CLINICAL PRACTICAL GUIDELINES IN MANAGEMENT OF BURN INJURY

INTRODUCTION

A burn injury is defined as damage to the skin caused by heat, radiation, friction or chemicals. The injuries sustained
are generally classified as:

I. Classification of Burn Injuries

1. Chemical – direct contact with chemicals

2. Contact – direct contact with hot objects
3. Electrical – direct contact with an electrical current
4. Flame – direct contact with open flame or fire
5. Flash – exposure to the energy produced by explosive material
6. Friction – rapid movement of a surface against the skin eg treadmill, MBA, etc
7. Radiation – exposure to solar energy, radiotherapy, laser or IPL
8. Radiant Heat – heat radiating from heaters, open fire places, etc
9. Scald – hot liquids such as hot water and steam, hot fats, oils and foods

II. Determining Severity of the Burn Injury

A. Depth of a Burn

The depth of tissue damage due to burn is dependent on the temperature and duration of contact with the
skin. Skin contact with heat, chemicals or electricity results in tissue destruction of variable degrees. Due to
thinner skin in the very young and the very old, special considerations are given to patients of these age
groups. Burn in these age groups may be deeper and more severe than they initially appear.

Epidermal, superficial dermal (superficial partial), deep dermal/(deep partial), and full thickness are terms to
describe the depth of burn injury.

Assessment of the Burn Wound Depth

Degree Depth Colour Blisters Capillary Refill Healing Scarring

First Epidermal Red Absent Brisk Within 7 days None
(Superficial Thickness) 1-2 sec Eg. Sunburn
Second Superficial Dermal Cherry Red / Present Brisk Within 14 days None
(Superficial Partial Pale Pink 1-2 sec Slight colour
Thickness) mismatch
Deep Dermal Blotchy Red / +/- Sluggish 21-35 days Yes
(Deep Partial Thickness) Mottled White >2 sec / Grafting may be
Absent required
Third Full Thickness White / Brown / No Absent Grafting required Yes
Black (charred)
/ Deep Red
Fourth Burns extending to deeper structures,
muscles, bone, joint
 Often it is not possible to predict the exact depth of a burn in the acute phase. Some 2nd degree burns will
convert to 3rd when infection sets in. When in doubt call it 3rd degree.

B. Extent of Burn Injury

i. Rule of Nine
It is commonly used to make an initial estimate of burn injuries.

 Adult  Children

For each year after 1 year, subtract

1% from the head and add ½% to
each leg until the age of 10 years when
adult proportions

ii. Palmar Method

For small and scattered burns, an estimate of the burn may be made
by using the palm of the patient’s hand which represents approximately
1 % of the patient’s body surface. This may be used for any part of the
body.

iii. Lund & Browder Chart

A more accurate assessment can be made of the burn injury especially in children, using the Lund &
Browder Chart.

First degree burns are not included in the estimate. Only partial and full thickness areas of burn are used
in estimating the extent of burn
 Area Birth-1yr 1-4 yrs 5-9 yrs 10-14yrs 15 yrs Adult 2O Burn 3O Burn TBSA%
Head 19 17 13 11 9 7
Neck 2 2 2 2 2 2
Ant Trunk 13 13 13 13 13 13
Post Trunk 13 13 13 13 13 13
R Buttock 2.5 2.5 2.5 2.5 2.5 2.5
L Buttock 2.5 2.5 2.5 2.5 2.5 2.5
Genitalia 1 1 1 1 1 1
R Upper Arm 4 4 4 4 4 4
L Upper Arm 4 4 4 4 4 4
R Forearm 3 3 3 3 3 3
L Forearm 3 3 3 3 3 3
R Hand 2.5 2.5 2.5 2.5 2.5 2.5
L Hand 2.5 2.5 2.5 2.5 2.5 2.5
R Thigh 5.5 6.5 8 8.5 9 9.5
L Thigh 5.5 6.5 8 8.5 9 9.5
R Leg 5 5 5.5 6 6.5 7
L Leg 5 5 5.5 6 6.5 7
R Foot 3.5 3.5 3.5 3.5 3.5 3.5
L Foot 3.5 3.5 3.5 3.5 3.5 3.5
Total

III. Initial Assessment and Management of Burn

The initial assessment of the burn patient is like that of a trauma patient

Primary Survey

A- Airway maintenance with cervical spine control

• Inspect the airway for foreign material/oedema. If the patient is unable to respond to verbal commands open
the airway with a chin lift and jaw thrust; stabilize neck for suspected C Spine injury.
• Keep movement of the cervical spine to a minimum and never hyperflex or hyperextend the head or neck.
• Insert Guedels airway if airway patency is compromised. Think about early intubation.

B- Breathing and Ventilation

• Expose the chest and ensure that chest expansion is adequate and bilaterally equal – beware
circumferential deep dermal or full thickness chest burns – is escharotomy required?
• Administer 100% oxygen.
• Ventilate via a bag and mask or intubate the patient if necessary.
• Examine for carbon monoxide poisoning – non burnt skin may by cherry pink in colour in a non-breathing
patient
• Monitor respiratory rate – beware if rate <10 or > 20 per minute.

C- Circulation with Haemorrhage Control

• Monitor the peripheral pulse for rate, strength (strong, weak) and rhythm,
• Apply capillary blanching test (centrally and peripherally to burnt and non-burnt areas) – normal return is two
seconds. Longer indicates hypovolaemia or need for escharotomy on that limb; check another limb.
 • Inspect for any obvious bleeding – stop with direct pressure.

D- Disability: Neurological Status

• Establish level of consciousness: GCS scale/ AVPU

A - Alert
V - Response to Vocal stimuli
P - Responds to Painful stimuli
U - Unresponsive
• Examine pupil response to light for briskness and equality.
• Be alert for restlessness and decreased levels of consciousness – hypoxaemia, shock, alcohol, drugs and
analgesia influence levels of consciousness.

E- Exposure with Environmental Control

• Remove all clothing and jewellery.

• Keep patient warm
• Roll and remove wet sheets and examine posterior surfaces for burns and other injuries.

Secondary Survey
A - Allergies
M - Medications
P - Past Illnesses
L - Last Meal
E - Events/Environment related to injury

IV. Fluids Resuscitation

A. Calculation of Fluid requirement:

• Fluid Resuscitation will be required for a patient that has sustained a burn >10% for children, >15% for
adults.
• Estimate burn area using Rule of Nines. For smaller burns the palmar surface (including fingers) of the
patient’s hand (represent 1% TBSA) can be used to calculate the %TBSA burnt.
• Insert 2 large bore, peripheral IV lines preferably through unburned tissue.
• Obtain patients body weight in kgs.
• Commence resuscitation fluids, PLR, at an initial rate of the Parkland Formula but adjust according to urine
output:

Parkland Formula: 4mls x kgs x % TBSA burnt

= IV fluid mls to be given in 24hrs following the injury
 Give ½ of this fluid in the first 8hrs from the time of injury
 Give a ½ of this fluid in the following 16hrs

• Children less than 30kg require maintenance fluids in addition to resuscitation fluids.
• Maintenance: Halliday- Segar formula
1st 10 kg: 100cc/kg
2nd 10kg: 50cc/kg
Next 10kg: 20cc/kg, for 24hrs

B. Resuscitation Fluid composition:

 First 24 Hours

Crystalloid fluid is the fluid of choice in the initial 24hrs of fluid resuscitation. With increased capillary
permeability, colloids have no sufficient influence on maintaining intravascular volume, during the initial
hours post burn. Due to the leakage of large molecules of protein through open capillary membranes, colloid
have little role in resuscitation. Between 18 to 24 hours the capillary leak begins to seal sufficiently so that
colloid may remain within the intravascular space. Colloid replacement at this time may be estimated at
0.5cc/kg/%burn. Either Albumin or Fresh Frozen Plasma is used and the calculated amount is replaced over
one to two hours.

Second 24 Hours

Capillary permeability approaches normal during the latter half of the first post burn day with restoration of
functional capillary integrity by the second post burn day. The amount and the composition of the fluids
required thus changes after the first 24 hours because of these pathophysiologic changes. 5 % dextrose in
water at the rate of 1cc/kg/%burn. The serum sodium should be maintained between 133 and 135mEq/dL

C. Monitoring of Resuscitation

Fluid resuscitation in each patient must be individualized, because each person has varied reactions and
responses to burn injury and fluid resuscitation. The optimal resuscitation regimen is that which decreases
volume and salt loading, prevents acute renal failure and has low incidence of pulmonary and cerebral
edema.

Hourly Urine output

Insert an IFC for all burns >15% and monitor urine output hourly. IV fluid rate is adjusted each hour
according to the previous hour’s urine output.
• REMEMBER: The infusion rate is guided by the urine output, not by formula.
• The urine output should be maintained at a rate
 Adult 0.5 – 1 ml / kg / hr
 Children 0.5 – 2ml / kg / hr – * aim for 1 ml/kg/hr*

• If urine output <0.5mls/kg/hr increase IV fluids by 1/3 of current IV fluid amount.

• If urine output >1ml/hr for adults or >2ml/kg/hr for children decrease IV fluids by 1/3 of current IV fluid
amount.
• More IV fluids are required:

 When pigmenturia (dark red, black urine) is evident. Pigmenturia occurs when
the person has endured thermal damage to muscle eg electrical injury. Mannitol
may be ordered if pigmenturia evident.

 Inhalation Injury.

 Delayed resuscitation.

Baseline Labs:
 Hb, Hct,
 Serum Electrolytes
  Arterial blood gas analysis
 CXR
 ECG as needed

V. Burn Center Referral

The American Burn Association has identified the following injuries as those requiring referral to a burn center
after initial assessment and stabilization at an emergency department:

1. Partial-thickness and full-thickness burns totaling greater than 10% TBSA in patients under 10 or over
50 years of age.
2. Partial-thickness and full-thickness burns totaling greater than 20% TBSA in other age groups.
3. Partial-thickness and full-thickness burns involving the face, hands, feet, genitalia, perineum, or major
joints.
4. Full-thickness burns greater than 5% TBSA in any age group.
5. Electrical burns, including lightning injury
6. Chemical burns.
7. Inhalation injury.
8. Burn injury in patients with preexisting medical disorders that could complicate management, prolong
the recovery period, or affect mortality
9. Any burn with concomitant trauma (e.g., fractures) in which the burn injury poses the greatest risk of
morbidity or mortality. If the trauma poses the greater immediate risk, the patient may be treated initially
in a trauma center until stable, before being transferred to a burn center. The physician's decisions
should be made with the regional medical control plan and triage protocols in mind.
10. Burn injury in children admitted to a hospital without qualified personnel or equipment for pediatric care
11. Burn injury in patients requiring special social, emotional, and/or long-term rehabilitative support,
including cases involving suspected child abuse.