- Partial-thickness burns greater than 10% of total body surface area in patients who are younger than 10 years old or older than 50 years old (photo credit) [Rule of nines to estimate TBSA]
- Partial-thickness burns over more than 20% of total body surface area in other age groups
- Burns that involve the face, hands, feet, genitalia, perineum, or major joints
- Third-degree burns in any age group
- Electrical burns, including lightning injury
- Chemical burns
- Inhalation injury
- Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affectmortality rate
- Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or death
- Burn injury in children at hospitals without qualified personnel or equipment for the care of children
- Burn injury in patients who will require special social, emotional or long-term rehabilitative intervention
Burn Depth -- It must be noted that burn wounds continue to mature, and damage to the skin continues for 24 to 48 hours secondary to several factors, including edema and coagulation of small vessels.
- Commonly caused by flame flash or ultraviolet exposure
- Generally pink, dry, and painful
- Epithelium is intact
- No risk for scarring
- Necrotic epidermis will generally slough within 1 or 2
days, revealing intact epidermis
- Require no specific care
- Signify that the dermis has been damaged
- Wet, pink or red, and edematous
- Generally heal with local wound care
- Further divided into superficial and deep,
corresponding to likelihood of rapid healing and risk
for poor scarring:
- Superficial second-degree burns
More sensitive and hyperemic
- Deep second-degree burns (photo credit)
Have higher potential for conversion to third degree
Early excision limits hypertrophic scarring
Third-degree burns (photo credit)
- Involve full thickness of the dermis
- Will not heal without surgery
- Leathery, dry, insensate, and waxy
- Notable absence of tissue edema compared with surrounding second-degree burned area
Fourth-degree burns (for picture go here)
- Extend through the subcutaneous soft tissue to tendon
- Associated with limb loss or the need for complex
The eMedicine article (5th reference below) by Edlich, et al is well worth reading. It includes a discussion of Skin Anatomy and Function, Burn depth, Pre-Hospital Treatment, Emergency Room Treatment, Fluid Resuscitation, Supportive Care, Burn Wound Management, and Nutritional Support.
It also makes this point of when not to treat:
When not to resuscitate
When patient survival is extremely unlikely after burn injury, the clinician must be encouraged not to begin fluid resuscitation. Elderly patients with large burns (>80% TBSA) will not survive. This decision must be made after thoughtful communication with family members. When resuscitation is not undertaken, make patients pain-free, keep them warm, and allow them to remain in a room with family members.
There are many several prognostic burn indexes (APACHE I and III, etc). They are used as a gauge for patient mortality. This index suggests that the patient’s age plus their full-thickness total body surface area burn plus 20 percent for inhalation equaled the likely mortality rate. So at my age (51 yr), if I had an 80% TBSA burn I would have very little likelihood of survival.
However, advances from early excision of burn eschar, skin grafting, early enteral feeding, and wound closure with advanced techniques (skin substitutes) have altered the simple mathematical calculation. Patients with a prognostic burn index of 90 to 100 now have a mortality rate in the 50 to 70 percent range, with poorer outcomes at both extremes of age. Still note that in my example using me as a patient: 51 yr + 80% = 131% chance of death. If my TBSA burn was on 50%, then I might have a fair chance of survival in a good burn unit these days.
Acute Burns; Plastic & Reconstructive Surgery. 121(5):311e-319e, May 2008; Grunwald, Tiffany B. M.D., M.Ed.; Garner, Warren L. M.D.
Acute Burns; Plastic & Reconstructive Surgery. 105(7):2482-2493, June 2000; Kao, Chia Chi M.D.; Garner, Warren L. M.D.
Treatment of Minor Burns; University of Utah Health Science Center's Burn Center
Emergency Care of the Burned Patient; University of Utah Health Science Center's Burn Center
Burns, Thermal; eMedicine Article; August 7, 2008; Richard Edlich MD, David Drake MD, William Long III MD