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MANAGEMENT OF BURNS. CPT Allen Proulx, MPAS, PA-C. OBJECTIVES. Describe the differences between partial and full-thickness burns. Describe how to estimate the size of a burn. Describe initial care of burns. Describe follow-up care of partial thickness burns. References for photos.

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management of burns


CPT Allen Proulx, MPAS, PA-C



  • Describe the differences between partial and full-thickness burns.
  • Describe how to estimate the size of a burn.
  • Describe initial care of burns.
  • Describe follow-up care of partial thickness burns.
references for photos
References for photos
  • Advanced Burn Life Support Course,

American Burn Association, 1994

  • Textbook of Military Medicine, Part I, Vol 5

Conventional Warfare, OTSG, 1991

  • Textbook of Surgery, Sabiston, editor

W. B. Saunders, 1986


American College of Surgeons, 1988

  • Burn care product info
depth of burn
Depth of burn

Partial thickness burn =

involves epidermis

Deep partial thickness =

involves dermis

Full thickness =

involves all of skin

partial thickness burns
Partial thickness burns
  • Sunburn is a very superficial burn.
  • Expect blistering and peeling in a few days.
  • Maintain hydration orally.
  • Heals in 3-6 days- generally no scaring
  • Topical creams provide relief.
  • No need for antibiotics
deeper partial thickness
Deeper partial thickness
  • Blisters are typical of partial thickness burns.
  • Don’t be in a hurry to break the blisters.
  • Heals in 14-21 days
  • Blisters provide biologic dressing and comfort.
  • Once blisters break, red raw surface will be very painful.
full thickness burn
Full thickness burn
  • Yellow, “leathery” appearance; or charred
  • Often have no sensation (nerve endings destroyed)
  • Outer edges might be partial thickness.
  • Initial management same as partial thickness.
  • Later will need skin grafts.
mixed partial and full thickness
Mixed partial and full thickness
  • Central yellow area might be full thickness.
  • Outer edges are probably partial thickness.
  • Initial management is the same.
  • Later will need skin grafts for the full thickness areas.
zones of burn wounds
Zones of Burn Wounds
  • Zone of Coagulation
    • devitalized, necrotic, white, no circulation
  • Zone of Stasis ‘circulation sluggish’
    • may covert to full thickness, mottled red
  • Zone of Hyperemia
    • outer rim, good blood flow, red
estimate the size of the burn
Estimate the size of the burn
  • The patient’s own palm is about 1% of his body surface area.
  • “Rule of Nines”
american burn assoc says send these to a burn center
American Burn Assoc says send these to a burn center
  • Partial thickness burns >10% BSA
  • Burns involving the face, hands, feet, genitalia, perineum, or major joints
  • full thickness/3 degree burn
  • Electrical, Chemical, and Inhalation burns
  • In combat, all but the most superficial burn should be evacuated
burn care products
Burn care products
  • < 20% TBSA 2nd degree – Silvadene (SVC) Cream BID
  • Any > 20% TBSA-SVC and Sulfamylon (SMC) alt BID
  • 3rd degree burn – SVC and SMC alt BID
  • *SMC only to the ears * Bacitracin Opth to face
care of small burns
Care of small burns
  • Clean entire limb with

soap and water (also under nails).

  • Apply antibiotic cream

(no PO or IV antibiotic).

  • Dress limb in position of function, and elevate it.
  • No hurry to remove blisters unless infection occurs.
  • Give pain meds as needed (PO, IM, or IV)
  • Rinse daily in clean water; in shower is very practical.
  • Gently wipe off with clean gauze.
  • In the pre-hospital setting, there is no hurry to remove blisters.
  • Leaving the blister intact initially is less painful and requires fewer dressing changes.
  • The blister will either break on its own, or the fluid will be resorbed.
blisters break on their own
Blisters break on their own

Upper arm burn day 1 day 2

Burn “looks worse” the next day because of blisters breaking and oozing

upper arm burn
Upper arm burn
  • Blisters show probable partial thickness burn.
  • Area without blister might be deeper partial thickness.


before and after debridement
Before and after debridement
  • Removing the blister leaves a weeping, very tender wound, that requires much care.
foot burn debridement
Foot burn debridement

Before debriding

and applying cream,

clean entire foot


toes and nails).

silver impregnated dressings silverlon
Silver- impregnated dressings (Silverlon)
  • Apply wet silver dressing

directly on the burn.

  • Creams or dressings

under the silver dressing

impede the antimicrobial action.

  • Keep it moist!
  • Remove it, rinse it out, replace it on the burn.
steps in using silver impregnated dressings
Steps in using silver-impregnated dressings
  • Clean the burn and surrounding area.
  • Soak silver-impregnated dressing and gauze in


  • Apply silver-impregnated dressing (over-lapping edges are best).
  • Wrap with the moist gauze.
  • Secure with mesh, gauze, or tape.
  • Keep it moist with WATER, every 12h or so More frequent in hot arid environments

Soak silver dressings and gauze

in WATER (not saline).

Apply the

silver dressing.

Wrap with moist gauze.

Secure with mesh, gauze, or tape.

first few days
First few days
  • Moisten dressing with WATER every 12h or so.
  • Remove outer gauze and silver dressing every day.
    • Inspect the burn.
    • Rinse exudate off burn.
  • Rinse exudate off silver dressing with WATER.
  • Return same silver dressing to the burn.
  • Apply new outer gauze moistened with WATER.

Moisten with WATER q12h or so.

Moisten well

to remove it each day.

Rinse it out, and put it back on the burn.

after several days
After several days
  • Replace silver dressing
    • every 2 - 5 days
    • depending on amount of exudate, cellular debris
  • First wet the silver dressing before removing it.
  • Don’t pull on it if it’s stuck – moisten it more.
  • Apply new moist silver dressing and gauze.
questions about small burns


  • Describe the differences between partial and full-thickness burns.
  • Describe how to estimate the size of a burn.
  • Describe initial care of small burns.
  • Describe follow-up and post-burn care.


burns of special areas of the body

Burns of special areasof the body




Hands and feet


  • Be VERY concerned for the airway!!
  • Eyelids, lips and ears often swell alarmingly.
  • In fact, they look even worse the next day.
  • But they will start to improve daily after that.
  • Cleanse eyes with warm water or saline.
  • Apply antibiotic ointment or liquid tears until lids are no longer swollen shut.
  • Bacitracin cream/ointment will serve
hands and feet
Hands and feet

This is rather deep and might require grafting.

But initial management is basic.

Dressings should not impede circulation.

Leave tips of fingers exposed.

Keep limb elevated.

hands and feet1
Hands and feet
  • Allow use of the hands in dressings by day.
  • Splint in functional position by night.
  • Keep elevated to reduce swelling.
hands and feet2
Hands and feet
  • Fingers might develop contractures if active measures are not taken to prevent them.
  • Shower daily, rinse off old cream, apply new cream.
  • Insert Foley catheter if unable to urinate due to swelling.
causes of death in burn patients
Causes of death in burn patients
  • Airway
    • Facial edema, and/or airway edema
  • Breathing
    • Toxic inhalation (CO, +/- CN)
    • Respiratory failure due to smoke injury or ARDS
edema formation
Edema Formation
  • Amount of edema can be immense (even without facial burns)
  • Depression of mental status can worsen problem
  • Edema peaks at 12 to 24 hours
  • Pediatric patients even more concerning
causes of death in burn patients1
Causes of death in burn patients
  • Circulation: “failure of resuscitation”
    • Cardiovascular collapse, or acute MI
    • Acute renal failure
    • Other end organ failure
  • Missed non-thermal injury
patients with larger burns
Patients with larger burns

First assess

  • CBA’s
  • “Disability” (brief neuro exam)
  • Expose


  • Examine rest of patient
  • Calculate IV fluids
  • Treat burn
  • “Flash” burns may refer to those that suddenly flare up, then die down quickly.
  • Patients may have burnt facial hair and carbon on lips.
  • Patients with this kind of facial burn will probably NOT need an artificial airway.
  • Give humidified oxygen while under close observation.
  • Record vital signs.
  • Check distal pulses and nail beds.
    • Keep him warm!
    • Loss of skin impairs ability to retain heat and fluids.
    • Being cold will cause vasoconstriction.
  • Monitor urine output (in larger burns, insert Foley catheter for hourly urine output). 30/50cc/hr
  • Monitor at least HCT and urine specific gravity.
  • When available, monitor electrolytes.
neuro status
Neuro status
  • The burn itself does not alter the level of consciousness.
  • If patient is not alert, think of other causes:
    • hypovolemia
    • carbon monoxide
    • head injury
  • Don’t allow swollen eyelids to prevent you from examining the pupils.
  • Test sensation and motion in burned extremities.
  • Undress the patient to examine the whole body.
  • But burned patients lose body heat quickly, so keep them warm.
  • To keep warm, use whatever means available:


heating lamps

bed frame

large box covered with blankets

head to toe exam
Head to toe exam
  • Obtain history and examine rest of body.
  • Ask about allergies, meds, medical conditions.
  • Look for other injuries.
calculate fluid requirements
Calculate fluid requirements

wt in kg x % burn x 2 - 4cc / kg / %

100 kg patient with 50% TBSA burn:

100 x 50 x 2 = 10,000cc = 10 liters RL

This is calculated for the first 24 hours post-burn.

Give half of this in first 8 hours.

Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially

calculate fluid requirements1
Calculate fluid requirements

Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially

How do we know if this is too much fluid, or too little?

Monitor at least:

urine output - in adults, around 50 cc / hr

Decreasing urine output = need for more fluids.

burn size in small children
Burn size in small children
  • The head accounts for about 18% (instead of 9%).
  • The legs account for about 13% (instead of 18%).
fluid requirements in children
Fluid requirements in children
  • Use same formula for fluids to replace loss from burns.
  • In children, add this amount to normal maintenance rate:

10 kg - about 40 cc / hr maintenance fluids

20 kg - about 60 cc / hr

30 kg - about 70 cc / hr

  • Expected urine output for child: 1 cc / kg /hr

for infant: 2 cc/ kg / hr

fluids requirements in children
Fluids requirements in children

20 kg child with 30% burn:

20 (kg) x 30(%) x 2 (cc/kg/%) = 1200 cc in 24 hr

Half of this in first 8 hr = 600 cc in 8 hr = 75 cc / hr initially

75 cc / hr for burn loss + normal 60 cc / hr maintenance =

135 cc / hr initially

  • How do you know if the patient is getting too much fluid,

or too little?

Check urine output, urine specific gravity, HCT

Be sure the patient’s airway, breathing and circulation are secure.
  • Then treat the burn wound itself.
  • In patients with large burns, do not initially spend much time carefully calculating fluids.
  • Instead, start an IV and start giving fluids rather rapidly while exam is being performed. DO NOT BOLUS! 500cc/hr is a good rule.
  • Later do the calculations.
special types of burn

Special types of burn

Circumferential burn

Burn requiring escharotomy

Electrical burn

Chemical burn

circumferential burn
Circumferential burn
  • Limb is burned all the way around.
  • Soft tissues under the skin always swell with burns

(due to capillary leak of fluids in first day or so).

  • There is a loss of skin expansion due to the loss of turgor/elasticity in burned tissue
  • Pressure inside limb gradually increases.
  • Eventually, pressure inside limb exceeds arterial pressure.
  • This requires escharotomy to relieve the pressure.
escharotomy indications
Escharotomy - indications
  • Circulation to distal limb is in danger due to swelling.
    • Progressive loss of sensation / motion in hand / foot.
    • Progressive loss of pulses in the distal extremity by palpation or doppler.
  • In circumferential chest burn, patient might not be able to expand his chest enough to ventilate, and might need escharotomy of the skin of the chest.
escharotomy complications
Escharotomy - complications


  • Bleeding: might require ligation of superficial veins
  • Injury to other structures: arteries, nerves, tendons

NOT every circumferential burn requires escharotomy.

  • In fact, most DO NOT need escharotomy.
  • Repeatedly assess neuro-vascular status of the limb.
  • Those that lose circulation and sensation need escharotomy.
  • Eschar = burned skin
  • Escharotomy = cut burned skin to relieve underlying pressure
  • Similar to bivalving a tight cast.
  • Cut along inside and outside of limb from good skin to good skin
  • Knife can be used, or cautery.
  • Use local or no anesthesia.

(Full-thickness burn should have no sensation, but underlying tissues do!)

escharotomy of forearm
Escharotomy of forearm
  • Incise along medial and/or lateral surfaces.
  • Avoid bony prominences.
  • Avoid tendons, nerves, major vessels.
  • Patient had escharotomy of

both legs.

  • Incisions will heal.
  • They will not be closed by DPC.
  • These large burns are often

treated by the “open” technique,

that is, without dressings.

electrical burn
Electrical burn
  • Outer skin might

not appear too bad.

  • But heat was conducted

along the bone.

  • Causes the most damage.
  • Burns from inside out.
  • Usually requires fasciotomy
  • Fascia = thick white covering of muscles.
  • Fasciotomy = fascia is incised (and often overlying skin)
  • Skin and fascia split open due to underlying swelling.
  • Blood flow to distal limb is improved.
  • Muscle can be inspected for viability.
  • Particles of phosphorus must be removed from under the skin.
  • Pick them off with forceps.
  • Must apply wet dressing to prevent re-igniting.
questions summary
  • Describe how to estimate the body surface area of burn.
  • Describe how to calculate initial fluid requirements in a patient with a large burn.
  • Describe intial management of a patient with a large burn.
  • Discuss indications and complications of escharotomy.
burn down dirty
  • Educate your Task Force!

proper technique for burning waste, wear of clothing

  • Do not hesitate to evacuate.
  • Burns other than inhalation generally don’t kill at point of injury- Bleeding and breathing injuries do!
  • Oral Abx if managing burn at BAS ?