Surgical Treatment of Burns Workup

  • Author: Gail E Besner, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP   more...
 
Updated: Apr 2, 2012
 

Laboratory Studies

Electrolytes and CBC count

Monitoring of electrolytes and blood counts is often helpful, especially with large burns requiring aggressive fluid resuscitation.

Carboxyhemoglobin level

Obtaining the carboxyhemoglobin level can be important in patients with inhalation injury, especially in those burned in enclosed spaces.

Prealbumin levels

These should be monitored weekly in patients with burns exceeding more than 20% of the total body surface area (BSA).

Fever workup (CBC count, urinalysis, and blood, urine, sputum, and wound cultures)

This should be performed as clinically indicated.

If invasive burn wound sepsis is suspected (clinical deterioration, a change in the appearance of the burn, an odor to the burn) definitive diagnosis can be obtained with quantitative burn wound cultures (requiring removal of at least 1 g of burned tissue at the bedside) and the microbiology laboratory is alerted that quantitative wound cultures are required. Invasive burn wound sepsis is defined as more than 105 organisms/g tissue.

An alternative method of diagnosing invasive burn wound sepsis is by burn wound biopsy with histologic examination showing bacteria invading viable tissue.

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Imaging Studies

Chest radiography can be helpful in patients who are intubated and in patients who have a suspected inhalation injury.

Chest radiography is also required as part of a complete fever workup, as indicated.

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Diagnostic Procedures

Calculation of the percent BSA burned can be performed using various approaches. The fastest initial estimate of percent BSA burned can be made using the pediatric rule of nines (see the image below).

Pediatric Rule of Nines. Pediatric Rule of Nines.

This is an adaptation of the adult rule of nines, which takes into consideration that, in children, the relative size of the head is larger and the relative size of the lower extremities is smaller.

Next, Lund and Browder charts can be used to more precisely calculate the percent BSA burned by mapping the injured areas of the body on charts detailing age-appropriate measurements (see the image below).

Lund and Browder Chart. Lund and Browder Chart.

Lastly, burn involvement can also be calculated based on the patient's palm. This is particularly useful for small scattered burns and is based on the estimate that the patient's palm (excluding the fingers) represents approximately 0.5% BSA.

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Contributor Information and Disclosures
Author

Gail E Besner, MD  John E Fisher Endowed Chair in Neonatal Reseach, Director, Pediatric Surgical Research, Department of Surgery, Nationwide Children's Hospital; Professor of Surgery and Pediatrics, Department of Surgery, Ohio State University College of Medicine

Gail E Besner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Burn Association, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Medical Women's Association, American Pediatric Surgical Association, Association for Academic Surgery, Federation of American Societies for Experimental Biology, Society of Critical Care Medicine, Society of Surgical Oncology, and Society of University Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Iyore Amy Otabor, MD  Clinical Instructor House Staff, Department of General Surgery, The Ohio State University College of Medicine

Iyore Amy Otabor, MD is a member of the following medical societies: American College of Surgeons, American Medical Student Association/Foundation, and Student National Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Denis Bensard, MD  Director of Pediatric Surgery and Trauma, Attending Adult and Pediatric Acute Care Surgery, Attending Adult and Pediatric Surgical Critical Care, Denver Health Medical Center; Professor of Surgery, University of Colorado School of Medicine

Denis Bensard, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, International Society for Minimally Invasive Cardiac Surgery, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, Society of University Surgeons, and Southwestern Surgical Congress

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Michael G Caty, MD  Professor of Surgery and Pediatrics, State University of New York at Buffalo; Consulting Staff, Department of Pediatric Surgery, Children's Hospital of Buffalo

Michael G Caty, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Physician Executives, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, and Association for Surgical Education

Disclosure: Nothing to disclose.

H Biemann Othersen Jr, MD  Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina

H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

Harsh Grewal, MD, FACS, FAAP  Clinical Professor of Surgery, Temple University School of Medicine; Chief, Division of Pediatric Surgery, Cooper University Hospital

Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education, Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, and Southwestern Surgical Congress

Disclosure: Nothing to disclose.

References

  1. Lowell G, Quinlan K, Gottlieb LJ. Preventing unintentional scald burns: moving beyond tap water. Pediatrics. Oct 2008;122(4):799-804. [Medline].

  2. O'Neill TB, Rawlins J, Rea S, Wood F. Complex chemical burns following a mass casualty chemical plant incident: How optimal planning and organisation can make a difference. Burns. Feb 20 2012;[Medline].

  3. Gupta SS, Singh O, Bhagel PS, Moses S, Shukla S, Mathur RK. Honey dressing versus silver sulfadiazene dressing for wound healing in burn patients: a retrospective study. J Cutan Aesthet Surg. Sep 2011;4(3):183-7. [Medline]. [Full Text].

  4. Jeschke MG, Finnerty CC, Kulp GA, Przkora R, Micak RP, Herndon DN. Combination of recombinant human growth hormone and propanol decreases hypermetabolism and inflammation in severely burned children. Pediatr Crit Care Med. Mar 2008;9:209-216. [Medline].

  5. Coruh A, Yontar Y. Application of Split-Thickness Dermal Grafts in Deep Partial- and Full-Thickness Burns: A New Source of Auto-Skin Grafting. J Burn Care Res. Nov 10 2011;[Medline].

  6. Chan MM, Chan GM. Nutritional therapy for burns in children and adults. Nutrition. Mar 2009;25(3):261-9. [Medline].

  7. Besner GE. Burns. In: Glick PL, Pearl RH, Irish MS, et al, eds. Pediatric Surgery Secrets. ed. Philadelphia, PA: Hanley & Belfus; 2000:246-52.

  8. Heimbach D. What's new in general surgery: burns and metabolism. J Am Coll Surg. Feb 2002;194(2):156-64. [Medline].

  9. Herndon DN, Hart DW, Wolf SE, et al. Reversal of catabolism by beta-blockade after severe burns. N Engl J Med. Oct 25 2001;345(17):1223-9. [Medline].

  10. Hildreth M, Gottschlich M. Nutritional support of the burned patient. In: Herndon D, ed. Total Burn Care. Philadelphia, PA: WB Saunders Co; 1996:237-45.

  11. Paddock HN, Fabia R, Giles S, Hayes J, Lowell W, Besner G. A Silver Impregnated Antimicrobial Dressing Reduces Hospital Length of Stay for Pediatric Burn Patients. J Burn Care Research. May-Jun 2007;28:409-411. [Medline].

  12. Peters DA, Verchere C. Healing at Home: Comparing Cohorts of Children with Medium-Sized Burns Treated as Outpatients With In-Hospital Applied Acticoat (TM) to those Children Treated as Inpatients with Silver Sulfadiazine. J Burn Care Research. Mar-Apr 2006;27:198-201. [Medline].

  13. Sheridan RL, Weber JM, Schnitzer JJ, et al. Young age is not a predictor of mortality in burns. Pediatr Crit Care Med. Jul 2001;2(3):223-224. [Medline].

  14. Kraft R, Herndon DN, Al-Mousawi AM, Williams FN, Finnerty CC, Jeschke MG. Burn size and survival probability in paediatric patients in modern burn care: a prospective observational cohort study. Lancet. Mar 17 2012;379(9820):1013-21. [Medline].

 
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Skin histology diagram.
Superficial partial-thickness burn.
Deep partial-thickness burn.
Full-thickness burn.
Pediatric Rule of Nines.
Lund and Browder Chart.
Endotracheal tube immobilization in children. The figure demonstrates a method using umbilical tape to secure a pediatric endotracheal tube in patients with facial burns.
Aquacel Ag adherent to burn wounds.
Use of Aquacel Ag. Appearance of healed burns 10 days later.
Escharotomy sites.
Left, Arm escharotomy. Right, Leg escharotomy.
Chest wall escharotomy.
 
 
 
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