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Burn Injury

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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

  • Epidemiology
  1. U.S. Incidence
    1. Emergency Department visits: 500,000 per year
    2. Hospitalizations: 40,000 per year
  2. Ages at higher risk of Burn Injury (bimodal distribution)
    1. Children
    2. Older adults
  • Causes
  1. 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
  • Pathophysiology
  1. Deep dermal injury
    1. Disrupts elasticity, mechanical barrier protection and vascular supply
    2. Results in scarring and non-healing wounds
  • Signs
  • Burn Degree
  1. Precaution
    1. Conversion to deeper burn may occur over ensuing days after initial injury
  2. First degree (Superficial burn)
    1. Pathophysiology
      1. Damage limited to Epidermis
    2. Findings
      1. Skin erythema that when touched, is painful and blanches (e.g. Sunburn)
    3. Causes
      1. Severe UV light exposure (sun)
      2. Minor thermal injury
    4. Course
      1. Healing occurs in 5-10 days
  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)
      2. Findings
        1. Wet, weaping lesions with clear Blisters
        2. Erythematous skin that when touched, is painful and partially blanches
      3. Course
        1. Healing occurs within 14 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. Wet, weaping lesions with clear Blisters
        2. White or pale to Yellow Skin that when touched does not blanch
      3. Course
        1. Healing typically takes >21 days
        2. Scarring and contractures are common complications (involves stem cells, follicles, glands)
  4. Third degree (Full thickness)
    1. Pathophysiology
      1. Kills all skin layers
      2. Also involves underlying subcutaneous fat
    2. Findings
      1. Waxy, leathery, dark-brown to black, tan or white skin
      2. Bright red burns without blanching or sensation are Third Degree Burns (contrast with pink Second Degree Burns)
      3. No sensation to touch
      4. No Capillary Refill
    3. Course
      1. Typically do not heal without skin grafting
      2. Contractures are a common complication
  5. Fourth degree
    1. Destroys all skin layers
    2. Also involves muscle, tendon or bone
  • 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]
  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% (inaccurate in obese patients)
  • 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
    1. Ages 10 to 50 years old: Burn area <10%
    2. Age under 10 or over 50: Burn area <5%
  • Management
  • Prevention
  • Burns in Children
  1. 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
  2. Kitchen
    1. Preferentially use the back Burners of the stove when cooking in the presence of children
  3. 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