Burns

Clinical Significance and Initial Assessment Priorities

Burns are a significant cause of traumatic injury encountered in the emergency department, ranging from minor superficial injuries to life-threatening, multisystem events. For the Certified Emergency Nurse (CEN), burns require rapid assessment, precise calculation of injury severity, and immediate intervention to prevent hypothermia, fluid loss, and infection. This topic is high-yield for both the CEN exam and clinical practice, as proper initial management directly impacts patient morbidity and mortality.^[1]

Essential Burn Classification Parameters

• Total Body Surface Area (TBSA): The percentage of skin surface affected by a burn; used to guide fluid resuscitation and disposition.
• Rule of Nines: A rapid estimation tool for TBSA in adults (head/neck 9%, anterior trunk 18%, posterior trunk 18%, each arm 9%, each leg 18%, perineum 1%).^[2]
• Lund and Browder Chart: More precise TBSA estimation method, accounting for age-related body surface proportions (used in children).^[3]
• Burn Depth: Classified as superficial (first-degree), partial-thickness (second-degree), full-thickness (third-degree), and fourth-degree (involves muscle/bone).
• Inhalation Injury: Airway mucosal damage from superheated gases or toxic chemicals; a leading cause of burn-related death.^[4]
• Escharotomy: Surgical incision through eschar (dead tissue) to relieve compartment syndrome in circumferential full-thickness burns.

Burn Mechanism Categories and Resuscitation Protocols

Burn Mechanism Categories

• Thermal: Flame, scald, contact with hot surfaces – most common.
• Chemical: Acids, alkalis, organic compounds – require copious irrigation.
• Electrical: High-voltage causes deep tissue damage; entrance/exit wounds visible; risk of cardiac dysrhythmias.^[5]
• Radiation: Less common in ED; ionizing radiation from industrial/or environmental sources.

Initial Burn Management (ABCDE Approach)

1. A – Airway with cervical spine protection: Assess for stridor, hoarseness, soot in sputum, singed nasal hairs (signs of inhalation injury). Consider early intubation if any sign present.^[4]
2. B – Breathing: Evaluate for carbon monoxide poisoning (pulse oximetry unreliable; check CO-oximetry). Administer 100% high-flow oxygen until carboxyhemoglobin <5%.^[6]
3. C – Circulation: Establish IV access through burned skin if necessary (central line may be needed). Start fluid resuscitation per Parkland formula (see below).
4. D – Disability: Brief neurologic exam; assess for other trauma sources.
5. E – Exposure / Environmental control: Remove all clothing and jewelry; keep patient warm to prevent hypothermia (burned skin cannot thermoregulate).

Parkland Formula (Adults)

This is the most commonly tested fluid resuscitation formula for burns >20% TBSA.^[2]

• Total fluid in first 24 hours = 4 mL × weight (kg) × %TBSA
• Give half of total in first 8 hours (from time of burn, not ED arrival)
• Give half in remaining 16 hours
• Crystalloid of choice: Lactated Ringer's (avoids hyperchloremic acidosis of normal saline).
• Monitor urine output goal: 30–50 mL/hour in adults (0.5-1 mL/kg/hr in children).^[7]

Clinical Presentation by Burn Depth and Type

• Inhalation injury signs: Hoarseness, stridor, dyspnea, carbonaceous sputum, singed nasal hairs, facial burns, elevated carboxyhemoglobin levels.
• Electrical burn warning: Entrance/exit wounds, muscle necrosis, myoglobinuria (red-brown urine), compartment syndrome, cardiac dysrhythmias (ventricular fibrillation most common).^[5]
• Chemical burn features: Pain, erythema, possible delayed presentation; alkali burns penetrate deeper than acid burns.

Diagnostic Workup and Burn Center Referral Criteria

Primary Assessment

• Airway patency with suspicion of inhalation injury – fiberoptic laryngoscopy for definitive evaluation if time permits.^[4]
• Breath sounds and chest rise; assess for circumferential chest burns causing restrictive airway mechanics.
• Pulse check; start cardiac monitoring if electrical mechanism.

Diagnostic Studies

• Arterial blood gas (ABG) with CO-oximetry: Detects carbon monoxide and methemoglobin levels.
• Complete blood count, chemistry panel, coagulation: Baseline for fluid and monitoring.
• Urinalysis: Check for myoglobinuria in electrical/ deep burns.
• Chest X-ray: Evaluate for pulmonary edema, rib fractures, or foreign bodies (blast-related).
• 12-lead ECG: For electrical burns or any suspicion of cardiac injury.^[5]

Burn Severity Classification (ABA Criteria for Burn Center Referral)

• Partial-thickness burns >10% TBSA in patients <10 years old or >50 years old
• Full-thickness burns >5% TBSA
• Burns to face, hands, feet, genitalia, perineum, or major joints
• Inhalation injury, electrical burns, chemical burns
• Concomitant trauma
• Patients with significant comorbidities (e.g., diabetes, heart disease)^[8]

Emergency Department Burn Management and Special Populations

Emergency Department Interventions

• Stop the burning process: Remove clothing, cool chemical/thermal burns with tepid water for 15–20 minutes (avoid hypothermia in large burns).^[3]
• Wound care: Cleanse with sterile saline; debride loose tissue; apply silver sulfadiazine or bacitracin (face). Avoid breaking blisters in palm/soles (protect underlying dermis).
• Cover with clean dry gauze or non-adherent dressing; for large TBSA use clean sheets until transfer.
• Pain management: IV opioids (morphine, fentanyl) titrated to effect. Avoid IM injections (erratic absorption).^[9]
• Tetanus prophylaxis: Update as needed per CDC guidelines.
• Escharotomy: For circumferential burns causing compartment syndrome – incisions made through eschar to restore perfusion.^[9]

Special Considerations

• Pediatric: Use Lund and Browder chart for TBSA; higher BMR; smaller airway – early intubation; maintain urine output 1-2 mL/kg/hr.^[3]
• Elderly: Thinner skin → deeper injuries; decreased cardiac reserve; higher mortality.^[2]
• Pregnant patients: Left lateral tilt to avoid aortocaval compression; fetal monitoring if >20 weeks gestation.

Common Complications in Burn Patients

Common Complications

• Hypothermia: Major risk due to loss of thermoregulation – warm fluids, warm room, avoid excessive exposure.
• Compartment Syndrome: In extremities or chest; signs include pain on passive stretch, pulselessness, paresthesia, pallor.
• Acute Kidney Injury: From hypovolemia, myoglobinuria, or sepsis.
• Infection: Burn wound sepsis is a leading cause of late death. Use strict aseptic technique.^[9]
• Carbon Monoxide Poisoning: Suspect in all flame/ smoke inhalation – treat with 100% O₂ or hyperbaric oxygen if severe (loss of consciousness, metabolic acidosis, COHb >25%).^[6]
• Fluid Overload: Over-resuscitation can lead to pulmonary edema, abdominal compartment syndrome.

CEN Exam Focus Areas and Clinical Priorities

• Memorize the Rule of Nines and Parkland formula – expect direct calculation questions.
• Know the difference between adult and pediatric burn management: Children need higher urine output and use Lund-Browder chart.
• Inhalation injury is a priority – look for facial burns, hoarseness, carbonaceous sputum.
• Electrical burns cause deep muscle damage disproportionate to surface appearance – watch for myoglobinuria and cardiac arrhythmias.
• Chemical burns: Irrigate with copious amount of water for at least 20 minutes; do not neutralize (exothermic reaction worsens injury).
• Do not apply ice or cold water to large burns – causes vasoconstriction and hypothermia.
• Fluid resuscitation should be guided by urine output, not formula alone.
• CEN loves burn center referral criteria – memorize ABA (American Burn Association) list above.

References & Sources

1. Emergency Nurses Association. (2020). Trauma Nursing Core Course (TNCC) Provider Manual (8th ed.). Jones & Bartlett Learning. https://shop.ena.org/trauma-nursing-core-course
2. American College of Surgeons. (2018). Advanced Trauma Life Support (ATLS) Student Course Manual (10th ed.). ACS. https://www.facs.org/quality-programs/trauma/atls/
3. Herndon, D. N. (Ed.). (2018). Total Burn Care (5th ed.). Elsevier. https://doi.org/10.1016/C2015-0-03364-2
4. Walker, P. F., Buehner, M. F., Wood, L. A., et al. (2019). Diagnosis and management of inhalation injury: An updated review. Critical Care, 23(1), 31. https://doi.org/10.1186/s13054-019-2321-9
5. Arnoldo, B. D., Purdue, G. F., Kowalske, K., et al. (2007). Electrical injuries: A 20-year review. Journal of Burn Care & Research, 28(3), 469–474. https://doi.org/10.1097/BCR.0B013E318053DC4C
6. Hampson, N. B., Piantadosi, C. A., Thom, S. R., & Weaver, L. K. (2012). Practice recommendations in the diagnosis, management, and prevention of carbon monoxide poisoning. American Journal of Respiratory and Critical Care Medicine, 186(11), 1115–1119. https://doi.org/10.1164/rccm.201207-1284CI
7. Pham, T. N., Cancio, L. C., & Gibran, N. S. (2011). American Burn Association practice guidelines burn shock resuscitation. Journal of Burn Care & Research, 32(3), 340–347. https://doi.org/10.1097/BCR.0b013e318217e3f9
8. American Burn Association. (2019). Burn Center Referral Criteria. https://ameriburn.org/resources/burn-center-referral-criteria/
9. Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2019). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier. https://evolve.elsevier.com/cs/product/9780323551496