Should have ordered in - The Emergency Medical Minute

should have ordered in

Chief Complaint:

Hand Burn


23-year-old right hand dominant male presenting to the emergency department for a burn to the left hand which he sustained just prior to arrival. He reports that he was frying chicken when the oil started on fire. In a panic, he ran with the pan outside of his home and the oil spilled onto the back of his left hand, primarily over his fingers. Initially reports 10/10 pain and immediate blistering to the area. During the time it took him to get to the ER he noted the skin started to slough and decreasing pain/sensation over the affected fingers. Also reporting stiffening sensation of his left index finger in which the burn was circumferential.

Pertinent Exam Findings:

General Appearance: Anxious appearing and uncomfortable Respiratory:No respiratory distress, lungs clear to auscultation
Musculoskeletal:Moving all fingers of the left hand normally, pain worse with flexion. 2+ radial pulses
Skin:Full thickness white appearing burn to the dorsal aspect of the left thumb from approximately the carpometacarpal joint to the interphalangeal joint, full thickness white appearing circumferential burn to the entire left index finger distal to the MCP joint, full thickness white appearing burn to the left dorsal middle finger from approximately the MCP joint to the DIP joint and full thickness white appearing burns to the dorsal left ring and short fingers from approximately the MCP joints to the PIP joints. Noted associated skin sloughing and decreased sensation over the previously described burns. Numerous small blisters to the dorsal left hand proximal to the phalanges with normal sensation.

ED Course:

Morphine, Tdap, and bacitracin to clean the wounds

Hospital Course:

Transferred to burn center after discussion with burn surgeon. He underwent an allograft. 1 month post follow up note stated recommendation to have the patient undergo laser therapy to his left upper extremity to treatalleviate symptoms that are associated with hypertrophic burn scars which include pain and pruritus. Pulsed dye, fractional CO2 laser has been chosen to treat the patient’s condition and it was anticipated the patient will require 6-12 treatments to be performed at 1 to 2-month intervals. He is continuing lotion application and range of motion exercises and was fitted for a compression glove to wear at night and occasionally during the day.

His physical exam at one month follow up was described as hyperpigmented, hypertrophic, re-epithelialization of skin with 100% healing. Full range of motion of all digits. Sensation intact. No open wounds.



A burn is an acute injury to the skin resulting in the death of skin cells by heat, radiation, chemical, friction, or electrical energy. Burn injuries are a prominent cause of accidental injury in the United States with about 486,000 people, incidence of 140 in 100,000 people, seeking medical care for their injury each year. Many of these people seek care in an Emergency Department with approximately 40,000 people requiring hospitalization for a burn injury each year. The mechanism, location, total area, and depth of a burn injury direct management and affect morbidity and mortality outcomes. Full-thickness burns, previously referred to as third-degree burns, are serious burn injuries that extend through the epidermis and all layers of the dermis. These types of burns are essential to identify as a clinician and account many of the poor outcomes related to burn injuries


The diagnosis of a burn injury is clinical and based off of a history consistent with a burn and a physical exam. The physical exam is essential to diagnosing burn injuries as it provides the classification of the burn and determination for burn center referral as well as any interventions.

The extent of a burn is denoted as a percentage of total body surface area and is estimated by the clinician. Estimated body surface area as a percentage is often done with the “rule of 9s” or a Lund and Browder chart seen below (Figure 1) with superficial burns excluded from this estimation. Burn depth is no longer classified as first-, second-, and third-degree burns. It is now classified as superficial, superficial partial-thickness, deep partial-thickness, and full thickness burns with fourth-degree burns still referring to any burn that involves the subcutaneous tissue or deeper structures such as muscle or bone. Location of the burns should be determined as burns in certain areas of the body (ears, perineum, volar forearms, medial thighs) can appear superficial and be much deeper. Other locations, such as the face, hands, feet, genitalia, perineum, or large joints, may necessitate transfer to a burn center. Burn injuries can then be more broadly classified using this information as mild, moderate, or severe to determine level of treatment indicated.

Full-thickness burns can be differentiated from partial-thickness burns clinically. Superficial partial-thickness burns form blisters between the epidermis and the dermis after onset and the skin is blanchable. Deep partial-thickness burns and full-thickness burns are difficult to distinguish between as they both do not blanch with pressure and can appear white, waxy, and firm. Deep partial-thickness burns almost always blister and can be painful to pressure at the site of the injury whereas full-thickness burns are typically anesthetic and present with an eschar. Burns should be reassessed as the full depth and extent of burn injury may not become apparent until 48-72 hours after the initial injury.

Management in ED:

Initial management of a severe burn is very similar to a trauma patient and starts with the ABC’s (Airway/Breathing/Circulation). Burn patients are at high risk of airway injury or compromise, therefore securing an airway is essential if the patient appears to be in respiratory distress or has signs consistent with inhalation injury. These signs include pharyngeal erythema, singed nasal hairs, hoarseness, or visible carbon debris in the airway and should be evaluated for on the primary examination to determine the extent of the injuries. As burns classically deplete intravascular volumes due to increased capillary permeability, consideration of fluid resuscitation is essential with extensive burns. There are several formulas to determine the amount of IV fluids a patient will require, but regardless of preference the fluid of choice is lactated ringers. It’s also important to do a full trauma evaluation after initial stabilization and fluid resuscitation as the patient may present with a concurrent trauma.

Treatment and wound care of the burns will depend on the extent and thickness of the burn. If there is still debris or some of the offending agent on the patient’s skin, copious irrigation is required to remove it. Irrigation should be performed after adequate analgesia has been established with intravenous opioids or local anaesthetic injected proximally to the injury if possible. Non-superficial burns should be covered in topical antibiotics (ex. silver sulfadiazine, bacitracin) and covered with non-adherent bandages and wrapped lightly. Eschars, or thickened/stiffened burned skin, may require an escharotomy which should be performed by a physician trained in the procedure. The edema secondary to burns can also lead to high pressures in the extremities which can lead to compartment syndrome. This is especially true with circumferential full thickness burns where an escharotomy may be performed to prevent compartment syndrome.

Depending on the severity of the burns, the patient may require a burn specialist for surgery and further management at a burn center, meaning admission to the hospital or transfer to a burn unit. Burns involving the hands (and feet), unless minor, should have a burn specialist consulted due to the high likelihood of disability with improper management. Partial thickness burns of the hands and feet can be managed outpatient with burn follow up, and joint involvement does not necessitate admission. Full thickness burns of the hands or feet will likely need intervention, especially if there is concern for compartment syndrome or motion defects. Comorbidities like diabetes, peripheral vascular disease, or other vascular conditions can contribute to worse wound healing and should be considered when debating admission. Finally, with all burns, look for distinguishing features like linear markings or suspicious histories that could indicate the burn was sustained from abuse of domestic violence.


The prognosis of hand burns is entirely dependent on the severity of the injury. Partial thickness burns will require wound care but can heal in a few weeks while full thickness burns (formerly third degree burns) will most likely require skin grafting. Amputation may be required if the graft/burn is not healing well as a result of either wound complications or comorbidities. Amputation may be inevitable if the patient suffers a fourth degree burn where burns lead to exposed bone. Therapy and exercises can help restore function after a full thickness burn, but an evaluation soon after treatment can indicate the level of recovery one should anticipate. The different measurements and tools required will not be covered in this case, but specific tests and programs will be ordered by a burn clinic.

Differential Diagnoses:

    • Thermal Burn
    • Chemical Burn
    • Full Thickness Burn
    • Partial Thickness Burn
    • Superficial Burn
    • Radiation Burn
    • Burn Wound Infection

Clinical Pearls:

    • With severe burn patients always remember your ABC’s and do a thorough exam to catch all injured areas.
    • Irrigation and debridement should be performed to remove any offending agent or contaminants.
    • Burns should be dressed with an antibiotic ointment and wrapped in non adherent bandages.
    • Eschars should be removed and be watchful for compartment syndrome in the distal extremities, especially with circumferential burns.
    • Partial thickness burns can likely be treated outpatient, full thickness burns will likely require specialist care and surgery/grafting.
    • Comorbidities that affect the peripheral blood vessels (DM, PVD) will make healing difficult.
    • Return of functionality in full thickness burns of the distal extremities is hard to immediately predict, but a burn clinic should be able to elucidate more information.

Figure 1:

Murari A, Singh KN. Lund and Browder chart-modified versus original: a comparative study. Acute Crit Care. 2019;34(4):276-281. doi:10.4266/acc.2019.00647


  1. American Burn Association. Burn Incidence Fact Sheet: Burn Incidence and Treatment in the United States: 2016. Accessed 18 February 2021.
  2. Crowe CS, Massenburg BB, Morrison SD, Naghavi M, Pham TN, Gibran NS. Trends of Burn Injury in the United States: 1990 to 2016. Ann Surg. 2019 Dec;270(6):944-953. doi: 10.1097/SLA.0000000000003447. PMID: 31274649.
  3. Monafo WW. Initial management of burns. N Engl J Med. 1996 Nov 21;335(21):1581-6. doi: 10.1056/NEJM199611213352108. PMID: 8900093.
  4. Warby R, Maani CV. Burn Classification. [Updated 2020 Sep 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.
  5. Cowan AC, Stegink-Jansen CW. Rehabilitation of hand burn injuries: current updates. Injury. 2013 Mar;44(3):391-6. doi: 10.1016/j.injury.2013.01.015. Epub 2013 Jan 24. PMID: 23352672.


Sarah Racine PA-C

Jackson Roos MSIV

Jack Spartz MSIII

Aaron Wolfe, D.O., FACEP


Stay up to date by
joining our mailing list!