are more severe)

 Superficial burns (first-degree and superficial second-degree burns)

 First-degree burns

 Damage above basal layer of epidermis

  Dry, red, painful ("sunburn")

 Second-degree burns

 Damage into dermis

 Skin adnexa (hair follicles, oil glands, etc,) remain

 Heal by re-epithelialization from skin adnexa

 The deeper the second-degree burn, the slower the

healing (fewer adnexa for re-epithelialization)

 Moist, red, blanching, blisters, extremely painful

 Superficial burns heal by re-epithelialization and usually do not

scar if healed within 2 weeks

 Deep burns (deep second-degree to fourth-degree burns)

 Deep second-degree burns (deep partial-thickness)

 Damage to deeper dermis

 Less moist, less blanching, less pain

 Heal by scar deposition, contraction and limited re-

epithelialization

 Third-degree burns (full-thickness)

 Entire thickness of skin destroyed (into fat)

 Any color (white, black, red, brown), dry, less painful

(dermal plexus of nerves destroyed)

 Heal by contraction and scar deposition (no epithelium

left in middle of wound)

 Fourth-degree burns

 Burn into muscle, tendon, bone

 Need specialized care (grafts will not work)

 Deep burns usually need skin grafts to optimize results and

lead to hypertrophic (raised) scars if not grafted

○ Age

 Mortality for any given burn size increases with age

  Children/young adults can survive massive burns

 Children require more fluid per TBSA burns

 Elderly may die from small (<15% TBSA) burns

○ Smoke inhalation injury

 Smoke inhalation injury doubles the mortality relative to burn size

○ Associated injuries

 Other trauma increases severity of injury

○ Delay in resuscitation

 Delay increases fluid requirements

○ Need for escharotomies and fasciotomies

 Increases fluid requirements

○ Use of alcohol or drugs (especially methamphetamine)

 Makes resuscitation more difficult

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American Burn Association Burn Unit Referral Criteria *

*Criteria not established for very large mass casualty incidents (MCI)

Summary of Burn Unit Referral Criteria (American Burn Association)

1. Second- and third-degree burns greater than 10% TBSA in patients under 10 or over
50 years of age

2. Second- and third-degree burns greater than 20% TBSA in other age groups

3. Second- and third-degree burns that involve the face, hands, feet, genitalia,
perineum, and major joints

4. Third-degree burns greater than 5% TBSA in any age group

5. Electrical burns, including lightning injury

6. Chemical burns

7. Inhalation injury

8. Burn injury in patients with pre-existing medical disorders that could complicate
management, prolong recovery, or affect mortality (e.g., significant radiation
 exposure)

9. Any patients with burns and concomitant trauma (e.g., fractures, blast injury) where
burn injury poses the greatest risk of morbidity or mortality. In such cases, if the
trauma poses the greater immediate risk, the patient may be treated initially in a
trauma center until stable before being transferred to a burn center. Physician
judgment will be necessary in such situations and should be in concert with the
regional medical control plan and triage protocols appropriate for the incident

10. Hospitals without qualified personnel or equipment for the care of children should
transfer children with burns to a Verified Burn Center with these capabilities

11. Burn injury in children who will require special social/emotional and/or long-term
rehabilitative support, including cases involving suspected child abuse or substance
abuse

Treatment

• General information

○ All burn patients should initially be treated with the principles of Advanced
Burn and/or Trauma Life Support

 The ABC�s (airway, breathing, circulation) of trauma take precedent

over caring for the burn

 Search for other signs of trauma

• Verified Burn Centers provide advanced support for complex cases

○ Certified by the American College of Surgeons (ACS) Committee on Trauma

and the American Burn Association (ABA)

○ Resources will give advice or assist with care

• Burn Unit Referral Criteria (PDF - 11 KB) (American Burn Association)

• Airway

○ Extensive burns may lead to massive edema

○ Obstruction may result from upper airway swelling

○ Risk of upper airway obstruction increases with

  Massive burns

 All patients with deep burns >35-40% TBSA should be

endotracheally intubated

 Burns to the head

 Burns inside the mouth

○ Intubate early if massive burn or signs of obstruction

 Intubate if patients require prolonged transport and any concern with

potential for obstruction

 If any concerns about the airway, it is safer to intubate earlier than

when the patient is decompensating

○ Signs of airway obstruction

 Hoarseness or change in voice

 Use of accessory respiratory muscles

 High anxiety

○ Tracheostomies not needed during resuscitation period

○ Remember: Intubation can lead to complications, so do not intubate if not

needed

• Breathing

○ Hypoxia

 Fire consumes oxygen so people may suffer from hypoxia as a result of

flame injuries

○ Carbon monoxide (CO)

 Byproduct of incomplete combustion

 Binds hemoglobin with 200 times the affinity of oxygen

 Leads to inadequate oxygenation

 Diagnosis of CO poisoning

 Nondiagnostic

 PaO2 (partial pressure of O2 dissolved in serum)

  Oximeter (difference in oxy- and deoxyhemoglobin)

 Patient color ("cherry red" with poisoning)

 Diagnostic

 Carboxyhemoglobin levels

 <10% is normal

 >40% is severe intoxication

 Treatment

 Remove source

 100% oxygen until CO levels are <10%

○ Smoke inhalation injury

 Pathophysiology

 Smoke particles settle in distal bronchioles

 Mucosal cells are die

 Sloughing and distal atelectasis

 Increase risk for pneumonia

 Diagnosis

 History of being in a smoke-filled enclosed space

 Bronchoscopy

 Soot beneath the glottis

 Airway edema, erythema, ulceration

 Nondiagnostic clinical tests

 Early chest x-ray

 Early blood gases

 Nondiagnostic clinical findings

 Soot in sputum or saliva

 Singed facial hair

 Treatment
  Supportive pulmonary management

 Aggressive respiratory therapy

• Circulation

○ Obtain IV access anywhere possible

 Unburned areas preferred

 Burned areas acceptable

 Central access more reliable if proficient

 Cut-downs are last resort

○ Resuscitation in burn shock (first 24 hours)

 Massive capillary leak occurs after major burns

 Fluids shift from intravascular space to interstitial space

 Fluid requirements increase with greater severity of burn (larger %

TBSA, increase depth, inhalation injury, associate injuries - see above)

 Fluid requirements decrease with less severe burn (may be less than
calculated rate)

 IV fluid rate dependent on physiologic response

 Place Foley catheter to monitor urine output

 Goal for adults: urine output of 0.5 ml/kg/hour

 Goal for children: urine output of 1 ml/kg/hour

 If urine output below these levels, increase fluid rate

 Preferred fluid: Lactated Ringer's Solution

 Isotonic

 Cheap

 Easily stored

 Resuscitation formulas are just a guide for initiating resuscitation

 Resuscitation formulas:

 Parkland formula most commonly used

 IV fluid - Lactated Ringer's Solution

  Fluid calculation

 4 x weight in kg x %TBSA burn

 Give 1/2 of that volume in the first 8

hours

 Give other 1/2 in next 16 hours

 Warning: Despite the formula suggesting

cutting the fluid rate in half at 8 hours,
the fluid rate should be gradually
reduced throughout the resuscitation to
maintain the targeted urine output, i.e.,
do not follow the second part of the
formula that says to reduce the rate at 8
hours, adjust the rate based on the urine
output.

 Example of fluid calculation

 100-kg man with 80% TBSA burn

 Parkland formula:

 4 x 100 x 80 = 32,000 ml

 Give 1/2 in first 8 hours = 16,000 ml in

first 8 hours

 Starting rate = 2,000 ml/hour

 Adjust fluid rate to maintain urine output of 50

ml/hr

 Albumin may be added toward end of 24 hours if

not adequate response

 Resuscitation endpoint: maintenance rate

 When maintenance rate is reached (approximately 24 hours),

change fluids to D50.5NS with 20 mEq KCl at maintenance
level

 Maintenance fluid rate = basal requirements + evaporative losses

  Basal fluid rate

 Adult basal fluid rate = 1500 x body surface area (BSA)

(for 24 hrs)

 Pediatric basal fluid rate (<20kg) = 2000 x BSA (for 24

hrs)

 May use

 100 ml/kg for 1st 10 kg

 0 ml/kg for 2nd 10 kg

 20 ml/kg for remaining kg for 24 hrs

 Evaporative fluid loss

 Adult: (25 + % TBSA burn) x (BSA) = ml/hr

 Pediatric (<20kg): (35 + % TBSA burn) x (BSA) =

ml/hr

○ Complications of over-resuscitation

 Compartment syndromes

 Best dealt with at Verified Burn Centers

 If unable to obtain assistance, compartment syndromes may

require management

 Limb compartments

 Symptoms of severe pain (worse with movement),

numbness, cool extremity, tight feeling compartments

 Distal pulses may remain palpable despite ongoing

compartment syndrome (pulse is lost when pressure >
systolic pressure)

 Compartment pressure >30 mmHg may compromise

muscle/nerves

 Measure compartment pressures with arterial line

monitor (place needle into compartment)

 Escharotomies may save limbs

  Performed laterally and medially throughout
entire limb

 Performed with arms supinated

 Hemostasis is required

 Fasciotomies may be needed if pressure does not drop

to <30 mmHg

 Requires surgical expertise

 Hemostasis is required

 Chest Compartment Syndrome

 Increased peak inspiratory pressure (PIP) due to

circumferential trunk burns

 Escharotomies through mid-axillary line, horizontally

across chest/abdominal junction

 Abdominal Compartment Syndrome

 Pressure in peritoneal cavity > 30 mmHg

 Measure through Foley catheter

 Signs: increased PIP, decreased urine output despite

massive fluids, hemodynamic instability, tight abdomen

 Treatment

 Abdominal escharotomy

 NG tube

 Possible placement of peritoneal catheter to

drain fluid

 Laparotomy as last resort

 Acute Respiratory Distress Syndrome (ARDS)

 Increased risk and severity if over-resuscitation

 Treatment supportive

• Wound Care

○ During initial or emergent care, wound care is of secondary importance

 ○ Advanced Burn Life Support recommendations

 Cover wound with clean, dry sheet or dressing. NO WET DRESSINGS.

 Simple dressing if being transported to burn center (they will

need to see the wound)

 Sterile dressings are preferred but not necessary

 Covering wounds improves pain

 Elevate burned extremities

 Maintain patient's temperature (keep patient warm)

 While cooling may make a small wound more comfortable,

cooling any wound >5% TBSA will cool the patient

○ If providing prolonged care

 Wash wounds with soap and water (sterility is not necessary)

 Maintain temperature

 Topical antimicrobials help prevent infection but do not eliminate

bacteria

 Silver sulfadiazine for deep burns

 Bacitracin and nonsticky dressings for more superficial burns

○ Skin grafting

 Deep burns require skin grafting

 Grafting may not be necessary for days

 Preferable to refer patients with need for grafting to Verified Burn

Centers or, if not available, others trained in surgical techniques

 Grafting of extensive areas may require significant amounts of

blood

 Patient's temperature must be watched

 Anesthesia requires extra attention

• Medications

○ All pain meds should be given IV

 ○ Tetanus prophylaxis should be given as appropriate

○ Prophylactic antibiotics are contraindicated

 Systemic antibiotics are only given to treat infections

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Special Burns

• General information

○ Often require specialized care

○ Calling a Verified Burn Center is advised

• Electrical injuries

○ Extent of injury may not be apparent

 Damage occurs deep within tissues

 Damage frequently progresses

 Electricity contracts muscles, so watch for associated injuries

○ Cardiac arrhythmias may occur

 If arrhythmia present, patient needs monitoring

 CPR may be lifesaving

○ Myoglobinuria may be present

 Color best indicator of severity

 If urine is dark (black, red), myoglobinuria needs to be treated

 Increase fluids to induce urine output of 75-100 ml/hr in adults

 In children, target urine output of 2 ml/kg/hour

 Alkalinize urine (give NaHCOi3)

 Check for compartment syndromes

 Mannitol as last resort

○ Compartment syndromes are common

○ Long-term neuro-psychiatric problems may result

 • Chemical Burns

○ Brush off powder

○ Prolonged irrigation required

○ Do not seek antidote

 Delays treatment

 May result in heat production

○ Special chemical burns require contacting a Verified Burn Center, for example:

 Hydrofluoric acid burn

• Radiation Burns

○ Burn care is same as other burns in first 24 hours and first few weeks

○ Wound breakdown may occur later in the course, consistent with time course

of cutaneous subsyndrome of Acute Radiation Syndrome

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American Burn Association Information

• The American Burn Association (ABA) is an organization of burn caregivers who have
set up a network to assist with management of burn disasters.

• The ABA has set up a system to verify burn centers (similar to Verified Trauma
Centers) as meeting standards for managing patients with burns of all types of
severity.

• Verified Burn Centers participate in disaster planning and have set up a network for
transporting burn patients throughout the country.

• Verified Burn Centers are always available for advice and assistance in managing burn
patients.

• To find the nearest Verified Burn Center near you,

○ contact the ABA Web site: www.ameriburn.org or

○ e-mail: info@ameriburn.org or

○ call: 312-642-9260

• The ABA offers ABA Advanced Burn Life Support (ABLS), a Self-directed, Web-based
 Learning Program.
Acknowledgement: This REMM Web page was prepared in consultation with Dr.
David Greenhalgh, President of the American Burn Association, August 2006
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