What is the optimal management approach for a patient with severe burns?

Optimal Management of Severe Burns

Initial Assessment and TBSA Measurement

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

• The Wallace rule of nines significantly overestimates TBSA and is particularly unsuitable for children, leading to excessive fluid administration during acute resuscitation 1
• In prehospital settings or mass casualty situations where the Lund-Browder method is impractical, use the serial halving method or the open hand method (palm plus fingers = 1% TBSA) 1
• Smartphone applications like E-Burn can facilitate accurate TBSA assessment 1
• Repeat TBSA measurements during initial management as burn appearance evolves 3

Immediate Specialist Consultation and Transfer

Contact a burn specialist immediately to determine whether the patient requires admission to a burn center, as specialist management improves survival, reduces complications, and facilitates rehabilitation. 1

• Use telemedicine for initial assessment when immediate specialist access is unavailable 1, 2
• Transfer patients directly to burn centers rather than sequential transfers, as direct admission improves survival and functional outcomes 1, 2
• Undertriage increases morbidity and mortality, while overtriage consumes inappropriate resources 1, 4

Burn Center Referral Criteria - Adults:

• TBSA >20% 2
• Deep burns >5% TBSA 2
• Age >75 years with any burn 2, 4
• Smoke inhalation injury 2
• Burns to face, hands, feet, flexure lines, genitals, or perineum (regardless of size) 1, 2
• Electrical burns (high or low voltage) 2
• Chemical burns 2
• Severe comorbidities (diabetes, COPD, renal insufficiency) 2, 4

Burn Center Referral Criteria - Pediatric:

• TBSA >10% 2
• Infants <1 year of age with any burn 2, 4
• Deep burns >5% TBSA 2
• Any electrical or chemical burn 2
• Circular burns 2
• Smoke inhalation 2
• Burns to function-sensitive areas 2

Airway Management

Perform early endotracheal intubation for patients with stridor, shortness of breath, facial burns, singed nasal hairs, cough, soot in the oral cavity, or history of fire exposure in an enclosed space. 5

• Remove patients with suspected inhalation injury from the enclosure immediately and administer high-flow oxygen 5
• Consider fibroscopy to assess airway and lung damage when inhalation injury is suspected 5
• Do not delay intubation in patients with actual or impending airway compromise 5, 6

Fluid Resuscitation

Initiate aggressive fluid resuscitation based on accurate TBSA calculations to maintain tissue perfusion, but avoid fluid overload that commonly results from TBSA overestimation. 1, 7

• TBSA overestimation in 70-94% of cases leads to excessive fluid administration 1
• Recent evidence suggests potential superiority of natural colloids over crystalloids during resuscitation 7
• Calculate the revised Baux score (age + TBSA + inhalation injury factor) to guide resource allocation and predict mortality risk 3
• Monitor for fluid overload during the perioperative period 7

Escharotomy

Perform escharotomy emergently if deep burns induce compartment syndrome in limbs or trunk that compromises airways, respiration, or circulation. 1

• Ideally perform escharotomy in a burn center by an experienced provider 1
• Monitor for signs including blue, purple, or pale extremities indicating poor perfusion 2

Pain Management

Administer titrated intravenous opioids or ketamine for severe burn pain, as burn pain is often intense and difficult to control. 2

• Over-the-counter acetaminophen or NSAIDs may be used for minor burns 2
• Pain management protocols require aggressive treatment given the severity of burn-related pain 7

Wound Management

Apply silver sulfadiazine cream 1% once to twice daily to a thickness of approximately one-sixteenth inch, continuing until satisfactory healing occurs or the burn site is ready for grafting. 8

• Reapply immediately after hydrotherapy and to areas where patient activity has removed the cream 8
• For superficial burns, petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera may be applied after cooling 2
• Clean wounds with tap water or isotonic saline if transfer is delayed 2
• Avoid prolonged use of silver sulfadiazine on superficial burns as it may delay healing 2

Early Surgical Intervention

Perform aggressive early surgical excision and skin grafting for full-thickness burns, as this approach combined with early hemodynamic management has significantly decreased morbidity and mortality. 5, 9

• Early excision and rapid wound coverage minimize physiologic alterations and hypermetabolic response 9
• Specialized burn centers provide necessary surgical techniques to prevent permanent functional disability 2

Infection Control

Do not use systemic antibiotics prophylactically; reserve antibiotics for clinically evident infections. 2

• Monitor for signs of infection including increased pain, redness extending beyond burn margins, swelling, or purulent discharge 2
• Antibiotic coverage should be combined with nutritional support to decrease hypermetabolic response and sepsis incidence 9

Nutritional Support

Initiate early enteral tube feedings to decrease the hypermetabolic response and prevent organ failure. 9

• Early enteral nutrition combined with wound closure measures decreases the incidence of sepsis leading to hemodynamic instability 9

Critical Pitfalls to Avoid

• Never delay burn center referral while attempting to "stabilize" patients with extensive burns, as undertriage increases morbidity and mortality 4
• Do not use the Wallace rule of nines for TBSA estimation in children or for fluid resuscitation calculations 1, 4
• Do not apply butter, oil, or other home remedies to burns 2
• Do not break blisters, as this increases infection risk 2
• Do not rely solely on TBSA when determining severity in patients with comorbidities like COPD or renal insufficiency, as these significantly increase mortality risk independent of burn size 4
• Do not delay specialist referral for any partial-thickness or full-thickness hand burn, as this leads to permanent functional impairment 2