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Thursday, January 22, 2009

BURNS

BURNS - Timothy L. Black, MD; James P. Miller, MD
BASICS
DESCRIPTION
• Tissue injuries caused by application of heat, chemicals, electricity, or irradiation to the tissue
• Extent of injury (depth of burn) is result of intensity of heat (or other exposure) and duration of exposure
- Partial thickness: 1st degree involves superficial layers of epidermis. 2nd degree involves varying degrees of epidermis (with blister formation) and part of the dermis.
- Full thickness: 3rd degree involves destruction of all skin elements with coagulation of subdermal plexus
• System(s) Affected: Endocrine/Metabolic; Skin/Exocrine
ALERT
Geriatric Considerations
• Prognosis poorer for severe burns
• Patients >60 years of age account for 11% of burns. (1)[C]
Pediatric Considerations Consider child abuse or neglect when dealing with hot water burns in children
• Observe distribution of burns.
• Pay attention to straight lines, especially if bilateral.
GENERAL PREVENTION
Skin grafts or newly epithelialized skin is highly sensitive to sun exposure and thermal extremes.
EPIDEMIOLOGY
• Predominant age: All ages
- Average age is 30 years
- 13% are infants, and 11% are >60 years of age
• Predominant sex: Males account for 70%
Incidence
Per year in US
• Total population: 1.2-2 million burns, 700,000 emergency room visits, 45,000-50,000 hospitalizations, 3,900 deaths due to burn-related complications (1,2)[C]
• In children: 250,000 burns, 15,000 hospitalizations, 1,100 deaths
• Estimated total cost of $2 billion annually for burn care in the United States (1)[C]
• 75% of burn related deaths are the result of house fires (1)[C]
RISK FACTORS
• Water heaters set too high
• Workplace exposure to chemicals, electricity, or irradiation
• Young children and elderly adults with thin skin are more susceptible to injury.
• Carelessness with burning cigarettes
• Inadequate or faulty electrical wiring
• Lack of smoke detectors
ETIOLOGY
• Open flame and hot liquid are most common (heat usually 15-45C)
• Caustic chemicals or acids (may show little signs or symptoms for the first few days)
• Electricity (may have significant injury with very little damage to overlying skin)
• Excess sun exposure
ASSOCIATED CONDITIONS
Smoke inhalation syndrome
• Occurs within 72 hours of burn
• Should be suspected in all burns occurring in an enclosed space
• Intubation, ventilation with positive end-expiratory pressure assistance


DIAGNOSIS
SIGNS AND SYMPTOMS
• 1st degree
- Erythema of involved tissue
- Skin blanches with pressure
- Skin may be tender
• 2nd degree
- Skin is red and blistered
- Skin is very tender
• 3rd degree
- Burned skin is tough and leathery
- Skin is not tender
History
• History of source of burn
• In children, check for consistency between the history and the burn's physical characteristics
Physical Exam
• Careful documentation of extent of burn and the estimated depth of burn
• Check for any signs suggestive of potential airway involvement: Singed nasal hair, facial burns, carbonaceous sputum, progressive hoarseness, or tachypnea
TESTS
• Children: Glucose (hypoglycemia may occur in children because of limited glycogen storage)
• Smoke inhalation: Arterial blood gas, carboxyhemoglobin
• Electrical burns: ECG, urine myoglobin, creatine kinase isoenzymes
Lab
• Hematocrit
• Type and cross
• Electrolytes, including blood urea nitrogen and creatinine
• Urinalysis
• Disorders that may alter lab results: Preexisting cardiac disease
Imaging
• Chest radiograph
• Xenon scan may be useful in suspected smoke inhalation.
• Other radiographs if other trauma involved
Diagnostic Procedures/Surgery
Bronchoscopy may be necessary in smoke inhalation to evaluate lower respiratory tract.
Pathological Findings
• 1st degree
- Devitalization of superficial layers of epidermis
- Congestion of intradermal vessels
• 2nd degree
- Coagulation necrosis of varying depths of epidermis
- Clefting of epidermis (blister)
- Coagulation of subdermal plexus
- Skin appendages intact
• 3rd degree
- Necrosis of all skin elements
- Coagulation of subdermal plexus
DIFFERENTIAL DIAGNOSIS
• Toxic epidermal necrolysis
• Scalded skin syndrome
TREATMENT
• Hospitalization for all serious burns
- 2nd-degree burns >10% body surface area, any 3rd-degree burn
- Burns of hands, feet, face, or perineum
- Electrical/lightning burns
- Inhalation injury
- Chemical burns
- Circumferential burn
• Transfer to burn center for (1,2,3)[C]
- 2nd- and 3rd-degree burns >10% body surface area in patients 10 years and >50 years of age
- 2nd-degree burns >20% body surface area and full thickness burns >5% BSA in any age range
- Burns of hands, feet, face, or perineum
- Electrical/lightning burns
- Inhalation injury
- Chemical burns
- Circumferential burn
- Chemical burns with threat of functional impairment
PRE-HOSPITAL (1)[C]
• Remove patient from source of the burn
• Extinguish and remove all burning clothing
• Remove all rings, watches, and jewelry
• Room-temperature water may be poured onto burn but only in the 1st 15 minutes following burn exposure
• Wrap patient to prevent hypothermia
• All patients should receive 100% O2 by face mask
GENERAL MEASURES
• Based on depth of burns and accurate estimate of total body surface area involved (rule of nines)
• Rule of nines (1)[C]
- Each upper extremity: Adult and child 9%
- Each lower extremity: Adult 18%; child 14%
- Anterior trunk: Adult and child 18%
- Posterior trunk: Adult and child 18%
- Head and neck: Adult 10%; child 18%
• Quick estimate (for smaller burns): The surface area of the patient's hand is ~1% of the body surface area.
• Tetanus prophylaxis (if not current)
• Remove all rings, watches, and other items from injured extremities to avoid tourniquet effect.
• Remove clothing and cover all burned areas with dry sheets.
• Flush area of chemical burn (for ~2 hours)
• 100% oxygen administration for all major burns; consider early intubation
• Do not apply ice to burn site.
• Nasogastric tube (high risk of paralytic ileus)
• Foley catheter
• Pain relief
- IV meperidine (Demerol), morphine, or methadone for severe pain
- Oral analgesics, such as acetaminophen (Tylenol) with codeine, acetaminophen with oxycodone (Percocet), or acetaminophen with hydrocodone (Lortab) for moderate pain
• ECG monitoring in 1st 24 hours following electrical burn
• Whirlpool hydrotherapy followed by silver sulfadiazine (Silvadene) occlusive dressings in severe burns
• Once- or twice-a-day cleansing with dressing changes
• Epilock or Elasto-Gel may be used as dressing in selected patients (especially useful for outpatient treatment of minor burns)
• Burn fluid resuscitation (1,2,3)[C]
- Calculate fluid resuscitation from time of burn, not from time treatment begins
- 2-4 mL Ringer's lactate  body weight (kg)  % body surface area burn (1/2 given in 1st 8 hours, 1/4 in 2nd 8 hours, and 1/4 in 3rd 8 hours). In children, this is given in addition to maintenance fluids and is adjusted according to urine output and vital signs.
- Colloid solutions are not recommended during the 1st 12-24 hours of resuscitation (1,2)[C], (4)[A]
• Other: Use of biological membranes or skin substitutes may be indicated for burn coverage.
Diet
• High-protein, high-calorie diet when bowel function resumes
• Nasogastric tube feedings may be required in early postburn period
• Total parenteral nutrition if NPO expected for >5 days
Activity
Early mobilization is the goal.
MEDICATION (DRUGS)
First Line
• Morphine small frequent IV doses (0.1 mg/kg/dose in children; 2.5-20 mg q2-6h in adults)
• Silver sulfadiazine (Silvadene) topically to burn site (can cause leukopenia)
• Electrical burn with myoglobinuria will require alkalinization of urine and mannitol
• No indication for prophylactic antibiotics.
• Consider H2 blockers (cimetidine, ranitidine, famotidine, or nizatidine) for stress ulcer prophylaxis in severely burned patients.
• Contraindications
- Specific drug allergies
• Precautions
- Be alert for respiratory depression with narcotics.
• Significant possible interactions
- Refer to manufacturer's profile for each drug.
Second Line
• Mafenide (Sulfamylon)full-thickness burn (caution: Metabolic acidosis)
• Silver nitrate 0.5% (messy, leaches electrolytes from burn, and causes water toxicity)
• Povidone-iodine (Betadine) may result in iodine absorption from burn, "tan eschar." Makes debridement more difficult.
• Travaseenzymatic debridement
SURGERY
• Escharotomy may be necessary in constricting circumferential burns of extremities or chest.
• Tangential excision with split-thickness skin grafts
FOLLOW-UP
PROGNOSIS
• 1st-degree burn: Complete resolution
• 2nd-degree burn: Epithelialization in 10-14 days (deep 2nd-degree burns will probably require skin graft)
• 3rd-degree burn: No potential for re-epithelialization, skin graft required
• Length of hospital stay and need for ICU care depend on extent of burn, smoke inhalation, and age
• A 50% survival rate can be expected with a 62% burn in ages 0-14 years, 63% burn in ages 15-40 years, 38% burn in age 40-65 years, 25% burn in patients >65 years (1,2,3)[C]
• 90% of survivors can be expected to return to an occupation as remunerative as their preburn employment.
COMPLICATIONS
• Gastroduodenal ulceration (Curling ulcer)
• Marjolin ulcersquamous cell carcinoma developing in old burn site
• Burn wound sepsisusually gram-negative organisms
• Pneumonia
• Decreased mobility with possibility of future flexion contractures
• Hypertrophic scarring common with burns
PATIENT MONITORING
According to extent of burn and treatment
REFERENCES
1. Teague H, Sweneki SA, Tang A. The burned patient: Assessment, diagnosis, and management in the ED. Trauma Reports. 2005;6:1-12.
2. Townsend C, Beauchamp RD, Evers BM, et al. eds. Sabiston Textbook of Surgery 17 ed. Philadelphia, PA: Elsevier Saunders, 2006.
3. Gillespie RW, Dimik AR, Hallberg PW. Advanced Burn Life Support Course Provider's Manual. Lincoln, NE: Nebraska Burn Institute; 1990.
4. Roberts I, Alderson P, Bunn F, et al. Colloids versus crystalloids for fluid resuscitation in critically ill patients (Review). Cochrane Database Sys Rev. 2006; Vol 1.

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