Burn Injury

Aka: Burn Injury, Burn Evaluation, First Degree Burn, Second Degree Burn, Burn of Second Degree, Third Degree Burn, Burn of Third Degree, Rule of 9, Rule of Nines, Burn Prevention, Fire-Related Injury, Thermal Burn, Thermal Injury

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II. Epidemiology

  1. U.S. Incidence of Burn Injury
    1. Emergency Department visits: 500,000 per year
    2. Hospitalizations: 40,000 per year (60% require burn center admission)
  2. Worldwide
    1. Incidence: 6.6 Million per year
    2. Deaths: 180,000 per year
  3. Ages at higher risk of Burn Injury (bimodal distribution)
    1. Children
    2. Older adults

III. Causes

  1. High Temperature Liquids or Scald Burn (80% of burns in young children)
    1. Hot liquids pulled off the counter
  2. Flame-related burns (more common in school age children and teens)
    1. Lighters
    2. Lighter fluid
    3. Fireworks
    4. Gasoline
  3. Contact Burns
    1. Contact with high Temperature objects

IV. Pathophysiology

  1. Thermal Burn injury
    1. External heat disrupts tissue layers resulting in damage
    2. Longer heat exposure results in deeper burn injuries
  2. Deep dermal injury
    1. Disrupts elasticity, mechanical barrier protection and vascular supply
    2. Results in scarring and Non-Healing Wounds
  3. Burn severity is dependent on multiple factors
    1. Patient specific (e.g. thinner skin at the extremes of age)
    2. Burn heat source
    3. Contact time with heat source
    4. Anatomic burn location (e.g. thicker skin on palms and soles)

V. Precautions

  1. Consider physical abuse
    1. Intimate Partner Violence
    2. Elder Abuse
    3. Nonaccidental Trauma in children with Burn Injury
      1. Physical abuse accounts for 5-6% of Burn Injury <12 years old
      2. Social workers typically review pediatric burns at burn centers and pediatric hospitals
      3. Involve child protective services and pediatric specialty center evaluation if suspected abuse
      4. Consider in delayed presentation, parental indifference and inconsistent history
      5. Consider in burns to hands or feet, buttocks or posterior legs
      6. Consider in well demarcated burns or linear or patterned burns
      7. Consider in symmetric burns and in those that do not spare the flexor crease
  2. Flash or flame burns have additional risks (when compared with contact burns)
    1. Smoke Inhalation
    2. Carbon Monoxide Poisoning
    3. Cyanide Poisoning
  3. Timing after Burn Injury affects presentation
    1. Early presentations of severe burns may lack Blistering
  4. Evaluate for other Traumatic Injury (esp. major mechanism, e.g MVA)
    1. See Secondary Survey
    2. Closed Head Injury
    3. Eye Trauma
    4. Chest Trauma
    5. Abdominal Trauma
    6. Musculoskeletal Trauma
  5. Altered Mental Status
    1. Burn Injury alone is typically associated with alert, Agitated Patient in pain
    2. Decreased level of conciousness (or Seizures) suggests other cause
      1. Carbon Monoxide Poisoning
        1. May be associated with Headache, Nausea, Vomiting, Dizziness, myalgias
        2. Obtain Carboxyhemoglobin level
      2. Cyanide Poisoning
        1. Associated with severe acidosis
        2. May be associated with Syncope or cardiovascular collapse
      3. Head Trauma

VI. Types

  1. Electrical Injury
  2. Lightning Injury
  3. Chemical Toxin
  4. Fire-Related Injury
    1. Thermal Burn
      1. Contact with hot surface and scald burns from liquid (>111 F, 43 C) account for 85% of pediatric burns
    2. Smoke Inhalation
      1. Occurs in 5-35% of hospitalized Burn Injury patients
    3. Acute airway compromise (airway edema)
    4. Carbon Monoxide Poisoning
    5. Cyanide Poisoning

VII. History

  1. See Trauma History (e.g. SAMPLE History)
  2. Comorbidities affecting burn healing and complications
    1. Diabetes Mellitus
    2. Tobacco Abuse
    3. Clotting or Bleeding Disorders
    4. Corticosteroid use
  3. Comorbidities affecting fluid Resuscitation and Electrolytes
    1. Congestive Heart Failure
    2. End-stage renal disease
    3. Hepatic failure

VIII. Signs: Burn Degree

  1. Precaution
    1. Conversion to deeper burn may occur over ensuing days after initial injury
  2. First degree (Superficial burn)
    1. Not included in burn total body surface area involvement
    2. Pathophysiology
      1. Damage limited to Epidermis (without injury to nerves, follicles or glands)
    3. Findings
      1. Dry Skin erythema that when touched, is painful and blanches (e.g. Sunburn)
      2. No Blisters
    4. Causes
      1. Severe UV light exposure (Sunburn)
      2. Minor Thermal Injury
    5. Course
      1. Healing occurs in 3-6 days (up to 5-10 days) without scarring
  3. Second degree (Partial thickness burn)
    1. Superficial partial thickness
      1. Pathophysiology
        1. Involves all of the Epidermis
        2. Also involves superficial Dermis (upper layers of papillary Dermis)
        3. Skin capillaries remain intact (distinguishes from deep partial thickness injury)
      2. Findings
        1. Wet, weaping lesions with clear Blisters
        2. Erythematous, soft skin that blanches with pressure
        3. When touched, skin is hypersensitive and painful
      3. Course
        1. Healing occurs within 14-21 days
        2. Scarring is possible but uncommon (deeper structures including stem cells are spared)
    2. Deep partial thickness
      1. Pathophysiology
        1. Involves all of the Epidermis
        2. Also involves deeper Dermis (lower layers of reticular Dermis)
      2. Findings
        1. Drier lesions than with superficial partial thickness
        2. White or pale to Yellow Skin that when touched does not blanch (or has decreased blanching)
        3. Hemorrhagic Blisters may be present
        4. Painful despite reduced Sensation to touch
        5. Skin is slightly tense (less soft than in superficial partial thickness burns)
      3. Course
        1. Healing typically takes >21 days (3-5 weeks)
        2. Scarring and contractures are common complications (involves stem cells, follicles, glands)
        3. Benefits from early evaluation by burn surgeon early operative management
  4. Third degree (Full thickness)
    1. Pathophysiology
      1. Kills all skin layers (involves all of Dermis)
      2. Also involves underlying subcutaneous fat and connective tissue
    2. Findings
      1. Waxy, dark-brown to black, tan or white skin
      2. Skin is stiff and leatherlike (contrast with soft skin of superficial burns)
      3. Bright red burns without blanching or Sensation are Third Degree Burns (contrast with pink Second Degree Burns)
      4. No Sensation to touch
      5. No Capillary Refill
    3. Course
      1. Burn center evaluation indicated in all cases
      2. Typically do not heal without skin grafting
      3. Contractures are a common complication
  5. Fourth degree
    1. Destroys all skin layers
    2. Also involves Muscle, tendon or bone

IX. Signs: Estimating Surface Area with Rule of 9's

  1. Precautions
    1. Estimate burn area only based on second and Third Degree Burns
      1. First Degree Burns do not count for calculation (Sunburn-like red, closed injury areas)
    2. Exercise caution in burn area calculation in children (overestimated by >200%)
      1. Can substantially affect fluid Resuscitation volume calculation (Parkland Formula)
      2. Goverman (2015) J Burn Care Res 36(5): 574-9 +PMID:25407387 [PubMed]
    3. Lund and Bowder Chart offers a more accurate assessment of burn area
      1. https://en.wikipedia.org/wiki/Lund_and_Browder_chart
      2. Murari (2019) Acute Crit Care 34(4): 276-81 +PMID:31795625 [PubMed]
  2. Infant Rule of 9s
    1. er_burn_RuleOf9_infant.png
    2. Head: 18%
    3. Torso Back: 18%
    4. Torso Front: 18%
    5. Leg Left: 14%
    6. Leg Right: 14%
    7. Arm Left: 9%
    8. Arm Right: 9%
  3. Adult Rule of 9s
    1. er_burn_ruleOf9_adult.png
    2. Torso Front: 18%
    3. Torso Back: 18%
    4. Leg Left: 18%
    5. Leg Right: 18%
    6. Head: 9%
    7. Arm Left: 9%
    8. Arm Right: 9%
    9. Genitalia: 1%
    10. Size of patients palm
      1. Entire palm and fingers: 1% TBSA (inaccurate in obese patients)
      2. Palm only: 0.5% TBSA
  4. Resources
    1. EasyTBSA
      1. Iphone/Android App - Calculate Body surface area in Burn Injury
      2. https://apps.apple.com/us/app/easytbsa/id1554943740
      3. https://play.google.com/store/apps/details?id=org.cnmc.EasyTBSA&hl=en_US&gl=US

X. Labs

  1. Not indicated in minor superficial Burn Injury
  2. Complete Blood Count
  3. Comprehensive metabolic panel
  4. Coagulation studies (PTT, INR)
  5. Creatinine Kinase (CK)
  6. Urinalysis
    1. Urine Dipstick Blood positive without Red Blood Cells on microscopy may indicate Myoglobinuria
  7. Electrocardiogram (EKG)
  8. Carbon Monoxide Level
    1. False Negatives may occur at presentation due to prehospital oxygenation
  9. Lactic Acid
    1. May be elevated in cyanide Poisoning (from combustion of synthetic materials in structure fires)
  10. Venous Blood Gas (VBG) or Arterial Blood Gas (ABG)

XI. Evaluation: Minor burn criteria

  1. Burn is not circumferential
  2. Burn is only injury
  3. Burn does not involve high risk areas
    1. Across major joints
    2. Face
    3. Hands or feet
    4. Perineum or genitalia
  4. Partial thickness burn surface area is limited (Second Degree Burn area)
    1. Ages 10 to 50 years old: Burn area <10%
    2. Age under 10 or over age 50 years old: Burn area <5% (<2% third degree, full thickness)

XII. Management

  1. See Burn Management

XIII. Prevention: General

  1. See Sunscreen
  2. Avoid Smoking inside the home

XIV. Prevention: Burns in Children

  1. Consider Nonaccidental Trauma, Intimate Partner Violence or Elder Abuse (see precautions as above)
  2. Bath
    1. Test bathwater before placing child in bath
    2. Set hot water heater to lowest setting (below 120 degrees F)
    3. Monitor children continuously when in the bath or near faucets
  3. Kitchen
    1. Preferentially use the back Burners of the stove when cooking in the presence of children
  4. Household
    1. Test smoke alarms on a regular basis
    2. Monitor children when near fireplace
    3. Keep children away from matches, fireworks, gasoline and explosives
    4. Keep children away from hot objects
      1. Never hold children while working with hot objects

XV. Prognosis: Increased mortality risk factors

  1. Age >60 years
  2. Associated Smoke Inhalation

XVI. References

  1. Lindquist and Myers (2025) Crit Dec Emerg Med 39(10): 4-14
  2. Mason and Yowler in Herbert (2016) EM:Rap 16(4):4-5
  3. Weir (2020) Crit Dec Emerg Med 34(12): 3-11
  4. Nemri and Fairbrother (2021) Crit Dec Emerg Med 35(9): 3-10
  5. Cuttle (2009) Burns 35(6): 768-75 [PubMed]
  6. Grunwald (2008) Plast Reconstr Surg 121(5): 311e-9e [PubMed]
  7. Hettiaratchy (2004) BMJ 328(7452): 1366-8 [PubMed]
  8. Lanham (2020) Am Fam Physician 101(8): 463-70 [PubMed]
  9. Lloyd (2012) Am Fam Physician 85(1): 25-32 [PubMed]
  10. Roberts (2003) Emerg Med News 25(3): 28-31 [PubMed]
  11. Sheridan (2005) Emerg Care 21(7): 449-56 [PubMed]

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