Chapter 11

Burn Injuries

Burn Injuries
OBJECTIVES
1. Describe how to assess the surface area of a burn injury.
2. Describe how to determine the depth of a burn injury.
3. Recognize key management strategies for burn injuries.
4. Recognize fluid resuscitation formulas.
5. Describe how mass burn casualties will be managed during a disaster.

I.

INTRODUCTION

Healthcare providers treating mass casualty victims will likely have to treat
individuals suffering burn injuries as they commonly result from natural and
manmade disasters. Burn injuries often follow an explosion and may occur in
conjunction with previously described injuries. Typically 25% to 30% of mass
casualty victims suffer burn injury. As an example, approximately one-third of
patients hospitalized in New York City on 9/11 had severe burn injuries.

II.

BURN CARE

Burn care differs from other types of trauma care provided during a mass casualty
event because it often requires a lengthy course of treatment. While major burns are
considered those that cover >20% of the total body surface area (TBSA), the
average burn injury suffered by individuals during a mass casualty event is a 50%
body surface area (BSA) burn. The latter requires an average 50-day length of stay
in the intensive care unit (ICU). Survival depends on rapid assessment and prompt
resuscitation as well as the treatment of comborbid conditions and associated
injuries such as smoke inhalation.

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Mortality following burn injuries is low, according to a retrospective review of 1,665

burn victims admitted to Massachusetts General Hospital and the Shriners Burns
Institute in Boston between 1990 and 1994. However, factors for increased mortality
include age >60 years, >40% of BSA burned and inhalation injury. For patients who
lack all risk factors, mortality rate is 0.3%; for those who have 1 risk factor, it is 3%;
for 2 risk factors, 33%, and all 3 risk factors, 90%. Burn victims of a mass casualty
incident typically have 2 of the 3 risk factors.

III.

SURFACE AREA AND DEPTH OF BURNS

Skin is the largest organ of the body. It has a variety of functions including
providing antiinfectious properties, fluid/electrolyte homeostasis and sensory
processing. The skin has 3 layers: the epidermis, dermis, and subcutaneous tissue
(Figure 1). A skin injury is determined based on the layer affected, the
temperature, and duration of exposure (Figure 2).

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Superficial

Epidermis

Superficial
Partial
Thickness
Deep
Partial
Thickness
Full
Thickness

Subcutaneous
Tissue

Figure 1: Skin Layers and Depth of Burn Injury (Source: How the Body Works,
Steve Parker)

-Protein Coagulation - Cell Death

-Denaturation of protein elements
recovery with short exposure
-Varying degree of cell injury
recovery likely
-No cell damage below this
temperature

Figure 2: Skin Injury

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To estimate medium to large burns in adults, use the Rule of Nines. (Figure 3) This
method divides the adult body into anatomic regions that represent 9%, or multiples
of 9%, of the total body surface. The Lund and Crowder chart can be used for a more
accurate assessment of burn areas in children as it compensates for the variation in
body
shape with age. Alternatively, the palm of a persons hand represents about 1% of
their body surface area.

Figure 3: The Rule of Nines (Source: Zimmerman JL (Ed): Fundamental Critical

Care Support, Third Edition, Society of Critical Care Medicine, 2002, Pg 9-15).

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Determining the depth of burn is essential for evaluating the severity of the burn and
planning for wound care. The depth of burn depends on the amount of energy
delivered in the injury and the relative thickness of the skin. Men have thicker skin
than women, but skin increases in thickness for both males and females as they age.

When the epidermis is burned, it results in a superficial burn. First-degree burns,

which are characterized by erythema, pain, and a lack of blisters, are not lifethreatening; sunburn is a common example. When the dermis is burned, the burn
can be either superficial partial or deep partial thickness. Second-degree burns are
characterized by a red or mottled appearance with associated welling and blister
formation. The surface may have a weeping, wet appearance and is painfully
hypersensitive. If the injury reaches the subcutaneous tissue, it is considered a full
thickness or third-degree burn. Third-degree burns typically appear dark and
leathery. The skin also may appear translucent, mottled, or waxy white. The surface
may be red, is generally dry and painless and does not blanch with pressure.

To estimate burn depth, focus on 4 elements: bleeding on needle prick, sensation,

appearance and blanching. Brisk bleeding after a superficial needle prick indicates
the burn is either superficial or superficial partial thickness. Delayed bleeding
suggests it is a deep partial thickness burn. A lack of bleeding suggests a full
thickness burn. While assessment of depth is important for planning treatment, it is
not necessary for calculating resuscitation formulas. Therefore, in acute situations a
lengthy depth assessment is inappropriate. One must keep in mind that a burn is a
dynamic wound, and its depth will change depending on the effectiveness of
resuscitation and re-evaluate initial estimates as part of a second survey.

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IV.

UPPER AIRWAY AND INHALATIONAL INJURIES

Inhalational injury refers to a wide range of airway and pulmonary problems

resulting from thermal injury. Upper airway damage and edema is due to direct heat
exposure, which usually does not affect the larynx. Lower airway injury can result
from inhalation of a particulate ( 5 microns) and chemical damage from incomplete
combustion products carried by smoke.

Inhalation injury can be categorized into the following clinical stages: acute, which is
characterized by hypoxia and asphyxia and occurs as late as 36 hours following the
burn injury, and pulmonary or airway edema, which occurs between 6 and 72 hours
following injury. Very often, infectious complications eventually develop both stages.

Signs of inhalational injury include the following: stridor/voice change/brassy cough;

carbonaceous sputum or carbon particles in the oropharynx; oropharynx
burns/bronchoscopy findings; singed nasal hair and face burns (some say the latter
are questionable signs) and full thickness or deep dermal burns to the face, neck or
upper torso. Flame burns or burns in enclosed spaces are clues to inhalational injury.
However, the clinical manifestations of inhalation injury may be subtle and frequently
do not appear in the first 24 hours. While waiting for evidence of pulmonary injury
from an x-ray or a change in blood gas, upper airway edema may preclude
intubation, forcing the need for a surgical airway.

A.

DIAGNOSIS

To diagnose inhalation injury, one must obtain a history and conduct a physical
examination. The history will provide valuable information about the nature and

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extent of the burn, the likelihood of inhalational injury, depth of burn, and probability
of other injuries. Arterial blood gases and carboxyhemoglobin content should be
determined, but these can be misleading if they are initially normal. Chest x-ray is
insensitive as an initial test because parenchymal changes may not be evident within
48 to 72 hours.

Diagnosis of inhalation injury is best confirmed by fiberoptic bronchoscopy, which

detects airway edema, mucosal sloughing or charring or soot in the upper airways. A
bronchoscopy is both diagnostic and therapeutic. Several ideas and clear secretions
remove mucus plugs help diagnosis pneumonia.

B.

MANAGEMENT

As a general approach to treating burn victims, one should assume that they have
major trauma and ignore the burns initially. Given that, the first priority is to assess
the patients airway, breathing and circulation. One should assess the airway to
determine whether it is compromised or at risk of becoming compromised. An airway
that is patent on arrival could occlude after admission. This is a particular concern for
children.

If there is any concern about the patency of the airway, then endotracheal intubation
is essential. Indications for intubation include erythema or swelling in the
oropharynx, change in voice with hoarseness or harsh cough, stridor or dyspnea,
circumferential neck burns, coma and the use of chemical aerosols in the incident.
Because there is a high probability of the need for a bronchoscopy in burn patients
with airway injury, choose an endotracheal tube of sufficient size for a definitive
airway.

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Different types of burn injuries tend to affect a persons breathing in different ways.
Direct thermal injury produces upper airway edema and/or obstruction whereas
inhalation of combustion and toxic fumes leads to chemical tracheobronchitis,
edema, and pneumonia. For patients with mechanical restriction, which is typically
caused by deep dermal or full thickness circumferential torso burns, one should
consider performing an escharotomy. Penetrating injuries can cause tension
pneumothorax, and the blast itself can cause lung contusions and alveolar trauma
that could lead to adult respiratory distress syndrome. For patients with blast lung
injury, mechanical ventilation should be considered. For patients with smoke
inhalation, which can lead to atelectasis and pneumonia, non-invasive management
with nebulizers and positive pressure ventilation with positive end-expiratory
pressure should be considered. However, patients may need a period of mechanical
ventilation as this allows adequate oxygenation and permits regular lung suctioning.

Patients who have experienced carbon monoxide (CO) poisoning should receive
immediate high-flow oxygen via a non-rebreathing mask. Patients with high CO
levels may experience headache and nausea, confusion, coma and death. Patients
with CO levels of <20% usually lack symptoms of CO poisoning. High-flow oxygen is
recommended even for patients suspected of CO exposure (e.g., victims burned in
enclosed areas) because it displaces CO much quicker than atmospheric oxygen.
Carbon monoxide, which disassociates very slowly, has a half-life of approximately 4
hours while the patient is breathing room air compared with 40 minutes while the
patient is breathing 100% oxygen. one should intubate the patient if his/her
respiration is depressed, ventilate patients with carboxyhemoglobin levels >25% to
30% and continue oxygen therapy until metabolic acidosis has cleared. For patients
who remain comatose, hyperbaric oxygen should be considered.

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Patients may experience cyanide exposure and poisoning as a byproduct of being in

a burning environment. Inhalational injury due to cyanide exposure causes tissue
asphyxiation. The organs most sensitive to cellular hypoxia are the central nervous
system and the cardiovascular system. The central nervous system reacts to low
concentrations of cyanide through hyperventilation, which increases exposure when
the route is inhalational. Higher levels of exposure could result in obtundation,
seizures and apnea. While low levels of cyanide increase cardiac output, high levels
can cause a variety of bradyarrhythmia and tachyarrhythmia. Signs of cyanide
intoxication include persistent neurologic dysfunction unresponsive to the use of
supplemental oxygen, cardiac dysfunction and severe lactic acidosis. Because lab
confirmation of the diagnosis could take up to 7 days, one should institute treatment
while awaiting confirmation. (See Chapter 10 for more information on chemical
exposures.)

When assessing the patients circulation, one should establish intravenous (IV)
access with 2 large bore cannulas preferably placed through unburnt tissue. This can
be used to take blood for checking full blood count, chemistries, blood group and
coagulation studies. Check peripheral circulation, as well. If there is any suspicion of
decreased perfusion due to circumferential burn, the tissue must be released with
escharotomies. Profound hypovolemia is not a normal initial response to a burn.
Hypotension could be caused by delayed presentation, cardiogenic dysfunction or an
occult source of blood loss (eg, chest, abdomen, pelvis).

Next, a neurological examination should be conducted to determine if the patient has

suffered any kind of disability. The Glasgow Coma Scale should be used to assess
patients for responsiveness. A burn victim may be confused because of hypoxia or

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hypovolemia. If the patient enters a coma following the burn injury, the cause is not
the burn itself. Among the potential causes are inhalational injury, CO/asphyxia,
intoxication, and closed head injury.

One should examine the patients entire body to get an accurate estimate of the burn
area and to check for concomitant injuries. Burn victims, especially children, quickly
become hypothermic, which can lead to hypoperfusion and deepening of burn
wounds. During the exam, patients should be covered and kept warm.

C.

FLUID RESUSCITATION

Burns covering >15% of the TBSA in adults and >10% in children warrant fluid
resuscitation. The goal of fluid resuscitation is to maintain tissue perfusion to the
zone of stasis and, in doing so, prevent the burn from deepening. Care is needed in
fluid resuscitation as too little fluid could cause hypoperfusion, too much could lead
to edema that will result in hypoxia. Furthermore, administering warm fluids will help
prevent hypothermia.

A resuscitation regimen should be based on the estimation of the burn area. To

monitor hourly urinary outputs reliably, an indwelling urinary catheter should be
inserted. A urinary catheter should be mandatory in all adults with injuries covering
>20% of TBSA.

The most commonly used fluid formula is the Parkland formula. This pure crystalloid
formula is easy to calculate and the rate is titrated against urine output (Table 1).

Table 1: Fluid Resuscitation

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Parkland formula - 4 ml/kg/% second and third degree, 1/2 in the first 8
hours of lactated Ringers solution

Second 24 hours - maintenance fluids, +/- 0.3 to 0.5 ml/kg/% burn as

albumin

Children - maintenance plus dextrose under age 2 - inadequate glycogen

stores in liver

Endpoint

Urine output 0.5-1.0 ml/kg/hr in adults

Urine output 1.0-1.5 ml/kg/hr in children

Apply in wounds >15% TBSA

Fluid formulas should be used only as guidelines. For example, the Parkland formula
can underestimate some injuries (eg, inhalation burns, extremely deep burns,
electrical conduction injuries, delayed resuscitation). Consequently, adequate urine
output will determine if the formula is sufficient. The patients fluid resuscitation
status should be monitored every 4 to 6 hours. The success of a fluid regimen relies
on adjusting the amount of resuscitation fluid against monitored physiological
parameters (eg, pulse, blood pressure, respiratory rate).

For chronic burn fluid management, fluids are typically administered in a rate that
accounts for urine output and evaporative or insensible losses. Caloric targets will
focus on metabolic demands and growth. Evaporative water loss should be calculated
by using the following equation: evaporative water loss (ml/hr) = (25 + % TBSA
burned) x TBSA. The TBSA is determined by rule of nines, not a fixed value. The fluid
required equals evaporative loss plus other losses, such as urine, stool and output
from drains.

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D.

ADDITIONAL MANAGEMENT CONSIDERATIONS

In addition to rapid assessment, prompt fluid resuscitation and mechanical

ventilation when necessary, successful burn management also involves wound care
and nutritional support.

The patients clothing should be removed to stop the burning process. Any clothing
with chemical involvement should be removed to limit contamination. After the
surface area and depth of a burn have been estimated, remaining dry chemical
powders should be brushed from the wound in a way to avoid direct contact with the
chemical. Next, the victims rings and bracelets should be removed, and the would
should be gently rinses with copious amounts of water. All loose skin and deroof
blisters should be removed for ease of dressing. Partial thickness burns are especially
painful when air currents pass over the surface area; covering the burn with clean
linens both relieves the pain and deflects the air currents. Using burn dressings
before transfer is controversial because burn centers can get a more accurate
assessment of damage and future treatment plans. A consultation with a burn center
should be conducted to determine specific wound care. To prevent hypothermia, the
patient should be covered with warm, clean, and dry linens.

Signs of burn wound sepsis include blackening, softening or premature separation of

eschar. The patient may experience confusion, a falling platelet count, a declining
urine output, hyperglycemia and sepsis. Burn wound sepsis is usually caused by a
gram-positive methicillin-resistant Staphylococcus aureus, and not pseudomonas.
Immediate excision of the infected eschar minimizes infection, hastens wound
healing, reduces blood loss and improves survival.

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Although early eschar excision virtually eliminates the risk of burn wound sepsis,
bacteria flourishes in burned dermis so there is still the risk of infection. However,
bacteria do not penetrate viable tissue. Permanent wound coverage can be
accomplished using autografts. Temporary wound coverage can be accomplished
using cadaver skin, pigskin or a synthetic skin product such as Biobrane.

The use of topical antimicrobials may lower infection rates. Silver sulfadiazine is a
commonly used agent. However, it may cause dermal hypersensitivity reactions and
transient leukopenia in a small percentage of patients. Mafenide acetate exhibits
superb eschar penetration, but it can cause metabolic acidosis and severe wound
pain. Silver nitrate is effective and safe, but it stains and can cause hyponatremia.
Bacitracin is inexpensive, but it can cause skin rashes. The use of systematic agents
as routine prophylaxis is no longer recommended.

When the resuscitative fluid phase is complete, one should begin nutritional support.
The gold standard is to begin nasoduodenal feedings within 24 hours for major burn
victims. Enteral nutrition is preferable as parenteral nutrition can cause a host of
complications including immuno-suppresion, line sepsis with endocarditis and/or
acalculous cholecystitis. Requirements for burn victims are not significantly different
from those of other trauma patients. Formulations that contain high protein, low fat
and linoleic acid, enriched vitamins A and C, zinc, histidine, cysteine, arginine, and
omega 3 fatty acids are recommended. Additional protein may improve immune
function and mortality.

E.

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Circumferential burns are rigid and burn eschar on an extremity does not stretch to
accommodate the tissue swelling that is occurring beneath it. Circumferential burns
of the chest can limit chest excursion and prevent adequate ventilation. A patient
with circumferential burns will most likely require an escharotomy. A patient with a
full thickness burn of the anterior and lateral chest wall that leads to severe
restriction of the chest wall motion, even in the absence of circumferential burn, also
may require escharotomy.

During an escharatomy, only the burnt tissue is divided, not any underlying fascia,
distinguishing this procedure from a fasciotomy. For a chest escharatomy,
longitudinal incisions are made down each mid-axillary line to the subcostal region.
The lines are joined up by a chevron incision running parallel to the subcostal
margin. These incisions create a mobile breastplate that moves with ventilation
(Figure 4).

Figure 4: Escharotomy Bedside procedure

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For an escharotomy of a limb, incisions are made along the midlateral or medial
aspects of the limb. Escharotomies are best done with electrocautery, as they tend
to bleed. Next, the tissue should be with dressing and dress the burn. Using a shield
incision for chest burns improves patient compliance. Escharotomies should be
performed either with an experienced burn surgeon or in consultation with one.
Initially, one should elevate and observe at risk limbs. If the patients hemodynamic
condition permits and spinal injury is excluded, elevation of the head and chest by
20 to 30 degrees can be helpful in reducing neck and chest wall edema.

Although fasciotomy is rarely required, it may be necessary to restore circulation for

patients with associated skeletal trauma, crush injury, high-voltage electrical injury
or burns involving tissue beneath the investing fascia.
V.

SPECIAL BURN REQUIREMENTS

Electrical burns are the result of a source of electrical power making contact with the
patients body. Characterized by entry and exit wounds, they are frequently more
serious than they appear on the surface, resulting in deep tissue damage. The heat
generated often causes second-degree burn injury. Electrical burns can result in
rhabdomyolysis, which can lead to acute renal failure, compartment syndromes and
cardiac arrest. They are often associated with secondary injuries such as falls and
muscle contractions. Management of electrical burns should include paying close
attention to the airway and breathing, establishing an IV line in an uninvolved
extremity, monitoring the patient with an electrocardiogram and placing an
indwelling catheter. If the patients urine is dark, it should be assumed that
hemochromogens are in the urine. There is no need to wait for lab confirmation
before instituting therapy for myoglobinuria. If the pigment does not clear with

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increased fluid administration, 25 grams of mannitol should be administered
immediately, adding 12.5 grams of mannitol to subsequent liters of the fluid
resuscitation formula to maintain the diuresis. Metabolic acidosis should be corrected
by maintaining adequate perfusion and adding sodium bicarbonate to alkalinize the
urine as necessary and increasing the solubility of myoglobin in the urine. One
should consider using mannitaol and alkalinizing urine, as not all nephrologists
believe in these measures, concentrating mostly on maintaining a large volume of
urine output.

Chemical injury can result from exposure to acids, alkalies or petroleum products.
The degree of injury is influenced by the concentration and amount of agent and
duration of exposure. Irrigate the chemical copiously with water. As previously
described, the chemical should be removed by irrigation or brushing it away if it is
dry powder. Alkali burns require longer irrigation with water than other chemical
burns.

Burn victims often experience soft tissue trauma as part of their injuries (Figure 5).
These injuries can range from soft tissue loss to complex fractures. Consequently,
treatment for soft tissue trauma can range from debridement of dead tissue to
surgical repair of soft tissues.

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Figure 5: Soft Tissue Trauma (Source: Maegele M, Gregor S, Steinhausen E, et al.

The long-distance tertiary air transfer and care of tsunami victims: Injury pattern
and microbiological and psychological aspects.Crit Care Med 2005; 33:1136-1140.
Burn victims can also go into burn shock. This form of shock causes cellular
changes to both burned and unburned tissue as well as potential membrane loss. It
also causes extracellular sodium loss. Treatment strategies for burn shock include
supporting plasma volume and organ perfusion, replacing extracellular (salt) loss to
cells, monitoring electrolytes and tracking the development of multi-organ failure.

VI.

BURN DISASTER MANAGEMENT

The American Burn Association (ABA) has developed a plan for the management of
mass burn casualties resulting from disasters and terrorist acts. As part of the plan,
the ABA has established Burn Specialty Teams (BSTs) that are specialized Disasters

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Medical Assistance Teams. In the event of a mass casualty incident, the BSTs are
deployed to provide burn expertise. They are composed of 15 burn-experienced
personnel including 1 surgeon, 6 registered nurses, 1 anesthesia provider, 1
respiratory therapist, 1 administrative officer and 5 support personnel. The 4 existing
BSTs are based out of Boston, Galveston, Minneapolis/St. Paul and Tampa, and 2
more are expected to be formed.

Additionally, the ABA has the ability to implement a system designed to track the
daily availability of burn beds for national emergencies. Although the system is
intended for military conflict, is can be used for civilian mass casualty events.
Patients would be transferred through designated embarkation points located
throughout the United States and then sent to one of the 70 participating burn
centers where a burn surgeon would conduct triage (Figure 6). The system would
be activated during a mass casualty incident, natural disaster or elevated terrorism
alert status. It would be run on a more frequent basis until the event or alert has
been resolved.

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Figure 6: Embarkation Points. Source: J Burn Care Rehabil 2005; 26: 1740182.

KEY POINTS

1. Partial thickness burnsor second-degree burnshave a red or mottled

appearance with associated welling and blister formation. The surface may
have a weeping, wet appearance and is painfully hypersensitive.
2. Full thickness burnsor third-degree burnsmay appear dark and leathery,
translucent, mottled, or waxy white. The surface may be red, is painless and
generally dry and does not blanch with pressure.
3. The clinical manifestations of inhalation injury may be subtle and frequently
do not appear in the first 24 hours. While waiting for confirmation from a

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chest x-ray or lab test results, airway edema may preclude intubation, forcing
the need for a surgical airway.
4. Accurate assessment of the BSA is crucial to calculate a resuscitation formula.
5. Resuscitation formulas are only guidelines; the patient must be monitored for
urine output to determine if the formula is sufficient.
6. A patient with circumferential burns will require escharotomy.
SUGGESTED READINGS
1. Injuries due to burns and cold. In: Advanced Trauma Life Support Program
for Doctors. 7th edition. Chicago, Ill: American College of Surgeons;2004:231241.
2. Hettiaratchy S, Papini R. ABC of burns: Initial management of a major burn:
Ioverview. BMJ. 2004;328:1555-1557.
http://bmj.com/cgi/content/full/328/455/1555. Accessed Sept. 5, 2006.
3. Hettiaratchy S, Papini R. ABC of burns: Initial management of a major burn:
IIassessment and resuscitation. BMJ. 2004;329:101-103.
http://bmj.com/cgi/content/full/329/7457/101. Accessed Sept. 5, 2006.
4. Papini R. ABC of burns: Management of burn injuries of various depths. BMJ.
2004;329:158-160. http://bmj.com/cgi/content/full/329/7458/158. Accessed
Sept. 5, 2006.
5. Serebrisky D. Inhalation injury.
http://www.emedicine.com/ped/topic1189.htm. Accessed Sept. 11, 2006
6. Ryan CM, Schoenfeld DA, Thorpe WP, et al. Objective estimates of the
probability of death from burn injuries. NEJM. 1998;338(6):362-366.
7. Barillo DJ, Jordan MH, Jocz RJ, et al. Tracking the daily availability of burn
beds for national emergencies. Journal of Burn Care & Rehab.
2005;26(2):174-182.
8. ABA Board of Trustees and the Committee on Organization and Delivery of
Burn Care. Disaster management of the ABA plan. Journal of Burn Care &
Rehab. 2005;26(2):102-106.

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