C H A P T E R 56 
Thermal Burns
PRINCIPLES
Background
Thermal burns are common injuries seen and managed in the
emergency department (ED). In most cases, burns are relatively
small in size and superficial in depth and can be managed entirely
by the emergency clinician without the need for emergent consul-
tation or admission. Accurate assessment of burn size and depth
followed by meticulous local wound care is all that is needed in
most cases. On the other hand, early management of the airway,
breathing, and circulation are essential in the treatment of major
burns. Emergency escharotomy may also be required sometimes,
especially with circumferential burns of the extremities, thorax,
and neck.
The ability of the skin to regenerate is largely dependent on
the depth of injury because regeneration occurs mostly from
underlying dermal skin appendages, such as the hair follicles and
sebaceous glands. Cooling of the burns as well as prevention of
wound desiccation and infection will help prevent conversion of
the burns from partial (second degree) to full thickness (third
degree). Unlike mechanical injuries, in which the maximal extent
of damage occurs immediately after injury, thermal burns are
dynamic and tend to progress over time. As a result, it may be
difficult to accurately assess burn depth and be able to predict the
potential for spontaneous healing without the need for burn
eschar excision and skin grafting during the initial ED assessment.
Although burn depth may be obvious in very superficial and very
deep burns respectfully, in many cases close follow-up and fre-
quent reassessments may be required to determine the appropri-
ate therapeutic plan. Consultation with a burn specialist is
recommended with obviously deep burns and when burn depth
is indeterminate.
Epidemiology
Although the number of burns in the United States has appeared
to be decreasing, a recent study from England suggests that this
trend may be reversing with an increase in total number of
burns.1,2 The overall survival rate from burns in the United States
is over 96% with 3400 deaths per year. Between the years 2003 to
2012 the case fatality rate from burns decreased 25% to 35%.3
Most burns occur in men in the working years of life. Although
scalds are the most common etiology of burns in children younger
than 5 years old, burns due to exposure to fire or flame predomi-
nate in all other age groups.3 Most burns are relatively small in
size with only 2% covering 40% total body surface area (TBSA)
or more. Currently, the burn size associated with a 50% case fatal-
ity (LA-50) is between 60% and 70% TBSA.4 The hospital length
of stay can be estimated and is roughly 1 day per percent TBSA
burned.3
Anatomy and Physiology
The skin is the largest organ of the body and is composed of three
main layers: the epidermis, the dermis, and the subcutaneous
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Adam J. Singer | Christopher C. Lee
layers. The epidermis provides a waterproofing and bacteria-
proofing layer, whereas the dermis (along with the subcutaneous
layer) gives the skin its toughness and durability. The dermis and
subcutaneous layers are also important sources of stem cells that
help regenerate the epidermis after thermal injury.
The main function of the skin is to serve as a barrier between
the internal and external environments minimizing fluid losses
and microbial invasion. Other important functions of the skin
include thermoregulation, sensory detection, and immune sur-
veillance. When large portions of the skin are lost or damaged,
there is a risk of hypovolemic shock and sepsis, and complete loss
of the skin is incompatible with life.
Pathophysiology of Burns
Burns are the result of exposure of the skin, to energy in the form
of heat. The degree of injury is dependent on the temperature and
duration of exposure as well as the structure of the skin. The skin
in the very young and elderly is relatively thin; therefore, they are
more prone to the development of deep burns. Temperatures
below 44°C are generally well tolerated and do not cause cell death
or injury even after prolonged periods of exposure. When the
temperature rises, there is damage to the cells ultimately leading
to cell death. Exposure of cells to supra-physiological tempera-
tures results in progressive denaturation or unfolding of protein
molecules with most proteins denatured at 60°C.5 The lipid bilayer
and membrane-bound adenosine triphosphates are especially vul-
nerable to thermal denaturation leading to disruption of the cel-
lular membrane and subsequent cellular necrosis.6 In addition to
classical cellular necrosis, cell death may also occur as a result of
apoptosis and necroptosis. Cellular necrosis (also known as
oncosis) is a result of depletion of the cell’s energy stores and loss
of integrity of the cellular membrane with subsequent cellular
swelling leading to bursting of the cell with significant associated
inflammation. In contrast, apoptosis is a highly programmed
active process characterized by shrinking of the cell and its
organelles, DNA fragmentation, and budding without cellular
swelling ultimately leading to cell death with minimal inflamma-
tion. Apoptosis is the result of activation of caspase proteases
that ultimately are the executors of cell death. A third mechanism
of cell death that has recently been reported is necroptosis in
which the cells also swell and burst.7,8 However, unlike classical
necrosis, necroptosis is an active programmed process that
requires the formation of an intracellular complex, which includes
receptor-interacting protein 3 (RIP-3). Autophagy (a pathway
that conserves energy by recycling intracellular macromolecular
waste) may also play a role in burn injury progression.9 The
importance of these findings is that it paves the way for the devel-
opment of potential therapies aimed at preventing necroptosis or
apoptosis.
The pathophysiology of burns in many ways resembles that of
myocardial infarction, stroke, and traumatic brain injury. In all of
these cases, a large number of cells are irreversibly damaged by
exposure to the most extreme injury conditions, whereas the cells
in the surrounding area are exposed to lesser insults putting them
at risk of death due to stasis or a reduction in blood flow. The
715
716 PART II  Trauma  |  SECTION Three  Soft Tissue Injuries
classical three zones of burn injury originally described by Jackson
include the central zone of irreversible necrosis, the intermediate
and potentially reversible zone of stasis, and the outermost revers-
ible zone of inflammation.10 Thermal injury sets into motion a
cascade of events, which includes inflammation, compromised
perfusion, oxidative stress, and recurring cycles of ischemia reper-
fusion.11 These processes result in the release of a large number of
toxic cytokines and mediators, as well as free oxygen and nitrogen
radicals leading to additional injury. For example, free radicals
damage vital proteins, lipids, and DNA leading to lipid peroxida-
tion and disruption of the cellular membrane. Occlusion of the
dermal microcirculation by red and white blood cells followed by
the formation of microthrombi further reduces perfusion to the
injured skin. Additionally increases in capillary permeability lead
to edema formation, which further compromises local blood flow.
Burn injuries are also characterized by a catabolic state with
up to a threefold increase in the metabolic rate often necessitating
enteral or parenteral nutrition. In addition to adrenergic stress,
burn hypermetabolism may be due in part to uncoupling of
oxidative phosphorylation in the mitochondria.12 Nonspecific
down regulation of the immune system also occurs due to defects
in both cell mediated and humoral pathways possibly as a
result of the release of mediators, such as interleukin-12 (IL-12)
and IL-17.13
Smoke inhalation-associated lung injury occurs in approxi-
mately 2% of burn victims with <20% TBSA burns and in 14%
of burns with 80% to 99% TBSA and contributes greatly to mor-
tality.14 Although more common with large burns, inhalation
injury can exist with or without cutaneous burns; however, its
presence is associated with a more than threefold increase in mor-
tality.14 Anatomically, injuries from smoke inhalation may involve
direct heat injury to the upper airway, chemical injury to the lower
airway, and systemic toxicity such as with inhalation of carbon
monoxide or cyanide. Unless exposed to steam, the heat dissipat-
ing properties of the upper airway generally restrict direct thermal
injury to the supraglottic structures. Lower airway and intratho-
racic injury is generally the result of exposure to various chemicals
contained in the smoke.
A large variety of toxic substances may be released with burning
materials, such as rubber and plastic including sulfur dioxide,
cyanide, nitrogen dioxide, ammonia, and chlorine, as well as toxic
aldehydes. These substance damage epithelial and endothelial cells
of the airways and their blood vessels leading to the formation of
pseudomembranes or airway casts consisting of cellular debris,
fibrin, and mucin that obstruct the airways and cause significant
mismatches in ventilation and perfusion (V/Q). Increases in
inflammatory mediators and reactive oxygen and nitrogen species
lead to further impairments in blood flow worsening V/Q mis-
match. Air trapping from the formation of ball valve obstructions
of the airway may also lead to regional barotrauma further injur-
ing the lungs. Mucociliary transport is also impaired leading to a
TABLE 56.1 
Clinical Estimation of Burn Depth
BLANCHES WITH
DEPTH APPEARANCE PRESSURE
Superficial (first degree) Red, no blisters
Superficial partial thickness Red, blisters
(second degree)
Deep partial thickness Red or white, no
(second degree blisters
Full thickness (third degree) Leather like, charred
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reduction in bacterial clearance and risk of infection. Loss
of surfactant can lead to alveolar collapse and atelectasis resulting
in further impairment in ventilation and oxygenation. The
toxic effects of carbon monoxide and cyanide are discussed in
Chapter 153.
CLINICAL FEATURES
Classification and Diagnosis of Burns
The prognosis and management of thermal burns are dependent
on the depth and surface area of the burn, emphasizing the need
for accurate estimates of burn depth and size. Unfortunately, both
estimations can be difficult and inaccurate. Although clinical
examination is most commonly used to determine burn depth
(even when performed by a burn specialist), its accuracy is only
50% to 75%.15 A large number of modalities have been evaluated
to improve the accuracy of clinical estimation of which only laser
Doppler imaging of dermal perfusion is used.16 However, its
use has been limited mostly to burn centers and research facilities.
The dynamic nature of burn injuries and their tendency to prog-
ress over time reemphasizes the need for close monitoring and
follow-up.
The depth of burns has traditionally been classified as first,
second, or third degree based on the degree of involvement of the
dermis (none, partial, and complete, respectively). Although first-
degree burns almost always heal within 1 week without any scar-
ring or sequelae, third degree burns generally require more than
3 weeks to heal and result in significant scarring (although this
dogma has recently been challenged).17 As a result, most third
degree burns (unless very small, usually less than 1 cm2) will
require surgical excision and skin grafting. Because the dermis is
relatively thick (up to 1 to 3 mm) and the ability of second degree
burns to heal spontaneously without much scarring is dependent
on how many dermal appendages survive, second degree burns
have been further classified as superficial partial (limited to the
upper or papillary dermis) and deep partial thickness burns
(including the deeper reticular dermis). In contrast, third degree
burns that involve the entire thickness of the dermis are called full
thickness. Clinical findings that help with estimating the burn
depth include color, presence of blisters, skin pliability, capillary
refill, and sensitivity to touch or needle prick (Table 56.1). Typical
examples of the appearance of different burn depths are presented
in Figures 56.1 to 56.3.
The percentage TBSA burned predicts mortality and helps
determine the amount of fluid resuscitation required. The Baux
score is the sum of the patient’s age and the percentage of TBSA
burned.18 In the original article, the Baux score that predicted
100% mortality was 100. A more recent study found that a Baux
score of 160 predicted 100% mortality, and a Baux score of 109.6
predicted 50% mortality (95% confidence interval), which is a
SENSITIVITY TIME TO NEED FOR EXCISION
TO PINPRICK PLIABILITY HEALING AND GRAFTING
+ ++ Soft 1 week −
+ ++ Soft 1 to 2 weeks −
± + Slightly tense 2 to 3 weeks +
− − Stiff, leather like >3 weeks +

Fig. 56.1.  Superficial partial thickness burn, which is pink and glisten-
ing. Some of the blisters have sloughed off.
Fig. 56.2.  Deep partial thickness burn. The white appearing area over
the dorsum of the hand is a deep partial thickness burn.
Fig. 56.3.  Full thickness burn over both feet. The central area is
depressed and has a yellowish color indicating it is a full thickness burn.
testament to improved therapy and outcomes.19 Estimation of
percentage of TBSA burned is often inaccurate. A retrospective
study of burns transferred to the Danish National burn center
found that 30% of the referrals were unnecessary due to overes-
timation of burn size.20 Air transports to another burn center
based on burn size estimation were significantly reduced when the
patients were evaluated by a burn specialist via telemedicine again,
suggesting that emergency clinicians tend to overestimate burn
size.21 Other than over-triage, over estimation of burn size may
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C H APTER 56  Thermal Burns 717
Fig. 56.4.  The “rule of nines” for estimating burn area in adults.
lead to excessive intravenous fluid administration that can result
in compartment syndromes and acute respiratory distress syn-
drome (ARDS).22
For large burns, Wallace’s “rule of nines” is often used to esti-
mate burn size. The “rule of nines” method divides the body into
areas that approximate 9% of the TBSA—the head and neck, each
upper extremity, the anterior or posterior surfaces of each of the
lower extremities, and half of the anterior or posterior surfaces of
the trunk (Figure 56.4). With children, the Lund-Browder chart
should be used that adjusts for age related differences in the dis-
tribution of body parts and sizes (Figure 56.5).23 For small burns,
the surface of the patient’s palm (including the palmer surface of
the fingers) can be used to estimate 1% of the TBSA.24 A number
of methods have been developed to increase the accuracy of burn
size estimation. Mobile applications and computer software help
improve burn size estimation.25,26 Burn severity has also been clas-
sified as mild, moderate, and severe based on a combination of
age, depth, and size (Table 56.2).
DIFFERENTIAL DIAGNOSES
The diagnosis and etiology of burns is generally straightforward.
A number of other diseases may sometimes masquerade as burns,
such as epidermal necrolysis and pemphigus.27-30 Epidermal
necrolysis is a spectrum of life-threatening mucocutaneous erup-
tions, including Steven-Johnson syndrome and toxic epidermal
necrolysis characterized by diffuse erythema and sloughing of
large areas of the skin, usually caused by a medication or infection.
718 PART II  Trauma  |  SECTION Three  Soft Tissue Injuries

DIAGNOSTIC TESTING
A A

1% Routine laboratory testing is generally of little value in evaluating

1% and managing patients with burns in the ED. Patients with sus-
pected inhalation injury should have a chest radiograph and
blood gas determination, including carbon monoxide levels. In
2% 13% 2% 2% 13% 2% patients with little or minimal symptoms or signs of inhalation
injury pulse oximetry and noninvasive determinations of carbon
1.5% 1.5% 1.5% 1.5% monoxide may be used. Patients with large burns requiring an
2.5% 2.5% admission should have baseline laboratory testing, including a
1% complete blood count, basic metabolic panel, blood type and
cross, and coagulation studies, which may all become impaired in
B B B B patients with large burns.
1.5% 1.5% 1.5% 1.5%

MANAGEMENT
C C C C Initial First Aid
Patients should be removed from the source of injury and any
garments and jewelry removed from the affected areas. Burns
1.75% 1.75% 1.75% 1.75% should be cooled with room temperature water.31 Direct exposure
to ice or iced water should be avoided because it may result in
frostbite. In patients with large burns careful monitoring of core
Relative percentages of areas affected by growth
body temperature is recommended to avoid hypothermia.32
Age Half of Half of one Half of one Although the subject of debate, in general blisters should be left
head (A) thigh (B) leg (C) intact.33 In the ED most blisters should be left intact; however, very
large or tense blisters, as well as those located over joints, should
Infant 9.5 2.75 2.5 probably be ruptured to ease local wound care. The burns should
1 yr 8.5 3.25 2.5 be covered with a clean dressing to minimize further trauma and
5 yr 6.5 4 2.75 reduce pain associated with air currents.
10 yr 5.5 4.25 3
15 yr 4.5 4.25 3.25 During transport to the ED patients with large burns (greater
Adult 3.5 4.75 3.5 than 20% in adults and greater than 10% in children) should have
two large bore intravenous catheters placed and fluid resuscitation
Fig. 56.5.  Lund-Browder chart.
should be initiated (see later for more details on fluid resuscita-
tion). Patients should be placed on supplemental oxygen to main-
tain oxygen saturation greater than 92%. Pain management using
TABLE 56.2  intravenous doses of an opioid is also recommended as per local
emergency medical service (EMS) protocols in hemodynamically
Classification of Burn Severity stable patients (see later for more details on pain management).
MILD MODERATE SEVERE
Children <5% TBSA 5% to 10% TBSA >10% TBSA
Airway Management
Adult <10% TBSA 10% to 20% TBSA >20% TBSA One of the most critical decisions in managing burn victims is the
need for and optimal timing of endotracheal intubation because
Elderly <5% TBSA 5% to 10% TBSA >10% TBSA injury to the upper airway may result in massive swelling of the
All <2% full 2% to 5% full >5% full thickness, tongue, epiglottis, and aryepiglottic folds. In some cases (such as,
thickness thickness, high high voltage, in the presence of significant oropharyngeal swelling, stridor,
voltage, inhalation, significant burn to and respiratory distress), the decision to intubate is obvious and
circumferential, face, eyes, ears, straightforward. In other cases, airway swelling may develop more
comorbid disease genitalia, or joints, gradually over several hours as fluid resuscitation proceeds. Clini-
significant associated cal signs such as facial burns, hoarseness, drooling, carbonaceous
trauma sputum, and singed nasal hairs certainly should raise the probabil-
Disposition Outpatient Admission Burn unit ity of inhalation injury. However, they are often unreliable and
poor predictors of injury. A recent prospective study of 100 burn
TBSA, Total body surface area. patients with suspected inhalation injury that were evaluated by
fiberoptic bronchoscopy found that 21% had no evidence of
upper airway involvement and 39% had no lower airway pathol-
The consequences and management of epidermal necrolysis are ogy. In contrast, 38% of patients with documented inhalation
very similar to those of large burns. Pemphigus includes a spec- injury did not have singed nasal hair.34 Traditionally emergency
trum of autoimmune bullous diseases characterized by the forma- clinicians have been encouraged to secure the airway as early as
tion of multiple blisters in the skin and mucous membranes. The possible, even prophylactically, prior to the onset of airway
blisters generally appear in the mucous membranes first followed obstruction. When in doubt, early intubation is encouraged;
by the skin. When left untreated, they may become generalized. however, the presence of neck or facial burns alone should not be
Inciting factors, such as medications, infections, and stress, may an indication for intubation. Recently there have been concerns
be identified. Child or elderly abuse must always be considered, that overly aggressive airway management may be detrimental to
especially when the history and pattern of burns are inconsistent patients.35-37 Inappropriate intubation and mechanical ventilation
with the physical findings. may lead to the ARDS possibly due to the release of inflammatory

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Fig. 56.6.  Fiberoptic view of inhalation injury. (Courtesy Dr. Marvin
Wayne.)
mediators. Ventilator-associated pneumonia is also seen in up to
30% of ventilated burn patients. A study of 1029 intubated burn
patients found that 17% underwent extubation within hours and
another 49% within 1 day of admission without the need for
reintubation, suggesting that tracheal intubation was unneces-
sary.35 Another study found that inhalation injury could not be
confirmed in more than half of the burned patients that were
intubated.37 The best way to confirm inhalation injury and the
need for endotracheal intubation is by directly visualizing the
upper airways with fiberoptic, video, or direct laryngoscopy using
topical anesthesia supplanted with mild to moderate sedation
when necessary. The presence of significant edema or soot in the
supraglottic region necessitates immediate intubation (Figure
56.6). When necessary, small doses (10 to 20 mg) of intravenous
ketamine can be used to sedate the patient without compromising
their ability to control the airway. An intravenous dose of glyco-
pyrrolate (0.1 to 0.2 mg) may also be considered prior to laryn-
goscopy to reduce secretions. Laryngoscopy may also be repeated
if the clinical condition changes. Rapid sequence induction should
be avoided unless direct visualization confirms that tracheal intu-
bation will be relatively easy. Rarely, a surgical airway is required
when it is not possible to endotracheally intubate the patient.
Awake intubation with generous amounts of topical anesthetics
with or without supplemental sedation should be used when a
difficult airway is suspected.
Breathing Management: Recognition and
Management of Inhalation Injury
A history of exposure to smoke in a closed space should always
raise the suspicion for smoke inhalation. Physical findings may
include facial burns, singed nasal hair, hoarseness, drooling,
stridor, and carbonaceous sputum. However, clinical signs may be
unreliable. Although the chest radiograph and CT scans of the
thorax may be helpful in some cases, direct visualization of the
upper airways remains the best method for confirming the pres-
ence of inhalation injury.
All patients with suspected inhalation injury should receive
supplemental humidified oxygen to maintain oxygen saturation
above 92%. Inhaled beta-agonists should be administered to
reduce bronchoconstriction associated with inhalation injury.38
Carbon monoxide levels should be measured using CO-oximetry
or noninvasive bedside devices. Cyanide toxicity should be sus-
pected in patients injured in a closed space, especially with
combustion of plastics and in the presence of lactic acidosis.
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C H APTER 56  Thermal Burns 719
BOX 56.1 
Indications for Endotracheal Intubation and
Mechanical Ventilation
Upper airway obstruction
Inability to handle secretions
Hypoxemia despite 100% O2
Patient obtundation
Muscle fatigue suggested by a high or low respiratory rate
Hypoventilation (PCO2 >50 mm Hg and a pH <7.2)
O2, Oxygen; PCO2, partial pressure of carbon dioxide.
TABLE 56.3 
Recommended Initial Ventilator Settings
Tidal volume 6–8 mL/kg
Respiratory rate 8–12 in adults
12–45 in children
Plateau pressures <35 cm H2O
I/E ratio 1 : 1 to 1 : 3
Flow rates 40–100 L/min
PEEP 8 cm H2O
I/E, Inspiratory-expiratory; PEEP, positive end-expiratory pressure.
Endotracheal intubation and mechanical ventilation are indicated
with persistent hypoxemia despite supplemental oxygen. Other
indications for intubation and mechanical ventilation are included
in Box 56.1. The best method of ventilation in patients with
inhalation injury is subject to debate.39 A large randomized
trial of patients requiring mechanical ventilation demonstrated
lower mortality with lower tidal volumes (6 mL/kg of predicted
weight).40 Maintaining airway plateau pressures below 35 mm Hg
is also desirable to avoid further injury from overinflation of the
poorly aerated lungs. This may lead to hypercapnia (permissive
hypercapnia), which should be tolerated as long as the PCO2
remains below 60 mm Hg and the pH remains above 7.2 and
there is no hemodynamic instability. Addition of positive end-
expiratory pressure (PEEP) may increase residual capacity and
improve oxygenation. Suggested initial ventilator settings are pre-
sented in Table 56.3. Some studies suggest that high frequency
percussive ventilation (HFPV) may improve oxygenation in
patients with inhalation injury when traditional methods (such
as, assist control) are ineffective.41 Prone positioning of the patient
may also be considered in hypoxic patients.42 Noninvasive ventila-
tion may be considered in awake, cooperative, spontaneously
breathing, hemodynamically stable patients who can maintain
their airway.43
Patients with smoke inhalation are at risk of developing pneu-
monia. Simple strategies such as elevating the head of the bed,
frequent position changes, and good oral care should be used.
However, prophylactic antibiotics do not reduce the risk of
ventilator-associated pneumonia.
A number of strategies have been used to help reduce the
copious secretions that tend to obstruct the airways. Broncho-
scopic lavage may be used to remove airway debris and secretions
that impede ventilation and enhance the inflammatory response.
Because intra-airway coagulation and fibrin deposition play a sig-
nificant role in the pathology of inhalation injury, anticoagulants
have also been evaluated. A recent systematic review of preclinical
720 PART II  Trauma  |  SECTION Three  Soft Tissue Injuries

and clinical studies concluded that inhaled anticoagulant regi-
mens improved survival and decreased mortality without altering
systemic markers of clotting and anticoagulation.44 An aerosolized
combination of an oxygen free radical scavenger and mucolytic,
N-acetylcysteine (the antidote for acetaminophen toxicity), with
heparin has been shown to improve outcomes in some but not all
studies.45,46 Its use, as well as bronchial lavage, should probably be
limited to the burn unit.
Circulation Management and Fluid Resuscitation
Burn injuries result in significant fluids losses and fluid shifts due
to loss of the epidermal barrier and an increase in capillary perme-
ability respectively. Leakage of plasma proteins into the interstitial
space during the early phases of a burn increases its oncotic pres-
sure, further contributing to fluid shifts and tissue edema.11 As a
result, a major focus of burn care is fluid resuscitation to restore
tissue perfusion and prevent hypovolemic shock. Intravenous
fluid resuscitation through large bore intravenous cannulas
should be instituted for most burns greater than 20% in adults
and greater than 10% in children.47 A number of formulas have
been proposed for estimating the fluid requirements of burn
patients (Table 56.4). Although these formulas are used as a
general starting point, frequent readjustments based on patient
response (vital signs, mental status, and hourly urine output) are
required to avoid both over and under resuscitation. Of all param-
eters, urine output is most accurate in assessing the clinical
response to fluid resuscitation with limited evidence of increased
benefit with utilization of more invasive hemodynamic monitor-
ing.48 Overly aggressive fluid resuscitation has been coined “fluid
creep” and can have devastating results, including worsening local
tissue edema with burn conversion, extremity compartment
syndrome, abdominal compartment syndrome, and pulmonary
edema.49 The Parkland formula is the most common method used
to calculate fluid requirements over the first 24 hours after injury
and is based entirely on lactated Ringer solution (see Table 56.4).
Half of the fluids are given within the first 8 hours from injury,
whereas the other half is giver over the next 16 hours. This formula
was based on a small number of animal and human studies.
However, a recent study found that patients managed with the
Parkland formula received on average 6.3 mL/kg per percentage
of TBSA over the first 24 hours instead of the recommended
4 mL/kg per percentage of TBSA, increasing the risk of over resus-
citation.50 The Modified Brooke formula, which calls for 2 mL/kg
per percentage of TBSA, may be a better starting point. The
United States Armed Forces Institute of Surgical Research has
recently proposed a simplified formula, the “rule of tens” in which
patients are administered 10 mL lactated Ringer solution for every
percentage of TBSA burned per hour, with hourly adjustments
based on clinical response and urine output with a target of
0.5 mL/kg per hour in adults and 0.5 to 1.0 mL/kg per hour in
children.51 With patients weighing more than 80 kg, an additional
100 mL/hour should be given for each additional 10 kg. The “rule
of tens” may lead to overestimation of fluid requirements in
patients weighing less than 40 kg and an underestimation in those
weighing more than 140 kg. Another method that has been shown
to improve the accuracy of estimated fluid requirements is the
Burn Resuscitation Index (BRI) that uses tables to assign a score
that is based on weight and estimated burn size.52 Colloids have
not been shown to be of benefit in burn patients, especially during
the first 12 hours, when capillary leakage is greatest.53 Recent
guidelines issued by the American Burn Association recommend
either the Parkland or Modified Brooke formulas with addition
of a colloid (such as, albumin) after the first 12 to 24 hours, espe-
cially in difficult to manage patients.47 The use of hypertonic
solutions has been studied with contradictory results; its use
should be limited to centers with considerable experience in use
of hypertonic saline.47
Escharotomy
With deep burns a leather-like necrotic eschar, which is stiff and
inelastic, covers the wound. When the eschar surrounds an
extremity or the neck, it may compress the underlying tissues

TABLE 56.4 

Burn Resuscitation Formulas

FORMULA FIRST 24 HOURS NEXT 24 HOURS
Parkland Lactated Ringer solution 4 mL/kg per percentage of burn; Colloids (5% albumin) in amount of 20% to 60% of plasma
1 within first 8 hours volume; glucose in water added to maintain urine output 0.5
2
to 1.0 mL/kg per hour in adults and 1 mL/kg/hr in children
Modified Parkland Lactated Ringer solution (mL) = 4 × kg × percentage of burn in Colloid infusion of 5% albumin at the amount 0.3 to
adults 1.0 mL/kg per percentage of burn every 16 hours
Evans Crystalloids in the amount of 1 mL/kg per percentage of burn, Crystalloids at 0.5 mL/kg per percentage of burn, colloids at
plus colloids at 1 mL/kg per percentage of burn, plus 2000 mL 0.5 mL/kg per percentage of burn, and the same amount of
glucose in water glucose in water as the first 24 hours
Brooke Lactated Ringer solution 1.5 mL/kg per percentage of burn, plus Lactated Ringer solution 0.5 mL/kg per percentage of burn,
colloids at 0.5 mL/kg per percentage of burn, plus 2000 mL colloids at 0.25 mL/kg per percentage of burn, and the same
glucose in water amount of glucose in water as the first 24 hours
Modified Brooke Lactated Ringer solution 2 mL/kg per percentage of burn in adults Colloids 0.3 to 0.5 mL/kg per percentage of burn, glucose in
and 3 mL/kg per percentage of burn in children water to maintain urine output
Monafo Solution containing 250 mEq Na, 150 mEq lactate, 100 mEq Cl; Solution titrated with 1
3 NS according to urine output
amount adjusted to urine output
Galveston Lactated Ringer solution at 5000 mL/m2 TBSA burned plus 3750 mL/m2 TBSA burned plus 1500 mL/m2 TBSA
2000 mL/m2 TBSA, 12 within 8 hours
Rule of ten Lactated Ringer solution at 10 mL per percentage of burn per hour Not applicable
for every 10 kg above 80 kg, 100 mL is added to this hourly rate
Cl, Chloride; Na, sodium; NS, normal saline; TBSA, total body surface area.

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Fig. 56.7.  Location of escharotomy incisions.
(vessels, nerves, muscle) leading to a compartment syndrome.54
Similarly, an eschar involving the thorax may impede ventilation.
When this occurs, emergent release of the tissue pressure by
making an incision through the eschar (escharotomy) is required
to prevent tissue necrosis and hypoventilation respectively.
Because the eschar is composed of necrotic tissue, escharotomy is
generally associated with little pain or blood loss. The amount of
blood loss can be further minimized by using electric cautery. To
be effective, the incisions should be down to the subcutaneous
level, allowing the stiff eschar shell to split open. The incisions
should also be slightly extended into normal tissue both proxi-
mally and distally. Along the extremities, the incisions are made
over the medial and lateral aspects to avoid damage to underlying
vital structures. With hand burns the incisions may need to be
extended into the fingers. The proper placement of escharotomy
incisions over the chest are displayed in Figure 56.7. The absence
of distal pulses as well as distal Doppler and pulse oximetry signals
indicate that an escharotomy is required. However, their presence
should not be used to exclude the need for emergent escharotomy.
Increased pain (especially with passive motion), pallor, weakness,
and sensory loss all may be signs of impending compartment
syndrome.
Local Wound Therapies
With most burn victims, care focuses on local wound therapies
aimed at protecting the burn from further injury and infection
and maintaining a moist wound environment that is most con-
ducive to healing. First-degree burns do not require any local
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C H APTER 56  Thermal Burns 721
treatment. However, topical application of a nonsteroidal anti-
inflammatory agent or aloe vera may reduce pain. In addition,
systemic administration of an analgesic, such as acetaminophen
or a nonsteroidal anti-inflammatory drugs (NSAIDs), should be
considered.
After cleaning the burn with soap and water, large or tense
blisters should either be aspirated with a needle or de-roofed and
any nonadherent necrotic tissue should be gently removed.33 If the
burn is very deep or involves a large area, the patient will require
admission, preferably to a burn unit. In this case, local wound
therapy should generally be performed in the burn unit. If the
patient is to be transferred, the burns should be covered with a
clean, nonadherent dressing. Small (<1% TBSA) full-thickness
burns that are being referred to a burn specialist within 48 hours
can be covered with an antimicrobial agent (such as, a triple anti-
biotic) and an outer absorptive dressing.
Management of partial thickness burns is subject to consider-
able debate as evidenced by the large number of natural and
synthetic agents and dressings available (Table 56.5). The two
methods of local treatment include a topical antibiotic ointment
or cream together with a nonadherent yet absorptive dressings or
one of many occlusive wound dressings (see Table 56.5). Oint-
ments are preferred over creams because they are better tolerated,
maintain a moist wound environment, and do not adhere to over-
lying dressings. With facial burns or over areas that are difficult
to dress, application of a topical antibacterial ointment is recom-
mended. Silver sulfadiazine cream has a wide antibacterial and
antifungal spectrum and should be considered in heavily con-
taminated or infected burns. A systematic review of 30 random-
ized controlled trials found that silver sulfadiazine was consistently
associated with poorer healing outcomes than biosynthetic (skin
substitute) dressings, silver-containing dressings, and silicon-
coated dressings.53 Therefore, silver sulfadiazine is no longer rec-
ommended for most burns. A recent randomized controlled trial
found that even burns treated with a petrolatum-impregnated
gauze without an antibacterial agent healed slightly faster that
silver sulfadiazine treated wounds.55 Use of topical agents is also
generally preferred for heavily exudating burns. When topical
agents are used, they should be applied once or twice daily after
washing the burn wound with mild soap and water while remov-
ing any nonadherent debris.
An alternative to topical antimicrobials, especially in burns
without heavy exudation, is one of a number of commercially
available occlusive dressings (see Table 56.5). Although generally
more expensive than topical agents, occlusive dressings require
less frequent dressing changes and are associated with less pain.
Therefore, occlusive dressings may also be cost effective when
compared to less expensive topical agents.56 A large number of
materials such as foams, alginates, silicones, hydrocolloids, and
hydrogels (with or without antimicrobial agents, such as very low
concentrations of silver) have been studied. A systematic review
of burn dressings in children with partial thickness burns found
that membranous dressings, such as Biobrane and amnion mem-
brane, improved healing, shortened hospital stay, and reduced
pain compared with an antibacterial impregnated gauze.57
However, the use of these biological dressings is best limited to a
burn specialist. Our recommendation is a silicone-coated foam
dressing impregnated with silver (Mepilex Ag) that is absorptive,
conforms to bodily contours, and is easy to remove without
causing additional injury to the tissues.58 With most of the occlu-
sive dressings, the dressing may be left in place for approximately
1 week unless obviously saturated or malodorous. Burns on the
extremities should be elevated to reduce swelling and care should
be taken to avoid tight compressive dressings.
A number of novel burn therapies have been investigated in
preclinical and clinical studies but are not yet recommended in
emergency settings. A systematic review of preclinical studies
722 PART II  Trauma  |  SECTION Three  Soft Tissue Injuries

TABLE 56.5 

Representative Topical Agents and Dressings for Burns

CATEGORY EXAMPLES ADVANTAGES DISADVANTAGES
NON-OCCLUSIVE, ABSORPTIVE
Gauze, nonadherent Telfa (Kendall, Mansfield, MA) Nonadherent, inexpensive Requires daily dressing changes
OCCLUSIVE
Foams Mepilex (Mölnlycke Health Care AB, Göteborg, Absorbs exudate, conforms to Opaque, may dehydrate wounds
Sweden); Curafoam (Kendall, Dublin, Ireland); Allevyn body site, prevents surrounding with minimal exudate
foam (Smith & Nephew, London, United Kingdom) maceration
Hydrocolloid DuoDERM (ConvaTec, Skillman, NJ); Tegasorb (3M, Absorbs exudates, protective Opaque, no antimicrobial
St. Paul, MN) cushioning of wound properties
Alginate SeaSorb (Coloplast, Humlebaek, Denmark); Algiderm Absorptive Frequent dressing changes
(Bard, Murray Hill, NJ); Melgisorb (Mölnlycke Health
Care AB, Göteborg, Sweden)
Nanocrystalline silver Acticoat (Smith & Nephew, Largo, FL); Aquacel Ag Antimicrobial, creates a moist Need to keep dressing moist
(ConvaTec, Skillman, NJ) environment, less frequent
dressing changes
Hydrogel Curagel (Kendall, Mansfield, MA); Flexigel (Smith & Rehydrates dry wounds Non-absorptive
Nephew, Largo, FL); Nu-Gel (Johnson & Johnson,
Arlington, TX)
Transparent films Tegaderm (3M, St. Paul, MN); OpSite (Smith & Transparent, inexpensive Non-absorptive
Nephew, Largo, FL)

suggested that warm water, simvastatin, erythropoietin, or cerium BOX 56.2 

nitrate may represent particularly promising approaches for
translation into clinical use in the near future to reduce the con-
version of superficial to deep burns.59 Another recent systematic
review and meta-analysis of growth factor therapy for partial
thickness burns concluded that this therapy (fibroblast growth
factor, epidermal growth factor, and granulocyte macrophage-
colony stimulating factor) might be an effective and safe add-on
to standard wound care for partial-thickness burns.60
Pain Management
Due to the direct stimulation of nociceptors in the skin and the
transmission of painful neural impulses via A-delta and C-fibers,
most burns are very painful. However, the pain in burn victims is
often undertreated.61 Routine monitoring of pain severity and the
use of pain management protocols have been shown to improve
pain management.62 Although pharmacological agents are the
cornerstones of burn pain management, non-pharmacological
methods (such as, cooling of the burn, covering the burn with a
dressing) and cognitive-behavioral therapy (such as, relaxation
and distraction) should be considered.63 Most national guidelines
for the management of burn-associated pain include acetamino-
phen (500 mg every 6 hours) or NSAIDs (such as ibuprofen
400 mg every 8 hours) for mild to moderate pain and opioids
(such as, fentanyl at 1 to 2 mcg/kg or morphine at 0.1 mg/kg) for
more severe pain.64 The addition of an anxiolytic, such as mid-
azolam or lorazepam, may be more effective than an opioid alone.
A systematic review of four experimental trials involving 67
patients found that intravenous ketamine (0.1 to 0.2 mg/kg)
showed some efficacy as an analgesic for burn injuries, with a
reduction in secondary hyperalgesia when compared with opioid
analgesia alone. Combination therapy with ketamine and mor-
phine also resulted in the abolishment of the wind-up pain phe-
nomena (the perceived increase in pain over time).65 Furthermore,
the side-effect profile seemed to be similar to opioids alone.
Despite initial studies suggesting that intravenous lidocaine may
be effective in treating severe burn pain, the current literature does
Criteria for Referral to a Burn Center
Partial thickness burns greater than 10% TBSA
Burns that involve the face, hands, genitalia, perineum, or major joints
Third degree burns in any age group
Electrical burns, including lightning injury (see Chapter 134)
Chemical burns
Inhalation injury
Burn injury in patients with preexisting medical disorders that could
complicate management, prolong recovery, or affect mortality
Any patient with burns and concomitant trauma (such as, fractures) in
which the burn injury poses the greatest risk of morbidity or
mortality
Burned children in hospitals without qualified personnel or equipment
for the care of children
Burn injury in patients who will require special social, emotional, or
rehabilitative intervention
TBSA, Total body surface area.
not support its use.66 The anticonvulsants gabapentin and prega-
balin (which inhibit presynaptic N-methyl-d-aspartate [NMDA]
receptors) may also be considered in burn patients with severe
pain despite traditional therapies.67 However, these therapies are
not useful in the immediate post burn period.
DISPOSITION
Most superficial and small burns can be managed in the ED by an
emergency clinician with close follow-up by a physician comfort-
able handling burns (usually a burn specialist) within the next 3
to 5 days. Patients with large or deep burns, burns involving sensi-
tive areas, and those with significant comorbidities and trauma
should be admitted. Criteria for referral to a burn center are pre-
sented in Box 56.2.68

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 C H APTER 56  Thermal Burns 723

KEY CONCEPTS
• After carefully removing the patient from the source of injury, burns
should be cooled with room temperature water while avoiding
hypothermia in patients with very large burns.
• Clinical signs such as facial burns, hoarseness, drooling,
carbonaceous sputum, and singed nasal hairs certainly should raise
the probability of inhalation injury; however, they are often unreliable
and poor predictors of injury severity.
• The best way to confirm inhalation injury and the need for
endotracheal intubation is by directly visualizing the upper airways
with fiberoptic, video or direct laryngoscopy using topical anesthesia
supplanted with mild to moderate sedation when necessary. The
presence of significant edema or soot in the supraglottic region
necessitates immediate intubation.
• Supplemental oxygen should be given in patients with suspected
inhalation injury and determination of carbon monoxide levels should
be performed.
• Fluid management to support vital organ perfusion and adequate
urine output using crystalloids by the Parkland formula or modified
Brooke formula should be administered as recommended by the
American Burn Association.
• Adequate pain relief for larger burns may be accomplished using
frequent intravenous titration with opioids supplemented with
sub-dissociative doses of ketamine.
• While patients with large (>20% for adults and >10% for children
and the elderly) or deep burns will require admission to a burn
center, most patients presenting to the ED will have small and
superficial burns that can be managed by over-the-counter topical
antibiotic ointments (silver sulfadiazine is no longer recommended
except for highly contaminated or infected wounds), or with one of
many commercially available burn dressings.

The references for this chapter can be found online by accessing the accompanying Expert Consult website.

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723.e2 PART II  Trauma  |  SECTION Three  Soft Tissue Injuries
CHAPTER 56: QUESTIONS & ANSWERS
56.1. A 30-year-old man presents with a burn to both anterior
aspects of his forearms after being burned by a radiator.
He has severe pain and has deep (reticular) dermis
extension of the burn. You call the consultant and describe
the burn as which of the following?
A. First-degree burn of 4.5% body surface area
B. Second-degree superficial burn of 9% body surface
area
C. Second-degree deep burn of 4.5% body surface area
D. Third-degree burn of 2.5% body surface area
E. Fourth-degree burn of 9% body surface area
Answer: C. Deep second-degree burns extend through the epider-
mis into the deep (reticular) dermis. Body surface area is deter-
mined by the rule of nines. Nine percent for each upper extremity
means that the forearm is approximately one fourth of 9%. Two
forearms burns are half of 9%. Second-degree burns are often
more painful than third-degree burns, in which all of the nerve
endings are destroyed.
56.2. A 3-year-old boy presents with circumferential burns
involving both upper extremities, including his hands,
from pulling a boiling pot of water off the stove. The
burns are mixed second-degree and third-degree burns.
Which of the following best describes the body surface
area burned and the most appropriate disposition?
A. 9% and admit to pediatrics with surgery consultation
B. 9% and transfer to burn unit
C. 18% and transfer to burn unit
D. 18% and admit to pediatric surgery
E. 20% and admit to pediatric intensive care unit
Answer: C. Children with burns over 10% total body surface area
(TBSA) should be transferred to a burn unit. In addition, hand
burns should be treated at a burn unit. Circumferential burns are
not consistent with a splash injury, and child abuse should be
suspected and reported.
56.3. A 55-year-old, 80-kg man presents with second-degree
burns of both his legs, front torso, and groin. What is the
initial fluid resuscitation according to the Parkland
formula?
A. 500 mL lactated Ringer solution in the first 4 hours
B. 1100 mL normal saline in the first hour
C. 1100 mL of lactated Ringer solution in the first hour
D. 2400 mL normal saline in the first hour
E. 4200 mL lactated Ringer solution in the first 4 hours
Answer: C. The amount of lactated Ringer solution required for
the first hour can be rapidly estimated with the Parkland formula
by multiplying the estimated total body surface area (TBSA) of
the second- and third-degree burn (55%) by body weight in kilo-
grams (80 kg) and dividing by 4.
56.4. A 25-year-old woman presents with a second-degree burn
to her right forearm after a grilling accident. You note
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areas of gray discoloration with decreased blanching in
the erythematous region of the burn. In addition to
irrigation, débridement, and dressing with a nonadherent
dressing, which of the following would be the most
appropriate treatment?
A. Apply silver sulfadiazine and follow-up with plastic
surgery in 1 week
B. Calculate the Parkland formula and administer fluids
before discharge
C. Educate the patient about daily dressing changes and
have her follow-up with plastic surgery in 24 to 48
hours
D. Immerse her forearm in ice water for pain control
E. Unroof soft blisters and have the patient follow-up
with her primary care physician in 1 week
Answer: C. The distinction between superficial and deep second-
degree burns is important in that deep second-degree burns often
do not heal within 2 or 3 weeks and may result in severe scarring
and contractures, especially in children. As a result, deep second-
degree burns that do not heal within 21 days may require excision
and skin grafting to minimize scarring. Deep second-degree burns
may also progress to third-degree burns during the course of
several days after injury. Burns over less than 20% TBSA can be
treated with oral hydration. Blisters are generally left intact ini-
tially if possible. They may later require débridement.
56.5. Which of the following is an indication for intubating a
patient who was found in a burning house?
A. Facial edema
B. Fire occurred in a closed space
C. Patient unable to handle own secretions
D. Singed eyebrows
E. Soot in the airway and singed nasal hair
Answer: C. See Box 56.1. Traditionally, inhalation injury was diag-
nosed on the basis of clinical findings, such as facial burns, singed
nasal vibrissae, carbonaceous sputum, and a history of injury
within a closed space. However, these findings are neither highly
sensitive nor highly specific. Nonetheless, these patients must be
closely observed for potential delayed airway compromise.
56.6. What is the most appropriate management for a
superficial partial thickness burn on the forearm?
A. A clean dry dressing, such as gauze
B. A commercially available silver containing dressing
C. Systemic antibiotics and silver sulfadiazine
D. Topical antibiotic ointment
E. B and D
Answer: E. Superficial partial thickness burns may be treated with
a topical antibiotic ointment or one of several commercially avail-
able silver releasing dressings. Silver sulfadiazine, as well as dry
dressings, will slow reepithelialization. Silver sulfadiazine is appro-
priate for infected or heavily contaminated burns. Systemic anti-
biotics are not indicated for non-infected burns.