BURN

DEFINITION:-

A burn is a type of injury to skin, or other tissues, caused by heat, cold, electricity,
chemicals, friction, or radiation.

Burn injury is a common cause of morbidity and mortality. Outcomes for burn patients
have improved dramatically over the past few years.

CAUSE:-

Burns are caused by a variety of external sources classified as

Thermal(heat
related)

Chemical

Electrical

Radiation

The most common causes of burns are:

a) Fire or flame (44%),
b) Scalds (33%),
c) Hot objects (9%),
d) Electricity (4%),
e) Chemicals (3%).

Specific causes:
a) Most (69%) burn injuries occur at home or at work (9%),
b) Most are accidental, with 2% due to assault by another and 1–2% from a suicide attempt.
c) Burn injuries occur more commonly among the poor.

Risk Factors:
a) Smoking and alcoholism are other risk factors.
b) Fire-related burns are generally more common in colder climates.
c) Specific risk factors include cooking with open fires or on the floor
d) Developmental disabilities in children and chronic diseases in adults.
 Thermal
 Fire and hot liquids are the most common causes of burns.
 Almost half of injuries are due to efforts to fight a fire. Scalding is caused by hot liquids or
gases and most commonly occurs from exposure to hot drinks, high temperature tap water
in baths or showers, hot cooking oil, or steam.
 Scald injuries are most common in children under the age of five.

 Chemical
Chemical burns can be caused by over 25,000 substances, most of which are either a strong base
(55%) or a strong acid (26%).

Most chemical burn deaths are secondary to ingestion. Common agents include:

 Toilet cleaners (sulfuric acid),

 Bleach (sodium hypochlorite),
 Halogenated hydrocarbons (as found in paint remover, among others).

 Electrical
 Electrical burns or injuries are classified as
 High voltage (greater than or equal to 1000 volts)
 Low voltage (less than 1000 volts)
 Lightning may also result in electrical burns. Risk factors for being struck include
involvement in outdoor activities such as mountain climbing, golf and field sports, and
working outside.
 Electrical injuries may also cause fractures or dislocations secondary to blunt force
trauma or muscle contractions. Contact with either low voltage or high voltage may
produce cardiac arrhythmias or cardiac arrest.

 Radiation
 Radiation burns may be caused by protracted exposure to ultraviolet light (such as from
the sun, tanning booths or arc welding) or from ionizing radiation (such as from radiation
therapy, X-rays or radioactive fallout).
 Sun exposure is the most common cause of radiation burns and the most common cause
of superficial burns overall.

 Non-accidental
 Reasons include: child abuse, personal disputes, spousal abuse, elder abuse, and business
disputes.
 Deliberate cigarette burns are preferentially found on the face, or the back of the hands
and feet.
 Bride burning, a form of domestic violence, occurs in some cultures, such as India where
women have been burned in revenge for what the husband or his family consider an
inadequate dowry. In Pakistan & India, acid burns represent intentional burns, and are
frequently related to domestic violence.
 Self-immolation (setting oneself on fire) is also used as a form of protest in various parts
of the world.
PATHOPHYSIOLOGY

Coagulation necrosis of skin & subcutaneous tissue due to heat

Release of vasoactive peptides

Altered capillary permeability

Loss of fluid Severe Hypovolemia

Decreased cardiac output Decreased myocardial function

Decreased renal blood flow (Renal failure) Oliguria

Impaired/ineffective pulmonary resistance Pulmonary

Breathing
edema
difficulty

Infection

Systemic inflammatory response

Multi-organ Dysfunction Syndrome (MODS)

CLASSIFICATION & SIGNS & SYMPTOMS

a) Classification by cause of mechanism

 Electrical Injury
 Chemical Burn- acid/alkali
 Thermal Injury
 Scald - spillage of hot liquids
 Flame Burns
 Flash burn due to exposure to natural gas, alcohol, combustible liquids
 Contact burns - hot metal objects
 Ionizing radiation
 Sunburn & Inhalation injury
b) Classification by degree & depth
  First-degree or superficial burns are defined as burns to the epidermis that result in a
simple inflammatory response. They are typically caused by exposure of the unprotected
skin to solar radiation (sun-burn) or to brief contact with hot substances, liquids or flash
flames (scalds). First-degree burns heal within a week with no permanent changes in skin
color, texture or thickness.

 Second-degree or partial-thickness burns result when damage to the skin extends

beneath the epidermis into the dermis. The damage does not, however, lead to the
destruction of all elements of the skin.
– Superficial second-degree burns are those that take less than three weeks to heal.
– Deep second-degree burns take more than three weeks to close and are likely to
form hypertrophic scars.

 Third-degree or full-thickness burns are those where there is damage to all epidermal
elements – including epidermis, dermis, subcutaneous tissue layer and deep hair follicles.
As a result of the extensive destruction of the skin layers, third-degree burn wounds
cannot regenerate themselves without grafting.

c) Classification by extent of burn

The extent of burn, clinically referred to as the total body surface area burned, is defined as
the proportion of the body burned. Several methods are used to determine this measurement;
the most common method is called “Rule of Nine”.

Wallace Rule of 9 (nine) Lund & Browder Method Palm Method

 Wallace Rule of 9:-

In this method the various surface of the body are equally divided in 9%

Sl Area Front Back Total

no
1. Head & 4.5% 4.5% 9%
neck
2. Trunk 9% 9% 18%
9% 9% 18%
3. UL (L) 4.5% 4.5% 9%
4. UL (R) 4.5% 4.5% 9%
5. LL (L) 9% 9% 18%
6. LL (R) 9% 9% 18%
7. Genital 1% 1%
side body Total 100%
 Lund & Browder method

Area Age
0 1 5 10 15 Adult
A= ½ of 9½ 8½ 6½ 5½ 4½ 3½
head
B= ½ of 2½ 3½ 4 4½ 4½ 4½
one
thigh
C= ½ of 2½ 2½ 2½ 3 3½ 3½
one
lower
leg

Front Back

 Palm method
 In patient with scattered burn the estimation of percentage of burn is done using Palm
method where the size of patient’s palm is equals to 1% of TBSA.

Signs & symptoms

Sl Types Layers involved Appearance Texture Sensation

no
1 Superficial Epidermis Red without blisters Dry Pain
(First degree)
2 Superficial Extends into Redness with clear Moist Very painful
partial superficial blister. Blanches
thickness dermis with pressure
(Second (papillary)
degree)
3 Deep partial Extends into Yellow or white. Fairly dry Pressure &
thickness deep dermis Less blanching. May discomfort
(Second (reticular). be blistering
degree)
4 Full thickness Extends through Stiff & white brown. Leathery Painless
(Third degree) entire dermis No blanching.
5 Fourth degree Extends through Black; charred with Dry Painless
entire skin & eschar.
into underlying
muscle &
bones.

DIAGNOSTIC EVALUATIONS

1. History collection:-

History should be taken

from the patient,
witnesses, family or
emergency response
personnel. History should include cause, time and duration of burn (including temperature of
water, names of chemicals or solutions or any other factors), comorbid illnesses, and other
associated injuries.

2. Physical examination:-

A careful physical examination should be done to diagnose depth & extent of burn using any of
the methods to determine the plan of care.

3. Investigations:-

 The investigation may be of varied components.

 Blood & biochemical investigations
The important but not limited investigations are-
 Total count
 Differential count
 Hb%
 Na+
 Urea
 Creatinine
 Mg++
 LFT
 BUN
 Blood glucose
 BT,CT
 ESR
 Imaging studies
X-Ray, CT scan, USG
 ABG evaluation
 ECG, cardiac enzyme analysis
 Culture (blood, tracheal, urine or any body fluid & wound exudates)

MANAGEMENT:-

Emergency Medical Surgical Hydrotherapy Dietary Nursing

1. Emergency/Initial management of Burn:

According to American College of Surgeon Burn patient should undergo a initial assessment
to determine the path of care.
 i. Primary survey

Organizing the evaluation of a burn patient in a manner similar to that of a trauma patient,
beginning with the ABCDE assessment (i.e, airway, breathing, circulation, disability, exposure)
of the primary advanced trauma life support survey.

ii. Secondary survey

For severe burn injuries after establishing airway, and proper fluid resuscitation a detailed survey
for the depth and surface area burnt can be done to organize the nest steps of care to save life ,
minimize multi-organ dysfunction and infection & related complications.

 Airway management

To reduce the chance of any devastating complications it should be done during triaging period.
A large amount of narcotics also depresses the respiratory drive. Smaller to medium sized burn
can initially have a stable airway but may develop stridor with increase edema size causing an
emergency intubation requirement.

 Assess for the need & establish prompt intubation & ventilator support
 Administer supplemental Oxygen with a saturation >90% for all patients.
 Include routine arterial blood gas determinations, chest radiographs, and
carboxyhemoglobin levels (maintain at < 7%) as part of the secondary assessment.
 Administer aerosolized treatments of heparin, TPA, acetylcysteine, and
terbutaline/steroid combinations.

 Intravenous access

 Place IV lines away from burned tissues to reduce any complications like infections or
dislodgement of IV catheter/cannula from the vein secondary to the developing burn
edema.
 Opt for central /peripheral lines. Avoid femoral access to reduce chance of infection until
& unless required.

 Additional Evaluations
 Place a Foley catheter for continuous output monitoring
 Administer nasogastric tube to decompress the stomach and consider beginning early
enteral feedings as part of the resuscitation is recommended.
 Assess peripheral pulses immediately, and evaluate all extremities and the chest wall for
potential compartment syndromes.

 Resuscitative fluid management

 The venerable Parkland formula, which advocated the guideline for total volume of the
first 24 hours of resuscitation (with Ringer lactate [RL] solution) at approximately 4
mL /kg body weight per percentage burn TBSA. With this formula, half the volume is
given in the first 8 hours post burn, with the remaining volume delivered over 16 hours.
Multiple formulas exist with variations in both the volumes per weight suggested and the
type or types of crystalloid or crystalloid-colloid combinations administered.

 It is preferable to isotonic sodium chloride solution (ie, normal saline [NS]) for large-
volume resuscitations because its lower sodium concentration (130 mEq/L vs 154
mEq/L) and higher pH concentration (6.5 vs 5.0) are closer to physiologic levels.

 The formula applied is-

For 1st 24 hrs-
4 ml of RL/ kg body weight X % TBSA=Fluid to be given in first 24 hrs.
- First ½ of the volume to be given in first 8 hrs.
- Second ½ of the volume to be given in second 16 hrs.
For 2nd 24 hrs-

Fluid in First 24 Crystalloid in Second 24- Colloid in Second 24-

Formula
Hours Hours Hours
RL at 4 mL/kg per 20-60% estimated plasma Titrated to urinary
Parkland
percentage burn volume output of 30 mL/h

 Vital Signs

 Routine vital signs, such as blood pressure and heart rate, can be very difficult to
interpret in patients with large burns.
 Tachycardia, normally a clue to hypovolemia, can be secondary to pain.
 High rise in temperature is usual in early period or can be a sign of infection in later
period.

 Vitamin-C

 Antioxidants as adjuncts to resuscitation is administered to minimize oxidant-mediated

contributions to the inflammatory cascade.
 Recently published data using an infusion of 66 mg/kg/h during the first 24 hours
demonstrate a 45% decrease in the required fluid resuscitation in a small group of
patients.

 End point of resuscitation

  Hourly urine output is a well-established parameter for guiding fluid management.
 The rate of fluid administration should be titrated to a urine output of 0.5 mL/kg/h or
approximately 30-50 mL/h in most adults and older children (>50 kg).
 The urge to maintain urine output at rates greater than 30-50 mL/h should be avoided.
 Performing a urinalysis at some point during the first 8 hours can be prudent, especially
for patients with larger burns.

 Colloid & Hypertonic Saline Administration

 Colloid solutions are used to both decrease edema and volume requirements and blunt
the myocardial depression phenomena observed with large burns.
 Albumin is the plasma protein that most contributes to intravascular oncotic pressure.
 Fresh Frozen Plasma (FFP) 0.5-1 mL/kg per percentage burn during the first 24 hours,
beginning 8-10 hours post burn as an adjuvant to RL solution resuscitation.
 Use of Dextran 40 in the early post burn period (first 8 h) at 2 mL/kg/h along with RL
solution before switching to some albumin or fresh frozen plasma plus RL solution
combination for the second 18-hour phase causes microcirculatory increase and thereby
reduce the edema.

 24-30 hrs after the insult a change in fluid management from RL solution to a
combination fluid infusion involving albumin and D5W is helpful in improving the
massive protein losses that have occurred from the burn wound during the first 24 hours.
Replacing this deficit with a steady infusion of 5% or 25% albumin solution can serve to
maintain a serum albumin concentration greater than 2, which can help reduce tissue
edema and improve gut function.

2. Medical management of Burn

 The goal of medical care is to prevent infection. Early excision and grafting is the current
standard of care and the primary surgical method for reducing infection risk and length of
hospital stay and increasing graft take.

 Wound care should be directed at thoroughly removing devitalized tissue, debris, and
previously placed topical antimicrobials.

 A broad-spectrum surgical antimicrobial topical scrub such as

 -Chlorhexidine Gluconate with adequate analgesia and preemptive anxiolytic in
order to permit adequate wound care.

 Multimodal pain management should therefore be considered. Opioid-sparing agents

include,
-Acetaminophen,
-Ketamine and
Alpha-adrenergic agonists such as
-Clonidine and
-Dexmedetomidine should be used.
 Non-steroidal anti-inflammatory agents should be avoided, as they impair wound healing
and increase the risk of acute kidney injury and bleeding.
 Topical antimicrobials to prevent and treat burn wound infection include,
-Mafenide acetate,
-Silver sulfadiazine,
-Silver nitrate solution and
-Silver-impregnated dressings.
 For localized MRSA burn wound infection,
-Topical Fusidic acid and
-Topical Gentamycin sulfate
-Topical vancomycin is more effective.

 For multidrug-resistant pathogen Colistin should be considered.

 For fungal wound infection,
-Voriconazole
-Posaconazole have broader antifungal activity.

 Hyperglycemia is associated with an increase in inflammatory response and occurs in

burned patients Tight glucose control has been suggested to improve survival and to
reduce the sepsis risk.

 Tetanus vaccination plus Anti-Tetanus Immunoglobulin should be administered to

patients who have no history of vaccination with Booster Tetanus Toxoid vaccination
given at 4 weeks and 6 months.

3. Surgical management of Burn:

The current therapy of acutely burn patient is based on
-Adequate resuscitation
- Early wound debridement & closure
- Support of post burn hyper metabolic response
-Control of infection
 Need for surgical treatment
1. Full thickness burn destroys all of the dermal elements which reduce the chance for
regeneration of cells in the injured area.
2. Partial thickness injury causes repopulation of injured area by over accumulation of
sweat glands, hair follicles along with affected dermal elements.

 Procedures:-

Surgical Versajet Enzymatic Skin Grafts Temporary Flap

Excisions hydro- debridement  Sheet graft wound solution
 Tangential surgery  Meshed coverage s
excision system skin graft  Allograft
Escharotomy  Xenograft
 Fascial
excision Cultured  Skin
epithelial cells substitutes
or Dermal
analogue
i. Surgical excisions

Complete debridement

It is the removal of dead, damaged or infected tissue, dirt or debris to improve the healing
potential of remaining healthy tissue.

a) Tangential excision

It implies the excision of necrotic surface of burn, taking repeated slices parallel to the skin
surface using a skin graft knife

b) Fascial excision

It is the excision of full thickness skin & subcutaneous tissue. It is a rapid & relatively bloodless
procedure & provides a reliable bed for skin grafting.

ii. Versajet hydro surgery

This system is a device based on the Venturi effect which is able to cut & aspirate debris
contemporarily. This process is more effective in partial-thickness burn.

iii. Enzymatic debridement

It is a highly selective method of wound debridement that uses naturally occurring proteolytic
enzymes manufactured by health care industry for eliminating devitalized tissue. Topical
enzymes like-
-Collagenase
-Papain

iv. Escharotomy

The tough leathery tissue that remains after a full thickness burn due to cut off of venous &
arterial flow & causing dysfunction, ischemia or necrosis is called an Eschar. In Escharotomy
both the damaged epidermis & dermis are destroyed along with sensory nerves in dermis
resulting in release of blood flow to the specific organ or part of the body.

v. Cultured epithelial cell

Culture Epithelia Autograft or “CEA” provides a permanent skin replacement for patients with
deep dermal or full thickness burns. Epicel grafts are made by patient’s own skin cells in an
incubator.

vi. Temporary wound coverage

Patients with extensive burns require temporary coverage with an

-Allograft

-Xenograft

-Skin substitute or Dermal analogue, due to insufficient or unavailable donor site.

a) Allograft

It is a tissue graft taken from a donor of the same species as the recipient but not genetically
identical. It is also called Allogenic grafting or Homo grafting.

e.g Human tissues.

b) Xenograft

The word ‘Xeno’ is a Greek word meaning stranger, guest or host. Xenografting is a surgical
grafting of tissue from one species to an unlike species (or genus or family).

e.g. Porcaine Xenograft which is a biosynthetic dressing made from Porcine collagen
containing Aldehyde cross linking.

c) Dermal analogue
A variety of skin substitutes or dermal analogues are available which can be broadly divided into
those which replace the epidermis or replace dermis. Epidermal substitutes are normally only a
few cell layers thick and lack normal dermal components.

Collagen based dermal substitutes are porous matrices that act as templates for dermal
regeneration. These products become revascularized over time & can be covered with a thin
epidermal graft to complete the coverage. Various skin analogues available are-

Sl no Product name Classification Characteristics

1 EpiDex Autologus Keratinocyte based.
Bioabsorbable polygactin mesh scaffold
2 Dermagraft Cellular with human fibroblasts (neonatal
origin).
Keratinocyte based cultured epidermal
3 Epicel Cellular
autograft.
Autologus cell suspension of
keratinocytes, fibroblasts, Langerhans
4 Recell Cellular
cells & melanocytes. Sprayable after
culture
5 Alloderm Acellular Human origin
6 Integra Acellular Bovine or shark origin. Bilayer matrix.
Biocomposite dressing, nylon fibers in
7 Biobrane Acellular
silicone with collage

vii. Flap solutions

Flap surgery involves transporting healthy, live tissue from one location of the body to another-
often to areas that have lost skin, fat, muscle movement &/or skeletal support. The various types
are-

 Local Flap= It is located next to the wound; the skin remains attached at one end in order
that the blood supply is left intact.
 Regional flap= It uses a section of tissue that is attached by a specific vessel.
 Bone or soft tissue flap= This type of flap is often used when bone and the overlying
skin are transported to a new location.
 Musculocutaneous flap (muscle & skin flap)= This type of flap is often used when the
area to be covered needs more bulk & increased blood supply.

e.g. Rebuilding of a breast after mastectomy.

 Microvascular free flap= Involves detaching and reattaching skin& blood vessels from
one site of body to another site. Microsurgery is used to attach the blood vessel.

4. Hydrotherapy for Burn:

 (See your procedure copy for hydrotherapy protocol & process)

5. Dietary management of Burn:

After a severe burn injury, a prolonged and persistent hyper metabolic response has been noted.
Therefore, the initiation of early and aggressive nutritional support is required. Delays in enteral
nutrition initiation are associated with gut mucosal damage, decreased absorption, and bacterial
translocation, leading to poorer outcomes.

 Carbohydrates should be delivered at a rate of 7 g/kg/day.

 Fat should comprise less than 25% of the calories obtained from non-protein sources.
 Albumin supplementation to maintain levels higher than 2 g/dL.
(Also see your procedure copy other dietary requirement & daily requirement of calorie
formula from your procedure copy).

6. Activity for Burn:

Patients may be as active as they can tolerate. Aggressive physical and occupational therapy of
extremity injuries is necessary to prevent long-term morbidity.

7. Nursing management of Burn:

(Prepare the nursing management with at least 15 nursing diagnosis considering Pre & post
operative nursing care).

LEGAL & ETHICAL ASPECTS OF BURN

INTRODUCTION

Burn injuries cost a uncountable no of lives throughout the world. Ethical & legal issues are of a
prime importance as the factors or the causes behind the injury varied. Ethical dilemmas may
occur when decisions need to be made about the treatment of incompetent patients. These
decisions may concern the initiation, continuation or termination of treatment.

ETHICAL PRINCIPLES

The ethical principles are-

 1. Autonomy
2. Beneficence
3. Non- maleficence
4. Justice

These right based ethics are the dominant principles which place the patient at the centre of
moral equation. An action is of moral worth only if it enhances & does not inhibit the rights of an
individual patient.

1. Autonomy:- The patient should be able to think & act without influence or control by
others.
2. Beneficence:-The patient should receive the benefit of an intended treatment.
3. Non- maleficence:-The patient should come to no harm.
4. Justice:- Treatment should be implemented in a fair & impartial manner.

ETHICAL & LEGAL ISSUES IN BURN CARE

In provision of care to the burn victim there are several prominent individual issues which
require potentially challenging ethical judgments. In each circumstance one must consider the
boundaries of medical law, the values of the health care profession & ethical principles &
theories. The various legal-ethical issues are-

a) The patient/ carer relationship

b) Consent to treatment
c) Informed consent
d) Consent in incompetent adult
e) Consent in minors
f) Refusing treatment
g) Medical futility
h) Withholding & withdrawing treatment
i) Assisted suicide
j) Research
k) Rationing & distributive justice

a) The patient/ carer relationship

In burn care the interaction between the patient & health care personnel can be characterized
by different models. The relationship inevitably may be prone to dominance by the healthcare
professional. It is the caregiver that has the command of the knowledge & skills relevant to the
patient’s predicament.
b) Models of patient/ physician/ health care worker interaction

In normal practice in order to respect the patient’s right of self-determination, he or she must
be engaged in a dialogue with the doctor or any health care personnel.

c) Consent to treatment
Health care professional should explain the nature, the purpose & the risk of a proposed
treatment to the patient & attendants. Failure to obtain consent is a breach of the professional’s
duty of care to the patient.

d) Informed consent
According to American judge Benjamin Cordoza, “Every human being of adult years &
sound mind has a right to determine what shall be done with his body, & a surgeon who
performs an operation without the patient consent commits an assault for which he is liable.”
Therefore a proper Informed consent must fulfill three principles, which are-
 Competence = The patient must be able to think rationally & thus make a personal
discerning decision.
 Absence of coercion = The patient has the right to give or refuse consent without
influence from others.
 Provision of adequate information = The patient must have enough relevant
information to make a valued judgment on the proposed treatment.

Consent is often sought when patients are anxious or in distress. This is particularly relevant to
the acute care of a burn victim. Where possible it is advisable to allow a reasonable interval
between obtaining consent and starting a treatment, in order that a patient can reflect calmly on
the relevant issues.

e) Consent in incompetent adult

In order to consent to treatment an adult must have the capacity to make decisions on his
or her own behalf. To be considered competent the patient must satisfy the following criteria:
 He or she must comprehend and retain the relevant information
 He or she must believe that information
 He or she must be able to deliberate rationally in order to achieve a final decision.

f) Consent in minors

A child could be deemed as having the capacity to consent if he or she has sufficient
understanding, intelligence and maturity to make a reasoned decision. If the criteria are not
fulfilled, then consent is not valid, and the parental right to determine consent must be exercised.
g) Refusing treatment

Some patients through their own deliberate life style choices place themselves at risk of illness
and yet are still eligible for treatment e.g. suicidal attempt in burn.
It is unethical for a doctor to withhold treatment from a patient on the basis of a moral
judgment that the patient's activities or lifestyles have contributed to the condition.
In the field of burn care, secondary reconstructive procedures are components of the
overall package of treatment. One cannot therefore ethically refuse to treat a patient. It is also
unreasonable and unethical to insist that a patient be screened to identify the level of risk to
healthcare workers. Patients can only be screened for diseases such as HIV, HEP-B, in-order to
identify risk to themselves or other members of the society, and then only with their consent.

h) Medical futility

For victims of major burns there is a relatively well-established relationship between the
severity of the injury and the chance of survival. The burns doctor can with reasonable
confidence identify a group of patients for whom medical intervention would be futile, and
would be associated with no precedent of survival. If an intervention (particularly CPR) is
deemed as futile by `consensus', then the issue of `patient autonomy is irrelevant. It is argued that
such an intervention need not be performed, even if previously requested by the patient.
Advocates of absolute patient autonomy would justify resuscitation on the grounds that, even if
the patient does not eventually survive, resuscitation may restore to the patient his or her
decision-making capacity.

i) Withholding & withdrawing treatment

If it is ethically sound to withhold a treatment on the grounds of a living will, or on the

grounds that such treatment is medically futile, then it can be argued that to withdraw a treatment
is equally sound and justifiable.
e.g. For patients who are terminally ill as result of their injuries inappropriate aggressive
treatments may actually worsen their quality of life.

j) Assisted suicide

The discussion of the ethical issues inherent in burn care would be complete without
referring to the subject of whether it is ethically valid for a doctor to assist a patient who wishes
to commit suicide. When a patient asks for help in ending his or her own life, it is imperative that
any doctor or health care worker considers what has led the patient to make such a request. E.g.
Is their pain control inadequate; is the patient able to make a reasoned judgment? Is the patient
suffering from depression that could readily be alleviated?
 Euthanasia or Mercy killing is still a ground for deliberate argument therefore. It might
take a very long period for a patient to legally get the permission for him/ herself to get
assistance in early death.

k) Research

It is imperative that the ethical characteristics of any proposed research project be

considered. If a patient suffers any harm as a result of the proposed treatment then the fact that
the patient gave consent does not exclude him or her (any health care worker conducting the
research) from being eligible for compensation. The patient should not enroll in a research
project due to a fear of being deprived of a potentially beneficial treatment. The patient has a
right to be fully informed of standard or alternative treatments, and of the extent of the current
knowledge of the proposed treatment.

l) Rationing & distributive justice

It is an inescapable reality of health care provision that resources have finite levels. Once
this premise is accepted the concept of rationing is morally sound provided that it is done so in a
manner deemed by society as fair. When a treatment is of marginal or unproven worth to the
individual, then the cost of that treatment and its impact on the rest of society must be
considered. Given the high cost of surgery and Intensive Care therapy, those working in burn
care can increasingly expect to be involved in dilemmas concerning resource allocation. Health
care workers should be aware of the financial implications of their actions & should also act as a
advocate for the right of patients without avoiding the possible consequences of limited facilities.

CONCLUSION

The care of burn victims is a worthy under taking, professionals should have no fear and
no reluctance to examine the moral basis of their decisions. Ethical decision making is the bread
and butter of burn care. Therapeutic advances and changes in society should impel those that
care for burn victims to reexamine and reapply the established medical ethical principles.
First 24 hours management of burn patient.

1. How to perform the Primary Survey and Secondary Survey?

The burn injury itself has a secondary role in the moment of primary survey. Directly on
admission Advanced Trauma Life Support (ATLS) guidelines must be performed and the
following points must be checked:
Airway: Early recognition of airway compromise followed by prompt intubation can be live
saving. If there is soot in the mouth consider early intubation even if the patient is breathing
normally.
Breathing: Determine if the patient is moving air or not.
Circulation: Obtain appropriate vascular access and a monitor device to control heart rate and
blood pressure.
Disability: Detect if there are any other manifestations including fractures and deformities,
abdominal injury or neurological deficit.
Exposure: The patient should be completely exposed and should be out of clothes. Exposure of
all orifices must be conducted in this part.
Fluid resuscitation: A mainstay in the treatment. This point is discussed in the third question
after the calculation of the total burned surface area (%TBSA) but the guidelines of Acute
Trauma Life Support (ATLS) should be followed in order to maintain the circulation process.
Note that a child is prone to hypothermia due to its high surface to volume ratio and lowfat mass.
Ambient temperature should be from 28° to 32°C (82° to 90°F). The patient’s core temperature
must be kept at least above 34°C.
Secondary survey is designed as a burn-specific survey. It is performed during admission to the
burn unit. Full history should be approached including:
 Detection of the mechanism of injury.
 Time of injury.
 Consideration of abuse
 Height and weight.
 Possibility of carbon monoxide intoxication based on the history of burns in a
closed area as well as the presence of soot in mouth and nose
 Facial burns.
Examination of the cornea is important as well as the ear in case of explosion trauma. A systemic
overview should be performed in this phase including a fast run on the abdomen, genital
region, lower and upper limbs (think: X-Ray C-Spine, Thorax, and Pelvic). If the patient is a
child, look for signs of abuse.
1. What are the main aspects of Resuscitation?
Calculation of the total burned surface (% TBSA) area is essential in this
part. Charles Baxter, MD, at Parkland Hospital, Southwestern
University Medical Centre, designed in the 1960s [8, 9] the Parkland
formula to calculate the fluid needs for the first 24 hours. Although
many modifications of this formula have been proposed this formula is
still one of the easiest ways to calculate the fluid volume for burn
patients.
4mL×Patient's body weight×TBSA=Volume to be given in the first 24
hours
50% of this volume is infused in the first 8 hours, starting from the time
of injury, and the other 50% is infused during the last 16 hours of the
first day.
The type of fluid administration is a debatable question. Lactated Ringer
has been commonly used and is even used up to date. On the other
hand, many centres suggest balanced electrolyte solutions like Ringer-
acetate to prevent the high dose administration of lactate. According to
our experience and to the best of our knowledge, we believe that
balanced electrolyte solutions are a safe option and therefore they are
recommended in our centre. Furthermore, specific burn populations
usually require higher resuscitation volumes sometimes as much as 30-
40% higher (close to 5.7 mL/kg/%TBSA) than predicted by the Parkland
formula [10, 11]. Klein et al have suggested that patients today are
receiving more fluid than in the past. Their purpose was to find
significant predictors of negative outcomes after resuscitation. They
concluded that higher volumes equalled a higher risk for complications,
i.e. lung-complications [12, 13]. These results support that fluid overload
in the critical hours of early burn management may lead to unnecessary
oedema [14].
 Overall, the use of Parkland formula is just a process of estimation.
Clinically, fluid needs of an individual, after the use of any suggested
formula, should be at least monitored by several important factors such
urine output, blood pressure and central venous pressure. An important
point and considered to be the goal in fluid resuscitation is to maintain a
urine output of approximately 0.5 ml/kg/h in adults and between 0.5
and 1.0 ml/kg/h in patients weighing less than 30 kg [15]. Failure to
meet these goals should be addressed with gentle upward corrections in
the rate of fluid administration by approximately 25% [16].
Due to the capillary leak, most burn centres advise not to use colloids
and other blood products within the first 24 hours [17]. If used in the
early phase (up to 12 h), it can lead to a prolonged tissue oedema and
consecutive lung complications. Furthermore colloids are not associated
with an improvement in survival, and are therefore more expensive than
crystalloids [18]. Liberati et al advocated that there is no evidence that
blood products (including human albumin) reduce mortality when
compared with cheaper alternatives such as saline [19].
Maintenance dose is provided after the first 24 hours. It can be
calculated as follows [1, 20]:
100ml/kg:for the first10kg50ml/kg:for the second10kg20ml/kg:every
kilogram above20kg
Special considerations for children:
Modified Parkland Formula is used for this category of patients as
follows [1, 21]:
4mL×Patient's body weight×TBSA×Maintenance fluid=Volume to be
given in the first 24 hours
2. 5.
What kind of routine interventions should be performed for
each case of burns during admission to the Burn Unit?
Injured patients differ in term of burns size and depth. Pre-existing
conditions play an important role in this phase. Central venous
catheter and arterial line are indicated if the patient is
hemodynamically unstable or if frequent blood gas analysis is required.
Furthermore, nasogastric tube and urinary catheter are indicated
in patients with 20% TBSA or more. Nasogastric tube will initiate
immediate feeding and decrease the possibility of ileus or aspiration.
Urinary catheter that is equipped with a temperature probe is preferred.
Before washing the patients, swabs for microbiological
examination should be taken from different areas including burn
areas, mouth, nose and the inguinal area. It should be made clear
that the patient is washed properly with warm water and then re-
evaluated regarding the total burned surface area (TBSA) as well as the
 degree of burns. A definite evaluation of the total burned surface area
(TBSA) can only be made when the patient is washed completely and the
wounds can be judged properly. In this phase, indication for surgery is
made including escharotomy, debridement and in certain situations skin
grafting. This point will be discussed in the 9th question.
3. 6.
What kind of laboratory tests should be done?
Basic laboratory tests include the following:
 Complete blood count (CBC) and Arterial blood gas (ABG)
analysis,
 Urea and Electrolytes (U&E),
 Prothrombin time (PT) / Partial thrombin time (PTT) and
International Normalized Ration (INR),
 Sputum Culture and Sensitivity,
 Creatine Kinase (CK) and C-reactive protine (CRP),
 Blood glucose,
 Urine drug test,
 Human chorionic gonadotropin (B-HCG): if the patient is female,
 Albumin test.
 Thyroid values and myoglobin measures.
4. 7.
Does the patient have Inhalation Injury and is Bronchoscopy
indicated for all patients?
Burns occurring in closed areas and all burns that are affecting the head
are subjected to inhalation injury [22, 23]. If Carbon monoxide (CO)
intoxication is suspected, perform arterial blood gas (ABG) analysis to
detect carboxyhemoglobin (COHb), immediate supply of 100% oxygen,
chest X-Ray and discuss the possibility of hyperbaric oxygen (HBO)
therapy. COHb higher than 20% or cases presented with neurological
deficits are absolute indications for HBO, whereas COHb amounts of
10% and higher are seen as relative indications for HBO [24]. Overall,
intubated burn patients provide a good access for bronchoscopy. In this
case, fiberoptic bronchoscopy can be used to evaluate the extent of
airway oedema and the inflammatory process that is caused by any form
of inhalation injury including the carbon monoxide (CO) intoxication
[22, 23]. On the other hand, the role of bronchoscopy is debatable in
terms of the therapeutic aspect as well as its invasive procedure.
5. 8.
What kind of consultations should be carried out
immediately?
Depending on the secondary survey, several consultations may be
necessary. In case of facial burns, consult:
  Otolaryngology (ENT) department: to exclude burns of the upper
airway, laryngeal oedema or in case of explosion rupture of the
tympanic membrane.
 Ophthalmology: to exclude erosion or ulceration of the cornea.
Follow the same procedure as performed in the primary survey. As
guided by the Advance Trauma Life Support (ATLS), consult or re-
consult if already performed:
 Trauma surgery,
 Abdominal surgery and
 Neurosurgery.
6. 9.
Does the patient need Emergency Surgery or not?
Debridement:
The term ''Debridement'' is not merely a surgical procedure.
Debridement can be performed by surgical, chemical, mechanical, or
autolytic procedures. Surgical modalities including early tangential
excision (necrectomy) of the burned tissue and early wound closure
primarily by skin grafts has led to significant improvement in mortality
rates and substantially lower costs in these patients [25, 26].
Furthermore, in some circumstances, escharotomy or
even fasciotomy should be performed.
Indications of surgical debridement:
1. 1.
Deep second degree burns.
2. 2.
Burns of any type, that are heavily contaminated
3. 3.
Third degree circumferential burns with suspected compartment
syndrome (think of: Escharotomy)
4. 4.
Circumferential burns around the wrist (think of: Carpal tunnel
release)
Benefits of surgical debridement:
1. 1.
To reduce the amount of necrotic tissue (beneficial for
prognosis)
2. 2.
To get a sample for diagnostic purposes (if needed).
Complications of debridement:
5. 1.
Pain.
6. 2.
 Bleeding.
7. 3.
Infection.
8. 4.
Risk of removal of healthy tissue.
Contraindications:
1. 1.
Low body core temperature below 34°C.
2. 2.
Cardiovascular and respiratory system instability.
Any trainee should be aware of the following terms:

Complications
Deep or Extensive Burns Complications
 Breathing problems
 Bone and joint problems
 Dangerously low body temperature
 Infection and sepsis
 Low blood volume
 Scarring
 Tetanus[28][29]
Infection is the most common complication. In order of frequency, potential complications
include pneumonia, cellulitis, urinary tract infections, and respiratory failure. Pneumonia
commonly occurs in those with inhalation injuries.[30][31]
Superficial partial-thickness burns are characterized by forming blisters within 24 hours between
the epidermis and dermis. These wounds are painful, red, and weeping and become blanch with
applying pressure. Initial burn assessments might be underestimated. Burns that initially seem to
involve epidermal in depth maybe later categorized as partial-thickness wounds. These burns
generally heal in one to three weeks; scarring is unusual, although discoloration may occur.
These burns generally heal without any functional impairment or hypertrophic scarring. Deep
partial-thickness wounds extend into the deeper dermis and have a different course than
superficial partial-thickness burns. Deep burns involve hair follicles and glandular tissue. They
almost always blister, are macerated, wet, or waxy dry, and demonstrate variable mottled
colorization. Deep burns do not blanch with applying pressure. If the infection is prevented and
spontaneous healing without grafting occurs, they will heal in two to nine weeks. Deep partial-
thickness wounds always result in hypertrophic scarring. A deep partial-thickness burn that does
not heal in two weeks would be considered a full-thickness burn in terms of functional and
cosmetic outcomes.[32][33]
Other Complications
 Anemia secondary to full-thickness burns of greater than 10% TBSA is common.
 Electrical burns may result in compartment syndrome or rhabdomyolysis.
 Blood clotting in the veins of the legs occurs in 6-25% of patients with extensive burns.
 The hypermetabolic state that may persist for years after a major burn may decrease bone
density and muscle mass.
 Keloids may form after a burn.
 Following a burn, psychological trauma and post-traumatic stress disorder may develop.
 Scarring may result in a disturbance in body image.
 In the developing world, significant burns may result in social isolation, poverty, and
child abandonment.[34][35][36]
 Monitoring fluid status — Confirming the adequacy of resuscitation is
more important than strict adherence to Parkland or any fluid resuscitation
formula. Monitoring urine output using an indwelling bladder catheter (eg,
Foley catheter) is a readily available means of assessing fluid resuscitation.
Hourly urine output should be maintained at 0.5 mL/kg/hr in adults. Patients
with minimal or no urine output after sustaining severe burns, despite
appropriate fluid resuscitation, generally do not survive.
 Clinical signs of volume status, such as heart rate, blood pressure, pulse
pressure, distal pulses, capillary refill, and color and turgor of uninjured skin
are monitored every hour for the first 24 hours. Inadequate fluid
resuscitation is the most common cause of diminished distal pulses in the
newly burned patient [24].
 Another potential cause of diminished pulses is peripheral edema, which
develops in many severe burn patients due to the large fluid volumes
needed for resuscitation. As edema increases, elevated compartment
pressures can compromise distal circulation and may require escharotomy.
(See 'Escharotomy' below.)
 Specific laboratory measurements such as mixed venous blood gas and
serum lactate concentration are additional important guides to the
adequacy of resuscitation [41]. A decrease in mixed venous oxygen
saturation and an increase in serum lactate suggest inadequate end-organ
perfusion (elevated serum lactate can also occur with carbon monoxide or
cyanide poisoning). (See "Carbon monoxide poisoning" and "Cyanide
poisoning".)
 If available, invasive monitoring, such as central venous pressure, may be
useful for monitoring fluid resuscitation, but it is generally not used in acute
burn management. The American Thoracic Society (ATS) consensus
conference report for the detection, correction, and prevention of tissue
hypoxia, as well as other ATS guidelines, can be accessed through the ATS
web site at www.thoracic.org/statements.
 Care should be taken not to give excess IV fluid beyond what is needed as
this may exacerbate pulmonary edema, a common problem among burn
 victims. However, some researchers have questioned the association
between fluid resuscitation volumes and pulmonary edema [12].
(See "Treatment of severe hypovolemia or hypovolemic shock in adults".)
 New technologies to guide fluid resuscitation are being developed, but
require further study before widespread implementation can be
recommended [45-48]. Esophageal echo-Doppler and cardiac output
monitoring are being studied with the goal of developing less invasive
means of assessing the adequacy of fluid resuscitation in patients with
severe burns. Other approaches being studied include Doppler ultrasound
measurement of kidney perfusion and computer-guided infusions based
upon urine output.
 Blood transfusion — Although evidence is limited, blood transfusions have
been associated with increased mortality in patients with severe thermal
burns, and we suggest that aggressive transfusion be avoided [49-51]. For
patients not at significant risk for an acute coronary syndrome (ACS), we
suggest transfusing patients with two units of packed red blood cells only if
the hemoglobin falls below 8 g/dL; for patients at risk for ACS, we suggest a
transfusion threshold of 10 g/dL. Transfusion of the trauma patient with
severe hemorrhage is discussed separately. (See "Initial management of
moderate to severe hemorrhage in the adult trauma patient".)
 Hemoconcentration occurs during the first several hours immediately
following a severe burn and transfusions are generally unnecessary.
Thereafter, bone marrow function is depressed and transfusions may be
needed. Erythropoietin has not been shown to prevent anemia or decrease
transfusion requirements and is not in general use at burn centers [13].
 Immediate burn care and cooling — Any hot or burned clothing, jewelry,
and obvious debris should immediately be removed to prevent further
injury and to enable accurate assessment of the extent of burns (caretakers
should take precautions to avoid injuring themselves when removing such
material).
 Burned areas should be cooled immediately using cool water
or saline soaked gauze. For small and moderate sized burns, cooling can
minimize the zone of injury. Multiple studies have investigated optimal burn
cooling, with durations from 15 minutes to three hours [52-54]. We
generally apply saline-soaked gauzes, at a temperature of approximately
12°C, for 15 to 30 minutes. Cooling tissue to around 12°C (54°F) during the
first several hours after injury effectively decreases pain from burns; ice and
freezing should be avoided to prevent frostbite, systemic hypothermia, and
extension of burn injury.
  Core body temperature is continuously monitored while cooling is
performed to help prevent hypothermia, especially when dealing with burns
greater than 10 percent TBSA; body temperature below 35°C (95°F) should
be avoided [55,56]. Warmed IV fluids can be used to maintain core body
temperature. (See 'Fluid resuscitation' above and "Accidental hypothermia in
adults".)
 Pain and anxiety management — Partial-thickness burns in particular can
be excruciatingly painful. IV morphine has been the mainstay of pain
management for patients with significant burns. These patients may
require extremely large doses of IV morphine or other opioids. It is
reasonable to give patients with significant burns benzodiazepines given the
anxiety associated with these injuries. The treatment of pain and anxiety in
critically ill and burn patients is discussed in detail separately.
(See "Management of burn wound pain and itching" and "Pain control in the
critically ill adult patient".)

SECONDARY SURVEY AND MANAGEMENT After the primary survey

and initial resuscitation measures are performed, a detailed secondary survey,

including a thorough physical examination and the management steps listed
below, should be undertaken. Injuries commonly missed in the secondary survey
include corneal abrasions and perineal wounds. The secondary survey is discussed
in greater detail separately. (See "Initial management of trauma in adults", section
on 'Secondary evaluation and management'.)
Laboratory studies and monitoring — Ongoing pulse oximetry and cardiac
monitoring are performed for all patients with significant thermal burns. Routine
laboratory studies obtained in such patients generally include: complete blood
count, electrolytes, blood urea nitrogen, creatinine, glucose, venous blood gas
(VBG), and carboxyhemoglobin. Arterial blood gas (ABG), chest radiograph, and an
electrocardiogram (ECG) are obtained in any patient at risk for inhalation injury.
Blood cyanide concentrations may be obtained for diagnostic confirmation, but
results are not available in time to be clinically useful. (See "Cyanide
poisoning" and "Inhalation injury from heat, smoke, or chemical irritants".)
A blood type and cross-match is obtained for any victim of significant trauma in
anticipation of the need for transfusion. Other laboratory studies that may be
useful in assessing muscle, cardiac, or end-organ injury include urine myoglobin,
serum creatine kinase, and serum lactate. The VBG is a useful tool for assessing
shock and the adequacy of resuscitation [57]. Findings from VBG analysis,
including base deficit, correlate with ABGs [58]. (See "Initial management of
trauma in adults" and "Rhabdomyolysis: Clinical manifestations and
diagnosis" and "Prevention and treatment of heme pigment-induced acute kidney
injury (including rhabdomyolysis)".)
Chemoprophylaxis — Patients with extensive burns are considered to be
immunosuppressed on the basis of altered neutrophil activity, T lymphocyte
dysfunction, and imbalance in the production of cytokines [59-61]. Bacterial
colonization of the burn eschar site can result. The burn also destroys the physical
barrier to tissue invasion, which permits spread of the bacteria to the dermis and
through the lymphatics along fibrous septae. Once invasion occurs, organisms can
proliferate, especially in necrotic tissue, and can invade blood vessels producing a
secondary bacteremia. Therefore, prophylaxis against infection
with topical antibiotics is given to all patients with nonsuperficial burns.
Tetanus — Tetanus immunization should be updated if necessary for any burns
deeper than superficial-thickness. Tetanus immune globulin should be given to
patients who have not received a complete primary immunization (table 3) [62].
(See "Tetanus-diphtheria toxoid vaccination in adults" and "Tetanus".)
Antibiotics — Topical antibiotics are applied to all nonsuperficial burns. If the
patient is immediately transferred to a burn center, burns are covered with clean,
dry dressings and antibiotics are applied at the burn center. Treatment can be
started in the emergency department (ED) if, for example, delays in transferring
the patient to a burn center are anticipated. The best treatment of blistered burns
is unclear. We apply topical antibiotics to partial thickness burns with intact
blisters. Topical chemoprophylaxis is typically continued until wound
epithelialization is complete. Prophylactic intravenous (IV) antibiotics are not
typically given [63,64].
Selection of the topical antibiotic should be made in consultation with the burn
center or admitting team, if treatment is begun in the ED. Classically, silver
sulfadiazine (SSD) is used to prevent infection; it should be avoided near the eyes
or mouth in those with sulfonamide hypersensitivity and in pregnant women,
newborns, and nursing mothers. Bacitracin is a good alternative topical antibiotic
in these individuals. Triple antibiotics (eg, polymyxin B, neomycin) can also be
used. Because of decreased cost, many favor bacitracin. Topical antibiotic
treatment is discussed in detail separately. (See "Topical agents and dressings for
local burn wound care", section on 'Antimicrobial agents'.)
Wound management — Burn wounds should be cleaned. Embedded bits of
clothing or other materials are removed by copious irrigation. Tar and asphalt can
be removed with a mixture of cool water and mineral oil but should not be
debrided. Copious amounts of polymyxin-B bacitracin zinc ointment (polysporin)
applied for several days will emulsify residual tar. Management of tar and asphalt
is discussed separately.

Gastrointestinal interventions — Shock from thermal burn injuries results in

mesenteric vasoconstriction predisposing to gastric distension, ulceration (so-
called Curling's ulcer), and aspiration. Therefore, a nasogastric tube should be
placed in patients with moderate or severe burns >20 percent TBSA [24]. High-risk
patients receive medication to reduce gastric acid secretion, but this is usually
initiated after admission. (See "Stress ulcers in the intensive care unit: Diagnosis,
management, and prevention".)
Although generally not begun in the ED, early enteral feedings (ie, within 24 hours
of injury) to meet basic patient energy needs attenuate the catabolic response to
burns and are associated with improved outcomes [75,76]. Overfeeding does not
help to maintain lean body mass and is associated with fatty liver so is to be
avoided [77]. (See "Nutrition support in intubated critically ill adult patients: Enteral
nutrition".)
Modulating the catabolic response — Major burns cause a hypermetabolic state
that is associated with a number of harmful physiologic derangements including
immunosuppression, impaired wound healing, muscle catabolism, and hepatic
dysfunction. A number of treatments are used to attenuate this hypermetabolic
state. These treatments are generally initiated in the intensive care unit but may
be started in the ED in close coordination with the burn team that will be assuming
care of the patient. (See "Hypermetabolic response to moderate-to-severe burn
injury and management".)

SUMMARY AND RECOMMENDATIONS

●Approach to initial assessment and treatment – Proper management

during initial resuscitation reduces the risk of death and major morbidity
associated with severe thermal burns. An algorithm for the initial assessment
and management of the burn victim is provided (algorithm 1). Early transfer
to a burn center should be arranged when injuries meet the criteria for major
burns (table 1). Emergency clinicians should coordinate patient care closely
with either the admitting team or, in the case of transfer, with the accepting
burn team. (See 'Initial assessment and treatment' above.)
●Initial stabilization – Initial management focuses on stabilizing the airway,
breathing, and circulation. Look for evidence of respiratory distress and
smoke inhalation injury, a common cause of death in the acute burn victim.
Initial assessment may reveal no evidence of injury, but laryngeal edema can
develop suddenly and unexpectedly. Aggressive airway management with
early intubation is warranted if there is evidence of inhalation injury such as
persistent cough, stridor, wheezing, hoarseness, deep facial or
circumferential neck burns, nares with inflammation or singed hair,
carbonaceous sputum or burnt matter in the mouth or nose, and blistering
or edema of the oropharynx. (See 'Initial interventions' above and 'Airway
management' above.)
●Assess extent and degree of burns – A combination of the burn
mechanism, burn depth, extent, and anatomic location helps determine the
overall severity of the burn injury and provides general guidance for the
preferred disposition and care of the burn victim. Therefore, it is important
that clinicians properly characterize the size and severity of the burns (figure
1 and table 2). (See 'Classification of burns' above and "Assessment and
classification of burn injury".)
●Fluid resuscitation – Vascular collapse from burn shock can occur as a
pathophysiologic response to severe burns. Rapid, aggressive fluid
resuscitation to reconstitute intravascular volume and maintain end-organ
perfusion is crucial. Fluid requirements are based initially upon a formula (eg,
modified Brooke) and subsequently upon patient response to the initial
intravenous (IV) fluids. (See 'Fluid resuscitation' above.)
•Initial fluid selection – In a patient with moderate or severe burns, we
suggest using Lactated Ringer (LR) for fluid resuscitation (Grade 2C).
(See 'Initial fluid selection' above.)
•Estimating initial fluid requirements – The modified Brooke formula
can be used to calculate initial fluid needs. According to this formula, the
fluid requirement during the initial 24 hours of treatment is 2 mL/kg of
body weight for each percent of total body surface area (TBSA) burned,
given IV (calculator 1). Superficial (epidermal) burns are excluded from this
calculation. One-half of the calculated fluid need is given in the first eight
hours, and the remaining half is given over the subsequent 16 hours. The
rate of infusion for IV resuscitation fluid should be as constant as possible;
rapid declines in infusion rates can lead to vascular collapse and an
increase in edema. (See 'Estimating initial fluid requirements' above.)
•Monitoring fluid status – Monitor urine output using an indwelling
bladder catheter (eg, Foley catheter). Hourly urine output should be
 maintained at 0.5 mL/kg in adults. Clinical signs of volume status, such as
heart rate, blood pressure, pulse pressure, distal pulses, capillary refill,
and color and turgor of uninjured skin, are monitored every hour for the
first 24 hours. Inadequate fluid resuscitation is the most common cause of
diminished distal pulses in the newly burned patient. A decrease in mixed
venous oxygen saturation and an increase in serum lactate suggest
inadequate end-organ perfusion. (See 'Monitoring fluid status' above.)
●Ancillary testing – Obtain a complete blood count, electrolytes, blood urea
nitrogen, creatinine, glucose, venous blood gas (VBG), lactate, and
carboxyhemoglobin. Arterial blood gas (ABG), chest radiograph, and an
electrocardiogram (ECG) are obtained in any patient at risk for inhalation
injury. (See 'Laboratory studies and monitoring' above.)
●Concern for carbon monoxide and cyanide exposure – Burn patients may
be exposed to carbon monoxide, requiring immediate treatment with high-
flow oxygen (and possibly hyperbaric oxygen). Clinicians should consider the
possibility of cyanide toxicity in any burn victim with an unexplained lactic
acidosis, depressed mental status, or cardiovascular instability; and keep a
low threshold for initiating treatment with antidotal therapy. (See 'Carbon
monoxide and cyanide' above.)
●Wound care – Cool and clean wounds, but avoid inducing hypothermia in
this process. Mild soap and water is suitable. Monitor the patient's core
temperature continually. Remove any jewelry and any hot or burned clothing
and obvious debris not densely adherent to the skin. Irrigation with cool
water may be used. Topical antibiotics (eg, silver sulfadiazine, bacitracin) are
applied to all nonsuperficial burns. If the patient is immediately transferred
to a burn center, burns are covered with clean, dry dressings, and antibiotics
are applied at the burn center. (See 'Wound management' above.)
●Pain and anxiety management – Give opioids (eg, morphine) to treat pain;
extremely high doses may be required. Benzodiazepines can help relieve
anxiety. (See 'Pain and anxiety management' above.)
●Chemoprophylaxis – Tetanus immunization should be updated, if
necessary, for any burns deeper than superficial thickness. Tetanus immune
globulin should be given to patients who have not received a complete
primary immunization (table 3). There is no role for prophylactic IV
antibiotics. (See 'Chemoprophylaxis' above.)
●Gastrointestinal interventions – A nasogastric tube should be placed in
patients with moderate or severe burns (ie, >20 percent TBSA) and
medications started to reduce gastric acid secretion. (See 'Gastrointestinal
interventions' above.)
●Modulating the catabolic response – A number of treatments are used to
attenuate the hypermetabolic state caused by burns. These treatments are
generally initiated in the intensive care unit but may be started in the
emergency department in close coordination with the burn team that will be
assuming care of the patient. For example, we institute glycemic control
using an insulin drip as early as possible. (See 'Modulating the catabolic
response' above.)