Diagnosis of BURNS

A burn is the partial or complete destruction of skin caused by some form of energy, usually thermal energy.

• Burn severity is dictated by:
  • Percent total body surface area (TBSA) involvement
    • Burns >20-25% TBSA require IV fluid resuscitation
    • Burns >30-40% TBSA may be fatal without treatment
    • In adults: "Rule of Nines" is used as a rough indicator of % TBSA
      
      Rule of Nines for Establishing Extent of Body Surface Burned

      Anatomic Surface	% of total body surface
      Head and neck	9%
      Anterior trunk	18%
      Posterior trunk	18%
      Arms, including hands	9% each
      Legs, including feet	18% each
      Genitalia	1%

      
      
      
    • In children, adjust percents because they have proportionally larger heads (up to 20%) and smaller legs (13% in infants) than adults
      • Lund-Browder diagrams improve the accuracy of the % TBSA for children.
    • Palmar hand surface is approximately 1% TBSA
      
      Estimating Percent Total Body Surface Area in Children Affected by Burns
      
      (A) Rule of "nines"
      (B) Lund-Browder diagram for estimating extent of burns
      (Adapted from The Treatment of Burns, edition 2, Artz CP and Moncrief JA, Philadelphia, WB Saunders Company, 1969)
      
      
  • Depth of burn injury (deeper burns are more severe)
    • Superficial burns (first-degree and superficial second-degree burns)
      • First-degree burns
        • Damage above basal layer of epidermis
        • Dry, red, painful ("sunburn")
      • Second-degree burns
        • Damage into dermis
        • Skin adnexa (hair follicles, oil glands, etc,) remain
        • Heal by re-epithelialization from skin adnexa
        • The deeper the second-degree burn, the slower the healing (fewer adnexa for re-epithelialization)
        • Moist, red, blanching, blisters, extremely painful
      • Superficial burns heal by re-epithelialization and usually do not scar if healed within 2 weeks
    • Deep burns (deep second-degree to fourth-degree burns)
      • Deep second-degree burns (deep partial-thickness)
        • Damage to deeper dermis
        • Less moist, less blanching, less pain
        • Heal by scar deposition, contraction and limited re-epithelialization
      • Third-degree burns (full-thickness)
        • Entire thickness of skin destroyed (into fat)
        • Any color (white, black, red, brown), dry, less painful (dermal plexus of nerves destroyed)
        • Heal by contraction and scar deposition (no epithelium left in middle of wound)
      • Fourth-degree burns
        • Burn into muscle, tendon, bone
        • Need specialized care (grafts will not work)
      • Deep burns usually need skin grafts to optimize results and lead to hypertrophic (raised) scars if not grafted
  • Age
    • Mortality for any given burn size increases with age
      • Children/young adults can survive massive burns
        • Children require more fluid per TBSA burns
      • Elderly may die from small (<15% TBSA) burns
  • Smoke inhalation injury
    • Smoke inhalation injury doubles the mortality relative to burn size
  • Associated injuries
    • Other trauma increases severity of injury
  • Delay in resuscitation
    • Delay increases fluid requirements
  • Need for escharotomies and fasciotomies
    • Increases fluid requirements
  • Use of alcohol or drugs (especially methamphetamine)
    • Makes resuscitation more difficult