Thermal Injuries: First, Second, and Third Degree Burns

Emergency Department Management of Patients With Thermal Burns

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Table of Contents
About This Issue

Classifying and measuring thermal burns in the ED will dictate all of the treatment decisions that follow:

First degree, second degree, third degree burns: How can you tell?

How should you calculate the total body surface area of burns?

IV fluids: what kind and how much? How can you tell when you've given the right amount?

Wound care: when should you debride blisters, and should you use silver dressings?

Escharotomy: when must it be done?

Was it really an accident or was it abuse?

Referral: How do you know when to refer a patient to a burn center?

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
  6. Differential Diagnosis
  7. Prehospital Care
    1. Prehospital Administration of Hydroxocobalamin
    2. Prehospital Cooling
    3. Prehospital Pain Management
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
  9. Diagnostic Studies
    1. Laboratory Testing
      1. Chemistry Panel
      2. Complete Blood Cell Count
      3. Arterial Blood Gas With CO-Oximetry Testing
      4. Lactate Level
      5. Cyanide Level
      6. Type and Screen
      7. Urine Pregnancy Testing
    2. Imaging
      1. Chest X-Ray
      2. Computed Tomography
      3. Bronchoscopy
  10. Treatment
    1. Airway Management
      1. Managing Inhalation Injury
      2. Carbon Monoxide and Cyanide Toxicity
    2. Cooling
    3. Intravenous Fluid Resuscitation
      1. Choosing Resuscitation Fluids
      2. Fluid Volume Resuscitation Formulas
      3. Monitoring Fluid Resuscitation
      4. Blood Transfusion
    4. Wound Care
      1. Unroofing, Debridement, and Surgical Excision
      2. Escharotomy
      3. Ocular Burns
    5. Antibiotics
    6. Pain Control
    7. Tetanus Prophylaxis
  11. Special Populations
    1. Pediatric Patients
    2. Pregnant Patients
  12. Controversies and Cutting Edge
    1. Analgesia
    2. Wound Care Controversies
    3. Assessment of Burn Depth With Laser Doppler Imaging
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls for Management of Burn Patients in the Emergency Department
  16. Time- and Cost-Effective Strategies
  17. Case Conclusions
  18. Key Points
  19. Clinical Pathway for Management of Burns in the Emergency Department
  20. Tables and Figures
    1. Table 1. Classification of Burns by Depth
    2. Table 2. Physical Examination of Burn Patients
    3. Table 3. Common Intravenous Resuscitation Formulas for Adult Burn Patients
    4. Table 4. Occlusive Dressings for Partial-Thickness Burns
    5. Table 5. Topical Therapies for Partial-Thickness Burns
    6. Table 6. Centers for Disease Control and Prevention Guidelines for Tetanus Wound Management
    7. Table 7. American Burn Association Burn Center Referral Criteria
    8. Figure 1. Zones of Burn
    9. Figure 2. Illustration of Burn Depth Classifications
    10. Figure 3. Lund and Browder Chart
    11. Figure 4. Rule of Nines
    12. Figure 5. Escharotomy
    13. Figure 6. Accidental Versus Intentional Scald
  21. References


Thermal burn injuries are a significant cause of morbidity and mortality worldwide. In addition to treatment of the burns, emergency clinicians must assess for inhalation injury, exposure to toxic gases, and related traumatic injuries. Priorities for emergency resuscitation include stabilization of airway and breathing, intravenous fluid administration, pain control, and local wound care. Special populations, including children and pregnant women, require additional treatment considerations. Referral to specialized burn care for select patients is necessary to improve long-term outcomes. This article reviews thermal burn classification and evidence-based treatment strategies.

Case Presentations

A 35-year-old chef presents to the ED after burning his right hand on a cooking surface at work. His vital signs are normal and his hand is blistered over half of the palmar surface. You place a nursing order for pain medication and a tetanus booster. As you leave the bedside, you try to recall whether he should be referred to a burn center and whether there are any evidence-based guidelines to help you select a dressing…

As you put down his chart, the nurse calls you to the resuscitation bay for a 22-year-old woman brought in by EMS from a house fire. Paramedics report that she required extrication from the collapsed house. She is minimally responsive, with soot visible in her oropharynx and extensive burns to her abdomen, back, and right upper extremity. Her vital signs are: temperature, 37.5°C (99.5°F); heart rate, 140 beats/min; blood pressure, 85/40 mm Hg; respiratory rate, 35 breaths/min; and oxygen saturation, 88% on room air. As you prepare to intubate her and start IV fluid resuscitation for her hypotension, you wonder which resuscitation fluid you should select and how to best monitor the patient’s response. You wonder whether anything other than her extensive burns may be causing her hypotension and altered mental status…

Your next patient is a 3-year-old boy brought in by his mother for scald burns to his feet. The mother says that yesterday the child picked up a bowl of hot soup and accidentally spilled its contents. He appears fussy and has symmetric, well-demarcated, full-thickness burns to both feet from the ankles down. His vital signs are: temperature, 37°C (98.6°F); heart rate, 120 beats/min; blood pressure, 90/55 mm Hg; respiratory rate, 22 breaths/min; and oxygen saturation, 98% on room air. You are concerned about the delay in seeking care and wonder whether this might be more than an accidental burn…



The American Burn Association (ABA) reports that nearly half a million people suffer thermal burns each year in the United States.1 According to World Health Organization estimates, as many as 265,000 people worldwide die annually of thermal burns.2 The economic burden of thermal burn injury is also substantial: In the United States in 2000, the annual direct-care cost of treating pediatric burns alone was $211 million.2 This does not take into account the economic impact of rehabilitation and long-term disability. Efforts to prevent thermal burns through regulation and public health initiatives have reduced the incidence in developed countries; however, burn injuries still account for approximately 0.5% of all United States emergency department (ED) visits annually.3 This issue of Emergency Medicine Practice reviews the guidelines on assessment of burns and how these assessments are used for optimal management of fluid resuscitation, in addition to the latest evidence on burn-wound care, pain control, and the criteria for referral to specialized care.


Critical Appraisal of the Literature

A literature search was performed in PubMed using the search terms burn, burns, and inhalation burn. The search identified approximately 4600 original articles that were screened and narrowed to articles of highest quality evidence and relevance. Only articles with abstracts available in English were included.

The Cochrane Database was searched for systematic reviews using the key term burn, which identified 11 articles. A search of the Database of Abstracts of Reviews of Effects (DARE) and Center for Reviews and Dissemination (CRD) databases did not reveal any unique publications not previously identified in the PubMed search. A search of the National Guidelines Clearinghouse identified 1 relevant guideline. The ABA Consensus Guidelines (2012) and ABA Practice Guidelines: Burn Shock Resuscitation (2008) were also reviewed. The former is a consensus statement, whereas the latter identifies the level and category of evidence upon which each of its recommendations is based. International guidelines from the World Health Organization and the European Burn Association were also reviewed.

Overall, the clinical evidence on thermal burns is of moderate strength, consisting of relatively few large, well-designed clinical trials and many smaller trials and observational studies. When possible, recommendations in this article are evidence-based. Recommendations based on common practice or expert consensus are explicitly noted as such.


Risk Management Pitfalls for Management of Burn Patients in the Emergency Department

2. “I gave prophylactic oral antibiotics to a patient with a partial-thickness burn. The patient had an allergic reaction, and now my colleagues are saying that I should have never given the antibiotic in the first place.”

Systemic prophylactic antibiotics do not benefit burn patients. Use topical dressings for local wound care. Treat with systemic antibiotics only if a clinically apparent infection develops.

5. “I thought that fluid-resuscitating the patient according to the Parkland formula during the 8 hours he was awaiting transfer in my ED was enough. I didn’t realize he wasn’t making any urine.”

Use clinical endpoints, such as urine output, to assess and guide IV fluid administration. Formulas are merely a guideline, and IV fluid administration may need to be decreased or increased depending on how the patient responds.

6. “I assumed the patient was hypotensive due to the extensive burns he sustained in the house fire. I didn’t consider that he might have intra-abdominal hemorrhage.”

Burn patients are at risk for traumatic injuries and should undergo a comprehensive trauma survey and diagnostic testing per Advanced Trauma Life Support guidelines.


Tables and Figures

Burn - First Degree Burn - Burn Treatment - Thermal Burn - Trauma CME - Table 1. Classification of Burns by Depth



Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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Publication Information

Juliana Tolles, MD, MHS

Peer Reviewed By

Boyd Burns, DO; Christopher Palmer, MD

Publication Date

February 1, 2018

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