Burns%20-%20initial%20management Management

• Extremes of age (<5 or >60 years old)
• Site of injury
  
  • Face, hands or perineum
  • Feet (dermal or full-thickness loss)
  • Any flexure, particularly the neck or axilla
  • Circumferential dermal or full-thickness burn of limb, torso or neck
• Inhalational injury – any substantial injury, including carbon monoxide (CO) poisoning
• Mechanism of injury
  • Chemical injury >5% of the total BSA
  • Exposure to ionizing radiation
  • High-pressure steam injury
  • High-tension electrical injury
  • Hydrofluoric acid burn >1% of total BSA
  • Suspicion of non-accidental injury
  • Electrical burns (including lightning injury)
• Partial-thickness burns of  >10% total BSA
• Large size (dermal or full-thickness loss)
  • <16 years old - >5% of total BSA
  • >16 years old - >10% of total BSA
• Coexisting conditions
  • Any serious medical condition
  • Any associated injuries
• Patients requiring social, emotional or rehabilitation intervention
• Burns with or without trauma at high risk for morbidity and mortality 
• Patients with worsening wounds within the past 72 hours with wounds starting to produce scarring and presence of any degree of contracture
• Refer all significant burn injuries to surgery for proper wound debridement

American Burn Association Burn Center Transfer Criteria

• Second- and third-degree burns >10% BSA in patients <10 or >50 years old
• Second- and third-degree burns >20% BSA in other age groups
• Second- and third-degree burns involving the face, hands, feet, genitalia, perineum, and major joints
• Third-degree burns >5% BSA in any age group
• Electrical burns and lightning injury
• Chemical burns
• Inhalation injury
• Burn injury in patients with pre-existing medical conditions
• Any patients with concomitant trauma (eg fractures)
• Burn injury in patients who require special social/emotional and/or long-term rehabilitative support, including suspected child abuse or substance abuse

European Burns Association Burn Centre Transfer Criteria

• Superficial dermal burns on more than:
  • 5% BSA in children <2 years old
  • 10% BSA in children 3-10 years old
  • 15% BSA in children 10-15 years old
  • 20% BSA in adults of age
  • 10% BSA in seniors >65 years old
• Patients needing burn shock resuscitation
• Patients with burns on the face, hands, genitalia or major joint
• Deep partial-thickness burns and full-thickness burns in any age group and extent
• Circumferential burns in any age group
• Burns of any size with concomitant trauma
• Burns with suspicion of inhalation injury
• Major electrical burns
• Major chemical burns
• Diseases associated to burns such as toxic epidermal necrolysis, necrotizing fasciitis, staphylococcal scalded child syndrome and if the involved area is 10% in children and 15% for adults
• Burn patients needing special social, emotional or long-term rehabilitation

• Assess the ABCDEs of resuscitation

Airway

• Assess whether airway is compromised or is at risk of compromise
  
  • Inhalation of hot gases will result in a burn above the vocal cords and the burn will become edematous over the next few hours, especially after fluid resuscitation has begun
  • In small children, the small airway diameter is vulnerable to any narrowing
• Direct inspection of the oropharynx should be done by anesthesiologist
• Intubate if there is concern about the patency of the airway, symptomatic inhalation injury, or any thermal injury to the face, mouth or oropharynx

Indications for Intubation

• Erythema or swelling of the oropharynx on direct visualization
• Change in voice, with hoarseness or harsh cough
• Stridor, tachypnea or dyspnea
• Burns >20-25% BSA
• Pulmonary toilet
• Extensive and deep facial burns
• Difficulty swallowing
• Decreased level of consciousness where airway protective reflexes are impaired

Breathing

• Assess lung status by bilateral auscultation, and respiratory rate and depth determination 
• Breathing problems are those that affect the respiratory system below the vocal cords
• The effect of circulating inflammatory mediators can reduce lung compliance in the absence of overt inhalational injury
• All burn patients should receive 100% oxygen through a humidified non-rebreathing mask

Causes of Compromised Breathing

• Mechanical restriction to breathing
  
  • Deep second-degree and third-degree circumferential burns of the chest can limit chest expansion and ventilation
  • May require escharotomy, thus refer for surgical consult

• Blast injury
  
  • Penetrating blast injury may cause pneumothorax
  • The blast itself may cause lung contusions and alveolar trauma that may lead to acute respiratory distress syndrome (ARDS)

• Smoke inhalation
  
  • The products of combustion act as irritants to the lungs which may cause bronchospasms, inflammation and increased sputum formation
  • The ciliary action of pneumocytes is impaired in inhalation injury, and atelectasis and/or pneumonia may follow
  • Non-invasive managements, such as nebulization and positive pressure ventilation with positive end-expiratory pressure (PEEP), may be attempted

• Carboxyhemoglobin (HbCO)
  
  • All patients with large burns and/or closed space burns should be assumed to have CO poisoning until otherwise proven
  • Blood gas analysis may reveal metabolic acidosis and decreased partial pressure of oxygen in arterial blood (PaO₂)
  • CO poisoning may be mild (<20% HbCO), moderate (20-40% HbCO) or severe (40-60% HbCO)
  • Delivery of 100% oxygen counteracts the effects of CO and enhances its clearance
  • Oxygen therapy should be continued until the metabolic acidosis is resolved

Circulation

• Patients requiring intravenous (IV) resuscitation:
  
  • Children with burns >10% BSA
    • Those with ≥30% BSA burns need a central venous access
  • All inhalational injury for control of fluid intake
  • All high-tension and electrical injuries to ensure forced alkaline diuresis and to prevent myoglobinuric renal failure
• IV assessment should be established using large-bore needles, preferably on the unburnt area
  • Consider giving 20 mL/kg boluses of lactated Ringer’s solution or normal saline if there is inadequate pulse or child is hemodynamically compromised
• Parkland formula is used to compute for the total fluid to be given in the 1st 24 hours post-burn
  • 4 mL lactated Ringer’s solution/kg per % BSA burn
• Administer ½ of calculated volume over the 1st 8 hours and the other ½ of calculated volume over the next 16 hours
• Urine output must be monitored in all patients requiring IV fluids
  • Adequate urine output is >1 mL/kg/hour in children and 0.5-1 mL/kg/hour in adolescents
• Total target urine output is increased to 1-2 mL/kg/hour for electrical burns due to risk of high myoglobin levels
• Titrate infused IV fluid based on the child’s response to therapy:
  • Adequate urine output
  • Normal pulses
  • Normal blood pressure (BP)
• Extremities must be assessed for any deep or full-thickness circumferential burn as these may occlude perfusion to distal extremities
  • Peripheral circulation must be checked with a Doppler
  • There is an increased risk for compartment syndrome to develop during fluid resuscitation as burned tissue loses the ability to stretch
  • A decreased perfusion due to circumferential burn warrants referral to surgery for early escharotomy and debridement

Disability, Neurologic Deficit and Gross Deformity

• Identify any serious injuries or gross deformities
• Assess patient’s level of consciousness using the AVPU method: Alert, responds to Verbal stimuli, responds only to Painful stimuli, Unresponsive 
• Neurologic status must be briefly assessed by evaluating level of consciousness using the Glasgow coma scale
  • A Glasgow coma score of ≤8 warrants intubation
• Cerebral injury may be caused by hypoxia from smoke inhalation or hypovolemia from fluid loss
• Signs of increased ICP and progressive neurologic deterioration must be treated immediately
  • Hyperventilate patient using bag-valve mask to lower partial pressure of carbon dioxide in arterial blood (PaCO₂) to promote cerebral vasoconstriction
  • Use Mannitol cautiously because it promotes osmotic diuresis, which may exacerbate hypovolemia
•  Consult with neurosurgery for co-management if there is persistent increase in ICP

Exposure/Environmental Control

• All smoldering clothing or clothing saturated with hot liquid should be cut away to facilitate exam
• Children easily become hypothermic so they should be warmed with radiant warmers or heated blankets and IV fluid as soon as possible
• Cleanse area with warm saline or mild soap and water
• Cover the burned area with clean dry sheet and apply cold wet compresses to small injuries
  
  • Do not use cold compress dressings on large burn surface area (>15% BSA) as this will decrease body temperature
• In chemical injury, brush off any remaining chemical if powdered or solid, then use copious irrigation or wash the affected area with water
  •  Call poison control for the neutralizing agent to treat a chemical ingestion
•  If burn is caused by hot tar, use mineral oil to remove the tar
•   Debride open wounds and necrotic tissue
  •  Unruptured blisters should be left intact and dressed

• Secondary survey includes a head-to-toe exam of the patient to determine any concomitant injuries
• Evaluate for associated injuries, common if the child fell from a height during the burn incident and injuries to spine, bones and thoracic or intra-abdominal organs may occur
  • Child should be placed on cervical spine precaution until these injuries are ruled out
• Ventricular tachycardia and fibrillations are common when burn results from high-electric voltage injury
• Children with burns >15% BSA should not be given anything per orem and require insertion of nasogastric tube to prevent aspiration
• Insertion of a Foley catheter is mandatory to monitor urine output in patients requiring IV resuscitation
• Pain control can be managed initially with intramuscular (IM) or IV analgesics
• Elevate affected extremities to reduce edema and pain