Emergency Department Management of Patients With Thermal Burns

Points

• 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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Pearls

• 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

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Clinical Pathway for Management of Burns in the Emergency Department 

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MDCalc Score Calculators

Parkland Formula for Burns:

https://www.mdcalc.com/parkland-formula-burns

 

 

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