Highlights & Basics
- Cutaneous burns can usually be managed in an outpatient setting. Early management affects long-term outcome.
- Severity is assessed by burn size (% total body surface area) and depth (first to fourth degree).
- Initial treatment of minor burns consists of wound cooling, cleaning, and dressing. Pain management and tetanus prophylaxis are important.
- Serious burns are most effectively managed in regional burn centers.
- Prognosis varies from excellent to poor depending on the severity of the burn. Associated injuries (such as inhalation injury or trauma) adversely affect the prognosis.
- The majority of patients will have satisfying outcomes.
Quick Reference
History & Exam
Key Factors
erythema
dry and painful burns
wet and painful burns
dry and insensate burns
burns affecting subcutaneous tissue, tendon, or bone
cellulitis
clouded cornea
Other Factors
Diagnostics Tests
1st Tests to Order
complete blood count
metabolic panel
carboxyhemoglobin
arterial blood gas
fluorescein staining
computed tomography scan of head and spine
wound biopsy culture
wound histology
Treatment Options
acute
suitable for outpatient care
suitable for outpatient care
with suspected wound infection
requires inpatient care
requires inpatient care
with suspected wound infection
Definition
Classifications
Standard clinical classification of burns according to depth
- Erythema involving the epidermis only
- Usually dry and painful
- Typical of severe sunburn.
- Superficial partial-thickness burns involving the epidermis and upper dermis
- Deep partial-thickness burns involving the epidermis and dermis
- Usually wet and painful
- Typical of scalding injury.
- Full-thickness burns involving the epidermis and dermis and damage to appendages
- Usually dry and insensate
- Typical of flame or contact injury.
- Involve underlying subcutaneous tissue, tendon, or bone
- Typical of high-voltage electrical injury.Images
Vignette
Common Vignette 1
Common Vignette 2
Other Presentations
Epidemiology
- An estimated 486,000 people with burn injuries receive medical treatment.
- 40,000 people require hospitalization, and more than 60% of these hospital admissions are to the 128 hospitals with specialized burn centers.
- Fire and burns account for about 3275 deaths.
- Around 13,000 people require hospital attention from specialist burns injury services.
- 5% of the significant trauma workload in England and Wales is a result of burn injury.
- In-hospital mortality for burn patients is 1.51%.
- Nearly 173,000 children are moderately or severely burned.
- 17% of children with burns have a temporary disability and 18% have a permanent disability.
Etiology
- Caused by heat, from hot liquids, flame, or contact with heated objects
- In young children, about 70% of burns caused by scalding from hot liquids
- In older children and young working adults, flame injuries are more likely
- In older adults, scalds and cooking accidents are most common.
- Caused by low-, intermediate-, and high-voltage exposures, causing a variety of local and systemic injuries.
- Caused by exposure to industrial or household chemical products.
- Approximately 20% of burns in younger children involve abuse or neglect.
Pathophysiology
- Involves the coagulation of injured tissue, and to some degree incites progressive microvascular reactions in the surrounding dermis.[6]
- In animal models, the secondary injury caused by these microvascular changes has been truncated by a variety of administered substances, but none has been demonstrated to be clinically useful.[7]
- As burns become larger than about 20% of the total body surface area (TBSA), a systemic response ensues, driving fluid loss and release of vasoactive mediators from the injured tissue. Clinically this results in early capillary leak, interstitial edema, and organ dysfunction, which is addressed through burn fluid resuscitation.[8] [9] Historically, burn resuscitation was done primarily with crystalloid, but in recent years the use of colloid has increased.[10]
- In well-resuscitated patients, this physiology will self-extinguish and be replaced by a hypermetabolic response, with a near doubling of cardiac output and resting energy expenditure over the next 24 to 48 hours. The magnitude of this response, peaking in those with injuries of 60% or more TBSA, is as high as twice the normal basal metabolic rate.[11] Accelerated gluconeogenesis, insulin resistance, and increased protein catabolism are associated with this response and have major implications for subsequent support of burn patients. The mechanism is not well understood but it is assumed to involve a combination of factors including a change in hypothalamic function; increased glucagon, cortisol, and catecholamine secretion; deficient gastrointestinal barrier function with translocation of bacterial byproducts; bacterial contamination of the burn wound with systemic release of similar products; and some element of enhanced heat loss via transeschar evaporation of fluid. Nutritional support of this physiologic response is essential. Numerous efforts to modify this process pharmacologically have proven less routinely effective.[12] Growth hormone has been advocated in seriously burned children, but data are not compelling and this is not widely practiced at present.[13] Data suggest that use of anabolic steroids may favorably influence burn physiology while also being less expensive, but this practice has not been broadly adopted either.[14]
- The subsequent natural history of burns is driven by the wound. A burn wound is initially clean but is rapidly colonized by endogenous bacteria. As these bacteria multiply, proteases liquefy the eschar, which then separates, leaving a bed of granulation tissue or healing burn depending on the depth of the injury. In healthy patients with small burns this septic process is often well tolerated. However, when injuries are larger, systemic infection results, resulting in poor survival of patients with burns involving >40% TBSA managed without early wound excision.[15]
Images
Diagnostic Approach
- A proper and complete evaluation of the patient
- A careful evaluation of the wound.
Evaluation of the patient
- Airway maintenance; with cervical spine protection if a fall or blunt force trauma is suspected.
- Breathing and ventilation.
- Circumferential full-thickness burns of the trunk and neck may impair ventilation and require close monitoring.
- Circulation and cardiac status.
- Increased circulating catecholamines often elevate the adult heart rate to 100-120 bpm; higher heart rates may indicate hypovolemia from an associated trauma, inadequate oxygenation, or unrelieved pain or anxiety.
- Abnormal cardiac rhythms may be due to electrical injuries, underlying cardiac abnormalities or electrolyte imbalances.
- Circulation in a limb with a circumferential or nearly circumferential full-thickness burn may be impaired by edema.
- Typical indicators of compromised circulation (pain, pallor, paresthesia) may not be reliable in a burned extremity.
- Absence of a radial pulse below an upper limb circumferential burn suggests impaired circulation.
- Disability, neurologic deficit and gross deformity. Typically, the patient with burns is initially alert and oriented. If not, consider associated injury, carbon monoxide poisoning, substance abuse, hypoxia, or pre-existing medical conditions.
- Determine the patient's level of consciousness using the AVPU method:
- A - Alert
- V - Responds to verbal stimuli
- P - Respond only to painful stimuli
- U - Unresponsive
- The Glasgow Coma Scale (GCS) is a more definitive tool used to assess the depth and duration of coma and should be used to follow the patient's level of consciousness.
- Exposure and environmental control. Expose and completely undress the patient, and examine for major associated injuries. Stop the burning process, if applicable
- Maintain a warm environment to prevent hypothermia.[25]
- History (injury circumstances including time and mechanism of injury, and medical history) and accurate pre-injury weight.
- Complete head-to-toe evaluation of the patient.
- Determination of burn severity, including percentage total body surface area burned (TBSA) and burn depth.
- Initial investigations to assess for dysfunction of other organ systems, or establish baseline function (e.g., complete blood count [CBC], metabolic panel including blood urea nitrogen [BUN] and glucose).
- Consideration of the possibility of abuse or neglect.
- Consideration of associated trauma, with additional specialized tests (e.g, blood tests, imaging) as needed.
- Management elements of the secondary survey include further adjustment and monitoring of fluid resuscitation (after TBSA determination), pain and anxiety management, psychosocial support, and wound care. See Management approach for further details.
Evaluation for abuse or neglect
Evaluation of the burn wound
- Most accurately estimated using a Lund-Browder diagram that compensates for changes in body proportions with ageImage
- A simpler alternative is the "rule of nines":Image
- The head and neck represents 9% TBSA (18% in infants)
- Each lower extremity 18% (15% in infants)
- Each upper extremity 9% (10% in infants)
- The anterior and posterior torso 18% each (16% in infants), and
- For scattered or irregular burns the palmar surface of the patient's hand represents approximately 1%.
- First-degree burnsImage
- Erythema involving the epidermis only
- Usually dry and painful.
- Second-degree burnsImage
- Superficial partial thickness burns involving the epidermis and upper dermis
- Deep partial thickness burns involving the epidermis and dermis
- Usually wet and painful.
- Third-degree burnsImage
- Full-thickness burns involving the epidermis and dermis and damage to appendages
- Usually dry and insensate.
- Fourth-degree burnsImage
- Involve underlying subcutaneous tissue, tendon, or bone.
- Burns are commonly deeper than they appear at first exam, so often it is prudent to describe initial impressions and re-evaluate wounds the following day.[31]
- Near or completely circumferential burns should be identified for special monitoringImage
- If involving the torso, such wounds can interfere with ventilation, or even contribute to intra-abdominal hypertension
- When burns involve an extremity, limb-threatening ischemia may occur 12 to 24 hours after the injury.
- Can be diagnosed by clinical exam, cultures of wound biopsies, and burn wound histology. Most authors advocate diagnosis by clinical exam only
- Most common organisms are Staphylococcus aureus andPseudomonas aeruginosa
- A classification scheme includes:[32]
- "Burn impetigo" or superficial infection with loss of epithelium (usually associated with S aureus and Streptococcus pyogenes and is particularly common in burns of the scalp)
- Open burn-related surgical wound infection (develops in excised wounds and donor sites)
- Burn wound cellulitis (spreading dermal infection in uninjured skin around a burn wound or donor site)
- Invasive burn wound infection.
Investigations in patients with significant burns
Risk Factors
History & Exam
Tests
Differential Diagnosis
Rash in children
Differentiating Signs/Symptoms
- No accident in the history.
Differentiating Tests
- No specific test.
Toxic epidermal necrolysis (Stevens-Johnson syndrome)
Differentiating Signs/Symptoms
- Rash and blisters develop after a new medication (often anticonvulsants). Ulceration may occur in areas that could not be exposed to thermal or chemical agent, and on mucous membranes or conjunctivae.
Differentiating Tests
- Skin biopsy shows keratinocyte apoptosis with detachment of the epidermal layer of the skin from the dermal layer. The area of separation may contain a number of CD8-positive T lymphocytes, and the dermis may contain CD4-positive T lymphocytes and macrophages, depending on the stage of the disease when the biopsy is taken.[33]
Differentiating Signs/Symptoms
- Most common in infants. Exfoliation usually follows erythematous cellulitis and rash. Preceding Staphylococcus aureus infection of skin, throat, mouth, nose, and/or umbilicus, often with fever, malaise, and irritability.
Differentiating Tests
- Culture of local or distant focus of colonization (often negative). Gram stain may confirm staphylococcal infection.
- Biopsy shows separation at granular layer of epidermis.
Criteria
- Head and neck represent 9% (18% in infants)
- Each lower extremity is 18% (15% in infants)
- Each upper extremity is 9% (10% in infants)
- Anterior and posterior torso are 18% each (16% in infants)
- For scattered or irregular burns the palmar surface of the patient's hand represents approximately 1%.Image
Treatment Approach
Acute burn management
- Rinsing chemical burns on the skin or in the eyes with running water.
- Covering a burn with a clean wet cloth or plastic cling wrap to protect it during transit to medical care (burns on an extremity should be covered rather than wrapped to allow for possible swelling).[25]
- Do not deroof or aspirate blisters, as this may increase the risk of infection.
- Most burns can be managed in the outpatient setting by nonspecialists, but inadequately coordinated outpatient burn care can make for a frustrating and painful experience for the patient.[36] The key is careful patient selection and a well-rehearsed care plan.
- Patients with smaller burns who have adequate support at home can generally be managed in the outpatient setting if this is deemed appropriate. Wounds of the face, ears, hands, genitals, and feet have a functional and cosmetic importance out of proportion to their wound size. In such cases, early specialty evaluation is advisable, unless the injuries are very superficial. Most burns selected for outpatient management are superficial and heal within 2 weeks. If this is not the case, patients may benefit from specialty evaluation.
- Some patients initially managed in the clinic setting will subsequently require admission. Reasons prompting admission include:
- Increased pain and anxiety
- Inability to keep scheduled appointments
- Delayed healing
- Signs of infection
- Wound that appears deeper than initially estimated. Burn depth is commonly underestimated during the first days after injury.
- Serious burns are most effectively and least expensively managed in organized programs focused on burn care. An increasing body of data support the efficacy of concentration of serious burns in regional programs.[39]
- The American Burn Association (ABA) has established criteria for determining which patients require referral to a specialized burn center, but local resources and practice patterns should be taken into account. The ABA states that the following burn injuries should be referred:[39]
- Partial-thickness burns of >10% total body surface area
- Burns that involve the face, hands, feet, genitalia, perineum, or major joints
- Third-degree burns in any age group
- Electrical burns, including lightning injury
- Chemical burns
- Inhalation injury
- Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality
- Burned children in hospitals without qualified personnel or equipment for the care of children
- Burn injury in patients who will require special social, emotional, or rehabilitative intervention
- Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient's condition may be stabilized initially in a trauma center before transfer to a burn center. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols.
An expert consensus panel has proposed updating and extending the original ABA referral criteria to include the following additional referral criteria/considerations:[40]- Full-thickness burns ≥ 5% TBSA burned.
- Children and older adults (>55 years of age). These patients may benefit from referral to a burn center to access the multidisciplinary team resources, even when TBSA burned is less than 10% (partial or full thickness).
- Smaller burns should be followed up in burn center outpatient settings as soon as possible after injury, and preferably within a week.
- Consider telemedicine consultations as an alternative to immediate transfer or outpatient referral for selected patients.
- Internationally, burn center transfer criteria vary and may depend on local resources and/or configuration of specialist burn services.[41] In UK practice, for example, specialized burn services are designated as burn facilities, burn units, and burn centers according to the level of injury complexity they manage. A burn facility offers inpatient care for noncomplex burn injuries at the level of a standard plastic surgical floor (criteria include burns of TBSA 2% to 4.9%). Burn units will accept patients requiring higher levels of care (including TBSA burned ≥5%), while burn centres accept the most severe and complex cases (e.g., TBSA burned ≥30% for adults and older children, or ≥15% if under 1 year old).[38]
- A survival benefit has been demonstrated for patients with serious burns if they are managed in a dedicated high-volume burn center.[42]
- A number of nonburn medical and surgical conditions (e.g., frostbite, Stevens-Johnson syndrome/TENS, and necrotizing soft-tissue infection) require the same specialized resources as burns. These conditions are increasingly recommended for referral to burn units for initial assessment and care.[40] [43]
Outpatient treatment: wound care and inspection
- Wound severity
- Patient age
- Patient comfort
- Family competence
- Availability of community nursing resources.
- Clean burn wounds with lukewarm tap water and a bland soap.
- Topical agents range from aqueous solutions to antibiotic-containing ointments and debriding enzymes. Very little efficacy data exist.[44] Empiric practices are poorly supported. There are a great number of approaches to the care of small burns.[45] Common sense and regular reassessment of wounds as they heal are central to successful treatment.
- Silver is an excellent antiseptic and there is a long history of its use in burn dressings despite a relative lack of evidence for efficacy.[46] It is applied in several forms, including silver sulfadiazine cream, aqueous silver nitrate solution, and dressings containing nanocrystalline silver.[47] Topical silver sulfadiazine is commonly used, as it is painless on application and has a broad spectrum of antibacterial activity, although some in vitro evidence suggests it may slow epithelialization to a modest degree and some guidelines advise against its use.[35] [46] [48] [49]
- There is limited experience with debriding enzymes in the outpatient setting, with no evolved standard of care. In some centers they play an important role, but in others their utility is limited by expense.
- Superficial burns can be treated with viscous antibacterial ointments containing low concentrations of various antibiotics.
- Wounds around the eyes can be treated with topical ophthalmic antibiotic ointments.
- Treat deeper ear burns with mafenide, as it is the only agent that will penetrate relatively avascular cartilage. This is important as infection of the cartilaginous skeleton of the external ear can cause significant deformity.
- Simple gauze wraps minimize soiling of clothing and protect the wound from trauma.
- Wound membranes are increasingly popular and effective, providing pain control, prevention of wound desiccation, and reduction of wound colonization. They help to create a moist wound environment with a low bacterial density, and are generally intended for use on selected clean superficial wounds and donor sites.[49] They should be used with caution, as deeper wounds placed in membrane dressings may become septic if they are not carefully monitored. Many will release silver for several days, reducing bacterial proliferation.[50] [51]
- In the first days immediately after burning, when wound depth is unclear, topical agents are often ideal. When it is clear that the wound is clean and superficial, a transition to membranes may be appropriate. The experience and comfort level of the treating physician is a major consideration when contemplating the routine use of membrane dressings.
- The wound should be kept generally clean and regularly inspected for infection.
- Outpatient burns tend to be small and superficial, presenting a relatively low risk of infection, so clean rather than sterile technique is reasonable.
- Accumulated exudate and topical medications should be gently cleansed with lukewarm tap water and a bland soap.
- Soaking adherent dressings prior to removal will minimize any pain associated with their removal.
- Gently cleanse wounds with a gauze or clean washcloth, inspect for any sign of infection, pat dry with a clean towel, and redress.
- Inspection for infectious complications is important: the patient and family should be advised to return promptly if they notice erythema, swelling, increased tenderness, lymphangitis, odor, or drainage.
- Wound inspection and cleansing will cause many patients significant anxiety and pain; some will benefit from an oral opioid given 30 to 60 minutes before a dressing change.
- The interval between dressing changes will vary, but most small burns are adequately managed with a daily cleansing and a dressing change.
- If wounds are clean and superficial and if surgery is not needed, wound check frequency can be reduced, or a membrane dressing can be applied.
- Scar management is an essential aspect of comprehensive burn care.
- Unfortunately, grading of scars is not uniformly done, although a variety of scales do exist.[52] Scar evaluation remains a largely subjective practice.
- In long-term scar management, pressure garments have been promoted for many years, although a meta-analysis failed to demonstrate reliable benefit. It may be that further study of subgroups with better scar measurement tools may demonstrate a benefit, but, for now, use is likely to remain program-dependent and anecdote-based.[53]
Inpatient treatment: fluid resuscitation, wound care, critical care, and surgery
- Initial evaluation and resuscitation
- Initial excision and biologic closure
- Definitive wound closure
- Rehabilitation and reconstruction.
- Usually the first 24-72 hours after injury.
- Document the full extent of the injury (including nonburn trauma) and perform fluid resuscitation.
- Carbon monoxide intoxication is best treated acutely by effective ventilation with 100% oxygen, but can be associated with delayed neurologic sequelae. Hyperbaric oxygen treatment is appropriate in selected stable patients with serious exposures, but it is not indicated for routine wound healing.[58]
- If burns involve >20% of the body surface, reduced capillary integrity becomes clinically important, with a resulting need for fluid resuscitation.[24] [25] [59] Capillary integrity is typically restored at approximately 24 hours. Any of the several burn formulas available may be used to initiate resuscitation; however, none can be assumed to be accurate in an individual patient. Bedside titration of infusions, based on physiologic endpoints, is important. Gentle titration is advised: for example, if the urine output falls to 0.25 mL/kg/hour, consider increasing the infusion rate by 10% and reassessing in 60 minutes, rather than infusing a large bolus of fluid. The Parkland formula is often used, and suggests 4 mL/kg/% burn over the first 24 hours, half in the first 8 hours. Young children should receive 5% dextrose in lactated Ringer solution at a maintenance rate to ensure they do not develop hypoglycemia.
- The role of colloid in burn resuscitation remains controversial. Very little good data exist. Despite evidence to the contrary from a meta-analysis, many clinicians advise inclusion of colloid (generally albumin) in burn resuscitation when burns are large to reduce anasarca (severe, generalised interstitial fluid accumulation).[63] [64] Solutions containing hydroxyethyl starch (HES) are not recommended due to their increased risk of adverse outcomes including kidney injury and death, particularly in critically ill patients, and their use has been suspended in Europe.[24] [59] [65] [66]
- Even patients with massive burns can have a good outcome if managed in a comprehensive burn program. Fluid resuscitation becomes increasingly challenging as burn size increases. War-time experience has added to our understanding of the resuscitation needs of the very severely injured.[67]
- Tetanus immunization should be updated in patients with wounds deeper than a superficial partial-thickness burn.
- Identification and removal of large areas of full-thickness burn before wound sepsis and systemic inflammation develop. This should be done using staged hemostatic and minimally ablative techniques.[72]
- Near- or completely circumferential burns should be identified for special monitoring and possible escharotomy:[24] [25]Image
- Burns of this sort on the torso can interfere with ventilation or even contribute to intra-abdominal hypertension.
- On extremities, such burns may cause limb-threatening ischemia within 12-24 hours.
- Escharotomy can decompress such problems and can be done with coagulating electrocautery; anesthesia or sedation is generally required in children.
- When performing escharotomy it is important not to damage uninjured skin or superficial neurovascular structures.
- Ideally, close wounds with autograft. Temporary wound membranes can be useful for large wounds. This strategy changes the natural history of the injury from inevitable systemic sepsis and inflammation to a more controlled wound-closure situation.
- Amniotic membrane can be an accessible and effective temporary membrane, but blood-borne infectious disease screening remains a concern and should be considered.[73]
- The role of antibiotic prophylaxis during acute burn surgery remains unclear.
- Duration varies depending on wound size and complexity.
- The objective is to replace any temporary membranes with autograft and to close small complex wounds, such as on the hands and face.
- May take many weeks if donor sites are severely limited.
- Intensive care is an important component of the first 3 phases of care. Ideally, an embedded intensive care unit is part of the burn program, so that coordination between the medical and surgical needs of the patients is seamless. A burn critical care capability can be organized in various ways, but must always foster a strong collaboration between the surgical, medical, nursing, and other disciplines.[74]
- Deep venous thrombosis is a risk in all injured patients. There are few studies of this in burn patients to support a specific approach. Each unit should develop its own policy for monitoring, prophylaxis, and treatment.[75]
- This is the longest phase of care.
- Ideally, begins with early ranging and splinting, and antideformity positioning.
- As wounds are closed and patients moved from intensive care, passive and active motion and strengthening become important.
- Scar management and emotional support are extremely useful for most patients.
- Burn reconstructive procedures are ideally planned as soon as functional or aesthetic deformities hinder further recovery.
- Pruritus can be a persistent discomfort in the first months after wound closure and should be addressed with nonpharmacologic as well as pharmacologic means.[79]
- Planning for long-term plastic and reconstructive surgery needs should be considered in disaster scenarios, as this need will continue after the flurry of initial activity and attention.[80]
- Attention to pain and anxiety are essential in all phases of care. This is usually done by infusion of opioids and benzodiazepines (e.g., morphine sulfate and midazolam). Each unit should establish their own protocols and dosing regimens. Nonpharmacologic therapies, such as music therapy, can be useful in selected patients. Virtual reality is an innovative, new, nonpharmacologic, noninvasive analgesic technique. Although only few studies are available, positive initial experiences have been reported and a systematic review found it to be an effective adjunct for treatment of pain during wound dressing changes and physical therapy.[81] [82]
- Burn patients typically remain alert and oriented even with major burns, and can remember events at the time of the injury and for several hours afterward. Health care providers should be sensitive to the variable emotions experienced by burn patients and their families at all stages of treatment, and consider the psychosocial needs of the survivor during and following hospitalization and rehabilitation.[24]
Treatment of wound infection
- Burn wound cellulitis responds readily to antibiotics in most cases.Image
- Burn impetigo is usually associated with Staphylococcus aureus and Streptococcus pyogenes and is particularly common in burns of the scalp. Treatment requires wound cleansing, which often mandates shaving of nearby hair-bearing areas, and grafting of full-thickness areas.
- Treat open burn-related surgical wound infections with debridement of necrotic and infected material with delayed wound closure.
- Invasive burn wound infection is a serious problem, usually addressed by excision, and systemic and topical antibiotics.
Treatment Options
suitable for outpatient care
wound cleaning and topical antibiotic prophylaxis
Primary Options
- silver sulfadiazine topical
(1%) apply to the affected area(s) once or twice daily
- silver sulfadiazine topical
- mafenide topical
(8.5%) apply to affected area(s) once or twice daily
- mafenide topical
Comments
- Patients with smaller burns who have adequate support at home can generally be managed in the outpatient setting. Wounds of the face, ears, hands, genitals, and feet have a functional and cosmetic importance out of proportion to their wound size. In such cases, early specialty evaluation may be prudent. Most burns selected for outpatient management are superficial and heal within 2 weeks. If this is not the case, patients may benefit from specialty evaluation.
- Clean burn wounds with lukewarm tap water and a bland soap.
- Superficial burns can be treated with viscous antibacterial ointments containing low concentrations of various antibiotics. Silver is an excellent antiseptic and is used in burn wound care in several forms, including silver sulfadiazine cream, aqueous silver nitrate solution, and dressings containing nanocrystalline silver.[47] Topical silver sulfadiazine is commonly used, as it is painless on application and has a broad spectrum of antibacterial activity, although some in vitro evidence suggests it may slow epithelialization to a modest degree and some guidelines advise against its use.[35] [46] [48] [49]
- Treat deeper ear burns with mafenide, as it is the only agent that penetrates relatively avascular cartilage. This is important as infection of the cartilaginous skeleton of the external ear can cause significant deformity.
tetanus immunization
Comments
- Indicated in patients with no current immunization.
opioid analgesic
Primary Options
- morphine sulfate
10-30 mg orally (immediate-release) every 4 hours when required initially, titrate dose according to response
- morphine sulfate
Comments
- Many patients will have significant anxiety and pain with wound inspection and cleansing.
- Some will benefit from an oral opioid given 30 to 60 minutes prior to a planned dressing change.
with suspected wound infection
antibiotics ± surgical debridement
Primary Options
- cefadroxil
1 g orally/day given in 1-2 divided doses
- cefadroxil
Comments
- Regular monitoring of burn wounds allows for the early recognition of infection. Once infection has been identified, it requires aggressive management, which may include admission, intravenous antibiotics, observation, and surgical debridement if wounds are deep.
- Burn wound cellulitis responds readily to antibiotics in most cases.
- Burn impetigo is usually associated with Staphylococcus aureus and Streptococcus pyogenes and is particularly common in burns of the scalp. Treatment requires wound cleansing, which often mandates shaving of nearby hair-bearing areas, and grafting of full-thickness areas.
- Follow local protocols for selection of antibiotic and appropriate dosing.
requires inpatient care
assessment for admission to a burn center
Comments
- Patients who cannot take fluid by mouth, need burn resuscitation, potentially have inhalation injury, or cannot be managed in the outpatient setting should be admitted for inpatient care. Where possible, consult with a specialist burns center and arrange transfer as appropriate.
- Some patients initially managed in the clinic setting will subsequently require admission. Reasons prompting admission include: increased pain and anxiety; inability to keep scheduled appointments; delayed healing; signs of infection; and wounds that appear deeper than initially estimated (burn depth is commonly underestimated during the first days after injury).
- Serious burns are most effectively managed in organized programs focused on burn care. The American Burn Association (ABA) states that the following burn injuries should be referred to a burn center: partial-thickness burns of >10% total body surface area; burns that involve the face, hands, feet, genitalia, perineum, or major joints; third-degree burns in any age group; electrical burns, including lightning injury; chemical burns; inhalation injury; burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality; burned children in hospitals without qualified personnel or equipment for the care of children; burn injury in patients who will require special social, emotional, or rehabilitative intervention; and patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality.[39]
- An expert consensus panel has proposed updating and extending the original ABA referral criteria to include the following additional referral criteria/considerations:[40] full-thickness burns ≥ 5% TBSA burned; children and older adults (>55 years of age, who may benefit from referral to a burn center to access the multidisciplinary team resources, even when TBSA burned is less than 10%); smaller burns should be followed up in burn center outpatient settings as soon as possible after injury, and preferably within a week; consider telemedicine consultations as an alternative to immediate transfer or outpatient referral for selected patients.
- Internationally, burn center transfer criteria vary and may depend on local resources and/or configuration of specialist burn services.[41]
fluid resuscitation
Comments
- If burns involve >20% of the body surface, reduced capillary integrity becomes clinically important, with a resulting need for fluid resuscitation (usually given as crystalloid solutions). Capillary integrity is typically restored at approximately 24 hours. Any of the several burn formulas available may be used to initiate resuscitation but none can be assumed to be accurate in an individual patient. Bedside titration of infusions, based on physiologic endpoints, is important.
- The Parkland formula is often used and suggests 4 mL/kg/% burn over the first 24 hours, half in the first 8 hours, generally as lactated Ringer solution. The evidence for choice of crystalloid fluids for critically ill patients in general is conflicting, with very little good data specific to burn resuscitation.[59] [60] [61] [62]
- Young children should receive 5% dextrose in lactated Ringer solution at a maintenance rate to ensure they do not develop hypoglycemia.
- Even patients with massive burns can have a good outcome if managed in a comprehensive burn program. Fluid resuscitation becomes increasingly challenging as burn size increases. War-time experience has added to our understanding of the resuscitation needs of the very severely injured.[67]
- The role of colloid remains controversial. Very little good data exist and, despite evidence to the contrary from a meta-analysis, many clinicians advise inclusion of colloid (generally albumin) in burn resuscitation when burns are large to reduce anasarca (severe, generalized interstitial fluid accumulation).[63] Solutions containing hydroxyethyl starch (HES) are not recommended due to their increased risk of adverse outcomes including kidney injury and death, particularly in critically ill patients, and their use has been suspended in Europe.[24] [59] [65] [66].
supplemental oxygen and supportive care
Comments
- Patients with airway involvement or major burns generally require intubation and mechanical ventilation, although intubation should be done selectively.[25] [57] Carbon monoxide intoxication is best treated acutely by ventilation with 100% oxygen, but can be associated with delayed neurologic sequelae. Hyperbaric oxygen treatment is appropriate in selected stable patients with serious exposures, but it is not indicated for routine wound healing.[58]
- Wound healing requires adequate nutritional support. General needs are debated and individual needs vary, but in general 25-40 kcal//kg/day, depending on the extent and severity of injuries, is a reasonable starting estimate of caloric needs for most patients. More refined calculations can be achieved with other equations, such as the Harris-Benedict equation, or needs can be measured using indirect calorimetry. A reasonable protein target is 1.5 to 2 grams/kg/day, and trace element and vitamin needs should also be met.
- Nutritional needs in most patients can be effectively provided by the enteral route. In occasional very ill patients, parenteral nutrition can be safely administered with good effect.[83]
- Wound dressing frequency and type vary substantially between burn centers and the individual needs of patients. In general, when eschar exists, agents with a broad antibacterial spectrum and penetration are advisable. In superficial burns or postoperative wounds, prevention of desiccation is particularly important. In the presence of skin grafts, graft stability is an essential consideration. Within these general principles, the variety of possibilities and practices is vast, and a single best practice cannot be defined. Familiarity with a program of care leads to optimal results.
- Burn patients experience exaggerated heat loss from their wounds and should be managed in settings where environmental heating is available.
tetanus immunization
Comments
- Indicated in patients with no current immunization.
- Update tetatus immunization in patients with wounds deeper than a superficial partial-thickness burn.
surgery
Comments
- In patients with severe burns, identification and removal of large areas of full-thickness burn is required, before wound sepsis and systemic inflammation develop. This should be done using staged hemostatic and minimally ablative techniques.[72] Near- or completely circumferential burns should be identified for special monitoring and possible escharotomy.[24] [25] If involving the torso, such wounds can interfere with ventilation or even contribute to intra-abdominal hypertension. When they involve an extremity, limb-threatening ischemia may occur 12 to 24 hours after the injury. Escharotomy can decompress such problems. The procedure can be done with coagulating electrocautery. When performing escharotomy it is important not to damage uninjured skin or superficial neurovascular structures. Anesthesia or sedation is generally required in children.
- Ideally, close wounds with autograft. Temporary wound membranes can be useful in patients with large wounds. This strategy changes the natural history of the injury from inevitable systemic sepsis and inflammation to a more controlled wound-closure situation.
- Amniotic membrane can be an accessible and effective temporary membrane, but blood-borne infectious disease screening remains a concern and should be considered.[73]
- Definitive wound closure is achieved by replacing any temporary membranes with autograft and closing small complex wounds, such as on the hands and face. When donor sites are severely limited, this phase may take many weeks.
- The role of antibiotic prophylaxis during acute burn surgery remains unclear.
deep venous thrombosis (DVT) prophylaxis
Comments
- DVT is a risk in all injured patients. There are few studies of this in burn patients to support a specific approach. Each unit should develop its own policy for monitoring, prophylaxis, and treatment.[75]
intravenous opioid plus benzodiazepine ± nonpharmacologic therapy
Primary Options
- morphine sulfate
consult specialist for guidance on dose
and
- midazolam
consult specialist for guidance on dose
- morphine sulfate
Comments
- Attention to pain and anxiety are essential in all phases of care. This is usually done by infusion of opioids and benzodiazepines (e.g., morphine and midazolam).
- Each unit should establish their own protocol and dosing regimens. A typical initial dosing of infusion is shown below.
- Even during resuscitation, it is important to ensure attention is paid to patient comfort. Pain and anxiety can have adverse physiologic and emotional consequences.[68] Nonpharmacologic therapies, such as music therapy, can be useful in selected patients. Virtual reality is an innovative, new, nonpharmacologic, noninvasive analgesic technique. Although only few studies are available, positive initial experiences have been reported and a systematic review found it to be an effective adjunct for treatment of pain during wound dressing changes and physical therapy.[81] [82] Successful early pain control can enhance important aspects of long-term outcome.[69] The psychosocial needs of the patient should be considered during and following hospitalization and rehabilitation.[24]
with suspected wound infection
antibiotics ± surgical excision
Primary Options
penicillin G sodium
4 million units intramuscularly/intravenously every 4 hours, maximum 24 million units/day
- cefadroxil
1 g orally/day given in 1-2 divided doses
- cefadroxil
Secondary Options
- vancomycin
15-20 mg/kg intravenously every 8-12 hours
- vancomycin
Comments
- Regular monitoring of burn wounds allows for the early recognition of infection. Once infection has been identified, it requires aggressive management, which may include intravenous antibiotics, observation, and surgical excision if wounds are deep.
- Burn wound cellulitis responds readily to antistaphylococcal antibiotics such as a first-generation cephalosporin (e.g. cefadroxil ) in most cases. If resistant species are suspected or documented by culture and sensitivity, appropriate antibiotics should be prescribed. If MRSA is suspected or documented by culture, it is reasonable to begin treatment with vancomycin.
- Burn impetigo is usually associated with Staphylococcus aureus and Streptococcus pyogenes and is particularly common in burns of the scalp. Treatment requires wound cleansing, which often mandates shaving of nearby hair-bearing areas, and grafting of full-thickness areas.
- Open burn-related surgical wound infections are treated with debridement of necrotic and infected material with delayed wound closure.
- Invasive burn wound infection is a serious problem, usually addressed by excision and treatment with systemic antibiotics (e.g., penicillin) or a first-generation cephalosporin (e.g., cefadroxil). Antibiotics are supportive in the management of burn wound infection.
- Follow local protocols for selection of antibiotic and appropriate dosing.
Emerging Tx
New antibiotics
Prevention
Primary Prevention
Follow-Up Overview
Prognosis
Monitoring
- Durable and functional wound closure:
- The primary objective
- Requires attention to areas of fragile healing and to any residual or new areas of functionally limiting contracture.
- Scar management:
- Particularly important in the first years after injury
- Although the available tools are limited, attention to programs of massage and compression, supplemented with judicious use of surgery, can improve function and appearance, and reduce pruritus.
- Emotional support:
- Essential to a complete recovery, for both the patient and their loved ones[91]
- Ideally coordinated through the burn center.
Complications
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Key Articles
Other Online Resources
Referenced Articles
Guidelines
Treatment
Summary
This guideline summarizes evidence for evaluation and first aid intervention for medical, injury, and environmental emergencies. Includes recommendations for thermal and chemical burns.Published by
American Heart Association; American Red Cross
Published
2020
Summary
Includes criteria for determining which patients require referral to a specialized burn center.Published by
American Burn Association; American College of Surgeons
Published
2007
Summary
This guideline provides recommendations for the nutritional support of the trauma patient, based on studies of trauma and burn patients.Published by
Eastern Association for the Surgery of Trauma
Published
2004
Summary
International guidelines for first aid program managers, scientific advisory groups, first aid instructors, and first responders.Published by
International Federation of Red Cross and Red Crescent Societies
Published
2020
Summary
UK recommendations for the initial management of burn patients in the pre-hospital environment.Published by
Royal College of Surgeons of Edinburgh Faculty of Pre-Hospital Care; British Burn Association
Published
2020