What are the initial steps in managing a burn patient?

Initial Management of Burn Patients

Begin with immediate assessment of burn depth, total body surface area using the Lund-Browder chart (not Rule of Nines), and initiate aggressive fluid resuscitation with 20 mL/kg Ringer's Lactate within the first hour for adults with ≥10% TBSA burns or children with ≥5% TBSA burns. 1

Immediate Assessment (First 15 Minutes)

Airway and Inhalation Injury Evaluation

• Check specifically for circumoral burns, oropharyngeal burns, and carbonaceous sputum—these indicate inhalation injury which significantly increases mortality 1
• Secure airway early if any signs of inhalation injury are present, as progressive edema can make intubation impossible within hours 1

Burn Classification

• Classify by depth: superficial, partial-thickness, or full-thickness 1
• Measure TBSA using Lund-Browder chart exclusively—the Rule of Nines overestimates TBSA in 70-94% of cases, leading to dangerous fluid overload 1
• For rapid field assessment, use the patient's palm and fingers (approximately 1% TBSA) 2
• Reassess TBSA during initial management to prevent overtriage and undertriage 1

Identify High-Risk Burns Requiring Specialist Care

These require specialized care regardless of size: 1

• Face, hands, feet, genitals
• Full-thickness burns
• Circumferential burns (risk of compartment syndrome)
• Electrical burns (deeper tissue damage than apparent)

Fluid Resuscitation Protocol (Within First Hour)

Immediate Bolus

• Administer 20 mL/kg of Ringer's Lactate (preferred balanced crystalloid) within the first hour 1, 3
• Establish IV access in unburned areas when possible 2
• Never use normal saline (0.9% NaCl) as primary resuscitation fluid—it causes hyperchloremic metabolic acidosis and acute kidney injury 1

Calculate 24-Hour Requirements (Parkland Formula)

• Standard formula: 2-4 mL/kg/%TBSA of Ringer's Lactate over 24 hours 1, 3
• For electrical burns: use modified formula of 3-4 mL/kg/%TBSA due to deeper tissue damage 3
• Pediatric patients: approximately 6 mL/kg/%TBSA due to higher surface area-to-weight ratio 1

Fluid Administration Schedule

• Give half of calculated 24-hour volume in first 8 hours post-burn 1, 3
• Give remaining half over next 16 hours 1, 3
• Time starts from moment of burn injury, not from arrival 3

Monitoring Targets

• Urine output: 0.5-1 mL/kg/hour (adults) 1, 3
• For electrical burns with myoglobinuria: maintain 1-2 mL/kg/hour to prevent acute kidney injury 3
• Adjust fluid rates based on urine output, not rigid adherence to formula 1

Colloid Administration (8-12 Hours Post-Burn)

Initiate 5% albumin at 8-12 hours post-burn in severe burns to reduce crystalloid volumes and prevent "fluid creep" 1

• Target serum albumin >30 g/L with doses of 1-2 g/kg/day 1
• This reduces crystalloid administration, organ failure, and mortality 1
• Never use hydroxyethyl starch (HES)—it is contraindicated in burns 1
• Avoid gelatins due to negative effects on coagulation 1

Wound Management

Initial Wound Care

• Clean with tap water, isotonic saline, or antiseptic solution 2
• Perform in clean environment 2
• Provide deep analgesia or procedural sedation before wound care—this is typically very painful 2

Topical Antimicrobials

• Apply silver sulfadiazine 1% cream once to twice daily to thickness of 1/16 inch, covering burn areas at all times 4
• Continue until satisfactory healing or ready for grafting 4
• Reapply after hydrotherapy and patient activity 4
• Do not use prolonged silver sulfadiazine on superficial burns—it may delay healing 2

Dressing Application

• When applying dressings to extremities, prevent tourniquet effect by avoiding circumferential constriction 2
• Monitor distal perfusion regularly with circular dressings 2
• Dressings are not required but may be used based on patient needs 4

Critical Complications to Monitor

Compartment Syndrome

• Monitor circumferential third-degree burns for compartment syndrome—can cause acute limb ischemia or thoracic/abdominal compartment syndrome 1
• Perform escharotomy within 48 hours if circulatory impairment develops 1, 2
• Escharotomy should ideally be performed at a burn center by experienced provider 1, 2

Fluid Creep Prevention

• "Fluid creep" (excessive fluid administration) causes compartment syndrome, pulmonary edema, and abdominal compartment syndrome 1, 5
• Avoid early overresuscitation 5
• Use albumin as routine component or for "rescue" 5
• Adhere strictly to protocols and urine output targets 5

Cardiovascular Support

• If hypotension persists despite adequate fluid resuscitation, evaluate cardiac function and consider vasopressors 1, 3
• Do not simply increase fluid rates further 6

Specialist Consultation and Transfer

Contact burn specialist immediately to determine need for transfer to burn center—this improves survival, reduces complications, and decreases length of stay 1, 2

• Use telemedicine if direct consultation unavailable 1, 2
• Transfer criteria include: burns ≥10% TBSA (adults), ≥5% TBSA (children), involvement of face/hands/feet/genitals/flexures, full-thickness burns, circumferential burns, electrical burns 1, 2

Critical Pitfalls to Avoid

• Never use Rule of Nines for TBSA calculation—use Lund-Browder chart only 1
• Never delay escharotomy when indicated—poorly timed escharotomy increases morbidity 1
• Never underestimate fluid requirements in electrical burns—tissue damage is deeper than surface appearance 1, 3
• Do not routinely administer prophylactic antibiotics unless specifically indicated for infection 2
• Avoid prolonged external cooling devices (e.g., Water-Jel) to prevent hypothermia 2
• Never perform escharotomy without proper training or specialist consultation 2