Burn Injuries:  When to Treat or Refer

Patients with a burn injury can present anywhere seeking care; a local urgent care, emergency department, or primary care clinic, for example.  Would you know what to do if faced with this type of patient? Do you treat the patient or refer them somewhere else? Burn injuries can be challenging and making the wrong decision can have serious consequences for the patient.  The purpose of this article is to provide education regarding the nature of burn injuries and a systematic approach to assessment and decision making.

BURN INCIDENCE AND TREATMENT STATISTICS

The American Burn Association reports that there are approximately 1.1 million burn injuries that require medical attention annually with 50,000 of these being serious enough to require hospitalization.  Of these patients, 20,000 will have a major burn involving 25 percent or greater of their total body surface area, and more than 4,500 will die as a result of their burn injury. On average, someone dies in a fire every 2 hours or is injured as a result of a burn every 23 minutes. The leading causes of burn injury are from fire-flame, scalds, contact with hot objects, electrical or chemicals.  Males are more likely than females to sustain a burn injury (68% males and 32% females). Children and the disabled are more vulnerable to being burned with 24% of all burn injuries in children being under the age of 15.

As a result of these staggering numbers, it is likely that you, as a healthcare provider, will have an encounter with someone who has been burned.  What exactly is it about a burn injury that poses such a challenge to treatment? To answer that question, it is important to have a clear understanding of the role of the largest organ in the human body; skin.

SKIN STRUCTURE AND FUNCTION

The skin is composed of three distinct layers, each having its own important function, and provides the outer layer of protection for all other body parts. Skin is waterproof and flexible and keeps the internal environment of the body stable.

EPIDERMIS

The epidermis is the outermost skin layer and it functions to prevent loss of water/fluids and provide protection from mechanical and chemical injury.  The epidermis has a major role in protecting against bacteria, viruses and parasites. Melanocytes (pigment cells) lie within this layer and have a vital role in protection from UV radiation.  Keratinocytes (skin cells) are also found in the epidermis and provide additional protection and are responsible for the formation of finger and toenails. Langerhans cells are specialized immune cells.

DERMIS

The dermis lies beneath the epidermis and is much thicker.  It is composed of dense fibers of collagen and elastin and provides a support network for the epidermis.  The dermis contains a large majority of the body’s water and has a vital role in thermoregulation. Hair follicles, sweat glands, sebaceous glands and apocrine glands all originate from within the dermis.

SUBCUTAENEOUS LAYER

The subcutis is a network of collagen fibers and adipose (fat cells) that functions to protect the body from external trauma and insulate it from the cold.  Fat is stored in this layer, as well as many blood and lymphactic vessels and nerves.

TYPES OF BURNS

You have probably heard burns referred to as first-degree, second-degree or third-degree.  While that nomenclature is certainly appropriate, you will hear burn professionals referring to the varying depths of injury as partial, deep partial and full thickness.  Each categorization of burn has distinct appearances, standards of treatment and recommendations for referral to a burn center. You can expect to feel anxious, and perhaps overwhelmed, when encountering a patient with a burn injury, however, using the appropriate assessment skills will make the encounter less stressful for both clinician and patient.

SUPERFICIAL PARTIAL THICKNESS BURNS (FIRST-DEGREE)

Superficial partial thickness burns involve only the epidermis and appear red with mild skin swelling.  These types of burns do not have associated blisters or peeling of the skin. The epidermis remains intact and will easily blanche.  These types of burns are quite painful and usually heal without aggressive intervention. Sunburn commonly causes this type of burn.

Treatment is fairly conservative.  Patients will achieve considerable relief by applying cool cloths or compresses.  Usually no topical ointment is required and over-the-counter pain medications can be used for pain relief.  These types of burns heal within days and do not require further treatment unless the burn covers a large area or the patient is a baby or elderly person.  

PARTIAL THICKNESS BURNS (SECOND DEGREE)

Partial thickness burns involve both epidermis and dermis.  The skin will havea pink to red appearance with fluid filled blisters and sloughing of the skin and will easily blanche.  The blisters may rupture and leak proteinaceous fluid. Patients with this degree of burn will have a lot of pain and require treatment.  Whether or not you choose to treat this type of burn, or refer to a burn center, depends on a few other assessment criteria to be discussed in the next section.

Immediate treatment consists of cool cloths or compresses and pain medication.  If the burn does not meet criteria for referral to a burn center, treatment consists of daily soap and water washings and topical ointments/creams.  Appropriate choices are Silver Sulfadiazine 1% (Silvadene) to all areas except the face or neck. Silvadene is contraindicated if the patient is allergic to Sulfa products.  Polysporin ointment or Mupirocin ointment 2% (Bactroban) are also acceptable choices for topical treatment. Usually the blisters will pop and slough within a few days. This type of burn will heal in 7-10 days.

If thepartial thickness burn, however, has  a more cherry to deep red appearance, appears not quite so moist and blanches less, the patient probably has a deep second degree burn, in which case you should refer this one.  Deep second degree burns can be more difficult to manage and can convert to a full thickness burn.

FULL THICKNESS BURNS (THIRD DEGREE)

Full thickness burns involve all three layers of the skin and permanently destroys the tissue.  The skin will often have a brown to white leathery appearance or may even appear waxy .  The injured area will likely be painless and will not blanche at all. These degree of burns always require referral to a burn center.  Immediate treatment consists of covering the burn with a clean bandage, pain medication if needed, and fluid resuscitation if the burn constitutes a large area.

Fourth degree burns are a very deep full thickness burn and will have a charred appearance.  These degree of burns extend below the subcutaneous fat and most always include muscle, tendon or bone.

CALCULATING TOTAL BODY SURFACE AREA

Now that you can recognize the types of burn, another important factor to take into consideration is how much body surface area does the burn affect.  The accuracy of this calculation can determine if the patient needs to be referred.

There are two methods for calculating total body surface area (TBSA).    The clinician can make a quick determination by referencing the patient’s palm as being 1% of their body surface area.  This method is more commonly used with smaller body surface area burns.  

The second method is by breaking down the body into regions of “9”.  Different areas of the body can be assessed by knowing how much body surface area each comprises.   Each arm equals 9% with the hand being an additional 2.5%. Each leg is 18%, the anterior torso 18%, posterior torso 18%, each foot 3%, genitalia 1%, each buttock 2.5%, head and neck 9%.  The Lund-Browder chart provides easy visual reference for calculating total body surface area (TBSA). This method is best used for larger burns.

Another method is to determine the area not burned and minus that from 100.  This calculation can be used best for catastrophic burn patients of > 80%.

GUIDELINES FOR TRANSFER TO BURN CENTERS

Now that you can recognize what degree of burn a patient has and can calculate the TBSA, the next important decision to make is to determine if you can treat this injury or transfer the patient to a burn center.

The American Burn Association recommends transfer to a burn center for patients who meet the following criteria:

  1. Partial thickness burns >/= 20% TBSA in patients aged 10-50 years old.
  2. Partial thickness burns >/= 10% in children under the age of 10 or adults older then age 50.
  3. Full thickness burns >/= 5% in any age (however burn clinicians recommend referring any third degree burn).
  4. Patients with partial or full thickness burns that involve the hands, feet, face, eyes, ears, perineum, and/or major joints.
  5. Patients with high-voltage electrical injuries or lightning strikes.
  6. Chemical burns.
  7. Inhalation injuries.
  8. Patients with burns complicated by other trauma in which the burn poses the greatest risk of morbidity or mortality.  If the trauma poses the greatest risk the patient should be transferred to a trauma center for immediate stabilization.
  9. Patients with comorbidities that could complicate management, prolong recovery, or affect mortality.
  10. Hospitals without qualified personnel or equipment for the care of children.
  11. Patients who will require special social/emotional and/or long term rehab, including patients with suspected abuse, substance abuse, etc.

EMERGENCY BURN MANAGEMENT

It is important to treat the patient with a burn injury similarly to any other trauma patient and not get preoccupied with the burned skin only.  Remember to always assess the status of ABC, use airway and C-spine precautions, stop the burning process, and remove all clothing and jewelry.

Beginning with airway, always assess the potential for inhalation injury, as well.  Always assume the patient likely has a concomitant inhalation injury if any of the following criteria are met:

  1. The person was in an enclosed space such as a house, room , car or other vehicle.
  2. The person has darkened or reddened oral and/or nasal mucosa.
  3. The person has burns to the face, lips, nares, singed eyebrows, singed nasal hairs.
  4. The person has carbon or soot on their teeth, tongue or throat.
  5. The person has a raspy, hoarse voice or a cough.
  6. The person has stridor or is unable to clear secretions.
  7. The person has circumferential neck burns.

IF you suspect an inhalation injury, immediately administer 100% oxygen via face mask until intubation can be accomplished.  Once C-spine has been cleared elevate the head of the bed 30-90 degrees to decrease facial/arirway edema.

Next, insert two large bore IV’s.  You may have no choice but to insert the catheters into a burned area, however, always use a non-burned area first if possible.  Now that you can calculate the total body surface area of burn, fluid resuscitation can be initiated. The Parkland Formula is an easy to calculate means for appropriate fluid needs for the critically burned patient.

The Parkland Formula is as follows:

2-4cc Ringers Lactate x body weight in kg x TBSA (use 2 cc patients > 14 years old, 3 cc for children < 14 years old, 4 cc for electrical injuies).

Administer half of this amount over the first 8 hours post burn and the remainder over the next 16 hours.  The goal of fluid rescuscitation is to achieve urine output of 30-50 cc/hr in an adolscent or adult, 75-100 cc/hr with a high voltage electrical injury, and 1 cc/kh/hr in children under 30 kg,  The rate of fluid can be increased in increments of 1/3 to achieve these parameters.

Remember to treat the burn patient as any other trauma patient.  Assess for other trauma and head injuries and treat appropriately.  Next, try to obtain an accurate patient history to include how the person was burned and what time, concomitant injuries, allergies, medical/surgical history and current medications.

Patients with a burn injury will have a lot of pain.  Morphine Sulfate is the preferred medication and should always be given intravenously.  Do not use ice or cold fluids as this can cause hypothermia rather quickly in a person with even a moderate size burn injury.

Health care providers  should not focus on wound care measures other than to remove all burned clothing and jewelry, remove foreign debris and wrap the burned areas with clean or sterile gauze, towels, or sheets.  Other interventions that are necessary include obtaining a chest x-ray or any other areas of suspected trauma, insert an NG tube if nausea and vomiting are present or the patient is intubated.  Monitor VS and urine output, obtain a rainbow of labs including ABG if inhalation is suspected and keep the patient NPO.

ESCHAROTOMIES

If a burn patient has circumferential burns to the chest/torso, or even just a large enough TBSA of full thickness burn to the chest area,  the ability to properly ventilate the patient can be compromised. Additionally, circumferential full thickness burns to an extremity can quickly cause critical limb ischemia due to swellling and tight eschar.  In some situations, emergency escharotomies must be performed. This surgical procedure should only be acccomplished by trained physicians, outside of a burn center setting, and involves using a scalpel or bovie to make incisions through the eschar to release the tight eschar.  Always asses the ability of the chest to adequately expand and frequently check the quality of peripheral pulses to affected extremities. If pulses cannot be felt, check with a hand held doppler. Full thickess or circumferential burn to the chest or torso with signs of inadequate perfusion or inability to ventilate always necessitates an escharotomy to the chest.  Full thickness, circumferential burns to an extremity with absent pulses always necessitates an escharotomy to the affected limb.

TO SUMMARIZE

Having a systematic approach to assessing a burn patient can help ease the fear and stress associated with managing this type of patient.  Being able to estimate the degree and total body surface area will help guide the clinician to determine if the patient meets any of the criteria that the American Burn Association has established  for referral to a burn center. The Rule of Nines is a simple tool that provides a systematic approach to determining TBSA. The Parkland Formula provides as easy to calculate formula for fluid resuscitation  based on the TBSA. Emergency management is similar to any other trauma patient in that the main focus should be on airway, breathing, circulation and stabilizing other associated trauma.

REFERENCES

CDC Injury Prevention: Burns (PDF file). Retrieved from https://www.cdc.gov/masstrauma/factsheets/public/burns.pdf

American Burn Association Burn Injury Fact Sheet.  Retrieved from https://ameriburn.org

American Burn Association Burn Center  Referral Criteria. Retrieved from 

ameriburn.org/public-resources/burn-center-referral-criteria/

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