Burns Injury

The anterior chest is 36/2/2 (9), right arm is (9), anterior surface of the left leg is 18/2 (9) and groin area is (1) = 28%.

ATLS approach:

A – Airway with C-spine control

• High-flow oxygen please comp plea
• In a closed-space fire there is high risk of inhalation injury; Look for signs of airway burns and inhalation injury (soot, hoarseness, singed nasal hairs, stridor, facial burns) as it may cause airway oedema
• Early intubation airway oedema due to closed-space fire suspected

B – Breathing

• RR, SpO₂
• ABG including carboxyhaemoglobin level
• Consider cyanide poisoning if severe smoke inhalation
• Ensure adequate ventilation can be achieved; tracheal or pulmonary burns can impair effective gastric exchange and circumferential chest burns may require escharotomy to allow ventilation

C – Circulation

• Two large-bore IV cannulas
• Begin crystalloid (Hartman's / Ringers' lactate) resuscitation using the Parkland formula: 4 mL × (weight) kg × 28% = mL in 24 h; Give half in the first 8 hours from the time of the injury, and the second half in the following 16 hours; avoid colloids and deduct fluids already given
• Insert Foley catheter

D – Disability

• GCS
• Glucose
• Pupils

E – Exposure

• Remove clothing and jewellery
• Avoid hypothermia using warm ambient temperature, clean blankets, convection heaters, cling film

Secondary management

• Analgesia: IV opioids, Inhaled 70% nitrous oxide for acute pain
• Wound care: Cover burns with cling film or clean dry dressings; do not dress blisters; elevate limbs
• Stress ulcer prophylaxis: Start PPI or H2 antagonist
• Tetanus prophylaxis
• Escharotomy for circumferential chest and limb burns
• Begin early enteral feeding (within 6–12 hrs)
• Referral to burns centre if: TBSA >15%, inhalation injury, full-thickness, hands, face or perineum involvement etc.
• Ongoing monitoring of fluids, vitals, urine output

• In the first 24 hours after burns, capillary permeability is massively increased.
• Colloids (e.g., albumin) leak out of vessels into the interstitial space.
• Their oncotic effect pulls even more fluid out of the circulation.
• This causes paradoxical third-space fluid accumulation, worsening oedema.
• Can worsen airway oedema in inhalation injuries.
• Therefore: use crystalloids only in first 24 h; colloids may be used later when capillary integrity improves.

Clinical indicators

• Urine output (best marker): Aim UOP of 0.5 to 1 mL/kg/hr in adults
• Peripheral warmth
• CRT
• HR and BP
• Mental status
• Respiratory status
• Core temperature e.g. rectal temperature

Biochemical indicators

• Lactate and base deficit; improvement suggests adequate perfusion
• Haematocrit; but unreliable after transfusion or haemolysis

Invasive monitoring if available

• Central venous pressure and its response to fluid challenges
• Cardiac index / dynamic measures if in ICU

Avoid over-resuscitation:

• Look for pulmonary oedema
• Look for abdominal compartment syndrome
• Look for limb compartment syndrome

Early

• Burn shock: Hypovolaemia leads to ↓BP, ↑HR, ↑SVR, ↓CO
• Respiratory complications: Airway obstruction, CO poisoning, cyanide toxicity, ARDS
• Electrolyte abnormalities: ↓/↑Na, ↑K, ↓Ca
• Renal failure from hypovolaemia or pigment nephropathy
• Myoglobinuria / haemoglobinuria
• Coagulopathy due to DIC and hypothermia
• Sepsis
• Infection, cellulitis
• Compartment syndrome of the limbs or chest

Late

• Multi-organ failure
• Scarring and contractures
• Chronic pain
• Psychological trauma
• Hypermetabolic state
• Malnutrition
• Functional impairment

Superficial / partial-thickness

• Red or white
• Moist, blistering
• Painful / highly sensate
• Blanches on pressure
• Capillary refill present
• Heals without grafting

Deep partial-thickness or full-thickness

• White, black, or leathery
• Dry, waxy
• Insensate as nerve endings are destroyed
• No capillary refill
• Does not blanch
• Requires grafting