What is the initial management for a patient presenting with a second-degree burn wound in a hospital setting using the Advanced Trauma Life Support (ATLS) protocol?

Hospital Management of Second-Degree Burns Using ATLS Protocol

For second-degree burns presenting to the hospital, immediately initiate the ATLS primary survey (Airway, Breathing, Circulation) with particular attention to airway compromise from inhalation injury, followed by aggressive fluid resuscitation using the Parkland formula for burns ≥10% TBSA in adults or ≥5% TBSA in children, while simultaneously cooling the wound and providing adequate analgesia. 1, 2, 3

Primary Survey and Initial Assessment

Airway Management

• Assess immediately for signs of inhalation injury: facial burns, singed nasal hairs, soot around nose/mouth, difficulty breathing, or altered consciousness 1
• Patients with suspected inhalation injury require 100% oxygen via high-concentration mask or mechanical ventilation with FiO₂ 100% for 6-12 hours 1
• Consider early endotracheal intubation if airway compromise is actual or impending, as burned tissue swells rapidly 1, 4
• The 9th edition ATLS defines hemodynamic instability as blood pressure <90 mmHg with heart rate >120 bpm, skin vasoconstriction (cool, clammy, decreased capillary refill), altered consciousness, and/or shortness of breath 1

Breathing Assessment

• Evaluate for circumferential chest burns that may restrict respiratory excursion 3
• Monitor for signs of compartment syndrome requiring emergency escharotomy: blue, purple, or pale extremities indicating poor perfusion 2, 5

Circulation and Fluid Resuscitation

• Establish IV access in unburned areas when possible; consider intraosseous access if IV cannot be rapidly obtained 5
• For adults with burns ≥15% TBSA and children with burns ≥10% TBSA, administer 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate) within the first hour 2, 3, 5
• Calculate 24-hour fluid requirements using the Parkland formula: 2-4 mL/kg/%TBSA burned 3
• Administer half of the calculated 24-hour requirement in the first 8 hours post-burn, with the remaining half over the next 16 hours 3
• Children require higher fluid volumes (approximately 6 mL/kg/%TBSA) due to higher surface area-to-weight ratio 3
• Monitor urine output hourly, targeting 0.5-1 mL/kg/hour in adults as the primary parameter for fluid adjustment 3

Critical Pitfall: Use the Lund-Browder chart, NOT the Rule of Nines, for TBSA assessment, as the Rule of Nines overestimates TBSA in 70-94% of cases, leading to excessive fluid administration and "fluid creep" 2, 3

Accurate TBSA Assessment

• The Lund-Browder chart is the gold standard for TBSA measurement in both adults and children 2, 3
• For rapid field assessment, use the patient's palm plus fingers (approximately 1% TBSA) 2, 3
• Reassess TBSA during initial management to prevent overtriage and undertriage 3
• Consider digital tools like smartphone applications (E-Burn) to facilitate accurate assessment 2, 3

Pain Management

• Provide titrated intravenous opioids or ketamine for severe burn pain before wound care procedures 1, 2
• Multimodal analgesia should be used with all medications titrated based on validated comfort and analgesia assessment scales 1
• Over-the-counter analgesics (acetaminophen or NSAIDs) are reasonable for less severe pain 1, 2
• Burn injuries trigger inflammation and capillary leakage, increasing risk of adverse effects from analgesics, making titration essential 1

Wound Care and Dressing

Initial Wound Management

• Cool the burn immediately with clean running water for 5-20 minutes to limit tissue damage and reduce pain 1, 2
• Monitor children closely for hypothermia during active cooling, particularly with larger burns 2
• Clean the wound with tap water or isotonic saline solution 2, 5
• Remove jewelry before onset of swelling to prevent constriction and vascular ischemia 1

Dressing Application

• After cooling, loosely cover the burn with a clean, non-adherent dressing 1, 2
• For partial-thickness burns, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera after cooling 1, 2
• Apply silver sulfadiazine cream 1% once to twice daily to a thickness of approximately one-sixteenth of an inch, covering burn areas at all times 6
• Continue treatment with silver sulfadiazine until satisfactory healing occurs or the burn site is ready for grafting 6
• When applying dressings to extremities, prevent bandages from causing a tourniquet effect and monitor distal perfusion regularly 5

Critical Pitfall: Avoid prolonged use of silver sulfadiazine on superficial burns as it may delay healing 2, 5

Advanced Interventions

Albumin Administration for Severe Burns

• For burns >30% TBSA, initiate 5% human albumin between 6-12 hours post-burn to reduce crystalloid volumes and prevent complications 3
• Target serum albumin levels >30 g/L with doses of 1-2 g/kg/day 3
• Albumin administration significantly reduces mortality (OR=0.34,95% CI 0.19-0.58, P<0.001) and reduces abdominal compartment syndrome from 15.4% to 2.8% 3

Escharotomy

• Perform escharotomy emergently if deep circumferential burns induce compartment syndrome compromising circulation or respiration 2, 3, 5
• Ideally perform escharotomy in a burn center by an experienced provider 2, 5
• Monitor for signs requiring escharotomy: blue, purple, or pale extremities indicating poor perfusion 2

Specialist Consultation and Transfer Criteria

Mandatory Burn Center Referral

• Contact a burn specialist immediately to determine need for burn center admission 2, 3
• Adults with second-degree burns >20% TBSA require burn center referral 2
• Children with second-degree burns >10% TBSA require burn center referral 2
• All second-degree burns involving face, hands, feet, genitals, or perineum require burn center referral regardless of size 1, 2, 3
• Use telemedicine for initial assessment when immediate specialist access is unavailable 2, 3
• Transfer patients directly to burn centers rather than sequential transfers, as direct admission improves survival and functional outcomes 2, 3

Monitoring and Ongoing Management

Hemodynamic Monitoring

• Monitor arterial lactate concentration for adequacy of resuscitation 3
• Use advanced hemodynamic monitoring (echocardiography, cardiac output monitoring, central venous pressure) in patients with persistent oliguria or hemodynamic instability 3
• If hypotension persists despite adequate fluid resuscitation, evaluate cardiac function with echocardiography before initiating vasopressors 3
• Monitor intra-abdominal pressure as abdominal compartment syndrome risk is significantly reduced with albumin use 3

Infection Prevention

• Do not routinely administer systemic antibiotics prophylactically; reserve for clinically evident infections 2, 5
• Monitor for signs of infection: increased pain, redness extending beyond burn margins, swelling, or purulent discharge 2
• Do not break blisters, as this increases infection risk 2

Additional Considerations

• Consider thromboprophylaxis for severe burns 5
• Monitor for and manage acute kidney injury, a common complication in severe burns 3
• Avoid "fluid creep" (excessive fluid administration) as it can lead to compartment syndrome, acute respiratory distress syndrome, and acute kidney injury 3

Critical Pitfall: Never delay specialist referral for any partial-thickness burn involving functional areas (hands, feet, face, genitals), as this leads to permanent functional impairment 2