Learning Objectives
After reading this article the reader will be able to:

1. Describe the structure and function of skin.
2. Discuss the causes and treatment of inhalation injuries.
3. Explain the three degrees of thermal burns.
4. Identify one method of approximating burn surface area.
5. Describe and apply treatment modalities for the burn patient.

Introduction
Burn injuries are second only to motor vehicle collisions as the leading cause of accidental death in the United States. It is estimated between 2 to 2.5 million people seek medical treatment for burns each year. Of this number, between 100,000 to 150,000 burn patients are hospitalized and between 8,000 and 10,000 burn patients die as a result of their burn injuries.

Burn deaths tend to occur in a bimodal distribution. Death is either fairly immediate after the injury or it occurs weeks later as a result of multi-system organ failure. Overall, morbidity and mortality from burn injury have decreased by 50% in the United States over the past 20 years. Recent data indicate a 50% mortality rate for 98% total body surface area (TBSA) burns in children 14 years of age and younger, and a 50% mortality rate for 75% TBSA burns in other age groups. This decline is due to prevention efforts, an overall decrease in the number of patients with potentially fatal burns, and improved clinical management of persons who sustain severe burns. Advances in treatment include an improved understanding of burn resuscitation, enhanced wound coverage, improved support of the hypermetabolic response to burn injury, more appropriate infection control, and improved treatment of inhalation injuries.

The majority of burn injuries (68%) occur in the home, while most of the remainder of burn injuries (24%) occur in industrial settings. In addition, like other forms of trauma, burn injury appears to primarily be a disease of the young. Thirty-eight percent of burn patients are younger than 15 years of age, 31% are between 15 and 44 years of age, 24% are between 44 and 64 years of age, and 7% are 65 years of age or older. The two age groups most at risk for death from burn injury are the very young (children less than 5 years old) and the elderly (adults older than 65 years old). The mortality rate for these two groups is five times greater than the mortality rate for other age groups.

Anatomy and Physiology of the Skin
The skin, which is considered to be the largest organ in the body, has numerous functions. These functions include: protection from injury and infection, regulation of body temperature, prevention of body fluid loss, and sensory contact with the environment. Any type of burn injury will interrupt and compromise these functions.

The skin is composed of two layers, the epidermis and the dermis (Figure 1). The epidermis is the outer, thinner layer; the dermis is the inner, thicker layer. The outer layer of the epidermis, or stratum corneum, consists of dead, keratinized cells. This layer protects against dehydration, trauma, light, and infection. The inner, or basement, layer of the epidermis consists of cells that migrate upward to become surface keratin. The dermis, which lies directly below the epidermis, is a thick gel-like matrix with collagen and elastin fibers. This area of the skin contains blood vessels; lymphatics; sweat and sebaceous glands; hair follicles; and sensory fibers for pain, touch, pressure, and temperature. Below the dermis is the hypodermis, or subcutaneous tissue. This layer overlies the muscles and bones and consists primarily of connective tissue and adipose tissue. Functions of the subcutaneous tissue include cushioning and insulation.

Pathophysiology of Burn Injury
Although the causes of burn injury vary, the body’s local and systemic responses are generally quite similar. What follows is a brief overview of the local and systemic changes that occur with burn injury. Depth of burn injury and determination of burn size will be discussed later in this article.

Local Changes
Temperatures above 44 degrees C (111 degrees F) produce thermal tissue injury. The degree of tissue destruction correlates with the intensity (temperature) of the energy source, the duration of exposure, and the conductive nature of the tissue exposed. The area of damage can be divided into three zones: the zone of coagulation, the zone of stasis, and the zone of hyperemia.

Cells in the zone of coagulation, located at the central area of the burn, are necrotic from the time of exposure – these are the cells that have the most intimate contact with the heat source. Extending peripherally from this zone is the zone of stasis. Cells in the zone of stasis have a moderate degree of tissue insult, decreased tissue perfusion, and associated vascular damage and vessel leakage. Cells in this area may survive under ideal circumstances, but often progress to necrosis within 24 to 48 hours post injury. The outermost zone is known as the zone of hyperemia. This zone is characterized by vasodilatation and inflammation. This region is generally not at risk for further necrosis and contains clearly viable tissue from which the healing process begins.

Systemic Changes
Significant burns are associated with a massive release of inflammatory mediators into the wound and also into other body tissues. These mediators produce vasoconstriction and vasodilatation, increased capillary permeability, and edema in both local and distant organs.

Fluid Shifts
The body’s response to thermal injury results in varying degrees of tissue damage, cellular impairment, and fluid shifts. Initially, there is a decrease in blood flow to the burned area followed by an increase in arteriolar vasodilatation. Concurrently, the release of vasoactive substances from the burned tissue results in increased capillary permeability, which leads to wound edema. The increased capillary permeability also results in protein loss, which aggravates edema in non-burned tissue. These fluid shifts, combined with insensible fluid loss from the burn wound and an increase in basal metabolic rate, lead to hypovolemia.

Cardiovascular Effects
Cardiovascular effects of acute burn injury include loss of plasma volume, increased peripheral vascular resistance, and decreased cardiac output. Cardiac output is decreased due to decreased blood volume, decreased venous return to the heart, increased blood viscosity, and decreased cardiac contractility. Cardiac output is almost completely restored with adequate resuscitation.

Renal Effects
With the decrease in circulating plasma due to fluid shifts, there is a resultant increase in hematocrit. This decreased plasma volume and increased hematocrit, combined with the decrease in cardiac output associated with acute burn injury, leads to decreased renal blood flow and decreased glomerular filtration rate. The net effect is oliguria, which, if left untreated, leads to acute tubular necrosis and renal failure. Prior to 1984, acute renal failure in burn injuries was almost always fatal. The latest research indicates an 88% mortality for severely burned adults and a 56% mortality rate for severely burned children in whom acute renal failure develops during the post-burn period. The necessity for early, appropriate fluid resuscitation to decrease the incidence of renal failure and its associated high mortality rate cannot be underestimated.

Gastrointestinal Effects
Acute burn injury results in a decrease in gastrointestinal blood flow. This increases the occurrence of mucosal hemorrhages in the stomach and duodenum. Burns greater than 20% TBSA can also lead to adynamic ileus. In the patient being transported by air, this must be addressed.

Immune System Effects
Burn injury causes a global depression in immune function. With burns greater than 20% TBSA, impairment of immune function is directly proportional to burn size. This places the burn patient at great risk for infectious complications such as bacterial wound infection, pneumonia, and fungal and viral infections. This depressed immune function is also typified by prolonged allograft skin survival on burn wounds.

Hypermetabolism
After severe burn injury and resuscitation, hypermetabolism develops. This phase is characterized by tachycardia, increased cardiac output, increased energy expenditure, increased oxygen consumption, massive proteolysis and lipolysis, and severe nitrogen loss. This hypermetabolic phase may last for months, leading to massive weight loss and decreased strength.

Types of Burns
Burns are categorized as thermal, electrical, chemical, or radiation. Each type of burn presents special challenges for both the patient and the healthcare team. Burn treatment during the initial resuscitation phase is discussed in great detail later in this article. What follows is a description of each category of burn. Special considerations for each type of burn are touched upon briefly in this section.

Thermal
The majority of burns are thermal in origin: flame burns, scald burns, and contact with hot substances. Thermal burns cause damage by increasing the rate at which the molecules within an object (the body) move and collide with each other. This energy produces heat and results in cellular damage (Figure 2). The extent of burn injury depends upon the amount of heat energy transferred to the patient’s skin. This is dependant upon the burning agent’s temperature, concentration of heat energy, and length of contact time.

Special Treatment Considerations: In addition to general burn treatment, thermal burns should be covered with a dry, sterile dressing. For very large burns, the patient can be placed between two dry, sterile sheets. This prevents air currents from passing over the burned areas, which can cause significant pain. Ice should not be used to cool the burned area, as this can lead to frostbite. Wet dressings should not be used, as this can lead to hypothermia.

Electrical
Electrical burns account for 3-5% of all treated burn injuries in the United States. Although all age groups are affected, there are two age-related injury peaks worth noting. The first peak occurs from infancy to four years of age. Burn injury in this age group is primarily due to contact with exposed electrical cords and outlets (Figure 3). The second age-related peak occurs between 20-25 years of age. These injuries occur predominantly in males who suffer work or industrial injuries.

There are several factors that contribute to electrical burn severity. These include voltage and amperage, resistance of body tissue, type and path of current, and duration and intensity of contact.

Voltage and Amperage
Voltage injuries are divided into high voltage (>1000 volts) and low voltage (<1000 volts). Most household currents (110 to 220 volts) produce low voltage injury, which is similar to thermal injury in that there is no transmission to the deeper tissues. High voltage injury, on the other hand, consists of varying degrees of cutaneous burn at the entry and exit wounds combined with hidden destruction of deep tissue all along the path of the current. Amperage cannot be as easily measured, but is actually a better indicator of potential tissue damage than voltage is.

Resistance of Body Tissue
Electrical burns occur when contact is made with a high-voltage current. The electrical current enters the body, travels along the path of least resistance, and exits at a grounding point. When the current meets resistance along its path, heat is generated and burn injury occurs. Because of this heat generation, those body tissues that produce more resistance (tissues, tendons, fat, and bone) will have more damage than those body tissues that do not produce as much resistance (nerves, blood vessels, and muscle).

Type and Path of Current
The current pathway is an important determinant of severity of injury. It is important to remember that, although entry and exit wounds from an electrical burn injury may appear minor (Figures 4 and 5), there is often significant deep tissue damage between these two points on the patient’s body. Significant complications of electrical burn injury include cardiac arrhythmias, respiratory muscle paralysis, thrombosis, renal failure, open or comminuted bone fractures, and the need for amputations.

Electrical burn injury results in approximately 1,000 fatalities annually. The mortality of hand-to-hand current passage is estimated to be 60%; the mortality of hand-to-foot current passage is estimated to be 20%; the mortality of foot-to-foot current passage is estimated to be 5%. Direct current (DC) tends to leave a discrete exit wound, while alternating current (AC) tends to be more explosive.

Special Treatment Considerations: Electrical burn patients must have their respiratory and cardiac systems evaluated. These patients are typically admitted to the hospital and placed on continuous cardiac monitoring during the first 24 hours post injury. The key to managing the patient with electrical burn injury lies in treatment of the wound. As stated, the most significant injury lies in the deep tissue – where tissue is often necrotic and subsequent edema formation can cause vascular compromise distal to the injury. Immediate escharotomy and/or fasciotomy may be required if distal circulation is affected. Current literature also advocates early wound exploration of affected muscle beds and debridement of devitalized tissues. Numerous wound re-explorations may be required until the wound is completely debrided. Amputation may be necessary. In addition to wound care management, patients with electrical burn injury must be assessed and treated for the possibility of concomitant trauma. Treatment must also address the presence of myoglobinuria. If myoglobinuria is present, vigorous IV fluid resuscitation is needed to try to prevent renal failure. Urine output is maintained at >100cc/hour or 2cc/kg/hour until clear. Often sodium bicarbonate and/or mannitol are used to increase the extraction and excretion of the myoglobin. When calculating IV fluid resuscitation, it is important to note that patients with electrical burn injury may require additional IV fluid volume over and above what has been calculated by the % TBSA observed. This is because most of the burn lies in the deep tissue and cannot be assessed by a standard physical examination.

Chemical
Chemical burns occur when household cleaners are mishandled or through industrial exposure. It is important to remember that the burning and destruction of tissue will continue until the chemical agent is neutralized or diluted with water. The degree of tissue damage as well as the level of toxicity is dependent upon the chemical nature of the agent, the amount and concentration of the agent, its mechanism of action, and the duration of skin contact (Figure 6).

In general, chemical burns denature the biochemical makeup of the cell membrane and destroy the cell. Most chemical burns are caused either by strong acids or by strong alkalis. Strong acids cause coagulation necrosis from protein precipitation while strong alkalis cause liquefaction necrosis.

Special Treatment Considerations: Chemical agents must be removed in the prehospital environment. Failure to do so will result in continued burn injury to your patient and contamination of your transport vehicle (ground or air) and the Emergency Department, with the associated risk of exposure and injury to the entire health care team. Powdered chemicals should be brushed from the skin prior to flushing with copious amounts of water. Remove all contaminated clothing. Chemical eye injuries require continuous irrigation until instructed by a burn physician. Do not attempt to neutralize chemical burns in the field. Rather, irrigate with copious amounts of clean water – several liters (>15-20) may be required. If the chemical composition of the agent is known (acid or base), monitoring the pH of the irrigation runoff gives a good indication of irrigation effectiveness. Fluid resuscitation is guided by % TBSA burned; however, fluid requirements may differ dramatically from the amount calculated. For this reason, patients with chemical burn injury (like those with electrical burn injury) should be closely monitored for signs of adequate tissue perfusion, such as urine output.

Radiation
Radioactive injury is rare, but devastating. Radiation burns, which can be ionizing or non-ionizing, typically result when material is not properly handled. Once again, decontamination is paramount. Once the patient is decontaminated, radiation burns are treated like any other type of burn.

Special Treatment Considerations: Decontamination should be undertaken by specially trained rescuers and should occur prior to the initiation of treatment.

Inhalation Burn Injury
Prior to determining the extent of your patient’s burns, assess for the presence of inhalation injury, which is an important determinant of mortality in fire victims. Inhalation injury is present in 20 to 50% of patients admitted to a burn center and 60 to 70% of patients who die at burn centers. These statistics make inhalation injury the leading cause of death in fire victims.

Inhalation injury is found most often when a combination of three conditions is present: closed space incident, presence of heavy smoke, and a history of unconsciousness. Of the patients burned in an enclosed space, 75% will have significant inhalation injury (Figures 7 and 8). Other indicators of possible inhalation injury include: evidence of facial burns, dark tinged/carbonaceous sputum, profuse secretions, lacrimation, singed nasal hair, progressive hoarsening of the patient’s voice, edema of the tongue or pharynx, wheezing, stridor, hypoxemia, tachycardia, and hypercarbia. It is important to note that each of these findings has poor sensitivity and specificity. Definitive diagnosis is typically made by bronchoscopy, which can reveal early inflammatory changes such as erythema, ulceration, and prominent vasculature in addition to infraglottic soot. Many burn centers prefer at least a size 8.0 endotracheal tube in the adult patient to allow the staff to perform bronchoscopy through the endotracheal tube.

It is also important to note that inadequate IV fluid resuscitation in inhalation injury is associated with an increase in the severity of pulmonary injury and, as a result, increased risk of death. In reality, in the presence of significant inhalation injury, IV fluid resuscitation needs may be up to 2cc/kg/% TBSA more than would be required if inhalation injury were not present. As with other burn types, it is important to monitor for signs of adequate tissue perfusion, such as a normal urine output.

Pediatric Considerations
Because of the relatively small size of the pediatric airway, upper airway obstruction from inhalation injury may be especially rapid in onset. The proper size endotracheal tube must be selected and adequately secured. In addition, because the pediatric rib cage is not fully ossified, pediatric patients become exhausted rapidly due to decreased chest wall compliance with restrictive circumferential burns to the thorax. Escharotomy to the chest wall must be performed at the first sign of ventilatory impairment.

There are three categories of inhalation injury: carbon monoxide poisoning, injury above the glottis, and injury below the glottis. All three categories require treatment at a specialty burn care facility. Each is discussed in greater detail below.

Carbon Monoxide Poisoning
Carbon monoxide (CO) is a colorless, odorless, tasteless gas released from the incomplete combustion of organic materials. Because CO binds to the hemoglobin molecule in the red blood cell with an affinity greater than 200 times that of oxygen, profound hypoxemia results. It is important to note that the patient’s pulse oximetry reading will be falsely elevated and may appear normal despite severe hypoxemia. Signs and symptoms of CO poisoning include: tachycardia, tachypnea, headache, nausea, and dizziness. Skin and lip color may be normal, pale, or cherry red.

In the hospital setting, a carboxyhemoglobin level may be drawn to help determine the extent of inhalation injury. Normal carboxyhemoglobin levels are zero. In smokers or truck drivers exposed to heavy traffic, carboxyhemoglobin levels may be as high as 15. Carboxyhemoglobin levels of 15 to 40 may produce neurological dysfunction (weakness, dizziness, nausea/vomiting, and severe headache) while carboxyhemoglobin levels of 40 to 60 will produce obtundation or severe decrease in level of consciousness. All patients will suspected carbon monoxide poisoning must be placed on 100% oxygen until their carboxyhemoglobin level is below 15. Hyperbaric therapy has also been found to be very successful for patients with carboxyhemoglobin levels of 25 to 40%.

Inhalation Injury Above the Glottis
In general, inhalation injury above the glottis can be either thermal or chemical. Except for very rare events, thermal injury to the respiratory tract is typically limited to the upper airways. Heat damage from this type of inhalation injury is often severe enough to produce upper airway obstruction. In patients who are severely hypovolemic, supraglottic edema may not occur until fluid resuscitation is well under way. Patients with inhalation injury above the glottis often require early endotracheal intubation to prevent the progression to complete airway obstruction.

Inhalation Injury Below the Glottis
Inhalation injury below the glottis is usually chemical. Respiratory distress is usually evident during exposure to noxious fumes. Because the onset and severity of symptoms is unpredictable, however, these patients must be admitted and observed for at least 24 hours. These patients are at risk for worsening hypoxia and increasing respiratory distress. Patients with inhalation injury below the glottis often require endotracheal intubation and complex ventilator management to prevent the progression to adult respiratory distress syndrome (ARDS) and multi system organ failure (MSOF).

Determining the Severity of a Burn
The severity of burn injury is determined primarily by the extent of the total body surface area (TBSA) that is burned and, to a lesser extent, by the depth of the burn. However, other factors also contribute to burn severity and patient recovery. These include: patient age; concomitant trauma; pre-existing medical conditions; and burns to critical areas such as the face, hands, feet, and genitalia.

Determining % TBSA Burned
The “Rule of Nines” is often used to determine TBSA during the initial resuscitation phase. The Rule of Nines is based on the premise that various anatomic regions make up 9% of the TBSA (Figure 9). In the pediatric patient the Rule of Nines differs slightly because of the large surface area of the child’s head and the smaller surface area of the lower extremities (Figure 10).

In the case of scattered burns, the “Palm Method” may be used. The palmer surface of the patient’s hand (including the surface of the digits) represents approximately 1% of his or her TBSA (in actuality, the palmar surface is equal to roughly 0.8% TBSA in males and 0.7% TBSA in females). The palmar surface of the patient’s hand, minus the palmar surface of the digits, is approximately 0.5% TBSA for that patient (in actuality, the area of the palm alone is 0.5% TBSA in males and 0.4% TBSA in females). It is imperative that the patient’s palm, not the examiners, be used.

Determining Burn Depth
Burns are also classified according to the depth of tissue injury. Burns can be classified as first-degree, second-degree, and third-degree. In addition, some clinicians use the term fourth-degree burns.

First-Degree
First-degree burns are also known as superficial burns and involve only the epidermis (Figure 11). There is local pain and redness, but no blisters. An example of a first-degree burn is a sunburn (Figure 12). These burns typically heal spontaneously, without scarring, in two to five days. Treatment is aimed at comfort measures. It is very important to remember that first-degree burns are not included when calculating % TBSA burned for fluid resuscitation and initial burn treatment.

Second-Degree
Second-degree burns are also known as partial thickness burns and involve both the epidermis and the dermis (Figure 13). Second-degree burns are further divided into superficial second-degree burns (or “superficial partial thickness burns”) and deep second-degree burns (or “deep partial thickness burns”), depending on the depth of tissue injury. Superficial second-degree burns are red, painful, and often blister (Figure 14). Deep second-degree burns appear more pale and mottled. Because the patient’s tactile and pain sensors are intact, second-degree burns are extremely painful. Second-degree burns tend to heal in 7 to 35 days. There is no need for grafting. If second-degree burns become infected, they can convert to a third-degree, or full thickness, burn.

Third-Degree
Third-degree burns are also known as full thickness burns because the entire layer of the epidermis and dermis is destroyed (Figure 15). These burns are variable in color and can be white, waxy, red, or brown (Figure 16). Third-degree burns are dry and painless, but any surrounding second-degree burns will be moist and painful. Third-degree burns may heal by re-epithelialization from the wound edges, but will often require grafting.

Fourth-Degree
Fourth-degree burns extend into the muscle and bone. They are charred in appearance.

Critical Burn Areas
Critical burn areas are those areas that, when burned, present additional complications due to loss of function, airway compromise, risk for amputation, or the need for plastic surgery. Critical burns areas include the face, hands, feet, groin, joints, and circumferential burns.

Initial Assessment and Management of the Burn Patient
Care of the burn patient must proceed in a systematic and thorough manner. First and foremost, all sources of heat and burning must be removed to prevent further injury to either the patient or the caregivers. For chemical and radiation burns, the patient must be decontaminated. In the case of electrical injury, the patient must be safely removed from the source of electric energy by rescuers skilled in this endeavor.

The primary and secondary survey may then be initiated. A convenient approach the primary and secondary surveys can be summarized by the pneumonic “ABCDEFGH”:

A – Airway
B – Breathing
C – Circulation, C-Spine Immobilization, Cardiac Status
D – Disability / Neurologic Deficit
E – Expose and Examine
F – Fluid Resuscitation, Foley, and Fahrenheit
G – Gastric Tube
H – History and Head to Toe

Airway
The patient’s airway status must be assessed immediately. The airway may need to be opened using a chin thrust or jaw lift maneuver. The patient may require insertion of an oral or nasal pharyngeal airway. Early endotracheal intubation may prevent the need for an emergency cricothyroidotomy or tracheotomy. Suction may be necessary, especially if the patient has copious secretions. Keep in mind the speed with which inhalation injury can result in total airway obstruction!

Breathing
The patient’s breathing status must be assessed next. The examiner must assess the adequacy of the rate and depth of respiration. Lungs sounds should also be evaluated. Burn patients should be placed on 100% oxygen by non-re-breather mask, especially if they have greater than 20% TBSA burns. If available, humidified oxygen should be used. Circumferential burns to either the neck or the chest may impair ventilation and should be watched closely. Emergent escharotomy may be necessary.

Circulation
Assessment of the patient’s circulation includes heart rate, blood pressure, skin color, sensation, peripheral pulses, and capillary refill. “Burn shock” is due to the loss of fluid from the vascular compartment into the area of injury. The greater the % TBSA involved, the greater the fluid loss, and the greater the likelihood of shock. Initial fluid management includes two IV infusions of warm Ringer’s Lactate through large-bore IV cannulas, preferably through unburned skin. Fluid resuscitation is guided by a fluid resuscitation formula and, once a foley catheter has been inserted, urine output. If absolutely necessary, IVs may be placed through burned tissue. If this is necessary, a longer IV catheter may be indicated. This is because, as edema to burned areas increases, the resultant swelling may cause the catheter hub to be pushed out, which, in turn, may cause the IV catheter to be pushed out of the vessel lumen. If IVs are placed through burned tissue, they are typically sutured in place.

Circumferential burns to a limb may result in circulatory compromise distal to the burned area due to edema formation. Circulation checks should be performed frequently. Burned extremities should also be elevated above the level of the heart to help lessen edema formation. Emergent escharotomy may be necessary.

C-Spine Immobilization
It is important to place the patient in full spinal motion restriction if there is any possibility of concomitant trauma. This must be done before doing anything to flex or extend the spine.

Cardiac Status
The patient’s cardiac status is also assessed. Cardiac monitoring is indicated, especially with any large burn, electrical burn injury, or pre-existing cardiac disease.

Disability / Neurologic Deficit
If the burn patient is not awake, alert, and oriented, consider the possibility of associated injury, substance abuse, hypoxia, or pre-existing medical conditions. The patient’s level of consciousness can be assessed using the Glascow Coma Scale or the “AVPU” method:

• A = Alert
• V = responds to Verbal stimuli
• P = responds to Painful stimuli
• U = Unresponsive

Expose and Examine
If not already done, remove all clothing and jewelry in order to visually examine all parts of the patient’s body. As with extremity trauma, jewelry is removed early because significant swelling may occur, making removal more difficult later and, possibly, restricting circulation. Clothing that is adhered to the burned area should be left in place; it will be removed at the burn center in the whirlpool tub.

Fluid Resuscitation
Initiate two large bore IVs with warm Ringer’s Lactate, if possible. IV fluid resuscitation should take place according to a burn formula. The Consensus Formula for fluid resuscitation combines the Parkland Formula and the Modified Brook Formula (Figure 17). The Consensus Formula is as follows:

• 2-4 cc of Ringer’s Lactate x Body Weight (Kg) x %TBSA
• Half of this amount is infused in the first eight hours from time of injury
• The remainder is infused over the next 16 hours post burn
• It is important to use the fluid resuscitation formula because over- or under- administration of IV fluid can have a detrimental effect on your patient.

Example
Using 4cc / kg / %TBSA, a 70kg patient with 65% TBSA (2nd and 3rd degree) burns would receive the following IV fluid in the first 24 hours post injury:

• 4cc x 70kg x 65% TBSA = 18,200 cc in the first 24 hours
• 1/2 of this in the first 8 hours = 9,100 cc in the first 8 hours (or 1,138 cc per hour)
• 1/2of this in the next 16 hours = 9,100 cc during hours 9 through 24 post injury (or 569 cc per hour)

Foley
A Foley catheter may be inserted to help guide fluid resuscitation. This is especially true if the %TBSA burned exceeds 20% or if the patient requires fluid resuscitation. As with endotracheal intubation, this should be performed early in the management of the burn patient because edema may make insertion at a later time impossible. Accurate measurement of hourly urine output is important in monitoring the adequacy of fluid resuscitation. With thermal burns, urine output is maintained at 30-50cc/hour in the adult patient and 1.0cc/kg/hour in the pediatric patient. If urine output exceeds this amount, the IV fluids will be decreased slightly until the desired urine output is achieved. If urine output falls short of this amount, the IV fluids will be increased slightly until the desired urine output is achieved. In electrical burns, however, a higher urine output is desired. In the adult patient, 50 -100cc/hour (or more) may be desired until the urine is clear. This is in an effort to prevent renal failure from myoglobinuria.

Fahrenheit
It is important to maintain normothermia, or normal body temperature, in burn patients. This is done by keeping the transport environment warm, using warming lights when available, using warm IV fluids, using blankets as needed, and applying dry dressings to burned areas.

Gastric tube
Prior to transport, a gastric tube (nasogastric or orogastric) should be inserted to combat the problem of adynamic ileus and also to help decompress the stomach and decrease the risk for vomiting and aspiration. This is especially true if the patient will be transported at high altitudes or has greater than 20% TBSA burned.

History
The patient’s medical history and the history of events pertaining to the burn injury are obtained once the patient’s ABCs have been stabilized.

History of Events: Questions to ask include:

• What events preceded the burn injury?
• What caused the burn?
• Did the burn occur in an enclosed space?
• Is there a possibility of smoke inhalation?
• Were any toxic chemicals involved?
• Was there any related / concomitant trauma?
• When was the patient’s last meal? Last fluid intake?

Medical History: Questions to ask include:

• Is there any pre-existing disease or associated illness (diabetes, hypertension, cardiac, or renal disease)?
• Does the patient take any medications?
• Does the patient smoke, drink alcohol, or use illegal drugs?
• Does the patient have any allergies?
• When was the patient’s last tetanus shot?

Head to Toe
The patient’s burn injury may be the most obvious injury. However, other serious or life threatening injuries may also be present. A thorough head to toe examination is done once the patient’s ABCs have been stabilized.

Additional Burn Management Principles
Pain Relief
Morphine is indicated for control of pain in the burn patient. Morphine should be given IV because changes in fluid volume and tissue blood flow will make absorption by any other method (such as IM) unpredictable. Pain medication should be given in small, frequent doses to aid in patient comfort. The pain associated with burns is typically significant and burn patients can tolerate a tremendous amount of pain medication. Burn patients may also receive fentanyl (a synthetic narcotic) and versed (a medication with anxiolytic and amnestic properties).

Assess Extremity Pulses Regularly
It is important to assess for decreased circulation to areas distal to circumferential burns. The circumferential burn tends to be constrictive in nature. In addition, swelling within the extremity can further impair circulation. Venous return is affected first. As the swelling continues, arterial circulation is obstructed. Early signs and symptoms of circulatory compromise include numbness and pain in the extremity. As swelling continues, pulses become diminished. If left untreated, ischemia and necrosis will develop. If suspected, an escharotomy may be necessary. Escharotomies are typically performed on both the lateral and the medial aspect of the affected extremity.

Assess for Ventilatory Limitation
Circumferential chest burns may restrict respiration and a chest escharotomy may be necessary. Children, because of their more pliable rib cage, are more apt to be affected than adults.

Update Tetanus
If the patient has not had a tetanus shot in the previous five years, or cannot recall or respond to questions regarding tetanus status, a tetanus injection is given IM.

Provide Emotional Support
Burn injury is a very traumatic experience. Health care providers must be sensitive to variable emotions from burn patients and their families.

Initial Laboratory and Other Studies
A variety of lab studies may also be drawn and analyzed. Baseline laboratory tests are necessary to evaluate the patient’s subsequent progress and response to therapy. Tests include: hematocrit and hemoglobin, electrolytes, blood urea nitrogen, urinalysis, and a carboxyhemoglobin. In addition, arterial blood gases, an electrocardiogram, and a chest x-ray may be ordered.

Transfer and Transport: Criteria for Transfer to a Burn Center
A burn center is a facility that has made an institutional commitment to care for the burn patient. Burn centers are staffed by a multi-disciplinary team of professionals with expertise in the care of the burn patient. This care includes both the acute phase and also the rehabilitation phase. Burn center staff also participate in education of all health care providers and participate in research related to burn injury.

It is not uncommon for burn patients to be transferred to the closest appropriate emergency department or trauma center for immediate evaluation and stabilization prior to transfer to a recognized burn center. Refer to your local protocols.

The American Burn Association has identified the following burn injuries as those that require transfer to, and treatment at, a burn center:

• 2nd or 3rd degree burns of more than 10% TBSA in patients under 10 and over 50 years of age.
• 2nd or 3rd degree burns of more than 20% TBSA in any other age group.
• 2nd or 3rd degree burns to critical areas – those burns that pose a serious threat of functional or cosmetic impairment and involve the face, hands, feet, genitalia, perineum, and major joints.
• 3rd degree burns greater than 5% TBSA in any age group.
• Significant electrical burn injuries including lightening injury.
• Chemical injuries with serious threat of functional or cosmetic impairment.
• Inhalation injury with burn injury.
• Circumferential burns of an extremity or the chest.
• Burn injury in patients with pre-existing medical conditions that could complicate management, prolong recovery, or affect mortality.
• Any burn patient with concomitant trauma in which the burn injury poses the greatest risk of morbidity and mortality. However, if the trauma poses the greatest immediate risk, the patient may be treated in a designated trauma center initially and, once stabilized, transferred to a burn center.
• Burned children should be transferred to a burn center with qualified, pediatric-trained personnel and equipment.
• Patients with toxic epidermal necrolysis syndrome, such as Stevens-Johnson Syndrome, may be transferred to a burn center for care.

Summary
Burn care and survival from burn injury has improved dramatically with the advent of specialty burn treatment centers. It is now possible for those with burns greater than 85% TBSA to survive when proper treatment is begun early enough. The treatment we render in the field, in the emergency department during the initial resuscitation, and during transfer to a designated burn center phase will have a profound impact on patient morbidity and mortality.

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