Points and Pearls Digest | Management of Patients With Thermal Burns

Emergency Department Management of Patients With Thermal Burns

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  • First-degree burns are superficial and involve only the epidermis. Second-degree burns are partial thickness and involve the dermis. Third-degree burns are full-thickness and invade subcutaneous structures.
  • If prehospital cooling has not been initiated, de­layed cooling in the ED may still be helpful.
  • Physical examination findings are the only way for emergency clinicians to classify burns; however, they are only moderately reliable for estimating burn depth.
  • Treat empirically for inhalation-related toxicity in unstable patients and those with altered mental status.
  • When there is concern for cyanide toxicity from smoke inhalation, administer hydroxocobalamin 5 g IV. This is preferred over sodium nitrite and sodium thiosulfate.
  • The Lund and Browder Chart should be used to estimate total body surface area (TBSA) burned. Other measurement methods (eg, rule of nines) are less accurate, particularly in children.
  • Patients with > 20% TBSA burns rapidly become volume depleted. Use the Parkland formula (www.mdcalc.com/parkland-formula-burns) or modified Brooke formula to resuscitate with a crys­talloid fluid, such as lactated Ringer’s solution.
  • Titrate fluid resuscitation to a urine output of 0.5-1 mL/kg/hour in adults and 1-1.5 mL/kg/hour in children.
  • All wounds should be irrigated, and devitalized tis­sue needs to be debrided.
  • Partial-thickness burns require a dressing. Avoid silver-based dressings, as they are associated with longer healing time.
  • Emergent escharotomy should be considered if there is absent or decreased pulse oximetry, absent or decreased pulses, elevated compartment pres­sures, or new-onset neurologic deficits.
  • There is insufficient evidence to recommend either prophylactic antibiotics or antibiotic wound dress­ings in burn patients.
  • Be aggressive in the treatment of pain related to burns; opioids are typically used.
  • In children, consider the possibility of nonacci­dental injury when their presentation to the ED is delayed or when burns are symmetrical, have clear upper wound margins, or appear with old or unrelated injuries.
  • For more information on managing children with burns, see Pediatric Emergency Medicine Practice is­sue on burns at: www.ebmedicine.net/PedBurns. For burn-related nonaccidental trauma: www.ebmedicine.net/PedNAT.

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  • Do not include superficial (first-degree) burns in the calculation of TBSA.
  • The presence of pain cannot be used to ex­clude a full-thickness burn.
  • Prehospital cooling of burns (under cool run­ning water for ≥ 20 minutes) is associated with significantly decreased burn depth.
  • Intubate early for burns to the upper airway or if there is airway edema, stridor, or other signs of compromise. Delay may make intubation impossible, as tissue become more edematous.
  • Inability to ventilate due to chest eschar is an emergent indication for escharotomy.
  • Avoid over-resuscitation and fluid-creep by monitoring vital signs closely.

Table 7. American Burn Association Burn Center Referral Criteria

Table 1. Components of the Multinational Association of Supportive Care in Cancer (MASCC) Risk Index

Access more tables and figures here

Clinical Pathway for Management of Burns in the Emergency Department 

Clinical Pathway for Emergency Department Management of Metastatic Spinal Cord Compression

Access the Clinical Pathway here


MDCalc Score Calculators
Parkland Formula for Burns:
Most Important References
  • Rae L, Fidler P, Gibran N. The physiologic basis of burn shock and the need for aggressive fluid resuscitation. Crit Care Clin. 2016;32(4):491-505. (Review)DOI: http://dx.doi.org/10.1016/j.ccc.2016.06.001
  • Bartlett N, Yuan J, Holland AJ, et al. Optimal duration of cooling for an acute scald contact burn injury in a porcine model. J Burn Care Res. 2008;29(5):828-834. (Animal study; 17 subjects) DOI: https://doi.org/10.1097/BCR.0b013e3181855c9a
  • Agarwal P, Sahu S. Determination of hand and palm area as a ratio of body surface area in Indian population. Indian J Plast Surg. 2010;43(1):49-53. (Prospective study; 600 patients)DOI: http://dx.doi.org/10.4103/0970-0358.63962
  • Nguyen L, Afshari A, Kahn SA, et al. Utility and outcomes of hydroxocobalamin use in smoke inhalation patients. Burns. 2016. (Retrospective review; 273 patients)DOI: http://dx.doi.org/10.1016/j.burns.2016.07.028
  • Vlachou E, Gosling P, Moiemen NS. Hydroxyethylstarch supplementation in burn resuscitation--a prospective ran­domised controlled trial. Burns. 2010;36(7):984-991. (Randomized controlled trial; 26 patients)DOI: http://dx.doi.org/10.1016/j.burns.2010.04.001
  • Eljaiek R, Heylbroeck C, Dubois MJ. Albumin administra­tion for fluid resuscitation in burn patients: a systematic review and meta-analysis. Burns. 2016. (Systematic review; 4 randomized clinical trials, 140 patients)DOI: http://dx.doi.org/10.1016/j.burns.2016.08.001
  • Aziz Z, Abu SF, Chong NJ. A systematic review of silver-containing dressings and topical silver agents (used with dressings) for burn wounds. Burns. 2012;38(3):307-318. (Systematic review; 14 randomized controlled trials, 877 patients) DOI: http://dx.doi.org/10.1016/j.burns.2011.09.020
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Publication Information

Juliana Tolles, MD, MHS

Peer Reviewed By

Boyd Burns, DO; Christopher Palmer, MD

Publication Date

February 1, 2018

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