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2025 PACUPrep BCCCP Preparatory Course Burn Wound Care Diagnostic Evaluation and Risk Stratification in Burn Injury and Sepsis

Lesson 99, Topic 2

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Diagnostic Evaluation and Risk Stratification in Burn Injury and Sepsis

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Learning Objective

Apply diagnostic and classification criteria to assess burn injuries, infection status, and sepsis to guide initial management.

I. Clinical Assessment of Burn Depth and Extent

Accurate bedside evaluation of burn wounds guides fluid resuscitation, timing of debridement, and infection prevention.

Visual Inspection: Assess wound color (ranging from pink to white, brown, or charred), capillary refill, presence of blisters, and pain response to distinguish superficial from deep injuries.
Zones of Injury: Recognize the three distinct zones described by Jackson to anticipate wound evolution: the central zone of coagulation (necrotic core), the surrounding zone of stasis (at risk of progression), and the outer zone of hyperemia (likely to recover).
Advanced Techniques: While clinical assessment is primary, specialized tools can aid in ambiguous cases. Laser Doppler imaging provides objective perfusion mapping, and thermography offers surface temperature data, though it is sensitive to environmental conditions.

Clinical Pearl: Salvaging the Zone of Stasis

The zone of stasis represents viable but compromised tissue. Early identification and optimized fluid resuscitation can salvage this at-risk tissue, preventing its progression to full-thickness necrosis and thereby reducing the overall severity of the injury.

II. Laboratory and Microbiologic Diagnostics

Integrate wound and blood cultures with key biomarkers to differentiate colonization from invasive infection and to detect the onset of sepsis in the context of a systemic inflammatory response.

A. Microbiologic Cultures

Wound Cultures: Quantitative tissue biopsy is the gold standard, with a bacterial load >10⁵ colony-forming units (CFU) per gram of tissue defining invasive wound infection. Surface swab techniques are less reliable as they risk under-sampling deep pathogens.
Blood Cultures: When systemic infection is suspected, obtain paired aerobic and anaerobic culture sets from separate sites, ideally before initiating or escalating antibiotic therapy.

B. Key Biomarkers

Biomarkers in Burn Injury and Sepsis
Biomarker	Threshold / Finding	Clinical Interpretation & Notes
Procalcitonin (PCT)	>2.0 ng/mL	Levels rise in response to bacterial infection. Serial measurements improve specificity for sepsis after the initial post-burn inflammatory surge subsides.
C-Reactive Protein (CRP)	Elevated	A highly sensitive but non-specific acute-phase reactant. Trends over time are more useful for monitoring therapeutic response than for diagnosis.
Lactate	>2 mmol/L	Indicates tissue hypoperfusion and metabolic stress. Lactate clearance (rate of normalization) is a key goal of resuscitation and correlates with improved survival.
Interleukin-6 (IL-6)	Elevated	A pro-inflammatory cytokine that is often elevated in bloodstream infections, but its moderate specificity limits its role to an adjunctive diagnostic test.

Clinical Pearl: The Diagnostic Triad

Diagnosis of infection in burn patients should never rely on a single parameter. A robust diagnosis is made by combining three elements: (1) clinical signs of infection, (2) positive culture results, and (3) trends in biomarkers. This integrated approach helps distinguish benign colonization from true invasive disease.

III. Burn Severity Scoring Systems

Standardized scores are used to predict mortality, guide triage decisions, and provide a common framework for research comparisons.

Common Burn Severity Scoring Systems
Scoring System	Components	Primary Use
TBSA Assessment	Rule of Nines (adults), Lund-Browder chart (pediatrics)	Rapid estimation of burn extent to guide fluid resuscitation.
Baux Score	Patient Age + % TBSA	Simple, rapid mortality prediction. A score >140 is often considered unsurvivable.
Revised Baux Score	Patient Age + % TBSA + 17 (if inhalation injury present)	Improved mortality prediction by accounting for the significant impact of inhalation injury.
ABSI Score	Age, Gender, % TBSA, Inhalation Injury, Full-Thickness Burn	More complex but provides a more nuanced and accurate mortality prediction.

Limitations: It is critical to remember that these scores can misclassify outcomes in certain populations, such as obese and geriatric patients. Clinical judgment and consideration of comorbid conditions must always be used to adjust the predicted risk.

Clinical Pearl: Scores as Guides, Not Absolutes

Burn severity scores are invaluable for initial triage and communication but should be treated as guides, not definitive prognostic tools. Always integrate patient-specific factors, response to therapy, and overall clinical trajectory into the decision-making process.

IV. Sepsis-3 Criteria and Burn-Specific Adaptations

The systemic inflammatory response to a major burn can mimic sepsis, making diagnosis challenging. Burn-specific criteria help adapt standard definitions to account for burn-induced inflammatory changes and the effects of sedation.

Standard SOFA Score: The Sepsis-3 definition of sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Clinically, this is identified by an acute increase in the Sequential Organ Failure Assessment (SOFA) score of ≥2 points.
Burn SOFA Modifications: In sedated burn patients, key components of the SOFA score are unreliable. Modifications may include replacing the Glasgow Coma Scale with enteral feeding intolerance and replacing bilirubin with hyperglycemia (>180 mg/dL) as markers of organ dysfunction.
The “3 H’s” of Burn Sepsis: This simplified screening tool helps identify patients needing a full sepsis evaluation. The presence of any two triggers a workup:
- Hypoxia: New PaO₂/FiO₂ ratio <300 or SpO₂ <92% on FiO₂ ≥0.4
- Hypovolemia: Persistent hypotension despite adequate fluid resuscitation
- Hyper-/Hypothermia: Core temperature ≥38.5°C or ≤36.0°C

Clinical Pearl: Enhanced Detection with Adapted Criteria

Burn-adapted sepsis criteria are crucial for early detection. By incorporating metabolic disturbances (hyperglycemia) and nutritional challenges (feeding intolerance) that are unique to severe burn physiology, clinicians can identify organ dysfunction sooner than with standard criteria alone.

V. Integrated Risk Stratification Algorithm

A structured, algorithmic approach combines clinical findings, laboratory data, and scoring systems to standardize care and trigger timely surgical and medical interventions.

Figure 1: Integrated Algorithm for Burn Patient Management. This stepwise pathway ensures key diagnostic and therapeutic actions are performed in a logical sequence, from initial assessment to risk stratification and intervention.

Empiric Antibiotic Therapy Examples

Common Empiric Antibiotics for Suspected Burn Sepsis
Agent	Typical Dose	Key Monitoring Parameters
Vancomycin	15–20 mg/kg IV q8–12h	Target trough 15–20 mg/L; monitor renal function (SCr, BUN).
Piperacillin-Tazobactam	4.5 g IV q6h (extended infusion)	Adjust dose for renal impairment; monitor for signs of allergy.
Cefepime	2 g IV q8h	Monitor for neurotoxicity, especially in patients with renal impairment.
Linezolid	600 mg IV/PO q12h	Monitor complete blood count (CBC) for potential myelosuppression.

Clinical Pearl: The Algorithmic Advantage

Using a stepwise, algorithmic pathway ensures that critical interventions like timely debridement, appropriate antibiotic therapy, and goal-directed hemodynamic support are consistently applied. This standardization of care helps reduce morbidity and improves outcomes across a diverse patient population.

References

Jackson DM. The diagnosis of the depth of burning. Br J Surg. 1953;40(164):588–596.
Devgan L, Bhat S, Aylward S, Dougherty W. Modalities for the assessment of burn wound depth. J Burns Wounds. 2006;5:e2.
Pape SA, Skouras CA, Byrne PO. An audit of the use of laser Doppler imaging in the assessment of burns of intermediate depth. Burns. 2001;27(3):233–239.
Church D, Elsayed S, Reid O, et al. Burn wound infections. Clin Microbiol Rev. 2006;19(2):403–434.
Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801–810.
Boehm D, Menke H. Sepsis in Burns—Lessons Learnt from Developments in the Management of Septic Shock. Medicina (Kaunas). 2022;58(1):26.
Rowan MP, Cancio LC, Elster EA, et al. Burn wound healing and treatment: review and advancements. Crit Care. 2015;19:243.
Kamolz LP, Andel H, Schramm W, et al. Lactate: Early predictor of morbidity and mortality in patients with severe burns. Burns. 2005;31(8):986–990.

2025 PACUPrep BCCCP Preparatory Course

Pulmonary

Participants 432

Diagnostic Evaluation and Risk Stratification in Burn Injury and Sepsis

Diagnostic Evaluation and Risk Stratification in Burn Injury and Sepsis

Learning Objective

I. Clinical Assessment of Burn Depth and Extent

II. Laboratory and Microbiologic Diagnostics

A. Microbiologic Cultures

B. Key Biomarkers

III. Burn Severity Scoring Systems

IV. Sepsis-3 Criteria and Burn-Specific Adaptations

V. Integrated Risk Stratification Algorithm

Empiric Antibiotic Therapy Examples

References