Burn Management

This will review how to evaluate burns, the “rule of 9’s”, resuscitation efforts, zones of injury, and organ systems that are affected.

Burns are a major source of morbidity with ~2 million burns in the US resulting in ~60,000 hospitalizations and 6,000 deaths per year.


The first phase of caring for a burn patient consists of a primary and secondary survey to evaluate the extent and severity of the burns. The primary survey assesses the patient’s airway, breathing, circulation, disability/neurological assessment, exposure/environmental control. The secondary survey is more specific in determining where the burns are, how the patient got them, what the depth of each burn is, and what the percentage of total body surface area (%TBSA) is burned.

When determining the %TBSA burned, follow the “Rule of 9’s”. You can divide the body into sections that roughly each make up 9% of the body. Another easy rule of thumb is using the size of the patient’s hand to estimate 1% TBSA.


Patients with large body burns (>15% TBSA) need to be aggressively fluid resuscitated. We use the Parkland Formula to calculate how much they’ll need in the first 24 hours. It is also useful to use other serologic markers to guide resuscitation such as urine output, lactic acid, mixed venous saturation, CVP, and cardiac output.

As you evaluate the wounds, keep in mind the 3 zones of injury. The Zone of Coagulation is the layer of skin with necrosis and has irreversible full thickness damage. The Zone of Stasis is characterized by decreased tissue perfusion and is potentially salvageable. The Zone of Hyperemia is the outer most layer that is red due to vasodilation around the burn site - this skin usually heals well.

Burns are a multi-organ system problem. Cardiovascularly these patients are extremely hypovolemic secondary to leaky capillaries. The respiratory system can be affected from inhalation injuries as well as ARDS from large body area burns. If you are suspecting an airway injury, securing the airway early is usually a safe idea with a follow up bronchoscope to assess the damage. Metabolically burn patients increase their basal metabolic rate by 3xs. And lastly, these patients' immune systems become down regulated, leaving the body open to a variety of infectious attacks.