The initial measures in burn care are identical to any trauma situation. Begin by following the Airway, Breathing, Circulation (ABCs) of trauma, which start with airway. Does your patient need to be intubated? As with any trauma patient, someone with a Glasgow Coma Scale (GCS) less than eight, significant airway trauma, an inability to protect their airway, or respiratory distress with impending respiratory failure warrants intubation. Unfortunately, this algorithm gets a whole lot more complicated when you add in a burn. Patients with large burns >40–50 % total body surface area (TBSA) require a great deal of intravenous fluid resuscitation. If not electively intubated, i.e., prior to beginning resuscitation, one can find oneself struggling to intubate a patient who is now in distress with a “difficult” airway due to the edema that comes along with a burn resuscitation. Inhalational injury with subsequent pulmonary insufficiency is another indication for intubation that is specific to the burn patient. The mere act of inhaling smoke does not translate into an inhalational injury. Likewise, the presence of the singed facial hair and oral soot, while worrisome, does not mandate emergent intubation. However, these findings combined with “hard signs” such as dyspnea, increased work of breathing, stridor, or a feeling of chest tightness indicate a need for immediate airway control. Inhalational injury will be discussed later on at length; suffice it to say for now that the initial management indications for intubation are basically the same as for any trauma patient. If your patient appears to be having symptoms of impending respiratory failure, do not hesitate to intubate them.

You have made it past one of the most difficult decisions in initial burn care. We will at this point assume that we are dealing with an isolated burn. What comes after the completion of the ABCs? Place the patient on a sterile sheet. Establish two large-bore peripheral IVs preferably through the non-burned skin, but if necessary, there is nothing wrong with using a burned extremity. If you choose to do so, however, make sure you suture in the IV! Send some basic labs, and if your patient was trapped indoors, add a carboxyhemoglobin level. Begin warming the patient by placing warm blankets and turn up the temperature in the room to about 90 °F. Spend a couple of minutes talking to the paramedics or family members present. Record the time of burn as this will be important later. Ask some questions about the circumstances, particularly if this occurred in a confined space. Find out if the patient is a smoker or has other pulmonary or medical problems. If the patient is a child, ask specific questions about what happened and document what is said.

Now determine the burn size. We cannot emphasize the importance of this step enough. Forget the rule of nines! This is a great way to approach burns in the field, during triage, or perhaps in a hotel room, but a horrible way to start a resuscitation as the rule of nines is notoriously inaccurate. The total body surface area (TBSA) is your starting point for treatment and both underestimation and overestimation can be detrimental. Use specific burn charts such as the chart included at the end of this chapter (Fig. 69.1). How do you tell the depth of a burn based on physical appearance? First-degree burns look like a sunburn. They are red, dry, and painful. Do not count these burns in your percentages! Only second-, third-, and fourth-degree burns count toward TBSA. Second-degree burns are also red and painful but appear blistered or wet. They have a Nikolsky sign which is elicited by rubbing the burn and seeing the outer epidermis peel away. Do not be afraid to touch the burn because knowing the difference between first and second degree is of critical importance. Second-degree burns can be divided into superficial or deep partial-thickness burns. Superficial burns will typically heal in <3 weeks. Deep partial-thickness burns will result in significant scarring if allowed to heal spontaneously. Third-degree, or full-thickness, burns have penetrated through to the level of the nerve endings which are themselves injured which can sometimes result in an insensate burn. When you touch this burn, you will feel that it is hard and leathery, and it will appear deep red, pale pink, or white. Finally, a fourth-degree burn extends past the skin and into the fat and musculature underneath. The burn is hard, insensate, and white/brown. You can sometimes see outlines of thrombosed cutaneous vessels underneath the burn. Do not forget that the burned skin does not burn equally throughout. There will be areas of third degree mixed with first and second.

Once you have your burn percentage, you are ready to make some big decisions. Burns that are larger than 20 % TBSA for adults or larger than 10 % TBSA in children or the elderly need a formal fluid resuscitation. If your patient falls into this category, place a Foley catheter and, if intubated, an orogastric tube (OGT). There are several formulae used to estimate resuscitation needs, but the one used most frequently and the one we recommend is the Parkland formula. The Parkland formula estimates that a person will need 4 cc/kg/% second- and third-degree burn in the first 24 h post burn (4 cc/kg/% TBSA). This is given as lactated Ringer’s solution with half given over 8 h and the other half over the next 16 h. Note how much fluid was given prior to your starting point beginning from the time of burn. Your patients may already be behind the curve or ahead of it depending on how much fluid they have received before getting to you. This will influence your resuscitation. Calculate the rate of IVFs based on burn size and start your resuscitation at that rate. When calculating fluid resuscitation needs, remember that the 8 h and 16 h times are from TIME OF BURN and not from the time you start your resuscitation. For example, a 70-kg young male comes in with second- and third-degree burns totalling 60 % TBSA burn and has already received 2 L of fluid in the field with a burn time of 2 h prior to arrival.

Start your fluid rate at 1400 cc/h for the next 6 h with the plan being to drop that down to 525 cc/h for the following 16 h. Looking at this fluid amount of 16 L should make the point about intubating large burns a little more clear. If you are caring for a burned patient outside of a specialized center, you should carry out all formal resuscitations in an intensive care unit (ICU). The less time spent in the emergency room (ER) the better. Quickly get your patient to a more controlled setting where temperature, vital signs, and urine output can be more methodically measured.

One final note is worth mentioning before we leave the subject of burn care delivered in the emergency room. It is a commonly known fact that as both age and TBSA burned increase, so do the risks of death. This is especially problematic in patient age 65 years or older as their decreased physiologic reserve and higher numbers of medical comorbidities make survival from a large burn challenging. The senior author has demonstrated that in a geriatric cohort, when the sum of age and TBSA burned reaches 130, survival becomes anecdotal as mortality rates of 95 % and higher are seen (Fig. 69.2). Note too, that this is for all geriatric patients regardless of their pre-injury health.

Given such grim prognostic information, it is reasonable to ask what the ethical approach should be to patients with such a small chance of survival to discharge. For we must remember that survival of a large burn is not like survival from an episode of, say, diverticulitis-induced sepsis. With the latter, patients can expect over time to return to the same quality of life and condition that they had before they got sick. When recovering from a large burn, however, in our practice, we constantly seek to impress on the patient and their family that life as they know it has changed forever. During the recovery phase, the rehab regimens are exhausting while the lifetime spent dealing with the sequelae of hypertrophic scarring and contractures require tremendous psychological and physical reserves.

Futility of care can mean different things to different people, and it is not the authors’ intent to parse the widely varying definitions for the term. There is only one definition with which no one would argue, and that is a universally lethal injury with a 100 % fatality rate during the index admission. It is human nature to gravitate toward terms like “always” and “never,” particularly in clinical care, but these are difficult to use in practice as it seems that one can always find the exception that proves the rule. Note that here we are not discussing quality of life issues (which make the conversation about futility even grayer), but frank survival. Unfortunately, the provider can find himself/herself caught between two mutually exclusive ethical imperatives. On the one hand, there is an ethical obligation to involve the patient (or usually in situations this dire, their surrogate decision maker) in any decisions regarding treatment options so as to preserve their autonomy. On the other hand, once the provider is convinced that the point of futility of care has been reached, the provider has an ethical obligation to the patient to limit further pointless interventions with the pain and discomfort that they cause. The first ethical principle is reflexive to providers, but in our experience, the second is less so. In discussing this conundrum with other providers, they will frequently default to a strategy of asking the surrogate for a decision while recommending that comfort care be pursued. The problem with this strategy is that the surrogate can ask that aggressive care be pursued despite the physician’s recommendation of comfort care, and at that point the physician is “locked in” to a plan which they feel may be ethically questionable. Remember, we are talking here about a situation where the provider feels that death is a certainty and not one in which quality of life is the main consideration, because in that situation, clearly one must preserve the right to autonomy, and no conflict between ethical duties exists.

So what to do? The senior author will relay his practice in light of the data shown in Fig. 69.2. Personally, for a patient age 65 years or older who arrives with a burn in which the sum of the patient’s age and the portion of total body surface area with full thickness burn is greater than or equal to 130, I will assess whether they had preexisting frailty syndrome. While multiple frailty assessment tools exist, I have found that frequently frailty is one of those entities which you just know it when you see it. It is interesting that the geriatricians have been aware of the importance of frailty syndrome on outcomes for years while its importance in surgical fields has only recently come to be appreciated. Our data shows that if a sum of 130 is nearly universally lethal in all geriatric patients regardless of subset, it seems like a good-faith assumption that it is a universally un-survivable insult in the frail geriatric patient. As a result, if the burned geriatric patient has a sum of 130 and is not frail, I will go talk to the surrogate decision makers and recommend comfort care while ultimately abiding by whatever treatment regimen they decide upon. If I ascertain that the burned geriatric patient has a sum of 130 and is frail, I will unilaterally initiate comfort care, withhold fluid resuscitation, and tell the surrogate decision makers that this is a lethal injury with my expectation that their loved one will expire in the next 6 to 12 h. In doing so, I feel that I am honoring my ethical duty to the patient to forego interventions that have no promise of benefit, which at that time is my highest ethical duty. I do not undertake this algorithm in patients younger than 65 years.

Your patient is now in the ICU. What next? Weigh the patient as soon as possible and go back and recalculate your fluid needs if necessary. Warm the room to 90 °F. Wound debridement is one of the first things done after getting to the ICU. Make sure the room has fully warmed and then take a plastic basin with tap water and pour a small bottle of chlorhexidine soap into the water (about 4 oz should be fine). Using gauze pads, begin to wash the patient, debriding away the dead skin in the process. You are basically peeling off the burned blisters. Once fully debrided, apply silvadene cream generously to the wound. Silvadene is a good broad-spectrum antimicrobial, and it will provide some pain relief as burns exposed to air are very painful. If dealing with facial burns, use bacitracin instead of silvadene. Wrap the burns with fine mesh gauze and then a gauze kling wrap to hold it in place. Burns change over time. Go back and revise your diagram after debridement. Things you thought were deep may now appear more superficial. Likewise, burns that initially appeared as second or first degree may evolve into something worse. Revise your numbers if you find that the burn was bigger than you first estimated. Perform these dressing changes twice daily taking care to wash all silvadene off each time so that the actual wound gets cleaned and you do not end up just layering new silvadene on top of old.

Pain control is something that the patient will need starting in the field. Burned patients require enormous amounts of narcotics that most physicians are uncomfortable in giving. Burns are exceedingly painful, and in order to adequately treat them, you must step out of your comfort zone. For initial debridement in the non-intubated patient, we generally will use morphine 5 mg IV with repeat dosing in 15 min. You may repeat this multiple times if necessary. Additionally, lorazepam 1 mg IV is used for the initial debridement, and then oral lorazepam is given as a 1-mg dose for subsequent dressing changes. The initial dressing change is generally the most painful, but your patient may still require the same morphine dosages for the next few dressing changes. Begin morphine by patient controlled analgesia (PCA) right away with a setting of 2 mg IV every 6 min with a 40 mg lockout. You may need to bolus more on top of this for breakthrough pain. Remember to watch for signs of narcotic overdose, such as decreased respiratory rate or inability to wake up promptly, and treat accordingly. The intubated patient is much less stressful for the provider. Instead of a PCA, they should be on a narcotic and sedative protocol but will need an additional bolus for dressing changes as well. We recommend the same morphine dosing as the non-intubated patient, but instead of lorazepam, we typically use midazolam 5 mg IV.

Elderly patients are a bit different and are much more sensitive to narcotics and benzodiazepines. Therefore, do not use lorazepam or midazolam in a non-intubated elderly patient. Instead of morphine, use hydromorphone with a PCA setting of 0.15 mg every 6 min with a 1 mg 1 h lockout. Dressing changes can be premedicated with 1–2 mg of oral hydromorphone.

The principles of early burn excision and grafting are important for reducing burn sepsis and should be a factor in your mind. While definitive burn management is beyond the scope of this chapter, ideally the burn should be excised and grafting begun within the first 3–5 days. Continue to work on getting your patient to a burn surgeon who is better prepared to offer definitive treatment.

Particularly concerning is the deep circumferential burn. An eschar has lost all elasticity, and once underlying edema from fluid resuscitation sets in, it acts as a tourniquet putting the burned extremity in jeopardy. Careful monitoring for pulse changes with decreasing Doppler signal is important to identify an at-risk extremity. In addition, circumferential burns of the chest can constrict chest wall movements making ventilation more difficult and causing a rise in airway pressures. Escharotomies can be performed at the bedside if your patient is intubated and can be adequately sedated. If not, it may be better to do in the operating room where general anesthesia can be delivered.