Burns (Thermal)

Symptoms

• Pain (intact in partial-thickness; ABSENT in full-thickness — neural destruction)
• Dyspnea, hoarseness, stridor, soot in nares/mouth — suspect airway burn
• Anxiety, agitation
• Loss of consciousness or carbon monoxide poisoning symptoms (headache, confusion, cherry-red skin — late finding)

Signs / physical exam

• Superficial (first-degree): erythema, dry, painful, blanches; epidermis only; e.g., sunburn; heals in 3-7 days without scarring; NOT counted in TBSA
• Superficial partial-thickness (second-degree): pink-red, MOIST, BLISTERS, very painful, blanches; epidermis + papillary dermis; heals in 7-21 days with minimal scarring
• Deep partial-thickness (second-degree): mottled red/white, drier, less blanching, decreased pinprick sensation, often blistered; epidermis + deep dermis; heals in 3-8 weeks with scarring, often needs grafting
• Full-thickness (third-degree): white, leathery, charred, or waxy; DRY, INSENSATE, non-blanching, may show thrombosed vessels; involves full dermis; requires grafting; scarring inevitable
• Subdermal (fourth-degree): extends into fat, muscle, bone; charred, may have eschar; reconstructive surgery, amputation
• Calculate TBSA — Rule of Nines (adult): head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, perineum 1%. Children: head 18%, each leg 14% (modified). Patient's palm = ~1% TBSA — useful for scattered burns. ONLY partial- and full-thickness count; superficial burns excluded.
• Inhalation injury signs: facial burns, singed nasal hair, carbonaceous sputum, hoarseness, stridor — low threshold for intubation; airway swells over 12-24 hours

Classic findings

Painful red blistered partial-thickness burn versus white insensate dry full-thickness burn.

Diagnostic criteria

Clinical depth assessment + TBSA calculation. Major burn (American Burn Association burn center transfer criteria): partial-thickness >10% TBSA; any full-thickness; face/hands/feet/genitalia/major joints/perineum; electrical/chemical/inhalation injury; comorbidities; pediatric burns at non-pediatric centers; concomitant trauma.

Labs

• All major burns: CBC, BMP, glucose, lactate, ABG with carboxyhemoglobin (suspect CO poisoning), cyanide level if industrial/structure fire, troponin (electrical burns), CK (rhabdomyolysis), urinalysis (myoglobinuria), type and cross
• Give 100% O2 empirically to all suspected CO poisoning (COHb correlates poorly with symptoms); consider hyperbaric O2 for COHb >25%, neurologic/cardiac involvement, syncope, or pregnancy
• Cyanide poisoning → hydroxocobalamin
• Wound cultures for delayed presentation or signs of infection

Imaging

• Chest X-ray (baseline + 24-48 h for inhalation injury progression)
• CT brain if altered mental status, trauma history
• Bronchoscopy if inhalation injury suspected — gold standard for diagnosis
• Imaging for associated trauma (fall from height, MVC)

First-line

• Initial management — ATLS approach: Airway (low threshold to intubate before edema; cuffed tube), Breathing (100% oxygen, manage inhalation injury), Circulation (large-bore IV access; avoid burned skin if possible), Disability, Exposure (remove clothing/jewelry, prevent hypothermia)
• Stop the burning process: cool with room-temperature water 10-20 min (do NOT use ice → tissue injury, hypothermia); remove smoldering clothing and jewelry
• Fluid resuscitation for >20% TBSA partial/full-thickness burn (adult) or >10% (child):
• • Parkland formula: 4 mL × kg × %TBSA Lactated Ringer's over first 24 hours; ½ over first 8 hours from time of injury, ½ over next 16 hours
• • Titrate to urine output 0.5 mL/kg/h adult, 1 mL/kg/h child <30 kg; avoid over-resuscitation
• Pain control: IV opioids — morphine, hydromorphone, fentanyl; titrate; address anxiety
• Tetanus prophylaxis per immunization history
• Wound care:
• • Superficial: cool compresses, aloe vera, NSAIDs
• • Partial-thickness: cleanse, debride loose tissue, apply topical antimicrobial — silver sulfadiazine (avoid on face and in G6PD deficiency, pregnancy, infants <2 mo), bacitracin, mupirocin, silver-impregnated dressings (Acticoat, Mepilex Ag); biological/synthetic dressings (Biobrane, Suprathel); cover with non-adherent dressing
• • Avoid prophylactic systemic antibiotics — only treat documented infection
• Nutritional support — enteral feeding early; caloric needs increased 1.5-2x baseline
• Stress ulcer prophylaxis (PPI or H2 blocker)
• DVT prophylaxis once hemodynamically stable
• Burn center transfer per American Burn Association criteria

Inhalation injury

• Early intubation if any concern (low threshold — airway can swell rapidly over 12-24 h)
• 100% supplemental oxygen until carboxyhemoglobin documented normal
• Bronchoscopy for diagnosis and pulmonary toilet
• Albuterol, mucolytics, inhaled heparin/N-acetylcysteine (specialized centers)
• Mechanical ventilation may be needed for ARDS

Circumferential / eschar formation

• Monitor for compartment syndrome (extremity, chest, abdomen)
• Escharotomy (longitudinal incision through full-thickness eschar) at bedside or OR
• Fasciotomy if compartment pressures elevated

Definitive coverage

• Early excision and split-thickness skin grafting for deep partial-thickness and full-thickness burns (typically within 1 week)
• Allograft or biologic skin substitutes (Integra) for large burns lacking donor sites
• Cultured epidermal autograft for massive burns

Second-line / adjunct

• Rehabilitation: physical/occupational therapy from day 1 — splinting, positioning, range-of-motion to prevent contracture
• Pressure garments + silicone sheets for hypertrophic scar prevention (6-12 months)
• Mental health support — PTSD, depression, body image
• Long-term scar management: laser therapy, surgical revision; itch management (gabapentin, antihistamines)
• Counsel on sun protection of healed burn skin (depigmentation/scar pigmentation)