Burns and Wounds - Kofi's Learning Hub

🎯 Burn Classification by Depth

Burn depth determines healing potential, treatment approach, and surgical requirements:

Superficial (First-Degree) Burns

Depth: Epidermis only
Appearance: Pink/red, dry, no blisters
Sensation: Painful
Healing: 3-7 days, no scarring
Examples: Sunburn, minor scalds

Partial Thickness (Second-Degree) Burns

Superficial Partial: Papillary dermis, moist, blisters, painful
Deep Partial: Reticular dermis, wet, whitish, decreased sensation
Healing: 2-3 weeks (superficial), 3-8 weeks (deep)
Scarring: Minimal (superficial), significant (deep)
Treatment: May require grafting if deep

Full Thickness (Third-Degree) Burns

Depth: Entire dermis and appendages
Appearance: Leathery, white/brown/black, dry
Sensation: Insensate (nerve destruction)
Healing: No spontaneous healing
Treatment: Requires excision and grafting

Fourth-Degree Burns: Extend through skin into underlying muscle, tendon, or bone. These life-threatening injuries require complex reconstruction and often result in permanent disability or amputation.

🧬 Burn Assessment & TBSA Calculation

Accurate burn assessment guides resuscitation and treatment decisions:

Rule of Nines (Adults)

Head & neck: 9% (4.5% anterior, 4.5% posterior)
Each upper limb: 9% (4.5% anterior, 4.5% posterior)
Anterior trunk: 18%
Posterior trunk: 18%
Each lower limb: 18% (9% anterior, 9% posterior)
Perineum: 1%

Lund-Browder Chart (Children)

More accurate for children due to proportionally larger heads
Head: 19% at birth, decreasing with age
Lower extremities: 13% at birth, increasing with age
Age-specific charts account for body proportion changes

Palmar Method

Patient's palm: ~1% of TBSA
Useful for: Scattered burns, small area estimation
Includes: Fingers and palm, not dorsal hand
Accuracy: Quick estimate for burns <15% TBSA

Clinical Insight: Only partial and full thickness burns are included in TBSA calculation for fluid resuscitation. Superficial burns are not included as they don't significantly impact fluid requirements. The rule of nines provides a rapid initial estimate, but the Lund-Browder method is more accurate, especially in children.

💊 Acute Burn Management

Systematic approach to acute burn care following ATLS principles:

Primary Survey (ABCDE)

Airway: Assess for inhalation injury, hoarseness, stridor, facial burns
Breathing: Monitor for respiratory distress, carbon monoxide poisoning
Circulation: IV access, fluid resuscitation, assess peripheral perfusion
Disability: Neurological assessment, consider CO intoxication
Exposure: Remove clothing, jewelry, complete examination

Fluid Resuscitation (Parkland Formula)

Formula: 4 mL × kg × %TBSA (partial and full thickness)
Half: Administer first half over first 8 hours from burn time
Half: Second half over next 16 hours
Maintenance: Add maintenance fluids for children
Monitoring: Urine output (0.5-1 mL/kg/hr adults, 1-1.5 mL/kg/hr children)

Wound Initial Care

Cooling: Cool running water for 20 minutes (first 3 hours)
Cleaning: Gentle cleansing with mild soap or antiseptic
Debridement: Remove devitalized tissue, intact blisters may be left
Dressings: Appropriate topical antimicrobial and non-adherent dressings
Tetanus: Update prophylaxis if indicated

Inhalation Injury: Suspect with facial burns, singed nasal hairs, carbonaceous sputum, hoarseness, or history of enclosed space fire. Requires early intubation as airway edema can progress rapidly. Monitor carboxyhemoglobin levels and consider 100% oxygen until COHb <10%.

⚠️ Burn Complications & Special Considerations

Early recognition and management of burn complications:

Early Complications (0-72 hours)

Airway obstruction: From progressive edema
Hypovolemic shock: From fluid shifts
Compartment syndrome: Circumferential burns
Carbon monoxide poisoning: Inhalation injury
Hypothermia: Impaired thermoregulation

Late Complications (>72 hours)

Infection: Leading cause of mortality
Sepsis: From wound or catheter-related
Metabolic complications: Hypermetabolism, catabolism
Contractures: From scarring and immobility
Psychological impact: PTSD, depression, anxiety

Special Burn Types

Electrical burns: Small surface injury with deep tissue damage, cardiac monitoring, myoglobinuria management
Chemical burns: Copious irrigation, specific antidotes for some chemicals
Circumferential burns: Monitor for compartment syndrome, may require escharotomy
Pediatric burns: Higher fluid requirements, different TBSA calculations, suspect abuse with specific patterns

Compartment Syndrome in Burns: A surgical emergency requiring immediate intervention:

Signs: Pain out of proportion, paresthesia, pallor, paralysis, pulselessness (late sign)
Location: Most common in extremities with circumferential burns
Diagnosis: Clinical examination, compartment pressure measurement (>30 mmHg)
Treatment: Emergency escharotomy or fasciotomy
Complications: Nerve damage, muscle necrosis, limb loss if untreated

📊 Wound Dressing Selection Guide

Dressing Type	Indications	Advantages	Disadvantages	Change Frequency
Silver Sulfadiazine	Partial thickness burns, infected wounds	Broad-spectrum antimicrobial, soothing	Can cause transient leukopenia, eschar formation	Daily or BID
Mepilex Ag	Partial thickness burns, donor sites	Sustained silver release, non-adherent, absorbent	More expensive, not for heavily exudating wounds	3-7 days
Bacitracin/ Polysporin	Facial burns, superficial wounds	Good gram-positive coverage, minimal resistance	Limited spectrum, requires frequent application	BID-TID
Mafenide Acetate	Cartilage burns (ears), infected wounds	Excellent eschar penetration, gram-negative coverage	Painful application, metabolic acidosis risk	BID
Hydrofiber with Silver	Moderate to heavy exudate wounds	High absorbency, sustained antimicrobial activity	Requires secondary dressing, can dry out wound	1-3 days
Xeroform	Donor sites, superficial abrasions	Non-adherent, maintains moist environment	Limited antimicrobial activity	3-7 days

🏥 Wound Healing Principles

Understanding the phases of wound healing guides appropriate interventions:

Phases of Wound Healing

Hemostasis (Immediate): Vasoconstriction, platelet aggregation, clot formation
Inflammatory (0-6 days): Neutrophil and macrophage infiltration, debridement
Proliferative (4-24 days): Granulation tissue, angiogenesis, epithelialization
Remodeling (21 days-2 years): Collagen reorganization, scar maturation

Factors Affecting Wound Healing

Local factors: Oxygenation, infection, venous sufficiency
Systemic factors: Age, stress, diabetes, medications, nutrition
Lifestyle factors: Smoking, alcohol, nutrition, obesity
Wound characteristics: Size, depth, location, mechanism

Clinical Insight: The concept of wound bed preparation (TIME framework) provides a systematic approach to chronic wound management: Tissue (debridement), Infection/Inflammation (control), Moisture (balance), and Edge (advancement). Addressing all four components optimizes healing potential.

🔄 Chronic Wound Management

Comprehensive approach to non-healing wounds:

Pressure Injuries (Staging)

Stage 1: Non-blanchable erythema of intact skin
Stage 2: Partial thickness loss with exposed dermis
Stage 3: Full thickness loss, not through fascia
Stage 4: Full thickness loss with exposed bone/tendon
Unstageable: Obscured by slough or eschar
Deep Tissue Injury: Purple/maroon discoloration

Diabetic Foot Ulcers

Pathophysiology: Neuropathy, ischemia, infection combination
Assessment: Monofilament testing, ABIs, wound characteristics
Off-loading: Essential for healing, total contact casts
Infection control: Culture-guided antibiotics, surgical debridement
Advanced therapies: Negative pressure, growth factors, skin substitutes

Venous Stasis Ulcers

Location: Typically medial lower leg (gaiter area)
Appearance: Irregular shape, shallow, granulation tissue
Management: Compression therapy, leg elevation, wound care
Complications: Dermatitis, infection, Marjolin's ulcer (rare)

Burn Center Referral Criteria: Transfer to specialized burn care for: partial thickness burns >10% TBSA, full thickness burns, burns involving face, hands, feet, genitalia, perineum, major joints; electrical/chemical burns; inhalation injury; circumferential burns; patients with comorbidities; or suspected abuse.

🎯 Nutritional Support in Burns

Hypermetabolic response requires aggressive nutritional support:

Nutritional Requirements

Calories: 25-30 kcal/kg + 40 kcal/%TBSA burned (Curreri formula)
Protein: 1.5-2 g/kg/day, essential for wound healing
Micronutrients: Vitamin C, zinc, copper for collagen synthesis
Route: Enteral preferred over parenteral if gut functional
Monitoring: Prealbumin, nitrogen balance, weight trends

Pharmacological Adjuncts

Oxandrolone: Anabolic steroid reduces catabolism
Propranolol: Beta-blockade reduces hypermetabolism
Recombinant Human Growth Hormone: Enhances protein synthesis
Insulin: Tight glucose control improves outcomes

Clinical Insight: Early enteral nutrition (within 4-6 hours of burn injury) maintains gut integrity, reduces bacterial translocation, and modulates the hypermetabolic response. Post-pyloric feeding may be necessary with ileus or high aspiration risk.

🧠 Key Clinical Principles

Accurate burn assessment (depth and TBSA) guides appropriate resuscitation and treatment
Early fluid resuscitation according to Parkland formula prevents hypovolemic shock
Airway assessment and management takes priority in major burns
Infection prevention through appropriate dressings and topical antimicrobials is crucial
Nutritional support addresses the hypermetabolic state and supports healing
Multidisciplinary approach including surgery, nursing, therapy, and psychology optimizes outcomes
Rehabilitation begins immediately and continues throughout recovery

🎯 Clinical Pearls

Essential considerations for burns and wounds management:

Cool burns with running water for 20 minutes within 3 hours of injury
Calculate fluid resuscitation based on partial and full thickness burns only
Monitor urine output as the best indicator of adequate resuscitation
Elevate burned extremities to reduce edema
Provide adequate analgesia - burn pain is severe and undertreated
Consider tetanus prophylaxis in all burns except superficial
Involve burn specialists early for complex cases

Nursing Considerations:

Perform thorough wound assessment including size, depth, location, and characteristics
Monitor for signs of infection: increased pain, erythema, purulence, fever
Provide meticulous wound care with appropriate dressing selection
Manage pain effectively with scheduled and breakthrough medications
Educate patients and families on wound care, signs of complications
Coordinate multidisciplinary care including nutrition, therapy, psychology
Document wound progress with photographs when appropriate

🧭 Conclusion

Burn and wound management requires a systematic approach from initial assessment through rehabilitation. Accurate classification of burn depth and calculation of total body surface area involved guides appropriate fluid resuscitation and determines the need for surgical intervention. Comprehensive care addresses not only the physical wound but also the metabolic, infectious, nutritional, and psychological aspects of recovery. A multidisciplinary approach involving emergency physicians, burn surgeons, specialized nurses, physical and occupational therapists, nutritionists, and mental health professionals provides the best opportunity for optimal functional and cosmetic outcomes. Understanding wound healing principles and appropriate dressing selection further enhances care for both acute burns and chronic wounds.

Burn and wound management requires systematic assessment, appropriate resuscitation, meticulous wound care, and comprehensive rehabilitation to optimize patient outcomes and quality of life.