APPROPRIATE HEALTH CARE:
. HOSPITALIZATION for all serious burns :
. Second degree burns over 10% body surface area (BSA), any 3rd degree burn
. Burns of hands, feet, face or perineum
. Electrical/lightning burns
. Inhalation injury
. Chemical burns
. Circumferential burn
. TRANSFER TO BURN CENTER FOR :
. 2nd and 3rd degree burns over 10% BSA in patients under 10 years and over 50 years of age
. 2nd and 3rd degree burns over 20% BSA in any age range
. Burns of hands, feet, face or perineum
. Electrical/lightning burns
. Inhalation injury
. Chemical burns
. Circumferential burn
. Chemical burns with threat of functional impairment
GENERAL MEASURES:
. Based on depth of burns and accurate estimate of total body surface area (BSA) involved (Rule of nines)
. Rule of nines
. Each upper extremity - adult and child 9%
. Each lower extremity - adult 18%; child 14%
. Anterior trunk - adult and child 18%
. Posterior trunk - adult and child 18%
. Head and neck - adult 10%; child 18%
. Quick estimate (for smaller burns)
. The surface area of the patients hand is approximately 1% of their BSA.
. Tetanus prophylaxis (if not current)
. Remove all rings, watches, etc., from injured extremities to avoid tourniquet effect
. Remove clothing and cover all burned areas with dry sheet
. Flush area of chemical burn (for approximately 2 hours)
. 100% oxygen administration in all major burns, consider early intubation
. Do not apply ice to burn site
. Nasogastric tube (high risk of paralytic ileus)
. Foley catheter
. Pain relief
. IV Demerol, morphine or methadone for severe pain
. Oral analgesics eg, Tylenol with codeine, Percocet,
Lortab) for moderate pain
. ECG monitoring in fi rst 24 hours following electrical burn
. Whirlpool hydrotherapy followed by silver sulfadiazine (Silvadene) occlusive dressings in severe burns
. Once or twice a day cleansing with dressing changes
. Epilock or Elasto-Gel may be used as dressing in selected patients (especially useful for outpatient treatment
of minor burns)
. Burn fluid resuscitation. Calculate fluid resuscitation from time of burn, not from time treatment begins.
. 2-4 mL Ringers lactate x body weight (kg) x % BSA burn (1/2 given in fi rst eight hours, 1/4 in second
eight hours and 1/4 in third eight hours). In children, this is given in addition to maintenance fl uids and is
adjusted according to urine output and vital signs.
. Colloid solutions are not recommended during the first 12-24 hours of resuscitation
. Other
. Use of biological membranes or skin substitutes may be indicated for burn coverage
SURGICAL MEASURES
• Escharotomy may be necessary in constricting circumferential burns of extremities or chest
• Tangential excision with split thickness skin grafts
ACTIVITY : Early mobilization is the goal
DIET: High protein, high calorie diet when bowel function resumes; nasogastric tube feedings may be required in early post-burn period. TPN if NPO expected for > 5 days.
DRUG(S) OF CHOICE :
• Morphine small frequent IV doses (0.1 mg/kg/dose in children; 2.5-20 mg q 2-6 hours in adults)
• Silver sulfadiazine (Silvadene) topically to burn site (can cause leukopenia)
• Electrical burn with myoglobinuria will require alkalinization of urine and mannitol
• No indication for prophylactic antibiotics
• Consider H2 blockers: cimetidine, ranitidine, famotidine, or nizatidine for stress ulcer prophylaxis in severely
burned patients
ALTERNATIVE DRUGS:
• Mafenide (Sulfamylon) - full thickness burn (caution: metabolic acidosis)
• Silver nitrate 0.5% (messy, leaches electrolytes from burn and causes water toxicity)
• Povidone-iodine (Betadine) may result in Iodine absorption from burn, tan eschar. Makes débridement more
difficult.
• Travase-enzymatic débridement
PREVENTION/AVOIDANCE: Skin grafts or newly epithelialized skin is highly sensitive to sun exposure and thermal extremes
POSSIBLE COMPLICATIONS :
• Gastroduodenal ulceration (Curling ulcer)
• Marjolin ulcer - squamous cell carcinoma developing in old burn site
• Burn wound sepsis-usually gram negative organisms
• Pneumonia
• Decreased mobility with possibility of future flexion contractures
EXPECTED COURSE/PROGNOSIS :
• First degree burn: complete resolution
• Second degree burn: epithelialization in 10-14 days (deep second degree burns will probably require skin
graft)
• Third degree burn: no potential for re-epithelialization, skin graft required
• Length of hospital stay and need for ICU care depends on extent of burn, smoke inhalation and age
• A 50% survival can be expected with a 62% burn in ages 0-14 years, 63% burn in ages 15-40 years, 38%
burn in age 40-65 years, 25% burn in patients over 65 years
• 90% of survivors can be expected to return to an occupation as remunerative as their pre-burn employment