Burns Management

Introduction

A burn is a form of trauma, and a major burn is resuscitated like any other major trauma: with a structured primary survey, active correction of physiological derangement, and early identification of the features that mean a patient needs specialist burns unit care. Classifying burn depth, estimating %TBSA and calculating the Parkland formula are covered in detail elsewhere; this article focuses on the acute emergency department decisions that determine whether a patient survives the first hours - airway timing, fluid titration, and the specific hazards of electrical and chemical mechanisms.

The single idea worth holding onto throughout is that burns evolve. A patient who looks stable on arrival can develop airway obstruction, compartment syndrome or hypovolaemic shock over the following hours as oedema and fluid shifts progress - reassessment is not optional, it is the core of safe burns management.

Primary survey in burns

ABCDE applies as in any acutely unwell patient, with burns-specific emphasis at each step.³

• Airway - assess for inhalation injury (see below) and secure the airway early if there is any doubt, before swelling progresses
• Breathing - a circumferential burn to the chest can itself restrict ventilation and may need escharotomy; consider carbon monoxide and cyanide toxicity in any fire-related burn in an enclosed space
• Circulation - large-bore IV access sited through unburnt skin where possible; begin fluid resuscitation calculations from the time of injury
• Disability - reduced consciousness at the scene raises suspicion of carbon monoxide poisoning or a head injury sustained during the same incident
• Exposure - stop the burning process, remove smouldering or chemical-soaked clothing and jewellery, estimate depth and %TBSA, and actively prevent hypothermia, since extensive burns impair thermoregulation and cooling used as first aid can itself contribute to heat loss

Airway and inhalation injury

Inhalation injury is suggested by facial burns, singed eyebrows or nasal hair, soot around the mouth or nose, carbonaceous sputum, hoarseness, stridor, or a history of being in an enclosed space with smoke or fire. It matters because airway oedema from thermal and chemical injury to the upper airway can progress over several hours, turning a patent airway at presentation into an obstructed one by the time a bed is found on intensive care.

Suspected carbon monoxide poisoning (reduced consciousness, headache, or a fire in an enclosed space) is treated with high-flow oxygen and a carboxyhaemoglobin level sent on the blood gas; cyanide toxicity from burning synthetic materials is considered in a patient with unexplained lactic acidosis or cardiovascular instability out of proportion to the burn itself, and treated with hydroxocobalamin where suspected.

Fluid resuscitation in practice

The Parkland formula (4 mL x body weight in kg x %TBSA of crystalloid over 24 hours, half in the first 8 hours from the time of injury) gives a starting estimate for burns over roughly 15-20% TBSA in adults, but it is a starting point, not a target to hit exactly.²

• Titrate to urine output, generally aiming for 0.5 mL/kg/hour in adults (higher in children and in electrical burns with myoglobinuria) - this catheter-guided approach corrects for the formula's inherent imprecision
• Under-resuscitation causes hypovolaemic shock and acute kidney injury; over-resuscitation ('fluid creep') worsens oedema, can precipitate abdominal compartment syndrome, and converts partial-thickness burns to full-thickness by impairing local perfusion
• Reassess regularly - heart rate, blood pressure, urine output and lactate, adjusting the infusion rate rather than running it unattended on the calculated schedule
• Analgesia with titrated IV opioids should run in parallel from the outset; burns pain is severe and undertreating it is both unkind and physiologically counterproductive

Electrical burns

Electrical injury causes damage along the path of least resistance through the body - typically nerve and blood vessel before muscle and bone - so the visible entry and exit wounds can dramatically understate the extent of deep tissue destruction.

• Cardiac monitoring - electrical current can cause immediate arrhythmia (including cardiac arrest) or delayed conduction abnormality; a 12-lead ECG and a period of cardiac monitoring are routine after any significant electrical injury
• Creatine kinase and myoglobin - deep muscle damage causes rhabdomyolysis, risking acute kidney injury; check CK and monitor urine output and colour
• Higher fluid targets - urine output targets are increased (often to 1-1.5 mL/kg/hour) if myoglobinuria is present, to protect the kidneys
• Compartment syndrome - actively assess limbs for this, since deep muscle injury and swelling can compromise perfusion even where the overlying skin looks relatively unaffected
• Lightning injury is a variant with its own pattern - cardiac and respiratory arrest at the scene, and a tendency to spare the skin while causing profound neurological and cardiac effects

Chemical burns

The mainstay of treatment is prompt, copious irrigation with water to dilute and remove the causative agent, continued for longer than for thermal burns - often 20-30 minutes or more, guided by resolving pain and, for eye involvement, normalising pH.

• Alkali burns tend to be deeper and more progressive than acid burns, because of ongoing liquefactive tissue necrosis, and need particularly thorough irrigation
• Eye involvement needs urgent, prolonged irrigation and ophthalmology assessment - do not delay irrigation to arrange the referral
• Remove contaminated clothing promptly, with staff wearing appropriate personal protective equipment to avoid secondary exposure
• Brush off dry powder chemicals before irrigating with water, since some (for example certain metals) react exothermically with water

Escharotomy

A circumferential full-thickness burn forms an inelastic band (eschar) that does not expand as the underlying tissue swells, progressively compressing blood vessels and, over the chest, restricting ventilation. Escharotomy - a surgical incision through the full thickness of the burnt skin along defined lines - releases this constriction.

The decision to perform escharotomy is clinical: diminishing or absent distal pulses, prolonged capillary refill, worsening pain or paraesthesia in a circumferentially burnt limb, or rising airway pressures and reduced chest wall movement with a circumferential chest burn. It should not wait for compartment pressure measurement or imaging, since the diagnosis is made at the bedside and delay risks irreversible ischaemia.

Referral and transfer

Patients meeting national burns referral criteria - by %TBSA, depth, site, mechanism, age or suspected non-accidental injury - need discussion with a specialist burns service and, often, transfer.¹ Before transfer, stabilise rather than rush: secure the airway if there is any doubt (intubating before a long transfer is far safer than doing so en route), ensure fluid resuscitation is running and calculated correctly from the time of injury, cover the burn (cling film applied in layers, not wrapped circumferentially) and keep the patient warm.

Special groups

• Children - proportionally larger head and shorter limbs mean the adult rule of nines overestimates or underestimates TBSA depending on site; use an age-adjusted chart, and keep the threshold for specialist referral lower than in adults for a given %TBSA
• Older adults - thinner skin means a given thermal exposure causes a deeper burn than the same exposure in a younger patient, and pre-existing cardiac or renal disease narrows the margin for error in fluid resuscitation
• Suspected non-accidental injury - a burn pattern inconsistent with the given history, delayed presentation, or a sharply demarcated 'glove and stocking' scald suggesting forced immersion should trigger formal safeguarding assessment alongside the medical management, not instead of it

Red flags

Prognosis

Outcome in major burns is determined as much by the quality of the first hours of resuscitation as by the injury itself - timely airway control, correctly calculated and titrated fluid resuscitation, and early recognition of the need for escharotomy or specialist transfer materially change survival and long-term function. This is why burns management is taught as an emergency resuscitation skill first, and a wound care skill second.