What are the initial steps in the emergent management of severe burns in adults?

Emergent Management of Burns

Immediate Scene Safety and Initial Assessment

Stop the burning process immediately by removing the patient from the heat source, extinguishing flames, and removing all clothing and jewelry; then assess airway, breathing, and circulation before proceeding with burn-specific interventions. 1

Airway Management

• Intubate early if there is any evidence of inhalation injury or impending airway compromise, including circumoral burns, oropharyngeal burns, carbonaceous sputum, or facial burns. 2
• Do not wait for respiratory distress to develop—airway edema progresses rapidly in the first 24-48 hours. 3
• Signs requiring immediate intubation include stridor, hoarseness, difficulty swallowing, or respiratory distress. 4

Burn Surface Area Assessment

• Use the Lund-Browder chart for accurate TBSA measurement—never use the Rule of Nines, which overestimates TBSA in 70-94% of cases and leads to dangerous fluid overload. 2
• For rapid field assessment, use the patient's palm and fingers (approximately 1% TBSA). 5
• Reassess TBSA during initial management as burn appearance evolves. 5
• Digital tools like smartphone applications (E-Burn) can facilitate accurate assessment. 5

Fluid Resuscitation

For adults with burns >15% TBSA and children with burns >10% TBSA, immediately administer 20 mL/kg of Ringer's Lactate within the first hour. 6

Parkland Formula Protocol

• Calculate 24-hour fluid requirements: 2-4 mL/kg/%TBSA of Ringer's Lactate (never use normal saline as it causes hyperchloremic acidosis and acute kidney injury). 2
• Administer half of the calculated volume in the first 8 hours post-burn, then the remaining half over the next 16 hours. 2
• Children require higher volumes (approximately 6 mL/kg/%TBSA) due to higher surface area-to-weight ratio. 2

Monitoring and Titration

• Titrate fluids hourly to maintain urine output of 0.5-1 mL/kg/hour—this is your primary resuscitation endpoint. 2
• Monitor arterial lactate concentration for adequacy of resuscitation. 2
• Use advanced hemodynamic monitoring (echocardiography, cardiac output monitoring) if oliguria or hemodynamic instability persists despite adequate fluid administration. 2
• Avoid "fluid creep" (excessive fluid administration) as it causes compartment syndrome, ARDS, and acute kidney injury. 2

Albumin Administration

• For burns >30% TBSA, initiate 5% human albumin between 6-12 hours post-burn to reduce crystalloid volumes and prevent complications. 2
• Target serum albumin levels >30 g/L with doses of 1-2 g/kg/day. 2
• Albumin reduces mortality (OR=0.34) and abdominal compartment syndrome from 15.4% to 2.8%. 2
• Never use hydroxyethyl starch (HES)—it is contraindicated in burns per the European Medicines Agency. 2

Vascular Access

• Establish IV access in unburned areas when possible. 6
• Consider intraosseous access if IV access cannot be rapidly obtained. 6

Pain Management

Provide aggressive analgesia before any wound manipulation—burn wound care requires deep analgesia or procedural sedation. 6

• Administer IV opioids (morphine or fentanyl) titrated to effect. 4
• Consider procedural sedation for extensive or painful burns during wound care. 6

Wound Care

Initial Wound Management

• Clean burn wounds with tap water, isotonic saline, or antiseptic solution in a clean environment. 6
• Assess burn depth (superficial, partial-thickness, full-thickness) to guide management. 6
• Blister management should ideally be determined with burn specialist consultation. 6

Dressing Application

• Apply silver sulfadiazine cream 1% once to twice daily to a thickness of approximately 1/16 inch; continue until satisfactory healing or the burn is ready for grafting. 7
• Reapply immediately after hydrotherapy or if removed by patient activity. 7
• When applying circumferential dressings, monitor distal perfusion regularly to prevent tourniquet effect. 6
• Dressings are not required but may be used based on individual patient needs. 7

Critical Pitfall

• Avoid prolonged use of silver sulfadiazine on superficial burns as it may delay healing. 6

Escharotomy

Perform escharotomy immediately if deep circumferential burns cause compartment syndrome compromising circulation or respiration—ideally at a burn center by an experienced provider. 5

• Indications include circumferential third-degree burns with signs of vascular compromise, respiratory compromise from chest wall restriction, or elevated compartment pressures. 2
• Never delay escharotomy when indicated—perform within 48 hours if circulatory impairment develops. 2
• Monitor intra-abdominal pressure as abdominal compartment syndrome risk is significant. 2

Specialist Consultation and Transfer

Contact a burn specialist immediately (ideally via telemedicine if not readily available) to determine need for burn center transfer—this improves survival and reduces complications. 2

Burn Center Referral Criteria

• Burns >15% TBSA in adults or >10% TBSA in children. 6
• Burns involving face, hands, feet, genitals, perineum, or flexure lines. 5
• Full-thickness burns regardless of size. 2
• Inhalation injury. 2
• Electrical or chemical burns. 4
• If transfer is indicated, admit directly to the burn center—avoid intermediate stops. 5

Additional Critical Interventions

Prevent Hypothermia

• Avoid prolonged use of external cooling devices (e.g., Water-Jel dressings) after initial cooling. 6
• Maintain normothermia during resuscitation. 3

Infection Prevention

• Do not routinely administer prophylactic antibiotics unless specifically indicated for infected wounds. 6
• Monitor for signs of infection during ongoing care. 4

Thromboprophylaxis

• Consider thromboprophylaxis for severe burns per American College of Chest Physicians guidelines. 6

Assess for Associated Injuries

• Evaluate for inhalation injury, carbon monoxide poisoning, cyanide toxicity, and traumatic injuries. 4
• Check carboxyhemoglobin levels if smoke inhalation is suspected. 4

Common Pitfalls to Avoid

• Using the Rule of Nines for TBSA assessment (leads to 70-94% overestimation). 2
• Delaying specialist consultation (increases morbidity and mortality). 6
• Using normal saline instead of Ringer's Lactate for resuscitation. 2
• Performing escharotomy without proper training or consultation. 6
• Applying circumferential dressings without monitoring distal perfusion. 6
• Routine use of prophylactic systemic antibiotics. 6
• Underestimating fluid requirements in electrical burns (deeper tissue damage than apparent). 2