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Burn Management

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1. Classification of Burns

By Depth

By Size: Rule of Nines (Adults)

• In children, the head is proportionally larger and the lower limbs smaller - use Lund and Browder charts for accuracy.
• A useful aid: the patient's palm (including fingers) = approximately 1% TBSA for irregular burns at any age.
• First-degree burns are excluded from TBSA calculations for resuscitation purposes.

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2. Initial Assessment (ABCDE)

• Airway: Assess for inhalation injury - signs include singed nasal hairs, hoarse voice, carbonaceous sputum, stridor, facial burns. Early intubation is preferable to delayed intubation after airway edema develops.
• Breathing: Check for circumferential chest burns restricting ventilation; monitor SpO2 and consider CO poisoning (give 100% O2).
• Circulation: IV access (two large-bore lines), assess for shock, begin fluid resuscitation, insert Foley catheter.
• Disability: Neurological status (especially in electrical and inhalation injuries).
• Exposure: Completely expose and document all burns; prevent hypothermia.

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3. American Burn Association (ABA) Criteria for Burn Center Transfer

1. Partial-thickness burns >10% TBSA
2. Burns involving face, hands, feet, genitalia, perineum, or crossing major joints
3. Full-thickness (3rd degree) burns of any size in any age group
4. Electrical burn injuries
5. Chemical burn injuries
6. Inhalation injury
7. Burns with significant pre-existing medical comorbidities
8. Burns with concomitant trauma where the burn is the dominant risk
9. Burned children in hospitals without qualified pediatric personnel/equipment
10. Burns requiring specialized social, emotional, or rehabilitative intervention

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4. Fluid Resuscitation

Parkland (Baxter) Formula - Adults

4 mL × body weight (kg) × % TBSA burned of Lactated Ringer's (LR) in the first 24 hours

• Half given in the first 8 hours (timed from injury, not from arrival)
• Half given over the next 16 hours
• Add maintenance fluids separately (many online calculators omit this)
• Titrate to urine output 0.5-1.0 mL/kg/hour in adults

• 4 × 65 × 35 = 9,100 mL in 24 hours
• First 8 hours: 4,550 mL (~570 mL/hr)
• Next 16 hours: 4,550 mL (~285 mL/hr)

Pediatric Formulas

Key Resuscitation Principles

• Underresuscitation → decreased cardiac output, end-organ damage, conversion of burns to deeper wounds
• Overresuscitation ("fluid creep") → pulmonary edema, abdominal compartment syndrome, extremity compartment syndromes
• Patients with inhalation injury typically require volumes well in excess of formula estimates
• Burns >20% TBSA often produce a hypodynamic circulatory state in the first hours (reduced BP, reduced peripheral perfusion) - support with temperature maintenance, volume, and vasopressors if needed
• After 24 hours, a hyperdynamic state evolves: tachycardia, increased temperature, enhanced peripheral flow, and muscle catabolism

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5. Inhalation Injury

• Three types: CO/cyanide poisoning (systemic), supraglottic thermal injury (airway edema), and subglottic chemical injury (lower airway)
• CO poisoning: treat with 100% O2 (reduces CO half-life from ~5 hours to ~1 hour); consider hyperbaric O2 if available and severe
• Inhalation injury dramatically increases predicted mortality for any given burn size
• Patients with confirmed inhalation injury require early, secure intubation

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6. Initial Wound Care

Topical Agents

Wound Dressings

• Superficial/superficial partial-thickness burns: Clean, moist dressings with topical antibiotic; non-adherent primary layer
• Deep partial-thickness/full-thickness burns: Antimicrobial dressings or temporary biological cover (allograft, xenograft, dermal substitutes such as Integra) while awaiting definitive surgery
• Wounds that will not heal within 17-21 days are at high risk of hypertrophic scarring and should be considered for surgical intervention

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7. Escharotomy

• Indicated for circumferential deep partial or full-thickness burns causing vascular compromise (extremities) or ventilatory restriction (chest)
• Technique: Full-thickness longitudinal incisions through the burned skin/eschar to the edges of normal skin, using electrocautery, until subcutaneous fat protrudes
• Deep fascial compartment decompression (fasciotomy) is additionally required for deep thermal burns, high-voltage electrical injuries, and crush injuries
• Lateral canthotomy is performed for retro-orbital edema from deep facial burns when intraocular pressures are excessive

Escharotomy Incision Sites

• Upper extremity: medial and lateral longitudinal lines
• Lower extremity: medial and lateral longitudinal lines; fibular head is a landmark
• Chest: bilateral anterior axillary line incisions connected by a transverse subcostal incision
• Hand: dorsal incisions over the 2nd and 4th metacarpals (interosseous release); avoid volar surface when possible

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8. Nutrition

• Large burns have an absolute requirement for nutritional supplementation - preferably via early enteral (tube) feeding
• Epithelialization, granulation tissue formation, and immune function all depend on adequate nutrition
• Caloric needs: 25 kcal/kg/day + 40 kcal/% TBSA is a common starting estimate; large burns may require 50%-100% above basal requirements
• Protein needs: approximately 1.2-2 g/kg/day
• Monitor and correct hyperglycemia (insulin resistance is universal in major burns)

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9. Surgical Management

Timing of Excision

• Early excision (within the first week) is preferred for unequivocal full-thickness burns:
  • Increased survival in mid-size to large full-thickness burns
  • Better cosmesis for smaller burns
  • Reduces infection risk and catabolism
• Data do NOT support early excision of partial-thickness or mixed-depth burns with only a small full-thickness component
• Wounds likely to heal within 17 days should generally be allowed to do so

Tangential Excision

• Sequential removal of thin layers of non-viable tissue until a viable bleeding wound bed is reached
• Healthy dermis: pearly white after tourniquet exsanguination
• Healthy fat: bright yellow; compromised fat: dull yellow-orange-brown
• Blood loss can be substantial - tourniquet use (extremities), tumescent injection (trunk), topical epinephrine/thrombin soaks, and limiting excision per session are all strategies

Skin Grafting

• For burns >40% TBSA: rapid wound closure is the primary life-saving goal - the best defense against sepsis, catabolism, and death
• When donor sites are insufficient, dermal substitutes (e.g. Integra, AlloDerm) can provide temporary biological wound closure; STSG is applied in a second stage

Exposed Vital Structures

• Bone, periosteum, tendon, major vessels, and nerve are poor graft beds
• Require coverage with local or regional flaps or tissue transfers

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10. Special Burn Types

Electrical Burns

• Cutaneous injury understates the true extent of injury - massive deep tissue (muscle) necrosis can occur along the current path
• Risk of cardiac arrhythmias (monitor ECG for 24 hours minimum with high-voltage exposure), renal failure from myoglobinuria
• Forced diuresis + alkalinization of urine to prevent tubular obstruction
• Often require fasciotomy; amputation rates are high for high-voltage injuries

Chemical Burns

• Immediate and copious water irrigation (30+ minutes) is the single most important first intervention
• Alkali burns (lye, cement) tend to penetrate deeper and longer than acid burns
• Do NOT attempt chemical neutralization (exothermic reaction worsens injury)
• Hydrofluoric acid (HF): unique - systemic hypocalcemia is life-threatening; treat with topical/intradermal/IV calcium gluconate

Radiation Burns

• Occur from therapeutic radiation, industrial accidents, or nuclear events
• Often associated with underlying bone marrow suppression; manage with wound care, infection prevention, and hematology input

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11. Complications

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12. Long-Term Care and Rehabilitation

• Compression garments: worn 23 hours/day for up to 2 years to reduce hypertrophic scarring
• Silicone gel sheets: adjunct to compression for scar management
• Physiotherapy and occupational therapy: range of motion, ADLs, splinting
• Psychological support: PTSD is common; early involvement of behavioral health
• Reconstructive surgery: scar revisions, Z-plasties, contracture releases, tissue expansion, and flaps as needed
• Multidisciplinary team: burn surgeon, physiatrist, physical/occupational therapist, wound care nurse, dietitian, behavioral health

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Summary: Key Numbers in Burn Management

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