Burn Injury Resuscitation And The Importance Of Early Measures

Burn Injury Resuscitation And The Importance Of  Early Measures

In the first step assessing a burn and planning resuscitation involves a careful examination of all body surfaces. A standard Lund-Browder chart is readily available in most emergency departments for a quick assessment of TBSA burns.See the image below.Lund-Browder chart.

The Lund-Browder chart. If the Lund-Browder chart is not available, the “rule of nines” is fairly accurate in adult patients.See the rule of nines as follows. Note that a patient’s palm is approximately 1% TBSA and can be used for estimating patchy areas.See the image below.

Rule of nines.

The Rule of nines.

Each arm – 9% TBSA

Anterior thorax – 18% TBSA

Posterior thorax – 18% TBSA

Each leg – 18% TBSA

Perineum – 1% TBSA

Head/neck – 9% TBSA

When treating pediatric patients, the head is a proportionally larger contributor to body surface area (BSA), while the upper legs contribute less. This difference is reflected in the slight differences noted in the pediatric Lund-Browder diagram.

A useful tool for estimating BSA of spotty burns is the close approximation of just less than 1% BSA to the patient’s palm size. Only second-degree burns or greater should be included in the TBSA determination for burn fluid calculations.

The Burn depth has come to be classified into several fairly standardized categories. It include superficial (first-degree) burns, partial-thickness (second-degree) burns, full-thickness (third-degree) burns, and devastating full-thickness (fourth-degree) burns.

The Superficial (first-degree) burns are limited to epidermal layers and are equivalent to a superficial sunburn without blister formation.

The Partial-thickness (second-degree) burns are also called dermal burns and can be superficial partial-thickness burns or deep partial-thickness burns.

The Superficial partial-thickness burns involve the superficial papillary dermal elements and are pink and moist with exquisite pain upon examination. Blister formation appears with the level of the burn. This type of burn is expected to heal well within several weeks, without skin grafting.

See image below.

Superficial partial-thickness burn.

The Superficial partial-thickness burn. Deep partial-thickness burns involve the deeper reticular dermis. They can have a variable appearance ranging from pink to white with a dry surface. Sensation may be present but is usually somewhat diminished, and capillary refill is sluggish or absent. Burns of this depth routinely require excision and grafting for satisfactory healing.

See image below.

Deep partial-thickness burn.

The Deep partial-thickness burn. Full-thickness (third-degree) burns extend into the subcutaneous tissues and have a firm, leathery texture and complete anesthesia upon examination. Clotted vessels can be observed through the eschar.

See image below.

Full-thickness burn.

The Full-thickness burn. Fourth-degree burns are devastating full-thickness burns that extend into muscle and bone.

Estimating burn depth at the extremes of severity is relatively easy. Differentiating the subtleties between dermal-level burns is difficult, even for experienced surgeons. However, this distinction is more important for planning excision and grafting of the burn than for resuscitation.

Burns that initially appear to be limited to epidermal layers (ie, first-degree burns), and thus are not included in resuscitation calculations, may develop the blistered characteristics of dermal level burns over several hours. Evaluation of burn depth with laser Doppler in the first few days of treatment has been an effective adjunct in some centers for assessing moderate to severe burns.

In evaluating burn depth, considering the burn in the context of which factors individually determine burn depth is important. These factors are the temperature, mechanism (eg, electrical, chemical), duration of contact, blood flow to the skin, and anatomic location. The keratinized epidermal depth can vary dramatically by body area from less than 1 mm in the thinnest areas (eyelids, genitals) to 5 mm (palms and plantar surfaces), offering varying degrees of thermal protection.

Also the dermal elements of young children and geriatric patients are somewhat thinner than those of healthy adults, which explains the observation that burns in persons of these age groups are usually more severe than similar insults in other patients.

Outside the reports of burn size and depth are notoriously unreliable, especially from referring physicians with little experience with burns. Estimates state that reports of burn size are estimated correctly only one third of the time and that burn sizes are frequently significantly overestimated (averaging 75% larger than burn unit size estimates).

Practitioners should still assume that the burn is somewhat worse than described and be prepared to fully reevaluate the burn upon the patient’s arrival because burn size has significant influence on all aspects of the initial management.

Table 1. Differences in TBSA With Age

Infant Age 1 Y Age 5 Y Age 10 Y Age 15 Y Adult
Head 19 17 13 11 9 7
Neck 2 2 2 2 2 2
Anteriortrunk 13 13 13 13 13 13
Posteriortrunk 13 13 13 13 13 13
Buttock 2.5 2.5 2.5 2.5 2.5 2.5
Perineum 1 1 1 1 1 1
Thigh 5.5 6.5 8 8.5 9 9.5
Leg 5 5 5.5 6 6.5 7
Foot 3.5 3.5 3.5 3.5 3.5 3.5
Upperarm 2.5 2.5 2.5 2.5 2.5 2.5
Lowerarm 3 3 3 3 3 3
Hand 2.5 2.5 2.5 2.5 2.5 2.5

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