Burns

As my family plans to ignite the forest of candles on my birthday cake, it dawns on me that I may need to manage my own burn. So as a Happy Birthday gift to myself, we’ll talk about burns briefly. Since I still behave like I am a member of the pediatric population (got a sweet new Razor scooter for Christmas), it is appropriate to consider only kids at this point.

Estimate the Area:
o The Rule of Nines – often used; many times overestimates the area
o Lund and Browder chart accounts for changes in body surface area with age; still subjective
o Surface area of the patient’s palm and fingers =~1%; more easily used on smaller areas
o DO NOT include areas of only erythema (only de-epithelialized areas are included)
o Pick a method and base your initial fluid resuscitation on it, but then don’t forget to monitor Urine Output (much more important in determining your efforts).
o Calculated resuscitation fluids should be ADDED to Maintenance fluids in pediatric patients!

The Depth:
o Traditionally taught of as 1st, 2nd, 3rd degree… but preferred lingo is now:

Epidermal (~ 1st degree): Painful, red, no blisters
Superficial Dermal (~2nd degree): Painful, pink, small blisters

Deep Dermal (~3rd degree): reduced pain, blotchy, blisters, No Cap Refill
Full Thickness: No sensation, white or black, no blisters, No cap refill

Blisters – to debride them or not?
o This is often debated… with literature to support both sides (as often is the case)
o Here is what I was taught and what I’ve come to understand:
– Without debridement, you cannot truly assess the depth of the burn
– Thermal damage continues after the initial contact with heat source; some believe that the blister may exacerbate this continued thermal injury.
– Small, less than 6mm can be left alone.
– Most large blisters will rupture on their own and then carry greater risk of infection
– So, debride blisters that are >6mm.

o Ensure good analgesia (conscious sedation if appropriate – gotta love ketamine or propofol during a birthday talk!)… and debride with sterile gauze soaked in saline.
o Dress after debriding and assessing the depth. Biosynthetic dressings may cost more upfront, but have many advantages (including less dressing changes).
Enoch, S, Roshan, A, Mamta, S. Emergency and early management of burns and scalds. BMJ 2009; 228:b1037

Sargent, RL. Management of blisters in the partial-thickness burn: an integrative research review. J Burn Care Res 2006; 27:66.