1st- and superficial 2nd-degree burns heal by epithelialization (primarily from hair follicles)

  Extremely deep burns, electrical burns, or compartment syndrome can cause rhabdomyolysis with myoglobinuria (Tx: hydration, alkalinize urine)

ADMISSION CRITERIA¹

  2nd- and 3rd-degree burns > 10% BSA in patients aged < 10 or > 50 years

  2nd- and 3rd-degree burns > 20% BSA in all other patients

  2nd- and 3rd-degree burns to significant portions of hands, face, feet, genitalia, perineum, or skin overlying major joints

  3rd-degree burns > 5% in any age group

  Electrical and chemical burns

  Concomitant inhalational injury, mechanical traumas, preexisting medical conditions

  Injuries in patients with special social, emotional, or long-term rehabilitation needs

  Suspected child abuse or neglect

BURN ASSESSMENT

  Deaths highest in children and elderly (trouble getting away)

  Scald burns – most common

  Flame burns – more likely to come to hospital and be admitted

  Assessing percentage of body surface burned (rule of 9s)

•  Head = 9, arms = 18, chest = 18, back = 18, legs = 36, perineum = 1

•  Can also use patient’s palm to estimate injury (palm = 1%)

  Parkland formula

•  Use for burns ≥ 20% only – give 4 cc/kg × % burn in first 24 hours; give ½ the volume in the first 8 hours

•  Use lactated Ringer’s solution (LR) in first 24 hours

•  Urine output best measure of resuscitation (0.5–1.0 cc/kg/h in adults, 2–4 cc/kg/h in children < 6 months)

•  Parkland formula can grossly underestimate volume requirements with inhalational injury, ETOH, electrical injury, post-escharotomy

•  Important to use LR in first 24 hours

•  Colloid (albumin) in 1st 24 hours causes ↑ pulmonary/respiratory complications → can use colloid after 24 hours

  Escharotomy indications (perform within 4–6 hours):

•  Circumferential deep burns

•  Low temperature, weak pulse, ↓ capillary refill, ↓ pain sensation, or ↓ neurologic function in extremity

•  Problems ventilating patient with significant chest torso burns

•  May need fasciotomy if compartment syndrome suspected after escharotomy

  Risk factors for burn injuries – alcohol or drug use, age (very young/very old), smoking, low socioeconomic status, violence, epilepsy

CHILD ABUSE

  Accounts for 15% of burn injuries in children

  History and exam findings that suggest abuse:

•  History – delayed presentation for care, conflicting histories, previous injuries

•  Exam – sharply demarcated margins, uniform depth, absence of splash marks, stocking or glove patterns, flexor sparing, dorsal location on hands, very deep localized contact injury

LUNG INJURY

  Caused primarily by carbonaceous materials and smoke, not heat

  Risk factors for airway injury – ETOH, trauma, closed space, rapid combustion, extremes of age, delayed extrication

  Signs and symptoms of possible airway injury – facial burns, wheezing, carbonaceous sputum

  Indications for intubation – upper airway stridor or obstruction, worsening hypoxemia, massive volume resuscitation can worsen symptoms

  Pneumonia – most common infection in patients with > 30% BSA burns

•  Also most common cause of death after > 30% BSA burns

UNUSUAL BURNS

  Acid and alkali burns – copious water irrigation

•  Alkalis produce deeper burns than acid due to liquefaction necrosis

•  Acid burns produce coagulation necrosis

  Hydrofluoric acid burns – spread calcium on wound

  Powder burns – wipe away before irrigation

  Tar burns – cool, then wipe away with a lipophilic solvent (adhesive remover)

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