What is the definition, clinical presentation, and management of burns?

Burns: Definition, Clinical Presentation, and Management

Definition

Burns are tissue injuries caused by thermal, chemical, electrical, or radiation energy that result in protein denaturation, cellular destruction, and loss of the skin's protective barrier function. This leads to inflammation, capillary leak syndrome, hypermetabolism, and increased susceptibility to infection 1.

Clinical Presentation

Severity Assessment

Burns are classified by:

Depth:

• Superficial (First-degree): Epidermis only, painful, erythematous, no blistering
• Partial-thickness (Second-degree): Extends into dermis, extremely painful, blistering, moist appearance
• Full-thickness (Third-degree): Destroys entire dermis, painless (nerve destruction), white/charred appearance, leathery texture

Total Body Surface Area (TBSA):

• Use the "Rule of Nines" in adults or Lund-Browder chart for children
• Accurate TBSA assessment is critical but difficult in the first minutes after injury 2

Key Clinical Features to Assess

Immediate concerns:

• Airway compromise: Look for facial burns, singed nasal hairs, carbonaceous sputum, hoarseness, stridor, or respiratory distress 3
• Circumferential burns: Assess for compartment syndrome in limbs or thorax/abdomen causing respiratory compromise 2
• Inhalation injury: Increases mortality significantly, especially with delayed transfer 2
• Hemodynamic instability: Burns induce early hypovolemic shock from capillary leak, with cardiac output nadir at 4 hours 2

Management Algorithm

Initial Resuscitation (First Hour)

Immediate fluid resuscitation is mandatory for severe burns to prevent hypovolemic shock and reduce mortality. 2

Adults with TBSA >10% and children with TBSA >10%:

• Administer 20 mL/kg of balanced crystalloid solution (Ringer's Lactate preferred) within the first hour 2
• Ringer's Lactate is superior to 0.9% NaCl, which causes hyperchloremia, metabolic acidosis, and increased acute kidney injury 2

Vascular access:

• Obtain IV access immediately, preferably in unburned areas
• If IV access fails rapidly, use intraosseous route
• Central femoral access is last resort 2

Continued Fluid Resuscitation (First 24-48 Hours)

Use resuscitation formulae as starting estimates only—actual rates must be titrated to clinical response. 2

Adults:

• Calculate using Parkland formula: 2-4 mL/kg/%TBSA over 24 hours
• Give half in first 8 hours, remaining half over next 16 hours
• Target urine output: 0.5-1 mL/kg/h 2

Children:

• Require higher fluid intake: approximately 6 mL/kg/%TBSA over 48 hours
• Add maintenance fluids using Holliday-Segar 4-2-1 rule to modified Parkland formula (3-4 mL/kg/%TBSA) 2
• Children with 10-20% TBSA may benefit from reduced fluid volumes 2

Critical adjustment principle:

• Fluid rates must be adjusted continuously based on urine output, lactate, and hemodynamic parameters to avoid both under-resuscitation and "fluid creep" 2
• Both insufficient and excessive fluids increase morbidity 2
• Consider advanced monitoring (echocardiography, cardiac output monitoring) for persistent instability 2

Albumin administration:

• For TBSA >30%, administer human albumin after the first 6 hours to reduce mortality 2

Cooling

Cool burns with TBSA <20% in adults and <10% in children if no shock is present. 2

• Cooling for 20-40 minutes reduces burn depth and need for skin grafting
• Also provides pain relief
• Do not cool extensively burned patients or those in shock (risk of hypothermia)

Pain Management

Pain from burns is severe and requires aggressive multimodal analgesia with titrated IV opioids and ketamine. 2

• Use validated pain assessment scales
• Titrated IV ketamine combined with opioids is highly effective for severe burn pain 2
• Short-acting opioids (e.g., fentanyl) are preferred for procedural pain
• Inhaled nitrous oxide useful when IV access unavailable
• General anesthesia may be necessary for highly painful procedures 2
• Combine pharmacologic with non-pharmacological techniques (virtual reality, hypnosis) when patient is stable 2

Wound Care

Wound dressing is NOT a priority—perform only after adequate resuscitation. 2

• Requires clean environment and deep analgesia/general anesthesia
• Clean with tap water, saline, or antiseptic solution
• Avoid prolonged silver sulfadiazine use on superficial burns (delays healing) 2
• Cover with fatty substance (Vaseline) and dressings to reduce pain and heat loss
• Consult burn specialist for dressing selection and blister management

Escharotomy

Escharotomy should be performed at a burn center within 48 hours if circumferential third-degree burns cause compartment syndrome, circulatory impairment, or respiratory compromise. 2

• Only urgent indication is compromised airway movement/ventilation 2
• Carries risks of hemorrhage and infection; poorly performed escharotomy increases morbidity 2
• If transfer impossible, obtain specialist consultation before attempting

Transfer Criteria

Direct admission to burn center is preferred for severe burns requiring specialized care. 2

Consider burn center transfer for:

• TBSA >10% in adults, >10% in children
• Full-thickness burns
• Burns involving face, hands, feet, genitalia, perineum, major joints
• Electrical or chemical burns
• Inhalation injury
• Circumferential burns
• Comorbidities complicating management

Common Pitfalls

• Underestimating fluid needs: Formulae are starting points only; failure to titrate leads to organ dysfunction
• Over-resuscitation ("fluid creep"): Excessive fluids cause compartment syndromes, prolonged ventilation, increased mortality
• Delayed airway management: Inhalation injury and facial burns can cause rapid airway obstruction
• Inadequate pain control: Burn pain is among the most severe; undertreating causes unnecessary suffering and anxiety
• Using 0.9% NaCl instead of balanced crystalloids: Increases complications
• Cooling extensive burns: Causes hypothermia and worsens shock
• Attempting escharotomy without expertise: High complication risk; transfer to burn center instead