I can count the number of severe burns I’ve seen in residency on one hand. I suspect that’s true for many of us, especially if you don’t work at a burn center. The problem is that these patients can be really sick and require a lot of urgent management. So today we’re going to discuss the 5 key elements of emergency burn care.
1. Think about the airway
Airway difficulty is a leading cause of death in burn patients. Even patients without evidence of severe facial burns can rapidly develop pharyngeal edema that can close off the airway and make intubation difficult to impossible. A significant portion with signs of smoke inhalation develop complete airway obstruction and there is no reliable way to know which patients these are. Warning signs are:
- persistent cough
- singed nostrils
- black sputum
- blistering in the mouth
Be aggressive in tubing these patients. Earlier is better. If you intubate, use a lung-protective strategy (6 ml/kg). Albuterol can help with bronchospasm.
2. Consider CO and cyanide poisoning
- A CO level is MANDATORY in patients with moderate or severe burns.Treat an elevated CO level with O2 and consider referral for hyperbaric oxygen.
- The presence of AMS, elevated lactate, or cardiac arrest should make you think about cyanide. You should always treat cyanide in burn patients with hydroxycobalamin (5 g IV over 15 minutes). Treatment with other cyanide antidotes can worsen oxygen carrying capacity through methemoglobin production.
3. Start aggressive fluid resuscitation with LR.
- You can use the parkland formula, but a more physiologic way is to put in a foley and monitor urine output. You can potentially use IVC US as an adjunct.
4. Local wound care
- Burned areas should be cooled with saline soaked gauze
- You should apply topical antibiotics like bacitracin or triple antibiotic
- In severe burns, patients may require escharotomy. This is rarely needed in the ED but consider it in the patient with severe chest burns who you cannot ventilate because of large eschar. This is the recommended incision: (image courtesy of UpToDate). Note that the incision only goes deep enough to penetrate the eschar.
5. Start planning for disposition early.
- Severe burns should be transferred to a burn center.
- Full referral criteria (which include a lot of patients) can be found here, but include:
- Partial thickness burns (1st or 2nd degree) greater than 10% surface area.
- Burns involving face, hands, feed, genitalia, major joints.
- Third degree burns
- Electrical, chemical, or inhalation injuries.
Rice, Phillip, et al. Emergency care of moderate and severe thermal burns in adults. UptoDate
American Burn Association. Burn Center Referral Criteria. http://www.ameriburn.org/BurnCenterReferralCriteria.pdf
Parkland formula for burns. MdCalc. http://www.mdcalc.com/parkland-formula-for-burns/