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Management of Burns in Casualty (Emergency Department)

1. Immediate Scene/Pre-Hospital Actions

• Remove the patient from the source of injury safely
• Extinguish flames by smothering or dousing with water
• For chemical burns: irrigate copiously with clean water
• For electrical burns: remove from contact only when safe (non-conducting equipment / power off)
• Remove non-adherent clothing, jewelry, and gross debris in the field
• Apply room-temperature water compresses (20-25°C) - NOT ice

2. Primary Survey: A-B-C-D-E-F

A - Airway (Most Critical First Step)

• Airway management is the single most critical first step
• Early endotracheal intubation is indicated when inhalation injury is diagnosed - do not delay, as edema may not be apparent for 24 hours but will rapidly worsen
• Indications for immediate intubation:
  • Hoarse voice, brassy cough, stridor, wheezing
  • Subjective dyspnea (very concerning sign)
  • History of confinement in a burning/enclosed building
  • Impaired mentation
• Clinical signs of inhalation injury: facial burns, singed eyebrows/nasal hairs, oropharyngeal carbon deposits, carbonaceous sputum, oropharyngeal mucosal injury
• Note: perioral burns and singed nasal hairs alone do not confirm upper airway injury - inspect the oral cavity and pharynx further
• Preferred method: orotracheal intubation

B - Breathing

• Assess for spontaneous respirations, stridor, wheezing, rales
• Administer 100% oxygen immediately via non-rebreather mask
• Assume carbon monoxide (CO) poisoning if the patient was in an enclosed space
  • Measure carboxyhemoglobin (COHb) levels
  • Continue 100% O2 for at least 6 hours
  • Hyperbaric oxygen: evidence is limited (Cochrane review found insufficient evidence); still considered in critically ill patients and pregnant women
• Suspect cyanide toxicity in fires involving mattresses/upholstery - treat with hydroxocobalamin (Cyanokit) if coma or metabolic (lactic) acidosis is present

C - Circulation

• Establish large-bore peripheral IV access early (2 IVs for burns >40% TBSA)
• IV placement through burned skin is safe and acceptable if no unburned sites are available
• If peripheral access fails: central venous or intraosseous (IO) access
• Cardiac monitoring: high-voltage burns can cause cardiac arrest; low-voltage may cause delayed arrhythmia
• Initiate ATLS-based primary survey concurrently

D - Disability

• Assess GCS and neuro status
• Stabilize cervical spine - high-voltage burns can cause tetanic contractions severe enough to fracture the cervical or lumbar spine

E - Exposure

• Expose the patient fully - remove all non-adherent and smoldering clothing
• Brush away dry chemicals first, then irrigate
• Alkalis: forceful irrigation for up to 1 hour
• Examine for associated injuries (falls, jumps from buildings, MVCs)
• Cover with a clean, dry blanket to prevent hypothermia

F - Fluids

3. Burn Assessment

Burn Depth Classification

Estimating TBSA (Total Body Surface Area)

• Head and neck: 9%
• Each upper limb: 9%
• Chest (anterior): 9%, Abdomen (anterior): 9%
• Upper back: 9%, Lower back: 9%
• Each thigh: 9%, Each lower leg: 9%
• Genitalia: 1%

Important: Only count second- and third-degree burns when calculating fluid resuscitation requirements. Do NOT include first-degree burns.

4. Fluid Resuscitation

ABLS-Recommended Formulas (Advanced Burn Life Support, 2011):

Replacement fluid = 4 mL x weight (kg) x %TBSA

Timing of Fluid Administration:

• Half the calculated volume in the first 8 hours (from the time of burn, NOT from time of hospital arrival)
• Remaining half over the next 16 hours (hours 9-24)
• Give as a constant infusion, NOT as a bolus

US Army "Rule of 10" (simpler bedside formula):

1. Estimate TBSA to the nearest 10%
2. %TBSA x 10 = initial fluid rate in mL/hr (for adults 40-80 kg)
3. For every 10 kg above 80 kg, increase the rate by 100 mL/hr

Monitoring Adequacy of Resuscitation:

• Insert Foley catheter for accurate hourly urine output
• Target urine output: 0.5 mL/kg/hr in adults, 1 mL/kg/hr in children (<40 kg)
• Adjust infusion rate based on urine output response
• Also monitor: vital signs, CVP/PCWP if central line placed

5. Wound Care in Casualty

Minor Burns (outpatient):

• Cool with room-temperature water (20-25°C) - ice must be avoided
• Remove clothing, jewelry, gross debris
• Debride ruptured blisters; intact blisters are generally left alone
• Moist dressings - nonadherent layer + absorbent outer gauze
• Topical agents: silver sulfadiazine, bacitracin, or honey-based dressings
• Do NOT use prophylactic systemic antibiotics (not recommended by ABA)
• Tetanus prophylaxis: minor burns are tetanus-prone wounds; update immunization if >10 years or unknown status

Major Burns (transfer to burn center):

• Remove wet cooling dressings before transfer
• Cover wounds with dry gauze dressings for transport
• Do NOT use ice or iced solutions
• Preferably transfer to burn center within 72 hours

6. Temperature Management

• Measure core temperature frequently
• Strategies: warm IV fluids, warm the room, cover with sheets/blankets, radiant or convective warming
• Avoid prolonged exposure of the patient

7. Analgesia

• IV opioids (narcotics) are the mainstay - use liberally and do not withhold
• Begin analgesics in the field/prehospital phase
• Fentanyl, morphine, or ketamine can be used depending on hemodynamic status

8. Mortality Estimation: Baux Score

9. Criteria for Referral to a Burn Centre (ABA Guidelines)

• Partial-thickness burns >10% TBSA
• Any full-thickness burn
• Burns involving face, hands, feet, genitalia, perineum, or major joints
• Electrical burns (including lightning)
• Chemical burns
• Inhalation injury
• Burns in patients with pre-existing medical conditions that may complicate management
• Burns with associated trauma
• Children in hospitals without pediatric burn services
• Patients requiring special social, emotional, or rehabilitative intervention

10. Special Burn Types

• Roberts and Hedges' Clinical Procedures in Emergency Medicine, Chapter 38
• Schwartz's Principles of Surgery, 11th Ed., Chapter 8
• Pfenninger and Fowler's Procedures for Primary Care, 3rd Ed.
• Miller's Anesthesia, 10th Ed.
• Fishman's Pulmonary Diseases and Disorders