Management of Severe Burns

Initial Assessment and Classification

• The American Burn Association recommends that burns be classified by depth (superficial, partial-thickness, full-thickness) and total body surface area (TBSA) to determine appropriate management strategy 1
• Adults with burns ≥10% TBSA and children with burns ≥5% TBSA require formal fluid resuscitation, according to the American College of Surgeons 2, 1
• Burns involving the face, hands, feet, genitals, or those with full-thickness compromise require specialized care regardless of size, as stated by the American Burn Association 1
• Assess for inhalation injury, which significantly increases mortality, by checking for circumoral burns, oropharyngeal burns, and carbonaceous sputum, as recommended by the Anaesthesia journal 3

Fluid Resuscitation Protocol

• For initial resuscitation, administer 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate) within the first hour, as recommended by the American College of Surgeons 2, 4
• Calculate 24-hour fluid requirements using the Parkland formula (2-4 mL/kg/%TBSA), according to the American Burn Association 2, 1
• Administer half of the calculated 24-hour fluid requirement in the first 8 hours post-burn, with the remaining half over the next 16 hours, as stated by the American College of Surgeons 2, 1
• For children, higher fluid volumes may be required (approximately 6 mL/kg/%TBSA) due to their higher surface area-to-weight ratio, as recommended by the American Academy of Pediatrics 4, 1
• Monitor urine output (target: 0.5-1 mL/kg/hour) to guide fluid administration, according to the American College of Surgeons 2, 4

Management of Complications

• Monitor for compartment syndrome in circumferential third-degree burns, which can lead to acute limb ischemia or thoracic/abdominal compartment syndrome, as recommended by the Anaesthesia journal 3
• Consider escharotomy for third-degree circumferential burns causing constriction and increased compartmental pressure, ideally performed at a Burns Center, as stated by the American Burn Association 3, 4
• If hypotension persists despite adequate fluid resuscitation, evaluate cardiac function and consider vasopressors, according to the American College of Surgeons 4, 1
• Monitor for and manage acute kidney injury, which is a common complication in severe burns, as recommended by the American College of Surgeons 4

Common Pitfalls to Avoid

• Avoid "fluid creep" (excessive fluid administration) as it can lead to complications including compartment syndrome, as recommended by the American Burn Association 2, 1
• Do not use normal saline (0.9% NaCl) as primary resuscitation fluid as it is associated with a higher risk of hyperchloremic metabolic acidosis and acute kidney injury, according to the American College of Surgeons 4
• Never delay escharotomy when indicated, as poorly timed or performed escharotomy is associated with increased morbidity, as stated by the Anaesthesia journal 3
• Avoid underestimating fluid requirements in electrical burns, which often cause deeper tissue damage than is apparent on the surface, as recommended by the American College of Surgeons 2

Uso de Coloides en Pacientes con Quemaduras Graves

Recomendaciones para el Uso de Albúmina

• La administración de albúmina humana se sugiere en pacientes con quemaduras graves para mantener niveles séricos de albúmina >30 g/L, con dosis típicas de 1-2 g/kg/día, lo que puede reducir los volúmenes de cristaloides y la morbilidad asociada, según la Agencia Europea de Medicamentos (EMA) y la Agencia Nacional de Seguridad del Medicamento (ANSM) 5, 6
• La albúmina al 5% debe iniciarse entre 8-12 horas post-quemadura en pacientes con quemaduras graves para reducir la administración de cristaloides y prevenir el "fluid creep" 5, 7
• Mantener niveles séricos de albúmina >30 g/L con dosis de aproximadamente 1-2 g/kg/día ayuda a disminuir los volúmenes infundidos de cristaloides y la morbilidad resultante 5, 6, 7

Contraindicaciones y Precauciones

• Los almidones de hidroxietilo (HES) están contraindicados en quemaduras graves según la Agencia Europea de Medicamentos (EMA) y la Agencia Nacional de Seguridad del Medicamento (ANSM) 5, 6
• No usar gelatinas ni otros almidones sintéticos debido a efectos negativos sobre la coagulación y función plaquetaria 8

Evidencia de Beneficios

• La administración de albúmina al 5% reduce los volúmenes de cristaloides administrados y disminuye la incidencia de falla orgánica y mortalidad en pacientes con quemaduras graves 7
• La administración de coloides puede reducir complicaciones relacionadas con la sobrecarga de líquidos, incluyendo síndrome de distrés respiratorio agudo, lesión renal aguda congestiva y síndrome compartimental abdominal 5, 6

Consideraciones Pediátricas

• En pediatría, la albúmina se ha incluido empíricamente en protocolos de resucitación, aunque sigue siendo controversial 5, 6
• En niños con quemaduras graves, la administración temprana (8-12 horas) de albúmina al 5% reduce la administración de cristaloides, la incidencia de fluid creep y la estancia hospitalaria 5, 6

Nivel de Evidencia

• La mayoría de los estudios son observacionales, con evidencia de calidad moderada 7
• Un pequeño estudio multicéntrico controlado no detectó diferencias significativas en falla orgánica entre albúmina al 5% y el grupo control 5, 7

Burn Surface Area Assessment and Fluid Management

Assessment Methods

• The American Society of Anesthesiologists recommends using the Lund-Browder chart, not the Rule of Nines, for measuring total body surface area (TBSA) burned in both adults and children, as the Rule of Nines significantly overestimates TBSA, leading to fluid overadministration in 70-94% of cases 9, 10, 11
• The Lund-Browder chart provides the most accurate TBSA measurement and is considered the gold standard, with a pediatric version available 9, 10, 11
• In prehospital or mass casualty situations, the serial halving method or palm method (open hand = 1% TBSA) can be used for TBSA assessment 11
• Digital tools like smartphone applications (e.g., E-Burn) can facilitate accurate TBSA assessment 9
• TBSA should be reassessed during initial management to prevent overtriage and undertriage 9, 11

Critical Pitfalls to Avoid

• The American Burn Association warns against using the Rule of Nines, as it leads to systematic overestimation and excessive fluid administration 9, 11
• Delayed escharotomy for circumferential third-degree burns causing compartment syndrome requires escharotomy within 48 hours if circulatory impairment develops 11

Specialist Consultation and Transfer

• The American College of Surgeons recommends contacting a burn specialist immediately to determine the need for transfer to a burn center, which improves survival, reduces complications, and decreases length of stay 10, 11
• Burns involving face, hands, feet, genitals, or flexure lines require specialist consultation 11
• Telemedicine can reliably improve TBSA measurement and prevent both overtriage and undertriage when specialists are not readily available 11

Severe Burns Management Guideline

Fluid Resuscitation and Monitoring

• The American Society of Anesthesiologists recommends adjusting fluid infusion rates continuously based on urine output, targeting 0.5-1 mL/kg/hour in adults 12
• Hourly urine output is the primary parameter for fluid adjustment, as recommended by the European Society of Anaesthesiology 12
• Monitor arterial lactate concentration for adequacy of resuscitation, as suggested by the American College of Surgeons 12
• Use advanced hemodynamic monitoring (echocardiography, cardiac output monitoring, central venous pressure) in patients with persistent oliguria or hemodynamic instability, as recommended by the Society of Critical Care Medicine 12
• If hypotension persists despite adequate fluid resuscitation, evaluate cardiac function with echocardiography before initiating vasopressors, as suggested by the American Heart Association 12

Albumin Administration

• For patients with total body surface area (TBSA) >30%, initiate 5% human albumin between 6-12 hours post-burn to reduce crystalloid volumes and prevent complications, as recommended by the European Burn Association 12
• Target serum albumin levels >30 g/L with doses of 1-2 g/kg/day, as suggested by the American Burn Association 12
• Albumin administration significantly reduces mortality (OR=0.34, 95% CI 0.19-0.58, P<0.001) when studies with high bias are excluded, according to the Cochrane Review 12
• Albumin reduces abdominal compartment syndrome from 15.4% to 2.8% (P<0.05), as reported by the Journal of Trauma and Acute Care Surgery 12

Compartment Syndrome Management

• Monitor intra-abdominal pressure as abdominal compartment syndrome risk is significantly reduced with albumin use, as recommended by the World Society of the Abdominal Compartment Syndrome 12

Burn Assessment and Management

Initial Assessment and Intervention

• For rapid field assessment of burn surface area, use the patient's palm and fingers (approximately 1% TBSA), and consider using digital tools like smartphone applications (E-Burn) to facilitate accurate assessment, as recommended by the American Burn Association 13
• Burns involving face, hands, feet, genitals, perineum, or flexure lines require specialist consultation and possible transfer to a burn center, according to the American College of Surgeons 13
• If transfer to a burn center is indicated, admit directly to the burn center, avoiding intermediate stops, as advised by the American Burn Association 13
• Perform escharotomy immediately if deep circumferential burns cause compartment syndrome compromising circulation or respiration, ideally at a burn center by an experienced provider, as recommended by the American College of Surgeons 13

Initial Fluid Management for Deep Second-Degree Burns

Threshold for IV Fluid Resuscitation

• Children require formal IV fluid resuscitation when Total Body Surface Area (TBSA) ≥5-10% 14

Recommended Management

• For a 70kg adult with 5% TBSA deep second-degree burns, an initial bolus of 20 mL/kg of balanced crystalloid (Ringer's Lactate preferred) within the first hour may be administered if clinical circumstances warrant IV access, which is approximately 1,400 mL for this patient 14, 15

Fluid Choice Rationale

• Ringer's Lactate is the first-line crystalloid solution over normal saline because it has electrolyte concentrations closer to plasma and does not increase the risk of hyperchloremic metabolic acidosis and acute kidney injury like normal saline does 14, 15
• Balanced solutions have electrolyte concentrations closer to plasma, making them a better choice than normal saline 14, 15

Monitoring Parameters

• If IV fluids are administered, target urine output of 0.5-1 mL/kg/hour, which is approximately 35-70 mL/hour for a 70kg patient 14

Special Considerations for Deep Second-Degree Burns

• Deep second-degree burns may occasionally require escharotomy if circumferential, and monitoring for compartment syndrome is necessary if burns are circumferential on extremities 14, 15
• Escharotomy should be performed at a Burns Centre within 48 hours if circulatory impairment develops, and the only urgent indication for immediate escharotomy is compromised airway movement or ventilation 14, 15

Evidence‑Based Management of Burn Patients with Femoral Fractures

Hemodynamic Impact of Femoral Fracture Types

• Intracapsular femur fractures cause minimal blood loss in burn patients because the fracture is surrounded by a low‑vascular capsule that tamponades bleeding. 16
• Extracapsular femur fractures can result in substantial blood loss—often exceeding 1 L—due to exposure of cancellous bone, contributing additional hemorrhagic stress to the burn‑induced shock state. 16

Analgesia and Early Resuscitation Protocols

• Analgesic regimen during the first hour of resuscitation should include short‑acting opioids combined with ketamine to provide effective pain control while preserving hemodynamic stability in adult burn patients with ≥10 % TBSA and a femoral fracture. 17
• Fluid resuscitation must follow the Parkland formula (2–4 mL/kg per %TBSA), delivering half of the calculated volume within the first 8 hours to achieve adequate intravascular volume before orthopedic intervention. 17
• Hourly urine output should be measured and maintained at 0.5–1 mL/kg/h as the primary endpoint for successful resuscitation in this combined injury cohort. 17

Timing of Orthopedic Intervention and Burn Wound Care

• Definitive orthopedic fixation (internal or external) should be undertaken within 24 hours after hemodynamic targets are met, allowing simultaneous initiation of burn wound debridement and dressing changes. 17