Step 2 CK · Surgery

Burns & Wound Management

Name: Burns & Wound Management
Creator: Veli Bakalov, MD

Depth, TBSA, Parkland fluids, and the airway you secure before it swells shut

Surgery·Trauma·4 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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Burn depth: superficial (red, painful, blanches, no blisters); superficial partial (blisters, moist, very painful, blanches); deep partial (less pain, sluggish blanch); full-thickness (white/leathery, dry, painless, no blanch) → grafting.
Adult rule of nines: head 9, each arm 9, each leg 18, anterior trunk 18, posterior trunk 18, perineum 1; palm ≈1%; count only partial- and full-thickness burns.
Parkland: 4 mL × kg × %TBSA of lactated Ringer's over 24 hours, half in the first 8 hours from the time of the burn; titrate to urine output 0.5 mL/kg/h in adults, 1 mL/kg/h in children.
Inhalation injury (enclosed space, facial burns, singed nasal hairs, carbonaceous sputum, hoarseness, stridor) → intubate early, before edema closes the airway.
Carbon monoxide: pulse oximetry is falsely normal → measure carboxyhemoglobin by co-oximetry; treat with 100% oxygen, hyperbaric oxygen if severe.
Cyanide (burning plastics) inhibits cytochrome c oxidase → lactic acidosis, normal PaO2, bright-red venous blood → hydroxocobalamin with sodium thiosulfate.
Circumferential full-thickness burns → escharotomy for lost distal pulses or restricted chest expansion.
Electrical burns: deep damage far beyond the skin → rhabdomyolysis (aggressive fluids), arrhythmias (continuous ECG), compartment syndrome.
Silver sulfadiazine does not penetrate eschar (leukopenia); mafenide penetrates eschar and cartilage but causes metabolic acidosis; infection is the leading cause of death after resuscitation.

Priorities: the airway comes first

A fixed sequence. Burn care follows the trauma primary survey: secure the airway, stop the burning, estimate depth and TBSA, resuscitate by Parkland, and catch the silent killers (carbon monoxide, cyanide, compartment syndrome).

AirwayIntubate early for inhalation injury.
Stop the burningRemove clothing and jewelry; cool with room-temperature water; irrigate chemical burns copiously.
Depth and TBSACount only partial- and full-thickness burns.
FluidsParkland lactated Ringer's, titrated to urine output.
Toxins and constrictionCO, cyanide, escharotomy; burn center transfer.

Initial burn management

Secure the airway before it swells. Suspect inhalation injury with an enclosed-space fire, facial burns, singed nasal hairs, carbonaceous sputum, soot in the oropharynx, hoarseness, or stridor. Intubate early, before progressive edema makes the airway impossible; do not wait for overt respiratory failure. Bronchoscopy can confirm injury below the cords.

Depth and TBSA

Burn depth

Depth	Appearance	Pain	Blanching and healing
Superficial (epidermis)	Red, no blisters (sunburn)	Painful	Blanches; heals without scarring
Superficial partial-thickness	Blisters, moist	Very painful	Blanches; heals without a graft
Deep partial-thickness	Mottled, less moist	Less painful	Sluggish blanch; often excised and grafted
Full-thickness	White or leathery, dry	Painless (nerves destroyed)	No blanch; needs grafting

More pain can mean a less deep burn: intact nerves hurt, whereas full-thickness burns are numb.

Rule of nines. In adults: head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, perineum 1%. The patient's own palm is about 1% and helps tally scattered or irregular burns. Count only partial- and full-thickness burns, not superficial ones. Children have proportionally larger heads, so use an age-adjusted chart.

Fluid resuscitation: Parkland

4 mLper kg per %TBSA of lactated Ringer's over 24 hours

½ in 8 hfirst half within 8 hours of the burn, the rest over 16 hours

0.5 mL/kg/hadult urine output target (1 mL/kg/h in children)

The formula. Parkland = 4 mL × body weight (kg) × %TBSA of lactated Ringer's over 24 hours. The 8-hour clock starts at the moment of the burn, not at hospital arrival, so front-load early. Formal resuscitation is generally needed for burns ≥20% TBSA in adults.

Worked examples. A 70-kg adult with burns of the entire anterior trunk and both entire arms has 18 + 9 + 9 = 36% TBSA: 4 × 70 × 36 = 10,080 mL over 24 hours. With 50% TBSA, the total is 14 L, and 7 L is due in the first 8 hours.

The formula is only a starting point: titrate to urine output. Over-resuscitation causes pulmonary edema and abdominal or extremity compartment syndrome.

Inhalation injury and toxic gases

Carbon monoxide vs cyanide

Feature	Carbon monoxide	Cyanide
Mechanism	Forms carboxyhemoglobin, impairing oxygen delivery	Inhibits cytochrome c oxidase, blocking oxygen use (from burning plastics and synthetics)
Clues	Headache, confusion, nausea; pulse oximetry falsely normal	Severe lactic (anion-gap) acidosis, normal PaO2, bright-red venous blood from a narrowed arteriovenous O2 difference
Diagnosis	Carboxyhemoglobin by co-oximetry	Clinical picture plus lactate
Treatment	100% oxygen; hyperbaric oxygen for severe cases	Hydroxocobalamin, with sodium thiosulfate

Why the saturation lies. Standard pulse oximetry cannot distinguish carboxyhemoglobin from oxyhemoglobin, so a confused, dyspneic fire victim can read 99%. Treat on suspicion with 100% oxygen by non-rebreather, which shortens the carboxyhemoglobin half-life from about 4–5 hours to roughly an hour. Hyperbaric oxygen (half-life about 20–30 minutes) is reserved for severe poisoning, such as loss of consciousness, neurologic deficits, or pregnancy.

Escharotomy, electrical injury, and referral

Cut the constricting eschar. Circumferential full-thickness burns form rigid eschar that acts like a tourniquet: on a limb it causes compartment syndrome and loss of pulses; on the chest it restricts ventilation. Escharotomy, an incision through the eschar, restores perfusion and chest expansion; fasciotomy is added if compartment pressures stay high.

Electrical burns hide deep damage. Tissue destruction far exceeds the skin appearance: rhabdomyolysis with myoglobinuria (aggressive fluids to keep urine flowing and protect the kidneys), cardiac arrhythmias (continuous ECG monitoring), and compartment syndrome (fasciotomy). TBSA-based formulas underestimate their fluid needs.

Burn center referral (American Burn Association criteria) includes partial-thickness burns over 10% TBSA, any full-thickness burn, burns of the face, hands, feet, genitalia, perineum, or major joints, electrical or chemical burns, inhalation injury, circumferential burns, and extremes of age.

Wound care and complications

Topical burn antimicrobials

Feature	Silver sulfadiazine	Mafenide acetate
Eschar penetration	Poor	Penetrates eschar and cartilage (ears, nose)
Comfort	Soothing	Painful
Adverse effects	Transient leukopenia; a sulfonamide, so avoid near term (kernicterus); avoid on the face	Carbonic anhydrase inhibitor → metabolic acidosis

Infection kills after resuscitation. Burns drive a hypermetabolic, catabolic state, so adequate protein and calories (early enteral feeding) are essential. Infection and sepsis are the leading cause of death after initial resuscitation; early excision and grafting reduce infection and length of stay. Update tetanus for every burn.

Curling ulcer is the gastric stress ulcer specific to burns; Cushing ulcer follows CNS injury and raised intracranial pressure.

Clean, moist, and nourished heals. Debride devitalized tissue, keep a moist, balanced wound bed, and control infection. Clean incisions close by primary intention; contaminated or tissue-deficit wounds heal by secondary intention.