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Chapter 3. Initial Assessment ofBurn Patient
105
F . An example of a cold injury to the foot that has been
rewarmed. Cold injuries commonly occur to exposed areas of the
face or distal extremities, such as fingers or toes (as in this case).
Careful assessment of clinical features following rewarming efforts
is essential. In a select group of patients with ischemic wounds that
do not reperfuse after rewarming, diagnostic angiography and fibrinolytic therapies may be warranted
warming (stage 1); insensate or pallid followed by blistering
and pain with restored perfusion in response to warming
(stage 2); insensate, pallid, or hard followed by hemorrhagic
blisters and variable pain or perfusion in response to warming (stage 3) [35]. Depending on the status of reperfusion
after thaw, fibrinolytic therapies may be indicated [36].
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M. A. DePamphilis and R. L. Sheridan
Early burn center consultation can facilitate prompt decision-making in equivocal cases.
Electrical Injury
Electrical injuries (see Chap. 13) are classified as either high
voltage (>1000 V) or low voltage (<1000 V) [37]. Contact
with a low-voltage source may cause locally destructive burn
wounds at the contact site but uncommonly result in systemic
sequelae (Fig. 3.14). High-voltage exposure is rare but
requires meticulous attention due to the potential for massive
underlying tissue damage and multisystem trauma [38].
Emergency personnel should extricate the patient from the
scene of an electrical exposure with a non-conducting mate-
F . A mid-range electrical injury sustained from contact
with a 220-volt power source. Following direct contact with an
energy source, current will travel the path of least resistance, generating heat that inflicts deep thermal injury. In this case, contact
resulted inlocally destructive burn wounds to the hand and digits of
deep- partial thickness (tissues with mottled cherry red and white
appearance) and full-thickness injury (waxy, white surface)
Chapter 3. Initial Assessment ofBurn Patient
rial, only once they have been assured that the electrical current has been turned off.
Patients that present with electrical injuries require a vigilant initial assessment, which typically results in referral to a
specialized burn center. When collecting an electrical injuryspecific history, it is important to gather information related
to the voltage and amperage of the source, type of circuit
(AC/DC), points of contact, duration of contact, potential for
trauma, and any presence of flame or ignition of clothing.
Depending on the extent of electrical exposure, a patient may
have burn wounds that are accompanied with a set of concomitant injuries or complications. During the secondary
survey, special attention is warranted for the following
common examples including compartment syndromes, myocardial injury, musculoskeletal injuries, neurologic sequelae,
ocular sequelae, myoglobinuria, and renal failure.
Clinicians should be on high alert for concomitant trauma
or complications in all patients that present with high-voltage
exposure. For these patients cardiac rhythm should be monitored for 24–72 hours post-injury, thorough neurological and
ocular examinations should be completed, creatine kinase and
renal markers should be followed closely, and Foley catheters
should be placed to track pigmenturia. Injured extremities
should be assessed frequently for intracompartmental edema
[39]. Muscle compartments are especially at risk and may
require prompt fasciotomy. In some instances, amputation
may also be necessary but this decision should be deferred to
the specialists at the receiving burn center. A baseline ophthalmologic examination for late development of cataracts is
advisable in patients with high-voltage injuries.
107
Non-accidental Injury
Non-accidental injuries include suspected cases of abuse,
negligence, assault, self-inflicted harm, or substance abuse.
Non-accidental injury is not only limited to children. Any
patient should be admitted to the hospital if there is suspicion
108
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M. A. DePamphilis and R. L. Sheridan
of non-accidental injury, even if the injury itself is of little
physiologic significance. During the initial assessment, clinicians should ensure that they have detailed documentation of
the stated history and of the wound presentation. Burn diagrams should be carefully completed, and photographic documentation is ideal. These injuries will often require special
social/emotional support. Psychosocial services and social
work should be consulted immediately. Suspicious nonaccidental injuries must be filed with the appropriate local
and state agencies.
Approximately 20% of burns in young children are associated with maltreatment although this can occur in any age
group [40]. The potential for abuse or neglect should be considered for every child. When applicable, important history
information that should be gathered as part of the initial
assessment include water temperature, duration of contact,
caretakers involved, documentation of conflicting reports
from involved caretakers, delay in seeking treatment, and
prior injuries. Subsequently, during burn wound evaluation of
the secondary survey, the following points should be evaluated and documented including the uniformity of burn depth,
absence of splash marks, sharply defined wound margins,
porcelain-contact sparing, flexor sparing, stocking or glove
patterns, dorsal location of contact burns of the hand, and
localized very deep contact burns (Fig.3.15).
Chapter 3. Initial Assessment ofBurn Patient
F . When assessing a child with burn injuries, it is imperative to be familiar with burn patterns that are indicative of child
maltreatment. Immersion scald burns secondary to child abuse will
typically present with uniform burn depth, defined wound margins,
porcelain-contact sparing, flexor sparing, and/or absence of splash
marks. Flexor sparing can be detected by the presence of a striped
“zebra” pattern of burned-unburned-burned zones at a flexor surface, signifying a tightly flexed position at the time of burn. Note the
popliteal flexor sparing pattern in this case example, suggesting child
abuse tub immersion of the lower extremity (left). Maltreatment
should also be considered in cases of contact burns, such as in this
case example of an immersion contact burn sustained from a heated
iron (right). Note the uniform burn depth with glove pattern distribution and well-demarcated margins that are located on the dorsal
surface of the child’s hand, a burn pattern consistent with child
abuse. Detailed documentation and photography of any evidence
consistent with maltreatment are essential. All suspicious cases must
be filed with the appropriate local and state agencies
109
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Chapter 4
Initial Management
andResuscitation
LeopoldoC.Cancio andJillM.Cancio
Introduction
Successful initial care of a patient with extensive burns sets
the stage for a long recovery process. Although there are
many steps on the way to recovery, the first step is one of the
most important. Mistakes made during the resuscitation
phase of care may cause irreversible damage, leading to loss
of life, limb, or eyesight. In this chapter, we will review how to
successfully traverse this most important phase of care, focusing on the care of the critically ill burn patient. A key message
is that early care of a burn patient should be undertaken,
whenever possible, in consultation with a burn center.
Big Problem or Little Problem?
An accurate determination of burn size is a key initial step in
caring for any burn patient, but burn size is often overestimated by referring hospitals by a factor of 100% or more
L. C. Cancio (*) · J. M. Cancio
US Army Institute of Surgical Research, Fort Sam Houston,
San Antonio, TX, USA
e-mail: leopoldo.c.cancio.civ@health.mil; jill.m.cancio.civ@health.mil
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. O. Lee (ed.), Essential Burn Care for Non-Burn Specialists,
https://doi.org/10.1007/978-3-031-28898-2_4
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L. C. Cancio and J. M. Cancio
[1]. There are several reasons why this is problematic. Burn
size is a major determinant of fluid resuscitation requirements. Burn size also influences the decision to intubate, or
not to intubate, a burn patient (see below). Burn size, along
with age and the presence of inhalation injury, is an independent predictor of postburn mortality risk [2] and thus is used
in triage decisions.
The Rule of Nines can provide a quick estimate of burn
size (Fig.4.1). Also, the Rule of Hands is very helpful for
small and irregularly shaped burns. It states that at any age, a
patient’s hand (palm and fingers) equals about 1% of their
total body surface area (TBSA). This initial estimate should
then be refined using the Lund-Browder diagram, which
divides the body into smaller areas than does the Rule of
Nines, and which also takes age-related changes into account.
With an accurate burn size estimate in hand, one may then
determine whether a patient should be considered for burn
center referral. The American Burn Association (ABA)
guidelines, in brief, recommend referral of patients who meet
the following criteria [3]:
• Burn size of 10% TBSA or greater
• Special mechanisms: inhalation, chemical, electric
• Full-thickness burns
• Functionally significant burns, e.g., hand or face
• Patients with special medical or psychosocial needs
Furthermore, burn size helps determine who should be
admitted to an intensive care unit (ICU). All patients with
burn size of 20% or greater, and those with possible inhalation injury, are admitted to the ICU.Previously healthy
young persons with burns in the 10–19% TBSA range
might be orally resuscitated on a burn ward. On the other
hand, those in the 10–19% range who are children, who are
elderly, or who have complex medical problems belong in
the ICU.
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