You have a new patient!
A 26-year-old male presents to the emergency department with burns on his face, arms, hands, and torso. He states that he was burning trash in his front yard without his shirt on when a big explosion occurred. He appears distressed and short of breath. The presence of singed nasal hairs is also noted. Examination reveals multiple partial- and full-thickness burns with blisters and surrounding redness. His vitals are as follows: HR: 130 BP (taken on R calf): 130/80 RR: 30 SpO2: 75%. His weight: 75kg
What do you need to know?
Importance
Burn injuries result from various sources and can range in severity. The mortality rate from thermal burns is directly related to the size of the burn [1]. Large and deep burns can trigger systemic responses, such as shock, which can lead to death. Three key risk factors that increase the likelihood of complications include: age over 60 years, inhalation injuries, and non-superficial burns (partial and full-thickness) covering more than 40% of the total body surface area (TBSA) [2].
Epidemiology
Burn injuries are a significant public health issue, with approximately 450,000 individuals seeking medical attention annually, and about 45,000 requiring hospitalization [2]. Residential fires are the leading cause of burn-related deaths, contributing to nearly 3,500 fatalities per year. Smoking materials, such as cigarettes, are the primary cause of fire-related deaths, while other fatal injuries stem from motor vehicle crashes, electrical contact, or exposure to chemicals. Men constitute 71% of burn patients, with children under five representing 17% [2]. Most burns occur at home (65%) and involve less than 10% total body surface area (67%). Advances in burn care have improved survival rates to 96% [2]. Roughly 86% of all burns are caused by thermal injury. Flame and scald burns are the leading causes of burns in children and adults. Inhalation injury is present in two-thirds of patients with burns greater than 70% of TBSA.
Pathophysiology
Burn injuries, caused by heat, chemicals, electricity, or radiation, trigger a complex interplay of local and systemic responses. At the cellular level, burn wounds are divided into three distinct zones: coagulation, stasis, and hyperemia. The central zone of coagulation undergoes irreversible cell death due to protein denaturation, necessitating surgical intervention in many cases. Surrounding it, the zone of stasis contains viable but at-risk cells that can either recover with proper care or progress to necrosis. The outer zone of hyperemia typically recovers fully within days due to its inflammatory response and intact blood flow [2-4].
Burns prompt a robust inflammatory response, increasing capillary permeability and causing fluid shifts that lead to edema. Local edema compromises blood flow and cell survival in the zone of stasis, while systemic edema in large burns contributes to hypovolemia, the primary cause of burn shock. Immediate and adequate fluid resuscitation is critical to prevent worsening injury and maintain organ perfusion [2-4].
Specific burn types exhibit unique pathophysiologies. Inhalation injuries from superheated gases or toxic smoke cause airway edema, inflammation, and potentially fatal complications like carbon monoxide poisoning and ARDS [5]. Chemical burns differ by agent, with acids causing coagulation necrosis and alkalis leading to deeper liquefaction necrosis. Electrical burns often involve extensive internal damage along the current’s path, risking cardiac arrhythmias and systemic effects. Radiation burns, though rarer, involve cellular damage through ionizing radiation exposure [2-4].
Systemically, extensive burns induce a hypermetabolic state, immune suppression, and systemic inflammatory responses affecting multiple organs. Cardiovascular effects, such as burn shock, respiratory compromise, and heightened infection risks, are key complications. Patient outcomes hinge on factors like burn depth, TBSA, age, inhalation injury presence, and quality of initial management, underscoring the importance of specialized burn center care.
Burn Depth
Burn depth classification is fundamental to assessing burn injuries, guiding treatment decisions, and predicting outcomes. Accurate determination of burn depth, particularly for partial-thickness burns, remains challenging, even for skilled clinicians. This underscores the need for continued research and advanced technologies to enhance diagnostic precision.
Traditionally, burns are categorized into four classes based on the extent of tissue damage [4]:
- Superficial Thickness (First-Degree) Burns: These affect only the epidermis, presenting with redness, pain, and warmth without blistering. Healing occurs within a few days without scarring.
Partial-Thickness (Second-Degree) Burns: These penetrate the dermis and are subdivided into:
Superficial Partial-Thickness Burns: Involving the upper dermis, they are painful, moist, and blistered, typically healing within 2–3 weeks with minimal scarring.
Deep Partial-Thickness Burns: Reaching deeper dermal layers, these burns cause damage to sweat glands and hair follicles. They are less painful due to nerve damage, appear mottled and dry, and may require 3–8 weeks or longer to heal, often resulting in scarring or contractures.
Full-Thickness (Third-Degree) Burns: These burns destroy the entire epidermis and dermis, extending into subcutaneous tissue. They appear white, brown, or charred with a leathery texture and are insensate due to nerve destruction. Healing requires surgical intervention, such as skin grafting, and leaves significant scars.
Fourth-Degree Burns: Extending into muscles, bones, tendons, or ligaments, these burns are characterized by blackened tissue and often result in loss of the affected part.
These classifications provide a framework for clinicians to tailor interventions and anticipate patient needs, particularly in severe or complex burn cases. The illustration below displays the various categories of burn depth [4].
Medical History
Accurately gathering a burn history is critical for evaluating the injury’s severity, identifying risks, and tailoring management. The AMPLET mnemonic is widely recommended for systematic collection of essential information regarding the event and the patient’s medical background. Additionally, specific questions based on the type of burn provide crucial details for precise assessment and treatment [2-4, 6].
Allergies (A):
Identifying drug and environmental allergies is essential to avoid adverse reactions during treatment.
Medications (M):
A detailed list of current medications, including prescription drugs, over-the-counter remedies, herbal supplements, and home treatments, is vital to anticipate potential drug interactions or complications.
Past Medical History (P):
Knowledge of pre-existing conditions, such as diabetes, cardiovascular disease, lung disorders, or bleeding tendencies, helps predict how the patient may respond to burn injuries and resuscitation. Tetanus immunization status should also be reviewed and updated if necessary (see “T”).
Last Meal or Drink (L):
Documenting the patient’s last meal or drink is crucial for surgical planning, as recent food intake may require delays in procedures involving anesthesia.
Events/Environment Relating to Incident (E):
A detailed account of the burn incident helps identify the mechanism of injury, the risk of inhalation injury, and associated trauma. Important elements to document include:
- Type of burn: Thermal, chemical, electrical, or radiation.
- Cause of burn: Flame, scald, contact with hot objects, chemicals, or electricity.
- Incident location: Indoor/outdoor, enclosed space, smoke presence.
- Duration of exposure: Time spent in contact with the burn source.
First aid administered: Cooling, cleaning, or dressing of the burn before medical evaluation. - Suspicion of abuse or neglect: Look for inconsistencies in the history, patterns of injury, or delays in seeking care. Specific questions include:
- How did the burn occur?
- Who was present?
- How long to extinguish flames?
- Was the area cooled? With what and for how long?
- Were explosions, blasts, or chemical spills involved?
- Was the patient trapped or unconscious?
Tetanus and Childhood Immunizations (T):
Ensuring tetanus immunization is current (within five years) is crucial. In children, assessing overall immunization status helps anticipate potential complications.
Specific Questions Based on Burn Type [2-4,6]
Thermal Burns:
- How did the burn occur?
- What was the heat source (e.g., flame, scald, or hot object)?
- Was clothing involved, and how quickly was it removed?
- Was a flammable liquid (e.g., gasoline) involved?
Chemical Burns:
- What was the chemical agent?
- How did exposure occur, and how long was contact?
- What decontamination measures were taken?
- Is a Material Safety Data Sheet (MSDS) available?
Electrical Burns:
- What type of electricity was involved (high voltage/low voltage, AC/DC)?
- What was the duration of contact?
- Was the patient thrown or did they fall?
Physical Examination
The physical examination of a burn patient is a systematic process designed to assess the severity of the burn injury, identify associated injuries or complications, and guide treatment decisions. A comprehensive and thorough examination is critical for determining the need for transfer to a burn center and predicting potential outcomes [2-6]. Make sure to assess for concomitant trauma (especially after a blast injury or fall).
First, perform decontamination if the person has been exposed to a chemical substance. If possible, expose the patient to a warm room. Immediately assess the airway, breathing, and circulation (ABCs), see details below.
Primary Survey
The primary survey prioritizes life-threatening conditions using the ABCDE approach [2,4,6]:
A. Airway
- Assess for patency: Check for obstruction, swelling, or soot in the mouth and nose. Examine for posterior oropharynx edema and singed facial and nasal hairs carefully.
- Listen for abnormal breath sounds: Stridor, wheezing, or decreased breath sounds may indicate inhalation injury or airway compromise.
- Consider early intubation: Severe facial burns, inhalation injury, or altered mental status may necessitate securing the airway. Please do not delay airway procedure if you suspect inhalation injury.
B. Breathing
- Assess respiratory rate and effort: Look for tachypnea, labored breathing, or cyanosis.
- Auscultate lung sounds: Wheezing, rales, or rhonchi may suggest inhalation injury or pulmonary complications.
- Administer high-flow oxygen: Use 100% oxygen via a non-rebreather mask, particularly for moderate to severe burns patients or patients with suspected inhalation injury.
C. Circulation
- Monitor heart rate and rhythm: Look for tachycardia, bradycardia, or arrhythmias.
- Measure blood pressure: Hypotension may indicate shock or blood loss.
- Assess capillary refill and skin color: Delayed refill, pallor, or cyanosis indicates poor perfusion.
- Establish IV access: Insert two large-bore IVs for moderate to severe burn patients, particularly for burns covering >20% TBSA.
- Control bleeding: Bleeding suggests additional injuries.
D. Disability
- Assess level of consciousness: Use the AVPU scale (Alert, Verbal, Pain, Unresponsive) or Glasgow Coma Scale (GCS).
- Evaluate neurological status: Check pupils, motor strength, and sensation.
E. Exposure and Environmental Control
- Remove clothing and jewelry: Fully expose the patient to assess burns but prevent further constriction.
- Identify deformities: Look for fractures or dislocations.
- Maintain warmth: Use clean, dry sheets and blankets to prevent hypothermia.
Secondary Survey
Once the primary survey stabilizes life-threatening conditions, conduct a detailed evaluation [2,4]:
A. History
Obtain a complete history using the AMPLET mnemonic, covering allergies, medications, past medical history, last meal, events surrounding the burn, and tetanus immunization status (see Medical History above).
B. Head-to-Toe Examination
- Head and Neck: Assess for burns, singed hair, soot, inhalation injury, corneal damage, and tympanic membrane injury.
- Chest: Listen to breath sounds, observe chest expansion, and evaluate for circumferential burns that may impair breathing.
- Abdomen: Inspect for burns, palpate for tenderness, and consider the risk of abdominal compartment syndrome with circumferential burns.
- Extremities: Look for burns, fractures, diminished pulses, or signs of compartment syndrome. Assess sensation and motor function.
- Genitalia and Perineum: Inspect for burns and swelling, and assess urinary retention.
- Back and Buttocks: Examine these areas during log rolling, ensuring full exposure and injury identification.
C. Burn Wound Assessment
- Burn size: Estimate TBSA using the Rule of Nines (see images below) [7] or the Lund and Browder chart.
- Burn depth: Classify burns as superficial, partial-thickness (superficial or deep), full-thickness, or fourth-degree. Note that burn depth may evolve over time (see figure about burn depth above).
- Document wound characteristics: Describe color, texture, moisture, blisters, and eschar.
Burns are classified into degrees based on the depth of tissue damage, with each classification displaying distinct pathophysiological features, clinical findings. The following section covers specific clinical information related to burn depth.
Superficial (First-Degree) Burns
Superficial burns involve only the epidermis, the outermost layer of the skin. These burns are characterized by warm, dry, and red areas that blanch with pressure. Blistering is absent, and the skin typically heals within a few days without scarring. Sunburn is a classic example of a superficial burn.
Partial-Thickness (Second-Degree) Burns
Partial-thickness burns extend beyond the epidermis into the dermis and are further divided into superficial and deep categories.
- Superficial Partial-Thickness Burns: These burns affect the upper dermis and are very painful. Surrounding erythema, moisture, and blistering are common features. These burns blanch when pressed and typically heal with minimal scarring in 2–3 weeks.
- Deep Partial-Thickness Burns: These penetrate deeper into the dermis, potentially damaging sweat glands and hair follicles. They are less painful due to nerve ending destruction and appear drier, with a mottled red or white surface that does not blanch. Healing takes longer and often results in scarring or contractures. Scalds and flash burns are typical causes of partial-thickness burns.
Full-Thickness and Beyond (Third- and Fourth-Degree) Burns
Full-thickness burns destroy the entire epidermis and dermis, often extending into subcutaneous fat and, in severe cases, deeper structures such as muscle and bone (fourth-degree burns). These burns result in decreased sensation due to nerve destruction. The affected areas appear white, brown, or leathery, with a dry texture, and they do not blanch when pressed. Examples include chemical burns, electrical burns, fully immersed thermal burns, and severe frostbite. Healing requires surgical intervention, such as skin grafting, and significant scarring is inevitable.
Clinical Images of Selected Burn Injuries
Acing Diagnostic Testing
The diagnostic approach to burn patients varies based on the severity of the burn, the suspected complications, and the presence of associated injuries. A systematic evaluation using targeted laboratory tests and imaging helps guide treatment decisions and monitor potential complications.
Patients with Minor Burns
For patients with minor burns and no associated injuries, laboratory testing is generally unnecessary unless other trauma or medical conditions are present.
Patients with Moderate to Severe Burns
Moderate to severe burns necessitate a more comprehensive diagnostic evaluation [2,6]:
- Complete Blood Count (CBC): Assesses anemia, infection, or thrombocytopenia.
- Comprehensive Metabolic Panel (CMP): Monitors electrolyte imbalances, fluid shifts, and kidney or liver function.
- Creatine Kinase (CK): Detects muscle damage.
- Arterial Blood Gases (ABG) and Carboxyhemoglobin Levels: Essential for suspected inhalation injury to evaluate oxygenation, carbon monoxide poisoning, and acidosis.
- Blood Cyanide Levels: Performed if cyanide poisoning is suspected, though results may take time. Treatment is often initiated based on clinical suspicion [2].
- Serum Lactate: Elevated levels indicate tissue hypoperfusion, inadequate resuscitation, or exposure to carbon monoxide or cyanide [6].
- Coagulation Studies: Identifies coagulopathies, which are common in severe burns.
- Chest X-Ray (CXR): Evaluates lung damage in inhalation injury and confirms endotracheal tube placement in intubated patients [2,6].
Patients with Electrical Burns
Electrical burns require specialized evaluation due to the unique nature of the injuries:
- Electrocardiogram (EKG): Necessary for detecting cardiac dysrhythmias, especially in high-voltage injuries. Patients with abnormal EKG findings should be observed until normalization [6].
- Creatine Kinase (CK): Elevated levels indicate rhabdomyolysis caused by muscle damage [6].
- Urinalysis: Detects myoglobinuria, a sign of rhabdomyolysis, which can impair kidney function. However, urinalysis has limited specificity [6].
Imaging for Burn Patients
Imaging studies provide critical insights, particularly for inhalation or electrical injuries:
- Chest X-Ray (CXR): Evaluates lung damage in inhalation injury and confirms endotracheal tube placement in intubated patients. Useful for identifying pulmonary complications, such as pneumothorax, and confirming intubation tube placement [6].
- Fiberoptic Bronchoscopy: A definitive tool for diagnosing inhalation injury, revealing findings like soot, edema, mucosal blisters, and hemorrhages [5].
- Chest CT Scan: Offers detailed imaging of lung injuries and is particularly helpful when CXR findings are inconclusive [5].
Risk Stratification
Burn injuries are categorized as minor, moderate, or severe based on several factors that help predict outcomes and guide management. These include the depth of the burn, the percentage of total body surface area (TBSA) affected, and the age of the patient, with burns in individuals under 10 years or over 50 years considered more severe. The presence of associated injuries, such as smoke inhalation or other traumas, also increases the severity. Burns involving high-risk areas—the face, hands, feet, or genitalia—are particularly concerning due to their potential impact on function, aesthetics, and quality of life.
Risk Stratification Criteria
- Minor
- Adults: Partial-thickness burns affecting < 15% TBSA
- Pediatrics: Partial-thickness burns affecting < 10% TBSA
- No full-thickness burns
- No involvement of the face, hands, feet, or genitalia
- No cosmetic impairment
- Note: Superficial burns are not included in TBSA calculations.
- Moderate
- Adults: Partial-thickness burns affecting 15–20% TBSA
- Pediatrics: Partial-thickness burns affecting 10–15% TBSA
- Full-thickness burns affecting < 10% TBSA
- No involvement of the face, hands, feet, or genitalia
- No cosmetic impairment
- Severe
- Adults: Any burn depth affecting > 25% TBSA
- Pediatrics: Any burn depth affecting > 20% TBSA
- Full-thickness burns affecting > 10% TBSA
- Involvement of the face, hands, feet, or genitalia
- Cosmetic impairment
- Circumferential burns: Burns extending completely around the chest or a limb:
- Can cause compartment syndrome or increased pressure in the affected area.
- This is particularly dangerous in the chest, where it can restrict breathing and may require escharotomy (incisions into the burned tissue) to relieve the pressure.
Referral to a Burn Center
Referral to a specialized burn center is recommended based on the following criteria from the American Burn Association (ABA) [8]:
- Partial-thickness burns >10% TBSA.
- Burns involving the face, hands, feet, genitalia, perineum, or major joints.
- Full-thickness (third-degree) burns in any age group.
- Electrical or chemical burns.
- Inhalation injury.
- Burns in patients with pre-existing conditions that complicate management.
- Burns with concomitant trauma or special care needs.
Management
Effective management of burn patients begins with prompt stabilization of the airway, breathing, and circulation (ABC). Airway management is critical in cases of full-thickness facial burns, significant soot in the nose or mouth, hoarseness, stridor, respiratory depression, or altered mental status. In such scenarios, establishing a definitive airway through endotracheal intubation is necessary to prevent airway compromise. Breathing should be assessed by monitoring oxygen saturation and providing supplemental oxygen as needed to address hypoxemia, especially in patients with inhalation injuries. Circulation assessment involves evaluating distal pulses, particularly in patients with circumferential burns, which may restrict blood flow and necessitate escharotomy. For burns exceeding 20% TBSA, prompt initiation of intravenous fluid (IVF) resuscitation is essential to maintain hemodynamic stability and prevent burn shock. This systematic approach ensures early intervention to mitigate life-threatening complications. Extensive details on primary and secondary survey was given in the physical examination section.
General Principles in Management of Burns
Burn management follows consistent principles across all mechanisms of injury, prioritizing first aid, pain control, and fluid resuscitation.
First Aid
Immediate first aid involves removing the causative agent and any clothing, jewelry, or objects that may retain heat or constrict circulation. Cooling the affected area with water is effective for small burns but must be used cautiously with larger burns to prevent hypothermia [9].
Analgesia
Burn injuries and wound care are extremely painful, making pain management a critical component of care. Opioid pain medications should be considered to provide adequate relief, particularly for severe burns or during dressing changes [2,6].
Fluid Resuscitation
Fluid replacement is essential for patients with extensive burns to prevent hypovolemia and burn shock. Adults with partial- or full-thickness burns covering >20% TBSA require fluid resuscitation, while this threshold is lower (>10% TBSA) for pediatric and elderly patients [2,6].
Two common formulas guide fluid calculations:
- Parkland Formula: Volume (mL) = 4 × weight (kg) × % TBSA burned. Half of the total volume is given in the first 8 hours, and the remaining half over the subsequent 16 hours.
- Modified Brooke Formula: Volume (mL) = 2 × weight (kg) × % TBSA burned for adults, or 3 × weight (kg) × % TBSA burned for children, administered evenly over 24 hours.
Hartmann’s solution or lactated Ringer’s is the preferred replacement fluid. Fluid titration, based on urine output, ensures appropriate volume without overloading:
- Adults: Maintain urine output at 0.5–1.0 mL/kg/hour.
- Pediatrics: Maintain urine output at 1.0–1.5 mL/kg/hour.
Fluid resuscitation is a dynamic process requiring hourly re-evaluation to ensure adequacy and prevent complications [2,6]. The fluid rate must be carefully titrated based on the patient’s urinary output and physiological response. Hourly urine output, measured using an indwelling bladder catheter, serves as a reliable indicator of resuscitation adequacy in patients with normal renal function.
- Adults: Maintain urine output at 0.5 mL/kg/hour (approximately 30–50 mL/hour).
- Young Children (≤30 kg): Target 1 mL/kg/hour.
- Pediatric Patients (>30 kg, up to age 17): Maintain output at 0.5 mL/kg/hour.
- Adults with High-Voltage Electrical Injuries and Myoglobinuria: Ensure a urine output of 75–100 mL/hour until urine clears.
This individualized approach to fluid management helps maintain renal perfusion, ensures effective resuscitation, and minimizes the risk of under- or overhydration.
Thermal Burns
Thermal burns occur when excessive heat is applied to the skin, resulting in tissue destruction. Initially, this process may cause inflammation and initiate the healing response. However, if the heat intensity or duration is sufficient, coagulative necrosis ensues, leading to irreversible cell death and localized tissue loss. The severity and type of burn depend on various factors, including the heat source, duration of exposure, and depth of tissue involvement.
The treatment of thermal burns varies based on severity [2, 6, 10].
Minor burns are managed by cleaning the area and applying topical aloe and a barrier dressing. Pain is controlled with oral analgesics, such as NSAIDs or acetaminophen/paracetamol. Patients can be discharged with outpatient follow-up for wound monitoring.
Moderate burns require cleaning with water and debridement of large blisters. Wound care involves the application of a topical antibiotic with a dressing or an antibiotic-impregnated bandage. Pain management may include oral or intravenous analgesia, with narcotics as needed. Fluid resuscitation, either oral or intravenous, is determined by the percentage of total body surface area (%TBSA) affected. Tetanus immunization should be updated if the last dose was over 10 years ago. Consultation with a burn specialist is advised, with possible admission or transfer to a burn center.
Severe burns necessitate cleaning with water, pain management with oral or intravenous analgesia, and application of a dressing without antibiotics or ointments if transfer to a burn center is confirmed. Intravenous fluid resuscitation is essential, along with prompt referral and admission to a burn center. Circumferential full-thickness burns may require escharotomy to prevent complications such as compartment syndrome.
Electrical Burns
Electrical burns can present with a wide range of injuries due to the effects of electrical current and the conversion of electrical energy into thermal injury. High-voltage electrical exposure can also result in blunt trauma caused by the patient being propelled away from the electrical source.
Extent of injuries depends on the voltage type:
- Low voltage: Commonly seen in children who come into contact with electrical cords or outlets.
- High voltage: Typically occupational injuries from power lines or utility poles, often leading to deep tissue and organ damage.
- Lightning: Frequently occurs during outdoor recreational or work activities, especially in rainy seasons.
Deep tissue injury assessment:
Patients presenting with full-thickness burns, painful passive range of motion, and elevated creatine kinase (CK) levels should be presumed to have deep tissue injury.
- These patients require fluid resuscitation and referral to a burn center when possible.
Muscle damage results in a breakdown known as rhabdomyolysis, which can lead to renal failure and multi-organ failure if not treated promptly.
Management [2,3,11]
General Principles
- Cardiac Monitoring: Patients with suspected electrical burns should undergo continuous cardiac monitoring for 12–24 hours to detect dysrhythmias.
- Compartment Syndrome Monitoring: Close monitoring is essential for signs of compartment syndrome.
- Stress Ulcer Prophylaxis: Administer proton pump inhibitors (PPIs) or H2 blockers, especially in patients who are NPO, as electrical burns carry a higher risk of ulcer formation compared to other burns.
Analgesia
- Severe pain from deep tissue injuries often necessitates IV narcotic analgesia.
Fluids
- Initiate fluid resuscitation with 1L/hr isotonic fluids in adults.
- Avoid using the Parkland or Modified Brooke formula, as the %TBSA burned does not accurately reflect the extent of deep tissue injury in electrical burns.
- Titrate fluid administration to maintain urine output:
- Adults: 100 mL/hr
- Children: 1.5–2 mL/kg/hr
Referral
Patients with suspected deep tissue injury should be referred to a burn center when available to ensure comprehensive care.
Chemical Burns
Superficial chemical burns may conceal deeper tissue injuries, making them more challenging to assess than thermal burns. Tissue damage is often underestimated, necessitating frequent reassessment of wounds and clinical status.
Management [2,12]
- Fully expose the patient as soon as possible to minimize ongoing tissue damage. Providers should wear personal protective equipment (PPE) before starting decontamination.
- Copious irrigation is critical and should be performed immediately, continuing for at least 30 minutes or until neutral skin or eye pH is achieved (using serial litmus paper).
- Exceptions to irrigation: Dry lime, elemental metals, and phenol require alternative treatments instead of water irrigation.
- Patients with chemical burns should be referred to a burn center for specialized care.
Radiation Burns
- Cutaneous manifestations of radiation exposure have a slower onset compared to thermal burns [2,13]. Symptoms such as erythema, calor (warmth), and pruritus may appear hours to days after exposure.
- Waxing and waning of symptoms:
- A latent phase without visible cutaneous symptoms often follows initial erythema, calor, and pruritus (1–2 days post-exposure).
- A second wave may occur days to a week later, presenting as erythema, calor, pruritus, desquamation, ulceration, or necrosis.
- Subsequent waves of symptoms are more common with potent radiation forms (e.g., beta- and gamma-waves), occurring months post-exposure.
- High radiation doses are associated with systemic effects, including hair loss and acute radiation syndrome (ARS):
- ARS symptoms include loss of appetite, fatigue, headache, nausea, vomiting, and diarrhea.
Management
- Anti-inflammatory medications should be administered during the latent phase when cutaneous symptoms are absent.
- As with chemical burns, all patients with significant radiation burns should be referred to a burn center for evaluation and management.
Inhalation Injuries
General Overview
Inhalational injuries are a leading cause of mortality in burn patients. They are commonly associated with thermal injuries, which cause upper airway edema, and chemical injuries, which result in damage to the lower airway and lung parenchyma.
Assessment
Evaluating for inhalational injuries involves identifying key clinical signs, such as soot in the oropharynx, singed facial hair, or other indications of airway compromise. For chemical burns, determining the substances burned or combusted is critical to understanding the nature of the injury. Diagnostic tools include obtaining arterial blood gas (ABG) analysis and chest X-ray when available to assess respiratory function and lung involvement.
Management [2,5]
Maintaining a Patent Airway
Ensuring a clear airway is critical in burn patients. Prompt airway management is crucial in inhalational injuries. A low threshold for endotracheal intubation is necessary in cases of airway compromise, severe burns, or full-thickness/circumferential burns involving the chest or neck. If progressive airway edema is observed, fiberoptic intubation is preferred, provided it is available. Given the rapid progression of airway edema, early intubation is advised to prevent airway obstruction and ensure adequate ventilation.
Oxygen Therapy
Patients with suspected inhalation injuries should receive humidified 100% oxygen via a non-rebreather mask immediately. This is particularly important in cases of carbon monoxide poisoning, as high-flow oxygen effectively reduces carboxyhemoglobin levels, improving oxygen delivery to tissues.
Fluid Resuscitation
Inhalation injuries increase fluid requirements beyond those predicted by burn size alone. Fluid resuscitation must be carefully balanced to avoid under-resuscitation, which risks hypoperfusion, and over-resuscitation, which can lead to complications such as pulmonary edema or compartment syndrome.
Medications
Several medications may be employed to address specific symptoms:
- Bronchodilators: Relieve bronchospasm and improve airway patency.
- Mucolytics: Help thin and loosen mucus, facilitating its clearance from the airways.
- Nebulized Heparin: Prevents fibrin cast formation in the airways, reducing the risk of airway obstruction.
Ventilatory Support
Mechanical ventilation may be required for patients with severe respiratory compromise. Ventilator settings must be carefully optimized to prevent ventilator-induced lung injury. Techniques such as low tidal volume ventilation and high-frequency percussive ventilation may offer benefits in managing patients with compromised pulmonary function.
This comprehensive approach ensures effective airway management and respiratory support in burn patients with inhalation injuries.
Special Patient Groups
Pediatric Patients
Thermal Burns
- Fluid Resuscitation:
- In addition to using the Parkland formula for fluid replacement, pediatric patients require maintenance intravenous fluids (mIVF) to meet baseline hydration needs.
- Children under 5 years of age should have glucose added to their mIVF to prevent hypoglycemia.
Electrical Burns
- The majority of management principles are similar to those for adults.
- Oral Burns:
- Oral burns, often caused by chewing on electrical cords, require special attention. Burns at the commissure (corner of the lips) have a high risk of bleeding due to erosion of the labial artery.
- All significant oral burns should be admitted for observation and plastic surgery consultation to prevent and manage complications.
Pregnant Patients
Electrical Burns
- For pregnant patients with electrical burns, obstetric consultation is essential to assess maternal and fetal health.
- Continuous monitoring of fetal heart tones is necessary to evaluate the well-being of the fetus following an electrical injury.
When To Admit This Patient
The American Burn Association released updated guidelines in December 2022 for burn patient referral and management.
According to these guidelines:
- Moderate to Severe Burns: Patients with moderate to severe burns, as defined by burn depth and total body surface area (TBSA), require hospital admission for comprehensive burn staging and treatment.
- Minor Burns: Patients with minor burns, such as superficial burns or those involving <10% TBSA superficial partial-thickness burns, can be managed in an outpatient setting.
To prevent secondary infection, patients discharged with minor burns must have access to appropriate topical ointments and dressings. Patients with partial-thickness burns should undergo regular wound checks following discharge to monitor healing and prevent complications.
Revisiting Your Patient
The patient’s burns were classified as moderate to severe, and he was intubated due to the presence of singed nasal hairs and significant respiratory distress. Using the Rule of 9s, the total burn area was calculated to be 31.5% TBSA, including the face (4.5%), the front of both arms and hands bilaterally (4.5% each), and the torso (18%).
Given the depth of the burns, lactated Ringer’s IV resuscitation was initiated, with a target of delivering 4725 mL in the first eight hours, as calculated using the Parkland formula. A Foley catheter was placed, and urine output was titrated to 0.5 mL/kg/hr. The patient also received IV analgesia and was subsequently transferred to a burn center for further management.
Authors
Michaela Banks
Michaela Banks is a current resident at Louisiana State University in New Orleans in Emergency Medicine. She graduated with a degree in Psychology and Global Health from Duke University and went on to obtain her MD and MBA from the University of Virginia. During residency, she has become particularly interested in burns and outcomes, and gave an oral presentation on the “Association Between Compliance with an Organized State Burn Triage Center and Burn Outcomes” at ACEP 22. Michaela also serves on the Emergency Medicine Residents’ Association Board of Directors.
Anthony Dikhtyar
Dr. Dikhtyar is a graduate of St. George’s University School of Medicine and recently matched into Emergency Medicine at TriStar Skyline Medical Center in Nashville, TN. His professional interests include medical education, medical photography, and global health in the former Soviet Union. His most recent publications can be found in the Visual Journal of Emergency Medicine.
Jacquelyne Anyaso
Jackie Anyaso, MD, MBA is a second-generation Nigerian immigrant born and raised in Chicago, Illinois. She attended medical school at the University of Illinois at Chicago and will be completing her emergency medicine training at Harvard-Affiliated Emergency Residency Program. Her ultimate goal is to serve vulnerable populations in efforts to reduce healthcare disparities. Her clinical interests include critical care medicine, global health, and the intersection between medicine and business. Outside of medicine, she enjoys community service, traveling, and spending time with family and friends.
Ashley Pickering
Before medical school I had a diverse career path, which included biomedical engineering, outdoor education, working as an EMT on a Colorado ski patrol, and critical care nursing. I lived out west for 15 years, mainly in CO, and went to medical school at University of Arizona in Tucson before moving to Baltimore for residency at University of Maryland. Currently I am a Global Emergency Medicine Fellow at University of Colorado. Throughout my training I have found ample opportunities to pursue my interest in building emergency care globally. I have researched the barriers to accessing emergency care in rural Uganda, helped to provide emergency care training in Sierra Leone and Liberia and am currently the Executive Director of Global Emergency Care a non-profit training non-physician clinicians in Uganda. My current focus is on quality of emergency care in LMICs. I am working on an WHO Emergency Care Toolkit implementation project which explores the impact of basic emergency care educational and process improvements on clinical indicators of quality, as well as the experiences patients and staff.
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References
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- American Burn Association. (2018). Advanced Burn Life Support Course Provider Manual 2018 Update. https://ameriburn.org/wp-content/uploads/2019/08/2018-abls-providermanual.pdf
- Schaefer TJ, Szymanski KD. Burn Evaluation And Management. [Updated 2022 Aug 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430741/
- Jeschke MG, van Baar ME, Choudhry MA, Chung KK, Gibran NS, Logsetty S. Burn injury. Nat Rev Dis Primers. 2020;6(1):11. Published 2020 Feb 13. doi:10.1038/s41572-020-0145-5
- Foncerrada G, Culnan DM, Capek KD, et al. Inhalation Injury in the Burned Patient. Ann Plast Surg. 2018;80(3 Suppl 2):S98-S105. doi:10.1097/SAP.0000000000001377
- Emergency Care of Moderate and Severe Thermal Burns in Adults. UpToDate. Feb. 2023. https://www.uptodate.com/contents/emergency-care-of-moderate-and-severe-thermal-burns-in-adults?topicRef=349&source=see_link#H4430737.
- Department of Health. Determining Total Body Surface Area. From: https://www.health.state.mn.us/communities/ep/surge/burn/tbsa.pdf Accessed December 1, 2024.
- Guidelines for Burn Patient Referral. From: https://ameriburn.org/resources/burnreferral/ Accessed: December 1, 2024.
- Burns. WikiEM. 21 Nov. 2021; 4:1-2. https://wikem.org/wiki/Burns#Evaluation.
- Treatment of Minor Thermal Burns. UpToDate. Feb. 2023. https://www.uptodate.com/contents/treatment-of-minor-thermal-burns#H20.
- Electrical injuries and lightening strikes: Evaluation and management. UpToDate. Mar 2023. https://www.uptodate.com/contents/electrical-injuries-and-lightning-strikes-evaluation-and-management#H3065280448
- Topical chemical burns: Initial assessment and management. UpToDate. Mar 2023. https://www.uptodate.com/contents/topical-chemical-burns-initial-assessment-and-management
- Cutaneous Radiation Injury (CRI): A Fact Sheet for Clinicians. 4 Apr. 2018. https://www.cdc.gov/nceh/radiation/emergencies/criphysicianfactsheet.htm
- Guidelines for Burn Patient Referral. From: https://ameriburn.org/wp-content/uploads/2023/01/one-page-guidelines-for-burn-patient-referral-16.pdf
FOAm and Further Reading
Burns. Stanford Medicine: Healthcare. https://stanfordhealthcare.org/medical-conditions/skin-hair-and-nails/burns.html
http://www.webmd.com/first-aid/tc/burns-topic-overview
http://www.nationalburnservice.co.nz/emergencyplan.htm
https://flippedemclassroom.wordpress.com/2012/12/02/burn/
http://www.mdcalc.com/parkland-formula-for-burns/#about-equation
Reviewed and Edited By
Erin Simon, DO
Dr. Erin L. Simon is a Professor of Emergency Medicine at Northeast Ohio Medical University. She is Vice Chair of Research for Cleveland Clinic Emergency Services and Medical Director for the Cleveland Clinic Bath emergency department. Dr. Simon serves as a reviewer for multiple academic emergency medicine journals.
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
