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General information
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All burn patients should initially be treated with the principles of Advanced Burn and/or Trauma Life Support


The ABC s (airway, breathing, circulation) of trauma take precedent over caring for the burn Search for other signs of trauma

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Verified Burn Centers provide advanced support for complex cases

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Certified by the American College of Surgeons (ACS) Committee on Trauma and the American Burn Association (ABA) Resources will give advice or assist with care

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Burn Unit Referral Criteria (PDF - 11 KB) (American Burn Association) Airway
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Extensive burns may lead to massive edema Obstruction may result from upper airway swelling Risk of upper airway obstruction increases with


Massive burns


All patients with deep burns >35-40% TBSA should be endotracheally intubated

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Burns to the head Burns inside the mouth

Intubate early if massive burn or signs of obstruction



Intubate if patients require prolonged transport and any concern with potential for obstruction If any concerns about the airway, it is safer to intubate earlier than when the patient is decompensating

Signs of airway obstruction

 

Hoarseness or change in voice Use of accessory respiratory muscles

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High anxiety

Tracheostomies not needed during resuscitation period Remember: Intubation can lead to complications, so do not intubate if not needed

Breathing
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Hypoxia


Fire consumes oxygen so people may suffer from hypoxia as a result of flame injuries

Carbon monoxide (CO)

   

Byproduct of incomplete combustion Binds hemoglobin with 200 times the affinity of oxygen Leads to inadequate oxygenation Diagnosis of CO poisoning


Nondiagnostic
  

PaO2 (partial pressure of O2 dissolved in serum) Oximeter (difference in oxy- and deoxyhemoglobin) Patient color ("cherry red" with poisoning)

Diagnostic


Carboxyhemoglobin levels
 

<10% is normal >40% is severe intoxication

Treatment
 

Remove source 100% oxygen until CO levels are <10%

Smoke inhalation injury



Pathophysiology


Smoke particles settle in distal bronchioles

   

Mucosal cells are die Sloughing and distal atelectasis Increase risk for pneumonia

Diagnosis
 

History of being in a smoke-filled enclosed space Bronchoscopy

 

Soot beneath the glottis Airway edema, erythema, ulceration

Nondiagnostic clinical tests

 

Early chest x-ray Early blood gases

Nondiagnostic clinical findings

 

Soot in sputum or saliva Singed facial hair

Treatment
 

Supportive pulmonary management Aggressive respiratory therapy

Circulation
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Obtain IV access anywhere possible

   

Unburned areas preferred Burned areas acceptable Central access more reliable if proficient Cut-downs are last resort

Resuscitation in burn shock (first 24 hours)



Massive capillary leak occurs after major burns

 

Fluids shift from intravascular space to interstitial space Fluid requirements increase with greater severity of burn (larger % TBSA, increase depth, inhalation injury, associate injuries - see above) Fluid requirements decrease with less severe burn (may be less than calculated rate) IV fluid rate dependent on physiologic response
   

Place Foley catheter to monitor urine output Goal for adults: urine output of 0.5 ml/kg/hour Goal for children: urine output of 1 ml/kg/hour If urine output below these levels, increase fluid rate

Preferred fluid: Lactated Ringer's Solution

  

Isotonic Cheap Easily stored

 

Resuscitation formulas are just a guide for initiating resuscitation Resuscitation formulas:


Parkland formula most commonly used

 

IV fluid - Lactated Ringer's Solution Fluid calculation



4 x weight in kg x %TBSA burn

  

Give 1/2 of that volume in the first 8 hours Give other 1/2 in next 16 hours Warning: Despite the formula suggesting cutting the fluid rate in half at 8 hours, the fluid rate should be gradually reduced throughout the resuscitation to maintain the targeted urine output, i.e., do not follow the second part of the formula that says to reduce the rate at 8

hours, adjust the rate based on the urine output.



Example of fluid calculation

 

100-kg man with 80% TBSA burn Parkland formula:

 

4 x 100 x 80 = 32,000 ml Give 1/2 in first 8 hours = 16,000 ml in first 8 hours Starting rate = 2,000 ml/hour

  

Adjust fluid rate to maintain urine output of 50 ml/hr Albumin may be added toward end of 24 hours if not adequate response

Resuscitation endpoint: maintenance rate



When maintenance rate is reached (approximately 24 hours), change fluids to D50.5NS with 20 mEq KCl at maintenance level

Maintenance fluid rate = basal requirements + evaporative losses



Basal fluid rate



Adult basal fluid rate = 1500 x body surface area (BSA) (for 24 hrs) Pediatric basal fluid rate (<20kg) = 2000 x BSA (for 24 hrs)


May use
  

100 ml/kg for 1st 10 kg 0 ml/kg for 2nd 10 kg 20 ml/kg for remaining kg for 24 hrs

Evaporative fluid loss

 

Adult: (25 + % TBSA burn) x (BSA) = ml/hr Pediatric (<20kg): (35 + % TBSA burn) x (BSA) = ml/hr

Complications of over-resuscitation


Compartment syndromes
 

Best dealt with at Verified Burn Centers If unable to obtain assistance, compartment syndromes may require management Limb compartments


Symptoms of severe pain (worse with movement), numbness, cool extremity, tight feeling compartments Distal pulses may remain palpable despite ongoing compartment syndrome (pulse is lost when pressure > systolic pressure) Compartment pressure >30 mmHg may compromise muscle/nerves Measure compartment pressures with arterial line monitor (place needle into compartment) Escharotomies may save limbs
  

Performed laterally and medially throughout entire limb Performed with arms supinated Hemostasis is required

Fasciotomies may be needed if pressure does not drop to <30 mmHg

 

Requires surgical expertise Hemostasis is required

Chest Compartment Syndrome



Increased peak inspiratory pressure (PIP) due to circumferential trunk burns Escharotomies through mid-axillary line, horizontally across chest/abdominal junction

Abdominal Compartment Syndrome

Pressure in peritoneal cavity > 30 mmHg



Measure through Foley catheter

Signs: increased PIP, decreased urine output despite massive fluids, hemodynamic instability, tight abdomen Treatment
   

Abdominal escharotomy NG tube Possible placement of peritoneal catheter to drain fluid Laparotomy as last resort

Acute Respiratory Distress Syndrome (ARDS)

 

Increased risk and severity if over-resuscitation Treatment supportive

Wound Care
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During initial or emergent care, wound care is of secondary importance Advanced Burn Life Support recommendations


Cover wound with clean, dry sheet or dressing. NO WET DRESSINGS.



Simple dressing if being transported to burn center (they will need to see the wound) Sterile dressings are preferred but not necessary Covering wounds improves pain Elevate burned extremities

   

Maintain patient's temperature (keep patient warm)



While cooling may make a small wound more comfortable, cooling any wound >5% TBSA will cool the patient

If providing prolonged care

 

Wash wounds with soap and water (sterility is not necessary) Maintain temperature

Topical antimicrobials help prevent infection but do not eliminate bacteria

 

Silver sulfadiazine for deep burns Bacitracin and nonsticky dressings for more superficial burns

Skin grafting
  

Deep burns require skin grafting Grafting may not be necessary for days Preferable to refer patients with need for grafting to Verified Burn Centers or, if not available, others trained in surgical techniques
  

Grafting of extensive areas may require significant amounts of blood Patient's temperature must be watched Anesthesia requires extra attention

Medications
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All pain meds should be given IV Tetanus prophylaxis should be given as appropriate Prophylactic antibiotics are contraindicated


Systemic antibiotics are only given to treat infections