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

ATLS Management for Burn Injury

Immediately initiate the ATLS primary survey (Airway, Breathing, Circulation, Disability, Exposure) 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 with clean running water for 5-20 minutes and providing titrated intravenous opioids or ketamine for pain control. 1

Primary Survey: ABCDE Approach

Airway Assessment and Management

• Assess immediately for signs of inhalation injury including facial burns, singed nasal hairs, soot around nose/mouth, difficulty breathing, or altered consciousness 1
• Consider early endotracheal intubation if airway compromise is actual or impending, as burned tissue swells rapidly and can lead to loss of airway 2, 1
• Administer 100% oxygen via high-concentration mask or mechanical ventilation with FiO₂ 100% for 6-12 hours if inhalation injury is suspected 1
• Critical pitfall: Do not delay intubation—once airway edema develops, intubation becomes extremely difficult or impossible 1

Breathing and Ventilation

• Evaluate for circumferential chest burns that may restrict respiratory excursion 1
• Maintain normoventilation; avoid hyperventilation as it increases mortality in trauma patients 2
• Do not use excessive positive end-expiratory pressure (PEEP) when ventilating severely hypovolemic burn patients, as this compromises venous return and can cause cardiovascular collapse 2

Circulation and Fluid Resuscitation

• Establish IV access in unburned areas when possible 1
• 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 1, 3
• Calculate 24-hour fluid requirements using the Parkland formula: 2-4 mL/kg/%TBSA burned 1, 3
• Administer half of the calculated 24-hour fluid requirement in the first 8 hours post-burn (calculated from time of injury, not time of presentation), with the remaining half over the next 16 hours 3
• Critical pitfall: Do not use normal saline (0.9% NaCl) as primary resuscitation fluid—it increases risk of hyperchloremic metabolic acidosis and acute kidney injury 3

Disability and Neurological Assessment

• Assess mental status using ATLS classification system 2
• Altered consciousness may indicate carbon monoxide poisoning, hypoxia, or hypovolemic shock 2

Exposure and Environmental Control

• Remove all clothing and jewelry immediately before swelling develops to prevent constriction and vascular ischemia 2
• Maintain normothermia, especially in children during cooling procedures 2, 4

Accurate TBSA Assessment

• Use the Lund-Browder chart, NOT the Rule of Nines, as the Rule of Nines overestimates TBSA in 70-94% of cases, leading to excessive fluid administration and "fluid creep" 3, 4
• In prehospital settings, use the patient's palm plus fingers (approximately 1% TBSA) or serial halving method 4, 3
• Reassess TBSA during initial management to prevent overtriage and undertriage 3

Immediate Wound Management

• Cool the burn immediately with clean running water for 5-20 minutes to limit tissue damage and reduce pain 2, 4, 1
• Monitor children closely for hypothermia during active cooling, particularly with larger burns 2, 4
• After cooling, loosely cover burns with clean, non-adherent dressing while arranging transfer 2, 4
• Critical pitfall: Do not apply butter, oil, ice directly to burns, or break blisters 4

Pain Management

• Provide titrated intravenous opioids or ketamine for severe burn pain before wound care procedures 1, 4
• Use multimodal analgesia with all medications titrated based on validated comfort assessment scales 1
• Over-the-counter analgesics (acetaminophen or NSAIDs) are reasonable for minor burns 2, 4

Monitoring and Ongoing Resuscitation

• Target urine output of 0.5-1 mL/kg/hour in adults as the primary parameter for fluid adjustment 3, 1
• Monitor arterial lactate concentration for adequacy of resuscitation 1, 3
• Use advanced hemodynamic monitoring (echocardiography, cardiac output monitoring) in patients with persistent oliguria or hemodynamic instability 1, 3
• Avoid "fluid creep" (excessive fluid administration) as it leads to compartment syndrome, acute respiratory distress syndrome, and acute kidney injury 1, 3

Advanced Interventions

• For burns >30% TBSA, initiate 5% human albumin between 6-12 hours post-burn to reduce crystalloid volumes and prevent complications 1, 3
• Target serum albumin levels >30 g/L with doses of 1-2 g/kg/day 3
• Perform escharotomy emergently if deep circumferential burns induce compartment syndrome (signs: blue, purple, or pale extremities indicating poor perfusion) 4, 1, 3
• Ideally perform escharotomy at a burn center by an experienced provider 4, 3

Mandatory Burn Center Referral Criteria

Contact a burn specialist immediately to determine need for burn center admission 4, 1

Adults requiring burn center referral:

• Second-degree burns >20% TBSA 1
• Deep burns >5% TBSA 4
• Any burns involving face, hands, feet, genitals, or perineum regardless of size 2, 4, 1
• Smoke inhalation injury 4
• High-voltage or low-voltage electrical burns 4
• Chemical burns 4
• Age >75 years with TBSA <20% 4
• Severe comorbidities (e.g., diabetes mellitus) 4

Pediatric patients requiring burn center referral:

• TBSA >10% 4
• Deep burns >5% TBSA 4
• Infants <1 year of age with any burn 4
• Any burns involving face, hands, feet, genitals, or perineum 4
• Circular burns 4
• Any electrical or chemical burn 4

Transfer considerations:

• Transfer patients directly to burn centers rather than sequential transfers, as direct admission improves survival and functional outcomes 4, 3
• Use telemedicine consultation if immediate specialist access is unavailable 4, 3
• Critical pitfall: Do not delay specialist referral for any partial-thickness or full-thickness hand burn, as this leads to permanent functional impairment 4