Severe Burns

ED Presentation

34F with no reported medical history BIBA with severe burns after house fire with estimated 70% TBSA involvement. On arrival, the patient was hypoxic, striderous, and unable to provide history. She was intubated for airway protection with some difficulty. Examination revealed deep partial and full-thickness burns to 70% of total body surface area including circumferential burns to bilateral upper extremities and extensive neck and anterior chest involvement. Initial fluid resuscitation and warming measures were instituted. Emergent bedside bronchoscopy revealed copious carbonaceous material throughout with attempts at lavage. Urine output was minimal despite aggressive resuscitation. Critical care transport to local burn facility was arranged where the patient ultimately expired.

Algorithm for the Management of Severe Burns

Algorithm for the Management of Severe Burns

Assessment of Burn Depth

Depth Cause Appearance Sensation
Superficial UV exposure Dry, red
Blanching
Painful
Superficial partial-thickness Scald (splash)
Short flash
Blisters, moist, red
Blanching
Painful to temperature/air
Deep partial-thickness Scald (spill)
Flame, oil, grease
Blisters, waxy dry, white/red
Non-blanching
Pressure
Full-thickness Scald (immersion)
Flame, steam, oil, grease, chemical, electrical
Waxy white, leathery grey, black
Non-blanching
Deep pressure

Estimating Burn Surface Area

Burn TBSA

Image from UWHealth.org

  • Trunk: 18% anterior, 18% posterior
  • Lower extremity (each): 9% anterior, 9% posterior
  • Upper extremity (each): 9%
  • Head/neck: 9%
  • Perineum: 1%

Burn Transfer Criteria

  • Partial thickness > 20% TBSA
  • Partial thickness > 10% TBSA for extremes of age (<10 or >50 years-old)
  • Any full-thickness
  • Burns involving face, hands, feet, genitalia, major joints
  • Electrical/chemical
  • Inhalation injury
  • Medical comorbidities impacting management/healing

See Also

References

  1. Monafo WW. Initial management of burns. N Engl J Med. 1996;335(21):1581–1586. doi:10.1056/NEJM199611213352108.
  2. Hettiaratchy S, Papini R. Initial management of a major burn: I–overview. BMJ. 2004;328(7455):1555–1557. doi:10.1136/bmj.328.7455.1555.
  3. Singer AJ, Della-Giustina D. Thermal Burns: Rapid Assessment and Treatment. Emergency Medicine Practice; 2000.
  4. Rice, PL. Emergency care of moderate and severe thermal burns in adults. In: UpToDate, Moreira ME (Ed), UpToDate, Waltham, MA. (Accessed on March 29, 2016)
  5. Gauglitz, GG. Overview of the management of the severely burned patient. In: UpToDate, Jeschke MG (Ed), UpToDate, Waltham, MA. (Accessed on March 29, 2016)