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Burns Management Guide

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🔥 Burns Management Guide

🛠️ Initial Management of Severe Burns: Always Look for Secondary Injuries
🫁 Airway: Suspected inhalation injury → call senior anaesthetic help early. Red flags: stridor, wheeze, voice change, soot in sputum, deep facial burns, enclosed-space exposure. 🚨 Call 2222 for anaesthetic support. Avoid cutting the ETT; place NG tube early. 🌬️ Breathing: Risk of carbon monoxide and cyanide toxicity. 🧪 Take ABG + COHb. Give 100% O₂ via non-rebreather. Consider hyperbaric O₂ if COHb >25%, LOC, pregnancy, or neuro features. 💉 Hydroxocobalamin = antidote for cyanide poisoning (plastics/synthetic fires). 💉 Circulation: 2x large-bore IVs (avoid burnt skin if possible). Bloods: FBC, U&E, LFT, CRP, Amylase, CK, cross-match, toxicology if needed. Fluid Resuscitation (Parkland formula): 💧 4 mL × Weight (kg) × % TBSA burned. ½ in first 8h, ½ in next 16h (from time of burn). Warmed Hartmann’s solution to avoid hypothermia. Catheterise → monitor urine output: 0.5–1 ml/kg/hr adults, 1–1.5 ml/kg/hr children. Example: 70 kg × 50% burns = 14 L → 7 L in 8h, 7 L in next 16h. ⚠️ Parkland is a guide — avoid “fluid creep.” Adjust to urine output and haemodynamics. 🧠 Disability: IV opiate analgesia (morphine titrated). Avoid IM. 💊 Adjuncts: paracetamol, ketamine (if unstable). Monitor GCS. 🩺 Exposure: Remove non-adherent clothing. 💦 Cool with water/wet compresses for 20 min (avoid hypothermia). 📏 Assess TBSA (Lund & Browder chart). 🤲 Cover with cling film (avoid face). ⚡ Other Considerations: Insert NG if ileus risk or extensive burns. Escharotomy may be required (circumferential limb/chest burns). Check tetanus status. NBM if surgery likely. 🛡️ Safeguarding: always consider NAI (immersion, cigarette burns, inconsistent history).

🛠️ Initial Management of Severe Burns: Always Look for Secondary Injuries

🫁 Airway: Suspected inhalation injury → call senior anaesthetic help early. Red flags: stridor, wheeze, voice change, soot in sputum, deep facial burns, enclosed-space exposure. 🚨 Call 2222 for anaesthetic support. Avoid cutting the ETT; place NG tube early.
🌬️ Breathing: Risk of carbon monoxide and cyanide toxicity. 🧪 Take ABG + COHb. Give 100% O₂ via non-rebreather. Consider hyperbaric O₂ if COHb >25%, LOC, pregnancy, or neuro features. 💉 Hydroxocobalamin = antidote for cyanide poisoning (plastics/synthetic fires).
💉 Circulation:
- 2x large-bore IVs (avoid burnt skin if possible).
- Bloods: FBC, U&E, LFT, CRP, Amylase, CK, cross-match, toxicology if needed.
- Fluid Resuscitation (Parkland formula): 💧 4 mL × Weight (kg) × % TBSA burned.
  - ½ in first 8h, ½ in next 16h (from time of burn).
  - Warmed Hartmann’s solution to avoid hypothermia.
  - Catheterise → monitor urine output: 0.5–1 ml/kg/hr adults, 1–1.5 ml/kg/hr children.
  - Example: 70 kg × 50% burns = 14 L → 7 L in 8h, 7 L in next 16h.
  - ⚠️ Parkland is a guide — avoid “fluid creep.” Adjust to urine output and haemodynamics.
🧠 Disability: IV opiate analgesia (morphine titrated). Avoid IM. 💊 Adjuncts: paracetamol, ketamine (if unstable). Monitor GCS.
🩺 Exposure: Remove non-adherent clothing. 💦 Cool with water/wet compresses for 20 min (avoid hypothermia). 📏 Assess TBSA (Lund & Browder chart). 🤲 Cover with cling film (avoid face).
⚡ Other Considerations:
- Insert NG if ileus risk or extensive burns.
- Escharotomy may be required (circumferential limb/chest burns).
- Check tetanus status.
- NBM if surgery likely.
- 🛡️ Safeguarding: always consider NAI (immersion, cigarette burns, inconsistent history).

🔥 Anyone with burns should also be presumed to have smoke inhalation injury — consider the ABCs and watch for stridor, hoarseness, or drooling. 😮‍💨 These patients are at risk for ARDS and airway compromise, which may require early intubation. 📞 Referral: Transfer to a burns centre if:

👶 >10% TBSA in children
🧑 >15% TBSA in adults
🩹 Any full-thickness burns
😷 Burns to face, hands, perineum, feet, flexures, or joints
⚡ Chemical, electrical, lightning injuries
🔥 Circumferential limb or chest burns
🚨 Suspected inhalation injury

🔥 Types of Burns

☀️ First Degree / Superficial: Epidermis only. Red, painful, no blisters. Heal without scarring.
💧 Second Degree / Partial Thickness: Epidermis + dermis. Red, blistered, very painful, moist. Heal with minimal scarring.
🪵 Third Degree / Full Thickness: All layers destroyed. White/charred/leathery. Painless (nerve damage). Needs grafting → scarring.

😷 Signs of Inhalational Injury

Facial/neck/chest burns
Singed nasal hair/eyebrows
Soot in sputum/oropharynx
Hoarseness, stridor, dyspnoea
Oropharyngeal swelling/erythema

⚠️ Complications of Burns

Compartment syndrome
Hypovolaemia, electrolyte imbalance
Infection, sepsis
Hypothermia
Neuropathic pain, pruritus
Hypertrophic scars, contractures
Psychological trauma: depression, anxiety, PTSD

📍 Special Areas of Concern

Face, hands, perineum, genitalia, feet, flexures, joints → functional & cosmetic impact.

🧪 Investigations

Bloods: FBC, U&E, glucose, clotting, CK, cross-match
ABG: lactate, HbCO
CXR if inhalation suspected

🧾 Management Overview

ABCDE approach 🔄
High-flow O₂ 💨
Fluid resuscitation 💧 (Parkland + urine monitoring)
Early intubation if airway risk 🫁
Wound care: cling film, sterile dressings 🩹
IV analgesia 💊
Nutritional support 🍲 (↑ metabolic demand, dietician input)
Escharotomy if needed ✂️
Tetanus prophylaxis 💉
Early burns unit referral 📞

📚 Teaching Commentary

Burns are a multisystem insult — airway, circulation, and metabolism all collapse if not managed promptly. The first 24h = airway + fluids, not definitive surgery. Always check for “hidden killers”: inhalational injury, CO or cyanide, associated trauma. UK practice: 🔗 burns care is regionalised → early referral is life-saving. Remember: 🧪 resuscitation is a balance — underdo it and they die of shock, overdo it and you worsen oedema, including airway swelling. And never forget the patient’s psychological and safeguarding needs — scarring and trauma can last far beyond the acute injury.

🔖 References

Case 1 – Adult flame burn with inhalation risk

A 38-year-old rescued from a house fire has facial burns, singed nasal hairs, hoarse voice, and cough with soot; mixed-depth burns to the anterior trunk and both upper limbs (~28% TBSA, Rule of Nines). Priorities: ABCDE with high-flow O₂ (100% non-rebreathe), early airway protection if progressive oedema/stridor, and blood gases including carboxyhaemoglobin (pulse oximetry unreliable). Start warmed IV fluids using the Parkland formula (4 mL/kg/%TBSA of lactated Ringer’s; give half in 8 h from time of burn), titrating to urine ≥0.5 mL/kg/h; insert urinary catheter and consider analgesia, tetanus, and escharotomy if circumferential chest/limb burns impair ventilation/flow. Cool the burn (20 min tepid water if <3 h from injury), cover with cling film, avoid ice. Refer to a UK burns centre (e.g., >10% TBSA, face/airway, hands/perineum, electrical/chemical, or inhalation injury) for debridement and definitive dressings/grafting.

Case 2 – Paediatric scald; safeguarding considerations

A 2-year-old pulls a kettle lead causing hot-water scald to the anterior chest and left arm; blistered, painful partial-thickness burns covering ~8% TBSA (use Lund–Browder chart). Manage with ABCDE, prompt analgesia (oral morphine/IN fentanyl as appropriate), tepid cooling for up to 20 min, non-adherent dressing (paraffin gauze) and cling film, elevation of the limb, and oral fluids ± IV if not tolerating; consider fluid resuscitation if >10% TBSA (many UK centres use 2–3 mL/kg/%TBSA in children) and maintain euglycaemia. Assess tetanus status. Document a careful history and injury pattern; involve senior review and safeguarding if concerns (e.g., clear immersion lines, inconsistent story). Arrange burns clinic follow-up within 24–48 h to monitor pain, infection, and function; early physiotherapy/splinting if joints are involved.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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