Burn Management According to ATLS 11th Edition Guidelines
The Advanced Trauma Life Support (ATLS) guidelines recommend using the standardized Lund-Browder chart for measuring total burned body surface area (TBSA) in both adults and children, as it is the most accurate method for TBSA quantification. 1
Initial Assessment and Triage
- Follow the ABCDEF approach from the Emergency Management of Severe Burns (EMSB) manual or the ABCDE approach from ATLS for initial assessment of burn patients 2
- Use the Lund-Browder chart to accurately measure TBSA, as it is more accurate than the Wallace rule of nines which tends to overestimate burn area 3, 1
- 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 decisions 1
Immediate Management
- Cool thermal burns immediately with clean running water for 5-20 minutes 3
- Monitor children being cooled with running water for signs of hypothermia 3
- Remove jewelry before the onset of swelling to prevent constriction and vascular ischemia 3
- Establish intravenous access in unburned areas; consider intraosseous access if IV access cannot be rapidly obtained 1, 4
- For adults with burns >15% TBSA and children with burns >10% TBSA, administer 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate) within the first hour 1, 4
Airway Management
- Immediately administer high-flow oxygen to patients with suspected inhalation injury 4
- Consider early intubation for patients with stridor, shortness of breath, facial burns, singed nasal hairs, cough, soot in oral cavity, or history of being in an enclosed fire 4
- Fibroscopy may be useful if airway damage is suspected 4
Wound Care
- Clean the burn wound with tap water, isotonic saline solution, or an antiseptic solution 1
- After cooling, loosely cover burns with intact skin or blisters with a clean cloth or nonadherent dry dressing 3
- For small partial-thickness burns being managed at home, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera with a clean nonadherent dressing 3
Criteria for Burn Center Referral
- Adults with TBSA burned > 20%, deep burns > 5%, presence of smoke inhalation, deep burns in functional areas, or high-voltage electrical burns 1
- Children with TBSA > 10%, deep burns > 5%, infants < 1 year of age, smoke inhalation injuries, deep burns in functional areas, or electrical/chemical burns 1
- Burns involving the face, hands, feet, and genitals require specialized care due to risk of permanent disability 3
- The American Burn Association recommends that patients with second- or third-degree burns involving the face, hands, feet, and genitals and those involving >10% body surface area (5% in children) be treated in a specialized burn center 3
Special Considerations
- Consult a burn specialist early, ideally through telemedicine if direct consultation is not available 1, 5
- Perform escharotomy if a deep burn induces compartment syndrome that compromises circulation, ideally in a burn center by an experienced provider 3, 1
- Provide adequate analgesia before wound cleaning and dressing application; over-the-counter analgesics such as acetaminophen or NSAIDs are generally recommended for burn pain 3, 5
- Monitor for signs of hypovolemic shock due to inflammation, capillary leak syndrome, and microcirculation alterations 1
Common Pitfalls to Avoid
- Overestimation of TBSA (occurs in 70-94% of cases), which can lead to excessive fluid administration 3, 1
- Delaying specialist consultation, which may increase morbidity and mortality 1
- Improper dressing application that restricts circulation 1
- Routine use of systemic antibiotics for prophylaxis 1
- Prolonged use of external cooling devices to prevent hypothermia 1
- Performing escharotomy without proper training or consultation 1