What is the appropriate treatment for a patient with severe burns to the extremities and face?

Management of Severe Burns to Extremities and Face

For patients with severe burns to the extremities and face, immediately assess for inhalation injury and airway compromise, intubate without delay if facial burns are severe or whole-face involvement is present, initiate aggressive fluid resuscitation with lactated Ringer's at 4 mL/kg/% TBSA over 24 hours, and arrange direct transfer to a burn center. 1, 2

Immediate Airway Assessment and Management

Suspect inhalation injury in any patient with facial burns, soot around nose/mouth, singed nasal hairs, or fire exposure in enclosed spaces 1. This is critical because:

• Normal oxygen saturation, chest X-ray, and arterial blood gases do NOT exclude inhalation injury and should not provide false reassurance 1
• Airway obstruction from edema can develop rapidly and unpredictably 1

Intubate immediately without delay if any of the following are present:

• Severe burns involving the whole face 1
• Deep circular neck burns 1
• Symptoms of airway obstruction 1
• Severe respiratory distress, hypoxia, or hypercapnia 1, 2
• Very extensive burns (TBSA ≥40%) 1

If intubation is performed, anticipate difficult airway and use video laryngoscopy if available, and avoid succinylcholine after 24 hours post-injury due to hyperkalemia risk 2.

Initial Wound Care and Cooling

Cool thermal burns with clean running water for 5-20 minutes immediately 1, 3. However:

• Do NOT cool burns >20% TBSA in adults due to hypothermia risk 2
• Monitor children closely for hypothermia during cooling 1, 3
• Remove all clothing and jewelry before swelling occurs to prevent vascular ischemia 1, 3

For small partial-thickness burns, apply petrolatum or petrolatum-based antibiotic ointment and cover with clean, non-adherent dressing 3. Silver sulfadiazine cream 1% is FDA-approved as an adjunct for prevention and treatment of wound sepsis in second and third-degree burns, applied once to twice daily to a thickness of approximately one-sixteenth inch 4.

Fluid Resuscitation Protocol

Begin aggressive fluid resuscitation with lactated Ringer's solution at 4 mL/kg/% TBSA burned over the first 24 hours 2. This is critical for severe burns:

• Adult patients with TBSA ≥20% and pediatric patients with TBSA ≥10% should receive 20 mL/kg of intravenous crystalloid within the first hour 3
• Use balanced crystalloid solutions rather than 0.9% NaCl to reduce risk of hyperchloremia and metabolic acidosis 3
• Titrate strictly to urine output of 0.5-1.0 mL/kg/hour (adults) to avoid "fluid creep" 2
• Do NOT use hydroxyethyl starches or colloids - these are contraindicated by the European Medicines Agency in severe burns 2

Pain Management

Provide aggressive analgesia with short-acting opioids and ketamine for burn-related pain 2. For less severe pain:

• Administer over-the-counter analgesics such as acetaminophen or NSAIDs 1, 3
• Consider titrated intravenous ketamine combined with other analgesics for severe pain 3

Compartment Syndrome Monitoring

Monitor closely for compartment syndrome requiring escharotomy, particularly with circumferential burns on extremities 2, 3. Escharotomy should be performed within 48 hours if circulatory impairment develops 3.

Infection Prevention and Nutritional Support

• Do NOT administer prophylactic systemic antibiotics - reserve for documented infection only 2
• Take wound swabs for bacterial and fungal cultures immediately and on alternate days 2
• Insert nasogastric tube and initiate continuous enteral feeding immediately if oral intake inadequate 2
• Provide 20-25 kcal/kg/day during acute catabolic phase 2
• Initiate routine thromboprophylaxis in the initial phase 2

Burn Center Transfer Criteria

Direct admission to a burn center is strongly preferred over staged transfer, as it reduces time to definitive treatment and improves morbidity and mortality 1, 3. The American Burn Association recommends burn center treatment for:

• Second- or third-degree burns involving face, hands, feet, genitals 1, 3
• Burns >10% TBSA in adults (>5% in children) 1, 3
• Burns >40% TBSA (significantly increases mortality risk) 2
• Contact burn specialists immediately via telemedicine if available to guide initial resuscitation 2

Critical Pitfalls to Avoid

• Avoid fluid overload ("fluid creep") - use conservative crystalloid approach guided strictly by urine output, not formulas alone 2
• Do not perform bronchial fibroscopy outside burn centers if smoke inhalation suspected - this delays transfer 2
• Avoid unnecessary prehospital intubation - nearly one-third are inappropriate and increase complications 2
• Defer extensive wound care until after resuscitation and arrival at burn center 2