History

Fact Explanation
History of accidental burn [1] Most burn injuries are accidental injuries [1]
Shortness of breath, wheezing [2] Due to air way irritation and obstruction, commonly due to inhalation injuries [2]
History of depression [3] Burn injuries due to suicidal attempts [3]
Numbness or tingling [2] Numbness or tingling may persist for a prolonged period of time after an electrical injury. [2]
References
  1. FECK G, BAPTISTE MS. The epidemiology of burn injury in New York. Public Health Rep [online] 1979, 94(4):312-318 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1431778
  2. STANDER MELANIE, WALLIS LEE ALAN. The Emergency Management and Treatment of Severe Burns. Emergency Medicine International [online] 2011 December, 2011:1-5 [viewed 27 August 2014] Available from: doi:10.1155/2011/161375
  3. WIECHMAN SA, PATTERSON DR. Psychosocial aspects of burn injuries BMJ [online] 2004 Aug 14, 329(7462):391-393 [viewed 27 August 2014] Available from: doi:10.1136/bmj.329.7462.391

Examination

Fact Explanation
Superficial burns (1st degree burns) [1] Dry and red, blanches with pressure,Painful. [1]
Superficial partial thickness burns ( 2nd degree burns) [1] Blisters, moist, red and weeping, blanches with pressure, Painful to air and temperature [1]
Deep partial thickness burns (2nd degree burns) [1] Blisters (easily unroofed); wet or waxy dry; variable color (patchy to cheesy white to red); does not blanch with pressure, Perceptive of pressure only [1]
Full thickness burns (3rd degree burns)[1] Waxy white to leathery gray to charred and black; dry and inelastic; does not blanch with pressure,sensation to deep pressure only [1]
4th degree burns [1] All skin layers are destroyed and extend into muscle, tendon, or bone [1]
Scarring, contractures [1] Scarring, contractures occur in deep partial thickness and full thickness burns [1]
Eschar [3] Black scab formed after burn injuries. The breached skin barrier is the hallmark of thermal injury. The body tries to maintain homeostasis by initiating a process of contraction, retraction, and coagulation of blood vessels immediately after a burn injury. zone of coagulation, comprises the dead tissues that form the burn eschar that is located at the center of the wound [3]
Dyspnea / stridor / ronchi [3] Due to airway compromise in inhalational burns causing air way iritation and obstruction. Thoracic eschars -Circumferential chest burns can also cause problems by limiting chest excursion and impairing ventilation. [3]
References
  1. MORGAN ED, BLEDSOE SC, BARKER J. Ambulatory management of burns. Am Fam Physician [online] 2000 Nov 1, 62(9):2015-26, 2029-30, 2032 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11087185
  2. LLOYD EC, RODGERS BC, MICHENER M, WILLIAMS MS. Outpatient burns: prevention and care. Am Fam Physician [online] 2012 Jan 1, 85(1):25-32 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22230304
  3. CHURCH D., ELSAYED S., REID O., WINSTON B., LINDSAY R.. Burn Wound Infections. Clinical Microbiology Reviews [online] December, 19(2):403-434 [viewed 27 August 2014] Available from: doi:10.1128/CMR.19.2.403-434.2006

Differential Diagnoses

Fact Explanation
Physical abuse [1] Burns comprise about 5 to 22% of all physical abuse. Intentional contact burns are deeper, they may be multiple and with well-defined margins. They are usually produced by hot iron, radiators, hair dryers, hair curling irons, stoves or immersion in boiling water. Contact burns with well defined margins and uniform depth, usually located in protected areas, are suggestive of abuse.[1]
References
  1. GONDIM ROBERTA MARINHO FALCãO, MUñOZ DANIEL ROMERO, PETRI VALERIA. Violência contra a criança: indicadores dermatológicos e diagnósticos diferenciais. An. Bras. Dermatol. [online] 2011 June, 86(3):527-536 [viewed 27 August 2014] Available from: doi:10.1590/S0365-05962011000300015

Investigations - for Diagnosis

Fact Explanation
Physical examination [1] Superficial burns (1st degree burns): Dry and red, blanches with pressure,Painful. Superficial partial thickness burns(2nd degree burns): Blisters, moist, red and weeping, blanches with pressure, Painful to air and temperature Deep partial thickness burns (2nd degree burns): Blisters (easily unroofed); wet or waxy dry; variable color (patchy to cheesy white to red); does not blanch with pressure, Perceptive of pressure only. Full thickness burns (3rd degree burns): Waxy white to leathery gray to charred and black; dry and inelastic; does not blanch with pressure,sensation to deep pressure only. 4th degree burns: All skin layers are destroyed and extend into muscle, tendon, or bone [1]
Fiberoptic bronchoscopy or xenon ventilation-perfusion scanning [2] results in more frequent and earlier diagnosis of inhalation injury. One of these examinations can be performed if the diagnosis of inhalation injury is in doubt [2]
Wallace rule of nines [1] The extent of a burn is expressed as the total percentage of body surface area (TBSA) affected by the injury. Accurate estimation of the TBSA of a burn is essential to guide management. Multiple methods have been developed to estimate the TBSA of burns. These methods are not used for superficial burns. The best known method, the “rule of nines,” is appropriate for use in all adults and when a quick assessment is needed for a child. -head and neck total for -front and back: 9% -each upper limb total for -front and back: 9% -thorax and abdomen -front: 18% -thorax and abdomen -back: 18% -perineum: 1% -each lower limb total for -front and back: 18% [1]
Lund and Bowder Chart [1] More accurate methods are required for definitive estimation of the extent of burns in children. The Lund and Browder method covers all age groups and is considered the most accurate method to use in pediatric patients as it compensates for the variation in body shape with age. [1]
References
  1. LLOYD EC, RODGERS BC, MICHENER M, WILLIAMS MS. Outpatient burns: prevention and care. Am Fam Physician [online] 2012 Jan 1, 85(1):25-32 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22230304
  2. MORGAN ED, BLEDSOE SC, BARKER J. Ambulatory management of burns. Am Fam Physician [online] 2000 Nov 1, 62(9):2015-26, 2029-30, 2032 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11087185

Investigations - Fitness for Management

Fact Explanation
Full blood count [1] High white blood cell counts due to infections. Infections can progress rapidly; some of the most common pathogens found in burn wounds include Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas aeruginosa, and Acinetobacter and Klebsiella species [1]
Random blood sugar [1] Diabetes can predispose the patient to infections [1]
Electrocardiography (ECG) [1] Cardiac arrest, either from asystole or ventricular fibrillation, is a common presenting condition in electrical burns. Other electrocardiographic (ECG) findings include sinus tachycardia, transient ST segment elevation, reversible QT segment prolongation, premature ventricular contractions, atrial fibrillation, and bundle branch block. [1]
References
  1. LLOYD EC, RODGERS BC, MICHENER M, WILLIAMS MS. Outpatient burns: prevention and care. Am Fam Physician [online] 2012 Jan 1, 85(1):25-32 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22230304

Investigations - Followup

Fact Explanation
Physical examination [1] There's a risk of contracture in deep partial thickness and full thickness burns which may need surgical referral [1]
References
  1. MORGAN ED, BLEDSOE SC, BARKER J. Ambulatory management of burns. Am Fam Physician [online] 2000 Nov 1, 62(9):2015-26, 2029-30, 2032 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11087185

Investigations - Screening/Staging

Fact Explanation
Severity - (Based on history,Physical examination & total body surface area burned) [1] Minor burns: < 10 percent TBSA burn in adult < 5 percent TBSA burn in young or old < 2 percent full-thickness burn. Moderate burns: 10 to 20 percent TBSA burn in adult 5 to 10 percent TBSA burn in young or old 2 to 5 percent full-thickness burn High-voltage injury Suspected inhalation injury Circumferential burn Concomitant medical problem predisposing the patient to infection (e.g., diabetes, sickle cell disease). Major burns: > 20 percent TBSA burn in adult > 10 percent TBSA burn in young or old > 5 percent full-thickness burn High-voltage burn Known inhalation injury Any significant burn to face, eyes, ears, genitalia or joints Significant associated injuries (e.g., fracture, other major trauma). [1]
References
  1. MORGAN ED, BLEDSOE SC, BARKER J. Ambulatory management of burns. Am Fam Physician [online] 2000 Nov 1, 62(9):2015-26, 2029-30, 2032 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11087185

Management - General Measures

Fact Explanation
Initial management [1] Any clothing that is hot or burned should be removed immediately from the patient's body. Clothing that has been exposed to chemicals should also be removed to avoid exposing the skin to continued burn insult. Ideally, burns should be cooled immediately after they occur.Early cooling with water (within 30 minutes of the burn) reduces burn depth and pain [1]
Primary survey [1] All burns are considered trauma; therefore, the initial evaluation should include a primary survey, ensuring that body surface areas are covered after inspection because damage to the epidermis can result in temperature regulation problems. Because of the risk of airway edema and possible inhalation injury, burns to the face or neck should always prompt evaluation of the patient’s airway, regardless of the burn size. [2]
Tetanus toxoid [1] Tetanus immunization should be updated in patients with wounds deeper than a superficial partial-thickness burn [1]
Antibiotics [1] Infection can involve the depth and extent of a burn, converting a superficial partial-thickness burn into a deep partial-thickness burn or even a full-thickness burn. An infected burn is also more susceptible to blood invasion and sepsis. Because of these risks, all suspected burn infections warrant aggressive management, including hospital admission and parenteral antibiotic therapy. [1]
Analgesics [1] Analgesics should be given to control the pain.nonsteroidal anti-inflammatory drugs are often appropriate for use in patients with small burn wounds. Aspirin products should be avoided because of platelet inhibition and the risk for bleeding. [1]
Managing post burn pruritus and neuropathic pain [1] Pruritus and neuropathic pain are common postburn complications. Histamine H1 receptor antagonists such as cetirizine are the safest pharmacologic treatment for postburn pruritus. pregabalin reduces postburn neuropathic pain [1]
Social support [1] Symptoms of depression and anxiety are common and start to appear in the acute phase of recovery. Acute stress disorder (occurs in the first month) and post traumatic stress disorder (occurs after one month) are more common after burns than other forms of injury. Patients with these disorders typically have larger burns and more severe pain and express more guilt about the precipitating event. The severity of depression is correlated with a patient's level of resting pain and level of social support [3]
References
  1. MORGAN ED, BLEDSOE SC, BARKER J. Ambulatory management of burns. Am Fam Physician [online] 2000 Nov 1, 62(9):2015-26, 2029-30, 2032 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11087185
  2. LLOYD EC, RODGERS BC, MICHENER M, WILLIAMS MS. Outpatient burns: prevention and care. Am Fam Physician [online] 2012 Jan 1, 85(1):25-32 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22230304
  3. WIECHMAN SA, PATTERSON DR. Psychosocial aspects of burn injuries BMJ [online] 2004 Aug 14, 329(7462):391-393 [viewed 27 August 2014] Available from: doi:10.1136/bmj.329.7462.391

Management - Specific Treatments

Fact Explanation
Fluid management [1] In those with poor tissue perfusion, boluses of isotonic crystalloid solution should be given. In children with more than 10-20% TBSA (total body surface area) burns, and adults with more than 15% TBSA burns, formal fluid resuscitation and monitoring should follow. The Parkland formula can help determine the volume of intravenous fluids required over the first 24 hours. Fluid Requirements = TBSA burned(%) x Weight (kg) x 4mL The formula is based on the affected individual's TBSA and weight. Half of the fluid is administered over the first 8 hours, and the remainder over the following 16 hours. The time is calculated from when the burn occurred, and not from the time that fluid resuscitation began. Children require additional maintenance fluid that includes glucose. Additionally, those with inhalation injuries require more fluid [1]
Wound care [1] wound must be cleaned. Scrubbing the wound with povidone/iodine solution , chlorhexidine or other cleaning agents is not recommended. Cleaning the wound with sterile water is generally adequate to remove debris. Blisters that prevent proper movement of a joint or that are likely to rupture should be debrided. Burn wounds heal best in moist—not wet—environments that promote reepithelialization and prevent cellular dehydration. This environment is best created by applying a topical agent or occlusive dressing to reduce fluid loss.Topical agents provide pain control, promote healing, and prevent wound infection and desiccation. Silver sulfadiazine is commonly used [1]
Treatment of hypertrophic scarring and contractures [2] Application of pressure to burn wounds is generally recommended to minimize hypertrophic scarring. Scar contractures result in disfigurement and disability. If detected early, a contracture can be treated with silicone inserts and pressure. If the contracture is more developed, a continuously worn static splint is added to maintain sustained stretch. Once full range of motion is achieved, splinting can be reduced to nighttime use until the scar fully matures. Surgical intervention should be considered if the contracture is not completely reduced. [2]
Surgical excision and skin grafting [2] Surgical excision and skin grafting beginning less than 72 hours after injury is beneficial and is indicated for nonscald full-thickness burns in children and in adults younger than 30 years of age. All other patients with suspected full-thickness burns should be observed for eight to 10 days, as nothing is lost by delaying surgical excision.5 It is also best to wait two weeks before assessing the need for surgery in children with hot-water scald burns because overly aggressive excision and skin grafting in this group has resulted in worse outcomes [2]
Escharotomy [3] A circumferential deep dermal or full thickness burn is inelastic and on an extremity will not stretch. Fluid resuscitation leads to the development of burn wound oedema and swelling of the tissue beneath this inelastic burnt tissue. Tissue pressures rise and can impair peripheral circulation. Circumferential chest burns can also cause problems by limiting chest excursion and impairing ventilation. Both of these situations require escharotomy, division of the burn eschar. Only the burnt tissue is divided, not any underlying fascia, differentiating this procedure from a fasciotomy. [3]
Treatment setting [1] Minor burns: out patient management ( < 10 percent Total body surface area-TBSA burn in adult < 5 percent TBSA burn in young or old < 2 percent full-thickness burn ) Moderate burns : Hospital admission (10 to 20 percent TBSA burn in adult 5 to 10 percent TBSA burn in young or old 2 to 5 percent full-thickness burn High-voltage injury Suspected inhalation injury Circumferential burn Concomitant medical problem predisposing the patient to infection (e.g., diabetes, sickle cell disease) Major burns : referral to special burn centers ( > 20 percent TBSA burn in adult > 10 percent TBSA burn in young or old > 5 percent full-thickness burn High-voltage burn Known inhalation injury Any significant burn to face, eyes, ears, genitalia or joints Significant associated injuries (e.g., fracture, other major trauma) [1]
Management of special areas such as perineum or face [1] Need referral to special burn centers. psychological and cosmetic concerns. Surgical interventions are required for cosmetic reasons. Burns the face are generally treated by exposure, largely because the difficulty of dressing . Where there is much crusting it may be necessary to apply an ointment such as petroleum jelly, particularly around the eyes, and frequent toilet of the eyes and orifices may be needed. [1]
References
  1. LLOYD EC, RODGERS BC, MICHENER M, WILLIAMS MS. Outpatient burns: prevention and care. Am Fam Physician [online] 2012 Jan 1, 85(1):25-32 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22230304
  2. MORGAN ED, BLEDSOE SC, BARKER J. Ambulatory management of burns. Am Fam Physician [online] 2000 Nov 1, 62(9):2015-26, 2029-30, 2032 [viewed 27 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11087185
  3. HETTIARATCHY S, PAPINI R. Initial management of a major burn: II--assessment and resuscitation BMJ [online] 2004 Jul 10, 329(7457):101-103 [viewed 27 August 2014] Available from: doi:10.1136/bmj.329.7457.101