Monday, September 15, 2008

Acute Burns -- When to Transfer

Plastic surgeons are often consulted for burns that present to the emergency department. The first decision to be made is whether the injury may be cared for at the presenting facility or should betransferred to a designated burn center. This assessment will include the size of the burn, the depth of the burn, the risk of morbidity and associated injuries (e.g., inhalation injury or trauma), and patient co-morbidities.

The American Burn Association developed the following criteria (pdf) for patients who need burn center referral/transfer:

  • 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 affect
    mortality 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.

First-degree burns

  • 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


Second-degree burns

  • 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:
  1. Superficial second-degree burns
    More sensitive and hyperemic
  2. Deep second-degree burns (photo credit)
    Have higher potential for conversion to third degree
    (full-thickness) burns
    Monitor closely
    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
    or bone
  • Associated with limb loss or the need for complex
    reconstruction

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.


REFERENCES

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

2 comments:

WhiteCoat said...

Another great review of a pertinent topic.
Thanks!

shadowfax said...

I also transfer to the burn center when there are circumferential burns, though it's not on the "official" list of indications.

Great review.