What are the initial steps in managing burns in an Intensive Care Unit (ICU) setting?

Burns Management in the ICU

Immediately initiate aggressive fluid resuscitation with 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate) within the first hour for adults with burns ≥10% TBSA and children with burns ≥5% TBSA, while simultaneously securing the airway only if specific criteria are met, not routinely. 1, 2

Initial Assessment and TBSA Calculation

• Use the Lund-Browder chart to accurately measure total body surface area (TBSA), as it is the most accurate method for both adults and children and prevents the 70-94% overestimation that occurs with other methods like the Wallace rule of nines. 1, 2

• For rapid field assessment, use the patient's open palm and fingers (approximately 1% TBSA) as a reference point. 1, 3

• Immediately consult a burn specialist, ideally through telemedicine if direct consultation is unavailable, to determine if transfer to a burn center is necessary. 1, 3

Airway Management - A Selective Approach

Do not routinely intubate patients with facial or cervical burns. 2 This is critical because unnecessary intubation in the prehospital setting occurs in almost one-third of patients and is associated with more complications. 2

Intubate only when specific criteria are present: 2

• Deep and circumferential neck burns

• Active symptoms of airway obstruction

• Extensive burns (TBSA ≥40%)

• Compromised airway movement and/or ventilation requiring urgent escharotomy 1

• Monitor patients with facial/cervical burns exposed to vapors or smoke inhalation closely for glottic edema risk, but resist the urge to intubate prophylactically. 2

Fluid Resuscitation Protocol

First Hour (Critical Window)

• Administer 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate) within the first hour for adults with TBSA ≥10% and children with TBSA ≥5%. 1, 2, 4

• Establish IV access in unburned areas when possible; use intraosseous access if IV cannot be rapidly obtained. 1, 3

• Central femoral venous access should be considered only as a last resort. 1

24-Hour Resuscitation Strategy

• Calculate total 24-hour fluid requirements using the Parkland formula: 2-4 mL/kg/%TBSA of Ringer's Lactate. 2, 4

• Administer half of the calculated volume in the first 8 hours post-burn, with the remaining half over the next 16 hours. 2, 4

• Children require higher volumes (approximately 6 mL/kg/%TBSA) due to their higher surface area-to-weight ratio. 2, 4

• Target urine output of 0.5-1 mL/kg/hour in adults to guide fluid administration, adjusting based on clinical response rather than rigidly following formulas. 2, 4

Why Ringer's Lactate Over Normal Saline

Use balanced crystalloid solutions (Ringer's Lactate) as first-line fluid, not 0.9% NaCl. 1 Normal saline is associated with higher risk of hyperchloremic metabolic acidosis and acute kidney injury in ICU populations, including burn patients. 1, 4

Colloid Administration (Albumin)

Start 5% human albumin between 8-12 hours post-burn in patients with severe burns (TBSA >30%) to reduce crystalloid administration and prevent fluid overload. 2, 4

• Maintain serum albumin levels >30 g/L with doses of 1-2 g/kg/day. 2, 4

• Albumin reduces the volume of crystalloids needed and decreases complications related to fluid overload, including compartment syndrome, acute kidney injury, and acute respiratory distress syndrome. 2, 4

Pain Management

Administer short-acting opioid analgesics and titrated ketamine according to validated comfort and analgesia scales before any wound manipulation. 2

• Ketamine can be combined with other analgesics to treat severe burn-induced pain. 2

• For highly painful lesions or procedures, general anesthesia is the most effective option. 2

• Inhaled nitrous oxide can be useful, especially when intravenous access is not available. 2

• Burn wound care typically requires deep analgesia or general anesthesia - never attempt wound care without adequate pain control. 2

Wound Care in the ICU

Perform wound care only after well-conducted resuscitation, in a clean environment, and with deep analgesia or general anesthesia. 2

• Clean wounds with running water, isotonic saline solution, or antiseptic solution. 3, 2

• Consult a burn specialist to define the most appropriate dressing and whether blisters should be aspirated or debrided. 2

• Apply appropriate dressings based on burn depth, TBSA, wound appearance, and patient condition. 3, 2

• Apply silver sulfadiazine cream 1% once to twice daily to a thickness of approximately one-sixteenth of an inch, continuing until satisfactory healing occurs or the burn site is ready for grafting. 5

• Avoid prolonged use of silver sulfadiazine on superficial burns, as it is associated with prolonged healing. 2

Compartment Syndrome and Escharotomy

Monitor for compartment syndrome in circumferential third-degree burns, which can cause acute limb ischemia, thoracic/abdominal compartment syndrome, decreased cardiac output, pulmonary compliance, hypoxia, hypercapnia, acute renal failure, and mesenteric ischemia. 1, 4

Perform escharotomy when deep circumferential burns cause compartment syndrome compromising airways, respiration, and/or circulation. 1, 3, 2

• The only urgent indication for immediate escharotomy is compromised airway movement and/or ventilation. 1

• For intra-abdominal hypertension or circulatory impairment, perform escharotomy within 48 hours of emergence. 1

• Escharotomy should ideally be performed only at a Burns Centre by an experienced provider, as poorly performed escharotomy is associated with increased morbidity, hemorrhage, and infection. 1, 3, 2

• If transfer is impossible, obtain specialist advice before performing the procedure. 1

Critical Pitfalls to Avoid

Beware of "fluid creep" (excessive fluid administration), which occurs in 70-94% of cases due to TBSA overestimation and leads to abdominal compartment syndrome, acute kidney injury, and acute respiratory distress syndrome. 2, 4

Never delay escharotomy when indicated, as poorly timed escharotomy is associated with increased morbidity. 4

Do not underestimate fluid requirements in electrical burns, which cause deeper tissue damage than apparent on the surface. 4

Avoid prophylactic intubation based solely on facial burns, as this leads to unnecessary complications in one-third of patients. 2

Do not routinely administer prophylactic antibiotics unless specifically indicated for infected wounds. 3, 2

Avoid prolonged use of external cooling devices (e.g., Water-Jel dressings) to prevent hypothermia. 3, 2

When applying circular dressings to limbs, monitor distal perfusion regularly to prevent tourniquet effect. 3, 2

Hemodynamic Monitoring and Support

• If hypotension persists despite adequate resuscitation, evaluate cardiac function with echocardiography and consider vasopressors. 2, 4

• Monitor for acute kidney injury, which is a common complication in severe burns. 2, 4

• Consider thromboprophylaxis for severe burns. 3, 2

Transfer Considerations

If transfer to a burn center is indicated, the patient should be admitted directly to the center whenever possible, as specialist management in dedicated burn centers is associated with better survival, reduced complications, shorter hospital stays, and lower costs. 1, 3, 2