Burn Classification & Assessment: Classification, Assessment & Initial Treatment

Burn injuries are medical emergencies that require prompt evaluation and structured management. Effective treatment depends on early assessment of burn severity, depth, and extent. A systematic approach ensures that life-threatening complications are managed immediately while planning definitive care. Understanding burn classification and assessment is essential for accurate diagnosis, proper intervention, and improved patient prognosis.

Initial Protocol for Burn Patients

Upon arrival, a set protocol guides the assessment, analysis, and treatment of burn patients. This systematic approach ensures all critical aspects are addressed efficiently.

Primary Survey in Burns Management

The initial and most crucial step is performing a primary survey using the ABCDE approach. This aims to rule out any immediate life-threatening injuries. The components are:

• Airway with Cervical spine stabilization

• Breathing with Ventilation

• Circulation and Hemorrhage control

• Disability limitation

• Expose and examine

Immediate Interventions During Primary Survey for Burns

During the primary survey, specific interventions are immediately initiated for burn patients:

• Oxygen Administration: Place a face mask and administer 100% oxygen. This is crucial due to potential inhalational burns or fumes causing airway damage.

• Intravenous Access: Secure two large IV cannulas. 16 gauge is preferred over 18 gauge for significant burns.

• Tetanus Prophylaxis: Administer 0.5 cc intramuscular tetanus toxoid (TT) as a prophylactic measure.

Warning Signs for Intubation in Burn Patients

It is critical to look for warning signs that necessitate immediate intubation in a burn patient. If any of these are present, the patient must be intubated immediately:

• Presence of hoarseness of voice (suggesting laryngeal edema due to inhalational burns).

• Presence of inspiratory stridor.

• Evidence of facial burns.

• Presence of severe wheezing on auscultation.

Secondary Survey in Burns Management

After the primary survey, proceed to the secondary survey to rule out any potentially life-threatening injuries. The primary goal for burn patients during this survey is the assessment of the extent of the burn, determining decisions for patient admission or transfer to a burn unit. This assessment of the extent/percentage of body surface area burnt is evaluated during the secondary survey.

Defining Significant vs. Insignificant Burns

The assessment classifies burns as significant or insignificant:

• Significant Burn: Total body surface area (TBSA) burnt is more than 15%.

• Management: Requires resuscitation, with Ringer's lactate as the fluid of choice. A Foley catheter is deployed to measure urine output to assess resuscitation response. Wound care management is also critical.

• Insignificant Burn: Total body surface area (TBSA) burnt is less than 15%.

• Management: Involves local management, primarily basic wound care and moist dressings.

Wound Irrigation and Debridement

Regardless of the burn's significance, wound irrigation and debridement must be performed.

Viable vs. Non-viable Tissue Management

Following debridement, tissue viability is assessed:

• Non-viable tissue: Requires skin grafting or flap reconstruction.

• Viable tissue: Managed with local burn wound care using topical agents and dressings.

Burn Management Algorithm

The overall algorithm for managing burn patients in casualty involves:

1. Primary Survey (ABCDE).

2. Immediate Interventions: Oxygenation (100% O2 via mask), securing two large IV cannulas, and administering tetanus toxoid.

3. Monitoring for warning signs for intubation.

4. Secondary Survey: Assessing for significant or insignificant burns.

5. Wound Management: Includes assessing the extent of the burn and initiating resuscitation protocols as needed. Maintaining oxygenation and secure IV lines is essential for patient stability.

Burn Wound Management: Thorough Wash

A crucial step in burn wound management is providing a thorough wash.

• Objective: The primary objective is not to sterilize the wound, but to provide a cool-down effect, preventing further heat dissipation into deeper tissues.

• Preferred Fluid: Tap water at room temperature is suitable (Memory Tip: While European room temperature is considered 15°C, 20-25°C is acceptable in the Asian subcontinent. The core concept is achieving a cool-down effect.).

• Duration: The wash should be run for 15 to 20 minutes. Prolonged washing can lead to hypothermia.

• Effectiveness Window: This intervention is only effective if the patient presents within 1 hour of the burn. After 1 hour, it becomes ineffective as tissue damage is already established.

Criteria for Admission in a Burn Ward

Admission to a burn ward is indicated if a patient cannot be safely managed at home. Specific criteria for admission include:

1. Suspected inhalational injury.

2. Requirement for fluid resuscitation.

3. Requirement for any form of surgery.

4. Burns on notorious sites: Hands, feet, and perineum.

5. Psychiatric illness or poor social background.

6. Suspicion of non-accidental burn.

7. Burns in extreme of age:

• Age less than 10 years.

• Age above 50 years.

8. Burns associated with potentially serious sequelae:

• Electrical burns.

• Alkali burns.

• Acid burns.

Assessment of Total Body Surface Area (TBSA) Burnt

Assessing the total body surface area (TBSA) burnt is a critical step.

• The most commonly used rule for TBSA assessment is the Valis rule, also known as the Rule of Nine.

• The best method for TBSA assessment is the Lund and Browder's chart.

Rule of Nine (Valis Rule) for TBSA Assessment

The Valis rule (Rule of Nine) is a frequently tested concept, differing for adults and children:

(Memory Tip: In adults, head and neck is 9%, lower limb is 18%. In children, head and neck is 18%, lower limb is 14%. Perineum is not separately counted in children.)

Definition of Significant Burn (Age-Based & Uniform)

The definition of a significant burn also depends on the age of presentation:

To avoid confusion, if age-specific data is not requested, a uniform definition for significant burn across all ages is ≥ 15% TBSA.

Classification of Burn Wounds by Depth

Burn wounds are classified based on their depth, which determines structures involved, symptoms, and healing potential.

Summary of Initial Assessment for Burns

The initial assessment of a burn patient involves a structured approach:

1. Primary Survey: Manage ABCDE and perform immediate interventions (oxygen, IV access, tetanus prophylaxis) while monitoring for warning signs for intubation.

2. Secondary Survey: Assess TBSA burnt using rules like the Valis Rule, and manage the wound, including debridement and viable/non-viable tissue assessment.

3. Burn Wound Management: Initiate a thorough wash within 1 hour of the burn, understanding its objective, appropriate fluid, and duration.

4. Evaluate criteria for admission to a burn ward.

5. Understand the definition of significant burns (age-based and uniform).

6. Utilize Jackson's Thermal Wound Theory to understand the zones of injury.

7. Classify burn wounds based on depth using clinical criteria.