Contents · 12 sections
- 1. Definition and epidemiology
- 2. Depth classification (Russia, 2017)
- 3. Burn surface area estimation
- 4. Prognosis: Frank index and the "100" rule
- 5. Burn disease — periods
- 6. First aid
- 7. Fluid resuscitation in burn shock
- 8. Local treatment
- 9. Special types of burns
- 10. Complications
- 11. Rehabilitation
- 12. FAQ
In a nutshell. A burn is damage to the skin and underlying tissues caused by thermal, chemical, electrical, or radiation agents. Severity is determined by depth (grades I–IV) and area (Wallace rule of nines or palm rule = 1 %). Fluid resuscitation in burn shock follows the Parkland formula: 4 mL × kg × % TBSA over 24 h, with half given in the first 8 h. Early cooling, early necrectomy, and autodermoplasty determine the outcome.
1. Definition and epidemiology
A burn is tissue trauma caused by thermal (flame, steam, hot liquid, contact with a hot object), chemical (acids, alkalis), electrical, or radiation factors. In Russia, about 400,000 burns are registered annually, 30 % of them in children. Mortality in extensive (> 40 % TBSA) burns remains high (20–50 %).
2. Depth classification (Russia, 2017)
| Grade | Affected layer | Clinical Practice |
|---|---|---|
| I | Epidermis | Erythema, pain; heals in 3–5 days without scarring |
| II | Epidermis + papillary dermis | Blisters with clear fluid, severe pain; heals in 10–14 days |
| IIIa | Part of the dermis, skin appendages preserved | Blisters with turbid content, moist eschar, pain preserved; heals in 3–6 weeks via epithelialization from appendages |
| IIIb | Entire dermis | Dense dry eschar, no pain; does not heal on its own — requires transplantation |
| IV | Subcutaneous tissue, muscles, bones | Charring; requires necrectomy and reconstruction |
The international classification (ABA) divides burns into superficial (I–II in Russia), partial-thickness (IIIa), and full-thickness (IIIb–IV).
3. Burn surface area estimation
Wallace rule of nines (adults)
- Head and neck — 9 %.
- Each upper limb — 9 %.
- Each lower limb — 18 %.
- Anterior trunk — 18 %.
- Posterior trunk — 18 %.
- Perineum — 1 %.
Rule of palms
The patient's palm area (including fingers) = 1 % of total body surface area. Useful for small and scattered burns.
In children — Lund-Browder chart
Children have a relatively larger head: in a newborn, the head is 18 %, and each lower limb is 14 %. Use age-adjusted Lund-Browder charts.
4. Prognosis: Frank index and the "100" rule
- Frank index: 1 point per % of superficial burn + 3 points per % of deep burn. > 70 — severe; > 90 — extremely severe.
- Rule of 100: age + % TBSA burn. < 60 — favorable prognosis, 60–100 — questionable, > 100 — unfavorable.
5. Burn disease — periods
- Burn shock (first 24–72 h) — hypovolemia due to capillary leak, pain, neuroendocrine response.
- Acute burn toxemia (days 3–12) — absorption of tissue breakdown products.
- Septicotoxemia (after day 10) — wound infection, sepsis.
- Convalescence — epithelialization, scarring, rehabilitation.
6. First aid
- Stop the damaging agent (extinguish flames, wash off chemicals).
- Cooling with cool water for 15–20 min (~15 °C) — reduces burn depth in the first 30 min.
- Do not apply ice — it exacerbates ischemia.
- Do not open blisters, do not apply oils, sour cream, or powders — they infect the wound.
- Aseptic dressing, analgesia (NSAIDs, for severe cases — morphine 0.1 mg/kg).
- Warming the patient (hypothermia in extensive burns!).
7. Fluid resuscitation in burn shock
Parkland formula
V = 4 mL × weight (kg) × % II–IV degree burn
- 50 % of the volume is infused in the first 8 h from the moment of the burn (not from admission!).
- The second 8 h — 25 %, the third 8 h — 25 %.
- Solution — Ringer's lactate (crystalloid).
- Target: urine output 0.5 mL/kg/h in adults, 1 mL/kg/h in children.
Indication for infusion: burns ≥ 15% in adults, ≥ 10% in children, ≥ 5% in the elderly.
Colloids (5% albumin) — from hours 8–12 in extensive burns and when crystalloids are ineffective.
8. Local treatment
Open and closed methods
- Closed (dressing) method — dressings with antiseptics (silver sulfadiazine, povidone-iodine, antibiotic ointments), foam and hydrocolloid dressings.
- Open method — face, perineum; drying of the eschar under a lamp.
Surgical treatment
- Early necrectomy (days 1–5) — excision of the eschar down to viable tissue; reduces mortality and septic toxemia.
- Decompression fasciotomy / necrotomy — for circumferential burns of the extremities and chest with compartment syndrome.
- Autodermatoplasty — transplantation of split-thickness autografts (usually 0.3–0.5 mm). In case of donor site deficiency — stamp method, 1:3–1:6 mesh grafts.
- Modern dressings: cultured autokeratinocytes, xenograft skin, collagen matrices (Matriderm, Integra).
9. Special types of burns
Chemical
- Alkalis — liquefactive necrosis, penetrate deeply.
- Acids — coagulative necrosis, dry eschar.
- Abundant water irrigation for 30–60 min; do not neutralize with an "opposite" reagent.
- Hydrofluoric acid (HF) — calcium gluconate topically and systemically.
Electrical
- Burn depth is significantly greater than visible; muscle damage → rhabdomyolysis, ARF.
- Arrhythmia risk — 24-hour ECG monitoring, especially when current passes through the chest.
- Monitoring of CK, urine myoglobin, infusion with forced diuresis.
Inhalation injury
- Suspicion: facial burn, singed nasal hairs, soot in sputum, hoarse voice, stridor.
- Fiberoptic bronchoscopy — gold standard for evaluation.
- Early intubation in case of increasing upper airway edema (subsequently impossible).
- If CO poisoning is suspected — 100% oxygen; CN⁻ — hydroxocobalamin.
10. Complications
- Burn shock, ARF, ARDS.
- Sepsis, wound infections (Pseudomonas, Staphylococcus, Candida).
- Curling's stress ulcers (stomach, duodenum) — PPI prophylaxis.
- Thromboembolic complications.
- Hypertrophic and keloid scars, contractures.
- Psychological disorders (PTSD, depression).
11. Rehabilitation
- Compression therapy (garments, bandages) for 18–24 months — prevention of hypertrophic scars.
- Silicone sheets for scars.
- Exercise therapy — prevention of contractures starting from week 1.
- Psychological support.
- Plastic surgery for contractures and deformities — in 1–2 years.
12. FAQ
When to hospitalize a burn patient?
Grade II–III burns > 10% in adults and > 5% in children; any burns of the face, neck, hands, feet, perineum, joints; electrical and chemical burns; inhalation injury.
Why is the Parkland formula not a dogma?
Some patients receive excess fluid (fluid creep) → edema, ARDS, compartment syndrome. Treatment is guided by urine output and hemodynamics, not just calculations.
Are antibiotics needed in the first hours?
Prophylactic systemic antibiotics are not indicated — they increase flora resistance. They are prescribed when signs of infection develop or during necrectomy.
What is the tetanus prophylaxis?
Burns are treated as a contaminated wound: if the last vaccination was > 5 years ago — tetanus toxoid (TT), if unvaccinated — TT + tetanus immunoglobulin.
Why shouldn't ice be used for first aid?
Intense cooling causes vasospasm, increased ischemia, and deeper burn injury. The optimum is running cool water.
See also: Wounds · Bleeding · Acute abdomen · Infusion therapy · Surgery catalog · Clinical scales