Burns Management

Clinical assessment

Based on history of exposure and examination of the burn wound. Key assessments: - Causative Agent (thermal, chemical, electrical). - Burn Depth (1st, 2nd superficial/deep, 3rd, 4th degree). - Burn Extent (% Total Body Surface Area - TBSA): Use 'Rule of Nines' (adults), Lund-Browder chart (children/more accurate), or patient's palm size (~1% TBSA) for smaller burns. Exclude simple erythema (1st degree) from TBSA calculation for fluid resuscitation. - Burn Location: Critical areas include face, neck, hands, feet, perineum, major joints, circumferential burns. - Associated Injuries: Assess for trauma (falls, explosions), inhalation injury (crucial!). - Patient Factors: Age, pre-existing medical conditions.

Investigations

• Assess airway patency and breathing carefully, especially if facial burns or suspected inhalation injury.
• Monitor vital signs (HR, BP, RR, SpO2, Temp).
• Monitor urine output (via catheter for major burns) - key indicator of resuscitation adequacy.
• Laboratory (Major burns): CBC, Electrolytes, Urea, Creatinine, Glucose, Albumin, Arterial Blood Gas (ABG), Carboxyhemoglobin (COHb) if smoke inhalation suspected. Type and cross-match blood.
• ECG (especially for electrical burns).
• Chest X-ray (if inhalation injury or other chest trauma suspected).

Diagnostic criteria

Clinical assessment of burn depth, extent (%TBSA), location, cause, associated injuries, and patient factors, leading to severity classification (Minor, Moderate, Major).

Non-pharmacological management

• Stop the Burning Process: Remove from source, extinguish flames (stop, drop, roll), remove hot/soaked/contaminated clothing (unless stuck).
• Cooling: Apply cool running water (NOT ice cold) to the burn area for up to 20-30 minutes, ideally within the first hour. Avoid excessive cooling causing hypothermia, especially in large burns.
• Airway Management: High index of suspicion for inhalation injury (facial burns, soot, hoarseness, stridor, enclosed space fire). Provide high-flow oxygen. Early intubation may be needed if signs of airway edema/compromise present or anticipated (often before transfer).
• Breathing: Supplemental oxygen for all moderate/major burns.
• Circulation (Fluid Resuscitation for Major Burns >15-20% TBSA Adult, >10-15% Child):
• - Establish large-bore IV access (preferably x2, through unburnt skin if possible).
• - Calculate fluid requirement using Parkland Formula (or similar): Total fluid in 1st 24h = 4 mL x Body Weight (kg) x %TBSA Burned.
• - Give isotonic crystalloid (Ringer's Lactate preferred, Normal Saline alternative).
• - Administer 50% of total calculated volume in the first 8 hours (from time of burn injury, not time of arrival).
• - Administer remaining 50% over the next 16 hours.
• - Titrate infusion rate based on Urine Output: Target = 0.5 mL/kg/hr (Adults), 1-2 mL/kg/hr (Children <30kg). Also monitor vital signs, mental status.
• Wound Care:
• - Clean the wound gently with sterile saline or clean water.
• - Debridement: Leave small blisters intact initially. Drain large or tense blisters aseptically, may leave roof intact or debride.
• - Dressings: Apply topical antimicrobial agent (Silver Sulphadiazine cream 1% preferred, unless contraindicated - pregnancy, sulfa allergy, infants <2mo). Cover with non-adherent gauze (paraffin gauze) and absorbent outer dressing. Change dressings daily or every 2-3 days depending on exudate/agent used. Exposure method (leaving burn open with cream in bed cradle) possible for extensive burns.
• - Escharotomy/Fasciotomy: Urgent surgical incision through eschar (or fascia) for circumferential burns of limbs or chest causing neurovascular compromise or respiratory restriction.
• Nutritional Support: Major burns induce hypermetabolic state. Early enteral feeding is crucial.
• Temperature Control: Prevent hypothermia (keep patient warm, warm IV fluids).
• Positioning/Splinting/Physiotherapy: Prevent contractures, maintain function.
• Chemical Burns: Brush off dry chemicals first, then irrigate copiously with water for extended period (20-30 mins or longer). Identify chemical if possible.
• Electrical Burns: Assess for cardiac arrhythmias (ECG), deep tissue injury (may look small externally), neurological deficits, fractures (from falls/muscle contractions), compartment syndrome.

Pharmacological treatment

• Analgesia: Provide adequate pain relief. Mild burns: Paracetamol, NSAIDs. Moderate/Severe burns: Opioids (e.g., Morphine IV) often required, especially during dressing changes. Consider multimodal analgesia.
• Tetanus Prophylaxis: Give TT booster if indicated.
• Topical Antimicrobials: Silver Sulphadiazine 1% cream commonly used. Alternatives: Mafenide acetate, Silver nitrate solutions, Chlorhexidine.
• Systemic Antibiotics: NOT routinely indicated prophylactically. Use only to treat confirmed burn wound infection (signs: increasing pain, cellulitis, change in wound appearance, systemic signs like fever) or other infections (e.g., pneumonia). Culture wound/blood if infection suspected to guide therapy.
• Antacids / H2 blockers / PPIs: Stress ulcer prophylaxis for major burns.
• Anticoagulation: DVT prophylaxis for major burns/immobile patients.

Monitoring

Frequent monitoring of vital signs, urine output, SpO2, mental status. Monitor wound for signs of healing or infection. Monitor electrolytes, renal function, nutritional status in major burns. Monitor neurovascular status of limbs (esp. circumferential burns).