What are the steps to diagnose a scald burn?

How to Document a Scald Burn Diagnosis

Document the scald burn diagnosis by recording the mechanism of injury, calculating total body surface area (TBSA) using the Lund-Browder chart, assessing burn depth through clinical examination (recognizing that initial appearance may be misleading), and noting any associated injuries or comorbidities.

Essential Components of Scald Burn Documentation

Mechanism of Injury

• Record the specific source of the scald (hot water, steam, hot liquids) and duration of exposure, as these factors influence burn depth progression 1
• Document any circumstances suggesting prolonged exposure, particularly in patients with altered consciousness, neurological disorders, dementia, or alcohol intoxication, as these are associated with deeper injuries than initially apparent 1
• Note if the injury occurred in a bathtub, as these scalds frequently present with misleading "lobster redness" that progresses to full-thickness burns despite initial erythematous appearance 1

TBSA Calculation

• Use the Lund-Browder chart as the standardized method for calculating TBSA in both adults and children, as it is the most accurate quantification method available 2, 3
• Record the extent of actual epidermal detachment separately from erythema on a body map, as detachment (not erythema) has prognostic value for mortality risk 2
• Include both detached epidermis AND detachable epidermis (Nikolsky-positive areas) in your measurement 2
• Be conservative in your estimation, as TBSA is overestimated in 70-94% of cases, leading to excessive fluid administration 2, 3
• Avoid using the Rule of Nines, especially in children, as it significantly overestimates TBSA and fails to account for age-related body proportions 2

Burn Depth Assessment

• Document burn depth as superficial, partial thickness, or full thickness, but explicitly note that scald burns are clinically difficult to assess during the early postburn period and may appear more superficial than they actually are 4
• Be particularly cautious with erythematous areas in scald injuries, as these frequently progress to full-thickness burns over the first 2-3 days, especially in bathtub scalds 1
• Consider obtaining a skin biopsy with histological workup if the clinical assessment is uncertain, particularly in cases with prolonged heat exposure 1
• Plan for repeated assessments during the first 72 hours, as initial depth estimates are often inaccurate and burn appearance evolves 5, 6

Critical Documentation Elements

• Record patient age, as pediatric patients and elderly patients have different risk profiles and TBSA calculations 2, 6
• Document any neurological or psychiatric disorders, as 81% of severe bathtub scalds occur in patients with these conditions 1
• Note the presence of inhalation injury, circular burns, or burns in function-sensitive areas, as these affect referral decisions 3
• Calculate and document the revised Baux score (age + TBSA% + inhalation injury factor) to objectively quantify injury severity and guide transfer decisions 5

Common Pitfalls in Scald Burn Diagnosis

• Do not rely on initial erythema to determine burn depth in scald injuries—these wounds are notoriously misleading and tend to declare themselves as deeper over 48-72 hours 1, 4
• Avoid making definitive surgical decisions within the first 72 hours, as only half of clinically indeterminate scald injuries ultimately require surgical intervention when assessed at 2 weeks 4
• Do not use palm-only measurements (0.5% TBSA) when you mean palm-plus-fingers (1% TBSA) for quick field estimates 2
• Recognize that smaller burns tend to be overestimated while larger burns tend to be underestimated, particularly in pediatric populations 6

Documentation for Referral Decisions

• Adults with TBSA >20%, deep burns >5%, or smoke inhalation require burn center referral 3
• Children with TBSA >10%, deep burns >5%, age <1 year, or any electrical/chemical component require burn center referral 3
• Document early specialist consultation, ideally through telemedicine if direct consultation is unavailable 3