What are the guidelines for burn management according to the Advanced Trauma Life Support (ATLS) 11th edition?

Burn Management According to ATLS 11th Edition

The Advanced Trauma Life Support (ATLS) 11th edition recommends early fluid resuscitation with balanced crystalloid solutions for adults with burns >15% TBSA and children with burns >10% TBSA, starting with 20 mL/kg within the first hour, followed by formula-based resuscitation adjusted according to clinical and hemodynamic parameters. 1, 2

Initial Assessment and Triage

• Use the Lund-Browder chart as the most accurate method for total body surface area (TBSA) quantification 1, 2
• For quick field estimation, use the patient's palm and fingers (approximately 1% TBSA) as a reference 1
• Determine burn depth (superficial, partial thickness, or full thickness) to guide management 2
• Be aware that TBSA is frequently overestimated (in 70-94% of cases), which can lead to excessive fluid administration 2

Criteria for Referral to Burn Centers

• Adults with TBSA burned >20%, deep burns >5%, smoke inhalation, deep burns in functionally sensitive areas, or high-voltage electrical burns 2
• Adults with TBSA <20% but with: age >75 years, severe comorbidities, suspected smoke inhalation, deep circular burns, burns in function-sensitive areas, TBSA >10%, deep burns 3-5%, electrical or chemical burns 2
• Children with TBSA >10%, deep burns >5%, infants (<1 year), severe comorbidities, smoke inhalation, deep burns in function-sensitive areas, circular burns, electrical or chemical burns 2

Initial Fluid Resuscitation

• Administer 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate) within the first hour for adults with burns >15% TBSA and children with burns >10% TBSA 3, 1
• Establish intravenous access in unburned areas when possible; consider intraosseous access if IV access cannot be rapidly obtained 3, 1
• For ongoing resuscitation, use the modified Parkland formula (2-4 mL/kg/%TBSA over the first 24 hours) as a starting point 3
• For children, calculate daily basal fluid intake requirement using Holliday and Segar's 4-2-1 rule and add this to the fluid requirement determined by the modified Parkland formula (3-4 mL/kg/%TBSA) 3
• Adjust fluid rates based on clinical response, particularly hourly urine output (target 0.5-1 mL/kg/hour in adults) 3

Monitoring and Adjustment of Fluid Therapy

• Monitor urine output as the primary indicator for fluid resuscitation adequacy 3
• Consider additional parameters including arterial lactate concentration and advanced hemodynamic monitoring for patients with hemodynamic instability or persistent oliguria 3
• Be vigilant for both under-resuscitation and fluid overload ("fluid creep"), as both are associated with increased morbidity 3
• If hypotension persists despite appropriate fluid resuscitation, consider vasopressors after evaluating cardiac function and intravascular volume status 3

Wound Care

• Clean burn wounds with tap water, isotonic saline solution, or an antiseptic solution before applying dressings 3
• Perform wound care in a clean environment, typically requiring deep analgesia or general anesthesia 3, 1
• Apply appropriate dressings based on burn depth, TBSA, wound appearance, and patient's general condition 3
• When applying dressings, particularly on limbs, prevent bandages from causing a tourniquet effect 3
• Monitor distal perfusion regularly when circular dressings are applied 1
• Avoid prolonged use of external cooling devices (e.g., Water-Jel dressings) to prevent hypothermia 3

Special Considerations

• Evaluate the need for escharotomy if a deep burn induces compartment syndrome that compromises circulation 1, 2
• Avoid routine antibiotic prophylaxis to prevent selecting multidrug-resistant bacteria 3
• Consider thromboprophylaxis for severe burns patients in the initial phase 3
• For thermal burns, provide immediate cooling with clean running water for 5-20 minutes, while monitoring for hypothermia, especially in children 3
• Provide adequate analgesia with over-the-counter pain medications such as acetaminophen or NSAIDs for burn pain 3

Common Pitfalls to Avoid

• Overestimating TBSA, leading to excessive fluid administration 2
• Delaying specialist consultation, which increases morbidity and mortality 2
• Improper dressing application that restricts circulation 2
• Prolonged use of silver sulfadiazine on superficial burns, which may delay healing 3
• Performing escharotomy without proper training or consultation 2
• Using systemic antibiotics for prophylaxis when not indicated 3