1. Kelsey Pfeiffenberger
Burns
Kelsey Pfeiffenberger

2. Non-complex Burns Previously described as minor burns
Any partial thickness thermal burn covering ≤15% total body surface area (TBSA) in adults or ≤10% in children (≤5% in children younger than 1 year) that does not affect a critical area
Critical areas include burns on the hands, feet, face, perineum or genitals, burns crossing joints, and circumferential burns
Also includes deep dermal burns covering ≤1% of the body

3. How to determine TBSA Lund and Browder Chart “Rule of Nines”
Palmar surface
burns-and-planning-resuscitation-the-rule-of-nines/12698

5. Definitions of Burn Depth
Superficial partial thickness burns:
First degree :
Superficial burns affect only the epidermis
Second degree:
Superficial dermal burns extend into the upper layers of the dermis
Deep dermal burns extend into the deeper layers of the dermis but not into the subcutaneous tissue
Full thickness burns:
Third and fourth degree burns may extend into the muscle and bone

6. Pathophysiology
All burn injuries cause a local response consisting of inflammation, regeneration, and repair
In superficial areas and around the edges, ingrowth of capillaries and fibroblasts, followed by formation of granulation tissue and scarring occurs during the repair process
Zone of coagulation/necrosis
Zone of stasis
Zone of hyperaemia

7. Assessment Primary Survey
Airway maintenance with cervical spine control
Breathing and ventilation
Circulation with hemorrhage control
Disability (neurological assessment)
Exposure (preventing hypothermia)
Fluid resuscitation
In patients who are clearly well, other than the non- complex burn, it is acceptable to move straight to the Secondary Survey

8. Secondary Survey
Consists of the patient history and the physical examination of the burn
Identifies issues that could impact the management of the patient or implications for transfer

9. When to refer
Criteria for referring patients with complex wounds to specialized burn units includes:
>10% total body surface area in children and >15% in adults
All full thickness burns, deep dermal burns >5% in adults and all deep dermal burns in children
Chemical or electrical burns
Burns on the face, hands, genitals, perineum, or large joints, circumferential deep burns, inhalation injury, associated injuries, and septic burn wounds
A non-complex burn that has not healed within 2 weeks should be referred to a burn surgeon for possible excision and grafting
If non-accidental injury is suspected in children, immediate hospital admission is required regardless of the degree of the burn

10. Mechanisms of injury Thermal mechanisms Electrical burns
Chemical burns
Sun burn
Children, elderly, those with reduced mental capacity, reduced mobility, or sensory impairment are at an increased risk of burn injury

11. Patient History HPI Mechanism of injury What was the exact cause?
When did it occur?
How did it come into contact with the patient?
For how long was the patient exposed to the injuring agent?
Was any first aid performed?
Depending on the cause, you would want to ask more specific questions related to the injuring agent

12. Patient History Medical history
Past and current medical problems
Medications
Photosensitizing medications: thiazide diuretics, sulfa-containing agents, tetracyclines such as doxycycline, griseofulvin, phenothiazines, nalidixic acid, and St. John’s wort
Vaccinations
Tetanus (vaccine should be administered if one was not received within the last 5 years)
Nutrition status
Allergies
Smoking and alcohol use
Abuse
Possible pregnancy
A thorough history could provide clues as to why the injury occurred and what may be needed in the treatment plan

13. Clinical Manifestations
First degree burns
Painful, red, blanches with pressure, and swollen
Most common causes: ultraviolet radiation, scalding, low-intensity steam exposure, and brief contact with a hot object
Superficial dermal burns
Painful red blisters or broken epidermis with a weeping surface
Most common causes: scalds or brief exposure to a flame
Deep dermal burns
Dry and blotchy or mottled with a cherry red stained appearance
Blanching with pressure does not occur and sensation is variable
Superficial burns can be extremely painful compared to deep burns because the nerve endings remain intact and exposed

16. Diagnosis
Primarily diagnosed from the patient history and physical examination

17. Diagnostic Tests There are no diagnostic tests for burns
If there is a concern about infection, a procalcitonin (PCT) level can be ordered
A PCT of 0.56 ng/mL has a sensitivity of 75% and a specificity of 80% when compared with quantitative swab culture; however, this is not considered diagnostic but it should prompt the provider to look for a possible cause for the infection
Most burn wound infections are caused by methicillin- resistant Staphylococcus aureus, Acinetobacter baumannii- calcoaceticus complex, Pseudomonas aeruginosa, and Klebsiella species

18. Differential Diagnoses and Red Flags
Cellulitis
Characterized by pain, swelling, redness, and warmth
Usually caused by an acute infection from a cut, laceration, or fissure
Toxic epidermal necrolysis
Characterized by widespread erythema and bullous detachment of the epidermis and mucous membranes
Affects more than 30% of the body surface area
Most commonly caused by medications
Stevens-Johnson syndrome
Less severe than TEN
Affects less than 10% of the body surface areas

19. Prognosis
Depends on the extent of the tissue damage, comorbidities, associated injuries, or complications
Complications include sepsis, gangrene, or neurologic, cardiac, cognitive, or psychiatric dysfunction
Superficial and superficial dermal wounds usually heal within 1 week
Dermal burns may take up to 2 to 3 weeks to heal

20. First Aid
Cool the burn with running water between 12o and 18oC within 20 minutes after the injury
Should be continued for up to 30 minutes
Can also use a wet compress
Applying ice is not recommended because it can cause vasoconstriction
Burns should be covered immediately after cooling to prevent bacterial colonization, dessication, and relieve pain from exposed nerve endings
Polyvinylchloride film, such as cling film, Glad wrap, or Saran wrap, makes excellent dressings in emergency situations
In hot or humid climates, dressings become rapidly saturated and wounds should be left exposed or loosely covered

21. Treatment
Treatment aims at reducing inflammation, preventing infection, relieving pain, and promoting healing
Irrigate with normal saline or warm tap water to remove foreign bodies, soluble debris, or necrotic tissue
Blisters should only be removed if they are greater than 1 cm; if they are smaller they should be left intact

22. Treatment: Dressings
Dressings should maintain a moist environment, contour easily, be non-adherent, retain close contact to the wound, easy to apply and remove, painless, protect against infection, and be cost-effective
The first dressing change should be 48 hours after the injury then every 3 to 5 days after
Practice guidelines suggest dressing selections based on the extent of injury
Superficial epidermal burns
Soothing gels such as aloe vera or moisturizing cream
Superficial dermal burns and deep dermal burns: the dressing depends on the amount of exudate
Foams, alginates, hydrocolloids, hydrogels, and honey dressings can be used

24. Treatment: Antimicrobials
Topical antimicrobials can be used to prevent infection in second degree burns
Oral antimicrobials are not recommended for prevention
Silver sulfadiazine (SSD) cream
Broad-spectrum
Can be applied as a thick layer but needs to be washed off and redressed daily

25. Treatment study
Open dressings with petroleum gel (Vaseline) vs. standard gauze silver sulfadiazine dressings in minor superficial partial thickness burns
Petroleum gel may be as effective as silver sulfadiazine in regard to re-epithelialization and incidence of infection
Open dressings with petroleum gel was superior to silver sulfadiazine in ease of removal, adherence to the wound bed, and time required to change the dressings
Petroleum gel costs $7 and silver sulfadiazine (Flamazine) costs more than $60 excluding the gauze

26. Pain Management
Non-steroidal anti-inflammatory drugs or aspirin should be the first choice
Weak opioids such as codeine can be used for mild to moderate pain
Topical corticosteroids can be applied for symptomatic relief in extensive sun burn

27. Education Nutrition Skin care Burn prevention at home
Signs of infection
Sunscreen and avoiding direct sun exposure
Non-perfumed moisturizers
Burn prevention at home

28. Questions?

29. References
Atiyeh, B., Barret, J. P., Dahai, H., Duteille, F., Fowler, A., Enoch, S., Zhao-fan, X. (2014)
International best practice guidelines: Effective skin and wound management of
noncomplex burns. Retrieved from
Cohen, V. (2015, October 21). Toxic Epidermal Necrolysis. Retrieved from
Edlich, R. F. (2015, September 1). Thermal Burns. Retrieved from
Genuino, G. A. S., Baluyut-Angeles, K. V., Espiritu, A. P. T., Lapitan, M. C. M., & Buckley, B.
S. (2014, November 1) Topical petrolatum gel alone versus topical silver sulfadiazine
with standard gauze dressings for the treatment of superficial partial thickness burns in
adults: A randomized controlled trial. Burns, 40 (7), Retrieved from

30. Goroll, A. H. & Mulley, A. G. (2014). Primary care medicine: Office evaluation and
management of the adult patient (7th ed.). Philadelphia, PA: Lippincott Williams
Wilkins.
Hospenthal, D. R. (2014, August 27). Burn Wound Infections. Retrieved from
Papadakis, M. A. & McPhee, S. J. (2016). Current medical diagnoses & treatment (55th ed.). New York, NY:
McGraw-Hill Education.