• In most UK centres receiving major burn injuries, primary assessment is usually carried out in teams led by anaesthetics or A&E consultants. It is however important to be familiar with burns resuscitation (steps highlighted in pink are burns specific)

• Airway maintenance with cervical spine control

  • Check patency of airway including foreign bodies​

  • Jaw thrust/ chin lift

  • Assess for evidence of inhalation injury - singed nasal hair, carbonaceous sputum, hoarse voice, burns around lips, soot

  • Identify circumferential neck burns

  • C-spine control with rigid collar, sand bags and tape

• Breathing​

  • Expose chest and ensure expansion adequate and symmetrical​

  • Identify circumferential chest burns

  • Supplemental high flow oxygen via non-rebreathing mask

  • Ventilate using bag-valve-mask if necessary

  • Assess respiratory rate and oxygen saturations

• Circulation with haemorrhage control​

  • ​Check central pulses​​ and capillary refill of limbs

  • 2 large bore IV cannulae, preferably in unburned skin - IO access if difficult

  • Take blood for FBC/ U&E/ Coagulation screen/ Cross-match/ Carboxyhaemoglobin/ βHCG if female/ ABG

  • Stop visible bleeding with direct pressure

  • Commence fluid resuscitation with 250ml Hartmann's boluses

  • Identify circumferential limb burns

• Disability​

  • Conscious level (AVPU - Alert, Voice, Pain, Unconscious)​

  • Pupils' response to light

  • Check blood glucose

• Exposure​

  • Remove all clothing and jewellery​

  • Log roll patient to examine the posterior surfaces

  • Keep patient warm

• Indications

  • Adult >15% TBSA​

  • Child >10% TBSA

• Modified Parkland's formula

  • Total volume to be given in 24 hours from time of burn = 3-4ml x patient's weight (kg) x %TBSA​

  • Children require add maintenance fluid

    • 100:50:20 rule

      • 100ml/kg/24hrs for the first 10kg of the child's weight​

      • 50ml/kg/24hrs for the next 10kg of the child's weight

      • 20ml/kg/24hrs for the next 10kg of the child's weight

    • 4:2:1 rule​

      • 4ml/kg/hr for the first 10kg of the child's weight​

      • 2ml/kg/hr for the next 10kg of the child's weight

      • 1ml/kg/hr for the next 10kg of the chil'd weight

  • FIrst half to be given in 8 hours, second half in following 16 hours

  • Only serves as reference to commence fluid resuscitation​​

• Continue to monitor urine output and maintain >0.5ml/kg/hour in adult and >1ml/kg/hour

• Urinary catheter if

  • Adult >20% TBSA​

  • Child >15% TBSA

• Haemoglobinuria/ Myoglobinuria​

  • Increase urine output to 2ml/kg/hr​

  • Mannitol 12.5g/litre resuscitation fluid

• Analgesia - strong opiates titrated to effect

• Trauma series CT or X-ray cervical/ chest/ pelvis

• Electrocardiogram

• NG tube for large burns to reduce gastroparesis

• Supraglottic​

  • Inhalation of hot gases​

  • Oedema of tissues that leads to airway obstruction

• Subglottic​

  • Inhalation of products of combustion​

  • Production of inflammatory mediators and reactive oxygen species in airway mucosa and lung parenchyma

  • Oedema and casts formed by shedding of mucosa

  • Lower airways plugged with debris

  • Disruption of the alveolar-capillary membrane and the formation of inflammatory exudates and loss of surfactant, resulting in interstitial oedema causing hypoxaemia and reduced lung compliance

• Systemic intoxication injury​​

  • C​arbon monoxide

    • 250 times the affinity for haemoglobin as oxygen

    • Irreversibly binds with haem​

    • CO level of 60% is fatal

    • Headache, confusion, nausea, fatigue, disorientation, irritability, hallucination, ataxia, syncope, convulsions, coma, death

    • Treat with high flow oxygen or hyperbaric oxygen (if available)

  • Cyanide

    • Binds to cytochrome system, causing anaerobic metabolism​

    • Loss of consciousness, neurotoxicity and convulsions

    • Metabolised by liver enzyme rhodanese

    • Treat with hydroxocobalamin or sodium thiosulphate

• Ideally performed in theatre

• Involves longitudinal division of eschars from healthy skin to healthy skin down to subcutaneous fat in order to alleviate airway (neck) or ventilatory (chest) problems, or limb ischaemia from restricting eschars

• Careful to avoid important structures (ulnar nerve over medial epicondyle of elbow, common peroneal nerve of fibular neck)

• Risks of bleeding requiring haemostasis

• History

  • Allergies​

  • Medications

  • Past medical history

  • Last meal

  • Events

• Top-to-toe examination ​as per ATLS

• Re-evaluate

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