Burn Injury : Mnemonic Approach (ATLS)

Mnemonic: BURNS

Burn depth and body surface area (BSA)

Burn degree	Burn depth	Features	Healing
	Mnemonic: Number of degrees = Number of structures involved	Mnemonic: RBCS
1st	Superficial (epidermis only)	Red	<1 wk
2nd	Partial thickness – superficial (epidermis + papillary dermis)	Blister + Blanches	1-3 wks
	Partial thickness – deep (epidermis + reticular dermis)	Compared to superficial partial thickness: Deep = Dermal appendages involved + Decreased: a. Moistness (Dry) b. Color (Mottled red) c. Blanching d. Pain	>3 wks, usually requires surgical treatment
3rd	Full thickness (epidermis + dermis + subcutaneous fat)	Charred and Contractures (leathery dry, no blanching, painless)	Rare, unless surgical treatment
4th	Epidermis + dermis + subcutaneous fat + fascia/muscle/bone	Surrounding area (second degree) pain increased	Never – requires surgical treatment

Burned Body Surface Area (BSA) for 2nd and 3rd degree burns

Wallace Rule of 9:

Structures	BSA (%) – Adults	BSA (%) – Infants
Head and neck	9	18
Upper limbs (each)	9	9
Trunk – anterior	18	18 (trunk and perineum)
Trunk – posterior	18	18 (including 2.5% for each buttock)
Perineum	1
Lower limbs (each)	18	14

Comparison with other methods

	Lund & Browder	Rule of 9s	Palmar
Theory	Age-based assessment	Body divided in 9% areas	Patient’s palm is 1%
Advantages	“Gold-standard” accuracy	Efficient	Minor Burn Estimation
Disadvantages	Inefficient	Over-estimation	User variability

Mortality prediction:

3 factors: Mnemonic – BAI

1. Burn BSA >40%
2. Age >60 years
3. Inhalational injury

Baux score (% mortality) = Age + BSA

• BSA >70% in elderly or Baux score >130 = Near 100% mortality
• Score <80 is considered good and >100 is considered bad

Revised Baux score = Baux score + 17 (for inhalational injury)

Urine output monitoring

Aim:

1. Adults: 0.5 ml/kg/hr
2. Children <30 kg: 1 ml/kg/hr
3. Electrical injury: 1-1.5 ml/kg/hr

Resuscitation and Referral

a. Early intubation: Indications –

• Airway obstruction signs (hoarseness, stridor, retractions)
• Burn surface area >40-50%
• Circumferential neck burns
• Deep facial burns
• Edema (significant)
• Fatigue of respiration
• GCS <8
• Hypoxemia despite 100% 0xygen, Hypoventilation (PCO2 >50 mmHg and pH <7.2)

b. Fluid resuscitation: For 2nd and 3rd degree burn >20% BSA

Initial resuscitation with warmed RL

Fluid	Adult	Pediatric (<14 year)	Electrical burn
Rate	2 ml X kg X BSA	3 ml X kg X BSA	4 ml X kg X BSA
Children <30 kg		+ 3 ml X kg X BSA D5RL at maintenance rate	RL

c. Referral to burn center: Indications –

1. Second degree (partial thickness) burn >10% BSA
2. Third degree (full thickness) burn
3. Burns to face, hand, feet, genitalia or major joints
4. Electrical, chemical or inhalational burns
5. Comorbidities
6. Concomitant trauma
7. Patients requiring special social, emotional or rehabilitative intervention
8. Pediatric burns without qualified personnel or equipment

NG decompression

Indications:

1. Nausea/vomiting
2. Abdominal distension
3. Burns >20%

Surgery

Conservative management is appropriate for superficial burns and mixed superficial burns that will heal in 2 weeks. More complex burns may require excision and skin grafting. Excision and primary closure is not generally practiced as there is a high risk of infection.

Escharotomy:

• Indicated in circumferential full thickness burns to the torso or limbs.
• Careful division of the encasing band of burn tissue will potentially improve ventilation (if the burn involves the torso), or relieve compartment syndrome and oedema (where a limb is involved)

Reference: ATLS 10th edition