One of the most important principles to remember with any burn patient is that they are a trauma and toxicology patient first. Don’t get distracted by the burns. Perform your primary and secondary survey as you normally would with a trauma patient and address the burns later...
The Parkland Formula is passé... Modified Brooke/Parkland Formula is recommended as a starting point for fluid resuscitation for burns >15% BSA in children and >20% BSA in adults. Patients with inhalation injuries generally require more fluid resuscitation (closer to 4mL x %BSA x kg) however the extent of injury is impossible to quantify accurately...
Superficial Burns: These present as a blanching, dry, red discoloration of the skin. These burns are painful. Think of a really bad sun burn. Basically you rub some lotion on these patients, and suggest they try aloe. You can ignore all the other treatments I talk about below. These burns should heal in about 3-6 days, so let them know they’ll be feeling kinda miserable for a hot sec.
Superficial Partial Thickness: These burns typically occur from a splash or a flash burn. The burn itself is blistered, pink, moist, and is painful. These patients may need a burn center if they have a partial burn >10% TBSA or a burn to their important pieces (face, hands, genitalia, etc.)
Step away from your MDCalc – we’re going to calm that scorching stress-induced acid reflux with an update on the emergency department management of burns.
Silver Sulphadiazine (SSD) creams have been commonly used in the past for the treatment of burns, however their effectiveness has been questioned.
There is little evidence to suggest that SSD creams reduce bacterial infections in burns and local hypersensitivity reactions are common. Another downfall of SSD creams is they need to be removed and reapplied daily. This is inconvenient and expensive.
Most burns units have stopped recommending the use of SSD creams.
Carbon monoxide and cyanide are strongly associated with house fires – assume exposure to both until proven otherwise. It is reasonable to treat any undifferentiated, symptomatic patient with high flow oxygen and hydroxocobalamin empirically; asymptomatic patients can wait safely for blood work on high flow oxygen alone. The decision making regarding use of HBOT, in particular, is complex – early consultation with a medical toxicologist is strongly encouraged.
Poor cardiac function, cardiac arrest or a high lactate can be clues to cyanide poisoning and just start 100% O2 while you wait for a co-ox, since CO tox is pretty likely.
Cyanide toxicity should be strongly considered in the proper context: enclosed-space fire and presence of inhalation injury with altered level of consciousness (GCS < 13), profound shock (SBP < 90mmHg), high serum lactic acid (lactate > 10mmol/L), and/or a narrow arterio-venous gradient (PaO2 on an arterial blood gas is similar to the PaO2 on a venous blood gas).
Recommendation: In confirmed or suspected cyanide toxicity, the hydroxocobalamin (Cyanokit) should be given as soon as possible, at a starting dose of 5 grams (70mg/kg in pediatrics,
The Parkland Formula is passé. Modified Brooke/Parkland Formula is recommended as a starting point for fluid resuscitation for burns >15% BSA in children and >20% BSA in adults. Patients with inhalation injuries generally require more fluid resuscitation (closer to 4mL x %BSA x kg) however the extent of injury is impossible to quantify accurately, so instead, end-organ perfusion should be monitored carefully to help guide management.
Hydrofluoric acid is found in a variety of products and used in multiple industries, so exposure, while not exceedingly common, is not rare. Know how to treat HF toxicity and prevent contamination among the health care team managing these injuries.
Determining Total Body Surface Area...
Partial thickness > 20% TBSA Partial thickness > 10% TBSA for extremes of age (<10 or >50 years old). Any full thickness Burns involving face, hands, feet, genitalia, major joints. Electrical/chemical Inhalation injury. Medical comorbidities impacting management/healing
The “rule-of-nines” is the most common in the prehospital environment. This calculation needs to be adjusted in infants and children due to their proportionally larger heads and smaller legs. It is important to remember that the “rule-of-nines” often overestimates the total area of burned skin. Another method is to use the dorsal surface of the patient’s hand as 1% to estimate the total extent of burns on the body. Finally, a Lund-Browder diagram may be filled out and is what is typically used by burn surgeons.
There is no conclusive clinical evidence to justify routine prophylactic intubation. In case of suspected airway burn and/or injury by inhalation, the recommendation is to complement the medical evaluation with an examination of the oropharynx via fiberoptic bronchoscopy or laryngoscopy (direct or indirect) to identify airway edema, its evolution, and then decide whether intubation is appropriate.
The vast majority of burns that present to the ED can be managed as outpatients usually by the patient’s family doctor, but many emergency physicians do not feel comfortable with burn management. Burn management often follows the preferences and experiences of plastic surgeons, so the overarching caveat for everything below is that you should check with your local plastic surgery group for what they recommend.
These patients are often the sickest in the department and many are on their way to the ICU. There are life-saving interventions that are begun in the emergency department with significant impacts on morbidity and mortality, and many are discussed in this episode.
The large number of therapies used to treat second degree burns attests to the lack of consensus regarding optimal management. Considerable controversy revolves around whether to leave burn blisters intact or not. Some burn centers insist that every blister be debrided while others are equally vehement that they remain intact. While blisters contain several substances that inhibit wound healing,86,87 the preponderance of evidence (mostly animal data) suggests leaving blisters intact speeds healing and reduces infection.
There is just too much info around burns (from cyanide poisoning,,, to awake nasotracheal intubation) and there are just so many learning points and I could only include so many - so I apologize for having the leave some things out. its already a dense one!
Local burn treatment includes cooling, cleansing, and debridement of the wounds upfront. However, no consensus on topical treatment currently exists. Usually superficial burns and superficial partial thickness burns (such as sunburns) do not require any topical agent.
The most common mechanism of burn injuries in children
younger than 3 years old is thermal insults. Thermal burn injuries comprise an overwhelming majority of pediatric burn admissions to burn centers...
Clearly, there is not strong evidence. However, there isn’t even a hint that deroofing blisters or debriding uninfected burns is helpful. Seeing as the procedure adds time, pain, and maybe the risks of sedation, it doesn’t seem justified to me.
Note that for children, the surface area of their head comprises a larger percentage of body surface area when compared to an adult, so the rule of 9s needs to be adjusted.
The primary cause of burn injuries in patients under five years of age is scalding. Inhalation is less prevalent than in adults, but in the setting of structure fires children are less capable of escaping from confined spaces, and therefore are more susceptible to inhalation injury.
Intubate early. Inhalation injuries can result in delayed aggressive airway edema causing patients to lose their airways quickly, making them difficult to intubate.
Burns in the ED are not easily classifiable on the initial assessment and they may convert to deeper burns over the next few days. Use caution when classifying burns and counseling patients and families about prognosis. Patients require close follow up of the wound for reassessment and ongoing care.
In light of changing perspectives on burn pathophysiology, the BC Provincial Major Burns Working Group recommends a resuscitation formula of 3 mL/kg/%Total Body Surface Area (TBSA).
In addition to new concepts in fluid resuscitation for burns, novel therapies such as high dose vitamin C, early colloid administration, and selective use of vasoactive agents to improve perfusion pressures are also gaining traction in complex burn care.
Circumferential burns, as well as those involving the face, ears, eyes, perineum, joints, or in those with renal failure or diabetes, are not considered minor burns.
Whichever formula is used, the critical point to remember is the fluid amount calculated is just a guideline. The patient’s vital signs, mental status, capillary refill, and urine output must be monitored and fluid rates adjusted accordingly.