Classification Categories

First Degree

• Involves epidermis only
• Erythematous and painful skin
• Looks like sunburn

Second Degree (Partial Thickness)

• Superficial partial thickness
  • Extends beyond epidermis superficially into dermis
  • Red and weepy appearance
  • Very painful
  • Formation of blisters
• Deep partial thickness
  • Extends deep into dermis
  • May appear mottled
  • Dry and pale appearance

Third Degree (Full Thickness)

• Extends through epidermis, dermis, and into subcutaneous tissues
• Dry, leathery appearance
• May be charred, mottled, or white
• If red, will not blanch with pressure
• Painless in the center of the burn

American Burn Association Classification of Burns

Minor

• Second-degree burns over 15% BSA (body surface area) for adult or <10% BSA for child
• Third-degree burns of 2% or less

Moderate

• Second-degree burns over 15 to 25% BSA for adult or 10 to 20% BSA for child
• Third-degree burns of 2% to 5% BSA
• Burns not involving eyes, ears, face, hands, feet, or perineum

Major

• Second-degree burns >25% BSA for adult or >20% BSA for child
• Third-degree burns 10% BSA
• All burns of hands, face, eyes, ears, feet, or perineum
• All inhalation injuries
• Electric burns
• All burns with associated complications of fractures or other trauma
• All high-risk patients (with such conditions as diabetes, COPD, or heart disease)

Emergency Care of Burn Injuries

• First, evaluate respiratory system for distress or smoke inhalation (any abnormal respiratory findings in rate, effort, noise, or observations of smoky odor of breath or soot in nose or mouth).
• Assess cardiovascular status. (Look for symptoms of shock.)
• Assess percentage and depth of burns, as well as presence of other injuries.
• Flush chemical contact areas with sterile water; 20 to 30 minutes of flushing may be needed to remove chemical. Fifteen to 20 minutes of normal saline irrigation is preferable for chemical burns to eyes. Contact lens must be removed prior to eye irrigation.
• Insert IV line(s) for major and some moderate burns. (Establish more than one large-bore IV site if possible.) Attempt to insert IV(s) in unburned area(s).
• Weigh patient to establish baseline and assist in determination of fluid needs.
• Fluid resuscitation with Ringer’s lactate or Hartmann’s solution for the first 24 hours as follows:
  • 4 mL fluid × kilograms of body weight × percent of burned BSA.
  • Administer ½ of fluid in first 8 hours.
  • Administer ¼ of fluid in second 8 hours.
  • Administer ¼ of fluid in third 8 hours.
    NOTE: Time is calculated from time of injury, not time of admission.
• Administer analgesics as indicated.
• Remove easily separated clothing. Soak any adherent clothing to facilitate removal.
• Cover burn area with sterile dressing.
• Hold NPO until function of GI system is evaluated.
• Insert NG tube for gastric decompression if indicated.
• Insert Foley catheter (to monitor urine output) for severe and some moderate burns.
• Assess need for and administer tetanus prophylaxis (see Tetanus Prophylaxis).
• Frequently monitor vital signs (be aware that patients who have inhaled smoke are subject to progressive swelling of the airway for several hours following injury), ABGs, and serum electrolytes.
• Monitor urine output and titrate fluids to maintain:
  • 30 to 50 mL urine/h in the adult
  • 0.5 to 2 mL urine/kg of body weight/h in the child

NOTE: Keep patient warm. Removal of clothing may result in rapid and dangerous drop in temperature.