Early resuscitation after burn injury is key to mitigate shock. Follow the Parkland formula for resuscitation in burns greater than 20% total body surface area (TBSA).
Use lactated Ringer’s solution, not normal saline, as a resuscitation fluid to avoid hyperchloremic metabolic acidosis.
Do not administer bolus intravenous fluids during initial burn resuscitation. This can lead to abdominal compartment and secondary extremity compartment syndromes.
Consider early use of colloid (packed red blood cells, fresh frozen plasma, or albumin) in patients with low urine output despite adequate fluid resuscitation.
Communicate with local burn center before performing escharotomy.
Intubate prior to transfer in patients with extensive head, neck, or facial burns; elevated carbon monoxide levels (>30%), large burns (>40% TBSA), obtundation, or symptoms of early airway obstruction.
In austere conditions, resuscitate orally when possible, graft only full-thickness burns and in small aliquots, and minimize ventilator use.
Approximately 1.25 million people are burned annually in the United States, of whom 30,000 are admitted to burn centers and 3400 succumb to their injury.1,2 Traditionally, the highest incidence of burn injury occurs at the two extremes of age. During the first few years of life, burns are primarily due to liquid scalds and then, after the age of 60, injuries are commonly due to both flame and scald burns.2-4
Between 1971 and 1991, burn deaths decreased by 40% with a concomitant 12% decrease in deaths associated with inhalation injury.5 Since 1991, burn deaths per capita have decreased 25% according to the Centers for Disease Control and Prevention (https://www.cdc.gov/injury/wisqars/index.html). These improvements are in part due to prevention strategies resulting in fewer burns of lesser severity as well as significant advances in treatment, particularly in children. Current reports indicate a 50% mortality for 98% total body surface area (TBSA) burns in children age 14 years and younger.6 A healthy child with any size burn can be expected to survive.7 The same is not true for those age 45 years or older, where improvements have been more modest, particularly in patients over 65 years of age, in whom a 35% TBSA burn still results in a 50% mortality.8
Burn Center Referral Criteria
The decision for in-hospital care of a burned victim varies with burn size, age, premorbid conditions, the patient’s home situation, and access to local expertise. Patients with larger burns may benefit from treatment in specialized burn centers. These centers have dedicated resources and the required multidisciplinary approach to maximize outcomes from such devastating injuries.9 The American Burn Association and the American College of Surgeons Committee on Trauma have established guidelines to identify patients who should be transferred to a specialized burn center, and these include the following10: