THERMAL BURNS

Introduction
Background

Burn injuries account for an estimated 700,000 annual ED visits per year. Of these, 45,000 require hospitalization. Approximately half of these patients are hospitalized at one of the 125 specialized burn treatment centers in the United States.

Most burns are not life threatening, but each burn causes a significant amount of pain for the patient and often some degree of psychological trauma. At temperatures greater than 120 º F, a child's skin is burned severely enough to require surgery in 3 seconds. Rapid evaluation by the emergency physician (EP) is essential to address pain management, provide initial wound care, evaluate appropriate disposition, mitigate the psychological impact of the burn, and identify intentional burns. Follow-up for even superficial thickness burns is imperative, particularly when involving the hands, feet, face, genital area, or other particularly sensitive areas.

To effectively evaluate, treat, and prevent potential future burns, understanding the different methods of categorizing burns is helpful. The general categories include life-threatening versus non–life-threatening, accidental versus intentional, recreational versus occupational, and domestic (home or residence) versus industrial.

Identifying the type of burn is essential because interventions must be appropriately tailored to the underlying cause. Type of burns include thermal burns, chemical burns, and radiation burns. Thermal burns can be further classified according to skin depth and percentage of total body area burned. Additional descriptions for thermal burns include contact, flame, heat, and scalding. Accurate documentation of the burn location (such as ophthalmic, hand, face, inhalation, soles, or perineum) and measurement of involved surface area are essential for follow-up and specialist referral/consultation.
Pathophysiology

The skin is the largest organ of the body. Although not very active metabolically, the skin serves multiple functions essential to the survival of the organism, which may be compromised by the presence of a burn, including the following:

* Thermal regulation and prevention of fluid loss by evaporation
* Hermetic barrier against infection
* Sensory receptors that provide information about environment

The skin is divided into 3 layers, as follows:

* Epidermis: This is the outermost layer of skin composed of cornified epithelial cells. Outer surface cells die and are sloughed off as newer cells divide at the stratum germinativum.
* Dermis: This is the middle layer of skin composed of primarily connective tissue. It contains capillaries that nourish the skin, nerve endings, and hair follicles.
* Hypodermis: This is a layer of adipose and connective tissue between the skin and underlying tissues.

The most common type of burns are thermal burns. Soft tissue is burned when it is exposed to temperatures above 115ºF (46°C). The extent of damage depends on surface temperature and contact duration. A thermal burn causes coagulation of soft tissue. As the marginally perfused areas become reperfused, it is thought that there is a release of vasoactive substances causing formation of reactive oxygen species, which leads to increases in capillary permeability. This causes fluid loss as well as increasing plasma viscosity with resultant microthrombi formation.1

This third spacing of fluid "seals" at 18-24 hours, which is why the guidelines for fluid resuscitation are based on a 24-hour time scale. After the initial 24 hours, the fluid requirements abruptly drop as the capillary permeability returns to normal. Underresuscitation in this initial 24-hour time period leads to significant morbidity from hypovolemia and shock.

Burns may cause a hypermetabolic state manifested by fever, increased metabolic rate, increased minute ventilation, increased cardiac output, decreased afterload, increased gluconeogenesis resistant to glucose infusion, and increased skeletal and visceral muscle catabolism. Patients need support in this state, which continues until wound closure is complete.1 To a large degree, how the individual responds to the increased energy demands determine recovery.
Frequency
United States

Burns are a common problem seen in the emergency department. Nearly one million Americans seek ED treatment of burns each year. According to data provided by the American Burn Association, the incidence of burn injuries in the United States has declined from 2 million annual injuries estimated from 1957-1961. There has also been a decrease in the number of burns in the United States through 2000, but this appears to have stabilized since. Most burns are only partial thickness and occur on the extremities. Approximately 5% of individuals with burns presenting to the ED require admission.2

According to 2007 data from the US Fire Administration, in 2006, 3,245 Americans lost their lives, and another 16,400 were injured as the result of fire. Notably, although the number of fires and deaths due to fires has decreased from 1997 to 2006, the direct dollar loss in millions has significantly increased from $8,525 to $11,307. Not included in these data are the deaths or the monetary value attributed to fires caused by the terrorist attacks of September 11, 2001. In 2002-2004, the United States had one of the highest fire death rates reported in the industrialized world at 12.4 deaths per million population, a slight decrease from 12.9 deaths per million population last reported in 2003.3 Most of these fatalities (79.5%) occurred in the home.

Slightly different findings were released by the World Fire Statistics in 2007.4 They reported that the fire-related death rate in the United States was 1.39 deaths per 100,000 (18.6 per million) in the years 2002-2004. For comparison, fire-related death rates per 100,000 were higher in Finland and Hungary at 2.08 and 2.10, respectively.

States with the highest death rates in 2004 were the District of Columbia (36.1 per million), Mississippi (32.1 per million), and Alabama (25.6 per million). The states with the lowest rates were Colorado (4.3 per million), Vermont (3.2 per million), and Wyoming (2 per million).3 Interestingly, in 2006, fire killed more Americans than all natural disasters combined.3

From 1990-2006, an estimated 2,054,563 patients aged 20 years or younger were treated in US EDs for burn-related injuries, with an average of 120,856 cases per year.5
International

The incidence of burn injuries varies from country to country, typically peaking during the country's holiday period.

In 2007, the World Fire Statistics Centre released fire-related death data by country (from lowest to highest number of deaths per 100,000 person) from 2002-2004.4 The countries with the lowest incidences include Singapore (0.08) and Switzerland (0.51). Those with the highest include Finland (2.08) and Hungary (2.10).4

In the United Kingdom, more than 47 fire-related injuries occur every day.

In Greece, the estimated annual incidence of childhood firework injuries treated in EDs is 7 injuries per 100,000 children per year. Seventy percent of injuries occur in children aged 10-14 years. Boys sustain self-inflicted accidental injuries; girls are typically injured as bystanders. A sharp peak of firework injuries occurs in the spring when the Greek Orthodox Easter is celebrated.6

Interesting data from Northern Ireland allows a comparison of burn incidence before and after the enactment of firework legislation. In the prelegislation series, the mean number of patients admitted annually was 0.38 per 100,000, whereas in the postlegislation series, the mean was 0.43 per 100,000. The authors concluded that legislation did not significantly affect the incidence of burns. Also in Northern Ireland, blast injuries to the hand account for more than 50% of injuries in this series.7
Mortality/Morbidity

Although fire-related deaths still rank fifth in the leading causes of unintentional injury-related deaths,8 the number of deaths from fires and burns has declined since the 1960s. Improvements in burn care (ie, quality burn centers, recognition, and effective management of burn shock) have reduced the number of deaths in the early postburn period. Improved wound management and antibiotics have decreased deaths from burn wound infection as well. The legislature has passed acts aimed at the prevention of injury due to fires. In 1971, the Flammable Fabrics Act was passed in an attempt to regulate the sale of flammable children’s clothing, especially that of sleepwear in infants, as it was noted to be a major cause of morbidity and mortality. Over time, this decreased the number of fire-related deaths and injuries in children.9

However, the greatest factors in the reduction of burn-related deaths is the use of smoke detectors and regulations on hot water heater temperature. In the United States, most people killed in house fires die from smoke inhalation rather than from burns (see Smoke Inhalation and Toxicity, Carbon Monoxide).

Race

Native American and black children are more than 2 times and 3 times as likely to die in a fire than white children, respectively.8 Black children and adolescents had the highest rates of burn and fire-related deaths. This is attributed to the decreased likelihood of minorities to engage in safe practices (fireplace guards, smoke alarm use, and adjusting water heater temperature).8
Age

Minor burns are more common in younger adults, often as a result of cooking or occupational exposures. Teenaged males are at increased risk of injury from fireworks; scald injuries are more common in young children. Most scald injuries in young children result from improper setting of domestic hot water heaters and spillage of cooking pots or beverages. Both types of injuries are easily prevented.

Most children aged 4 years and younger who are hospitalized for burn-related injuries suffer from scald burns (65%) or contact burns (20%). Most scald burns to children, especially small children aged 6 months to 2 years, are caused by hot foods or liquids spilled in the kitchen or other areas where food is prepared and served.

Water heater temperature must be set lower than 120°F. Within 3 seconds, a child's skin can be burned severely enough to require surgery when they are scalded with water temperature greater than 120°F.

The EP must consider intentional injury when burn patterns, such as absence of splash marks, stocking glove distribution, sharply defined wound margins, soles, palms, and pinpoint "cigarette ash" burns, are identified. Children aged 4 years and younger and children with disabilities are at the greatest risk of burn-related death and injury, especially scald and contact burns.

The leading cause of residential fire-related death and injury among children aged 9 years and younger is due to carelessness. Fires kill more than 600 children aged 14 years and younger each year and injure approximately 47,000 other children. Approximately 88,000 children aged 14 years and younger were treated at hospital EDs for burn-related injuries; 62,500 were thermal burns and 25,500 were scald burns. The most common causes of product-related thermal burn injuries among children aged 14 years and younger are hair curlers, curling irons, room heaters, ovens and ranges, irons, gasoline, and fireworks.

Elderly persons are also at increased risk not only for having a burn-related injury but for having increased morbidity due to their thinner skin and decreased healing abilities.
Clinical
History

The EP must consider the type of burn (thermal, chemical, radiation) and the location during early burn management. Once it has been determined that the burn is a thermal burn, the EP can add to the description: contact (with source name), scald (with fluid or gas type), heat, and flame. Systemic injury, duration, intentional versus accidental, and location of the burn must all be considered during the critical early burn period.

Other important points to determine include the patient's tetanus immunization status as well as the components of the history including past medical history, medications, and allergies.

Ascertain the history early because often the paramedics may be the only source of information about the event.

History should also include the following:

* Medical personnel must consider abuse as a cause of burns in all children. As many as 10% of abuse cases involve burns (see Pediatrics, Child Abuse).
* Components of the history that should raise suspicion of abuse include the
o Multiple/conflicting stories of how injury was sustained
o Injury attributed to a sibling
o Injury claimed to be unwitnessed
o Injury incompatible with developmental level of the child
o Presence of adult male who is not child's father (such as mother's boyfriend) living in household
* Characteristics of the burn that should raise suspicion of abuse include the following:
o Pattern burns that suggest contact with an object
o Cigarette burns
o Stocking, glove, or circumferential burns
o Burns to genitalia or perineum
* All health care personnel are obligated to contact appropriate law enforcement and protective services if they suspect the burn was intentional.
* Medical personnel must be aware that burns resulting from abuse or neglect may also be seen in the geriatric population.

Physical

Burn depth is described as superficial, partial thickness, or full thickness (corresponding to first, second, or third degree). (See Causes for more information.)

* Superficial (first-degree) burns involve only the epidermis.
o Tissue blanches with pressure.
o Tissue is erythematous.
o Tissue damage is minimal.
o Edema may be present; generally blisters do not form.
o Sunburn is a classic example of this type of burn (see Sunburn for more details and management).
o These wounds are red, dry, painful, and generally heal in 3-6 days without scarring.10
* Partial-thickness burns (second-degree) are often further delineated into superficial and deep types.
o Epidermis and portions of the dermis are involved.
o Blisters usually form either very quickly or within 24 hours.
o Superficial and deep partial-thickness can be difficult to differentiate at the bedside. The difference lies in the depth of penetrance into the dermis with the transition occurring at about half of dermal depth. Superficial partial-thickness burns usually blanch and do not result in scarring. Deep partial-thickness burns often do not blanch and do scar. The deeper the injury, the longer the healing time, which may vary from 7-21 days in the more superficial dermis burns to greater than 21 days in the deep dermis burns.
o Adnexal structures (eg, sweat glands, hair follicles) are often involved, but enough of these structures are preserved for function, and the epithelium lining them can proliferate and allow for regrowth of skin.
o If deep second-degree burns are not cared for properly, edema, which accompanies the injury, and decreased blood flow in the tissue can result in conversion to full-thickness burn.
o These wounds are red, wet, and painful (with decreasing pain, color, and moisture with increasing depth into the dermis).10
* Full-thickness (third-degree) burns extend completely through the skin to subcutaneous tissue. They may involve underlying structures including tendon, nerves, muscle, or bone (sometimes previously referred to as fourth-degree burn). Full- and partial-thickness burns are shown in the image below.
*

Partial- and full-thickness burns from a structur...
Partial- and full-thickness burns from a structure fire. Note facial involvement.

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Partial- and full-thickness burns from a structur...

Partial- and full-thickness burns from a structure fire. Note facial involvement.

o These burns are characterized by charring of skin or a translucent white color, with coagulated vessels visible below.
o The area is insensate, but the patient complains of pain, which is usually a result of surrounding second-degree burn.
o As all of the skin tissue and structures are destroyed, healing is very slow. Full-thickness burns are often associated with extensive scarring because epithelial cells from the skin appendages are not present to repopulate the area.
o These wounds vary from waxy white, to charred and black often with a leathery texture, they are dry and usually painless to touch. These wounds generally do not heal on their own.10
* Burn extent
o The more body surface area (BSA) involved in a burn, the greater the morbidity and mortality rates and the difficulty in management. Emergency medical services (EMS) personnel tend to overestimate the extent of the burn, whereas ED personnel tend to underestimate it.
o An individual's palmar surface classically represents 1% of the BSA, but, in actuality, it represents about 0.4%, whereas the entire hand represents about 0.8%.11,12 A simple method to estimate burn extent is to use the patient's palmar surface including fingers to measure the burned area. Burn extent is calculated only on individuals with partial-thickness or full-thickness burn.
o Another quick method is to use the Rule of Nines to estimate the extent of burn injury (as is shown in the image below).
o

Rule of nines for calculating burn area.
Rule of nines for calculating burn area.

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Rule of nines for calculating burn area.

Rule of nines for calculating burn area.
o The head represents a greater portion of body mass in children than it does in adults. Lund and Browder first described a method for compensating for the differences, and the Lund and Browder Chart is used to calculate BSA in children (as is shown in the image below).
o

Lund and Browder chart illustrating the method fo...
Lund and Browder chart illustrating the method for calculating the percentage of body surface area affected by burns in children.

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Lund and Browder chart illustrating the method fo...

Lund and Browder chart illustrating the method for calculating the percentage of body surface area affected by burns in children.
o If the chart is unavailable, estimate BSA by the Rule of Nines and adjust for age as follows:
+ In children younger than 1 year, the head and neck are 18% of BSA and each leg is 15% of BSA. The torso and arms represent the same percentages as in adults (10% and 16%, respectively).
+ For each year older than 1 year, add 0.5% to each leg and decrease percentage for the head by 1% until adult values are reached.
* On the basis of burn extent and depth, EPs can determine the severity of burn injury and whether the patient requires transfer to a burn center. The American Burn Association has developed criteria for burn center admission, as follows:
o Full-thickness (third-degree) burns over 5% BSA
o Partial-thickness (second-degree) burns over 10% BSA
o Any full-thickness or partial-thickness burn involving critical areas (eg, face, hands, feet, genitals, perineum, skin over any major joint), as these have significant risk for functional and cosmetic problems
o Circumferential burns of the thorax or extremities
o Significant chemical injury, electrical burns, lightning injury, coexisting major trauma, or presence of significant preexisting medical conditions
o Presence of inhalation injury
o Greater than 15% BSA in adults
o Greater than 10% BSA in children
o Hand and foot burns can lead to significant morbidity if not properly treated; therefore, most are treated with aggressive therapy. However, with careful follow-up, the patient may be monitored on an outpatient basis.

Causes

* Flame burns
o Contact with open flame causes direct injury to tissue.
o Flame may ignite clothing. Although natural fibers tend to burn, synthetic fibers may melt or ignite, adding a contact burn component to the injury.
o If the burn occurs in an enclosed area, the patient is also at risk for CO poisoning and cyanide poisoning as well as inhalational injury from the smoke and heat.
* Contact burns
o Contact burns result from direct contact with a hot object.
o Burn injury is confined to the point of contact.
o Examples are burns from cigarettes and tools (eg, soldering irons, cooking appliances, curling irons).
* Scalds
o Scalds result from contact with hot liquids (as is shown in the image below).
o

Child with burns from a scald. Hot soup was spill...
Child with burns from a scald. Hot soup was spilled when the child grabbed the handle of a pot. Note the full-thickness burn to left upper part of the chest. Edema of the lips and blisters on the face and nose indicate second-degree burns of the face.

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Child with burns from a scald. Hot soup was spill...

Child with burns from a scald. Hot soup was spilled when the child grabbed the handle of a pot. Note the full-thickness burn to left upper part of the chest. Edema of the lips and blisters on the face and nose indicate second-degree burns of the face.
o The more viscous the liquid and the longer the contact with the skin, the greater the damage.
o Accidental scalds often show a pattern of splashing, with burns separated by patches of uninjured skin.
o In contrast, intentional scalds often involve the entire extremity, appearing in a circumferential pattern with a line that marks the liquid surface.
* Steam burns
o Steam burns most often occur in industrial accidents or result from automobile radiator accidents.
o These burns produce extensive injury from the high heat-carrying capacity of steam and the dispersion of pressurized steam and liquid.
o Steam inhalation can actually cause thermal injury to the distal airways of the lung.
* Gas burns
o Inhalation of hot gas normally does not injure distal airways, as the heat-exchange capacity of the upper airway is excellent.
o In this situation, the upper airway is at risk for thermal injury and subsequent occlusion due to edema.
o Distal airway injury is more likely to be due to the direct effects of the products of combustion on the mucosa and alveoli.
* Electrical burns, including lightning13
o Electrical burns produce heat injury by passing through tissue.
o Most problems from these burns present in patients exposed to more than 1000V.
o Children can have significant injury after exposure to 200-1000V.
o Ignition of clothing may produce some flame burn, but most of the injury is deep in the skin (see Electrical Injuries).
o Cardiac injury is prominent, and patients must be monitored for 4-72 hours depending on the strength of the voltage and the age of the patient.
o The EP must consider visceral injuries, long bone and spine fractures, myoglobinuria, and compartment syndromes.
* Flash burns
o Flash burns are a subset of flame burns and are a result of rapid ignition of a flammable gas or liquid.
o The body parts involved are those exposed to the agent when it ignites.
o Areas covered by clothing are usually spared.
o The face may be involved, but if this type of injury takes place outside, then the risk for inhalation injury is low. A careful examination of the airway is indicated.
o A classic example of this type of injury occurs when a person pours gasoline on a trash or leaf fire to increase the flame and is burned by the subsequent fireball.
* Tar burns (see Emergency Department Care)
* Chemical burns13
o Alkaline substances and acid substances can burn the skin and can be associated with systemic toxicity.
o Alkaline burns produce liquefactive necrosis and are considered higher risk burns due to their likelihood to penetrate deeper.
o Acid burns are the result of coagulation necrosis, limiting the depth and penetration of the burn.
o The upper GI tract and oropharynx may also be at risk if the chemicals were ingested; therefore, the EP should be aware that the airway may occlude due to edema.
o Circumoral burns may be present if the agent was ingested. Differential Diagnoses

Burns, Chemical
Burns, Ocular
Electrical Injuries
Hydrofluoric Acid Burns
Smoke Inhalation
Sunburn
Workup
Laboratory Studies

Severe burns (ie, full thickness or large surface area partial thickness) require a complete laboratory workup, including the following:

* CBC count
* Chemistry profile (especially BUN and creatinine to determine renal function)
* Liver function tests
* Arterial blood gases with carboxyhemoglobin levels
* Coagulation profile
* Urine analysis
* Type and screen
* Creatine phosphokinase (CPK) and urine myoglobin levels (in electrical injuries): The presence of myoglobin can signify muscle breakdown as well as impending kidney impairment.

These laboratory studies should be performed as soon as possible so that they may serve as a baseline as the patient is likely to experience fluid shifts and electrolyte derangements shortly after the burn takes place.
Imaging Studies

* Chest radiography
o Obtain a chest radiograph in all patients whose history or physical examination suggests the possibility of inhalation injury and in those who require intubation to manage the airway.
o The initial chest radiograph rarely shows significant findings of smoke inhalation.
* Other plain radiography: On the basis of history and physical findings, obtain other plain radiographs if indicated to identify other associated traumatic injuries.
* CT scanning: On the basis of history and physical findings, obtain CT scan if indicated to identify other associated traumatic injuries.

Other Tests

Fiberoptic bronchoscopy may also be performed for any patient suspected of having an inhalation burn. This may take place after initial stabilization and resuscitation in the ED.Treatment
Prehospital Care

The immediate goal is to remove the person from the source of the burn. This must be accomplished without endangering rescue personnel.

* Following extrication, initial care of the burn victim should follow the basic principles of trauma resuscitation, the airway, breathing, and circulation (ABCs).
o Burn victims rarely immediately die due to burn injury.
o Immediate death is the result of coexisting trauma or airway compromise.
o Perform a rapid primary survey to assess the status of the patient's airway, breathing, and circulation. Immediately correct any problems found.
o Remove constricting clothing and jewelry to prevent these items from exerting a tourniquetlike effect following the development of burn edema.
o During airway assessment, give careful attention to signs of inhalation injury. Findings such as carbonaceous sputum, singed facial or nasal hairs, facial burns, oropharyngeal edema, changes in the voice, or altered mental status suggest the possibility of inhalation injury. Assume inhalation injury in any person whose history suggests being confined in a fire environment. Secure the airway by endotracheal intubation, as necessary. Deliver high-flow supplemental oxygen via mask or endotracheal tube (see Smoke Inhalation; Toxicity, Carbon Monoxide; and Prehospital Recognition and Management of Cyanide Poisoning in Smoke Inhalation Victims (Slides With Transcript)).
o Fluid administration should begin immediately with warmed fluid if possible. Catheters may be placed through burned skin if unburned skin is unavailable. If intravenous access is not possible, one may consider using interosseous methods to obtain access. This is important because any burn that is greater than 15% of the total body surface area (TBSA) may produce shock due to hypovolemia.1
* Concurrently, emergency personnel must stop the burning process. Remove charred clothing and cool tissues with saline or clean water. Once the burn has been cooled, place the patient in dry, sterile sheets. Prolonged irrigation with cool fluids or leaving the victim in wet sheets will not improve the burn and greatly increases the risk of hypothermia, as well as macerating the healthy tissues surrounding the burn. Ice water should not be used as it may worsen the damage to the skin as well as promote hypothermia.13 "Cool the burn wound but warm the patient."1
* After more life-threatening issues have been addressed, cool minor burns with running tap water and dress them.
* Importantly, do not forget to provide the patient with adequate analgesia (see the Medication section).

Emergency Department Care

* After the airway is stabilized, assess the extent and depth of the burn injury, as outlined above.
* Airway edema can develop rapidly in a burn victim who has inhaled toxic products of combustion or heated gases. Perform intubation early in those patients who show signs of such inhalation (eg, singed nasal hairs, facial burns, oral burns, sooty sputum, respiratory difficulty manifested by stridor or wheezes), even in a patient without respiratory compromise on arrival. Fiberoptic laryngoscopy or bronchoscopy can be helpful in assessing the extent of airway involvement; however, it is often not readily available to the EP.
* Establish intravenous access and begin fluid resuscitation. Begin 2 large-bore peripheral lines and administer crystalloids. With the loss of the vapor barrier provided by intact skin, burn victims have large insensible fluid losses. Remember burn victims will need copious amounts of fluid as only 20-30% will remain in the intravascular space. Fluid needs for burn victims in the acute phase can be calculated using the Parkland formula, as follows:
o (2-4 cm3 of crystalloid) X (% BSA burn) X (body weight in kg)
o Example: A man who weighs 70 kg and has a 30% BSA burn would require (30) X (70 kg) X (4 cm3/kg) = 8400 cm3 in the first 24 hours.
o One half of the calculated fluid requirement is administered in the first 8 hours, and the balance is given over the remaining 16 hours. Thus, fluids would be given at 525 cm3/h for the first 8 hours, then at 262.5 cm3/h for the remaining 16 hours.
o Monitor typical markers of fluid status (eg, urine output) and adjust fluids accordingly. Placement of a Foley catheter simplifies monitoring of hourly urine output. Urine output should be maintained at 0.5 cm3/kg/h.
o This formula does not predict fluid resuscitation needs in electrical injuries accurately, and the presence of coexisting trauma may increase fluid volumes needed for resuscitation.
o If the need is expected to exceed 6 mL/kg of the percentage of TBSA burned per 24 hours, then the need arises to evaluate the intravascular volume with placement of a pulmonary artery catheter. If the volume is found to be adequate but urine output remains diminished, then dopamine (5 mcg/kg/min) may be used to increase renal perfusion.
* For children, an alternative formula to calculate fluid needs is the Galveston formula, which is based on BSA rather than body weight. Although many pediatric burn centers believe it is more accurate than the Parkland formula, it is more time-consuming to calculate.
o Lactated Ringer (LR) solution is used at 5000 cm3/m2 X % BSA burn plus 2000 cm3/m2/24 h of maintenance. One half of the total fluid is given in the first 8 hours, with the balance given over the next 16 hours. The maintenance fluid should then be Ringers lactate with 5% dextrose.
o In children, maintain urine output at 1 cm3/kg/h, a pulse of 80-180 per min (age dependent) and a base deficit of <2. * Treatment of tar burns o The boiling point of asphalt and roofing tar are 140 ºC and 232 ºC, respectively. Tar cools rapidly to between 93-104 ºC as soon as it leaves the heat source. Most likely, the tar is cool by the time the patient arrives in the ED. If not, the tar should be actively cooled to terminate thermal damage with room temperature saline or water. o Once the tar is firm, it should be picked, peeled, and debrided from the underlying tissue. Some degree of autodebridement will occur. Debriding is a balance between removing the foreign body (tar) and exposing the injured skin for evaluation and treatment. Judgment should be exercised as to how much debridement is appropriate in the emergency setting, as extensive debridement may require moderate-to-deep sedation. o If the skin has a light coat of tar and the patient does not complain about the underlying skin or surrounding tissue, leaving the asymptomatic tar in place may be acceptable. o Tar that is part of an obvious burn, blister, or tissue loss should be removed. o Tar on the conjunctiva should be removed by an ophthalmologist. o Applying ointments, such as polymicrobial antibiotic ointment, petroleum jelly, or mineral oil, can facilitate tar removal. Organic solvents, such as acetone or gasoline, must be not be used to remove the tar. If an ointment is used, it is recommended to leave it on for 2-4 hours at a time until the tar has dissolved. o Common household agents, such as mayonnaise, butter, sunflower seed oil, and baby oil, have been promoted to remove tar. Organic, nonsterile agents are easy to acquire and are available in large quantities, but they carry the risk of promoting wound infection or allergic reaction. Bacterial or fungal growth can occur if the tar is not completely removed and the organic agent is not completely rinsed off. * When circumferential full-thickness burns involving the extremities or the chest are present, escharotomy may be necessary. The eschar is tough and rigid. As edema forms in the injured extremity following the burn, the eschar restricts outward expansion of the tissue. As a result, interstitial pressure rises to the point that vascular flow is compromised. In short, the eschar behaves like a tourniquet. Incising the eschar allows return of flow and prevents further ischemic injury. Full-thickness burns are insensate so there is no need for the use of topical anesthetics. o Compression requiring escharotomy typically occurs 12-24 hours after an injury. o Perform escharotomy along the lateral aspect of the extremity with a linear and lengthwise incision. Use of an electrocautery simplifies the procedure and can reduce the amount of bleeding. o The incision should go completely through the eschar. The subcutaneous fat appears to bubble up into the escharotomy wound. o Bleeding is minimal and is easily controlled by pressure. o Upon completion of the escharotomy, a dressing with antibiotics is placed on the wound and the extremity is elevated to help maintain homeostasis. o If the chest is involved and the eschar compromises ventilatory motion, perform an escharotomy involving the anterior chest. Incisions are made along the costal margin, along the anterior axillary lines, and across the top of the chest, freeing up the anterior chest wall. * Most burns seen in the ED are minor. The key point in managing these wounds is to be sure that the patient receives adequate follow-up care. Cool the burn area with towels moistened with cool sterile saline. Avoid immersion in ice baths. * Burns of areas such as the face are best treated by an open technique. Wash the burn area, debride any open blisters, and cover wounds with topical antibiotics (eg, Neosporin, Bacitracin). * Fingers and toes should be wrapped individually with fluffed gauze separating the digits in order to prevent maceration and adherence. * Cover all partial-thickness wounds with antibiotic ointment. Silver sulfadiazine is commonly used but may not be available to the EP. * Steroids have no role in treating burn wounds. * Cleanse other areas with minor burns with the use of a mild soap and gentle scrubbing. A debate exists as to whether intact blisters should be debrided; the intact skin serves as a hermetic barrier, although the blister fluid can serve as an excellent medium for bacterial growth. Another argument for debridement is that removal of the blister roof allows topical agents to reach burn tissue. Blisters that are intact but are located in areas that have a high likelihood of rupture may be sharply debrided. The World Health Organization (WHO) recommends debridement of all bullae and excision of all adherent necrotic tissue.14 * Needle aspiration of the blisters should not be performed due to the high risk of inoculating the blister with bacteria and therefore inciting infection. * Debride open blisters. Wounds should then be treated with a topical antibiotic and dressed. Discharge the patient with explicit instructions on how to clean and dress the wound, and arrange follow-up care for evaluation of the wound. * Remember to check tetanus status of all patients and to administer tetanus immunization (Td) as appropriate. * Also remember to place and nasogastric (NG) or orogastric (OG) tube in those patients who are comatose as they tend to have gastric dilatation. * Intravenous antibiotics are not recommended in the initial treatment of most burn patients, as it may increase the chance of colonization with more virulent and resistant organisms.13 They should be reserved for those patients with secondary infections (notable as those with fever, malaise, or lymphangitis). Patients with secondary infections should also be admitted to the hospital because they may develop sepsis. Consultations * Refer patients with critical burns to a regional burn center for further management. Burns involving critical areas, if not referred to a burn center, should be evaluated by a burn surgeon or a plastic surgeon. * Admit patients whose history suggests the possibility of inhalation injury for observation. Medication Pain management and topical medication application are two therapeutic interventions for burns. Of the two, rapid and effective pain reduction is central to the care of patients with burns. The EP must recognize that, for the patient in pain, every minute without treatment is another minute with pain. Treat the patient's pain quickly and effectively. With few exceptions, the EP should not hesitate to insert an intravenous line, preferably in a nonburned area, and provide intravenous analgesia. Intravenous administration is ideal for the acute treatment of patients who require immediate pain relief. Oral medication is more suitable for patients who will be discharged to home. For most patients with only minor burns, nonsteroids anti-inflammatory drugs (NSAIDS) and acetaminophen are adequate for pain relief. However, the EP should not hesitate to use opioid analgesics for pain relief, especially in those patients with severe burns. If the patient has a burn that requires the patient to be transferred to a burn center, treatment should be limited to removing the source of the thermal burn, debriding contaminated tissue, and covering the burned area with a nonadhesive cover (petroleum-based gauze) then a sterile, dry towel or sheet. The emergency medical director should work with the emergency nursing director to establish thermal burn evaluation and treatment protocols including standing orders. If the nursing or triage staff can identify a thermal burn, estimate the degree, depth, and associated injuries (airway), then protocols and policies can be put into place so that the triage nurse can initiate pain intervention therapy. Regardless of the burn severity, standing orders to provide pain relief for the burned patient should be in place. A prudent emergency medical director should collaborate with commonly used burn centers. The sending and receiving facilities should have protocols for analgesic treatment, intravenous access, and burn dressing. Preapproved protocols and arrangements provide a seamless transfer of care for the burned patient. Analgesics Opiates provide rapid pain relief. Opiates can be titrated to achieve the desired comfort level for each patient. Opiates side effects can be reversed quickly. Morphine sulfate (Duramorph, Astramorph, MS Contin) DOC for burn pain treatment because of the reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Morphine sulfate administered IV can be dosed in numerous ways and is commonly titrated until desired effect is obtained. * Dosing * Interactions * Contraindications * Precautions Adult Initial IV, IM, or SC: 0.1-0.2 mg/kg; avoid IM and SC injections in burn patients Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h (2 mg is a good starting dose in patients who may be hypovolemic) Pediatric Neonates: 0.05-0.2 mg/kg/dose IV q4h Children: 0.1-0.2 mg/kg/dose IV q2-4h * Dosing * Interactions * Contraindications * Precautions Phenothiazines may antagonize analgesic effects; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects * Dosing * Interactions * Contraindications * Precautions Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult * Dosing * Interactions * Contraindications * Precautions Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus Precautions Avoid in respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate Physicians must be aware of a National Patient Safety Goal (NPSG): Do not abbreviate morphine sulfate "MS" or "MSO4" (always write clearly "morphine sulfate" to avoid confusion with other drugs); similar "forbidden" abbreviations under the NPSG guidelines include avoiding "SC" or "SQ" for subcutaneous injections (the provider must write legibly: "subcutaneously") Meperidine (Demerol) Narcotic analgesic with actions similar to those of other opiates. May produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine. * Dosing * Interactions * Contraindications * Precautions Adult 25-75 mg PO/IV/IM/SC q3-4h prn Pediatric 1-1.8 mg/kg (0.5-0.8 mg/lb) PO/IV/IM/SC q3-4h prn; not to exceed adult dose * Dosing * Interactions * Contraindications * Precautions Cimetidine and protease inhibitors may increase toxicity; hydantoins may decrease effects * Dosing * Interactions * Contraindications * Precautions Documented hypersensitivity; concurrent MAOIs; upper airway obstruction or significant respiratory depression; during labor when delivery of premature infant anticipated * Dosing * Interactions * Contraindications * Precautions Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus Precautions Caution in patients with head injuries because meperidine may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution postoperatively and with history of pulmonary disease (suppresses cough reflex); substantially increased dose levels, because of tolerance, may aggravate or cause seizures even if no prior history of convulsive disorders; monitor closely for meperidine-induced seizure activity if prior seizure history; caution in patients with a creatinine clearance <50 mL/min; avoid multiple injections in short time, particularly in patients >65 y

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderate to severe pain.

* Dosing
* Interactions
* Contraindications
* Precautions

Adult

1-2 tab or cap PO q4-6h prn for pain
Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen or 5 mg of hydrocodone bitartrate/dose >12 years: 750 mg acetaminophen PO q4h; not to exceed 5 doses/d acetaminophen or 10 mg of hydrocodone bitartrate/dose

* Dosing
* Interactions
* Contraindications
* Precautions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity

* Dosing
* Interactions
* Contraindications
* Precautions

Documented hypersensitivity; elevated intracranial pressure

* Dosing
* Interactions
* Contraindications
* Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions

Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Hydromorphone (Dilaudid)

A hydrogenated ketone of morphine. Hydromorphone is a narcotic analgesic. Analgesic action of parenterally administered Dilaudid is apparent within 15 min and usually remains in effect for >5 h.

* Dosing
* Interactions
* Contraindications
* Precautions

Adult

1-2 mg IV q2-4h
Pediatric

Not recommended

* Dosing
* Interactions
* Contraindications
* Precautions

Hydantoins may decrease effects; phenothiazines, CNS depressants, and tricyclic antidepressants may increase toxicity

* Dosing
* Interactions
* Contraindications
* Precautions

Documented hypersensitivity; obstetrical analgesia; increased intracranial pressure; respiratory depression; ulcerative colitis; Crohn disease; abdominal cramping and distention

* Dosing
* Interactions
* Contraindications
* Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions

Caution in patients with head injuries because may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution postoperatively and with history of pulmonary disease (suppresses cough reflex); increased dosing levels, because of tolerance, may aggravate or cause seizures (even without prior history); adjust dose in renal insufficiency (do not use in severe renal dysfunction); normeperidine metabolite accumulation may induce CNS toxicity; monitor closely for morphine-induced seizure activity if prior seizure history
Nonsteroidal anti-inflammatory agents (NSAIDs)

These agents are used most commonly for relief of mild pain. Although effects of NSAIDs in treatment of pain tend to be patient specific, ibuprofen is usually DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

These agents do not provide rapid relief of other agents and, except for ketorolac, must be administered to patients that do not have oral intake restrictions.

Ibuprofen (Ibuprin, Advil, Motrin)

Treatment of mild pain, if no contraindications. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which results in inhibition of prostaglandin synthesis.

* Dosing
* Interactions
* Contraindications
* Precautions

Adult

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric

<6 months: Not established 6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid >12 years: Administer as in adults

* Dosing
* Interactions
* Contraindications
* Precautions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants; may increase risk of methotrexate toxicity; may increase phenytoin levels

* Dosing
* Interactions
* Contraindications
* Precautions

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

* Dosing
* Interactions
* Contraindications
* Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions

Caution in CHF, hypertension, and decreased renal or hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy (monitor PT and bleeding)

Flurbiprofen (Ansaid)

Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase, causing inhibition of prostaglandin biosynthesis that may, in turn, result in analgesic and anti-inflammatory activities.

* Dosing
* Interactions
* Contraindications
* Precautions

Adult

200-300 mg/d PO divided bid/qid
Pediatric

Not established

* Dosing
* Interactions
* Contraindications
* Precautions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants; may increase risk of methotrexate toxicity; may increase phenytoin levels

* Dosing
* Interactions
* Contraindications
* Precautions

Documented hypersensitivity

* Dosing
* Interactions
* Contraindications
* Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions

Caution in coagulation abnormalities or during anticoagulant therapy (monitor PT and bleeding); acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, or renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Ketoprofen (Oruvail, Orudis, Actron)

Used for relief of mild to moderately severe pain and inflammation. Initially administer small dosages to patients with a small body size, elderly persons, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.

* Dosing
* Interactions
* Contraindications
* Precautions

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric

<3 months: Not established 3 months to 14 years: 0.1-1 mg/kg PO q6-8h >12 years: Administer as in adults

* Dosing
* Interactions
* Contraindications
* Precautions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants; may increase risk of methotrexate toxicity; may increase phenytoin levels

* Dosing
* Interactions
* Contraindications
* Precautions

Documented hypersensitivity

* Dosing
* Interactions
* Contraindications
* Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions

Caution in CHF, hypertension, and decreased renal or hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy (monitor PT and bleeding)

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which results in decrease in prostaglandin synthesis.

* Dosing
* Interactions
* Contraindications
* Precautions

Adult

500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric

<2 years: Not established >2 years: 2.5 mg/kg/dose PO q6-8h; not to exceed 10 mg/kg/d

* Dosing
* Interactions
* Contraindications
* Precautions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants; may increase risk of methotrexate toxicity; may increase phenytoin levels

* Dosing
* Interactions
* Contraindications
* Precautions

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

* Dosing
* Interactions
* Contraindications
* Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions

Caution in coagulation abnormalities or during anticoagulant therapy (monitor PT and bleeding); acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Ketoralac (Toradol)

Inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which results in decreased formation of prostaglandin precursors.

* Dosing
* Interactions
* Contraindications
* Precautions

Adult

30 mg IV/IM q6h; not to exceed 120 mg/d
10 mg PO q4-6h; not to exceed 40 mg/d
Combined duration of PO/IV/IM not to exceed 5 d
Pediatric

Not established; recommended dose is 0.4-1 mg/kg IM once

* Dosing
* Interactions
* Contraindications
* Precautions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

* Dosing
* Interactions
* Contraindications
* Precautions

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; do not administer into CNS

* Dosing
* Interactions
* Contraindications
* Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts (rare) usually return to normal during ongoing therapy; discontinue therapy if leukopenia, granulocytopenia, or thrombocytopenia persists
Topical antibiotics

Prophylaxis is given topically to patients with burns.

Neomycin and polymyxin B (Neosporin)

Used to treat minor infections. Inhibits bacterial protein synthesis and, thus, bacterial growth. Polymyxin B disrupts bacterial cytoplasmic membrane, permitting leak of intracellular constituents, causing inhibition of bacterial growth.

* Dosing
* Interactions
* Contraindications
* Precautions

Adult

Apply 1-4 times/d to affected areas
Pediatric

Apply as in adults

* Dosing
* Interactions
* Contraindications
* Precautions

None reported

* Dosing
* Interactions
* Contraindications
* Precautions

Documented hypersensitivity

* Dosing
* Interactions
* Contraindications
* Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions

Extended use can lead to resistant infections and thinning or atrophy of skin

Silver sulfadiazine (Silvadene)

Although expensive, Silvadene has antipseudomonal properties in addition to coverage for most gram-positive organisms. Avoid facial use.
Useful in prevention of infections from second-degree or third-degree burns. Has bactericidal activity against many gram-positive and gram-negative bacteria, as well as yeast.

* Dosing
* Interactions
* Contraindications
* Precautions

Adult

Apply using sterile technique to affected areas bid; wash burn prior to application to remove previously applied agent
Pediatric

<2 years: Not established >2 years: Apply as in adultsFollow-up
Further Outpatient Care

Many children may qualify for outpatient treatment for their burns. Although no official guidelines are recognized, many studies have shown that if the patient does not meet the criteria for inpatient admission and does meet the below criteria then they may be treated on an outpatient basis.10,13,14

* Airway compromise or inhalational injury must not be a concern.
* The wound must be less than 10% of body surface area so that fluid resuscitation is unnecessary.
* Child must be able to take in adequate fluid by mouth to make up for losses.
* Serious burns of the face, ears, hands, genitals, or feet or those with circumferential burns should generally be admitted. Superficial burns on the hands may be treated as outpatients if the patient has good follow-up care.15
* The family must have the resources to support an outpatient care plan.
* An adult caregiver should be able to stay with a child who may not be able to attend day care or school.
* A family member or visiting nurse must be able to properly perform wound cleansing, inspection, and dressing changes.
* Family must have transportation to clinic and emergency visits.
* Any suspicion of abuse precludes outpatient care.
* If surgery for a full-thickness wound is needed, prompt admission is generally indicated.

Patients discharged should be followed up the following day, preferably with a burn specialist, to access the adequacy of the dressing changes and pain management.

Patients and their families need guidelines and conditions that mandate return. These can be as simple as anxiety over dressing changes for the parents to signs and symptoms of infection such as cellulitis or sepsis.

If patients are being treated as outpatients and wound epithelialization has not begun after 2 weeks or if subsequent evaluations reveal a full-thickness burn greater than 2 cm, then the patient should be referred to a burn surgeon.10
Transfer

The American Burn Association has established the following criteria for referring patients to a burn center:16

* Any partial-thickness burn greater than 20% total body surface area (TBSA) in a patient of any age or greater than 10% TBSA in children younger than 10 years or adults older than 50 years
* Third-degree burns covering over 5% TBSA
* Second-degree or third-degree burns involving critical areas (eg, hands, feet, face, perineum, genitalia, major joints)
* Burns with associated inhalation injury
* Electrical or lightning burns
* Severe burns complicated by coexisting trauma: If traumatic injuries pose a higher risk to the patient than the burn injuries, the patient may need to be sent first to a trauma center.
* Preexisting disease that could complicate management of the burn injury
* Chemical burns with threat of cosmetic or functional compromise
* Circumferential burns on the extremities or the chest
* Children with severe burns (These patients should be sent to a facility that has personnel and equipment to care for children with burns.)
* Children may be transferred between burn centers if the one they were originally brought to are not qualified or do not have the equipment for the care of children.
* Any cases where abuse may be suspected as the cause of the burn or if the patient may require long-term rehabilitative support

Prior to transfer, referring physician needs to accomplish the following:

* Respiratory support
o If the patient is at risk for airway compromise or deterioration, perform intubation prior to transfer.
o Support with 100% oxygen.
o Stabilize circulatory status by fluid resuscitation.
o Administer Ringer solution at the rate indicated by the Parkland formula or at that rate adjusted for clinical status (eg, urine output).
o Ensure adequate vascular access for fluid resuscitation and administration of analgesics, if necessary.
o Give transporting personnel orders defining rate and amount of analgesics that can be administered during transport.

Care of the burn wound:

* Cover patients being transferred with a dry sheet.
* Transport crews should exercise care to prevent the patient from becoming hypothermic.
* Use of saline-soaked dressings increases risk of hypothermia.
* Application of antimicrobial creams may delay transfer, and these agents must be removed once the patient arrives at the burn center.

Physician-to-physician contact prior to transfer is essential. The accepting physician at the burn center can provide advice in caring for the burn patient and often can assist in arranging transfer. Documentation of what already has been performed for the patient and of any findings should accompany the patient to the burn center.
Complications

Complications of burns include the following:

* Scarring
* Cosmetic deformity
* Burn wound sepsis
* Acute respiratory distress syndrome (ARDS)
* Sepsis
* Death
* Contractures (especially in children, as the scar tissue cannot expand to keep pace with the growth of the child)

Prognosis

The prognosis varies from excellent to poor depending on the severity of the burn.
Patient Education

* Prevention is the best tool in the management of burn injuries. Campaigns stressing the use of smoke detectors and the adoption of laws mandating their use have decreased the mortality rate from burns significantly in North America. Additional materials useful for teaching burn prevention may be obtained from the American Burn Association.
* The development of flame retardant sleepwear and the famous program "Stop, Drop, and Roll" have prevented numerous fire-related injuries.
* Parents should create specific escape plans, discuss and practice them with their children in case quick escape from house emergencies is necessary.
* Children should not be allowed to play with lighters or fireworks.
* EPs should work with their local fire service to develop burn prevention programs as part of the fire service's fire prevention strategies.
* Discussions with patients who have sustained burn injuries should attempt to determine how the injury was sustained and what steps can be taken to prevent recurrence. As part of discussions with parents regarding risks in the home, EPs should ask parents if the water heater is set to 49°C (120°F). If parents do not know, encourage them to find out and have it adjusted if necessary. Simple interventions like this can have significant impact upon the lives of many.
* For excellent patient education resources, visit eMedicine's Burns Center. Also, see eMedicine's patient education articles Thermal (Heat or Fire) Burns and Sunburn.

Miscellaneous
Medicolegal Pitfalls

* Failure to consider abuse as the cause of burns in children
* Failure to recognize potential for airway involvement, even when classic signs of airway burns are absent: Signs of toxic inhalation may not be apparent for several hours after exposure, and the patient may deteriorate very rapidly.
* Failure to involve burn specialists in the care of burns, including minor ones that involve critical areas (eg, hand, face, feet, genitalia): Development of scars in these areas can have significant cosmetic and functional consequences.

Special Concerns

* Take a proactive approach in the community by discussing burn injury and burn prevention with organizations such as local media, school officials, and adult care center.
* Take the opportunity to remind the community about the dangers of fireworks, malfunctioning smoke detectors, and home water heater temperature (must be set below 120°F).