Treatment Guideline Chart
Thermal burns are burns due to external heat sources that raises skin and tissue temperature causing tissue cell death or charring. Flame is the most common type of burn. Inhalation injury is found in 30% of victims of major flame burns.
Chemical burns are due to strong acids, alkalis, detergents or solvents coming into contact with the skin. Tissues are damaged by protein coagulation or liquefaction rather than hyperthermic activity.
Electrical burns are due to electrical current or lightning coming in contact with the body.
First degree burns or superficial burns appears similar to sunburn that is painful, dry, swollen, erythematous without blisters and involves only the epidermis.
Second degree burns or partial-thickness burns has appearance of moist blebs, formation of vesicle and blister; underlying tissue is mottled pink and white with good capillary refill; this involves the entire epidermis and a variable portion of the dermal layer.
Third degree burns or full-thickness burns appears dry, leathery eschar, mixed white waxy, khaki, mahogany and soot stained. It involves the entire epidermis and dermis, leaving no residual epidermis cells, may include fat, subcutaneous tissue, fascia, muscle and bone.

Burns%20-%20initial%20management Management

Indications For Referral To A Burn Unit

  • 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

Primary Survey and Management

  • Assess the ABCDEs of resuscitation


  • 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


  • 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


  • 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 and Management

  • 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
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