What is the recommended approach for assessing and managing burn victims?

Assessment of Burn Victims

Use the Lund-Browder chart as your primary tool for calculating total body surface area (TBSA) in all burn victims, as it is the most accurate standardized method and accounts for age-related variations in body proportions. 1, 2

Primary Assessment Components

Airway, Breathing, and Circulation

• Perform immediate evaluation of airway patency, breathing adequacy, and circulatory status as the foundation of burn assessment 3
• Look specifically for circumoral burns, oropharyngeal burns, and carbonaceous sputum—these indicate inhalation injury requiring aggressive intervention 4
• Consider fiberoptic bronchoscopy and arterial blood gas analysis to confirm suspected inhalation injury 4

TBSA Calculation

• Calculate TBSA using the Lund-Browder chart rather than the Rule of Nines, which overestimates TBSA in 70-94% of cases and leads to excessive fluid administration 2, 5
• The Lund-Browder chart is mandatory for children because the Rule of Nines fails to account for their proportionally larger head and smaller lower extremities 2
• For quick field estimation when the chart is unavailable, use the patient's entire palmar hand surface (palm plus fingers = 1% TBSA; palm alone = only 0.5% TBSA) 2
• Smartphone applications (E-Burn, FireSync EMS, or 3D Burn) can reduce overestimation bias compared to manual methods 2

Burn Depth Assessment

• Determine burn depth using clinical criteria: superficial, partial thickness, or full thickness 5, 3
• Record epidermal detachment separately from erythema on your body map—the amount of epidermal detachment (not erythema) has prognostic value for mortality 2
• Include both detached epidermis AND detachable epidermis (Nikolsky-positive areas) in your measurement 2
• Perform repeated assessments during the first hours of care, as initial TBSA estimates are often inaccurate and burn appearance evolves 1, 2

Severity Stratification and Triage

Calculate Revised Baux Score

• Calculate the revised Baux score after accurate TBSA assessment to objectively quantify injury severity and determine need for specialized burn center transfer 1
• The score facilitates resource allocation in mass casualty incidents and helps determine which patients require specialist consultation 1
• Recalculate the score as needed during initial management as burn appearance may evolve 1

Transfer Criteria

• Refer patients with full-thickness burns, circumferential burns, or burns on the face, hands, feet, genitals, or perineum to a burn subspecialist 3
• Adults with burns >15% TBSA and children with burns >10% TBSA typically require hospitalization 5, 4
• Major burns (≥25% TBSA or ≥10% full thickness) should be transferred to a burn center, as should children or elderly victims with burns >10% TBSA 4
• Consult a burn specialist early, ideally through telemedicine if direct consultation is unavailable 5

Initial Resuscitation

Fluid Management

• Initiate resuscitation at 2 mL/kg/% TBSA burn (not the traditional 4 mL/kg/% TBSA) to reduce resuscitation fluid volumes 6
• 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 5
• Establish IV access in unburned areas when possible; consider intraosseous access if IV cannot be rapidly obtained 5
• Consider human albumin solution, especially in patients with larger burns, to lower resuscitation volumes and improve urine output 6

Monitoring

• Monitor for signs of hypovolemic shock due to inflammation, capillary leak syndrome, and microcirculation alterations 5
• Selectively monitor intra-abdominal and intraocular pressure during burn shock resuscitation 6
• After the acute 48-hour phase, replace evaporative and hypermetabolic fluid losses (3-5 liters per day for 40-70% TBSA burns) 4

Wound Assessment and Management

Initial Wound Care

• Evaluate for circumferential burns that may require escharotomy if restrictive eschar impairs ventilatory or circulatory function 5, 4
• Monitor distal perfusion regularly when circular burns or dressings are present to prevent compartment syndrome 5
• Clean the burn wound with tap water, isotonic saline, or antiseptic solution in a clean environment 5

Pain Management

• Provide adequate analgesia before wound cleaning and dressing application, as burn wound care typically requires deep analgesia or general anesthesia 5
• Use acetaminophen as first-line treatment for minor burns 3
• Opioids are the mainstay for severe burn pain management 3

Critical Pitfalls to Avoid

• Do not overestimate TBSA (occurs in 70-94% of cases)—this leads to excessive fluid administration and complications 2, 5
• Do not delay specialist consultation, which increases morbidity and mortality 5
• Do not routinely administer prophylactic antibiotics unless specifically indicated for infected wounds 5, 3
• Do not apply dressings that create a tourniquet effect or restrict circulation 5
• Do not use prolonged external cooling devices to prevent hypothermia 5
• Do not perform escharotomy without proper training or consultation—this should ideally be done in a burn center by an experienced provider 5