This document provides guidance on the initial assessment and management of a patient with burns. It details the patient's history of a 39-year-old man who suffered scalding burns after losing cold water in the shower. The physical exam found burns covering 9%, 18%, 18%, 18%, 9%, and 1% of the patient's body surface area. Key priorities for burn treatment include airway, breathing, circulation, exposing the skin, and wound care. Initial labs and assessments should evaluate for potential complications like inhalation injuries. Fluid resuscitation is critical and guidelines are provided for calculating fluid volumes based on the patient's weight, burn percentage, and urine output goals. Airway management may require intubation depending on signs

1. Frank W. Meissner, MD, FACP, FACC, FCCP
Director Emergency Medicine
Burns- ED Management

2. History
●39 y/o Argentinan Male
●Taking Shower Lost Cold Water
●Scalding Burn
●? Tetanus Status

3. Physical
Exam
9%
18% Back
18% Front
18% 18%
9% 9%
1° Red tender
epidermal only
2° red &
blistered
extreme pain
3° eschar- tough
&
leathery
full thickness

4. Burn Treatment Priorities
●Airway
●Breathing
●Circulation
●Expose Skin
●Wound Care

5. Initial Assessment
●Primary Survey
●Secondary Survey
○R/O associated injuries
●Pertinent Hx

6. Burn Hx
●Cause of burn?
●Did injury occur in enclosed space?
●Loss of conciousness?
●P (inhalation injury) > 0 ?
●Were hazardous chemicals involved?
●Any trauma? (esp blast)

7. Pertinent Medical Hx
●Preexisting Dz
●Esp DM, HTN, Cardiac, Renal Dz
●Medications/Etoh/DrugUse
●Allergies
●Td Status

8. Management Principles
●STOP THE BURNING PROCESS
●Assess for airway compromise & ventilatory
excursion
●Insert 2 big bore IV’s & N/G tube (if burn
BSA >20% BSA Gastric Ileus)
●Foley Cath
●Pain relief (morphine sulfate)
●Assess extremity pulses
●Remove clothes & potential constrictors;
escharotomy if indicated

9. Baseline lab studies
●Hct, lytes, BUN
●U/A
●CXR
●ABG (if indicated by resp distress)
●ECG (electrical burns)
●Carboxyhemoglobin (enclosed space)
●Glucose (Children)

10. Airway Management
●Carbon Monoxide Poisoning
●Supraglottic inhalation injury
●Infraglottic inhalation injury

11. Carbon Monoxide Poisoning
●Immediate threat in inhalation survivors
●CO-Hgb levels of <15 smokers &
truckers
●CO-Hgb levels of 15-40 => variable
CNS dysfunction
●CO-Hgb levels of 40-60% =>

12. CO-Hgb Treatment
●100% humidified O2
●Hyperbaric therapy for severe CNS
disturbance

13. Supraglottic Injury
●Direct thermal injury
●Inhalation of steam
●Aspiration of scalding liquids
●Explosions

14. Infraglottic Injury
●Chemical rather than thermal injury
●Exposure to noxious fumes
●Ammonia, chlorine, HCl, phosgene,
aldehydes, sulfur oxides, nitrogen oxides
●Tracheobronchitis with spasm + wheezing
may occur
●Delayed effects common
●Observe 24 hrs after inhalation

15. High Risk Airways
●Facial burns, singed nasal hair
●Agitation, tachypnea, anxiety, stupor,
cyanosis
●Rapid RR, flared nostrils, intercostal
retractions,
●Hoarse voice, brassy cough, grunting,
guttural resp sounds
●Rales, ronchi, distant breath sounds
●Erythema or swelling of oro-nasopharynx
●Sooty sputum

16. Agressive treatment
●Early intubation or surgical airway
●Escharotomy for circumferential burns of
chest
●Esp be agressive with children

17. Circulation
●GOALS OF FLUID RESUSCITATION
●Maintain vital organ function
●Avoid complications of inadequate or
excessive therapy

18. Resucitation Fluid Therapy
●Adults 2-4 ml/Ringer’s lactate * Kg body
wgt * % burn area - Hrly U.O.=30-50
ml/hr
●Children 3-4 ml/Ringer’s lactate * kg
body wgt * % burn area - Hrly U.O.=
1ml*kg*hr
●1/2 calculated volume => 1st 8hrs post
burn

19. Fluid therapy second 24hrs
●0.3-0.5 ml colloid-containing fluid * Kg
body wgt * % BSA burn
●Adult - lyte free fluid=> maintain U.O.
●Child-1/2 nml saline=> U.O.

20. Myoglobinuria & Hemoglobinuria
●U.O. > 75-100 ml/hr to clear pigment
●If unable to clear 12.5 gm Mannitol in
each liter of resuscitation fluid
●NaBicarb to alkalinize urine in severe
cases

21. Who MAY need more fluid?
●Electrical injuries
●Inhalation injuries
●Delayed resuscitation
●Burned while intoxicated

22. “Volume Sensitive” patients
●Pre-existing Cardiac Dz
●Extremes of age