Burns

Burned (updated)
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Diagnosis and reasoning

The emergency physician is typically the first point of contact for the patient with burns, and thus plays a crucial role in their emergent management. This should follow the Advanced Trauma Life Support (ATLS®) guidelines, starting with the primary survey and resuscitation. The primary survey should proceed in the standard manner, i.e. Airway, Breathing, Circulation, Disability, Exposure (ABCDE), keeping in mind caveats specific to burns. Thus, assessment of her airway reveals the presence of soot in the nares, hinting that inhalational injury might be present. The fact that she was trapped in her bedroom (i.e. a 'closed space') prior to being rescued adds to this possibility. It is essential to appreciate that patients with inhalation injuries may suddenly and rapidly develop upper airway edema (potentially resulting in complete airway obstruction). Thus, further evaluation in this regard is mandatory. Fortunately, her airway is patent, with no obvious swelling, while she is not in respiratory distress. A chest x-ray does not show features suggestive of inhalational injury, while an arterial blood gas assay (ABG) is within normal parameters. Thus, immediate intubation to protect the airway is probably not indicated, although she should be kept under close watch for subsequent respiratory distress and/or airway compromise. When assessing her breathing, it should be appreciated that patients trapped in a closed area are at risk of carbon monoxide poisoning. Standard pulse oximetry is unreliable in this setting; instead, a carboxyhemoglobin (COHb) level should be obtained. Fortunately, a COHb level of <10% does not necessitate further specific therapy. Burns may result in significant fluid loss; therefore, close assessment of her circulatory parameters is essential. This reveals the presence of tachycardia, a delayed capillary refilling time (CRFT), and tachypnea. This constellation of findings is suggestive of grade III hypovolemic shock. Thus, large bore intravenous (IV) access should be established and fluid resuscitation commenced immediately. Proper exposure is the final step of the primary survey; all clothes should be removed and all orifices visualized; the total burned surface area (TBSA) should be accurately estimated, along with the degree of burns. The TBSA in this patient is 13%, with all burns being superficial or deep secondary in degree; this meets the criteria for referral to a specialized burns unit. Note that fiberoptic bronchoscopy is performed to determine the extent of airway compromise in patients with features of inhalational injury; it is probably not indicated here. Escharotomy would have been indicated if third-degree circumferential burns were present.


Discussion

Each year, over a million individuals in the United States seek care for burns; while the majority of these are minor in nature, nonetheless, severe burns are an important cause of hospitalization, death, and long-term morbidity. The detailed management of burns is well covered in guidelines (such as those of the American Burn Society); thus, this text will only attempt to convey some of the important principles involved, mainly focusing on thermal burns. In order to understand how to manage burns, one needs to both appreciate the structure and role of the skin, as well as understand the pathophysiology underlying a burn injury, and the potential complications. The skin has two layers: the outer epidermis and the inner dermis, which are separated by a basement membrane; these protect against physical injury and microorganisms, prevent fluid loss, and aid thermoregulation. While superficial burn injuries involving only the epidermis are fairly well tolerated, deeper burns disrupt the functions of the skin, resulting in local and systemic disturbances. In particular, large burn injuries initiate a systemic inflammatory response, while also stimulating the sympathetic nervous system; as might be appreciated, this results in deleterious effects to almost every organ system. Of particular importance is the increased capillary permeability and intravascular depletion induced by the inflammation; this predisposes to hypotension and hypovolemic shock, as well as to oliguria and acute kidney injury (AKI). Strict IV fluid resuscitation should be done. The sympathetic overactivity predisposes to gastric stress ulcer formation and ileus, and also induces a catabolic state which may impair healing; adrenal stimulation may give rise to hypercortisolism, with subsequent hyperglycemia and insulin resistance. Note also that the systemic inflammation may give rise to an immunosuppressed state, predisposing to secondary infection. The initial evaluation and management of these patients should be guided by the Advanced Trauma Life Support (ATLS®) guidelines, i.e. the primary survey followed by the secondary survey. As with other conditions, the primary survey should be focused on identifying and treating life-threatening injuries; the burn itself takes a back seat at this point. Important considerations during the primary survey include early recognition of inhalational injury and airway compromise (for which prompt intubation should be performed); close evaluation of the circulatory parameters to detect if shock might be present; prevention of hypothermia (particularly in children, in whom there is a high surface to body mass ratio); and proper fluid resuscitation. The secondary survey should be performed as a burn-specific survey; important considerations here include determining if carbon monoxide intoxication might be present (particularly if the patient was in a closed area, and if examination revealed soot in the mouth and nose); and detection of circumferential burns. Common pitfalls include missing corneal burns (which should be suspected if the face is involved); missing rupture of the tympanic membranes (in individuals in whom the burns are secondary to an explosion); and missing perineal burns (which may subsequently be auto-contaminated by urine or feces). Basic laboratory investigations which should be obtained include a full blood count, arterial blood gas assay, renal functions and electrolytes, clotting profile, c-reactive protein (CRP), creatinine phosphokinase (CPK), blood glucose, and serum albumin levels. Quantification of the total burn surface area (TBSA) is an essential aspect of the management of these patients; in adults, Wallace's 'rule of nines' is widely used, as it is accurate and easy to compute. However, the rule of nines is less useful in children, as their heads are proportionally larger as compared to adults; for this age group, the Lund-Browder chart is best used instead. The burns identified should be categorized according to the depth of the injury, into first degree burns (minor epithelial damage only), second degree burns (complete epithelial damage), and third degree burns (complete epithelial damage and damage of the reticular dermis). Note that the American Burn Association (ABA) recommends that patients with one or more of the following be referred to a specialized burns unit: - Second degree (i.e. partial-thickness) burns greater than 10% TBSA - Third-degree burns in any age group - Burns that involve the face, hands, feet, genitalia, perineum or major joints - Inhalation injury - Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery or affect mortality - Burn injury in patients who will require special social, emotional or long-term rehabilitative intervention - Any patient with burns and concomitant trauma (such as fractures), in which the burn injury poses the greatest risk of morbidity or mortality. - Burned children in hospitals without qualified personnel or equipment for the care of children - Electrical burns, including lightning injury - Chemical burns Proper fluid resuscitation is a cornerstone of the management. While the Parkland formula has been traditionally used for this purpose, it is now superseded by the recommendations in the 10th edition of the ATLS (released in 2018). As per ATLS guidelines, the recommended volume of fluid for second and third-degree burns is: 2 ml x patient's body weight in kg x %TBSA. This should be provided in the form of lactated Ringer’s solution, with one-half of the calculated volume being administered over the first 8 hours after the burn injury; and the remaining half over the subsequent 16 hours. It should be appreciated that the above formula is only a guide to therapy; fluid requirements should always be tailored to the individual patient, based on their responses. Other important aspects of the management include pain control, prevention of hypothermia, deep venous thrombosis prophylaxis, prophylaxis against gastric stress ulcers, prevention of secondary infection, proper nutrition (potentially via nasogastric feeding), and careful monitoring of vital parameters and urine output. Rehabilitative therapy is important and should begin as soon as possible. Note that surgery may be indicated in certain patients; escharotomy should be performed in individuals with third-degree circumferential burns, while wound debridement may be required in patients with deep second degree or third degree burns, or if burn contamination is present. In addition, early wound closure by skin grafting or dermal substitutes or matrices can be considered if a large burn area exists. Synthetic substitutes materials are on increase in use can be considered.


Take home messages

  1. The initial management of patients with burns should proceed according to the ATLS® guidelines.
  2. Corneal, tympanitic and perineal burns are often easily missed unless specifically looked for.
  3. Proper fluid resuscitation is a cornerstone of the management.
  4. Persons with severe burns should be referred to a specialized burns unit for further management.

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