What is the initial management for burn patients?

From the Guidelines

The initial management for burn patients involves stopping the burning process, assessing airway, breathing, and circulation, and providing appropriate fluid resuscitation, with the goal of prioritizing stabilization and preventing further tissue damage while addressing the physiological stress response to burns, which includes increased capillary permeability leading to fluid shifts and potential hypovolemic shock, as suggested by experts in the field 1.

Key Steps in Initial Management

• Remove the patient from the source of the burn and stop the burning process by removing clothing and jewelry and irrigating chemical burns with water.
• Assess the airway for signs of inhalation injury such as facial burns, singed nasal hairs, carbonaceous sputum, or hoarseness, as early intubation may be necessary.
• For fluid resuscitation, the Parkland formula is commonly used: 4 mL × patient's weight (kg) × percentage of total body surface area burned, with half given in the first 8 hours and the remainder over the next 16 hours, as recommended by recent guidelines 1.
• Lactated Ringer's solution is preferred for fluid resuscitation, as it is a balanced crystalloid solution that can help address the physiological stress response to burns 1.
• Pain management should be addressed with intravenous opioids such as morphine (2-4 mg IV every 5-15 minutes as needed) or fentanyl (25-50 mcg IV every 5-15 minutes as needed) 1.
• Cover burns with clean, dry dressings or sterile sheets, and maintain normothermia to prevent further tissue damage and promote healing 1.
• Tetanus prophylaxis should be administered if needed, as burns can increase the risk of tetanus infection 1.

Importance of Specialist Management

• Referral to a burn specialist should be sought to determine whether the patient should be admitted to a burns centre, as specialist management can improve survival and functional prognosis 1.
• Telemedicine can be used to improve the initial assessment of severely burned patients and facilitate referral to a burns centre 1.
• An escharotomy should be performed if a deep burn induces compartment syndrome in the limbs or trunk that compromises the airways and respiration and/or circulation, ideally in a burns centre by an experienced provider 1.

From the Research

Initial Management of Burn Patients

The initial management of burn patients is crucial to reduce patient mortality and morbidity. Key aspects of initial management include:

• Accurate assessment of burn depth and percentage of total body surface area involved 2, 3
• Immediate care to stop the burn process and prevent further complications 3, 4
• Evaluation and management of airway, breathing, and circulation, following the principles of Advanced Trauma Life Support Guidelines 4
• Administration of high-flow oxygen and consideration for early intubation in patients with suspected inhalation injury 4
• Fluid resuscitation and cardiovascular stabilization, with the choice of fluid depending on various factors, including the severity of the burn and the patient's overall condition 5

Assessment and Referral

Assessment of burn depth and percentage of total body surface area involved is critical in determining the need for referral to a burn center. Key factors to consider include:

• Burn depth: superficial (first-degree), partial-thickness (second-degree), or full-thickness (third-degree) 3
• Percentage of total body surface area involved: greater than 20% may require referral to a burn center 6, 3
• Presence of concomitant injuries or underlying medical conditions, such as diabetes mellitus 3

Treatment and Care

Treatment and care of burn patients depend on the severity of the burn and the patient's overall condition. Key aspects of treatment and care include:

• Wound care and dressing to promote a moist environment and prevent infection 3
• Pain management and control 4
• Management of inhalation injury and respiratory support 4
• Fluid resuscitation and cardiovascular stabilization 5
• Consideration for early surgical excision and skin grafting for full-thickness burns 4