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Emergency and Acute Medicine – Burns
Overview And Definitions
Burns are acute injuries to skin and underlying tissues resulting from thermal, chemical, electrical, radiation, or mechanical energy transfer. Severity is determined by burn depth, total body surface area (TBSA) involved, anatomic location, and associated inhalation or systemic injury.
Etiology And Mechanisms
Burns are broadly classified into seven categories. Scald injuries result from hot liquids, grease, or steam. Contact burns arise from exposure to hot or cold surfaces. Thermal burns are caused by fire or open flames. Radiation burns occur from ionizing or nonionizing exposure. Chemical burns result from acids, alkalis, or other corrosive substances. Electrical burns occur from low- or high-voltage exposure and may cause deep tissue injury with minimal skin findings. Friction burns include road rash and rope burns.
Clinical Presentation And Associated Findings
Most burns demonstrate visible skin injury. Inhalation injury should be suspected with facial burns, pharyngeal erythema, singed nasal hair or eyelashes, carbonaceous sputum, and changes in respiratory mechanics such as wheezing, coughing, or tachypnea. Electrical and chemical burns may appear deceptively minor externally, sometimes showing only entry or exit wounds.
History should include an AMPLE assessment, burn source and environment, possibility of explosion, medical history, medications, allergies, and tetanus status. Carbon monoxide poisoning is the most common cause of death in fires and renders pulse oximetry unreliable. Cyanide poisoning should be considered when synthetic materials such as wool, nylon, silk, or polyurethane are involved.
Physical examination prioritizes airway assessment, followed by a full trauma survey. Evaluate the face, oropharynx, and nares for inhalation injury, assess the cervical spine when mechanism is concerning, examine the eyes for corneal burns, and estimate burn depth and surface area. In children, specific burn patterns may raise concern for nonaccidental injury.
Assessment Of Burn Severity
Burn size is expressed as a percentage of TBSA. In adults, the rule of nines estimates surface area: head and neck 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, and perineum or palm 1%. In infants and children, the head accounts for a larger percentage and the legs for less.
The Lund and Browder chart provides age-adjusted estimates and is more accurate. The palm method, where the patient’s palm and fingers equal approximately 1% TBSA, is useful for scattered burns.
Depth classification includes superficial (first-degree) burns involving only the epidermis with erythema and pain, healing without scarring. Partial-thickness (second-degree) burns involve the dermis and may be superficial or deep. Superficial partial-thickness burns are pink, moist, painful, and heal within weeks with minimal scarring. Deep partial-thickness burns have pale dermis, reduced sensation, and often result in scarring or contractures. Full-thickness (third-degree) burns extend through the dermis, producing leathery, insensate skin and requiring surgical management. Fourth-degree burns involve deeper structures such as fascia, muscle, or bone and cause significant disability.
Diagnostic Evaluation
Severe burns require laboratory evaluation including CBC, electrolytes, renal function, glucose, coagulation studies, type and crossmatch, and pregnancy testing when appropriate. Arterial blood gas with carboxyhemoglobin level is indicated for suspected inhalation injury. Cyanide levels may be obtained selectively. Imaging may include chest radiography. Bronchoscopy is useful to evaluate inhalation injury, and ECG monitoring is important in electrical burns and in older patients.
Prehospital And Initial Management
Immediate care focuses on stopping the burning process, removing contaminated clothing or jewelry, keeping the patient warm, and cooling burned areas when appropriate. Airway protection with early oxygen administration is essential, with prompt intubation for respiratory compromise. Early IV access and fluid resuscitation are critical in burns exceeding 20% TBSA. Adequate analgesia should be provided, wounds covered with clean materials, and patients transported promptly to a burn center when indicated.
Emergency Department Management
Airway control remains the top priority, with early intubation for upper airway involvement or circumferential neck burns. Provide supplemental oxygen, IV access, continuous monitoring, analgesia, and assessment for associated injuries.
Fluid resuscitation for partial- and full-thickness burns greater than 20% TBSA is guided by the Parkland formula in adults: 4 mL/kg/%TBSA using lactated Ringer solution, with half administered in the first 8 hours and the remainder over the next 16 hours. Urine output goals are 0.5 mL/kg/hr in adults and 1 mL/kg/hr in children.
Escharotomy is indicated for circumferential burns causing vascular or respiratory compromise. Wound care includes topical antibiotics, nonadherent dressings, and avoidance of prophylactic systemic antibiotics. Transfer to a burn center should not be delayed for wound care. Minor burns may be managed as outpatients with careful cleansing, blister management, topical therapy, and daily dressing changes.
Special Populations
Children require modified fluid resuscitation, with the Galveston formula providing more accurate estimates. They are at higher risk of hypothermia and hypoglycemia and require close monitoring. Nonaccidental trauma must be considered.
In pregnancy, maternal and fetal risks are significant, fluid needs may be higher, and early obstetric consultation and fetal monitoring are recommended.
Disposition And Follow-Up
Admission is required for moderate to severe burns, suspected abuse, inability to manage wounds, or need for specialized care. Burn center referral is indicated for extensive burns, involvement of critical areas, electrical or chemical burns, inhalation injury, or significant comorbidities.
Patients with minor, noncritical burns may be discharged if reliable, with close follow-up arranged within 1–2 days to reassess wound status, pain control, and infection.
Clinical Insights And Common Errors
Early airway protection and aggressive fluid resuscitation are critical determinants of outcome. Delayed recognition of inhalation injury can be fatal. Adequate pain control should never be deferred. Children require vigilant monitoring for hypoglycemia and hypothermia, and fluid needs must be reassessed frequently.
Overview And Definitions
Burns are acute injuries to skin and underlying tissues resulting from thermal, chemical, electrical, radiation, or mechanical energy transfer. Severity is determined by burn depth, total body surface area (TBSA) involved, anatomic location, and associated inhalation or systemic injury.
Etiology And Mechanisms
Burns are broadly classified into seven categories. Scald injuries result from hot liquids, grease, or steam. Contact burns arise from exposure to hot or cold surfaces. Thermal burns are caused by fire or open flames. Radiation burns occur from ionizing or nonionizing exposure. Chemical burns result from acids, alkalis, or other corrosive substances. Electrical burns occur from low- or high-voltage exposure and may cause deep tissue injury with minimal skin findings. Friction burns include road rash and rope burns.
Clinical Presentation And Associated Findings
Most burns demonstrate visible skin injury. Inhalation injury should be suspected with facial burns, pharyngeal erythema, singed nasal hair or eyelashes, carbonaceous sputum, and changes in respiratory mechanics such as wheezing, coughing, or tachypnea. Electrical and chemical burns may appear deceptively minor externally, sometimes showing only entry or exit wounds.
History should include an AMPLE assessment, burn source and environment, possibility of explosion, medical history, medications, allergies, and tetanus status. Carbon monoxide poisoning is the most common cause of death in fires and renders pulse oximetry unreliable. Cyanide poisoning should be considered when synthetic materials such as wool, nylon, silk, or polyurethane are involved.
Physical examination prioritizes airway assessment, followed by a full trauma survey. Evaluate the face, oropharynx, and nares for inhalation injury, assess the cervical spine when mechanism is concerning, examine the eyes for corneal burns, and estimate burn depth and surface area. In children, specific burn patterns may raise concern for nonaccidental injury.
Assessment Of Burn Severity
Burn size is expressed as a percentage of TBSA. In adults, the rule of nines estimates surface area: head and neck 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, and perineum or palm 1%. In infants and children, the head accounts for a larger percentage and the legs for less.
The Lund and Browder chart provides age-adjusted estimates and is more accurate. The palm method, where the patient’s palm and fingers equal approximately 1% TBSA, is useful for scattered burns.
Depth classification includes superficial (first-degree) burns involving only the epidermis with erythema and pain, healing without scarring. Partial-thickness (second-degree) burns involve the dermis and may be superficial or deep. Superficial partial-thickness burns are pink, moist, painful, and heal within weeks with minimal scarring. Deep partial-thickness burns have pale dermis, reduced sensation, and often result in scarring or contractures. Full-thickness (third-degree) burns extend through the dermis, producing leathery, insensate skin and requiring surgical management. Fourth-degree burns involve deeper structures such as fascia, muscle, or bone and cause significant disability.
Diagnostic Evaluation
Severe burns require laboratory evaluation including CBC, electrolytes, renal function, glucose, coagulation studies, type and crossmatch, and pregnancy testing when appropriate. Arterial blood gas with carboxyhemoglobin level is indicated for suspected inhalation injury. Cyanide levels may be obtained selectively. Imaging may include chest radiography. Bronchoscopy is useful to evaluate inhalation injury, and ECG monitoring is important in electrical burns and in older patients.
Prehospital And Initial Management
Immediate care focuses on stopping the burning process, removing contaminated clothing or jewelry, keeping the patient warm, and cooling burned areas when appropriate. Airway protection with early oxygen administration is essential, with prompt intubation for respiratory compromise. Early IV access and fluid resuscitation are critical in burns exceeding 20% TBSA. Adequate analgesia should be provided, wounds covered with clean materials, and patients transported promptly to a burn center when indicated.
Emergency Department Management
Airway control remains the top priority, with early intubation for upper airway involvement or circumferential neck burns. Provide supplemental oxygen, IV access, continuous monitoring, analgesia, and assessment for associated injuries.
Fluid resuscitation for partial- and full-thickness burns greater than 20% TBSA is guided by the Parkland formula in adults: 4 mL/kg/%TBSA using lactated Ringer solution, with half administered in the first 8 hours and the remainder over the next 16 hours. Urine output goals are 0.5 mL/kg/hr in adults and 1 mL/kg/hr in children.
Escharotomy is indicated for circumferential burns causing vascular or respiratory compromise. Wound care includes topical antibiotics, nonadherent dressings, and avoidance of prophylactic systemic antibiotics. Transfer to a burn center should not be delayed for wound care. Minor burns may be managed as outpatients with careful cleansing, blister management, topical therapy, and daily dressing changes.
Special Populations
Children require modified fluid resuscitation, with the Galveston formula providing more accurate estimates. They are at higher risk of hypothermia and hypoglycemia and require close monitoring. Nonaccidental trauma must be considered.
In pregnancy, maternal and fetal risks are significant, fluid needs may be higher, and early obstetric consultation and fetal monitoring are recommended.
Disposition And Follow-Up
Admission is required for moderate to severe burns, suspected abuse, inability to manage wounds, or need for specialized care. Burn center referral is indicated for extensive burns, involvement of critical areas, electrical or chemical burns, inhalation injury, or significant comorbidities.
Patients with minor, noncritical burns may be discharged if reliable, with close follow-up arranged within 1–2 days to reassess wound status, pain control, and infection.
Clinical Insights And Common Errors
Early airway protection and aggressive fluid resuscitation are critical determinants of outcome. Delayed recognition of inhalation injury can be fatal. Adequate pain control should never be deferred. Children require vigilant monitoring for hypoglycemia and hypothermia, and fluid needs must be reassessed frequently.
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