Stabilization of the Burn Victim

The initial approach to the burn victim is the same as any trauma victim: Airway with C-spine control, Breathing, Circulation. Never assume the burn victim is merely burned. The burn victim may have been injured by an explosion or fall. Airway compromise or lung injury may be present. Shock is often present in severely burned patients.

If airway burns are present (see the section on neck and airway injury), immediate intubation is wise. Once edema develops, intubation may be impossible, and even cricothyrotomy may not be successful due to upper tracheal edema. Assume airway burns are present in patients with severe facial burns, burns suffered in an enclosed space, and in those with nasal or oral burns. It's better to err on the side of intubation.

Place a large bore IV (two IVs if there is other trauma) in any patient with burns of 20% of BSA (body surface area) or more. IVs can be started through second or third-degree burns. Begin a rapid fluid infusion. After the primary survey is complete, estimate total fluid needs based on extent of body burn. Other injuries, and the patient's response to fluid infusion, may require infusion of more fluid than standard "burn resuscitation formulas."

If the patient is hypotensive, infuse fluid rapidly until the patient is hemodynamically stable. Give additional fluid based on burn resuscitation formulas.

Remove all clothing, including melted plastics or synthetics.

Draw blood for type & cross-match, CBC, electrolytes, blood gases, and carboxyhemoglobin. Even without hemorrhage, severely burned patients may require transfusion.

Place foley catheter to monitor urine output in response to fluid therapy.

Gastric distention is common with severe burns. Place an NG tube.

Admit the patient to the hospital, or transfer to a regional burn center, after all problems are diagnosed and stabilized.

Fluid Resuscitation

Over the first two hours, the normotensive patient should receive a bolus of fluid (NS or LR) equal to 1 mL x weight in kg x percent of body burned. If blood pressure, pulse rate, skin color, and urine output indicate good circulating volume, slow the infusion to a rate that will deliver an additional 1 mL per kg per percent burn over the next 6-8 hours. An additional 1-2 mL/kg/%burn is given over the next 16 hours.

1st day fluid needs = 4 mL x wt in kg x percent body burned: 1/4 as bolus 1/2 given by 8 hours all given in 24 hours

Estimation of Burn Area

Hand-size estimation: The surface area of smaller burns, or of many scattered burns, can be estimated by comparing the victim's hand size to the burn. One hand's size is about 1% of the body surface area. Three burned areas of about four hand's size each would be 12% of the body surface area.

Rule of 9's: The major body areas are divided such that each area is a multiple of nine. The head represents 9% of the body surface, and each arm is 9%. The front of each leg (to the groin) is 9%, and the back 9%. The front of the torso is 18%, and the back is 18%.

Hospital and Referral Criteria

Consider Hospital Admission Full-thickness burn more than 2% BSA Partial-thickness burns more than 10% BSA Deep burns over flexion creases Burns of hands, face, feet. Genital area burns

Consider Burn Center Transfer More than 25% BSA (20% in children and adults over 40) Full-thickness burns over 10% BSA Significant burns of face, hands, feet, genital areas Burns with other significant injury High-voltage electrical burns Respiratory burn

Copyright 1996 Mad Scientist Software Citation: Argyle, B., Trauma One! Computer Program Manual. Mad Scientist Software, Alpine UT, 1996.