CC CJM | Burns

Burn Classification & TBSA Assessment Burn severity depends on depth, extent (TBSA), location, and patient risk factors[1]. Depth is classified as partial-thickness (epidermal/dermal; painful, red, blistered) or full-thickness (dermal destruction, painless, leathery eschar, visible thrombosed vessels)[2]. TBSA is estimated using the Rule of Nines for adults or the Lund-Browder chart for children[6]. Referral to a burn center is indicated for partial-thickness burns >10% TBSA, chemical/electrical burns, inhalation injury, or burns of the face, hands, feet, genitalia, perineum, or joints[7]. Face, neck, and circumferential torso burns threaten ventilation[8]. Circumferential limb burns impair perfusion, requiring escharotomy[8][9].

Emergent Phase Pathophysiology & Resuscitation The emergent phase (first 72 hours) prioritizes burn shock and gas exchange[10]. Loss of capillary seal triggers a massive fluid shift from the intravascular to the interstitial space (third spacing), causing severe hypovolemia, hemoconcentration, high blood viscosity, and increased peripheral resistance[10]. Damaged cells release potassium (hyperkalemia), and sodium moves into the interstitium (hyponatremia)[13][14]. Inhalation injuries (carbon monoxide, above/below glottis) cause mucosal edema, obstruction, and pneumonia (the leading cause of death)[9]. Myoglobinuria (from electrical muscle damage) can block renal tubules, causing acute kidney injury (AKI)[18][19]. Priority care includes early intubation, 100% humidified O2, and resuscitation[20][21]. The ABA formula dictates 2–4 mL Lactated Ringer's per kg per % TBSA in the first 24 hours (half in the first 8 hours)[22]. Target clinical parameters are MAP >65 mmHg, HR <120 bpm, and adult urine output of 0.5–1 mL/kg/hr (75–100 mL/hr for electrical burns)[25].

Acute, Rehabilitative & Psychosocial Care The acute phase begins with diuresis and ends when wounds are nearly healed[26]. Sepsis, often from gram-negative bacteria or Candida, is a leading cause of death during this immunosuppressed period[27][28]. Stress-induced hypermetabolism causes protein catabolism and transient hyperglycemia, requiring early enteral nutrition and insulin[29]. Excision and grafting (autograft, CEA, or Integra) are vital for full-thickness wounds[32]. Pain is managed with continuous IV opioids, procedural breakthrough doses, and anxiolytics[36][37]. Continuous physical therapy and splinting prevent contractures[38][39]. In the rehabilitation phase, hypertrophic scars are minimized using custom-fitted pressure garments worn up to 23 hours daily for 12–18 months[40][41]. Hydration and antihistamines help relieve severe itching[40][42]. Older adults face higher mortality due to thinner skin, delayed healing, and co-morbidities[43]. Support groups and psychiatric interventions address emotional needs, body image changes, and PTSD[44].