Thermal Burns

Burns are described according to depth, with superficial burns involving only the epidermis, partial-thickness burns involving both the epidermis and part of the dermis, full-thickness burns destroying the entire epidermis and dermis, and subdermal burns involving the subdermal tissues.


  • Evaluation of burns involves five main components:
    • Evaluation of airway and breathing
    • Consideration of possible carbon monoxide and cyanide exposure
    • Estimation of involved TBSA
    • Determination of depth of burned skin (see Table 3.12)
    • Evaluate for involvement of critical parts and for circumferential burns.
  • Signs of inhalational injury:
    • Fire in enclosed space
    • Facial burns or singed nasal hair
    • Carbonaceous sputum, soot in mouth or nose
    •  Hoarseness, stridor, expiratory wheezing
  • To estimate involved TBSA in adults, the Rule of Nines is commonly used (see Figure 3.19):
    • 9 for each upper extremity
    • 18 for each lower extremity
    • 18 each for front and back of torso
    • 9 for the head
    • 1 for perineum
  • Estimation of burn depth may be difficult on initial evaluation.
  • For this reason, burns should be reevaluated in 24 hours as usually true depth and extent of tissue damage are not initially apparent.


  • Treatment for inhalational injury:
    • Humidified 100% O2
    • Intubation for:
      • Full-thickness face or perioral burns
      • Circumferential neck burns
      • Supraglottic edema and inflammation on bronchoscopy
      • Tachypnea, hypoxia, or AMS
  • The Parkland Formula provides a guide for fluid resuscitation for patients with significant burns:
    4 mL x %burn x weight (kg) = fluid requirement (mL) over first 24 hrs
    • Use only area of second- and third-degree burns to determine TBSA for resuscitation.
    • Give half over first 8 hours. Multiply by 3 mL instead of 4 mL in children and add maintenance fluids. The Parkland Formula is merely a guide, and adequate fluid must be given to maintain urine output.
  • Circumferential burns to extremities run the risk of circulatory compromise due to pressure from burn/swelling. Circumferential burns to the torso may interfere with breathing via constriction. Consider early escharotomy for both.
  • Blisters that are large or across joints should be ruptured, while smaller immobile ones may be left alone.
  • Pain Control:
    • Dilaudid 1mg IV
    • Morphine sulfate 10-30 mg po q3-4h prn
    • Norco 7.5/325 1 po q4-6h prn p
  • Topical Agents:
    • To Body:
      • Silvadene 1% cream apply bid. #85g tube  (not to face because of scarring risk).
      • Mupiracin topical 2% oint with dressing. #22g
      • Mafenide topical 11.2%, apply q6-8h or prn.
    • To Face:
      • Mupiracin topical  oint with dressing.
  • Tetanus immunization
    • 0.5 ml IM x1
  • ABx
    • Cefadroxil 0.5 - 1 g PO bid
  • Keep wounds out of sun to prevent scarring, and follow up in 24 hours.


  • Major: Burn center (see Table 3.13)
  • Moderate: Hospitalization
    • Partial-thickness 15-25% in 10 to 50-year-olds
    • Partial-thickness 10-20% in <10- or >50-years old
    • Full-thickness 2-10%
  • Minor: Outpatient
    • Partial thickness <15% in 10- to 50-year-olds
    • Partial thickness <10% in <10- or >50-year-olds
    • Full thickness < 2%

Criteria for Transfer to Burn Unit:

  • Partial-thickness burns greater than 10% total body surface area (BSA)
  • Burns that involve the face, hand, feet, genitalia, perineum, or major joints
  • Third-degree burns in any age group
  • Electrical burns, including lightning injury
  • Chemical burns
  • Inhalation injury
  • Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality
  • Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality
  • Burned children in hospitals without qualified personnel or equipment for the care of children
  • Burn injury in patients who will require special social, emotional, or long-term rehabilitative intervention

Burn Depth Features
Classified by Degree of Burn

Burn Depth Features Classified by Degree of Burn
Burn Depth Histology/Anatomy Example Healing
First degree Epidermis Sunburn 7 d
No blisters, painful    
Superficial second degree or superficial partial thickness Epidermis and superficial dermis Hot water scald 14–21 d, no scar
Blisters, very painful    
Deep second degree or deep partial thickness Epidermis and deep dermis, sweat glands, and hair follicles Hot liquid, steam, grease, flame 3–8 wk, permanent scar
Blisters, very painful    
Third degree Entire epidermis and dermis charred, pale, leathery; no pain Flame Months, severe scarring, skin grafts necessary
Fourth degree Entire epidermis and dermis, as well as bone, fat, and/or muscle Flame Months, multiple surgeries usually required

Burn Depth Features:
American Burn Association Burn Classification

Burn Depth Features: American Burn Association Burn Classification
Burn Classification Burn Characteristics Disposition
Major burn Partial thickness >25% BSA, age 10–50 y Burn center treatment
Partial thickness >20% BSA, age <10 y or >50 y
Full thickness >10% BSA in anyone
Burns involving hands, face, feet, or perineum
Burns crossing major joints
Circumferential burns of an extremity
Burns complicated by inhalation injury
Electrical burns
Burns complicated by fracture or other trauma
Burns in high-risk patients
Moderate burn Partial thickness 15%–25% BSA, age 10–50 y Hospitalization
Partial thickness 10%–20% BSA, age <10 y or >50 y
Full thickness burns 10% BSA in anyone
No major burn characteristics present
Minor burn Partial thickness <15% BSA, age 10–50 y Outpatient treatment
Partial thickness <10% BSA, age <10 y or >50 y
Full thickness <2% in anyone
No major burn characteristics present