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Burns: Clinical Estimation

by Julianna Jung, MD, FACEP

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    00:01 Hello. Now we’re gonna talk about burns and smoke inhalation.

    00:05 Burns are very common phenomenon.

    00:08 There are 85,000 ED visits per year in the United States related to burns, unfortunately, the vast majority are minor, only 2% of burns seen in the United States emergency departments cover more than 40% of the body surface area.

    00:25 There are 34,000 deaths per year in the world.

    00:29 Case fatality rate is directly correlated with how bad - with how much surface area is covered by burns, and so the greater the surface area the more likely you are to die from it.

    00:41 And once you get up to 60 to 70% total body surface area covered by burns, half of the patients are gonna die.

    00:48 We see scalding or liquid burns more commonly in children whereas we see flame burns more commonly in adults although obviously both groups can experience both types of burns.

    01:00 Burn severity is classified according to three factors. One are the patient factors - the patient’s age and comorbidities or major determinant of how well they’re gonna do following a burn.

    01:13 Burn depth and location is another feature of the classification so how deep the burn is and where on the body it is is gonna change outcomes and then lastly, how big the burn is or how much of the total body surface area or TBSA it covers.

    01:30 There are no hard and fast rules here so when we stratify burns into mild, moderate and severe, we should always be sort of looking at the big picture of the patient’s overall health and thinking about the impact of this burn on their life.

    01:44 And when in doubt, you should always treat a burn as a major burn, but there are some general guidelines that help us decide whether a burn should be treated as a mild event, a moderate event or a severe life threatening event.

    01:59 Mild burns are those that cover less than 10% of the total body surface area in adults, or less than 5% in extremes of age.

    02:09 In general, less than 2% of body surface area should be covered by full-thickness burns.

    02:14 Provided the patient meets this criteria and they are reasonably healthy, they can generally be managed on an outpatient basis.

    02:21 Moderate burns are those that cover 10 to 20% of the body surface area for adults and 5 to 10% at extremes of age.

    02:30 To have a moderate burn, you might have a higher percentage of full-thickness involvement and generally, any burn that sustained through high voltage exposures, is associated with inhalation injuries, is circumferential meaning it goes all the way around one part of the body, or if the patient has any significant underlying comorbid disease, we should consider their burns to be at least moderate and these patients generally merit admission to the hospital.

    02:57 For severe burns, we’re looking at greater than 20% of total surface area or greater than 10% at extremes of age and we’re looking at greater than 5% deep burns.

    03:08 We’re also looking at any high voltage injury, burns in sensitive areas like the face, eyes, ears, genitals and over joints, and we're also looking at patients who have significant associated trauma.

    03:21 These patients should really be managed in specialty burn units as their risk of morbidity and mortality is quite high.

    03:29 When we think about burn depth, we classified burns into four groups - superficial burns which had previously been known as first-degree burns; superficial partial thickness burns which is previously had been known as second degree burns; deep partial thickness burns which were also part of second degree in the past; and then full thickness or third degree burns.

    03:52 When we think about burns the clinical exam is really, really important so the appearance of the burn whether or not the patient has sensation there, what it feels like when you palpate it, these are all the things that help you figure out how deep the burn is.

    04:09 So generally superficial burns will look just like a sunburn, they’ll be red but not blistering or with minimal blistering.

    04:16 They’ll blanch with pressure, they’ll be very sensitive to pin prick or any kind of light touch will be quite painful.

    04:22 The tissue will feel soft and generally these are gonna get better within about a week.

    04:27 For superficial partial thickness burns, that’s where we're gonna start to see blistering began.

    04:33 Again, these burns will blanch with pressure, they will be sensitive to pin prick or light touch and the tissue should be soft and pliable so the real difference between the superficial partial thickness and the superficial is just the presence of blisters.

    04:48 It takes a little bit longer for those blisters to heal so generally you’re looking at about two weeks of healing time for these patients.

    04:55 Deep partial thickness burns have a different appearance compared to the more superficial burns we’ve already discussed, so these can be red but they are more commonly white and non-blistering.

    05:06 They don’t typically blanch with pressure although red areas might.

    05:10 They do retain some degree of sensitivity to pin prick but the thing that’s really different about them is the consistency of the burn tissue.

    05:18 So while the superficial burns, the tissue feels soft and pliable just like normal tissue, now the tissue’s gonna feel more tense, that’s because this tissue has literally been cooked resulting in chemical changes to the connective tissue and the protein structures inside of the tissue which you can actually feel the difference compared to normal soft pliable tissue.

    05:44 Your deep partial thickness burns take longer to heal and typically do require some degree of excision and skin grafting to heal completely.

    05:53 Full thickness burns are very striking and very easy to identify.

    05:57 These will actually appear leather like and charred.

    06:00 They are insensate, nonblanching, you can touch them, poke them, do whatever you want and the patient is not gonna feel anything and that’s cuz the nerve endings are actually burned away.

    06:12 They’re not pliable at all, they feel like hard, stiff leather and these take a significant amount of time to heal and do almost invariably require excision and grafting, again for coverage.

    06:26 So let’s offer some visual examples of the different burn types.

    06:31 This is a superficial partial thickness burn which like I said is gonna be red, it's gonna be shiny in appearance, it’s gonna be blistering and it’s gonna be very, very, sensitive so even light touch on this baby's skin is gonna probably produce some significant screaming cuz these are very painful.

    06:49 By contrast, here’s a deep partial thickness burn.

    06:53 So you can some redness across the knuckles and fingers but note the whitening in the area on the dorsum of the hand that’s very characteristic of a deep partial thickness burn and if you’re able to touch that, you’ll appreciate that the tissue’s not pliable it's actually tense and firm, again because of the chemical changes that have occurred with the connective tissue proteins.

    07:14 There are no blisters in that area although there are some more superficially burned areas further up on the wrist and forearm.

    07:22 The dorsum of the hand is non-blistering, so that’s very characteristic of a deep partial thickness burn.

    07:28 And then here’s an example of a full thickness burn.

    07:31 So this child has had both feet burned and I wanna call your attention to the central area in each burned region where you can see that the tissue is yellow and you can almost imagine that it’s tense and contracted and thickened and that’s gonna give you that sort of leathery texture when you go to palpate that skin.

    07:53 These burns as awful as they look are insensate because again, the nerve ending has been damaged in the course of burning.


    About the Lecture

    The lecture Burns: Clinical Estimation by Julianna Jung, MD, FACEP is from the course Toxicologic and Environmental Emergencies. It contains the following chapters:

    • Severity of Burns
    • Clinical Estimation of Burn Depth

    Included Quiz Questions

    1. Liquid burn
    2. Flame burn
    3. Chemical burn
    4. Inhalation injury
    5. High voltage exposure
    1. < 10% TBSA
    2. 10–15% TBSA
    3. 15–20% TBSA
    4. 20–25% TBSA
    5. > 25% TBSA
    1. Admit to burn unit
    2. Outpatient management
    3. Observe at the ED
    4. Admit to regular room
    5. Admit to ICU
    1. Full thickness
    2. Superficial burn
    3. Second degree burn
    4. Superficial partial thickness
    5. Deep partial thickness

    Author of lecture Burns: Clinical Estimation

     Julianna Jung, MD, FACEP

    Julianna Jung, MD, FACEP


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