For referring providers: Burn care resources

• Superficial injury which involves only the epidermis

• Pale skin tone

  • Red

  • Erythematous

• Dark skin tone

  • Erythematous

  • Areas that are darker than the patient’s normal pigmentation

• Painful

• Not included in a burn size assessment

• Complete burn assessment (see Burn Assessment section above)

• Does patient need to be transferred?

• Patients can be managed as outpatient

  • If they, or a family member, can perform wound care

  • Do not require oral narcotics

  • Are able to attend scheduled clinic appointments

• If a patient requires intravenous, intramuscular or intranasal narcotics, they may still be a candidate to be managed outpatient

For burns that are 20% of total body surface area (TBSA) or greater

• Complete primary survey

• Identify and treat life or limb threatening injures

  • Prioritize concurrent traumatic injuries

• Complete history

  • Mechanism

    • Thermal

    • Chemical

    • Electrical

    • Radiation

  • Circumstances of injury

  • Time of accident

• Replace fluids using Lactated Ringers (LR)

  • Decreased risk of hyperchloremic acidosis compared to normal saline in burn patients

• Cover the burn with plastic wrap to reduce insensible loss

• Obtain baseline labs

  • CBC

  • BMP

  • Magnesium

  • Phosphate

  • Calcium

  • Carbon monoxide and ABG (enclosed space fire)

• Prepare patient for transfer to burn center

• Multiply: 2 ml × patient’s weight (kg) × percent of TBSA burned = total volume needed

• Divide that total by 16 for Lactated Ringers starting rate

Example:

• Patient weight/TBSA:

  • 100 kg/TBSA of 45%

• Calculate total fluid needed:

  • 2 ml × 100 × 45 = 9,000 mL (anticipated total fluid needed).

• Determine rate:

  • 9,000 ÷ 16 = 560 mL per hour.

• Start Lactated Ringers at 560 ml per hour

Check urine output hourly to determine ongoing resuscitation needs:

• Urine output goals

  • Adults: 0.5 mL/kg/hour ideal body weight

  • Pediatrics 10-50 kg: 1mL/kg/hour ideal body weight

• Titrate LR infusion to maintain adequate urine output

  • If urine output in one hour is below goal, then increase LR by 10% of current rate

    • For example: if current rate is 300 ml/hour, new rate will be 330 ml/hour

  • If urine output in one hour is above goal, then decrease LR by 10% of current rate

    • For example: if current rate is 300 ml/hour, new rate will be 270 ml/hour

• Multiply: 3 ml x patient’s weight (kg) x percent of TBSA burned=total volume needed

• Divide that total by 16 for Lactated Ringers starting rate

Example:

• Patient weight/TBSA:

  • 45 kg/TBSA of 25%

• Calculate total fluid needed:

  • 3 ml x 45 x 25 = 3,375 ml (anticipated total fluid needs).

• Determine rate:

  • 3,375 ÷ 16 = 280 ml per hour

• Start Lactated Ringers at 280 ml per hour

For children under five years old, also initiate D5LR at a weight-based maintenance rate. This will NOT be titrated during resuscitation.

Check urine output hourly to determine ongoing resuscitation needs:

• Urine output goals

  • Adults: 0.5 mL/kg/hour ideal body weight

  • Pediatrics 10-50 kg: 1mL/kg/hour ideal body weight

  • Pediatrics <10kg: 2 ml/kg/hour

• Titrate LR infusion to maintain adequate urine output

  • If urine output in one hour is below goal, then increase LR by 10% of current rate

    • For example: if current rate is 300 ml/hour, new rate will be 330 ml/hour

  • If urine output in one hour is above goal, then decrease LR by 10% of current rate

    • For example: if current rate is 300 ml/hour, new rate will be 270 ml/hour

1. Administer oral pain medication one hour before attempting wound care (patients often require an opioid for premedication)

2. Gather necessary supplies:

• Antimicrobial soap

• Clean washcloths

• Towels

• Chuck pads (x two)

• Petroleum jelly based antibiotic ointment

• Non-stick or oil emulsion gauze

• Dry gauze

• Scissors

• Tape

• Compression bandages/stockings

3. Provide a clean surface for wound care.

• Place a chuck pad or towel under the burn

• Use antimicrobial soap and wet washcloth to wash the burn and surrounding skin

• Remove ALL loose, blistered or burned tissue. This may require moderate pressure to unroof blistered, loose skin. Remaining skin prevents direct contact of the antibiotic ointment with the wound and can serve as a nidus of burn infection.

4. Pat the burn and surrounding skin dry. Place the second chuck pad under the burn.

5. Apply the triple antibiotic ointment directly to the on-stick or oil emulsion gauze. Use enough ointment to cover entire gauze surface area. You may need to rub the ointment and gauze together to coat the gauze.

6. Apply the non-stick or oil emulsion gauze coated in ointment directly to the burn. Ensure there is a small border of this ointment-covered gauze on the intact skin surrounding the burn. You may need to cut the ointment-covered gauze or apply multiple pieces to cover the entire surface of the wound.

7. Wrap gauze around the extremity from distal to proximal ends of the wound. This holds the non-stick gauze in place and collects drainage. Trim excess gauze as needed. If you choose, you may secure the loose end of the gauze with tape.

8. Apply compression garment over the extremity. You may use stockings, elastic wraps such as ACE bandages or a tubular compression like Tubigrip. Do not use Coban for compression. It can limit movement and easily become a tourniquet as edema forms.

9. While the burn wound is open, the patient should wash and dress daily. If an oral opioid premedication is needed for gauze changes, please prescribe prior to discharge home.

Intubation should be considered for patients who:

• Experience respiratory or airway distress

  • Hoarseness

  • Wheezing

  • Stridor

  • Rales

  • Rhonchi

  • Cyanosis

  • Hypoxia

• Have a suspected burn inhalation injury

  • Injury occurred in an enclosed space WITH associated facial burns

  • Patient has

    • Singed nasal hairs

    • Carbonaceous sputum

    • Soot on teeth or tongue

    • Inflamed oral or nasal mucosa

• Significant or prolonged exposure to fumes, smoke, or steam

Prophylactic indicator for burns

• Burns of 40% TBSA (total body surface area) or greater

• Circumferential partial or full thickness torso burns

• Significant facial/neck burns (due to anticipated edema formation)

• Smoke inhalation after prolonged time in enclosed space fire (due to anticipated inhalation injury)