1st degree - blanching erythema, painful, no blisters

2nd degree, superficial - blanching erythema, painful, blisters

2nd degree, deep - non-blanching, painless, blisters

3rd degree - non-blanching white, leathery, painless

4th degree - involvement of muscles, tendons, bones

Admission criteria/referral to burn

• Partial thickness = 2nd degree > 10%

  2nd superficial partial thickness – Involves superficial dermis, but not reticular dermis

  • BLANCHES, pink and moist!! painful, blisters, hair follicles present, erythematous
  • Does not need skin graft

  

  2nd deep partial thickness – into deep dermis, involves reticular dermis

  • BLANCHES, NOT PAINFUL. Pink and WHITE but more dry, still has SOME sensation, lose hair follicles
  • Less sensitive to touch → reduced pain to pinprick
  • Needs skin grafting

  

• Full thickness = 3rd degree burn in any age

  3rd Full thickness - all the way through the dermis, (sub-dermal)

  • White leathery, waxy, No sensation at all, eschar, subQ exposed
  • Needs STSG

  

• Burn to hands, face, feet, genital, perineum, skin over major joint

• Electrical/lightening and chemical burn

• Inhalation injury

• Child abuse

1st degree, superficial – sunburn, blanches (epidermis only)

4th degree - deep = muscle, fascia bone, fat

Parkland resuscitation → No longer recommended by American Burn association. Use brooke formula

Only for burns >20% TBSA and > 2nd degree

Modified Brooke formula = 2 ml/kg/TBSA for burns > 15% TBSA 2nd degree or higher

• First ½ given 1st 8 hours, then next half given over latter 16 hours
• Should use lactated ringer
• Titrate to goal UOP .5-1 cc/kg/hour for ≥30 kg
• Prevents over resuscitation
• 2 cc, 70 kg, 20% → 2800 cc → 1400 cc for 1st 8 hrs → 175 cc/hr

For children:

• ALSO need to add D5 AND maintenance in addition to resuscitative fluid above in 1st 24 hours
• <30 kg titrate UOP to 1-2 cc/kg/hr
• ≥30 kg titrate UOP to 0.5-1 cc/kg/hr

Adult: Head 9, arms 9 each, chest/abd 18, back 18, legs 18 each, perineum 1

Child: head 18, legs 14 each, back 18, chest/abd 18, arms 9 each

MC electrolyte disturbance s/p resuscitation in extensively burned patients is hyperkalemia

Escharotomy

• Only considered for circumferential third degree burns
  • Perform at bedside with electrocautery
  • Prevents compartment syndrome. Waiting for OR will increase likelihood of compartment syndrome.
  • Fasciotomy not done with initial escharotomy
• When performed can help avoid compartment syndrome
• Sometimes may need to combine with fasciotomy if concerned about compartment syndrome
• Skin is usually insensate (full thickness burns), can be done without anesthesia
• For hands: in between metatarsals. Don’t do finger fasciotomy
• Extremities: medial and lateral aspect
• Elbow, watch medial epicondyle for ulnar nerve
• Snuff box – watch for superficial radial nerve
• Fibula watch for common peroneal artery
• Medial ankle: great saphenous

Inhalation injury

Lower Airway damage is caused by inhaled toxins

• Heat is mostly dissipated in upper airways
• Pulm blood flow increases in inhalation injuries
• Singed hairs are poor sensitivity → bronch to confirm

O2 saturations will be misleading → Always get ABG, and carboxyhemoglobin levels!! Use this to determine if need to intubate

Not all patients with inhalation injury need intubation!

• If there is hoarseness, stridor, > 40% TBSA burn, drooling  intubate

If there are signs of inhalation injury (face/neck burn, singed nasal hair, soot in nares) → next step is laryngoscopy/bronchoscopy

• In bronch if you see vocal cord edema, ulcers, blisters Intubate

All patients get 100% FIO2 X 6 hours

First week after burn

Enteral Feed in 24-48 hours

35-40 kcal/kg/day and 2-2.5 g protein/kg/day

Excise burn wounds within 24 hours only AFTER proper resuscitation.

Superficial (1st degree), superficial partial thickness (2nd) Xeroform bacitracin. Don’t need antibiotics.

Burn + MRSA → Mupirocin (Bactroban)

• Mupirocin binds to bacterial isoleucyl transfer-RNA synthetase resulting in the inhibition of bacterial protein synthesis

Anything deeper: silver sulfadiazine (needs abx)

• Side effect: decrease in WBC (transient leukopenia)
• Contraindicated on new skin grafts → destructive to grafts and lesions near the eye

Need skin graft for 2nd deep partial thickness and greater

Wounds to face/palms/soles/genitals defer grafting 1st week. Topical abx X 1 week

Autograft contraindicated if wound is positive for B hemolytic strep OR bacteria>105

STSG 0.014 inches

• Takes epidermis and small part of dermis
• donor site re-epithelizes from #1 hair follicles, and skin edges
• Takes 3 weeks to heal, can use donor site again after that
• More likely to survive 2/2 to better imbibition
• Less primary contracture, more secondary contracture
• Worse cosmetic result. Vs full thickness

Full thickness SG

Series of events after skin grafting: Day 1-3 imbibition, Day 3-4 inosculation (direct connection of vessels to graft), Day 5 neovascularization and angiogenesis

Silvadene (silver sulfadiazine)

Silver nitrate

Sulfamylon (mafenide sodium acetate)