Burns
Classification of Burns
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Superficial
Involves epidermis
Dry, red, blanches with pressure. Painful to light touch
Heals in 3-6 days. Will not scar.
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Superficial Partial-Thickness
Involves outer dermis
Weeping, red, blisters, blanch with pressure. Painful to light touch
Heals in 7-21 days. Typically does not scar.
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Deep Partial-Thickness
Involves deep dermis
Pale white blisters, blanches (sluggish). Painful to pressure only
Heals in >21 days; usually requires surgical management. Will likely scar.
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Full Thickness
Involves dermis and subcutaneous tissue
Dry, waxy white-charred black. Does not blanch with pressure. Painful to deep pressure only
Requires surgical excision and grafting. Will scar.
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Fourth Degree
Involve fascia and muscle
Extend through the skin into underlying soft tissue, muscle, and/or bone. Painful to deep pressure only
Requires surgical intervention. Will scar.
Measure TBSA
Calculating the total body surface area (TBSA) of a child who has suffered burns can be helpful in determining the extent of the injury and guiding fluid management. Do not include first-degree burns in TBSA calculations.
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For adults and children >10 yo:
The head represents 9% TBSA
Each arm represents 9% TBSA
Each leg represents 18%
The anterior and posterior trunk each represent 18% TBSA
For children (head is a larger proportion of body):
The head represents 18% TBSA (subtract 1% from head for each year >1 yo)
Each arm represents 9% TBSA
Each leg represents 14% (add 1/2% to each leg for each year > yo)
The anterior and posterior trunk each represent 18% TBSA
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The patient’s palm (including fingers) is approximately 1% TBSA. The palm excluding the fingers is approximately 0.5% TBSA.
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Smartphone applications can increase the efficiency, accuracy, and ease of estimating TBSA.
When to phone a friend?
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Social Work
Have a high suspicion for non-accidental trauma in children presenting with burns. Especially if the mechanism of injury is not consistent with exam findings or presentation is delayed. Burns that raise suspicion for abuse include: immersion burns confined to the hands, feet, legs, or buttocks when a child is immersed in hot water, patterned burns such as cigarette burns, or burns in unusual locations typically not exposed to heat.
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Burn Surgery
Criteria for surgical consult include: all full-thickness burns, partial-thickness burns >5% TBSA, or partial-thickness burns <5% TBSA if:
Proximity to eyes, ears, or airways
Involvement of scalp, genitalia, or soles of feet
Significant component crossing a joint, crossing the palmar aspect of hands, soles of feet, or circumferential burn
Mechanism involves treadmills, house fires, or hot oil
Any concern for NAT, fever >38.5, inhalation injury, and/or trauma
Management
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Running water over burns can offer some pain relief. Water or saline-soaked gauze may be applied while awaiting formal dressings. Ice water should be avoided as it can worsen the pain and extent of the injury.
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For minor burns, acetaminophen and ibuprofen are sufficient.
For moderate/severe burns, opioids are often indicated. We recommend IN fentanyl as a first line to get the pain under control while obtaining further IV access and prior to debridement.
For planned debridement/dressing, consider the need for procedural sedation with ketamine.
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Especially for any burns deeper than superficial partial-thickness.
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Sloughed or necrotic skin should be removed to minimize the risk of infection and accurately assess the extent of injury. Blisters should be unroofed to accurately assess the depth of injury. Small blisters <2 cm that do not cross joints or limit mobility can be left unroofed.
Chemoprophylaxis & Dressings
Superficial burns do not require dressing. Application of Aquaphor, aloe vera, or bacitracin 2-3x/day is sufficient. Partial-thickness burns require a topical dressing. The location of burns determines the antimicrobial agent and type of dressing:
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Burns are prone to rapid bacterial colonization. Application of topical antibiotics can mitigate potential invasive infections.
Antimicrobial ointments (polysporin, bacitracin, mupirocin): Can be used in areas of sensitivity (face, ears, perineum, fingers, toes) .
Erythromycin ointment: For burns in close proximity to the eyes
Silver Sulfadiazine cream (SSD 1%): Indicated for all other areas of the body.
Silver ions inhibit bacterial Indicated for all other areas of the body. DNA synthesis, thus preventing antimicrobial growth.
Should not be used in infants <2 months old.
Avoid contact with eyes as it is oculotoxic.
Sulfa-based drug so avoid in those with sulfa allergy.
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Silver-impregnated agents (Mepilex), do not require the application of topical antibiotics prior to dressing the wound and have less frequent dressing changes. However, they are difficult to secure in irregularly shaped and highly mobile areas.
Nonadherent dressings (Xeroform, Adaptic, Mepitel) require the application of antibiotic ointment prior to dressing. As these materials are more flexible, they are better for irregularly shaped areas (ears) or those with high mobility (fingers, toes, perineum). The downside is that they require more frequent dressing changes.
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Wrap the wound with dry dressing to provide protection and padding
Kerlix: Used to secure nonadherent dressings and when significant drainage is expected.
TubiFast Shirt: tubular net bandage to cover dressings.
