What are the step-by-step management protocols for a patient presenting to the Emergency Room (ER) with a burn?

Emergency Department Management of Burn Patients: Systematic Approach

Immediate Assessment and Stabilization (First 5 Minutes)

Upon arrival, immediately assess and secure the airway, breathing, and circulation before focusing on the burn itself. 1, 2

Primary Survey (ABCs)

• Airway: Assess for signs of inhalation injury including circumoral burns, oropharyngeal burns, carbonaceous sputum, facial burns, singed nasal hairs, hoarseness, or stridor 1, 3

  • Do NOT routinely intubate patients with facial or cervical burns 2
  • Specific intubation criteria: deep circular neck burns, symptoms of airway obstruction, extensive burns (TBSA ≥40%), or progressive respiratory distress 2
  • Unnecessary prehospital intubation occurs in one-third of cases and increases complications 2

• Breathing: Evaluate for respiratory compromise from circumferential chest burns or smoke inhalation 1, 3

  • Administer 100% humidified oxygen immediately 3
  • Monitor for signs of respiratory distress requiring positive-pressure ventilation 3

• Circulation: Assess for shock and establish IV access in unburned areas when possible 2, 4

  • Consider intraosseous access if IV access cannot be rapidly obtained 4
  • Check distal pulses in burned extremities for compartment syndrome 2, 4

Burn Assessment (Minutes 5-15)

Measure Total Body Surface Area (TBSA)

Use the Lund-Browder chart for accurate TBSA measurement in both adults and children—this is the gold standard. 1, 2, 5

• The Wallace rule of nines significantly overestimates TBSA and is NOT suitable for children 1
• For quick field estimation, use the patient's open palm (palm and fingers) = 1% TBSA 1, 2
• Repeat TBSA assessment during initial management as accuracy improves with serial measurements 1
• Critical pitfall: TBSA is overestimated in 70-94% of cases, leading to excessive fluid administration and complications including abdominal compartment syndrome, acute kidney injury, and ARDS 1, 2

Determine Burn Depth

• Superficial (first-degree): Red, painful, blanches with pressure 6, 7
• Partial-thickness (second-degree): Blistered, very painful, pink/red base 6, 7
• Full-thickness (third-degree): White/charred, leathery, painless due to nerve destruction 6, 7

Immediate Burn Cooling (If Within 3 Hours of Injury)

Cool burns with cold tap water (15-25°C) for at least until pain is relieved, but limit cooling in extensive burns to prevent hypothermia. 1, 5

• Cool adults with TBSA <20% and children with TBSA <10% in absence of shock 1
• Cooling times <40 minutes significantly reduce need for skin grafting 1
• Never apply ice directly to burns—this causes tissue ischemia 1
• Monitor children closely for hypothermia during cooling 5
• Stop cooling immediately if patient develops hypothermia or shivering 1, 2

Fluid Resuscitation (Critical for TBSA >15% Adults, >10% Children)

Begin aggressive fluid resuscitation immediately using the Parkland formula: 2-4 mL/kg/% TBSA of Lactated Ringer's solution over 24 hours, with half given in the first 8 hours. 2, 8

Specific Resuscitation Protocol

• Adults: 2-4 mL/kg/% TBSA of balanced crystalloid (preferably Lactated Ringer's) 2
• Children: Approximately 6 mL/kg/% TBSA due to higher surface-to-weight ratio 2
• Initial bolus: Administer 20 mL/kg of balanced crystalloid within first hour for adults with burns >15% TBSA and children >10% TBSA 4
• Calculate time from injury, NOT from arrival 2, 8

Resuscitation Endpoints

• Urine output: Target 0.5-1 mL/kg/hour in adults 2
• Adjust fluids based on clinical response, not rigid formula adherence 2
• Monitor for fluid overload complications 2

Colloid Administration

• Start 5% human albumin between 8-12 hours post-burn in severe burns (TBSA >30%) 2
• Maintain serum albumin >30 g/L with doses of 1-2 g/kg/day 2
• Albumin reduces crystalloid volume needed and prevents fluid overload 2

Pain Management

Administer titrated intravenous opioids or ketamine immediately—burn pain is severe and requires aggressive management. 1, 2

• First-line: Short-acting IV opioids (morphine, fentanyl) titrated to effect 1, 2
• Adjunct: IV ketamine can be combined with opioids for severe pain 1, 2
• Alternative: Inhaled nitrous oxide when IV access unavailable 1
• Use validated pain scales to guide dosing 1
• For highly painful procedures or extensive burns, consider general anesthesia 1
• Avoid: Alpha-2 agonists due to hemodynamic effects in acute phase 1

Wound Care (After Resuscitation Stabilized)

Wound care is NOT a priority initially—perform only after adequate resuscitation in a clean environment with deep analgesia or general anesthesia. 1, 2

Wound Cleaning

• Clean with tap water, isotonic saline, or antiseptic solution 1, 2, 4
• Remove loose debris and tissue 1
• Blisters: Leave intact and loosely cover with sterile dressing—this improves healing and reduces pain 1, 5
• Consult burn specialist regarding whether to aspirate or debride blisters 2, 4

Dressing Application

• Apply appropriate dressings based on burn depth, TBSA, and wound appearance 2, 4
• For extremity burns: Ensure dressings do not cause tourniquet effect—monitor distal perfusion regularly 4
• Cover burns loosely with clean, non-adherent dressing 4, 5
• Topical agents:
  • Silver sulfadiazine: Apply 1/16 inch thickness once to twice daily 9
  • Critical pitfall: Avoid prolonged use of silver sulfadiazine on superficial burns—it delays healing 2, 4, 5
  • Alternatives: Petrolatum-based ointments, honey, or aloe vera for superficial burns 5

Identify Need for Escharotomy

Perform emergency escharotomy if deep circumferential burns cause compartment syndrome compromising circulation or respiration—do not delay if indicated. 1, 2, 4

Indications for Escharotomy

• Circumferential third-degree burns of extremities with compromised distal circulation 2, 4
• Circumferential chest burns restricting ventilation 1, 2
• Signs: blue/purple/pale extremities, absent pulses, progressive numbness, increasing compartment pressure 4, 5

Escharotomy Considerations

• Ideally performed in burn center by experienced provider 1, 2
• If transfer not feasible, obtain specialist consultation before performing 4, 5
• Timely escharotomy reduces morbidity—do not delay when indicated 5

Determine Burn Center Referral Criteria

Contact burn specialist immediately via telemedicine or phone to determine if transfer to burn center is indicated—direct admission to burn center improves survival and functional outcomes. 1, 2, 5

Adult Referral Criteria (Any of the Following)

• TBSA >20% 2, 5
• Deep burns >5% TBSA 2, 5
• Burns to face, hands, feet, genitalia, perineum, or major joints (regardless of size) 2, 5
• Full-thickness burns 5
• Electrical burns (including lightning) 2, 5
• Chemical burns 5
• Inhalation injury 2, 5
• Circumferential burns 5
• Age >75 years with TBSA <20% and severe comorbidities 2, 5

Pediatric Referral Criteria (Any of the Following)

• TBSA >10% 5
• Deep burns >5% TBSA 5
• Age <1 year 5
• Burns to face, hands, feet, genitalia, perineum, or major joints 5
• Any electrical or chemical burn 5
• Inhalation injury 5
• Circumferential burns 5

Transfer Logistics

• If transfer indicated, admit directly to burn center rather than sequential transfers 2, 5
• Use telemedicine for initial assessment if direct consultation unavailable 1, 4
• Continue monitoring and resuscitation during transfer 4

Additional Critical Interventions

Tetanus Prophylaxis

• Administer tetanus toxoid if not up to date 6, 7

Antibiotic Considerations

• Do NOT routinely administer prophylactic antibiotics 2, 4, 5
• Reserve systemic antibiotics for clinically evident infections (>10^5 organisms/gram tissue with tissue invasion) 3

Thromboprophylaxis

• Consider for severe burns 2, 4

Special Populations

• Electrical burns: Do not underestimate fluid requirements—deeper tissue damage than surface appearance suggests 2
• Chemical burns: Continue irrigation and consult poison control/burn specialist 5
• Pregnant women: Require additional treatment considerations 7

Monitoring

• Continuous cardiac monitoring 8
• Hourly urine output 2, 8
• Serial vital signs 8
• Distal pulses in burned extremities 4, 5
• Signs of compartment syndrome 4, 5
• Arterial blood gases if inhalation injury suspected 3

Common Pitfalls to Avoid

• Overestimating TBSA leading to excessive fluid administration 1, 2
• Routine intubation of facial burns without specific indications 2
• Delaying specialist consultation 4, 5
• Breaking blisters unnecessarily 5
• Applying butter, oil, or home remedies 5
• Prolonged cooling causing hypothermia 1, 2
• Dressings causing tourniquet effect 4
• Routine prophylactic antibiotics 2, 4, 5
• Delaying escharotomy when indicated 5
• Using rule of nines in children 1