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Burns

Basics

  • Injuries caused by heat, chemicals, electricity, or radiation
  • Depth: superficial (epidermis), partial-thickness (epidermis + dermis), full-thickness (all skin elements destroyed)
  • Systems affected: endocrine/metabolic, pulmonary, skin/exocrine

Epidemiology

  • 4th most common trauma worldwide
  • Predominant age: 20–30 years; 13% infants; 11% >60 years
  • Male predominance (70%)
  • In the US: 1.2-2 million burns/year, 700,000 ER visits, 45,000-50,000 hospitalizations, ~3,900 deaths
  • House fires cause 75% of deaths
  • Burns from methamphetamine production increasing (chemical + thermal + explosion injuries)

Etiology and Pathophysiology

  • Most common causes: open flame, hot liquids (heat ≥45°C)
  • Chemical burns may have delayed symptoms
  • Electrical burns can cause deep injury with minimal skin findings
  • Exposure intensity and duration determine burn depth

Risk Factors

  • High water heater temperature
  • Workplace exposure (chemicals, electricity, radiation)
  • Thin skin in children and elderly
  • Cigarette-related fires (18% of fatal fires in 2006)
  • Faulty wiring, lack of smoke detectors (63% residential fires)
  • Arson (12.4% fatal fires)
  • Low socioeconomic status

General Prevention

  • Home safety education, functioning smoke alarms, fireguards
  • Safe water heater temperature (<54°C)
  • Safe storage/use of flammable substances

Commonly Associated Conditions

  • Smoke inhalation syndrome: thermal injury to respiratory mucosa + carbon monoxide poisoning
  • Occurs within 72 hours after burn, especially in enclosed space or explosion exposure

Diagnosis

History

  • Source and circumstances of burn
  • In children/elderly, assess for abuse/neglect

Physical Exam

  • Superficial: erythema, blanching, tenderness
  • Partial-thickness: red, blistered, very tender
  • Full-thickness: tough, leathery, nontender
  • Rule of 9s for BSA estimation
  • Signs of airway involvement: singed nasal hair, facial burns, carbonaceous sputum, hoarseness, circumferential neck burn, tachypnea

Diagnostic Tests

  • Children: glucose (risk of hypoglycemia)
  • Smoke inhalation: ABG, carboxyhemoglobin
  • Electrical burns: ECG, urine myoglobin, CK isoenzymes
  • Labs: hematocrit, type and crossmatch, electrolytes, BUN, creatinine, urinalysis
  • Imaging: chest X-ray; xenon scan for smoke inhalation
  • Bronchoscopy for airway evaluation in smoke inhalation

Treatment

Prehospital Care

  • Remove patient from burn source, extinguish flames, remove clothing
  • Cool burns with room temperature water within first 15 minutes
  • Prevent hypothermia with wrapping
  • Administer 100% oxygen

Hospitalization Indications

  • Partial-thickness burns >10% BSA
  • Any full-thickness burn
  • Burns of hands, feet, face, perineum
  • Electrical, lightning, chemical burns
  • Inhalation injury
  • Circumferential burns
  • High-risk age groups (<10 or >50 years) with smaller burns

General Measures

  • Accurate BSA and depth assessment (rule of 9s)
  • Tetanus prophylaxis if needed
  • Remove rings/watches to prevent tourniquet effect
  • Chemical burns: flush for ~2 hours
  • Early intubation for airway compromise
  • No ice application
  • Nasogastric tube for ileus risk
  • Foley catheter placement
  • Analgesia: IV opioids preferred
  • ECG monitoring in electrical burns
  • Daily wound cleansing and dressing changes
  • Fluid resuscitation (Parkland formula):
    2-4 mL Ringer lactate × kg × %BSA burned (half in first 8 hrs, half next 16 hrs)
    Children: add maintenance fluids; adjust by urine output/vitals
  • Avoid colloids first 12-24 hrs
  • Consider biologic membranes or skin substitutes for coverage

Inhalation Injury

  • Intubation, PEEP ventilation, lung protective strategies
  • Hyperbaric oxygen for CO poisoning >25%, coma, neurologic deficits, ischemic ECG changes, pregnancy

Medications

  • First line:
    IV morphine or hydromorphone for severe pain
    Oral analgesics for moderate pain
    Topical: mupirocin (MRSA coverage), neosporin or bacitracin ointments
    Avoid silver sulfadiazine due to poorer healing outcomes
  • Second line:
    Mafenide for full-thickness burns (effective against Pseudomonas, risk of acidosis)
    Silver nitrate 0.5% (electrolyte loss risk)
    Povidone-iodine (may impede debridement)
    Enzymatic debridement (Travase)

Surgery and Procedures

  • Escharotomy for circumferential burns causing compartment syndrome
  • Early tangential excision with split-thickness skin grafts reduces mortality and hospital stay
  • Various dressings (biosynthetic, biologic) reduce dressing changes and aid healing

Ongoing Care

  • Early mobilization
  • High-protein, high-calorie diet once bowel function resumes
  • Enteral nutrition within 24 hours improves outcomes
  • TPN if NPO >5 days

Patient Education

  • Sun protection for grafted/epithelialized skin
  • Isolate household chemicals
  • Maintain smoke detectors and fire evacuation plans
  • Use low-temp water heaters (<54°C)

Prognosis

  • Superficial burns: complete resolution
  • Partial-thickness: heal in 10-14 days (deep may require graft)
  • Full-thickness: require skin grafting
  • Mortality prediction scores: Baux score, Denver 2 score
  • Burn size correlates with morbidity/mortality (>60% BSA in children, >40% in adults high risk)
  • Survival rates vary by age and burn size
  • 90% survivors return to preburn employment level

Complications

  • Curling ulcers (gastroduodenal)
  • Marjolin ulcer (SCC in old burn scars)
  • Wound infection and sepsis (MRSA, VRE, gram-negative organisms)
  • Flexion contractures and decreased mobility
  • Hypertrophic scarring