Thermal Burns

Thermal burn injuries are common incidences here in Malaysia, mainly suffered by children, due to scalds from accidental splashing of hot oil and hot water like in this 9-months old infant who suffered about a 15% total BSA burn including the torso, left and right lower leg. We had two such cases within that same week.



(From Merck's Manual Online, URL: http://www.merck.com/mmpe/sec21/ch315/ch315a.html)

Estimation of the total BSA using the Wallace's Rule of Nine is not accurate in children because of the relatively larger head surface area.

Lund and Browder described a method for compensating for the differences and they came out with a chart (the Lund and Browder Chart to calculate BSA in children) [See above for the chart].

Click here for the more complete version available at the emedicine page.
URL: http://www.emedicine.com/emerg/TOPIC72.HTM

A Good Tip here:
If the chart is unavailable, can we still estimate BSA by using the Rule of Nines in children?
The answer is yes.
We can do so using the Rule of Nines and adjust for age as follows:

In children younger than 1 year:
- the head is 18% of BSA and each leg is 14% of BSA.
- the torso and arms represent the same percentages as in adults.

In children above 1 year old:
- For EACH year above 1 year old, add 0.5% to each leg
- For EACH yea above 1 year old, reduce 1.0% to the head by 1% until adult values are reached.
See the following excellent article in emedicine.com. URL: http://www.emedicine.com/emerg/TOPIC72.HTM

Other Q&As:
Is there any other formula to use to calculate fluid requirement besides Parkland formula?
You can use the Galveston formula, which is based on BSA rather than body weight. Although many pediatric burn centers believe it is more accurate than the Parkland formula, it is more time-consuming to calculate.
URL: http://www.emedicine.com/emerg/TOPIC72.HTM

How about the use of Silver Sulphadiazine (SSD)?
When I was a house officer (HO), SSD was recommended for all types of burns especially for first aid measure in A&E and for daily dressing, as long as it was a burn case, the HO would order for SSD dressing daily and the staff nurse would apply the SSD every time a burn dressing was changed.

But increasingly there are published papers to say comparing SSD with other methods like using hydrocolloid dressing (Duoderm), and even honey and found that SSD has not been found to be superior; in fact, worse in terms of healing rate, repigmentation, etc. Click here to read a good review article comparing SSD with other agents.

Evidence exists that the use of SSD may place patients at increased a risk of
1. developing neutropenia
2. erythema multiforme
3. crystalluria, and
4. methemoglobinemia


How about the use of other things like Vaseline (a petroleum based jelly product)?
Again there has been a comment regarding the inappropriate use of vaseline in minor burn.

The rationale behind is because, the important aim of emergent management of burn wound is to allow for dissipation of the latent heat of the burn; therefore, simple, plain cold water should do. Grease should never be applied to a fresh burn where the superficial part of the skin is missing. In addition to being occlusive, it is non-sterile, promotes bacterial proliferation on the surface of the wound, and may lead to infection. Click here to read this letter to the editor. Of course, having said that, it also depends on how deep the burn wound is (click here to read the manufacturer's reply), but my personal opinion is, for medical personnel, since we know how to assess the depth of wound, we can discern the appropriateness of using products like vaseline, but to a public member who is unsure of how to estimate, it is probably better to advise them to leave them all out and rather simply immerse in plain, cold water.

Shall we de-roof the blisters in the management of minor burns in emergency department?
There is some controversy over management of blisters, but large ones should probably be de-roofed, and dead skin removed with sterile scissors or a hypodermic needle. Smaller blisters should be left intact.
Click here to read the article in BMJ series.

Actually how to we define minor burns? This is important minor burns can be treated outpatient.
Either
- partial-thickness burns that are less than 15% of the total body surface area (TBSA) in people 10 to 50 years of age or
- partial-thickness burns that are less than 10% TBSA in children younger than 10 years or adults older than 50 years of age or
- full-thickness burns that are less than 2% TBSA in anyone

BMJ has published a series of 12 articles on Burns in the ABC of Burns. Click on the links to download the pdf version:

1. Introduction. Click here
2. Pathophysiology and Types of burn. Click here
3. First aid and treatment of minor burn. Click here
4. Initial Management of Major Burn I Click here
5. Initial Management of Major Burn II Click here
6. Management of Burn Injuries of various depths. Click here
7. Intensive care management and control of infection. Click here
8. Burn reconstruction. Click here
9. Rehabilitation after burn injury. Click here
10. Psychosocial aspects of burn injuries Click here
11. Burns in the developing world and burn disasters. Click here
12. When we leave hospital: a patient's perspective on burn injury Click here