What are the guidelines for managing burns in the Intensive Care Unit (ICU)?

Burns Management in ICU

Severe burns in adults and children require prompt, standardized management in the ICU setting, with fluid resuscitation, wound care, and monitoring of complications being the cornerstones of treatment.

Definition of Severe Burns

Adults

• Severe burns are defined as life-threatening or function-threatening burns with any of the following criteria 1:
  • Total body surface area (TBSA) burned > 20%
  • Deep burns > 5%
  • Presence of smoke inhalation
  • Deep burns in areas that might lead to functional sequelae (face, hands, feet, perineum)
  • Burns from high-voltage electricity
  • TBSA < 20% WITH one or more of: age > 75 years, severe comorbidities, smoke inhalation, deep circular burns, burns in function-sensitive areas, TBSA > 10%, deep burn 3-5%, low-voltage electrical burns, or chemical burns 1

Children

• Severe burns in children are defined by 1:
  • TBSA > 10%
  • Deep burns > 5%
  • Infants (< 1 year of age)
  • Severe comorbidities
  • Smoke inhalation injuries
  • Deep burns in function-sensitive areas
  • Circular burns
  • Electrical or chemical burns

Initial Assessment and Management

Burn Size Assessment

• Use the standardized Lund and Browder method to accurately measure total burned body surface area 1
• Accurate assessment is critical as inaccurate burn size estimation contributes to 9% of variance in fluid resuscitation 2

Fluid Resuscitation

• Begin fluid resuscitation for adults with burns ≥15% TBSA (most common threshold) 3
• The Parkland formula (4 ml/kg/%TBSA of lactated Ringer's solution over 24 hours) is the most widely used formula (87.5% of ICUs) 3
• Half of the calculated volume should be given in the first 8 hours post-burn, with the remainder over the next 16 hours 4
• Monitor urine output (0.5-1.0 ml/kg/hr) as the primary endpoint for adequacy of resuscitation 5
• Be vigilant for "fluid creep" - the tendency to give more fluid than calculated by the formula, which can lead to complications 4
• Consider early colloid use during the first 24 hours as it may reduce the risk of extremity compartment syndrome and renal failure 2

Respiratory Management

• Assess for and manage inhalation injuries, which often require more aggressive fluid resuscitation 4
• Ensure ventilation of ICUs with >10 air changes per hour, especially when high-flow nasal oxygen or non-invasive ventilation is in use 1

Wound Care

Topical Antimicrobial Therapy

• Apply silver sulfadiazine cream 1% to a thickness of approximately 1/16 inch once to twice daily 6

  • Cover burn areas at all times
  • Reapply whenever necessary after patient activity
  • Continue until satisfactory healing or until the burn site is ready for grafting 6

• For grafted areas, consider mafenide acetate 5% topical solution 7:

  • Cover grafted area with one layer of fine mesh gauze
  • Apply eight-ply burn dressing wetted with mafenide acetate solution
  • Keep dressing wet by irrigating every 4-6 hours
  • Continue until autograft vascularization occurs (typically about 5 days) 7

Monitoring and Managing Complications

Hemodynamic Monitoring

• Early signs of central circulatory hypovolemia may be present at 12 hours post-burn, supporting more rapid initial fluid infusion 8
• Monitor for signs of over-resuscitation, which is associated with increased risk of pneumonia and extremity compartment syndrome 2

Emergency Preparedness

• Have evacuation protocols in place for fire or other emergencies 1
• Ensure evacuation boxes are available with necessary equipment 1
• Train staff on emergency procedures including:
  • Location and operation of manual fire call points
  • Oxygen shut-off valves
  • Evacuation routes and procedures 1

Special Considerations

Oxygen Safety

• Be aware of fire risks with high-flow oxygen therapy 1
• In case of fire, immediately stop high-flow nasal oxygen or facemask/nasal cannulae oxygen delivery to affected patients 1
• Know the location of oxygen shut-off valves (area valve service units) 1

Staff Training and Support

• Ensure multidisciplinary training for all staff in their place of work as part of annual mandatory training 1
• Train nominated staff to select and safely use fire extinguishers 1
• Following any emergency incident, support staff with debriefing and access to occupational health assessment 1

Common Pitfalls to Avoid

• Underestimating burn size, which can lead to inadequate fluid resuscitation 3
• Overestimating burn size, which can lead to excessive fluid administration and complications 2
• Failing to adjust fluid rates based on urine output and other clinical parameters 5
• Neglecting to consider colloid use during the first 24 hours, which may reduce complications 2
• Inadequate emergency preparedness for ICU evacuation in case of fire or other disasters 1