Assessing burn depth

  • Superficial – 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 – affects the dermal layers. Can be sub-divided into superficial dermal, mid dermal, and deep dermal
  • Full thickness – all the way through the dermis and may also affect deeper tissues

 

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

Related Articles