Burns
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Assessing burn depth

  • Superficial aka first degree – epidermis (erythema) only. Can be differentiated from partial thickness by rubbing the skin. If the epidermis moves around, sliding over the deeper layers, this is a partial thickness burn
  • Partial thickness aka second degree – affects the dermal layers. Can be sub-divided into superficial dermal, mid dermal, and deep dermal
  • Full thickness aka third-degree – all the way through the dermis and may also affect deeper tissues
Types of burns
Types of burns. This file is taken from wikimedia commons and is licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.

 

Second degree burn
Second degree burn – as indicated by blistering. This file is taken from wikimedia commons and is licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.

Calculating burns area

  • Only include partial and full thickness areas
  • Remember that a single burn likely has patches of different thicknesses
  • If unsure if superficial or partial thickness, be cautious and include affected areas
  • Rule of 9’s
  • Useful because it allows for estimation of Total Body Surface Area of burn, which is later used in the calculation for fluid requirements

Fluid Requirements

  • Burns leads to lots of skin oedema which can cause hypovolemic shock
  • The modified parkland formulais used to calculate fluid requirements
  • Should be given if TBSA burns >15% in adults and >10% in children
  • Don’t forget other factors that may lower your threshold for giving fluids, including other traumatic injuries, or inhalational burns
  • Hartmann’s is fluid of choice
  • First ½ of the fluid should be given in the first 8 hours after the burn (not after the presentation)
  • Second half over the next 16 hours
  • Formula:
    • 4mls x TBSA Burn % x Weight (Kg)

Important Factors in History

  • Time burns occurred
  • Duration of exposure (helps assess burn depth)
  • Enclosed area? (Inhalation injury)

First Aid

  • Try to remove jewellery and clothing as appropriate. If clothing is stuck to burn, leave it alone
  • Choice of dressing varies widely between centres. Check local policies
  • Running under cool water can help. You should od this for 20 minutes or so, and is only useful if <3hours since burn. Be aware that if there is a large burn surface area, this can cause hypothermia

Specialist Management

  • Any patient with >10% TBSA (>5% in children) burns should be considered for transfer to burns unit. If there is any doubt about this, speak to the local burns centre for advice.
  • Other potential factors that might lower the threshold for transfer include:
    • Very young
    • Very old
    • Pregnant
    • Other significant co-morbidities or trauma
    • Chemical burns
    • Circumferential burns

Inhalational Injury

  • Occur in 20% of burns patients
  • 60% of facial burns patients
  • major cause of mortality

Causes of pathology in inhalational injury

  • Thermal injury to the airway
  • Chemical injury to the airway
  • Systemic effects from toxins (CO, cyanide – as a combustion product of some plastics / wools etc)
  • Hypoxia / asphyxia due to O2 consumption by the fire

Signs of airway injury

  • Upper airway
    • Singed nostrils / nostril hairs
    • Singed eyebrows
    • Facial burns
    • Soot in nose
    • Change in voice / hoarseness
    • Stridor
  • Lower airway
    • Wheeze
    • SOB
    • Pulmonary Oedema

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) currently works as a GP Registrar and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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