Trauma

Burns: Major

Initial/Prep/Goals

1. Severity Definition
   • Partial-Full thickness (2° to 3°), high-risk areas, BSA > 5%
2. Prehospital Care
3. ABCs, Vital Signs, Establish IVs
   • If intubation necessary, video laryngoscopy allows burn surgeon to visualize airway
   • IV fluids, Foley catheter for monitoring urine output
4. Early pain control with narcotics
5. Sterile gauze soaked with cool saline to burns
   • Refrain from applying topical antibiotic ointment until evaluated by a burn surgeon
   • Prophylactic antibiotics NOT indicated
6. Update Tetanus

Medical/Pharmaceutical

1. Pain Management
   • Opioid Pain medications
     • Choice should be based on
       • Physiology
       • Pharmacology
       • Physician experience
     • Individualized to the patient with frequent adjustment to
       • Patient responses
       • Narrow therapeutic effects
       • Adverse effects
     • Use as few opiate equivalents as possible to achieve desired pain control
     • Opioid pain medications should not be used in isolation
       • But in conjunction with nonopioid and nonpharmacological measures
     • Patients should be educated about the role of opioids and
       • Other pain medications in their recovery from burn injury
   • Nonopioid Pain Medications
     • Acetaminophen: Should be utilized on all burn patients
       • With care taken to monitor the maximal daily dose
     • Nonsteroidal anti-inflammatory drugs (NSAIDs)
       • Should be considered in all patients due to their safety profile and efficacy in other settings
       • The patient’s clinical picture including baseline comorbidities and
       • Kidney function as well as surgeon preference should be included in this decision
     • Neuropathic pain (Gabapentin, Pregabalin)
       • Considered as an adjunct to an opioid in patients who are having neuropathic pain or
       • Who are refractory to standard therapy
     • Ketamine: Consider for procedural sedation or in low doses as an adjunct to opioids
       • In those who reduced opioid consumption will be beneficial postoperatively
     • Dexmedetomidine/clonidine: Recommended for patients showing signs of withdrawal or prominent anxiety symptoms and
       • Dexmedetomidine as a first-line sedative in the intubated burn patient
     • IV Lidocaine: Cannot be recommended at this time as a first-line agent
       • But it is a reasonable second- or third-line adjuvant agent
     • Cannabinoids: Given the lack of evidence and the potential legal and political obstacles
       • We are unable to make a recommendation for the use of cannabinoids in the treatment of acute burn pain
   • Regional Anesthesia: Regional anesthesia for burn pain management has the potential to provide
     • Improved pain relief
     • Patient satisfaction
     • Opioid use reduction without serious risks or complications
   • Nonpharmacologic Treatments
     • Every patient should be offered a nonpharmacological pain control technique
       • At least as an adjunctive measure to their pain control regimen
       • When the expertise and/or equipment is available
         • Cognitive-behavioral therapy
         • Hypnosis and virtual reality have the strongest evidence.
2. IV fluids
   • Parkland: (4 mL) x (body weight in kg) x (% BSA burn) = total fluid for first 24 hrs
     • Give 1/2 in first 8 hrs from time of burn, rest over next 16 hrs
       • If patient presents 2 hrs after burn, must give initial fluid over 6 hrs (8 hrs - 2 hrs = 6 hrs)
     • After first 8 hrs of Parkland, fluids are generally titrated to maintain adequate urine output (0.5 mL/kg/hr)

Surgical/Procedural

1. Emergency Escharotomy
   • Bovi or scalpel can be used
   • Long access of digits, extremities, and trunk if circumferential burns with poor distal perfusion
   • Can use pulse oximetry on affected digit to assess for response
   • Rarely need to be done by ER physician

Disposition

1. Transfer/admission criteria
   • Any burn > 10% BSA in patients < 10 years old and > 50 years old
   • Burns involving > 12% of total BSA
   • Full thickness burns > 5% BSA
   • Significant burns of face, hands, face, eyes, ears and face, perineum or feet
   • Significant chemical or electrical burns
   • Concomitant inhalational injury or other mechanical injuries
   • Patients with special needs or significant comorbidities

Related Topics

• Overview
• Prehospital Care
• Minor Burn Treatment

References

1. Papini R. Management of burn injuries of various depths. BMJ Jul 17, 2004;329(7458):158-160
2. Stander M, Wallis LA. The emergency management and treatment of severe burns. Emerg Med Int. 2011; 2011:161375
3. DuBose JA, O'Connor JV, Scalea TM. Lung, Trachea, and Esophagus. In: Mattox KL, Moore, EE, Feliciano DV; (eds). Trauma, 7th ed., McGraw-Hill, Inc, 2013; Chapter 25
4. Pham TN, Cancio LC, Gibran NS. American Burn Association Practice Guidelines: Burn Shock Resuscitation. J of Burn Care and Research Jan-Feb 2008;29(1):257-266
5. Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Academic Emerg Med. May 2007;14(5):404-409
6. Romanowski KS, Carson K, Pape K, et al. American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient. J of Burn Care & Res. Nov/Dec 2020;41(6):1152-1164

Contributor(s)

1. Latham, Douglas E., MD
2. Tom, Jubil, MD

Updated/Reviewed: December 2020