Major burns management

FIRST AID

• ABC resuscitation
• cover burns with sterile dressings
• apply cool saline pack (15 C is optimum) for a maximum of 20 minutes (beware of hypothermia)
• after cooling apply dressings (or Glad Wrap if patient to be transferred)

RESUSCITATION

Airway

• intubate early if evidence of airway burns either due to thermal or chemical burns (swelling/burns to lips/tongue, singed nasal/facial hair, carbonaceous sputum, stridor, throat pain)

Breathing

• Give high flow oxygen initially - consider early HBO therapy for carbon monoxide or treatment for Cyanide Poisoning
• Circumferential chest wall burns may impair ventilation - consider urgent escharotomy
• Hypoxia and/or impaired ventilation may occur due to inhalation injury - carefully assess for airway tract and parenchymal injury

Circulation

• Cardiac arrest may be due to carbon monoxide or cyanide poisoning.
• Avoid venous access over burned area unless there are no alternatives.
• Adequate fluid resuscitation.

Disability

• Altered mentation may be due to carbon monoxide poisoning

Exposure

• Initial cold running water or soaks then dress (as per local protocols)
• Impaired temperature regulation due to skin loss can be significant - keep normo-thermic

ANALGESIA

• IV opiates as per protocol 
• repeat as needed to attain adequate analgesia.

Tetanus Prophylaxis

NGT (paralytic ileus occurs in extensive burns)

FLUID/ELECTROLYTE THERAPY

Parkland Formula (If burn > 15% in adults, or >10% in children)

• In first 24 hours,  4 ml per % burn per kg body weight (up to max 50% burn area)
• = replacement fluid (use colloid for resuscitation if shocked)
• replace lost fluid with Hartmann’s Solution
• does not include resuscitation fluid
• give first half during first 8 hours (from time of burn)
• give second half over next 16 hours

• Note: The formula is a guide only.
• aim to keep urine output > 50ml/hour (1ml/kg/hour in children) and haematocrit < 45%
• albumin, blood, potassium, is not usually required in first 24 hours.
• haematocrit 2-4 hourly is necessary initially, most fluid loss occurs in first 24 hours.
• may need a urinary catheter.

BEWARE

• pre-existing disease
• other injuries
• carbon monoxide and other toxic products
• respiratory burns

COMPLICATIONS

• Hypovolaemic shock
• Paralytic ileus
• Rhabdomyolysis/Hyperkaemia/Renal Failure
• Hypothermia
• ARDS

INVESTIGATIONS

• FBC
• EUC
• ABG - persistent metabolic acidosis may suggest CO/CN Poisoning
• COHb
• ECG
• CXR
• bHCG (if CO/CN Poisoning)