What are the primary recommendations for managing severe burns in the emergency department, particularly for patients with extensive burns or inhalation injury?

Challenges in Burn Management in the Emergency Department

Primary Assessment and TBSA Measurement Challenge

The most critical challenge is accurate burn surface area assessment, which is systematically overestimated in 70-94% of cases, leading to excessive fluid administration and preventable complications. 1

• Use the Lund-Browder chart exclusively for TBSA measurement in both adults and children, not the Wallace rule of nines which significantly overestimates burn area and is particularly unsuitable for children 1, 2
• In prehospital or mass casualty situations where the Lund-Browder method is impractical, use the serial halving method or open hand method (palm plus fingers = 1% TBSA) 1, 2
• Smartphone applications like E-Burn can facilitate accurate TBSA assessment when available 1, 2
• Repeat TBSA assessment during initial management to prevent both overtriage (consuming inappropriate resources) and undertriage (increasing morbidity and mortality) 1

Immediate Airway and Inhalation Injury Recognition

Inhalation injury remains one of the most challenging aspects of burn care and is a major determinant of mortality, yet there is no consensus among burn centers on optimal management. 3

• Activate emergency services immediately for any patient with signs of inhalation injury: facial burns, difficulty breathing, singed nasal hairs, or soot around nose or mouth 1
• Inhalation injury from hot smoke can rapidly cause airway loss due to swelling and may indicate carbon monoxide poisoning 1
• Patients with inhalation injury have increased risk for pneumonia (the leading cause of death) and multisystem organ failure 3
• Fiberoptic bronchoscopy should be performed to confirm diagnosis and assess severity of bronchial mucosal injury 4

Fluid Resuscitation Complexity

The challenge of "fluid creep" (excessive fluid administration) results from TBSA overestimation and leads to compartment syndrome, abdominal compartment syndrome, and acute respiratory distress syndrome. 5

• Initiate aggressive fluid resuscitation with 20 mL/kg of Ringer's Lactate (not normal saline) within the first hour for burns ≥10% TBSA in adults or ≥5% TBSA in children 5
• Calculate 24-hour requirements using Parkland formula (2-4 mL/kg/%TBSA), administering half in first 8 hours post-burn 5
• Monitor urine output hourly (target 0.5-1 mL/kg/hour) as the primary parameter for fluid adjustment 5
• Normal saline is associated with higher risk of hyperchloremic metabolic acidosis and acute kidney injury compared to balanced crystalloid solutions 5
• For TBSA >30%, initiate 5% human albumin between 6-12 hours post-burn to reduce crystalloid volumes and prevent complications, targeting serum albumin >30 g/L with doses of 1-2 g/kg/day 5
• Albumin administration reduces mortality (OR=0.34, P<0.001) and abdominal compartment syndrome from 15.4% to 2.8% 5

Specialist Consultation and Transfer Timing

Delayed referral to burn specialists increases morbidity and mortality, yet determining transfer criteria in real-time remains challenging. 1, 2

• Contact a burn specialist immediately to determine need for burn center admission—do not delay this consultation 1, 2
• Use telemedicine when immediate specialist access is unavailable to guide initial management and determine transfer urgency 1, 2
• Transfer patients directly to burn centers rather than sequential transfers, as direct admission improves survival and functional outcomes 1, 2

Mandatory Burn Center Referral Criteria:

Adults:

• TBSA >10-20% 2, 5
• Deep burns >5% TBSA 2
• Burns involving face, hands, feet, genitals, or perineum regardless of size 1, 2
• Inhalation injury 2
• Electrical or chemical burns 2
• Age >75 years with any significant burn 2
• Severe comorbidities (diabetes mellitus) 2

Pediatric patients:

• TBSA >5-10% 2, 5
• Deep burns >5% TBSA 2
• Infants <1 year with any burn 2
• Any electrical or chemical burn 2
• Circular burns 2
• Burns involving face, hands, feet, genitals, or perineum 2

Compartment Syndrome Recognition and Escharotomy Timing

Delayed escharotomy for circumferential third-degree burns causing compartment syndrome is associated with increased morbidity, yet determining the precise timing remains challenging. 5

• Monitor for signs of compartment syndrome: blue, purple, or pale extremities indicating poor perfusion 1, 2
• Perform escharotomy emergently if deep circumferential burns compromise circulation, respiration, or airway movement 2, 5
• Ideally perform escharotomy at a burn center by an experienced provider within 48 hours if circulatory impairment develops 2, 5
• The only urgent indication for immediate escharotomy is compromised airway movement or ventilation 5

Pain Management Challenges

Burn pain is often intense and difficult to control, requiring aggressive analgesia that many emergency providers undertreat. 2

• Administer titrated intravenous opioids or ketamine for severe burn pain 2
• Over-the-counter analgesics (acetaminophen or NSAIDs) are appropriate for minor burns 1, 2
• IV ibuprofen 800 mg every 6 hours has been shown safe in burn patients without significant adverse events 1

Wound Care and Infection Prevention

Determining appropriate wound coverage while avoiding treatments that delay healing presents a practical challenge in the ED. 1, 6

• Cool burns immediately with clean running water for 5-20 minutes to limit tissue damage and reduce need for subsequent care 1, 2
• Monitor children closely for hypothermia during active cooling, particularly with larger burns 1, 2
• Remove jewelry before onset of swelling to prevent constriction and vascular ischemia 1
• After cooling, loosely cover burns with clean, non-adherent dressing while arranging transfer 1, 2
• For small partial-thickness burns managed at home, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera after cooling 1
• Avoid prolonged use of silver sulfadiazine on superficial burns as it may delay healing 2, 6
• Do not use systemic antibiotics prophylactically; reserve for clinically evident infections 2

Critical Pitfalls to Avoid

• Never delay specialist referral for any partial-thickness or full-thickness burn involving hands, feet, face, or genitals—this leads to permanent functional impairment 2
• Never use the Wallace rule of nines for TBSA calculation—it causes systematic overestimation and fluid overload 1, 2
• Never break blisters—this increases infection risk 2
• Never apply butter, oil, or other home remedies to burns 2
• Never use normal saline as primary resuscitation fluid—use Ringer's Lactate 5
• Never delay escharotomy when compartment syndrome is evident 5
• Never underestimate fluid requirements in electrical burns, which cause deeper tissue damage than apparent on surface 5