What are the primary recommendations for managing burns in the Emergency Department (ED), particularly for patients with severe burns and potential complications such as hypovolemia, impaired oxygenation, and infection?

Managing Burns in the Emergency Department

Use the Lund-Browder chart—not the Rule of Nines—to assess total body surface area (TBSA), initiate immediate fluid resuscitation with Ringer's Lactate for burns ≥10% TBSA in adults or ≥5% in children, contact a burn specialist immediately for any hand/face/feet/genital burns or deep burns >5% TBSA, and aggressively manage pain with titrated IV opioids or ketamine while monitoring for compartment syndrome. 1, 2

Initial Assessment and TBSA Calculation

Accurate Burn Surface Area Measurement

• Always use the Lund-Browder chart for TBSA assessment in both adults and children, as it is the most accurate standardized method 1, 2
• The Rule of Nines overestimates TBSA in 70-94% of cases, leading to dangerous fluid overadministration and "fluid creep" complications 1, 2, 3
• In prehospital settings when the Lund-Browder chart is impractical, use the patient's open hand (palm plus fingers = 1% TBSA) or the serial halving method 1, 2
• Smartphone applications like E-Burn can facilitate accurate assessment 1, 2
• Reassess TBSA repeatedly during initial management to prevent both overtriage (wasting resources) and undertriage (increasing mortality) 1

Critical Pitfall to Avoid

The Wallace Rule of Nines is particularly unsuitable for children and systematically leads to excessive fluid volumes that cause compartment syndrome, abdominal compartment syndrome, and acute respiratory distress syndrome 1, 2, 3

Immediate Fluid Resuscitation

First Hour Management

• Administer 20 mL/kg of balanced crystalloid solution within the first hour for adults with TBSA ≥10% and children with TBSA ≥5% 1, 2, 3
• Use Ringer's Lactate as the first-line resuscitation fluid, not normal saline 1, 2, 3
• Normal saline causes hyperchloremic metabolic acidosis and increases acute kidney injury risk compared to balanced solutions 1, 3

24-Hour Fluid Protocol

• Calculate total 24-hour requirements using the Parkland formula: 2-4 mL/kg/%TBSA 2, 3
• Administer half of the calculated volume in the first 8 hours post-burn, with the remaining half over the next 16 hours 2
• Children may require higher volumes (approximately 6 mL/kg/%TBSA) due to higher surface area-to-weight ratio 2

Monitoring and Titration

• Target urine output of 0.5-1 mL/kg/hour as the primary parameter for adjusting fluid rates 2, 3
• Monitor arterial lactate concentration to assess resuscitation adequacy 2
• Use advanced hemodynamic monitoring (echocardiography, cardiac output monitoring) in patients with persistent oliguria or hemodynamic instability 2
• If hypotension persists despite adequate fluid resuscitation, perform echocardiography to evaluate cardiac function before initiating vasopressors 2

Albumin Administration for Severe Burns

• For TBSA >30%, initiate 5% human albumin between 6-12 hours post-burn to reduce crystalloid volumes and prevent fluid creep 2
• Target serum albumin levels >30 g/L with doses of 1-2 g/kg/day 1, 2
• Albumin reduces mortality (OR=0.34, P<0.001) and decreases abdominal compartment syndrome from 15.4% to 2.8% 2
• Never use hydroxyethyl starch (HES) or gelatins, as they are contraindicated in severe burns 2

Critical Pitfall: Fluid Creep

Avoid excessive fluid administration ("fluid creep"), which leads to compartment syndrome, abdominal compartment syndrome, acute respiratory distress syndrome, and congestive acute kidney injury 2, 3

Pain Management

Pharmacologic Approach

• Administer titrated intravenous opioids or ketamine for severe burn pain, as burn-induced pain is often intense and difficult to control 1, 2, 3
• Titrate all analgesics based on validated pain assessment scales to avoid under- or overdosing in the context of burn-induced hypovolemia and capillary leakage 1, 3
• Ketamine is particularly effective for burn pain and can limit morphine consumption 1
• Short-acting opioids are preferred for acute burn pain and dressing changes 1
• Inhaled nitrous oxide can be useful when IV access is unavailable 1
• For highly painful procedures, general anesthesia is an effective option 1

Non-Pharmacologic Adjuncts

• Combine non-pharmacological techniques (virtual reality, hypnosis) with analgesic drugs for dressing changes when the patient is stable 1
• Cool burns with running water for 5-20 minutes to reduce pain intensity 1, 3

Mandatory Specialist Consultation and Transfer Criteria

Immediate Burn Specialist Contact Required For:

• Any burns involving face, hands, feet, genitals, perineum, or flexure lines (regardless of size or depth) 1, 2, 4, 3
• Adults with TBSA >10% or children with TBSA >5% 2, 3
• Deep (partial-thickness or full-thickness) burns >5% TBSA 2
• Circumferential burns 2
• Electrical or chemical burns 2
• Smoke inhalation injury 1, 2
• Infants <1 year of age with any burn 2
• Adults >75 years with any significant burn 2
• Patients with severe comorbidities (diabetes, etc.) 2

Transfer Protocol

• Transfer patients directly to burn centers, avoiding intermediate stops, as direct admission improves survival, reduces complications, and decreases length of stay 1, 2, 3
• Use telemedicine consultation when immediate specialist access is unavailable to guide initial management and determine transfer urgency 1, 2, 3
• If the patient exhibits hemodynamic or respiratory instability and transportation time is long, consider a brief stabilization phase at a nearby institution before transfer 1

Critical Pitfall

Never delay specialist referral for any partial-thickness or full-thickness hand burn, as undertriage leads to permanent functional disability, increased morbidity, and mortality 2, 4, 3

Airway and Inhalation Injury Management

Assessment for Inhalation Injury

• Check for circumoral burns, oropharyngeal burns, and carbonaceous sputum, as inhalation injury significantly increases mortality 2
• Early warning signs include unusual sounds, odors, unexpected smoke, heat, or patient complaints 1

Airway Management

• Consider early endotracheal intubation for actual or impending airway compromise, though avoid overly aggressive intubation 5
• For airway fires (rare in ED but critical to know): remove tracheal tube immediately, stop all airway gases, remove burning materials, and pour saline into the airway 1

Carbon Monoxide Intoxication

• All children with CO intoxication exhibiting impaired consciousness and/or neurological, cardiac, respiratory, or psychological symptoms should receive hyperbaric oxygen therapy (HBOT), regardless of carboxyhemoglobin level 1

Wound Care and Cooling

Initial Cooling Protocol

• Cool burns with clean running water for 5-20 minutes in adults with TBSA <20% and children with TBSA <10% in the absence of shock 1, 3
• Cooling reduces burn depth progression and pain intensity 1, 3
• Monitor children closely for hypothermia during active cooling, especially with larger burns 4, 3
• Never apply ice directly to burns; if clean water is unavailable, ice wrapped in cloth may be used for superficial burns only 4

Wound Dressing

• After cooling, loosely cover burns with clean, non-adherent dressings 4, 3
• Clean wounds with tap water or isotonic saline if transfer to a burn center is delayed 1, 4
• Apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera for superficial burns managed at home 4
• Silver sulfadiazine 1% cream is standard treatment for partial-thickness burns, applied once to twice daily to a thickness of approximately 1/16 inch 6, 7
• Continue silver sulfadiazine until satisfactory healing occurs or the burn site is ready for grafting 6
• Avoid prolonged use of silver sulfadiazine on superficial burns as it may delay healing 4

Critical Pitfalls in Wound Care

• Never apply butter, oil, or other home remedies to burns 4, 3
• Do not break blisters, as this increases infection risk 4
• Do not use systemic antibiotics prophylactically; reserve for clinically evident infections 4, 7

Compartment Syndrome and Escharotomy

Recognition and Monitoring

• Monitor for compartment syndrome in circumferential third-degree burns, which can cause acute limb ischemia, thoracic compartment syndrome, or abdominal compartment syndrome 1, 2
• Watch for blue, purple, or pale extremities indicating poor perfusion 4
• Clinical signs include decreased cardiac output, pulmonary compliance, hypoxia, hypercapnia, acute renal failure, and mesenteric ischemia 1
• Monitor intra-abdominal pressure in severe burns, as abdominal compartment syndrome risk is significantly reduced with albumin use 2

Escharotomy Indications and Timing

• Perform escharotomy emergently if deep circumferential burns cause compartment syndrome compromising airways, respiration, or circulation 1, 2
• The only urgent indication is compromised airway movement and/or ventilation; otherwise, escharotomy should be performed within 48 hours of circulatory impairment emergence 1
• Ideally perform escharotomy at a Burns Center by an experienced provider, as poorly performed escharotomy increases morbidity 1, 2
• If immediate transfer is impossible, obtain specialist advice via telemedicine before performing escharotomy 1

Escharotomy Risks

Escharotomy carries risks of hemorrhage and infection, and improper technique is associated with increased morbidity 1

Infection Prevention

Monitoring for Infection

• Watch for signs including increased pain, redness extending beyond burn margins, swelling, or purulent discharge 4
• Prophylactic antibiotics are not indicated for most burn patients 4, 7

Key Challenges Summary

The primary challenges in ED burn management include:

1. Accurate TBSA assessment to prevent fluid overadministration (use Lund-Browder, never Rule of Nines) 1, 2, 3

2. Balancing aggressive fluid resuscitation while avoiding fluid creep complications 1, 2, 3

3. Controlling severe pain with appropriate titrated analgesics in the context of hypovolemia 1, 3

4. Recognizing mandatory transfer criteria and avoiding delays in specialist consultation 1, 2, 3

5. Early detection of compartment syndrome requiring emergent escharotomy 1, 2

6. Identifying inhalation injury that significantly increases mortality 1, 2