Burns and Smoke Inhalation
Thermal burns are classified into minor, moderate, and major, largely based upon burn depth and size in proportion to the patient’s total body surface area (TBSA). Burn size can be calculated by the “rule of nines.” Each upper extremity accounts for 9% TBSA, each lower extremity accounts for 18%, the anterior and posterior trunk each account for 18%, the head and neck account for 9%, and the perineum accounts for 1% (Fig. 7-1). Children less than 4 years old have much larger heads and smaller thighs in proportion to body size than do adults. In an infant, the head accounts for approximately 18% of the TBSA; body proportions do not fully reach adult percentages until adolescence. For smaller burns, an accurate assessment of burn size can be made by using the patient’s hand. The entire palmar surface of the hand, fingers included, represents 1% TBSA. Reassessment of burn size and depth is important, particularly early in the management of burn patients, because the extent of injury may not be initially apparent.
General Treatment
1. Remove the patient from the source of the burn.
a. If clothing is on fire, roll the patient on the ground or wrap him or her in a blanket to extinguish the flames.
b. Any hot or burned clothing, jewelry, and obvious debris should immediately be removed to prevent further injury and enable accurate assessment of the extent of burns.
c. If the burn is chemical, use large amounts of water (minimum 10 minutes of active rinsing) to wash off the agent(s). Do not apply a specific neutralizing agent, which may generate heat and worsen the injury.
d. If the eyes are involved, copiously irrigate them.
e. Because phosphorus ignites on contact with air, keep any phosphorus still in contact with the patient’s skin covered with water.
2. Perform a primary and secondary survey. Evaluate the airway for smoke inhalation. If present, administer oxygen by face mask, 5 to 10 L/min, and transport the patient to a medical facility (see Smoke Inhalation and Thermal Airway Injury, later). Be alert for vomiting into the face mask.
3. Treat burns by rapidly applying cool water (1° to 5° C [33.8° to 41° F]) for about 30 minutes. Local cooling of less than 10% of TBSA can be continued longer than 30 minutes to relieve pain; however, prolonged cooling of a larger TBSA burn may cause hypothermia and macerate skin. Cooling has no therapeutic benefit, other than pain control, if delayed more than 30 minutes after the burn injury.
4. Remove any jewelry from burned areas, fingers, and toes.
5. Update tetanus immunization as soon as possible.
6. Immediate evacuation to a burn center should be arranged when injuries meet the criteria for major burns (see later).
