In the United States alone, burns are responsible for 450,000 emergency department visits, 45,000 hospitalizations, and 3,500 deaths every year.1 Roughly half of those hospital admissions are to specialized regional burn centers.2 In 2009, there were 128 regional burn centers in 43 states, and 40% of admissions were due to fire or flame burns, while another 30% were due to scald injuries. The majority of scald injuries occur in children under the age of 5 years.3,4 Therefore, understanding the management of the burn patient is essential to all emergency physicians. Not only do burns cause local damage to the affected site, but large burns can also result in fluid and electrolyte abnormalities, metabolic acidosis, inflammatory response, and even myocardial dysfunction in severe cases.5
In the United States alone, burns are responsible for 450,000 emergency department visits, 45,000 hospitalizations, and 3,500 deaths every year.1 Roughly half of those hospital admissions are to specialized regional burn centers.2 In 2009, there were 128 regional burn centers in 43 states, and 40% of admissions were due to fire or flame burns, while another 30% were due to scald injuries. The majority of scald injuries occur in children under the age of 5 years.3, 4 Therefore, understanding the management of the burn patient is essential to all emergency physicians. Not only do burns cause local damage to the affected site, but large burns can also result in fluid and electrolyte abnormalities, metabolic acidosis, inflammatory response, and even myocardial dysfunction in severe cases.5
Local tissue damage is classified into three zones from the center out, termed the zone of coagulation, zone of stasis, and zone of hyperemia (Figure 21.1).
Zone of coagulation is the area of maximal injury containing irreversible tissue coagulation and necrosis.
Zone of stasis has decreased tissue perfusion but is potentially reversible. The tissue is at high risk for irreversible damage if any additional insults occur and is the area most targeted by therapies.
Zone of hyperemia is the outermost zone and has increased perfusion initially. Tissue in this zone should recover.
Burn injuries cause the release of cytokines and other inflammatory mediators to the site of the injury. However, in large burns, typically >20–30%, this inflammatory response can have systemic effects. Capillaries become more permeable, and fluids are lost to the interstitial space. Vasoconstriction occurs peripherally and in the splanchnic circulation, in addition to decreased overall myocardial contractility causing diffuse hypoperfusion. Bronchoconstriction and acute respiratory distress syndrome may also occur.
Figure 21.1 Layers in normal skin and superficial second-degree burn. (A) Normal skin layers. (B) Zones of injury with a superficial second-degree burn. The central coagulation zone is irreversibly damaged tissue. The zone of stasis may progress to necrosis or may recover, depending on good resuscitation and prevention of infection
As with all trauma evaluations, airway, breathing, circulation, disability, and exposure must be quickly evaluated in a primary survey.
Once the primary survey is completed and the patient has been stabilized, a complete secondary survey should be performed.
Remember to assess for all traumatic injuries, in addition to the burn, as many of these patients have been thrown, fallen, or were even in a motor vehicle accident.
Hypotension is rare in a burn patient. Any patient with hemodynamic instability and burn requires evaluation and resuscitation for the associated type of shock.
Always consider an inhalational injury, as airway swelling can occur very quickly.
If any of the above indicators are present and there is concern for inhalational injury, early intubation is recommended.
Other therapies that may be helpful are humidified supplemental oxygen and bronchodilators. However, do not delay intubation to attempt these therapies if there is concern for significant inhalational injury.5
Always consider carbon monoxide and cyanide poisoning in patients presenting with burns from fires, especially house fires or any other enclosed space.5
The “rule of nines” provides a quick estimation of TBSA burned in adults (Figure 21.5).
For children, the Lund-Browder diagram is available to help estimate TBSA (Figure 21.6).
Figure 21.2 Sunburn is a typical first-degree burn. The skin is erythematous and painful, but without blistering
(A) Superficial and deep second-degree burn from hot-water scald to the hand.
(B) Deep second-degree burn with central third-degree burn. Notice the classic color differentiation.
(C) Foot scald injury consisting of largely nonblanching pale appearing third-degree burn and erythematous deep second-degree burn over the medial forefoot
Figure 21.6 Lund-Browder diagram
Patients with TBSA >20% will need fluid resuscitation.9 The area affected no longer has the normal skin layer which acts as a semipermeable barrier to help avoid fluid loss through evaporation.5, 10 Fluid resuscitation is also beneficial to prevent burn shock from the systemic inflammatory reaction and prevent hypoperfusion to end organs and salvageable burn tissue.11 However, burn patients should not be hypotensive. If so, other etiologies of shock need to be investigated, such as cyanide poisoning, sepsis, trauma, hemorrhage, or myocardial infarction.9
Intravenous access is ideally placed in an unaffected area but may be placed through burned skin if necessary. Once obtained, the access must be sufficiently secured, which may require suturing if in a burned area.10
Lactated ringers (LR) is generally preferred over normal saline. LR is more similar to human plasma, while normal saline is less physiologic, with greater risk of metabolic and renal disturbance. Therefore, in large volumes normal saline can induce a hyperchloremic acidosis.11–13
Patients receiving fluid resuscitation should be monitored for signs of volume overload, especially concerning the development of pulmonary edema or acute respiratory distress syndrome, or in the chronically volume overloaded patient.
A urinary catheter should be placed for adequate input and output monitoring. The goal urine output is 1 mL/kg/hr.5
Figure 21.7 Burn resuscitation formulas
Circumferential burns may require an escharotomy in the emergency department (Box 21.1 and Figure 21.8). This can be assessed for by delayed capillary refill, decreased pulse oximetry distal to the burned area (<95% in a non-hypoxic patient), decreased Doppler signals, and absence of a palpable pulse in the affected extremity. If the patient is awake and alert, he/she may also complain of increasing pain, numbness, or tingling. Loss of motor activity and loss of pulses are late signs, but, if present, should prompt immediate escharotomy.14
Trunk escharotomies may also be required if the patient cannot be adequately ventilated due to chest constriction or if abdominal compartment syndrome develops. It is important to routinely monitor a patient’s ventilation status, including airway pressures, as well as oxygenation, and measure bladder pressures in patients that are at risk.2, 5, 14–16
To perform an escharotomy, standard sterile precautions should be used. For extremities, use a scalpel to create an incision on both the lateral and medial aspects from 1 cm proximal to 1 cm distal of the constricted tissue. These incisions may need to cross joints. Be very careful in these areas to avoid damaging underlying blood vessels and nerves. For the trunk, create an incision in the anterior axillary line bilaterally from the clavicle to below the costal margin or to the entire abdomen as needed. Then create a transverse incision to connect the two incisions at the superior chest and subcostal margin.14
Keys to Performing an Escharotomy:
Full thickness burns require no anesthesia, but deep partial thickness burns may require analgesia.
Incise just through the skin until the subcutaneous fat is exposed and the eschar is released. This should result in only minimal bleeding that can be controlled by local pressure.
Always reassess perfusion after the procedure to ensure adequate release.
Wound care over the escharotomy incisions is the same as to the adjacent burned tissue.
(A) Illustration of the recommended escharotomy incisions.
(B) Truncal and extremity escharotomies in a household fire victim
Carbon monoxide poisoning should always be considered in burn patients, especially those with inhalational injuries and any patient from a house fire or enclosed space.
There are no specific symptoms or signs for carbon monoxide poisoning, and patients presenting with trauma and burn injuries may be even more difficult to assess. The clinician must maintain a high degree of clinical suspicion in these patients. Patients may present with mild headache, confusion, chest pain, ataxia, seizures, hypotension, tachypnea, tachycardia, and even coma.5
For diagnosis, a carboxyhemoglobin level should be obtained. A co-oximeter can also be used. VBG or ABG can be used. Pulse oximetry cannot be relied upon because it does not differentiate between the wavelengths for carboxyhemoglobin and oxyhemoglobin and may give a falsely normal oxygen saturation. In severe poisoning, the patient may also have an elevated lactate, troponin, and anion gap metabolic acidosis.5
Treatment is supplemental oxygen. Hyperbaric oxygen can be considered in patients with neurologic symptoms, levels >25%, and pregnant women with levels >15%; however, this may be difficult given the patient’s need for trauma evaluation and burn care management.5
Cyanide can be found in plastics, wool, nylon, silk, polyurethane, and several other chemicals. Therefore, when any of these products burn, they can release cyanide into the air, causing inhalational exposure.5
Cyanide poisoning should be considered in all burn patients presenting from a house fire or other enclosed space.
Clinical features are nonspecific but include mild headache, dyspnea, seizures, coma, apnea, tachycardia, hypotension, and even cardiac arrest.5
Diagnosis is often clinical. A cyanide level can be obtained; however, treatment should be initiated immediately if the patient is believed to have significant cyanide toxicity. Laboratory abnormalities include elevated lactate (>10 demonstrates sensitivity over 85%) and anion gap metabolic acidosis. Patients with significant carbon monoxide poisoning are more likely to have cyanide toxicity as well.5
Treatment includes supplemental oxygen and the use of a cyanide treatment kit. Patients are given 10 mL of intravenous 3% sodium nitrite followed by 50 mL of intravenous 25% sodium thiosulfate solution. Sodium thiosulfate can then be repeated. Caution must be taken as nitrites can cause severe hypotension and methemoglobinemia. Sodium nitrite is contraindicated if carbon monoxide toxicity is present or suspected. Given this side-effect, 5 g intravenous hydroxocobalamin given over 30 minutes is first line if available. It is presumed to have less side-effects than nitrites but can also cause transient hypotension and anaphylaxis. However, it is more expensive and has a short shelf life so may not be stocked by many hospitals.5
All patients with moderate to large burns should have laboratory testing, including a CBC, electrolytes, BUN/creatinine, CK, and urinalysis. Hyperkalemia and rhabdomyolysis can be fatal complications of burns.2
Prophylactic antibiotics or steroids are not beneficial and may increase the incidence of systemic fungal infections.10
Indications for Transfer to a Regional Burn Center:
Any inhalational injury
>20% TBSA burned in adults
>10% TBSA burned in children or elderly
>5% TBSA full thickness burn
Any burns involving the face, genitalia, hands, feet, or over major joints
Additional traumatic injuries or patients with other significant comorbidities
Superficial and partial thickness burns can be very painful, especially during wound care. Ensure adequate analgesia for the patient which may require intravenous narcotics or anxiolytics.
Wounds should be cleaned and debrided if necessary. Most blisters can be left intact, but any large blisters that may restrict movement, such as over a joint, should be debrided.5
Tetanus vaccination status should be obtained and updated if last vaccination was >5 years ago.
After applying the ointment, a sterile dressing should be placed.
Minor burns can follow up with a primary care physician, but all others should follow up with a burn specialist.
Patients should be instructed on how to change their dressings daily and to return to the emergency department for any symptoms or signs of infection.5
Electrical injuries are less common than thermal burns, accounting for approximately 500 deaths every year in the United States. However, the nonfatal injuries can also carry a high morbidity. Injuries in children generally occur at home from electrical cords or sockets, while most injuries to adults occur at their workplace.17 Electrical injuries are the sixth leading cause of injury-related occupational deaths.18 Lightning strikes kill >50 people a year in the United States, with the majority being males between the ages of 20–44 years old (Figure 21.9).19, 20