Quick Recap
Trauma System, Protocol 5/8. Built on ATLS 11th Edition (2023) and ICU Protocols: A Step-wise Approach.
1. Burn Depth Classification
Superficial (first-degree, e.g., sunburn): erythema, pain, NO blistering. NOT life-threatening, no significant inflammatory response. Resuscitation NOT required; do NOT include first-degree burns in TBSA calculation.
Partial-thickness (second-degree):
- Superficial partial-thickness: moist, painful, homogeneously pink, blanches to touch, may have intact blisters
- Deep partial-thickness: drier, LESS painful, red/mottled, does NOT blanch to touch
Full-thickness (third-degree): leathery appearance, deep red/brown/waxy white, dry surface, does NOT blanch, PAINLESS to light touch or pinprick (nerve destruction).
Assessment technique: interact with the skin directly and wipe away blisters if needed to accurately assess size/depth — soot and blisters can obscure the wound base; very fair or darker skin tones can make visual depth assessment difficult, reinforcing the need for direct tactile assessment rather than visual inspection alone.
2. TBSA Estimation — Avoiding Errors
Rule of Nines: head/neck 9%, anterior trunk 18%, posterior trunk 18%, each arm (including hand) 9%, each leg (including foot) 18%, genitalia 1%. Children have proportionally LARGER heads (up to 20%) and SMALLER legs (13% in infants) than adults — use pediatric-adjusted charts or Lund-Browder diagrams for improved pediatric accuracy.
Palmar surface (palm + fingers together) approximates 1% BSA — useful for irregular/patchy burn patterns.
Tips to avoid over/underestimation:
- Do NOT include superficial (first-degree) burns in TBSA
- For larger burns, it may be easier to count UNBURNED area and subtract from 100
- Remember to log-roll the patient to assess the posterior surface — easily missed
3. Immediate Stabilization (ABCDE) — Airway
Assess first by asking the patient's name and listening for hoarseness (signifies upper airway burn) — a simple, rapid bedside screen.
100% oxygen for ALL burn patients during the primary survey; ALWAYS assume CO exposure if burned in an enclosed space.
Standard pulse oximetry gives FALSELY HIGH readings with elevated carboxyhemoglobin — confirm true oxyhemoglobin via CO-oximetry blood gas analysis, which also directly measures COHb (see Smoke/Inhalational Injury protocol, Respiratory System, for full CO/cyanide management detail).
Risk factors for upper airway obstruction: carbonaceous sputum, singed nasal hairs; deep burns >35-40% TBSA; burns involving face/neck/upper torso; need for prolonged transport.
Subglottic inhalation injury signs may be SUBTLE and progressively appear within the FIRST 12-24 HOURS — a normal initial exam does NOT exclude evolving injury; frequent reevaluation of airway status is crucial, since obstruction may not be present immediately.
Immediate intubation indications: airway obstruction signs (hoarseness, stridor, accessory muscle use, sternal retraction); respiratory compromise signs (inability to clear secretions, respiratory fatigue, poor oxygenation/ventilation); decreased consciousness with impaired airway protective reflexes.
Other airway intervention triggers: very large TBSA flame burns (typically >40-50%); extensive/deep facial burns; burns inside the mouth.
Intubation technique: place an APPROPRIATELY SIZED ETT for age/sex — the FIRST intubation attempt should be the DEFINITIVE one, performed by the most experienced clinician available. A too-small tube makes ventilation, secretion clearance, and bronchoscopy difficult/impossible; exchanging an ETT in a patient with DEVELOPING EDEMA is dangerous — do not undersize the initial tube expecting to "see how it goes." Standard adult bronchoscopes fit inside a 7mm ID ETT; most pediatric bronchoscopes fit inside a 4.5mm ID ETT.
Awake fiberoptic intubation for difficult cases; in-line cervical stabilization if C-spine injury is a consideration.
4. Breathing
Three general causes of breathing concern: hypoxia, CO poisoning, smoke inhalation injury. Obtain baseline CXR and ABG — normal values on admission do NOT exclude inhalation injury, which can evolve over the following 12-24 hours (same principle as Section 3's airway timing warning).
Deep circumferential CHEST burns can limit chest wall mobility — ventilate per ARDSnet low tidal volume protocol (6 mL/kg IBW), target plateau pressure <30 cmH2O, but a higher plateau pressure up to 40 cmH2O may be tolerated in this specific circumferential-chest-burn scenario given the mechanical restriction. Frequent escharotomies may improve breathing and airway pressures by releasing the constricting eschar.
5. Circulation — Burn Shock Physiology and Fluid Resuscitation
Burn shock is fundamentally DIFFERENT from typical hemorrhagic trauma shock — driven by MASSIVE CAPILLARY LEAK (fluid shifts from intravascular to interstitial space) proportional to burn severity, NOT primarily blood loss. Fluid requirement increases with: larger %TBSA, greater depth, inhalation injury, associated injuries.
Access: IV anywhere possible — unburned areas preferred, burned areas acceptable if necessary; central access if expertise available; cutdowns as a last resort.
Indication threshold: burn resuscitation fluids indicated for partial- and full-thickness burns >=20% TBSA. Burns 20-25% TBSA require IV fluid resuscitation; 30-40% TBSA may be fatal without treatment.
Preferred fluid: warmed isotonic crystalloid, PREFERABLY LACTATED RINGER'S (isotonic, inexpensive, easily stored/available).
Parkland formula (most commonly used): 4 mL/kg x %TBSA burn — give HALF in the FIRST 8 HOURS from time of injury (not time of arrival), the OTHER HALF over the NEXT 16 hours.
IMPORTANT CAVEAT: despite the formula's structural 8-hour "half" cutoff, the fluid rate should be GRADUALLY reduced throughout resuscitation to maintain the targeted urine output — do not apply an abrupt rate halving at exactly 8 hours; titrate continuously to the physiologic endpoints below.
Alternative formulas for reference: Brooke (1.5 mL/kg/%TBSA crystalloid + 0.5 mL/kg/%TBSA colloid); Galveston (pediatric, 5000 mL/m2 burned + 1500 mL/m2 total).
Resuscitation formulas are a GUIDE for INITIATING resuscitation, not a substitute for physiologic titration — the actual fluid rate must be adjusted to the patient's response.
Resuscitation endpoints (titrate to these, not to the formula alone): sensorium comfortable/arousable; base deficit <2; urine output 0.5 mL/kg/h (adult), 1 mL/kg/h (pediatric) — increase fluid rate if urine output falls below target. Insert an indwelling urinary catheter in ALL patients receiving formal burn resuscitation to allow this continuous titration.
Resuscitation endpoint/transition (~24h): once maintenance rate is reached, switch to D5/NS with 20 mEq KCl at maintenance level. Maintenance rate = basal requirement + evaporative losses: adult basal = 1500 mL x BSA (24h); pediatric (<20kg) basal = 2000 mL x BSA (24h); adult evaporative loss (mL/h) = (25 + %TBSA burn) x BSA; pediatric evaporative loss (mL/h) = (35 + %TBSA burn) x BSA.
Colloids/albumin: profound hypoproteinemia occurs after initial resuscitation; albumin favors interstitial fluid recruitment, but has shown NO mortality improvement, though it may LOWER complication rates compared to crystalloid alone. Cochrane evidence: NO benefit from colloids over crystalloids for critically ill trauma/burn/surgical patients; hydroxyethyl starch may INCREASE mortality — crystalloid remains the resuscitation fluid of choice.
Blood transfusion: hemoconcentration in the first several hours post-burn typically makes transfusion unnecessary; bone marrow function is subsequently depressed, and transfusion may become needed. Blood transfusion in severe burns is associated with increased mortality, BUT transfuse 2 units PRBC if Hb <8 g/dL (absent high ACS risk) or Hb <10 g/dL if the patient IS at high ACS risk — a nuanced, risk-adjusted threshold rather than a single fixed number.
6. Severity Assessment and Burn Unit Referral
Refer to a dedicated burn unit: severe burn injury complicated by major trauma or inhalational injury; chemical burns; high-voltage electrical burns; deep burns covering >20% TBSA in adults.
7. Secondary Survey — Burn-Specific History
AMPLE history (Allergies, Medications, Past illness/Pregnancy, Last meal, Events/Environment) with SPECIFIC attention to: mechanism of burn, duration of contact, circumstances, time of injury. Patients can sustain associated injuries while escaping a fire; explosions can cause fractures and internal injuries (CNS, myocardial, pulmonary, abdominal) — do not assume the burn is the only injury.
Be aware some burn injuries may be INTENTIONAL — self-immolation suicide attempts, or abuse (children and vulnerable adults) — match the patient's account to the burn pattern; a suspicious history should raise consideration of intentional injury.
8. Escharotomy
Circumferential burns (limb or chest) can create a constricting, non-compliant eschar that impairs distal circulation (limb) or chest wall excursion (thorax) as underlying tissue edema develops — escharotomy releases this constriction. Perform for absent/diminishing distal pulses in a circumferentially burned limb, or for chest wall burns compromising ventilation (Section 4).
9. Wound Care, Infection Control, and Nutrition
Nasogastric tube (small-bore) for gastric decompression AND to enable early enteral nutrition initiation. Antacids/stress ulcer prophylaxis; tetanus prophylaxis; IV analgesia.
Antibiotics: NOT given prophylactically for the burn wound itself in the absence of confirmed infection — treat documented infection per culture results.
Nutrition: severe burns are markedly HYPERMETABOLIC — early enteral nutrition is standard; pediatric caloric requirement formulas (Shriners/Galveston): 0-1yr: 2100 kcal/m2 TBSA/day + 1000 kcal/m2 TBSA burn/day; 1-11yr: 1800 + 1300 kcal/m2 TBSA burn/day; 12-18yr: 1500 + 1500 kcal/m2 TBSA burn/day.
10. Complications
Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have a RELATIVELY HIGH incidence in severely burned patients compared to other critically ill populations — %TBSA burned correlates with mean intra-abdominal pressure. Positive (daily and cumulative) fluid balance + high IAP + high extravascular lung water index + low abdominal perfusion pressure together suggest a POOR outcome. Non-surgical interventions can improve end-organ function; non-resolving IAH predicts worse outcomes (see Abdominal Compartment Syndrome protocol, GI & Hepatology System, for full IAH/ACS management framework — directly applicable here).
VTE risk: burn patients carry a real, actively studied DVT/thrombotic risk — apply standard VTE prophylaxis once bleeding risk allows.
Delayed/evolving airway compromise (Section 3), evolving pulmonary complications, and standard critical-illness complications (infection, multi-organ dysfunction) also apply.
11. Immediate Stabilization Checklist
Checklist:
12. Investigations
CXR and ABG (baseline, understanding normal results do not exclude evolving inhalation injury), CO-oximetry (COHb level; >10% often indicates significant exposure), serial urine output, base deficit trend, electrolytes, albumin, CBC, intra-abdominal pressure monitoring if ACS risk factors present.
13. Organ Support
Parkland-formula-guided, physiologically-titrated crystalloid resuscitation; lung-protective ventilation with burn-specific plateau pressure tolerance for circumferential chest burns; escharotomy for compartment-like physiology in limbs/chest; early enteral nutrition; standard ICU supportive care; IAH/ACS monitoring and management per the dedicated protocol.
14. Consultation Matrix
Consultation | Trigger | Timing |
Burn Surgery/Burn Unit | Referral criteria met (Section 6) | Immediate |
Anesthesia/Difficult Airway | Anticipated difficult intubation from facial/airway burns | Immediate |
Social Work/Child Protection | Suspected intentional injury | As indicated |
15. Monitoring Framework
Hourly urine output during active resuscitation, serial base deficit/sensorium assessment, frequent airway reassessment through the 12-24h evolution window, intra-abdominal pressure monitoring, serial Hb (transfusion threshold per risk category), nutrition/caloric delivery tracking.
16. Complications (Summary)
Evolving airway obstruction, ARDS/ventilatory compromise from circumferential chest burns, intra-abdominal hypertension/ACS, VTE, infection, multi-organ dysfunction from burn shock physiology. Prevention: frequent reassessment through the evolving-injury window, appropriately sized definitive-attempt intubation, physiologically-titrated (not formula-rigid) fluid resuscitation, proactive escharotomy, IAP monitoring. Rescue: escharotomy, ACS decompression per the dedicated protocol, standard ARDS/shock rescue therapies.
17. Escalation & De-escalation
Escalate: urine output below target despite formula-guided fluids -> increase rate; evolving airway compromise -> intubate without further delay; circumferential burn compromising perfusion/ventilation -> escharotomy.
De-escalate: ~24h resuscitation endpoint reached with stable urine output -> transition to maintenance fluids (D5/NS + KCl), wean toward standard ICU monitoring, advance enteral nutrition.
18. ICU Discharge Criteria
Fluid resuscitation complete and transitioned to maintenance, airway stable through the evolution window, no ongoing IAH/ACS concern, nutrition established, wound care plan in place, burn unit transfer completed if criteria met.
19. Documentation & Medicolegal Checklist
20. Key Guidelines
American College of Surgeons. Advanced Trauma Life Support, 11th Edition Course Manual, 2023 (Chapter 9: Thermal Injuries). American Burn Association burn unit referral criteria.
21. Landmark Evidence
Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2013;(2):CD000567 — no survival benefit from colloids, possible harm from hydroxyethyl starch.
22. Controversies
The precise blood transfusion threshold in severe burns remains debated given the documented association between transfusion and increased mortality, balanced against the real physiologic need in bone-marrow-suppressed, hypermetabolic burn patients — current practice uses a risk-stratified (ACS risk) threshold rather than a single universal number. Optimal albumin use timing/dose continues to be studied given the complication-reduction-without-mortality-benefit finding. IAH/ACS management in burn patients specifically (vs the general ACS population) may warrant burn-specific threshold consideration given the notably higher incidence in this population.
23. References
- American College of Surgeons. Advanced Trauma Life Support, 11th Edition Course Manual, 2023 (Chapter 9).
- Sagar S, et al. Burn Management. ICU Protocols: A Step-wise Approach, 2nd ed. Springer; 2020 (Ch. 13).
- Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2013;(2):CD000567.
- Toon MH, Maybauer MO, Greenwood JE, et al. Management of acute smoke inhalation injury. Crit Care Resusc. 2010;12:53.
- Wise R, Jacobs J. Incidence and prognosis of intra-abdominal hypertension and abdominal compartment syndrome in severely burned patients. Anaesthesiol Intensive Ther. 2016;48(2):95-109.
See also: Smoke/Inhalational Injury (Respiratory System) for full CO/cyanide co-management detail; Abdominal Compartment Syndrome (GI & Hepatology System) for the elevated-incidence IAH/ACS management framework; Polytrauma (Trauma System) for the xABCDE framework this protocol nests within.