1)         With respect to the clinical assessment of a patient presenting with a severe burn injury sustained in a house fire:

a)  Outline how burns are classified.

b)  List three methods for estimating the total body surface area affected by a burn injury.

c)  Other than the burn type and extent, list the other important features of the physical examination that should be noted as part of the initial clinical assessment  of the patient described above.

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College Answer

a)  Outline how burns are classified.

Burns are classified by depth of injury.

Superficial (formerly first degree):
•    Epidermis only

Partial Thickness (formerly second degree): 
•      Superficial

  • Epidermis and upper layer of dermis

•      Deep

  • Extend to deeper layer of dermis

Full Thickness (formerly third degree) 
•     All layers of dermis and may involve underlying tissue

b)  List three methods for estimating the total body surface area affected by a burn injury.

•    Lund-Browder Chart
•    The Rule of Nines
•    The Rule of Palm

c)  Other than the burn type and extent, list the other important features of the physical examination that should be noted as part of the initial clinical assessment  of the patient described above.

•    Basic   resuscitation   status:   Airway   patency,   Breathing,   Circulatory   status, Conscious level
•    Adequacy of resuscitation to date: heart rate, blood pressure, urine output
•    Evidence of associated trauma
•    Evidence of airway burn and inhalational injury: stridor, burns around nose and mouth, carbonaceous sputum
•    Presence of facial and/or corneal burns, perineal burns
•    Presence     of     circumferential    burns,     evidence    of     extremity    compartment syndrome, ventilator inadequacy
•    Evidence of rhabdomyolysis
•    Evidence of inhalation of toxic gases eg CO
•     Temperature
•    Adequacy of analgesia
•    Potential problems with vascular access
•    Evidence of drug / alcohol ingestion and/or co-morbid conditions eg epilepsy

Discussion

a)  Outline how burns are classified.

Little can be added to the college answer, as it is a fairly straightforward question. The table below comes from the Clinical Practice Guidelines of the Royal Children's Hospital in Melbourne.

Depth

Cause

Surface/colour

Pain sensation

Superficial

Sun, flash, minor scald

Dry, minor blisters, erythema, brisk capillary return

Painful

Partial thickness-superficial

(superficial dermal)

Scald

Moist, reddened with broken blisters, brisk capillary return

Painful

Partial thickness- deep

(deep dermal)

Scald, minor flame contact

Moist white slough, red mottled, sluggish capillary return

Painless

Full thickness

Flame, severe scald or flame contact

Dry, charred whitish. Absent capillary return

Painless

b)  List three methods for estimating the total body surface area affected by a burn injury.

The college gives the following three methods:

  • The Wallace Rule of Nines
    • The body is divided into areas each valued as 9%.
    • Not accurate in children
  • The Rule of Palm
    • The palm is considered to be 1% of the body surface area.
    • Good for estimating very small, or very large burns.
  • Lund-Browder Chart
    • Most accurate method; compensates for the change in body surface proportions in children

c)  Other than the burn type and extent, list the other important features of the physical examination that should be noted as part of the initial clinical assessment  of the patient described above.

The assessment of a burns patient is covered in greater detail by the BMJ series.

  • ABCs
  • Evidence of poor oxygen carriage or utilisation(carbon monoxide or cyanide toxicity)
  • Evidence of associated trauma
  • Evidence of airway burns
  • Presence of circumferential burns
  • Presence of corneal, perineal or genital burns
  • Vascular access
  • Hypothermia
  • Flid balance (and vigorous resuscitation)
  • Analgesia, and whether it is adequate
  • Features of intoxication
  • Features of non-accidental injury

References

References

The BMJ had published a series of 12 articles, titled "the ABC of burns". These are a valuable resource.

PRUITT Jr, BASIL A., DARYL R. ERICKSON, and ALAN MORRIS. "Progressive pulmonary insufficiency and other pulmonary complications of thermal injury."Journal of Trauma and Acute Care Surgery 15.5 (1975): 269-379.

Hettiaratchy, Shehan, and Remo Papini. "Initial management of a major burn: II—assessment and resuscitation." Bmj 329.7457 (2004): 101-103.

Hettiaratchy, Shehan, and Peter Dziewulski. "Pathophysiology and types of burns." Bmj 328.7453 (2004): 1427-1429.

Ansermino, Mark, and Carolyn Hemsley. "Intensive care management and control of infection." Bmj 329.7459 (2004): 220-223