What is the initial management protocol for burns in the Emergency Room (ER)?

Initial Management Protocol for Burns in the Emergency Room

The initial management of burns in the emergency room should include administering 20 mL/kg of balanced crystalloid solution in the first hour, establishing IV access in unburned areas, controlling pain, and applying silver sulfadiazine cream to a thickness of approximately 1/16 inch after cleansing and debriding the wounds. 1, 2

Initial Assessment and Stabilization

1. Airway, Breathing, Circulation (ABC) assessment

   • Secure airway if inhalation injury is suspected
   • Provide supplemental oxygen as needed
   • Establish IV access in unburned areas when possible

2. Fluid Resuscitation

   • First hour: Administer 20 mL/kg balanced crystalloid solution regardless of visible burn area 1
   • For burns ≥10% TBSA: Continue fluid resuscitation using formula-based calculations
   • Parkland Formula: 2-4 mL/kg/%TBSA for first 24 hours (half in first 8 hours) 1
   • Pediatric patients: Require higher volumes (approximately 6 mL/kg/%TBSA) plus maintenance fluids using Holliday-Segar formula (4-2-1 rule) 1
   • Rule of 10 can simplify initial hourly rate calculations for adults ≥50kg: 15 mL × BSA (to nearest 10%) 3

3. Fluid Selection

   • Standard: Lactated Ringer's solution for most burn patients 1
   • Exception: Use normal saline instead if patient has:
     • Traumatic brain injury (to prevent cerebral edema)
     • Hyperkalemia (Ringer's contains 4 mEq/L potassium)
     • Receiving blood products (to avoid calcium-citrate interactions)
     • Severe liver failure (compromised lactate metabolism)

Burn Wound Management

1. Wound Assessment

   • Calculate total body surface area (TBSA) burned using appropriate method (Rule of Nines, Lund-Browder chart)
   • Determine burn depth (superficial, partial-thickness, full-thickness)
   • Document time of injury and mechanism (thermal, chemical, electrical)

2. Wound Care

   • Remove clothing and jewelry from burned areas
   • Cleanse wounds with mild soap and water or saline
   • Debride loose, devitalized tissue and ruptured blisters
   • Apply silver sulfadiazine cream to a thickness of approximately 1/16 inch 2
   • Reapply cream to areas where it has been removed by patient activity
   • Dressings are optional but may be used based on individual requirements
   • Reapply silver sulfadiazine immediately after hydrotherapy 2

3. Pain Management

   • Implement multimodal analgesia immediately
   • Titrate analgesics based on validated pain assessment scales
   • Consider IV ketamine combined with other analgesics for severe burn pain
   • Incorporate non-pharmacological techniques during dressing changes for stable patients 1

Monitoring and Adjustments

1. Fluid Resuscitation Monitoring

   • Target urine output: 0.5-1 mL/kg/hour in adults
   • Target urine output: 1-2 mL/kg/hour in children and cases with myoglobinuria
   • Additional monitoring may include arterial lactate concentration, echocardiography, and hemodynamic parameters
   • Adjust fluid rates based on clinical response rather than rigid formula calculations 1

2. Special Interventions

   • Consider escharotomy for:
     • Compromised airway/ventilation (immediate indication)
     • Intra-abdominal hypertension or circulatory impairment (within 48 hours)
     • Should be performed at a Burns Center or after specialist consultation 1

Common Pitfalls and Caveats

• Avoid "fluid creep" - excessive fluid administration can lead to compartment syndromes and respiratory complications 4
• Don't underestimate burn size - inaccurate TBSA calculation can lead to inadequate resuscitation
• Beware of special populations:
  • Children require proportionally more fluid due to higher BSA/weight ratio
  • Elderly patients may have limited cardiac reserve and require careful fluid titration
  • Patients with pre-existing cardiac or renal disease need closer monitoring
• Silver sulfadiazine should be continued until satisfactory healing occurs or until the burn site is ready for grafting 2
• Avoid hypotonic solutions in patients with traumatic brain injury 1

The management of burn patients requires a systematic approach with careful attention to fluid resuscitation, wound care, and pain management. While formulas provide a starting point, clinical judgment and ongoing assessment are essential for optimal outcomes.