How should a burn be documented, including mechanism, anatomical location, depth, total body surface area, inhalation injury, and relevant comorbidities?

How to Document a Burn Injury

A burn should be documented systematically by recording the mechanism of injury, anatomical location using standardized terminology, depth classification, total body surface area (TBSA) using the Lund-Browder chart, presence of inhalation injury, and relevant comorbidities that affect prognosis. 1

Mechanism of Injury

Document the specific agent and circumstances:

• Thermal source: Hot liquids (scalds), flames, contact with hot objects, steam 2, 3
• Electrical: High-voltage vs. low-voltage 1, 4
• Chemical: Specific agent (e.g., hydrofluoric acid) 1, 4
• Radiation: Less common but requires documentation 3
• Environment: Whether injury occurred in enclosed space (critical for inhalation injury assessment) 1
• Time of injury: Essential for fluid resuscitation calculations 2

Anatomical Location

Use precise anatomical terminology and identify function-sensitive areas:

• Function-sensitive areas (require burn center referral regardless of size): Face, hands, feet, perineum, flexure lines 1, 5, 6
• Circular/circumferential burns: Document location (neck, extremities, thorax) as these may require escharotomy 1, 4
• Specific patterns: For scalds in children, document distribution patterns (e.g., symmetrical vs. asymmetrical, witnessed vs. unwitnessed) as these have child protection implications 7

Depth Classification

Document burn depth using clinical criteria:

• Superficial (first-degree): Intact skin, erythema only 1, 3
• Superficial partial-thickness (second-degree superficial): Blisters, painful, pink/red base 5, 3
• Deep partial-thickness (second-degree deep): White or mottled appearance, decreased sensation 5, 3
• Full-thickness (third-degree): Leathery, white/brown/black, painless due to nerve destruction 2, 3

Critical distinction: Deep burns >5% TBSA require burn center referral in both adults and children 1, 5

Total Body Surface Area (TBSA)

Use the Lund-Browder chart as the standardized method for both adults and children 1, 5, 6:

• This method accounts for age-related differences in body proportions and is more accurate than the Rule of Nines 1, 2
• The Rule of Nines significantly overestimates TBSA and is not suitable for children 1
• Alternative for small burns: The open hand (palm plus fingers) = 1% TBSA 1, 6
• Document percentage separately for partial-thickness and full-thickness burns 2

Common pitfall: TBSA is frequently overestimated in 70-94% of cases, leading to excessive fluid resuscitation 1. Repeat measurements during initial management to improve accuracy 1.

Inhalation Injury Assessment

Document presence or absence of inhalation injury indicators:

• Clinical signs: Facial burns, singed nasal hairs, soot around nose/mouth, carbonaceous sputum 1, 2
• Symptoms: Voice changes, stridor, laryngeal dyspnea, wheezing 1, 2
• History: Fire in enclosed space 1
• Diagnostic findings: Bronchoscopy findings if performed (though not recommended outside burn centers to avoid transfer delays) 1

Any suspected inhalation injury requires immediate activation of emergency services and potential intubation 1, particularly if combined with:

• Deep circular neck burns 1
• Symptoms of airway obstruction 1
• Very extensive burns (TBSA ≥40%) 1

Relevant Comorbidities

Document factors that affect prognosis and treatment decisions:

• Age: Infants <1 year and elderly >75 years have worse outcomes 1, 5, 2
• Pre-existing conditions: Cardiac, pulmonary, renal disease, diabetes 1, 2
• Immunocompromised status: Affects infection risk 2
• Medications: Anticoagulants, immunosuppressants 2

Burn Center Referral Criteria

Document whether the patient meets criteria requiring specialized burn center management:

Adults 1, 5, 4:

• TBSA >10% (>20% for definite referral)
• Deep burns >5%
• Burns to face, hands, feet, perineum, or flexure lines
• Circular burns
• Electrical or chemical burns
• Age >75 with TBSA >10%
• Severe comorbidities
• Smoke inhalation injury

Children 1, 5, 4:

• TBSA >10%
• Deep burns >5%
• Age <1 year
• Burns to function-sensitive areas
• Any electrical or chemical burns
• Circular burns

Documentation Template Structure

A complete burn documentation should include:

1. Mechanism: [Thermal/electrical/chemical] + specific agent + circumstances
2. Location: Anatomical areas involved + function-sensitive areas (yes/no) + circular (yes/no)
3. Depth: Superficial/superficial partial/deep partial/full-thickness by location
4. TBSA: __% using Lund-Browder chart (specify partial vs. full-thickness percentages)
5. Inhalation injury: Present/absent + clinical indicators
6. Comorbidities: Age + relevant medical conditions
7. Burn center criteria: Met/not met + specific criteria

This systematic approach ensures accurate triage, appropriate fluid resuscitation calculations, and timely referral to specialized care when indicated 1, 5.