What is the appropriate workup and management for a burn injury?

Workup and Management of Burn Injury

Initial Assessment and Severity Determination

Immediately cool the burn with clean running water for 5-20 minutes to limit tissue damage, then accurately measure total body surface area (TBSA) using the Lund-Browder chart—not the Rule of Nines—as the latter overestimates TBSA in 70-94% of cases, leading to dangerous fluid overload. 1, 2, 3

TBSA Measurement

• Use the Lund-Browder chart as the gold standard for both adults and children, as it provides the most accurate assessment 1, 2, 3
• The Wallace Rule of Nines significantly overestimates TBSA and causes excessive fluid administration in 70-94% of cases 1, 2, 3
• In prehospital settings, use the patient's palm plus fingers (approximately 1% TBSA) or serial halving method 1, 3
• Consider smartphone applications like E-Burn to facilitate accurate assessment 1, 3
• Reassess TBSA during initial management to prevent over- or undertriage 3

Burn Depth Classification

• Superficial burns: Involve epidermis only, heal without scarring 4
• Superficial partial-thickness: Involve superficial dermis, blanch with pressure 4
• Deep partial-thickness: Involve deep dermis, may not blanch, require specialist evaluation 1, 4
• Full-thickness: Involve all skin layers, appear white/charred, require excision and grafting 4

Immediate Specialist Consultation and Transfer Criteria

Contact a burn specialist immediately to determine need for burn center admission, as specialist management significantly improves survival, reduces complications, and facilitates rehabilitation. 1, 2, 3

Mandatory Burn Center Referral Criteria - Adults

• TBSA >10-20% 1, 2, 3
• Deep burns >5% TBSA 1, 3
• Burns involving face, hands, feet, genitals, perineum, or flexure lines regardless of size 1, 2, 3
• Circumferential burns 1
• Smoke inhalation injury 1, 3
• Electrical burns (high or low voltage) 1
• Chemical burns (especially hydrofluoric acid) 1
• Age >75 years with TBSA <20% 1
• Severe comorbidities (diabetes, etc.) with TBSA <20% 1

Mandatory Burn Center Referral Criteria - Pediatrics

• TBSA >5-10% 1, 3
• Deep burns >5% TBSA 1
• Age <1 year with any burn 1
• Burns involving face, hands, feet, genitals, perineum 1
• Circumferential burns 1
• Any electrical or chemical burn 1
• Smoke inhalation injury 1

Transfer Strategy

• Arrange direct admission to burn center rather than sequential transfers, as this reduces time to surgical excision, duration of mechanical ventilation, and mortality 2, 3
• Use telemedicine consultation if immediate specialist access unavailable 1, 2

Airway Management

Do not routinely intubate patients with facial burns alone; intubation should be reserved for specific high-risk criteria to avoid unnecessary procedures that increase complications. 5, 6, 7

Intubation Indications

• Standard indications: severe respiratory distress, severe hypoxia/hypercapnia, coma 5
• Facial burns with ALL of the following: 5
  • Deep circular neck burn, AND/OR
  • Symptoms of airway obstruction (voice change, stridor, laryngeal dyspnea), AND/OR
  • Very extensive burn (TBSA ≥40%)
• Smoke inhalation with signs of upper airway compromise 5, 6, 7
• Circumoral burns, oropharyngeal burns, carbonaceous sputum suggesting inhalation injury 3, 6

Airway Assessment

• Use nasolaryngoscopy for direct visual inspection to guide intubation decisions 6, 7
• Avoid bronchoscopy outside burn centers to prevent transfer delays 5
• In intubated patients with suspected lower airway injury, perform bronchoscopy to remove casts and assess injury extent 7
• Monitor closely for glottic edema development, especially with face/neck burns and smoke exposure 5
• Prepare for difficult intubation in patients with face/neck burns 5

Special Pediatric Considerations

• Tracheal intubation not recommended for hot liquid burns involving face/skull/neck without respiratory distress 5
• Monitor children closely for hypothermia during cooling, especially with larger burns 1

Fluid Resuscitation

For adults with TBSA ≥15% or children with TBSA ≥5-10%, initiate aggressive fluid resuscitation with 20 mL/kg balanced crystalloid (Ringer's Lactate) in the first hour, then calculate 24-hour requirements using the Parkland formula. 2, 3, 8

Initial Resuscitation Protocol

• Administer 20 mL/kg Ringer's Lactate within first hour for adults with TBSA ≥15% 2, 3
• Children require formal IV resuscitation when TBSA ≥5-10% 3
• Use Ringer's Lactate rather than normal saline to reduce risk of hyperchloremic metabolic acidosis and acute kidney injury 2, 3

24-Hour Fluid Calculation (Parkland Formula)

• Calculate total 24-hour requirement: 2-4 mL/kg × %TBSA 3
• Administer half in first 8 hours post-burn, remaining half over next 16 hours 3
• Children may require higher volumes (approximately 6 mL/kg/%TBSA) due to higher surface area-to-weight ratio 3

Monitoring and Titration

• Target urine output: 0.5-1 mL/kg/hour in adults, 1-1.5 mL/kg/hour in children 3, 8
• Adjust fluid rates hourly based on urine output as primary parameter 3
• Monitor arterial lactate concentration for adequacy of resuscitation 3
• Use advanced hemodynamic monitoring (echocardiography, cardiac output monitoring) in patients with persistent oliguria or hemodynamic instability 3
• If hypotension persists despite adequate fluids, evaluate cardiac function with echocardiography before initiating vasopressors 3

Colloid Administration

• For TBSA >30%, initiate 5% human albumin at 6-12 hours post-burn to reduce crystalloid volumes and prevent "fluid creep" 3
• Target serum albumin levels >30 g/L with doses of 1-2 g/kg/day 3
• Albumin reduces mortality (OR=0.34, P<0.001) and abdominal compartment syndrome from 15.4% to 2.8% 3
• Hydroxyethyl starch (HES) is contraindicated in severe burns 3
• Avoid gelatins and other synthetic starches due to negative effects on coagulation 3

Fluid Resuscitation Pitfalls

• Avoid "fluid creep" (excessive administration) as it causes compartment syndrome and other complications 3, 8
• Patients with delayed resuscitation, trauma, inhalation injury, or alcohol abuse may require >150% of predicted fluid 8
• Consider colloid addition at 12 hours if fluid requirements exceed 150% of predicted 8

Pain Management

Use multimodal analgesia with titrated intravenous opioids or ketamine for severe burn pain, as burn-induced pain is often intense and difficult to control with single agents. 5, 2

Pharmacological Approach

• Administer titrated IV opioids or ketamine for severe burn pain 5, 2
• Titrated IV ketamine can be combined with other analgesics to treat severe burn-induced pain 5
• All analgesic medications must be titrated based on validated comfort and analgesia assessment scales 5
• Short-acting opioids and ketamine are best for burn-induced pain and dressing changes 5
• Inhaled nitrous oxide useful when no IV access available 5
• Over-the-counter medications (acetaminophen or NSAIDs) appropriate only for minor burns managed at home 1, 2

Non-Pharmacological Techniques

• Combine non-pharmacological techniques with analgesic drugs for dressings when patient is stable 5
• Virtual reality or hypnosis techniques may reduce pain intensity and anxiety 5
• Cooling limited burned surfaces and covering with fatty substances (Vaseline) may improve pain control 5

Special Considerations

• Burn injuries trigger inflammation, hypermetabolism, and capillary leakage, increasing risk of adverse effects from analgesics 5
• Alpha-2 receptor agonists difficult to use in acute phase due to hemodynamic effects 5

Wound Care

After cooling, loosely cover the burn with a clean, non-adherent dressing while arranging transfer; clean with tap water or isotonic saline if transfer is delayed. 1, 2

Initial Wound Coverage

• Loosely cover with clean, non-adherent dressing after cooling 1, 2
• Clean wound with tap water or isotonic saline if transfer to burn center delayed 1, 2

Superficial Burns Managed at Home

• Apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera after cooling 1, 2
• Avoid prolonged use of silver sulfadiazine on superficial burns as it may delay healing 1

Critical Wound Care Pitfalls

• Never apply butter, oil, or other home remedies to burns 1, 2
• Do not break blisters as this increases infection risk 1
• Do not use systemic antibiotics prophylactically; reserve for clinically evident infections 1

Carbon Monoxide and Cyanide Poisoning

All patients with suspected CO poisoning after smoke inhalation should immediately receive 100% oxygen via high-concentration mask or mechanical ventilation for 6-12 hours. 5

Carbon Monoxide Management

• Administer 100% oxygen immediately without delay for suspected or confirmed CO poisoning 5
• Continue high-concentration oxygen for 6-12 hours 5
• In children, any child suspected of CO poisoning should receive 100% oxygen starting at first aid stage 5

Hyperbaric Oxygen Therapy (HBOT)

• HBOT indicated for patients with altered consciousness AND/OR neurological, respiratory, cardiac, or psychological symptoms, regardless of carboxyhaemoglobin level 5
• HBOT recommended for CO-poisoned pregnant women regardless of clinical presentation 5
• In children with CO intoxication exhibiting impaired consciousness and/or neurological, cardiac, respiratory, or psychological symptoms, treat with HBOT regardless of carboxyhaemoglobin value 5
• Evaluate HBOT indication case-by-case considering patient stability, severity of poisoning and burn, whether patient is child or pregnant woman, and availability of specialized team 5
• HBOT often contraindicated in severe burns due to hemodynamic/respiratory instability 5
• HBOT not indicated for burn wound healing despite some older literature 5

Cyanide Poisoning

• Suspect cyanide poisoning in all burn patients exposed to enclosed fire 7
• Treat cyanide poisoning with hydroxocobalamin 7

Emergency Escharotomy

Perform escharotomy emergently if circumferential third-degree burns cause compartment syndrome compromising circulation, respiration, or airway, but ideally at a burn center by an experienced provider. 1, 2, 3

Indications for Escharotomy

• Circumferential third-degree (and sometimes deep second-degree) burns causing: 1, 2, 3
  • Compartment syndrome with compromised airways, respiration, or circulation
  • Acute limb ischemia with neurological disorders and downstream necrosis
  • Thoracic or abdominal compartment syndrome with decreased cardiac output, pulmonary compliance, hypoxia, hypercapnia, acute renal failure, or mesenteric ischemia

Signs of Compartment Syndrome

• Blue, purple, or pale extremities indicating poor perfusion 1, 2
• Monitor intra-abdominal pressure for abdominal compartment syndrome 3

Timing and Location

• Perform within 48 hours if circulatory impairment develops 1, 3
• Ideally perform at burn center by experienced provider 1, 2, 3
• Only urgent indication for immediate escharotomy is compromised airway movement or ventilation 3
• Never delay escharotomy when indicated, as poorly timed procedures increase morbidity 3

Monitoring for Complications

Infection Surveillance

• Monitor for increased pain, redness extending beyond burn margins, swelling, or purulent discharge 1, 2
• Do not use systemic antibiotics prophylactically 1

Organ Dysfunction

• Monitor for acute kidney injury, common in severe burns 3
• Assess cardiac function if hypotension persists despite adequate resuscitation 3
• Monitor for acute respiratory distress syndrome 3

Inhalation Injury Assessment

• Inhalation injury increases mortality risk non-linearly with transfer time 2
• Assess for circumoral burns, oropharyngeal burns, carbonaceous sputum 3, 6