Behind the Knife ABSITE 2026: Mastering Burn Management

Burn Classification and Zones

• 🌡️ First-degree burns are superficial, involving only the epidermis.
• 🌡️ Second-degree burns are partial thickness, affecting the epidermis and part of the dermis, and can be superficial or deep.
• 🌡️ Third-degree burns are full thickness, involving the epidermis and the entire dermis.
• 🌡️ Fourth-degree burns extend into bone or muscle.
• 💡 The zones of burn injury include the zone of hyperemia (increased perfusion, may recover), zone of stasis (poor perfusion, questionable viability), and zone of coagulation (irreversible tissue loss).

Burn Assessment and Resuscitation

• 📏 The "Rules of Nines" for adults assign 9% to the head, 9% to each upper extremity, 18% to the anterior trunk, 18% to the posterior trunk, and 18% to each lower extremity, with genitalia at 1%.
• 👶 In pediatric patients, the head and neck is 18%, and each lower extremity is 14%, while upper extremities and trunk percentages remain the same as adults.
• ✋ A patient's palm can be used to estimate approximately 1% of total body surface area (TBSA) burned.
• 💧 The Parkland formula (4 mL/kg/%TBSA) and modified Brooke formula (2 mL/kg/%TBSA) are used for fluid resuscitation in burns >15-20% TBSA, with the first half of fluid given over 8 hours and the second half over the next 16 hours.
• 🎯 Urine output is a key monitoring parameter: 0.5 mL/kg/hr for adults and 1 mL/kg/hr for children.
• 💧 Lactated Ringer's is the classic fluid for resuscitation, though other crystalloids can be used.
• 🏥 Adjunct therapies include albumin, fresh frozen plasma, renal replacement therapy, and potentially ECMO for ARDS.

Airway Injury and Inhalation Concerns

• 💨 Bronchoscopy is recommended for patients with significant burns, especially from house fires.
• ⚠️ Intubation is considered for signs like upper airway stridor, worsening hypoxemia, massive fluid resuscitation, vocal cord edema, or soot on vocal cords.
• ☣️ Lower airway damage is often caused by inhaled toxins and potentially heat.
• 🏭 Patients burned in enclosed spaces require consideration for carbon monoxide poisoning and cyanide poisoning.
• 🩺 Symptoms of severe carbon monoxide poisoning include seizures, loss of consciousness, lactic acidosis, cellular hypoxia, and cardiac arrhythmias.
• ⚠️ Standard pulse oximetry is unreliable in carbon monoxide poisoning, showing falsely high readings.
• 💨 Treatment for carbon monoxide poisoning is high-flow oxygen, with hyperbaric oxygen therapy as an option for severe cases.
• 🧪 Cyanide poisoning is treated with the cyano kit (hydroxycobalamin), often indicated by severe lactic acidosis.

Topical Antimicrobials and Hypothermia

• 🦠 Bacitracin (2nd-degree burns) covers gram-positives; side effects include rash and nephrotoxicity.
• 🦠 Mupirocin is for staphylococcal infections, not prophylactic; side effect is irritation.
• 🦠 Silver sulfadiazine (SSD) (3rd-degree burns) provides gram-negative coverage; side effects include neutropenia and thrombocytopenia; contraindicated in sulfa allergy.
• 🦠 Mafanide acetate (3rd-degree burns) offers gram-negative coverage and is used for pseudomonas infections; a key concern is metabolic acidosis.
• 🦠 Silver nitrate (3rd-degree burns) provides gram-positive and negative coverage; side effects include methemoglobinemia, electrolyte imbalances, and skin staining; contraindicated in G6PD deficiency.
• 🥶 Mild hypothermia (90-94°F) presents with shivering and mild mental status changes.
• 🥶 Moderate hypothermia (84-89°F) involves agitation, combativeness, muscle spasticity, dilated pupils, and slow respirations.
• 🥶 Severe hypothermia (<84°F) can lead to prolonged QRS, Osborne waves, flaccidity, coma, and V-fib.
• ❤️ In hypothermia arrest, the principle is "not dead until warm."

Frostbite, Grafts, and Electrical Injury

• 🧊 First-degree frostbite is superficial with numbness and edema.
• 🧊 Second-degree frostbite has partial thickness injury with milky white blisters and atrophic healing skin.
• 🧊 Third-degree frostbite involves full thickness injury with hemorrhagic blisters and potential limb loss.
• 🧊 Fourth-degree frostbite extends to bone, presenting as black, mummified tissue.
• 🌡️ Frostbite treatment involves treating hypothermia first, then rapid rewarming in heated water; milky/clear blisters are drained, hemorrhagic ones are left intact.
• 🩹 Full-thickness skin grafts are used for joints and facial structures, have less secondary contracture but cannot be meshed and have higher donor site morbidity.
• 🩹 Split-thickness skin grafts are more versatile, can be meshed, and generally have better cosmetic outcomes, though prone to more secondary contracture.
• ⚡ Severe electrical injury requires high-volume resuscitation (aiming for 100 cc/hr urine output), cardiac monitoring, and monitoring for compartment syndrome in extremities.

Quick Hits

• 💨 Carbon monoxide poisoning treatment is 100% oxygen via face mask.
• 🧪 Hydrofluoric acid burns are treated with topical calcium gluconate gel.
• 🩸 Methemoglobinemia is treated with methylene blue.
• 🌱 First and second-degree burns heal via epithelialization from wound edges or hair follicles.