1. Burn Injuries Adaobi Okobi, M.D.

2. Learning Objectives Epidemiology Pathophysiology Classification of burns Red flags Treatment

3. Epidemiology Burns are the 3 rd leading cause of accidental death in the U.S. >120,000 children under 20 receive care for burns in the E.D. every year Under 5 years, scald burns cause 65% of thermal injuries

4. Pathophysiology Zone of coagulation- maximal injury from coagulation of proteins Zone of stasis- decreased tissue perfusion; tissue is potentially salvageable Zone of hyperemia- increased tissue perfusion

5. Classification of Burns

6. First Degree Dry No blisters Minimal or no edema Erythematous, blanches Very painful Epidermis only Heals in 2-5 days without scarring

7. Second Degree (Partial Thickness) Moist blebs, blisters Underlying tissue is mottled pink and white with fair cap refill Very painful Involves epidermis and reticular layers of dermis Superficial: 5-21 days Deep partial: 21-35 days with no infection; if infected converts to full thickness burn

8. Third Degree (Full Thickness) Dry, leathery eschar White or waxy appearance No blanching or bleeding Sensation: deep pressure Includes epidermis and dermis and may go down to subcutaneous fat, muscle or bone Will not heal without skin graft

9. Fourth Degree Extends into muscle or bone Sensation: only deep pressure Requires skin graft

10. Size of Burn Palm method- palm of patient’s hand is ~1% TBSA Lund-Browder method (Rule of nines)

12. Red Flags: Abuse

13. Resuscitation Airway Breathing Circulation Disability Exposure Fluids

15. Fluid Resuscitation Parkland formula: 4ml/kg/%TBSA (+ maintenance IVF if <5 years) Give 1 st half in 8 hours Give 2 nd half over next 16 hours D5LR is the fluid of choice in 1 st 24 hours Colloids (ie albumin) may be added to restore oncotic pressure and intravascular volume after the first 24 hours Urine output should be >0.5-1ml/kg/hr

16. Treatment Silver sulfadiazine cream- impedes epithelialization Topical antibiotics (Bacitracin) Chlorhexidine- antimicrobial skin cleanser Mafenide acetate- carbonic anhydrase inhibitor (treat patient with high bacterial load on wound) Providone-iodine ointment- controversial because of cytotoxicity and delay in wound epithelialization Bismuth-impregnated petroleum gauze (Xeroform) – helps prevent or control wound infection Skin graft

17. Treatment Pain control Clean with soap and water Debridement (large or painful blisters may be ruptured) Glycemic control High protein diet Prophylactic antibiotics- controversial Rehabilitation

18. Take Home Points Burns can be classified by size and depth First and superficial partial second degree burns are very painful Deep second, third and fourth degree burns are not painful because of damage to nerves Be suspicious of abuse for burns that do not match the mechanism of injury, immersion burns or cigarette burns Fluid resuscitation should be aggressive in the first 24 hours with monitoring of the urine output