General Information

After a chemical mass casualty incident, trauma with or without burns is expected to be
common.
Burn therapy adds significant logistical requirements and complexity to the medical response
in a chemical mass casualty incident.
Burns complicating physical injury and/or chemical injury decrease the likelihood of
survival.
Health care providers with burn expertise are needed to optimize burn care.
Consultation with American Burn Association Verified Burn Centers is recommended

Diagnosis of Burns

Definition: A burn is the partial or complete destruction of skin caused by some form of
energy, usually thermal energy.
Burn severity is dictated by:
Percent total body surface area (TBSA) involvement
 Burns >20-25% TBSA require IV fluid resuscitation
 Burns >30-40% TBSA may be fatal without treatment
 In adults: "Rule of Nines" is used as a rough indicator of % TBSA

Rule of Nines for Establishing Extent of Body Surface Burned

Anatomic Surface % of total body surface
Head and neck 9%
Anterior trunk 18%
Posterior trunk18%
Arms, including hands 9% each
Legs, including feet 18% each
Genitalia 1%

 In children, adjust percents because they have proportionally larger heads (up to 20%)
and smaller legs (13% in infants) than adults

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 o Lund-Browder diagrams improve the accuracy of the % TBSA for children.
 Palmar hand surface is approximately 1% TBSA

Estimating Percent Total Body Surface Area in Children Affected by Burns

Estimating Percent Total Body Surface Area Affected by Burns

(A) Rule of "nines"

(B) Lund-Browder diagram for estimating extent of burns
(Adapted from The Treatment of Burns, edition 2, Artz CP and Moncrief JA, Philadelphia,
WB Saunders Company, 1969)

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Depth of burn injury (deeper burns are more severe)
 Superficial burns (first-degree and superficial second-degree burns)
o First-degree burns
 Damage above basal layer of epidermis
 Dry, red, painful ("sunburn")
o Second-degree burns
 Damage into dermis
 Skin adnexa (hair follicles, oil glands, etc,) remain
 Heal by re-epithelialization from skin adnexa
 The deeper the second-degree burn, the slower the healing (fewer
adnexa for re-epithelialization)
 Moist, red, blanching, blisters, extremely painful
 Superficial burns heal by re-epithelialization and usually do not scar if
healed within 2 weeks

o Deep burns (deep second-degree to fourth-degree burns)

 Deep second-degree burns (deep partial-thickness)
o Damage to deeper dermis
o Less moist, less blanching, less pain
o Heal by scar deposition, contraction and limited re-
epithelialization

 Third-degree burns (full-thickness)

o Entire thickness of skin destroyed (into fat)
o Any color (white, black, red, brown), dry, less painful (dermal
plexus of nerves destroyed)
o Heal by contraction and scar deposition (no epithelium left in
middle of wound)
 Fourth-degree burns
o Burn into muscle, tendon, bone
o Need specialized care (grafts will not work)
 Deep burns usually need skin grafts to optimize results and lead to
hypertrophic (raised) scars if not grafted

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Age
Mortality for any given burn size increases with age
- Children/young adults can survive massive burns
- Children require more fluid per TBSA burns
- Elderly may die from small (<15% TBSA) burns
Smoke inhalation injury
- Smoke inhalation injury doubles the mortality relative to burn size
Associated injuries
- Other trauma increases severity of injury
Delay in resuscitation
- Delay increases fluid requirements
Need for escharotomies and fasciotomies
- Increases fluid requirements
Use of alcohol or drugs (especially methamphetamine)
- Makes resuscitation more difficult

American Burn Association Burn Unit Referral Criteria *

*Criteria not established for very large mass casualty incidents (MCI)

Summary of Burn Unit Referral Criteria (PDF - 7 KB) (American Burn Association)
1. Second- and third-degree burns greater than 10% TBSA in patients under 10 or over
50 years of age
2. Second- and third-degree burns greater than 20% TBSA in other age groups
3. Second- and third-degree burns that involve the face, hands, feet, genitalia, perineum,
and major joints
4. Third-degree burns greater than 5% TBSA in any age group
5. Electrical burns, including lightning injury
6. Chemical burns
7. Inhalation injury
8. Burn injury in patients with pre-existing medical disorders that could complicate
management, prolong recovery, or affect mortality (e.g., significant chemical
exposure)

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 9. Any patients with burns and concomitant trauma (e.g., fractures, blast injury) where
burn injury poses the greatest risk of morbidity or mortality. In such cases, if the
trauma poses the greater immediate risk, the patient may be treated initially in a
trauma center until stable before being transferred to a burn center. Physician
judgment will be necessary in such situations and should be in concert with the
regional medical control plan and triage protocols appropriate for the incident
10. Hospitals without qualified personnel or equipment for the care of children should
transfer children with burns to a Verified Burn Center with these capabilities
11. Burn injury in children who will require special social/emotional and/or long-term
rehabilitative support, including cases involving suspected child abuse or substance
abuse

Treatment

General information
o All burn patients should initially be treated with the principles of Advanced Burn
and/or Trauma Life Support
 The ABC's (airway, breathing, circulation) of trauma take precedent
over caring for the burn
 Search for other signs of trauma
o Verified Burn Centers provide advanced support for complex cases
 Certified by the American College of Surgeons (ACS) Committee on Trauma
and the American Burn Association (ABA)
 Resources will give advice or assist with care
o Burn Unit Referral Criteria (PDF - 7 KB) (American Burn Association)
o Airway
 Extensive burns may lead to massive edema
 Obstruction may result from upper airway swelling
 Risk of upper airway obstruction increases with
 Massive burns
All patients with deep burns >35-40% TBSA should be endotracheally
intubated
 Burns to the head

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  Burns inside the mouth
o Intubate early if massive burn or signs of obstruction
 Intubate if patients require prolonged transport and any concern with potential
for obstruction
 If any concerns about the airway, it is safer to intubate earlier than when the
patient is decompensating
o Signs of airway obstruction
 Hoarseness or change in voice
 Use of accessory respiratory muscles
 High anxiety
o Tracheostomies not needed during resuscitation period
o Remember: Intubation can lead to complications, so do not intubate if not needed

Breathing
o Hypoxia
 Fire consumes oxygen so people may suffer from hypoxia as a result of flame
injuries
o Carbon monoxide (CO)
 Byproduct of incomplete combustion
 Binds hemoglobin with 200 times the affinity of oxygen
 Leads to inadequate oxygenation
 Diagnosis of CO poisoning
 Nondiagnostic
PaO2 (partial pressure of O2 dissolved in serum)
Oximeter (difference in oxy- and deoxyhemoglobin)
Patient color ("cherry red" with poisoning)

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  Diagnostic
Carboxyhemoglobin levels
<10% is normal
>40% is severe intoxication
o Treatment
Remove source
100% oxygen until CO levels are <10%

o Smoke inhalation injury

Pathophysiology
 Smoke particles settle in distal bronchioles
 Mucosal cells are die
 Sloughing and distal atelectasis
 Increase risk for pneumonia
o Diagnosis
 History of being in a smoke-filled enclosed space
 Bronchoscopy
 Soot beneath the glottis
 Airway edema, erythema, ulceration
Nondiagnostic clinical tests
 Early chest x-ray
 Early blood gases
Nondiagnostic clinical findings
 Soot in sputum or saliva
 Singed facial hair
Treatment
 Supportive pulmonary management
 Aggressive respiratory therapy

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 o Circulation
 Obtain IV access anywhere possible
 Unburned areas preferred
 Burned areas acceptable
 Central access more reliable if proficient
 Cut-downs are last resort
o Resuscitation in burn shock (first 24 hours)
 Massive capillary leak occurs after major burns
 Fluids shift from intravascular space to interstitial space
 Fluid requirements increase with greater severity of burn (larger % TBSA,
increase depth, inhalation injury, associate injuries - see above)
 Fluid requirements decrease with less severe burn (may be less than calculated
rate)
 IV fluid rate dependent on physiologic response
- Place Foley catheter to monitor urine output
- Goal for adults: urine output of 0.5 ml/kg/hour
- Goal for children: urine output of 1 ml/kg/hour
- If urine output below these levels, increase fluid rate
Preferred fluid: Lactated Ringer's Solution
- Isotonic
- Cheap
- Easily stored

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Resuscitation formulas are just a guide for initiating resuscitation
Resuscitation formulas:

Parkland formula most commonly used

IV fluid - Lactated Ringer's Solution
Fluid calculation
4 x weight in kg x %TBSA burn
Give 1/2 of that volume in the first 8 hours
Give other 1/2 in next 16 hours
Warning: Despite the formula suggesting cutting the fluid rate in half at 8 hours,
the fluid rate should be gradually reduced throughout the resuscitation to
maintain the targeted urine output, i.e., do not follow the second part of the
formula that says to reduce the rate at 8 hours, adjust the rate based on the urine
output.

Example of fluid calculation

100-kg man with 80% TBSA burn
Parkland formula:
4 x 100 x 80 = 32,000 ml
Give 1/2 in first 8 hours = 16,000 ml in first 8 hours
Starting rate = 2,000 ml/hour
Adjust fluid rate to maintain urine output of 50 ml/hr
Albumin may be added toward end of 24 hours if not adequate response

Resuscitation endpoint: maintenance rate

When maintenance rate is reached (approximately 24 hours), change fluids to D50.5NS with
20 mEq KCl at maintenance level
Maintenance fluid rate = basal requirements + evaporative losses

Basal fluid rate

Adult basal fluid rate = 1500 x body surface area (BSA) (for 24 hrs)
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Pediatric basal fluid rate (<20kg) = 2000 x BSA (for 24 hrs)
May use
100 ml/kg for 1st 10 kg
0 ml/kg for 2nd 10 kg
20 ml/kg for remaining kg for 24 hrs
Evaporative fluid loss
Adult: (25 + % TBSA burn) x (BSA) = ml/hr
Pediatric (<20kg): (35 + % TBSA burn) x (BSA) = ml/hr

Complications of over-resuscitation
Compartment syndromes
Best dealt with at Verified Burn Centers
If unable to obtain assistance, compartment syndromes may require management
Limb compartments
Symptoms of severe pain (worse with movement), numbness, cool extremity, tight feeling
compartments
Distal pulses may remain palpable despite ongoing compartment syndrome (pulse is lost
when pressure > systolic pressure)
Compartment pressure >30 mmHg may compromise muscle/nerves
Measure compartment pressures with arterial line monitor (place needle into compartment)
Escharotomies may save limbs
Performed laterally and medially throughout entire limb
Performed with arms supinated
Hemostasis is required
Fasciotomies may be needed if pressure does not drop to <30 mmHg
Requires surgical expertise
Hemostasis is required
Chest Compartment Syndrome
Increased peak inspiratory pressure (PIP) due to circumferential trunk burns
Escharotomies through mid-axillary line, horizontally across chest/abdominal junction

1. Abdominal Compartment Syndrome

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Pressure in peritoneal cavity > 30 mmHg
Measure through Foley catheter
Signs: increased PIP, decreased urine output despite massive fluids, hemodynamic instability,
tight abdomen
Treatment
Abdominal escharotomy
NG tube
Possible placement of peritoneal catheter to drain fluid
Laparotomy as last resort
Acute Respiratory Distress Syndrome (ARDS)
Increased risk and severity if over-resuscitation
Treatment supportive
Wound Care
During initial or emergent care, wound care is of secondary importance

Advanced Burn Life Support recommendations

- Cover wound with clean, dry sheet or dressing. NO WET DRESSINGS.
- Simple dressing if being transported to burn center (they will need to see the wound)
- Sterile dressings are preferred but not necessary
- Covering wounds improves pain
- Elevate burned extremities
- Maintain patient's temperature (keep patient warm)
- While cooling may make a small wound more comfortable, cooling any wound >5%
TBSA will cool the patient
- If providing prolonged care
- Wash wounds with soap and water (sterility is not necessary)
- Maintain temperature
- Topical antimicrobials help prevent infection but do not eliminate bacteria
- Silver sulfadiazine for deep burns
- Bacitracin and nonsticky dressings for more superficial burns

Skin grafting

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 - Deep burns require skin grafting
- Grafting may not be necessary for days
- Preferable to refer patients with need for grafting to Verified Burn Centers or, if not
available, others trained in surgical techniques
- Grafting of extensive areas may require significant amounts of blood
- Patient's temperature must be watched
- Anesthesia requires extra attention
- Medications
- All pain meds should be given IV
- Tetanus prophylaxis should be given as appropriate
- Prophylactic antibiotics are contraindicated
- Systemic antibiotics are only given to treat infections

Special Burns

General information
Often require specialized care
Calling a Verified Burn Center is advised
Electrical injuries
Extent of injury may not be apparent
Damage occurs deep within tissues
Damage frequently progresses
Electricity contracts muscles, so watch for associated injuries
Cardiac arrhythmias may occur
If arrhythmia present, patient needs monitoring
CPR may be lifesaving
Myoglobinuria may be present
Color best indicator of severity
If urine is dark (black, red), myoglobinuria needs to be treated
Increase fluids to induce urine output of 75-100 ml/hr in adults
In children, target urine output of 2 ml/kg/hour
Alkalinize urine (give NaHCOi3)
Check for compartment syndromes
Mannitol as last resort
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Compartment syndromes are common
Long-term neuro-psychiatric problems may result
Chemical Burns
Brush off powder
Prolonged irrigation required
Do not seek antidote
Delays treatment
May result in heat production
Special chemical burns require contacting a Verified Burn Center, for example:
Hydrofluoric acid burn

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