Skin & Subcutaneous Tissue

Burns: classification and initial management

Clinical Overview and When to Suspect Significant Burn Injury

— ~400,000 ED visits/year; ~40,000 hospitalizations; ~3,000 deaths

— Scald burns predominate in children <5 and adults >65; flame burns predominate ages 20–60

— House fires account for the majority of fatal burns, usually via inhalation injury and CO toxicity, not skin burn alone

— Any flame, scald, or contact burn with blistering, charring, or full-thickness appearance

— Closed-space fire, facial soot, singed nasal vibrissae, hoarseness, carbonaceous sputum → inhalation injury until proven otherwise

— High-voltage electrical contact (>1000 V), lightning strike, or chemical exposure (acid/alkali/HF)

— Burns in patterns inconsistent with history (stocking-glove scalds, cigarette punctate burns, sparing of flexor creases) → non-accidental trauma

— Coagulation (central, irreversible) → stasis (salvageable with resuscitation) → hyperemia (recovers)

— Goal of resuscitation: prevent the zone of stasis from converting to necrosis through hypoperfusion

Definition: Burns are tissue injury from thermal, electrical, chemical, or radiation energy producing coagulative necrosis and a systemic inflammatory cascade proportional to depth and total body surface area (%TBSA).

Epidemiology in the US:

When to suspect a significant burn requiring formal assessment:

Pathophysiology zones (Jackson):

Systemic response: Burns >20% TBSA trigger burn shock — capillary leak, third-spacing, decreased cardiac output for 24–48 h, then hypermetabolic phase with catabolism lasting weeks to months.

Step 3 management: First decision in any burn patient is airway and inhalation injury assessment, not the burn itself — early intubation prevents catastrophic airway edema once resuscitation begins.

Board pearl: A patient pulled from a house fire who is "talking fine" but has facial soot and carbonaceous sputum should be intubated prophylactically before transfer; airway edema peaks at 12–24 h and a delayed intubation is a cricothyroidotomy.

Presentation Patterns and Key History

— Flame: Often full-thickness, frequently with inhalation injury; ask about closed space, duration of entrapment, loss of consciousness (CO/cyanide)

— Scald: Most common in pediatrics; immersion scalds (stocking/glove distribution, sharp waterline, sparing of flexion creases) are classic abuse patterns

— Contact: Iron, oven, exhaust pipe — usually deep, well-demarcated

— Flash: Brief, superficial-to-partial thickness over exposed areas; eyebrows/lashes often singed

— Electrical: Small entry/exit wounds belie massive deep tissue and muscle injury; ask voltage (low <1000 V vs high ≥1000 V) and AC vs DC

— Chemical: Ask agent, concentration, duration; alkali burns are deeper than acid

— Time of injury (drives fluid calculation — Parkland clock starts at injury, not arrival)

— First aid given (cool water, ice [harmful], topical agents)

— Tetanus status, comorbidities, medications, allergies, last meal

— Associated trauma: falls from height, jumping from windows, blast → maintain c-spine, look for occult injuries

— Enclosed space, prolonged exposure, unconsciousness

— Hoarseness, stridor, wheezing, brassy cough, dysphagia

— Facial burns, singed nasal hairs, soot in oropharynx, carbonaceous sputum

— Persistent metabolic acidosis with normal SpO₂ → cyanide (especially burning plastics/wool)

— Headache, confusion, cherry-red is unreliable, falsely normal pulse ox → CO poisoning (need co-oximetry for COHb)

Mechanism dictates injury pattern — get it explicitly:

Time-critical history:

Inhalation red flags:

Toxicology clues:

Social history: Smoking, alcohol, substance use, depression (self-immolation), domestic situation (intimate partner violence, child/elder abuse)

Key distinction: Pulse oximetry reads carboxyhemoglobin as oxyhemoglobin — a "normal SpO₂ 99%" in a fire victim is falsely reassuring. Order arterial co-oximetry and a lactate; lactate >10 in a burn patient suggests cyanide.

Board pearl: Always ask "what was burning?" — burning synthetics (couches, carpet, insulation) release HCN; this is the patient who needs hydroxocobalamin.

Physical Exam Findings and Burn Depth/Size Estimation

— Superficial (1st degree): Red, dry, painful, blanches; epidermis only (sunburn). Not counted in %TBSA.

— Superficial partial-thickness (2nd, superficial dermis): Pink, moist, blistered, very painful, brisk capillary refill; heals 1–3 weeks without scarring

— Deep partial-thickness (2nd, deep dermis): Mottled red-white, decreased sensation, sluggish blanching; heals 3–8 weeks, often needs grafting

— Full-thickness (3rd): Leathery, white/charred/waxy, dry, insensate, non-blanching, thrombosed vessels visible

— Fourth-degree: Extends to muscle, tendon, bone (electrical, prolonged contact)

— Rule of 9s (adults): head 9, each arm 9, each leg 18, anterior trunk 18, posterior trunk 18, perineum 1

— Pediatric modification: head 18, each leg 14 (head proportionally larger)

— Palmar method: patient's palm + fingers ≈ 1% TBSA — best for scattered or small burns

— Lund-Browder chart: most accurate, age-adjusted; used at burn centers

— Count only partial- and full-thickness burns; exclude superficial (1st degree)

— Circumferential burns of chest/extremities → impaired ventilation or distal ischemia → escharotomy

— Compartments: tense, pain on passive stretch, loss of pulses (late) → check pressures

— Ocular: fluorescein for corneal involvement; chemical burns need immediate irrigation to neutral pH

Primary survey first (ATLS): A-B-C-D-E with c-spine if trauma mechanism. Remove all clothing, jewelry, and contact lenses; stop the burning process (irrigate chemicals 20+ min, brush off dry powder first).

Burn depth — clinical exam is the standard:

%TBSA estimation methods:

Targeted exam findings:

Board pearl: A burn that initially looks "pink and blistered" can convert to deeper injury over 48–72 h with inadequate resuscitation — always reassess depth at 24 and 48 h.

Step 3 management: If you palpate a rock-hard, circumferential full-thickness chest burn with rising peak airway pressures on the ventilator, the next step is bedside escharotomy, not more sedation.

Diagnostic Workup — Initial Labs, Imaging, and Bedside Studies

— CBC, BMP, glucose, lactate, CK, urinalysis (myoglobin in electrical/deep burns)

— ABG with co-oximetry — gives PaO₂, pH, COHb, methemoglobin

— Type and screen, coags (PT/INR, PTT), pregnancy test in women of reproductive age

— Lactate as surrogate for cyanide and resuscitation adequacy

— Troponin and ECG in electrical injury (especially high-voltage or LOC/arrest)

— CXR: baseline; often normal early even with inhalation injury — a normal film does NOT exclude it

— CT/x-rays as dictated by trauma mechanism (falls, blasts, jumps from windows)

— C-spine imaging if mechanism warrants

— Fiberoptic bronchoscopy is the gold standard — visualizes soot, edema, mucosal sloughing, erythema below the cords

— Performed at intubation when possible; grades severity and guides bronchial toilet

— Nonsmoker baseline <3%, smoker <10%

— >10% symptomatic; >25% severe; >40% often fatal without treatment

— Half-life: 4–5 h on room air, ~80 min on 100% FiO₂, ~20 min in hyperbaric O₂

— Continuous cardiac monitoring × 24 h if LOC, arrhythmia on presentation, abnormal ECG, or high-voltage; otherwise low-voltage asymptomatic patients with normal ECG can usually be discharged

— Urine myoglobin / CK trend for rhabdomyolysis; maintain UOP 1–1.5 mL/kg/h until pigment clears

Labs to order on any major burn (≥20% TBSA, inhalation injury, electrical, or admitted patient):

Imaging:

Inhalation injury workup:

Carboxyhemoglobin interpretation:

Cyanide: levels are slow/unavailable acutely — treat empirically based on lactate >10, persistent acidosis, closed-space fire, neuro/cardiac collapse

Electrical injury:

CCS pearl: On a CCS burn case, order "type and screen, CBC, BMP, ABG with co-oximetry, lactate, CK, UA, CXR, ECG, tetanus immunization" as a standing block on arrival — these are virtually always indicated for major burns.

Board pearl: Bronchoscopy beats CXR for early inhalation injury; don't be reassured by a clean film.

Diagnostic Workup — Advanced and Confirmatory Studies

— Bronchoscopy for inhalation injury grading (Abbreviated Injury Score 0–4); guides ventilator strategy and predicts pneumonia/ARDS risk

— Indirect/laryngoscopy if airway exam concerning but intubation not yet committed — but err on early intubation; cannot "de-decide" once edema sets in

— Echocardiography in high-voltage electrical injury or burn shock unresponsive to volume — assess myocardial dysfunction

— Laser Doppler imaging — most validated tool to predict healing potential at 48–72 h; available at specialty burn centers

— Serial photographic documentation for medico-legal and consultative review

— Urine output is the primary endpoint: 0.5 mL/kg/h adults, 1 mL/kg/h children <30 kg, 1–1.5 mL/kg/h in electrical/myoglobinuric injury

— Lactate trend, base deficit, MAP >65, mentation

— Avoid pulmonary artery catheters routinely; use bedside ultrasound, arterial line, IVC variability for harder cases

— CK >5000 or rising; UA positive for blood without RBCs on micro → myoglobinuria

— Trend potassium, creatinine, phosphate, calcium, urine pH

— COHb from co-oximetry (not pulse ox)

— Cyanide levels are confirmatory only — do not delay hydroxocobalamin waiting for results

— Methemoglobin if cyanosis with normal PaO₂

— Skeletal survey in children <2 with concerning burns

— Photographs, social work consult, mandated reporting documentation

— Ophthalmology for retinal hemorrhages in suspected child abuse

When initial assessment doesn't fit, escalate evaluation:

Depth assessment adjuncts (when clinical exam ambiguous):

Resuscitation adequacy monitoring:

Rhabdomyolysis workup (electrical, deep flame, crush component):

Toxicology confirmatory testing:

Abuse/forensic workup when suspicion exists:

Key distinction: Lactate elevation in burns = either under-resuscitation OR cyanide toxicity. If you've given fluid appropriately and lactate stays >10, think cyanide and give hydroxocobalamin 5 g IV.

Board pearl: Hydroxocobalamin turns urine and skin red/pink and interferes with co-oximetry, falsely elevating COHb readings for hours — document baseline first.

Risk Stratification and First-Line Management Logic

— Partial-thickness burns >10% TBSA

— Any full-thickness burn

— Burns involving face, hands, feet, genitalia, perineum, or major joints

— Electrical (including lightning) and chemical burns

— Inhalation injury

— Burns in patients with significant comorbidities

— Burns with concomitant trauma (transfer to trauma center first if trauma dominates)

— Burns in children at hospitals without pediatric capability

— Burns requiring social, emotional, or rehabilitative intervention (suspected abuse)

— 4 mL × kg × %TBSA of lactated Ringer's, given over first 24 h from time of injury

— First half in first 8 h, second half over next 16 h

— Only burns ≥20% TBSA in adults (≥10% in children) need formal resuscitation

— Pediatric: add maintenance dextrose-containing fluids (low glycogen stores)

— ABA modified ("rule of 10") for adults 40–80 kg: start at 2 mL × kg × %TBSA, titrate to UOP — reduces "fluid creep" and abdominal compartment syndrome

— Two large-bore IVs (through unburned skin if possible; IO acceptable)

— Foley catheter for UOP monitoring

— NG tube for ileus prevention in burns >20%

— Warm room/warm fluids — burn patients lose thermoregulation rapidly

— Tetanus prophylaxis per CDC schedule

— Analgesia: IV opioids titrated (IM absorption unreliable due to edema)

Burn center referral criteria (American Burn Association):

Fluid resuscitation — Parkland formula:

Titrate to urine output, NOT the formula — the formula is a starting point only

Initial bundle on arrival:

Step 3 management: A 70-kg adult with 40% TBSA partial- and full-thickness flame burn: Parkland = 4 × 70 × 40 = 11,200 mL LR in 24 h; 5,600 mL in first 8 h from time of injury, then titrate to UOP 0.5 mL/kg/h. Avoid colloid in the first 12–24 h.

Board pearl: Do NOT include superficial (1st degree) burns when calculating TBSA for fluids — it overestimates and drives fluid creep.

Pharmacotherapy — First-Line Regimens

— IV opioids (morphine, fentanyl, hydromorphone) titrated to effect; PCA once stable

— Avoid IM/SQ — unreliable absorption with edema

— Adjuncts: acetaminophen, ketamine (especially for dressing changes), gabapentin for neuropathic pain in healing phase

— Silver sulfadiazine: broad spectrum, soothing; avoid on face, in sulfa allergy, G6PD deficiency, pregnancy near term, and infants <2 months (kernicterus risk); causes transient leukopenia

— Mafenide acetate (Sulfamylon): penetrates eschar — good for ear cartilage and infected burns; carbonic anhydrase inhibitor → metabolic acidosis, painful on application

— Bacitracin/petrolatum gauze: face and superficial burns

— Silver-impregnated dressings (Acticoat, Mepilex Ag): longer wear interval, less painful changes

— Tdap if not given in past 5 years for burn wounds

— TIG if unvaccinated or <3 doses

— Nebulized heparin + N-acetylcysteine + albuterol every 4 h for inhalation injury (reduces cast formation, improves mortality in some studies)

— Bronchodilators PRN

— CO: 100% FiO₂ via non-rebreather or ETT; hyperbaric O₂ if COHb >25%, LOC, neuro deficits, pregnancy with COHb >15%, or acidosis

— Cyanide: Hydroxocobalamin 5 g IV over 15 min (preferred over Lilly cyanide kit; safe in fire victims with concurrent CO)

— HF acid burns: Calcium gluconate gel topically, then subcutaneous/intra-arterial calcium for refractory pain; monitor for hypocalcemia, hypomagnesemia, hyperkalemia, QT prolongation

Analgesia:

Topical antimicrobials (for partial- and full-thickness burns after cleaning):

Tetanus prophylaxis:

Inhalation/airway adjuncts:

Toxin-specific antidotes:

GI prophylaxis: PPI or H2 blocker — Curling ulcer risk in burns >20% TBSA

DVT prophylaxis: Mechanical + chemical (LMWH) once bleeding risk acceptable — burn patients are hypercoagulable

Avoid: prophylactic systemic antibiotics (drives resistance), steroids (immunosuppression, no mortality benefit)

Board pearl: Prophylactic systemic antibiotics in burns increase resistant infection without reducing mortality — reserve for documented infection.

Procedures — Escharotomy, Grafting, and Airway Management

— Early intubation for: stridor, hoarseness with progressive symptoms, full-thickness facial/neck burns, deep oropharyngeal burns, GCS <8, large TBSA requiring massive resuscitation (anticipate airway edema)

— Use largest ETT possible (≥8.0) to allow future bronchoscopy and pulmonary toilet

— Secure with ties, not tape (tape won't stick to burned skin)

— Indications: circumferential full-thickness burns causing

— Chest: restricted ventilation, rising peak pressures

— Extremity: compartment syndrome signs, loss of distal pulses on Doppler, falling pulse oximetry of digit

— Neck: airway compromise

— Performed bedside; incision through eschar to subcutaneous fat along mid-medial and mid-lateral lines; minimal bleeding (full-thickness is insensate and avascular)

— Avoid crossing joints, ulnar nerve at elbow, peroneal nerve at fibular head

— Initial cleansing with mild soap and water; intact blisters: debate, but generally debride large/tense blisters and those crossing joints

— Early tangential excision and split-thickness skin grafting (STSG) within 3–7 days improves outcomes vs delayed

— Sheet grafts for face/hands; meshed grafts for larger areas

— Allograft, xenograft, dermal substitutes (Integra), cultured epithelial autografts for massive burns

— COHb >25%, neurologic symptoms, LOC, cardiovascular dysfunction, severe acidosis, pregnancy with COHb >15% or fetal distress

— Treat within 6 h ideally

— Copious water or saline irrigation; alkali burns 1–2 h minimum; never neutralize (exothermic reaction worsens injury)

— Exceptions: HF (calcium), elemental sodium/potassium (cover with mineral oil, mechanical removal — water causes ignition)

Airway management:

Escharotomy (NOT fasciotomy — though both may be needed):

Fasciotomy: Required for high-voltage electrical burns and deep thermal burns with true muscle compartment involvement

Wound care and debridement:

Hyperbaric oxygen indications (CO):

Chemical burns — irrigation:

CCS pearl: On CCS, the action "escharotomy at bedside" should be ordered as soon as a circumferential full-thickness burn impairs ventilation or perfusion — do not wait for the OR.

Special Populations — Elderly and Renal/Hepatic Impairment

— Thinner dermis → burns appear deeper; same heat → greater depth

— Higher mortality at lower %TBSA; the Baux score (age + %TBSA) is a classic predictor, with revised Baux adding inhalation injury (+17 points)

— Score ≥110–120 historically near-uniformly fatal; modern care has shifted this but still informs goals-of-care discussions

— Underlying CHF, CKD → narrow therapeutic window between under-resuscitation and pulmonary edema

— Start at lower end of Parkland (2 mL/kg/%TBSA), titrate aggressively to UOP

— Consider invasive monitoring (arterial line, bedside echo)

— Higher risk of abdominal compartment syndrome from fluid creep

— Anticoagulants/antiplatelets: bleeding with debridement/grafting; reverse as appropriate

— Diabetes: hyperglycemia worsens wound healing and infection — target glucose 140–180 mg/dL with insulin

— Beta-blockers may blunt tachycardic response, masking under-resuscitation; trend lactate and UOP closely

— Avoid nephrotoxins (NSAIDs, contrast, aminoglycosides where possible)

— Dose-adjust opioids (morphine metabolites accumulate — prefer hydromorphone/fentanyl)

— Silver sulfadiazine systemic absorption can cause crystalluria — caution in CKD

— Mafenide → metabolic acidosis poorly tolerated in CKD

— Coagulopathy increases bleeding risk during excision/grafting — correct INR pre-op

— Hypoalbuminemia worsens edema; selective albumin replacement may be considered after 12–24 h in severe cases

— Acetaminophen dose cap 2 g/day

Elderly (>65) burn patients:

Fluid resuscitation pitfalls in elderly:

Comorbidity considerations:

Renal impairment:

Hepatic impairment:

Step 3 management: A 78-year-old with 25% TBSA flame burn, CHF (EF 30%), and CKD III — start fluids at modified Parkland 2 mL/kg/%TBSA, place arterial line and Foley, target UOP 0.5 mL/kg/h, monitor for pulmonary edema, and discuss goals of care early given revised Baux >100.

Board pearl: In any elderly burn patient, early goals-of-care conversation is itself a quality-of-care metric.

Special Populations — Pediatrics, Pregnancy, and Non-Accidental Trauma

— TBSA estimation: use Lund-Browder (head 18% in infants, decreases with age; legs increase)

— Fluid resuscitation: Parkland 4 mL/kg/%TBSA LR PLUS maintenance dextrose-containing fluids (4-2-1 rule) — kids deplete glycogen rapidly and become hypoglycemic

— Target UOP 1 mL/kg/h

— Use weight-based dosing for all meds; opioids carefully titrated

— Hypothermia risk is severe — warm room, warm fluids, occlusive dressings

— Immersion scalds: sharp waterline, stocking/glove distribution, sparing of flexor creases (child holds limbs flexed), bilateral symmetry, buttocks "doughnut" sparing

— Burns inconsistent with developmental stage ("rolled into hot water" in pre-mobile infant)

— Multiple burns of different ages, cigarette punctate burns, branding patterns

— Delay in seeking care, changing histories, blaming siblings

— Mandatory reporting to child protective services — required by law in all states; document objectively

— Fluid resuscitation requirements unchanged; uteroplacental perfusion depends on maternal MAP

— Left lateral tilt after 20 weeks to offload IVC

— Fetal monitoring after 24 weeks for burns >20% TBSA or hemodynamic instability

— CO crosses placenta — fetal COHb is higher and clears slower than maternal; lower threshold for HBO: maternal COHb >15% or fetal distress

— Tetanus vaccination is safe; many topicals (silver sulfadiazine near term) are not — use bacitracin/petrolatum

— Similar abuse patterns; mandatory elder abuse reporting in most states

Pediatric burns:

Non-accidental trauma — when to suspect:

Pregnancy:

Older adults and dependent adults:

Key distinction: A scald with clear waterline, symmetric stocking distribution, and sparing of flexor creases is the textbook child-abuse immersion injury — call CPS and admit even if TBSA is small.

Board pearl: In pregnant burn victims with CO exposure, continue 100% O₂ for 5× the time needed to clear maternal COHb because fetal hemoglobin clears slower.

Complications and Adverse Outcomes

— Burn shock: under-resuscitation → AKI, multiorgan failure

— Abdominal compartment syndrome: over-resuscitation ("fluid creep") → bladder pressure >20 with new organ dysfunction — needs decompression

— Inhalation injury sequelae: airway obstruction, ARDS, pneumonia

— CO and cyanide toxicity: delayed neurocognitive sequelae weeks later

— Compartment syndrome of limbs (escharotomy/fasciotomy)

— Rhabdomyolysis with AKI, hyperkalemia, arrhythmia (electrical, deep thermal)

— Hypothermia from heat loss through burned skin

— Curling ulcer (stress gastric ulcer) — prevent with PPI

— Hypoglycemia in pediatrics

— Wound infection and sepsis — leading cause of late death; most common pathogens: Pseudomonas, Staph aureus (including MRSA), Acinetobacter, Candida

— Burn wound conversion: partial-thickness deepens to full-thickness with infection or hypoperfusion

— VTE — burns are markedly hypercoagulable

— Acalculous cholecystitis, SMA syndrome

— Hypermetabolic catabolic state — weight loss, muscle wasting; manage with high-calorie/high-protein nutrition (25–30 kcal/kg/day, 1.5–2 g/kg/day protein), early enteral feeding, propranolol and oxandrolone to attenuate catabolism

— Hypertrophic scarring and contractures — especially across joints; pressure garments, silicone, laser, surgical release

— Keloids (more common in darker skin types)

— Marjolin ulcer: squamous cell carcinoma arising in chronic burn scar decades later — biopsy any non-healing scar ulcer

— Neuropathic pain, pruritus, heterotopic ossification, heat intolerance

— PTSD, depression, body image distress — screen and treat

Early (hours to days):

Intermediate (days to weeks):

Late (months to years):

Key distinction: Over-resuscitation (fluid creep → abdominal compartment syndrome, pulmonary edema, extremity compartment syndrome) is now as common a cause of harm as under-resuscitation — titrate to UOP, not formula.

Board pearl: A patient with a 30-year-old burn scar developing a chronic ulcer needs biopsy for Marjolin (SCC).

When to Escalate Care — ICU, Burn Center, and Inpatient Triage

— Partial-thickness >10% TBSA, any full-thickness, special location, electrical/chemical, inhalation injury, comorbidities, suspected abuse, inadequate home support

— Burns >20% TBSA (fluid resuscitation needs)

— Inhalation injury or intubation

— High-voltage electrical injury

— Hemodynamic instability, significant comorbidities

— Need for invasive monitoring

— Apply ABA criteria; transfer after initial stabilization — secure airway, start fluids, place catheters, cover wounds with clean dry dressings (not wet — hypothermia)

— Communicate Parkland calculation, time of injury, and resuscitation already given to receiving center

— Burn surgery (early, even by phone for transfer)

— Anesthesia/ICU for airway

— Ophthalmology for ocular burns

— Plastics, urology, ENT for site-specific

— Social work and CPS/APS for suspected abuse

— Toxicology/poison control for chemical and inhalation

— Psychiatry for self-immolation

— <10% TBSA partial-thickness, no special locations, no inhalation, no comorbidity concerns

— Adequate pain control with oral analgesics

— Reliable follow-up within 24–48 h

— Ability to perform dressing changes (with home health if needed)

— Tetanus updated, prescriptions provided, return precautions given

Admission criteria (any major burn):

ICU admission criteria:

Burn center transfer:

Consultations to call:

Discharge criteria from ED (for minor burns):

CCS pearl: On a burn CCS case, the sequence is: ABCs → IV access → fluids → Foley → NG → analgesia → tetanus → topical antimicrobial → consult burn surgery → transfer to burn ICU. Move the clock only after each block of orders.

Step 3 management: Always stabilize before transfer — patients die in transport ambulances when transferred with marginal airways. Intubate, line, tube, and fluid-resuscitate first.

Key Differentials — Same-Category Causes (Other Skin/Burn Mimics)

— Drug reaction (sulfa, allopurinol, lamotrigine, anticonvulsants, NSAIDs) causing full-thickness epidermal sloughing

— Looks like burn but presents days after drug exposure with fever, mucosal involvement (oral, ocular, genital), positive Nikolsky sign

— <10% BSA = SJS, 10–30% = overlap, >30% = TEN

— Manage in burn unit with similar wound care; stop offending drug, supportive care, ophthalmology — steroids and IVIG controversial; cyclosporine and TNF inhibitors emerging

— Young children, exfoliative toxin from S. aureus; superficial epidermal split (subgranular), spares mucosa

— Treat with anti-staph antibiotics (nafcillin/oxacillin, vancomycin if MRSA), supportive care

— Target lesions, usually HSV-triggered; less extensive desquamation

— Autoimmune blistering — biopsy with immunofluorescence

— Pain out of proportion, crepitus, rapidly spreading erythema, systemic toxicity — surgical emergency, not a burn

— Cold injury with similar staging (superficial to full-thickness); manage with rapid rewarming in 37–39°C water, not dry heat; delayed demarcation — "frostbite in January, amputate in July"

— From oncologic treatment or radiation exposure; cumulative dose-dependent

— Chemotherapy (anthracyclines, vinca alkaloids), vasopressors, hyperosmolar fluids — local antidotes vary (dexrazoxane, hyaluronidase, phentolamine)

Stevens-Johnson syndrome (SJS) / Toxic epidermal necrolysis (TEN):

Staphylococcal scalded skin syndrome (SSSS):

Erythema multiforme major:

Pemphigus vulgaris, bullous pemphigoid:

Necrotizing fasciitis:

Frostbite:

Radiation dermatitis:

Chemical burn from extravasation (vesicants):

Key distinction: TEN vs burn — TEN has mucosal involvement and follows a drug; thermal burn has a mechanism and spares mucosa. Both go to a burn unit.

Board pearl: Positive Nikolsky in an adult on a new drug 1–3 weeks ago = TEN, not a burn. Stop the drug — this is the single highest-yield intervention.

Key Differentials — Other-Category Causes

— Faulty heater, generator indoors, car in garage — multiple family members ill, headaches, confusion

— Cherry-red is unreliable; co-oximetry diagnostic

— Treat with 100% O₂ ± HBO

— Industrial exposure, smoke inhalation, laetrile, sodium nitroprusside infusion

— Almond breath (unreliable), seizures, profound acidosis with normal PaO₂, arterialized venous blood

— Hydroxocobalamin or Lilly kit

— Dapsone, benzocaine sprays, nitrates, anilines

— Cyanosis unresponsive to O₂, "chocolate brown" blood, SpO₂ stuck around 85%

— Methylene blue (avoid in G6PD)

— Stridor, hoarseness, lip/tongue swelling — looks like inhalation but mechanism is allergic; ACE inhibitor history

— Treat with epinephrine, antihistamines, steroids; icatibant/C1 inhibitor for hereditary angioedema

— Pulmonary embolism, MI, asthma exacerbation, pneumonia — sort by history and workup

— Cardiac arrhythmia is the major concern; monitor ECG; full-thickness injury minimal

— Diffuse erythema, painful, blistering possible in severe cases; supportive care, NSAIDs, topical emollients, cool compresses

— Erythema and pain but no clear mechanism, no blistering pattern; treat as infection

— Necrotic ulcer with black eschar — context-dependent

Carbon monoxide poisoning without burn:

Cyanide poisoning without obvious burn:

Methemoglobinemia:

Anaphylaxis and angioedema:

Acute respiratory distress from non-burn causes:

Electrocution without thermal burn (low-voltage):

Sunburn (UV radiation):

Thermal injury mimics — cellulitis, erysipelas, contact dermatitis:

Eschar from spider bites (brown recluse), anthrax, ecthyma gangrenosum:

Step 3 management: In a confused patient pulled from a burning building, assume mixed CO + cyanide + thermal + inhalation until proven otherwise. Give 100% O₂, hydroxocobalamin if lactate >10 or hemodynamic collapse, secure airway, start Parkland.

Board pearl: Persistent metabolic acidosis after adequate fluid resuscitation in a fire victim = cyanide.

Secondary Prevention, Discharge Planning, and Long-Term Plan

— Topical antimicrobial (bacitracin or silver sulfadiazine — except sulfa allergy, face, or near-term pregnancy)

— Non-adherent dressing + gauze wrap; change daily after gentle cleansing with mild soap and water

— Oral analgesics (scheduled acetaminophen ± short course of opioids; ibuprofen if no contraindication)

— Tetanus updated before discharge

— Pruritus anticipated as wound heals — antihistamines, gabapentin, moisturizers

— Signs of infection: increasing pain, erythema spreading, purulent drainage, fever, foul odor → return immediately

— Sun protection (SPF 30+) of healing burns for at least 1 year to prevent permanent hyperpigmentation

— Moisturize 2–3× daily once epithelialized

— Pressure garments for hypertrophic scar prevention — wear 23 h/day for 6–12 months across high-tension areas

— Silicone sheets/gel for established scars

— Physical and occupational therapy for ROM, contracture prevention, ADL retraining — starts during hospitalization

— Nutrition: high-protein, high-calorie diet continues for months; multivitamin, vitamin C, zinc supplementation

— Anabolic adjuncts (oxandrolone) and beta-blockade (propranolol) to attenuate hypermetabolism in major burns

— Home fire safety: working smoke detectors on every floor, escape plan, fire extinguisher

— Water heater set ≤120°F (49°C) to prevent scalds

— Cooking safety: pot handles inward, no children in cooking zone

— Smoking cessation — leading cause of fatal house fires

— Electrical safety, chemical storage out of reach of children

Discharge medications and supplies (minor burn home care):

Wound care education:

Major burn long-term plan:

Secondary prevention (preventing recurrence):

Vaccinations: Tetanus, influenza, pneumococcal in major burn survivors (functionally immunocompromised)

Step 3 management: Every discharged burn patient gets tetanus update, written wound care instructions, scheduled follow-up in 24–48 h, return precautions, and a counseling moment on smoke-detector/water-heater settings.

Board pearl: Home water heaters at >130°F cause full-thickness scalds in <5 seconds — at 120°F it takes >5 minutes.

Follow-Up, Monitoring Parameters, and Rehabilitation

— Minor burns: recheck in 24–48 h to reassess depth (burns often "declare" themselves), then weekly until healed

— Larger/grafted burns: burn clinic at 1 week post-discharge, then every 2–4 weeks for months

— Scar/contracture surveillance at 3, 6, 12 months minimum

— Urine output q1h during resuscitation (0.5 mL/kg/h adult, 1 mL/kg/h peds, 1–1.5 mL/kg/h myoglobinuria)

— Daily weights (fluid status)

— Glucose q4–6h (hyperglycemia worsens healing)

— Daily wound assessment, swab if infection suspected

— Nutrition labs weekly: prealbumin, CRP, electrolytes, phosphate, magnesium

— VTE risk: continue prophylaxis until ambulatory

— ROM exercises at all joints under burn or near burn — even with fresh grafts (after initial graft-take period of 3–5 days)

— Splinting in anti-contracture position: neck in extension, axilla abducted, elbow extended, hand in "position of safety" (MCP flexed, IP extended), hip extended

— Pressure garments custom-fitted once wounds epithelialize

— Gait training, ADL retraining, return-to-work/school planning

— PTSD screening at 1, 3, 6 months — burn survivors have high rates

— Depression and anxiety screening (PHQ-9, GAD-7)

— Body image counseling, peer support groups (Phoenix Society)

— Pediatric burn camps for child survivors

— Burn Specific Health Scale, SF-36, return to work, school re-entry

— Continued mandated reporting if abuse identified

— Workers' compensation paperwork for occupational burns

— Disability assessment as indicated

Outpatient follow-up cadence:

Monitoring parameters during admission:

Rehabilitation — start day 1:

Psychosocial follow-up:

Functional outcomes tracking:

Reportable items:

Step 3 management: A burn outpatient with a partial-thickness hand burn returns at 48 h with deeper-appearing wound and decreased blanching — refer to burn surgery for likely grafting; do not "watch and wait" through the window for early excision.

Board pearl: Pruritus is the most common chronic complaint after burn healing — anticipate it and treat with antihistamines, gabapentin, and moisturizer; it predicts non-adherence to pressure garments.

Ethical, Legal, and Patient Safety Considerations

— Child abuse: suspicion is sufficient — physicians are mandated reporters in all 50 states; protected from civil liability for good-faith reports

— Elder/dependent adult abuse: mandated in most states

— Intimate partner violence: varies by state; offer resources regardless; document objectively without victim-blaming language

— Burns from criminal acts (assault, arson): may require law enforcement notification per state law

— Self-immolation: psychiatric evaluation mandated; consider involuntary hold

— Major burn victims often cannot consent due to intoxication, pain, intubation, hypoxia → proceed under emergency exception (implied consent) for life-saving care; document

— Surrogate decision-maker for non-emergent procedures (skin grafting, escharotomy if patient stable)

— Pediatric burns: parents consent — but if parental story suggests abuse, physician duty to protect the child supersedes parental refusal; court order if needed

— Massive burns in elderly (revised Baux >130–140) approach futility — early palliative care consultation, honest prognostication, family meetings

— Document patient preferences; respect advance directives

— Inter-facility transfer: most common pitfall is inadequate airway and under-resuscitation; use a transfer checklist (airway, IV access ×2, Foley, NG, fluid rate, time of injury, last vitals, wound coverage, tetanus, analgesia, weight, %TBSA)

— Sign-out to receiving team must include Parkland calculation, current rate, UOP trend

— Avoid fluid creep (monitor abdominal pressures in >25% TBSA)

— Glycemic control (140–180 mg/dL)

— Early enteral nutrition within 24–48 h

— VTE prophylaxis

— Aspiration precautions

— Wound infection surveillance

— Photographs (with consent or under abuse-investigation protocol) of all burns on admission

— Diagram with %TBSA, depth, location

— Time of injury vs time of arrival (drives Parkland calculation legally as well as clinically)

Mandatory reporting:

Informed consent edge cases:

Goals of care and futility:

Transition-of-care safety risks:

Patient safety quality measures:

Documentation:

Step 3 management: A 3-year-old with bilateral lower-extremity stocking-distribution scalds — admit even if TBSA is small, file CPS report, photograph, social work consult, skeletal survey. The medical urgency is moderate; the protective urgency is high.

High-Yield Associations and Rapid-Fire Clinical Facts

Parkland formula: 4 × kg × %TBSA LR over 24 h, half in first 8 h from time of injury

TBSA includes: partial- and full-thickness only — NOT superficial (1st degree)

Rule of 9s adult: 9-9-18-18-9-18-1; pediatric: head 18, leg 14

Burn shock peaks: 8–24 h; resuscitation needs decline after 24 h

Curling ulcer: stress gastric ulcer in burns; Cushing ulcer: with head injury

Inhalation injury triad: facial burns + singed nasal hairs + carbonaceous sputum

CO half-life: RA 4–5 h, 100% O₂ 80 min, HBO 20 min

HBO indications for CO: COHb >25%, LOC, neuro deficit, ischemia, severe acidosis, pregnancy COHb >15%

Cyanide treatment: hydroxocobalamin 5 g IV (turns urine red, interferes with co-oximetry)

HF acid burn: calcium gluconate gel; severe → IV/intra-arterial calcium; watch QT, K, Mg, Ca

Mafenide acetate: penetrates eschar (good for ear), causes metabolic acidosis (carbonic anhydrase inhibitor)

Silver sulfadiazine: broad spectrum; avoid in sulfa allergy, G6PD, face, pregnancy near term, infants <2 months, causes transient leukopenia

Escharotomy: circumferential full-thickness compromising ventilation/perfusion — bedside, through eschar to fat

Marjolin ulcer: SCC in chronic burn scar — biopsy any non-healing scar ulcer

Best resuscitation endpoint: UOP (not CVP, not formula)

Baux score: age + %TBSA; revised adds +17 for inhalation injury

Lund-Browder: most accurate %TBSA, age-adjusted

Palmar method: patient's palm + fingers = ~1% TBSA

Early excision and grafting: within 3–7 days reduces mortality, LOS, infection

Hypermetabolic phase modulators: propranolol, oxandrolone, early enteral nutrition, glycemic control

Suspicious pediatric pattern: stocking/glove scald with sharp waterline, flexor sparing, doughnut-spared buttocks

High-voltage electrical: >1000 V; AC worse than DC at same voltage (tetany prevents release); need cardiac monitoring × 24 h

Chemical irrigation: NEVER neutralize; minimum 20 min for acid, 1–2 h for alkali

Board pearl: When in doubt — airway first, fluids titrated to urine output, transfer to burn center, photograph, report if abused.

Board Question Stem Patterns

— Answer: Endotracheal intubation now, not "observation" — airway edema will close the window

— Answer: Co-oximetry for COHb and empiric hydroxocobalamin; pulse ox misses CO

— Parkland 4 × 70 × 40 = 11,200 mL; half (5,600) by 1600 (8 h from injury, not arrival)

— Answer: Bedside escharotomy along mid-axillary and infraclavicular lines

— Answer: Admit, report to CPS, social work, skeletal survey — classic immersion abuse

— Answer: Aggressive fluid resuscitation to UOP 1–1.5 mL/kg/h, monitor for hyperkalemia and arrhythmia, ECG monitoring

— Answer: Calcium gluconate gel; monitor calcium, magnesium, potassium, QT

— Answer: Pseudomonas wound infection — tissue biopsy/culture, systemic antipseudomonal antibiotic, surgical debridement

— Answer: Biopsy for Marjolin ulcer (SCC)

— Answer: TEN — stop drug, transfer to burn unit, supportive care; not a thermal burn

— Answer: Hyperbaric oxygen — lower threshold in pregnancy

"House fire, brought from closed space, hoarse voice, soot on face, talking normally"

"Burn patient with normal SpO₂ 99%, lactate 12, headache, found in burning building"

"70-kg adult, 40% TBSA flame burn, injured at 0800, arrives at 1000"

"Circumferential full-thickness chest burn, rising peak airway pressures on ventilator"

"Child <1 year with bilateral symmetric lower-extremity scalds, sharp waterline, sparing of popliteal fossae"

"Electrical burn with small entry/exit wounds, dark urine, CK 18,000"

"HF acid splash with severe pain, minimal skin findings"

"Burn patient on day 5 with new fever, increasing wound pain, green-tinged exudate"

"30 years after a thigh burn, patient develops a non-healing ulcer in the scar"

"Adult on lamotrigine 3 weeks, now with mucosal ulcers, positive Nikolsky, >30% epidermal sloughing"

"Pregnant patient at 28 weeks, house fire, COHb 18%, fetal HR with late decels"

Key distinction: Step 3 stems often hide the time of injury — extract it; Parkland clock starts there, not at presentation. Wrong answer trap: starting the 8-h window at arrival.

Board pearl: When the stem gives a specific number for COHb, CK, lactate, voltage, or TBSA, the answer is calculated or threshold-based — circle the number and match to an action.

One-Line Recap

Burn care is a time-driven, airway-first, fluid-titrated discipline: classify by mechanism/depth/%TBSA, secure the airway early in any inhalation-injury suspect, resuscitate with Parkland 4 mL/kg/%TBSA LR titrated to urine output (not formula), treat coexisting CO/cyanide empirically, escharotomy any circumferential full-thickness burn compromising ventilation or perfusion, transfer to a burn center by ABA criteria, and never miss the abuse pattern in a pediatric scald.

— Intubate early for facial burns, hoarseness, stridor, carbonaceous sputum, or large TBSA before edema closes the window

— Parkland 4 × kg × %TBSA LR over 24 h, half in first 8 h from time of injury, titrate to UOP 0.5 (adult), 1 (peds), 1–1.5 (myoglobinuria) mL/kg/h

— Avoid fluid creep — over-resuscitation causes abdominal compartment syndrome and pulmonary edema

— 100% O₂ for CO; HBO if COHb >25%, LOC, neuro deficits, ischemia, pregnancy COHb >15%

— Hydroxocobalamin 5 g IV for suspected cyanide (lactate >10, refractory acidosis)

— Calcium gluconate gel for HF burns; never neutralize chemical burns

— Bedside escharotomy for circumferential full-thickness chest/extremity compromise

— Early excision and split-thickness skin grafting within 3–7 days for deep partial- and full-thickness burns

— Topical mafenide (penetrates eschar, metabolic acidosis) vs silver sulfadiazine (broad, leukopenia, avoid in sulfa allergy/G6PD/face)

— Burn-center transfer per ABA criteria; report suspected abuse; pressure garments + PT/OT for contractures; biopsy any non-healing scar for Marjolin SCC; PTSD screening at 1, 3, 6 months

Airway, fluids, wounds, transfer:

Toxin-specific:

Surgical and definitive care:

Long view:

Board pearl: Get the time of injury, calculate Parkland from it, titrate to urine output, and photograph + report any pattern that doesn't match the history.