juliana tolles, md, mhs with thermal burns · 2019. 10. 20. · she is minimally responsive, with...

February 2018Volume 20, Number 2

Author

Juliana Tolles, MD, MHSAssistant Professor of Emergency Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA; Harbor UCLA Medical Center, Torrance, CA

Peer Reviewers

Boyd Burns, DOGeorge Kaiser Foundation Chair in Emergency Medicine, Associate Professor and Program Director, Department of Emergency Medicine, University of Oklahoma School of Community Medicine, Tulsa, OK

Christopher Palmer, MDAssistant Professor, Department of Anesthesia, Division of Critical Care & Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO

CME Objectives

Upon completion of this article, you should be able to:

1. Perform a comprehensive initial survey of a patient with a burn.

2. Apply evidence-based interventions for resuscitation of burn patients.

3. Assess and treat toxic exposures associated with burns.

4. Identify patients who require referral to a burn center.

Prior to beginning this activity, see “Physician CME Information” on the back page.

This issue is eligible for 4 trauma CME credits.

Emergency Department Management of Patients With Thermal Burns Abstract

Thermal burn injuries are a significant cause of morbidity and mortality worldwide. In addition to treatment of the burns, emergency clinicians must assess for inhalation injury, expo-sure to toxic gases, and related traumatic injuries. Priorities for emergency resuscitation include stabilization of airway and breathing, intravenous fluid administration, pain control, and local wound care. Special populations, including children and pregnant women, require additional treatment considerations. Referral to specialized burn care for select patients is necessary to improve long-term outcomes. This article reviews thermal burn classification and evidence-based treatment strategies.

Editor-In-ChiefAndy Jagoda, MD, FACEP

Professor and Chair Emeritus, Department of Emergency Medicine; Director, Center for Emergency Medicine Education and Research, Icahn School of Medicine at Mount Sinai, New York, NY

Associate Editor-In-ChiefKaushal Shah, MD, FACEP

Associate Professor, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

Editorial BoardSaadia Akhtar, MD

Associate Professor, Department of Emergency Medicine, Associate Dean for Graduate Medical Education, Program Director, Emergency Medicine Residency, Mount Sinai Beth Israel, New York, NY

William J. Brady, MD Professor of Emergency Medicine and Medicine; Chair, Medical Emergency Response Committee; Medical Director, Emergency Management, University of Virginia Medical Center, Charlottesville, VA

Calvin A. Brown III, MD Director of Physician Compliance,

Credentialing and Urgent Care Services, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA

Peter DeBlieux, MD Professor of Clinical Medicine, Interim Public Hospital Director of Emergency Medicine Services, Louisiana State University Health Science Center, New Orleans, LA

Daniel J. Egan, MD Associate Professor, Department

of Emergency Medicine, Program Director, Emergency Medicine Residency, Mount Sinai St. Luke's Roosevelt, New York, NY

Nicholas Genes, MD, PhD Associate Professor, Department of

Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

Michael A. Gibbs, MD, FACEP Professor and Chair, Department of Emergency Medicine, Carolinas Medical Center, University of North Carolina School of Medicine, Chapel Hill, NC

Steven A. Godwin, MD, FACEP Professor and Chair, Department of Emergency Medicine, Assistant Dean, Simulation Education, University of Florida COM-Jacksonville, Jacksonville, FL

Joseph Habboushe, MD MBA Assistant Professor of Emergency Medicine, NYU/Langone and Bellevue Medical Centers, New York, NY; CEO, MD Aware LLC

Gregory L. Henry, MD, FACEP Clinical Professor, Department of Emergency Medicine, University of Michigan Medical School; CEO, Medical Practice Risk Assessment, Inc., Ann Arbor, MI

John M. Howell, MD, FACEP Clinical Professor of Emergency

Medicine, George Washington University, Washington, DC; Director of Academic Affairs, Best Practices, Inc, Inova Fairfax Hospital, Falls Church, VA

Shkelzen Hoxhaj, MD, MPH, MBA Chief Medical Officer, Jackson

Memorial Hospital, Miami, FL

Eric Legome, MD Chair, Emergency Medicine, Mount Sinai West & Mount Sinai St. Luke's; Vice Chair, Academic Affairs for Emergency Medicine, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY

Keith A. Marill, MD Assistant Professor, Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA

Charles V. Pollack Jr., MA, MD, FACEP Professor and Senior Advisor for Interdisciplinary Research and Clinical Trials, Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA

Michael S. Radeos, MD, MPH Associate Professor of Emergency Medicine, Weill Medical College of Cornell University, New York; Research Director, Department of Emergency Medicine, New York Hospital Queens, Flushing, NY

Ali S. Raja, MD, MBA, MPH Vice-Chair, Emergency Medicine,

Massachusetts General Hospital, Boston, MA

Robert L. Rogers, MD, FACEP, FAAEM, FACP Assistant Professor of Emergency Medicine, The University of Maryland School of Medicine, Baltimore, MD

Alfred Sacchetti, MD, FACEP Assistant Clinical Professor, Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA

Robert Schiller, MD Chair, Department of Family Medicine,

Beth Israel Medical Center; Senior Faculty, Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, NY

Scott Silvers, MD, FACEP Associate Professor and Chair,

Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL

Corey M. Slovis, MD, FACP, FACEP Professor and Chair, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN

Ron M. Walls, MD Professor and Chair, Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA

Critical Care EditorsWilliam A. Knight IV, MD, FACEP Associate Professor of Emergency

Medicine and Neurosurgery, Medical Director, EM Advanced Practice Provider Program; Associate Medical Director, Neuroscience ICU, University of Cincinnati, Cincinnati, OH

Scott D. Weingart, MD, FCCM Associate Professor of Emergency

Medicine; Director, Division of ED Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY

Senior Research EditorsAimee Mishler, PharmD, BCPS Emergency Medicine Pharmacist,

Maricopa Medical Center, Phoenix, AZ

Joseph D. Toscano, MD Chairman, Department of Emergency Medicine, San Ramon Regional Medical Center, San Ramon, CA

International EditorsPeter Cameron, MD

Academic Director, The Alfred Emergency and Trauma Centre, Monash University, Melbourne, Australia

Andrea Duca, MD Attending Emergency Physician,

Ospedale Papa Giovanni XXIII, Bergamo, Italy

Suzanne Y.G. Peeters, MD Attending Emergency Physician, Flevo Teaching Hospital, Almere, The Netherlands

Hugo Peralta, MD Chair of Emergency Services, Hospital Italiano, Buenos Aires, Argentina

Dhanadol Rojanasarntikul, MD Attending Physician, Emergency

Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross, Thailand; Faculty of Medicine, Chulalongkorn University, Thailand

Stephen H. Thomas, MD, MPH Professor & Chair, Emergency

Medicine, Hamad Medical Corp., Weill Cornell Medical College, Qatar; Emergency Physician-in-Chief, Hamad General Hospital, Doha, Qatar

Edin Zelihic, MD Head, Department of Emergency

Medicine, Leopoldina Hospital, Schweinfurt, Germany

Go to the interactive PDF at www.ebmedicine.net/topics and click on the icon for a closer look at tables and figures.

http://www.ebmedicine.net/topics

Copyright © 2018 EB Medicine. All rights reserved. 2 Reprints: www.ebmedicine.net/empissues

evidence on burn-wound care, pain control, and the criteria for referral to specialized care.

Critical Appraisal of the Literature

A literature search was performed in PubMed using the search terms burn, burns, and inhalation burn. The search identified approximately 4600 original articles that were screened and narrowed to articles of highest quality evidence and relevance. Only articles with abstracts available in English were included. The Cochrane Database was searched for systematic reviews using the key term burn, which identified 11 articles. A search of the Database of Abstracts of Reviews of Effects (DARE) and Center for Reviews and Dissemination (CRD) databases did not reveal any unique publications not previously identified in the PubMed search. A search of the Na-tional Guidelines Clearinghouse identified 1 relevant guideline. The ABA Consensus Guidelines (2012) and ABA Practice Guidelines: Burn Shock Resuscita-tion (2008) were also reviewed. The former is a con-sensus statement, whereas the latter identifies the level and category of evidence upon which each of its recommendations is based. International guide-lines from the World Health Organization and the European Burn Association were also reviewed. Overall, the clinical evidence on thermal burns is of moderate strength, consisting of relatively few large, well-designed clinical trials and many smaller trials and observational studies. When possible, recommendations in this article are evidence-based. Recommendations based on common practice or expert consensus are explicitly noted as such.

Etiology and Pathophysiology

Burns occur when a heat source contacts skin. Al-though the temperature required to burn skin varies somewhat by skin location and time of exposure, prolonged exposure to temperatures above 40°C (104°F) causes protein denaturation.4 This process occurs more rapidly at higher temperatures. Only 10 seconds of exposure to 60°C (140°F) are required to cause a full-thickness burn. The zones of burn are generally agreed to be those described in 1959 by Jackson. (See Figure 1, page 3. ) The zone of coagulation, also known as the central zone, is the area of maximal damage and is anticipated to necrose. The surrounding zone of stasis is a penumbra of at-risk tissue that may heal if perfusion is adequately restored, but is at risk for necrosis. Some hypothesize that apoptosis due to oxidative stress may also be a mechanism for cell death in this zone.4 The outermost zone is the zone of hyperemia, and it is most likely to heal with adequate patient resuscitation and wound care. Burns that are larger than 20% of the total body

Case Presentations A 35-year-old chef presents to the ED after burning his right hand on a cooking surface at work. His vital signs are normal and his hand is blistered over half of the pal-mar surface. You place a nursing order for pain medica-tion and a tetanus booster. As you leave the bedside, you try to recall whether he should be referred to a burn center and whether there are any evidence-based guidelines to help you select a dressing… As you put down his chart, the nurse calls you to the resuscitation bay for a 22-year-old woman brought in by EMS from a house fire. Paramedics report that she required extrication from the collapsed house. She is minimally responsive, with soot visible in her orophar-ynx and extensive burns to her abdomen, back, and right upper extremity. Her vital signs are: temperature, 37.5°C (99.5°F); heart rate, 140 beats/min; blood pressure, 85/40 mm Hg; respiratory rate, 35 breaths/min; and oxygen saturation, 88% on room air. As you prepare to intubate her and start IV fluid resuscitation for her hypotension, you wonder which resuscitation fluid you should select and how to best monitor the patient’s response. You won-der whether anything other than her extensive burns may be causing her hypotension and altered mental status… Your next patient is a 3-year-old boy brought in by his mother for scald burns to his feet. The mother says that yesterday the child picked up a bowl of hot soup and accidentally spilled its contents. He appears fussy and has symmetric, well-demarcated, full-thickness burns to both feet from the ankles down. His vital signs are: tempera-ture, 37°C (98.6°F); heart rate, 120 beats/min; blood pres-sure, 90/55 mm Hg; respiratory rate, 22 breaths/min; and oxygen saturation, 98% on room air. You are concerned about the delay in seeking care and wonder whether this might be more than an accidental burn…

Introduction

The American Burn Association (ABA) reports that nearly half a million people suffer thermal burns each year in the United States.1 According to World Health Organization estimates, as many as 265,000 people worldwide die annually of thermal burns.2 The economic burden of thermal burn injury is also substantial: In the United States in 2000, the annual direct-care cost of treating pediatric burns alone was $211 million.2 This does not take into account the economic impact of rehabilitation and long-term disability. Efforts to prevent thermal burns through regulation and public health initiatives have reduced the incidence in developed countries; however, burn injuries still account for approximately 0.5% of all United States emergency department (ED) visits annually.3 This issue of Emergency Medicine Practice reviews the guidelines on assessment of burns and how these assessments are used for optimal manage-ment of fluid resuscitation, in addition to the latest

3 Copyright © 2018 EB Medicine. All rights reserved. February 2018 • www.ebmedicine.net

prospective observational studies have found that clinical estimation of burn depth by a burn surgeon or emergency physician accurately distinguishes between full-thickness and partial-thickness burns about 60% to 80% of the time.6 The presence of pain cannot be used to exclude a full-thickness burn; a retrospective review of 507 patients found that patients with isolated full-thickness burns had only slightly decreased pain scores compared to those with partial-thickness burns.7

Differential Diagnosis

In the majority of cases, the diagnosis of thermal burn will be clear from the history. In cases with un-clear history, consider chemical or electrical etiolo-gies of burn, as well as nontraumatic skin eruptions. Electrical burns generally have relatively small areas of deep burn to the skin, corresponding to the elec-trical current’s source and grounding locations. Most medical mimics of burn will have a more gradual onset, over hours to days, and will be associated with fever and an ill appearance. Nontraumatic causes of erythroderma and skin sloughing include staphylococcal scalded skin syndrome, Stevens-Johnson syndrome, and toxic epidermal necrolysis. Nontraumatic causes of bullae include pemphigus vulgaris, bullous pemphigoid, and necrotizing fasci-itis, among many others. Animal or insect bites and stings may also produce erythema and/or bullae; look for a central punctum. The differential diagnosis for patients presenting with thermal burns should also take into consider-ation potentially life-threatening airway burns result-ing from inhalation of hot air or chemical irritants, concurrent traumatic injury, and exposure to toxic gases, such as carbon monoxide or cyanide. Carbon monoxide binds to hemoglobin, preventing it from carrying oxygen to tissues, and it also binds to cyto-chrome oxidase at the mitochondrial level, preventing aerobic respiration. Cyanide does only the latter.8

surface area (TBSA) provoke a profound systemic inflammatory response, mediated by cytokines such as tumor necrosis factor (TNF), interleukin-6 (IL-6), and oxide species. Loss of plasma protein into the interstitium of burned areas produces hypoprotein-emia, causing systemic loss of oncotic pressure, and finally resulting in widespread tissue edema, even in nonburned areas.5 Intravascular volume dramatically decreases. The combination of these processes causes multiorgan failure, including pulmonary edema, myocardial depression, paralytic gastrointestinal ileus, and depression of red blood cell production.4 Burns can be classified by depth, according to the ABA criteria. (See Table 1 and Figure 2, page 4. ) Burn classification (by depth) and measure-ment (by TBSA calculation) are important to guide initial management and referral. Although physical examination findings are the only method available to the emergency clinician for estimating burn depth, they are only moderately reliable. Several

Figure 1. Zones of Burn

Reproduced from: Pathophysiology and types of burns. Shehan

Hettiaratchy, Peter Dziewulski. BMJ. Volume 328, pages 1427-1429.

© 2004 with permission from BMJ Publishing Group Ltd.

Table 1. Classification of Burns by Depth

Burn Thickness Deepest Skin Structure Involved

Appearance Pain Prognosis (Without Surgical Intervention)

Superficial (first-degree) Epidermis Dry, blanching erythema Painful Heals without scarring,

5-10 days

Superficial partial-

thickness (second-degree)

Upper dermis Blisters; wet, blanching

erythema

Painful Heals without scarring,

< 3 weeks

Deep partial-thickness

(second-degree)

Lower dermis Yellow or white, dry,

nonblanching

Decreased sensation Heals in 3-8 weeks;

likely to scar if healing

> 3 weeks

Full-thickness (third-degree) Subcutaneous structures White or black/brown,

nonblanching

Decreased sensation Heals by contracture

> 8 weeks; will scar

Adapted from: Elizabeth Haines, Hilary Fairbrother. Optimizing emergency management to reduce morbidity and mortality in pediatric burn patients.

Pediatric Emergency Medicine Practice. Volume 12, issue 5, pages 1-23. © 2015 EB Medicine. Used with permission. www.ebmedicine.net.

Epidermis

Zone of coagulation Zone of

stasis

Zone of hyperemia

Inadequate resuscitation

Zone of stasis lost

Zone of coagulation

Zone of stasis preserved

Adequate resuscitation

Dermis


suspected cyanide exposure (as indicated by history of smoke inhalation and altered mental status) found a 67% rate of survival and no clinically significant adverse effects; however, the study did not include a control group and excluded patients with facial burns or those with > 20% TBSA involvement.9 A European expert consensus panel has endorsed a prehospital protocol for administration of hydroxocobalamin to patients with a history suspicious for smoke inhala-tion and a Glasgow Coma Scale (GCS) score ≤ 9 or for those with hemodynamic instability and a GCS score ≤ 13.10 Neither the relative benefit of prehospital ver-sus hospital administration of hydroxocobalamin nor its cost-effectiveness has been prospectively studied. Prehospital CoolingAfter immediate life-threats have been assessed and treated, burns should be cooled for at least 20 minutes. A retrospective review of 695 pediatric burn patients in Vietnam found that those whose burns had been cooled with water at the scene of the injury had a significantly lower rate of deep-thickness burns compared to those whose burns had not been cooled (prevalence ratio of deep burns 0.68; 95% confidence interval, 0.55-0.85).11 Compared

Prehospital Care

After the patient has been moved to a safe environ-ment and any active flame extinguished, cloth-ing and jewelry over the affected area should be removed. The next priority is to stabilize airway, breathing and circulation. Respiratory failure should be managed with either noninvasive or invasive ventilation. Patients with signs of diminished perfusion or hypotension should be given intrave-nous crystalloid per local protocols. Hypotension observed at the scene of burn injury should raise suspicion for traumatic injuries or toxic exposures. Patients should be assessed for concurrent traumatic injuries and immobilized according to local prehos-pital protocols. For patients with suspected inhala-tion injury, 100% oxygen should be administered by nonrebreather face mask.

Prehospital Administration of HydroxocobalaminIt may be reasonable for prehospital providers to administer hydroxocobalamin for suspected cya-nide toxicity. A prospective study of 67 patients who received hydroxocobalamin at the scene of injury for

Figure 2. Illustration of Burn Depth Classifications

Images shown are noted by the classification of burn depth: (A) superficial burn; (B) superficial partial-thickness burn; (C) deep partial-thickness burn;

(D) full-thickness burn.

Lars H. Evers, Dhval Bhavsar, Peter Mailänder P. The biology of burn injury. Experimental Dermatology. Volume 19, pages 777-783. © 2010 John Wiley &

Sons A/S. Reprinted with permission.

A B

C D


that would prompt further evaluation for the source of shock. Assess for hypoxia or respiratory distress, which may indicate the need for emergent airway management. Examine the oropharynx for signs of inhalation injury, including stridor, singed nasal or facial hair, carbonaceous deposits in oropharyngeal mucosa or sputum, and facial burns. Signs of injury to the upper airways are an imperfect predictor of lower airway injury, as either lower or upper airway inhala-tion injury can occur in isolation.16,17

Next, estimate the TBSA of the burn. First-degree burns are not included in this calculation. The pre-ferred method is a Lund and Browder chart, which is a map of skin surface by body part, adjusted for age-dependent changes in body surface distribution.18 (See Figure 3, page 6. ) This method has the highest accuracy and interrater reliability, although it can be time-consuming to use.19 An alternative method, the “rule of nines,” divides each body surface into 9% (or a multiple of 9%) of TBSA. (See Figure 4, page 6. ) For example, the anterior chest is assumed to be 18%, and the arm assumed to be 9%. Although faster than using Lund and Browder charts, this method consistently overestimates the TBSA involvement and may result in excessive fluid administration.19,20 The patient’s palmar surface (palm and digits) may be used to estimate 1% TBSA, but this method is appropriate only for very small burns, as this approximation tends to overesti-mate the area of larger burns; the palmar surface is more precisely 0.9% TBSA in adults.21

Note any circumferential burns on the extremi-ties, chest, or neck. If circumferential burns are seen, assess perfusion of distal extremities and chest wall compliance with ventilation. Perform a complete secondary survey for traumatic injuries in all burn patients. If ocular involvement is suspected and the patient is sufficiently stable, perform a complete ophthalmologic evaluation, including visual acuity and slit-lamp examination with fluorescein staining.

Diagnostic Studies

Laboratory TestingFor patients with minor burns, < 20% TBSA without full-thickness burns, and without inhalation injury, no laboratory workup is mandated. For patients with ≥ 20% TBSA, inhalation injury, or persistent vital sign abnormalities, laboratory workup should consist of the following tests.

to other cooling methods (such as wet towels or evaporative cooling), a porcine study demonstrated significantly decreased final depth of burn in those animals treated with cool running water.12 Other animal studies have demonstrated that cooling times of ≥ 20 minutes were found to be associated with significantly decreased burn depth compared to cooling times of < 20 minutes.13 Transport of a critically ill patient takes priority over cooling if both cannot be performed simultaneously. Prehospital cooling does not appear to be associated with hypothermia. A retrospective review of 1215 burns patients from a trauma registry found an incidence of mild hypothermia on arrival to the ED of 1.6%; howev-er, hypothermia was correlated with total body surface involvement, not with prehospital cooling.14

Folk remedies such as aloe vera, saliva, and tea tree oil are popular and may have been applied by patients prior to medical contact. Animal studies have found that these remedies do lower skin tem-perature to a statistically significant degree, but have failed to show any long-term improvement in burn depth or wound healing.15

Prehospital Pain ManagementPrehospital providers may initiate treatment of pain with intravenous opioids, according local prehospi-tal protocols, after stabilizing the patient and cooling the burn. To minimize pain during transport, cover burns with either dry or wet dressings.

Emergency Department Evaluation

HistoryObtain a careful history of the circumstances and timing of the burn. Determine whether the burn oc-curred in an enclosed space or other context suspi-cious for smoke inhalation. In vulnerable popula-tions, ask detailed questions about the mechanism of injury to screen for inconsistencies suggestive of abuse (See the section, “Special Populations: Pedi-atric Patients,” page 14). The timing of burn injury is important because fluid resuscitation goals are calculated from the onset of injury, not the time of ED presentation. Ask first responders about any history of concurrent trauma, such as a fall, blast injury, or extrication. Review the patient’s medical history, which may influence anticipated morbidity and need for burn center referral. Ask about tetanus vaccination status.

Physical ExaminationThe goal of the physical examination in a burn patient is to establish resuscitation priorities. (See Table 2.) Immediate threats to the airway or hemodynamic in-stability due to traumatic injuries will take precedence over treatment of burn wounds. Note any vital sign abnormalities (such as tachycardia or hypotension)

Table 2. Physical Examination of Burn Patients

• Vital signs

• Oropharynx: carbonaceous sputum, intraoral burns

• Skin: estimate total body surface area and depth of burn

• Assess for circumferential injury

• Survey for trauma


“cherry-red” appearance of their skin), and pulse oximeter readings may be normal. Any COHb level > 15% suggests toxicity and should be treated (higher levels can be seen in smokers or due to background environmental exposures).22 An arte-rial blood gas is also useful for detecting metabolic acidosis due to cyanide toxicity, and hypercapnia or hypoxia due to respiratory failure. The PaO2/FiO2 ratio (partial pressure of oxygen in arterial blood/fraction of inspired oxygen) may also help predict the severity of inhalation injury.23

Lactate LevelLactate is produced by anaerobic metabolism, which may result from poor oxygen delivery to tissues or in-terruption of aerobic metabolism at the cellular level. In a burn patient with suspected inhalation injury, an elevated serum lactate level should prompt empiric treatment for cyanide poisoning, as lactate levels have been shown to correlate with serum cyanide levels in patients with suspected inhalation injury.24

Chemistry PanelA chemistry panel is useful to document baseline values, as patients with severe burns will require trending of end-organ function markers, such as cre-atinine. A bicarbonate level and anion gap can also help screen for a gap acidosis, which is associated with exposure to the toxic inhalants carbon monox-ide and cyanide.

Complete Blood Cell CountA complete blood cell (CBC) count is useful to establish baseline hemoglobin level, which may be trended to assess for developing anemia, either due to blood loss or hemodilution.

Arterial Blood Gas With CO-Oximetry TestingFor patients with respiratory distress, altered mental status, or in whom inhalation injury is suspected, measure carboxyhemoglobin (COHb). This is es-sential because patients with significant toxicity may not have classic examination findings (such as the

Figure 4. Rule of Nines

Source: Thermal Burns, Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eCitation: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide,

8e; 2016 Available at: http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109438787 Accessed: December 20, 2017

Copyright © 2017 McGraw-Hill Education. All rights reserved

Rule of Nines diagram for estimation of adult burn size.

Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM.

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide,

8e; 2016. www.accessemergencymedicine.com Copyright © The

McGraw-Hill Companies, Inc. Used with permission.

Figure 3. Lund and Browder Chart

Source: Thermal Burns, Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eCitation: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide,

8e; 2016 Available at: http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109438787 Accessed: December 20, 2017

Copyright © 2017 McGraw-Hill Education. All rights reserved

Lund-Browder diagram for estimation of burn size.

Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM.

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide,

8e; 2016. www.accessemergencymedicine.com Copyright © The

McGraw-Hill Companies, Inc. Used with permission.

http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109438787



patient’s airway, cool the burn (if within a reason-able time frame or not already performed in the field), treat for toxic exposures, administer intrave-nous fluid resuscitation, perform local wound care, control pain, and give tetanus prophylaxis.

Airway ManagementStabilizing the patient’s airway is the first priority in burn resuscitation. Patients with suspected inhalation injury should be immediately placed on 100% oxygen by nonrebreather face mask to preoxygenate for intu-bation (which is also the therapy of choice for carbon monoxide toxicity). Expert consensus endorses early intubation for burns to the upper airway, airway edema, stridor, or other signs of respiratory com-promise.29 Delay in establishing a definitive airway may make endotracheal intubation difficult or even impossible, as burned tissue becomes progressively edematous. No clear evidence exists about the extent of upper airway compromise or lower airway injury that are indications for intubation, so the decision must be made based on clinical judgment. Although succinylcholine is not recommended in burn patients more than 48 hours after injury due to upregulation of acetylcholine receptors and subsequent increased risk of hyperkalemia, it is not contraindicated in the early acute period (< 48 hours).30

Managing Inhalation InjuryPatients who have extensive inhalation injury are at risk for developing acute respiratory distress syndrome (ARDS),8 a syndrome of noncardiogenic pulmonary edema associated with decreased al-veolar compliance. The best ventilation strategy for burn patients with ARDS has not been established, but a low-tidal-volume strategy studied in a large randomized clinical trial of a broader population of patients with ARDS was found to reduce mortality and duration of mechanical ventilation.31 (The ARDS Network protocol is available at: www.ardsnet.org/ files/ventilator_protocol_2008-07.pdf) Bronchodila-tors such as albuterol and nebulized epinephrine have been shown to decrease bronchospasm due to inhalation injury and may be used, but there is no evidence of mortality benefit.8

Carbon Monoxide and Cyanide ToxicityExposure to both carbon monoxide and cyanide is common in patients who have inhaled smoke. Carbon monoxide binds to hemoglobin, displacing oxygen and shifting the hemoglobin-oxygen dis-sociation curve to the left. The result is hypoxia at a cellular level. Symptoms include altered mental status and seizures, and without treatment, long-term neurologic deficits can result.8 Patients with suspected carbon monoxide toxicity should receive 100% FiO2, which shortens the half-life of COHb to approximately 45 minutes. Therapy should continue

Cyanide LevelA serum cyanide level drawn in the ED will not re-sult in time to guide clinical management and need not be sent. Empiric treatment for suspected cyanide poisoning should be based on clinical suspicion.

Type and ScreenIn patients with concurrent trauma, blood transfu-sion may be required.

Urine Pregnancy TestingPregnant patients require adjustments to manage-ment of cyanide and carbon monoxide exposures. (See the “Special Populations: Pregnant Patients” section, page 15). Pregnant patients who are > 20 weeks' gestation will require fetal monitoring.

ImagingChest X-RayChest x-ray is not a sensitive screening test for inha-lation injury.25 It should be obtained only as needed for the evaluation of traumatic injuries or as judged clinically appropriate, based on examination find-ings.

Computed Tomography For patients with suspected concurrent traumatic injuries, obtain computed tomography (CT) scans in accordance with trauma society guidelines. Because chest CT is more readily available in the ED than bronchoscopy and can evaluate distal airways, there has been interest in its ability to predict inhalation injury. In a single-center study of 40 patients, the total luminal involvement of airways and bron-chial wall thickness seen on CT correlated with the number of days of mechanical ventilation, even after correcting for other markers of burn severity.26 CT findings of inhalation injury appear to be an inde-pendent predictor of respiratory distress or mortality in patients who undergo bronchoscopy, according to a separate retrospective study of 44 patients.27

BronchoscopyAlthough seldom available immediately in the ED, bronchoscopy may predict lower respiratory tract inhalation injury. A single-center retrospective study of 32 patients found that a 5-point scale for grading inhalation injury (which the authors termed the “ab-breviated injury score”) correlated with oxygenation, likelihood of developing respiratory distress syn-drome, and duration of mechanical ventilation.28

Treatment

For patients with extensive burns, inhalation injury, or complex medical problems, transfer to a burn center should be initiated in parallel with early treatment. Emergency clinicians should stabilize the

http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf

http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf


response to the burn.5 The ABA guidelines recom-mend intravenous fluid resuscitation for adults and children with > 20% TBSA burns.39 Smaller burns are not associated with significant systemic inflamma-tory response and can be treated with oral hydration alone. The goal of resuscitation is to maintain end-organ perfusion. Choosing Resuscitation FluidsThe choice of resuscitation fluid remains controver-sial, but most expert guidelines recommend crystal-loid, with a preference for lactated Ringer’s solution over normal saline (0.9% sodium chloride).39 There are no randomized trials comparing different types of crystalloid for burn resuscitation. There is no strong evidence to support use of colloids over crystalloids in burn patients. Several trials of colloid for supplementing crystalloid fluid resuscitation showed decreases in total volume of fluid administration, interstitial edema, and intra-abdominal pressure.40,41 Others found no differ-ence in measures of multiorgan dysfunction.42 A large meta-analysis of randomized controlled trials involving over 10,000 critically ill patients (includ-ing some burn patients) found no mortality im-provement when resuscitation with colloids was compared to resuscitation with crystalloids alone.43 An independent meta-analysis of 140 burn patients who received albumin as part of several random-ized controlled trials found a lower total volume of fluid administered during the resuscitation phase, but failed to demonstrate a mortality benefit.44 One prospective trial found an increase in pulmonary fluid accumulation for patients given colloids.45 There is equally poor evidence of benefit, and some evidence of harm, for the use of hypertonic crystalloid resuscitation fluid or hyperoncotic colloid solution. A single-center trial of 110 patients compar-ing hypertonic lactated saline to lactated Ringer’s solution found a decrease in fluid administration in the first 24 hours when the hypertonic solution was used, but it failed to demonstrate a mortality differ-ence.46 A separate study demonstrated a decrease in intra-abdominal pressure compared to isotonic lactated Ringer’s solution.47 A trial of 30 patients who received 6% hyperoncotic hydroxyethyl starch found increased mortality, with a hazard ratio of 7.2, in patients who received the hyperoncotic solution compared with those who received crystalloid.48

Fluid Volume Resuscitation FormulasMany formulas have been developed to estimate the appropriate volume of fluid resuscitation. Commonly used formulas include the Parkland formula and the Modified Brooke formula. (See Table 3, page 9. ) MDCalc.com has an online tool for calculating the Parkland Formula at:• www.mdcalc.com/parkland-formula-burns

until COHb levels are < 15%. The half-life of COHb can be shortened further with hyperbaric oxygen, but the benefits of this therapy are unclear. A sys-tematic review of 6 clinical trials of 1361 patients reported conflicting results regarding its efficacy and concern for bias in the trials that reported a benefit.32 Cyanide is toxic to cellular metabolism, and its level in burn patients has been found to correlate with mortality.24 There are 2 treatments for cyanide toxicity: hydroxocobalamin and sodium nitrite compound combined with sodium thiosulfate. Because sodium nitrite works by forming methemo-globin, which then chelates cyanide, it reduces the oxygen-carrying capacity of blood. This is a huge disadvantage for smoke-inhalation victims, who are likely to already have reduced blood-oxygen carry-ing capacity due to gas exchange abnormalities from lung injury and COHb. An ovine study found that, even in the absence of COHb, hydroxocobalamin produced a faster resolution of hypotension compared with sodium nitrite and sodium thiosulfate.33 Based on evidence from retrospective reviews and expert opinion, hydroxocobalamin 5 g IV should be administered to patients with suspected cyanide toxicity.10,34,35 If the patient fails to respond clinically to the first dose, an additional 5 g dose may be administered, up to a maximum of 10 g.36 Of note, hydroxocobalamin may interfere with some laboratory test results, so they should be drawn before administration. In the event that hydroxocobalamin is not available and carbon monoxide inhalation has been ruled out, sodium nitrite (300 mg IV) plus sodium thiosulfate (12.5 g IV) can be used as a second-line alternative. If hydroxocobalamin is not available and carbon monoxide inhalation is present, sodium thiosulfate can be used alone, but this is an inferior alternative, as it is known that it does not readily penetrate intracellularly in cerebral tissue.

CoolingIf cooling was not initiated immediately after a burn, delayed cooling may be considered, but there is conflicting evidence regarding its efficacy. An animal model that compared immediate cooling with de-layed cooling (up to 60 minutes after injury) found delayed cooling to be as effective as immediate cooling, using burn depth as a metric.37 However, a similar study that used burn-wound perfusion as the metric found delayed cooling was no better than no treatment at all.38 Nonetheless, there is little down-side to attempting it. Patients with extensive body surface area involvement may be at risk for hypo-thermia and should be monitored carefully.

Intravenous Fluid ResuscitationPatients with burns can become rapidly volume-de-pleted intravascularly due to systemic inflammatory


Blood TransfusionBurn patients commonly develop anemia due to blood losses, hemodilution from fluid resuscitation, or inflammatory response to the burn itself. The volume of packed red blood cell transfusion was found to be associated with increased rates of infection, in a retro-spective study of burn victims, echoing findings from studies of trauma and intensive care unit patients.57 Because no large studies have established a threshold for blood transfusion in burn patients, therapy should be based on evidence of physiologic need.

Wound CarePrior to dressing, burns should be irrigated with sterile water or normal saline. Devitalized tissue should be debrided.58

Superficial (first-degree) burns should simply be kept clean and dry. They require no special dressing because the dermis is intact. Partial-thickness wounds require a dressing to promote healing, reduce the risk of infection, and decrease pain. Emergency clinicians can choose either a topical ointment covered by a nonadherent dressing or an occlusive dressing. Despite the proliferation of new dressing products, there is scant evidence for the superior-ity of a single dressing type. A systematic review by the Cochrane group of 30 randomized controlled trials found no strong evidence that any particu-lar dressing reduces healing time.59 Topical silver sulfadiazine has been widely used for burn care, but more recent reviews suggest that it is associated with longer healing times. A systematic review of 14 randomized controlled trials involving 877 partici-pants comparing topical silver to nonsilver dressings found that topical silver was associated with longer healing time.60 In that review, no difference in rates of infection was found. An independent systematic review of 52 trials comparing topical silver to alter-native dressings (some of which contained silver) came to the same conclusions.61 Two further system-atic reviews that compared topical silver sulfadia-zine to other dressings in pediatric patients corrobo-rated these conclusions.62,63 Evidence regarding the effect of silver-impregnated dressings on healing time was equivocal.60

For facial burns, a meta-analysis of 5 random-ized controlled trials including 119 patients found that there was some low-quality evidence to suggest that occlusive dressings reduced healing time com-pared to topical agents, but there was insufficient evidence to draw a conclusion.64 A small random-ized controlled trial and cost-effectiveness analysis comparing topical silver agents to silver-impreg-nated dressings found that the dressings were more cost-effective.65,66 However, larger cost-effectiveness studies of nonsilver treatments have not been per-formed. It is reasonable for the emergency clinician to exercise clinical judgment to select a dressing that

There are no large randomized trials of resus-citation formulas comparing patient outcomes. Several retrospective reviews have demonstrated that patients with delayed resuscitation, inhalation injury, or deep-thickness burns are likely to require fluid volumes greater than those calculated by com-mon resuscitation formulas.39,49 Current ABA guidelines incorporate the litera-ture noted here, recommending crystalloid resus-citation according to weight, 2 to 4 mL × weight (kg) × %TBSA in the first 24 hours with the optional addition of colloid solutions.39,50 The guidelines note that hypertonic solution may be used, but should be employed with caution due to the risk of hyperna-tremia and other electrolyte imbalances. Monitoring Fluid ResuscitationThe ABA guideline emphasizes the importance of monitoring and adjusting fluid resuscitation using markers of perfusion, including vital signs, urine output, cardiac output, and lactate level. Most experts agree that urine output is an important measure of resuscita-tion, but no evidence supports an optimal hourly urine output target.51 The ABA recommends that resuscitation should be titrated to urine output of 0.5 to 1 mL/kg/hr in adults and 1 to 1.5 mL/kg/hr in children.39 Invasive hemodynamic monitoring of cardiac output has been hypothesized to be a more direct measure of organ perfusion than urine output. However, a meta-analysis of randomized controlled trials of invasive monitor-ing found no mortality benefit; additional study is needed.39,52,53 Research is ongoing to develop computer decision-support algorithms to dynamically guide fluid administration based on a feedback loop from physi-ologic measurements, but no large trials have been con-ducted.54,55 Despite this lack of evidence, experts agree that patient response to fluid resuscitation should be closely monitored to avoid overresuscitation—termed “fluid creep”—and its complications, such as abdominal compartment syndrome.56

Table 3. Common Intravenous Resuscitation Formulas for Adult Burn Patients

Parkland Formula

• First 24 hours: give 4 mL × weight (kg) × %TBSA; give one-half

in the first 8 hours and other half in the next 16 hours. Adjust rate

based on urine output.

• Second 24 hours: give 20% to 60% of calculated plasma volume

as colloid.

Modified Brooke Formula• First 24 hours: give lactated Ringer’s solution 2 mL × weight (kg)

× %TBSA; give one-half in the first 8 hours and other half in the

remaining 16 hours.

• Second 24 hours: give colloid at 0.3-0.5 mL × kg × %TBSA burn

+ D5W to maintain urine output.

Abbreviations: D5W, dextrose 5% in water; TBSA, total body surface area.


decrease the risk of infection and improve patient comfort.68 Based on expert opinion, it is reasonable to leave small unruptured blisters intact (< 6 mm in diameter) as well as those that are in areas of thick skin (palms and soles).69,70 Unroofing and debride-ment is reasonable for thin-walled or large blisters or blisters that interfere with functional movement. Full-thickness burns require surgical excision by a burn surgeon. For very small full-thickness burns, consultation from the ED or immediate transfer to a burn center may not be required, but close follow-up should be arranged.

balances patient preference for cost, comfort, and ease of use, with the caveat that multiple studies have demonstrated a longer healing time for topical silver sulfadiazine. (See Table 4 and Table 5.)

Unroofing, Debridement, and Surgical ExcisionTherapeutic unroofing and debridement of intact blisters in partial-thickness burns is controversial. Although there are many small studies, no large high-quality trials have been conducted.68,69 Ad-vocates for debridement cite nonviable tissue as a potential nidus for infection, especially if a blister left intact ruptures spontaneously later. However, leaving unruptured blisters intact may potentially

Table 4. Occlusive Dressings for Partial-Thickness Burns67

Dressing Advantages Disadvantages Cost

Acticoat® (polyethylene with

polyester/rayon core)

Has antimicrobial activity via delivering

nanocrystalline silver; comfortable; change

dressing every 3-7 days

Stains skin $30 per 5” × 5”

sheet

Aquacel® (sodium carboxymethyl-

cellulose on hydrofibers)

Comfortable; allows for drainage; change

dressing every 2 weeks

Only products containing silver have

antimicrobial activity

$30 per 4” × 5”

sheet

Amnion membrane (biologic) Decreases bacterial load; comfortable Experimental; not widely available Unknown

Biobrane® (biosynthetic skin

substitute)

Single dressing, allows for re-

epithelialization to occur, permitting a gas

and fluid exchange; controls pain

Costly $220 per 5” × 5”

sheet

DuoDERM® (hydrocolloid) Facilitates autolytic debridement; comfort-

able; change dressing every 3-7 days

Does not allow for exudate drainage; no

antibacterial activity

$6 per 6” × 6”

sheet

Tegaderm™/OPSITE®

(polyurethane film)

Easy to apply No ability for exudate to drain; only to

be used on mostly healed burns; no

antibacterial activity

$0.60 per 4” × 4”

sheet

Mepitel® (silicone) Easy to apply directly to wound; nonstick;

allows exudate drainage; change dressing

every 7-10 days

No antibacterial activity $7.00 per 4” × 4”

sheet



Table 5. Topical Therapies for Partial-Thickness Burns

Treatment Advantages Disadvantages Cost

Bacitracin Painless; can be applied to face and near mucous

membranes

Narrow antimicrobial activity $4 per 30 g

IntraSite®, NU-

GEL®, et al

(hydrogels)

Can absorb large volume of exudative drainage; weak

evidence for faster wound healing

Potential to macerate normal skin if applied beyond

wound edge

$8 per 15 g

Silver sulfadiazine Cheap; minor pain relief; wide-spectrum antibacterial

activity

May delay healing; may cause skin discoloration;

cannot be applied to face; painful to remove

$15 per 50 g

Mupirocin Good antimicrobial activity against gram-

positive bacteria and most methicillin-resistant

Staphylococcus aureus; can be applied to face

Expensive $40 per 22 g

Mafenide acetate Wide-spectrum antimicrobial activity; absorbs well

into eschar

Painful on application, cannot be applied to large

surface area due to risk of metabolic acidosis

$140 per

113.4 g




generally involves ocular adnexa. If thermal injury to the cornea is suspected, perform copious irriga-tion with approximately 1 liter of isotonic solu-tion to remove any foreign body debris. Although there is no evidence to support the use of antibiotic prophylaxis, experts recommend application of an ophthalmic antibiotic ointment (eg, tobramycin, bacitracin) in patients with thermal injury to the cornea. Ophthalmologic consultation is indicated for these patients.72

AntibioticsA meta-analysis and systematic review of 36 ran-domized clinical trials involving 2117 patients found insufficient evidence to recommend for or against the administration of systemic prophylactic antibiotics to prevent infection.73 A meta-analysis of 2 random-ized controlled trials of prophylactic antibiotics for patients in developing countries came to the same conclusion.74 Although widely used, the efficacy of topical antimicrobial agents is not well-established. A randomized trial of 50 adults with superficial partial-thickness burns comparing silver sulfadiazine oint-ment to petroleum jelly found comparable healing times and rates of infection between the treatments.75

Pain ControlThe mainstay of burn pain treatment is opioid an-algesia. Treatment of burn pain should be initiated early and reassessed frequently. Patients may require high doses of opioids for burn pain. A single-center retrospective study of fentanyl for treatment of pain during burn dressing changes found an average dose of 8 mcg/kg was required.76 If high doses are required, patients should be monitored for respira-tory depression. Topical local anesthetics such as lidocaine may be safe to use for burn analgesia. A small prospec-tive study reported administration of 0.7 g to 4.5 g of lidocaine to patients with burn TBSA 5% to 65%. The authors found no systemic toxicity and a significant reduction in pain scores at all TBSA, with the most significant pain reduction at TBSA < 30%.77 How-ever, no large trials have established a safe dosing for topical anesthetics to burns. Therefore, topical lidocaine should be reserved for very small surface-area burns. A meta-analysis found that ketamine is effective for primary treatment for burn pain and identified some evidence that it abolishes the “wind-up” phe-nomenon, or increased pain on repeated stimulation.78

Tetanus ProphylaxisTetanus prophylaxis should be given according to the Centers for Disease Control and Prevention (CDC) guidelines and the patient’s vaccination status. (See Table 6, page 14. )

EscharotomyCircumferential full-thickness burns to the ex-tremities can compromise distal perfusion, and full-thickness burns of the chest can restrict patient ventilation. Escharotomy, a skin incision to release tension caused by inelastic eschar, may be required to alleviate these effects. Evidence regarding escha-rotomy is limited to case series and expert opinion, but signs of decreased perfusion—including absent or decreased pulse oximetry (< 95%), absent or decreased pulses, elevated compartment pressures or new-onset neurological deficits—are generally agreed to be emergent indications.71 Inability to adequately ventilate a patient due to restriction from chest eschar is an indication for chest wall escharoto-my. All incisions should be deep enough to allow the eschar to move independently, but extension beyond the eschar should be avoided, as it risks injury to deeper structures. There is no consensus on the best location for escharotomy incisions, but most experts recommend incising the midlateral and midmedial areas of limbs in order to avoid arteries and nerves.71 (See Figure 5.) Ocular BurnsBecause of protective corneal reflexes, direct burns of the cornea are rare, and injury to ocular structures

Figure 5. Escharotomy

Recommended escharotomy incision lines.

Reichman EF. Emergency Medicine Procedures, 2e; 2013

www.accessemergencymedicine.com Copyright © The McGraw-Hill

Companies, Inc. Used with permission.

https://www.thieme-connect.de/bilder/hamipla/200703/498hm03



Clinical Pathway For Emergency Department Management Of Multiple ShocksClinical Pathway for Management of Burns in the Emergency Department

(Continued on page 13)

Patient presents with burn injury

• Conduct primary survey of airway, breathing, circulation, and

disability

• Remove clothing

• Initiate cooling measures if not already performed and < 60

minutes from injury

Complete survey for trauma

• Physical examination findings suggesting life-threatening

trauma?

• Circumferential burns with decreased distal perfusion or

neurologic deficit?

Initiate burn shock resuscitation

• Parkland formula (4 mL × weight (kg) × %TBSA, first half over 8

hours) (Class II) • Shriners-Cincinnati formula for children (4 mL × weight (kg) ×

%TBSA + 1500 mL/m2; first half over 8 hours) (Class II)• Obtain baseline laboratory values*• Initiate strict urine output monitoring; consider Foley catheter

Assess circulation

• Hypotension or signs of hypoperfusion?

• Suspicion for traumatic hemorrhage?

Evaluate and treat altered mental status

• If unable to protect airway, intubate if not already done (Class II)• Administer FiO2 at 100% if not already done (Class II)• Noncontrast CT head for TBI (Class II)• Arterial blood gas with CO-oximetry, if not already done

Assess airway

• Respiratory compromise, presence of burns to airway, or

carbonaceous sputum?

Estimate TBSA with Lund and Browder chart (Class II)• > %20 TBSA involvement?

• Inhalation injury?

Assess alterations in consciousness

• Altered mental status?

NO

NO

NO

YES

YES

YES

Manage airway compromise

• FiO2 at 100% (Class II)• Endotracheal intubation (Class II)If history of smoke inhalation or burn in enclosed space

• Obtain arterial blood gas with COHb and lactate (Class II)

*Laboratory testing includes CBC, basic metabolic panel, serum lactate, urine pregnancy test, type and screen (Class II).

For Class of Evidence definitions, see page 13.

Abbreviations: CBC, complete blood cell count; CN, cyanide; CO, carbon monoxide; COHb, carboxyhemoglobin; CT, computed tomography; IV,

intravenous; FiO2, fraction of inspired oxygen; RBCs, red blood cells; TBI, traumatic brain injury; TBSA, total body surface area.

Manage shock

• Initiate IV crystalloid resuscitation with 20 mL/kg bolus (Class II)• Perform trauma survey and control active bleeding

• Treat massive hemorrhage with 1:1:1 ratio of packed RBCs,

platelets, and fresh-frozen plasma (Class I)• Empiric treatment with hydroxocobalamin 5 g IV for CN toxicity if

history of smoke inhalation (Class III)

Continued on page 13

Diagnose and stabilize traumatic injuries

• Obtain additional images per trauma society guidelines (Class II)• Perform escharotomy for circumferential burns with decreased

perfusion or neurologic deficit (Class II)

YES

NO

YES

NO


Clinical Pathway For Emergency Department Management Of Multiple ShocksClinical Pathway for Management of Burns in the Emergency Department

(Continued from page 12)

Initiate wound care:

• Debride large (> 6 mm) or movement-limiting blisters (Class III)• Cleanse burns with soap and water (Class I)• Apply occlusive dressing or topical ointment with nonadherent

dressing (Class I)• Administer tetanus prophylaxis, if indicated (Class II)• Provide pain control with IV opioids (Class II), consider IV

ketamine (Class III)Assess for nonaccidental burns in vulnerable populations (elderly,

children)

• Are burns well-demarcated, symmetric, and even-thickness?

• Is mechanism consistent with injury?

• Is there delay in seeking care?

• Contact accredited burn center

• Continue cooling burn up to 60 min (Class II)• Treat pain with IV opioids (Class II), consider IV ketamine

(Class III) • Administer tetanus prophylaxis, if indicated (Class II)• Apply dressing as directed by receiving facility

Partial-thickness or full-thickness burns present?

• Contact adult or child protective services

• Perform further survey for nonaccidental trauma

• Admit

Discharge home if

• Partial thickness burn < 10% TBSA

• No inhalation injury

• Appropriate ability to follow up

• Either no sensitive areas involved (perineum, hands, face, feet,

joints) or can follow up closely as outpatient with burn center

Admit if

• Complex comorbidities

• Poor social support or follow-up

NO

NO

NO

YES

YES

YES

Abbreviations: IV, intravenous; TBSA, total body surface area.

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

Copyright © 2018 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Class I• Always acceptable, safe• Definitely useful• Proven in both efficacy and effectiveness

Level of Evidence:• One or more large prospective studies

are present (with rare exceptions)• High-quality meta-analyses• Study results consistently positive and

compelling

Class II• Safe, acceptable• Probably useful

Level of Evidence:• Generally higher levels of evidence• Nonrandomized or retrospective studies:

historic, cohort, or case control studies• Less robust randomized controlled trials• Results consistently positive

Class III• May be acceptable• Possibly useful• Considered optional or alternative treat-

ments

Level of Evidence:• Generally lower or intermediate levels of

evidence• Case series, animal studies,

consensus panels• Occasionally positive results

Indeterminate• Continuing area of research• No recommendations until further

research

Level of Evidence:• Evidence not available• Higher studies in progress• Results inconsistent, contradictory• Results not compelling

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.

(Continued from page 12)Are any of the following present?

• > 10% partial-thickness burn

• > 5% full-thickness burn

• Burns to hands, feet, face, perineum, genitals, or overlying joints

• Electrical or chemical burns

• Significant traumatic injuries

• Significant medical comorbidities

• Pediatric patient at nonpediatric facility

• Psychosocial complexities


requirements than adults, possibly because they have a higher ratio of body surface area to weight. A prospective study of 48 children found that pediatric patients may need up to 6 mL × kg × hr × %TBSA in the first 24 hours.83 The ABA resuscitation guideline recommends use of the Shriners-Cincinnati formula, which adds 1500 mL/m2 to the Parkland formula cal-culation, to be administered over the first 24 hours.39 Intentional injury must be considered in the eval-uation of all pediatric burns. Assessing for abuse can be challenging, as scald burns are the most common type of both accidental and nonaccidental pediatric thermal burns. A systematic review of 26 retrospective studies found that symmetric appearance to wounds, clear upper wound margins, and the presence of old or apparently unrelated injuries were associated with intentional scald injuries.84 Nonaccidental burns tended to involve immersion of the extremities, but-tocks, or perineum, whereas accidental burns were more likely to involve the upper body. (See Figure 6.) Time-to-presentation was not examined by enough high-quality studies to determine with a high degree

Special Populations

Pediatric PatientsGenerally, pediatric burns have a good prognosis. A retrospective study of 1443 patients published in 1991 found that pediatric mortality was higher compared with adults only in children aged birth to 48 months with burns > 30% TBSA.79 However, pe-diatric burn care differs from adult burn care in that it must encompass adjustments to TBSA calculation, accommodate different intravenous resuscitation requirements, and include assessment for abuse. The TBSA in pediatric patients should be calculated using a Lund and Browder chart, as it accounts for differences between adult and pediatric skin surface-area distributions. Multiple retrospec-tive reviews of pediatric burn patients referred to certified burn centers have found significant differ-ences in the TBSA calculated at the referring center compared with that calculated by the burn center providers.80,81 In the majority of patients, the TBSA was overestimated by the referring center. The au-thors hypothesized that differences in the estimates may have been due to the referring centers' use of the rule of nines tool, which is predicted to overesti-mate burn size in pediatric patients. Using the total palmar surface to estimate pediatric burn size may produce overestimates for the same reasons that it does in adults: Inexperienced providers may confuse the palmar surface area, which is 0.5% of TBSA in children, with the total palmar surface area, includ-ing digits, which approximates 1% TBSA.82 Children also have higher fluid resuscitation

Figure 6. Accidental Versus Intentional Scald

A: An intentional scald, showing bilateral lower limb and perineal/

buttock involvement, clear upper margins, and uniform depth.

B: An accidental scald, caused by pulling down a hot liquid, showing

irregular margins and variable depth.

Reprinted from Burns, Volume 34, Issue 8. S. Maguire, S. Moynihan,

M. Mann, T. Potokar, A.M. Kemp. A systematic review of the features

that indicate intentional scalds in children. Pages 1072-1081.

Copyright 2008, with permission from Elsevier.

Table 6. Centers for Disease Control and Prevention Guidelines for Tetanus Wound Management

Vaccination History Clean, Minor Wounds

All Other Woundsa

Tdap or Tdb TIG Tdap or Tdb TIG

< 3 doses or unknown Yes No Yes Yes

≥ 3 doses Noc No Nod No

aSuch as, but not limited to, wounds contaminated with dirt, feces, soil,

and saliva; puncture wounds resulting from missiles, crushing, burns,

and frostbite.bTdap is preferred to Td for adults who have never received Tdap.

Single-antigen tetanus toxoid is no longer available in the United

States.cYes, if > 10 years since the last tetanus toxoid-containing vaccine

dose.dYes, if > 5 years since the last tetanus toxoid-containing vaccine dose.

Abbreviations: Tdap, tetanus, diphtheria, and pertussis; Td, tetanus

and diphtheria [booster]; TIG, tetanus immune globulin.

Source: Centers For Disease Control Pinkbook: Chapter 21 Tetanus.

https://www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html

A

B

https://www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html


Controversies and Cutting Edge

AnalgesiaA systematic review of intravenous lidocaine for treatment of procedural pain during dressing changes found only 1 clinical trial of 45 patients who were given 3 boluses of lidocaine 1.5 mg/kg IV fol-lowed by 0.5 mg/kg IV boluses at 5-minute intervals in addition to patient-controlled opioid analgesia.87,88 The study found that intravenous lidocaine reduced pain scores compared with placebo but did not re-duce opioid requirements or increase patient satisfac-tion. Dexmedetomidine is an alpha-2-adrenergic ago-nist that is gaining increasing popularity for a variety of sedation indications. A meta-analysis of 266 burn patients who received dexmedetomidine in addition to analgesia for surgical procedures (such as burn dressing changes) found no difference in pain scores or adverse events but an increase in patients’ sedation score.89 Further studies are needed to establish the ap-plicability of these trials to the ED setting.

Wound Care ControversiesAloe vera is a popular natural plant remedy that is hypothesized to have wound-healing properties, based on animal data. A systematic review of aloe vera for the treatment of wounds, including a total of 168 patients, found that aloe vera did not alter burn wound healing time compared with silver sulfadiazine.90 All studies were of low quality with high risk of bias. Honey is a traditional remedy that has been used to treat wounds for many centuries. A system-atic review including a total of 992 patients conclud-ed that honey heals burns more quickly than some conventional wound dressings.91 It was unclear from the trials whether there was any difference in rates of infection or adverse events between honey and conventional dressings. In combined evidence from 2 trials, there was no difference in healing of partial-thickness burns between honey and silver sulfadia-zine at 6 weeks post burn, with a decreased rate of adverse events in the group treated with honey.91 Hyperbaric oxygen therapy is hypothesized to have a potential impact on wound healing through reduced edema, increased tissue oxygenation, and increased infection-resistance of tissue. A systematic review identified 22 trials using hyperbaric oxygen therapy, of which only 2 were judged of high enough quality to analyze.92 Both trials had significant meth-odological flaws, including lack of blinding and failure to examine long-term patient-centered outcomes. As such, evidence regarding hyperbaric oxygen therapy to promote burn wound healing is inconclusive.

of confidence that delayed presentation is associated with abuse; however, a recent single-center retrospec-tive study described an association between delayed presentation and nonaccidental injury.85

For more information about management of pediatric burn patients, see the May 2015 issue of Pediatric Emergency Medicine Practice, “Optimizing Emergency Management to Reduce Morbidity and Mortality in Pediatric Burn Patients” at www.ebmedicine.net/PedBurns. For more infor-mation about nonaccidental injury, see the July 2017 issue, "Nonaccidental Injury in Pediatric Patients: Detection, Evaluation, and Treatment" at www.ebmedicine.net/PedNAT.

Pregnant PatientsA fetus is especially susceptible to the toxic effects of cyanide and carbon monoxide. In animal studies, COHb levels in the fetus have been demonstrated to be up to 15% higher than those in the mother, and the elimination half-life is more than 3 times longer.86 A case report of a pregnant woman with a peak COHb of 5.6%, who delivered 4 days after her inhalation exposure, found a COHb level of 8.1% in the baby upon delivery.86 The level of maternal COHb likely to cause either fetal demise or teratoge-nicity has not been established because the correla-tion between maternal and fetal levels is imperfect, and effects on the fetus appear to vary with gesta-tional age.86 Therefore, pregnant burn patients with any level of COHb indicating exposure should be placed on 100% inhaled oxygen. Just as in nonpreg-nant patients, evidence regarding the use hyperbaric oxygen therapy is of poor quality, and no strong recommendation can be made. Cyanide is known to cross the placenta and reach the fetus. Hydroxocobalamin (pregnancy category C) for treatment of cyanide toxicity has not been studied in pregnant women, and there is some evidence of teratogenicity—specifically, skeletal and soft-tissue abnormalities—in mice and rabbits.85 However, be-cause cyanide toxicity carries the potential for fetal and maternal mortality, hydroxocobalamin was approved for treatment of pregnant women by the United States Food and Drug Administration in 2010.86 In the absence of any human clinical studies, it is reasonable to administer hydroxocobalamin to pregnant women with suspected cyanide exposure, especially those with concurrent carbon monoxide exposure. In critically ill pregnant burn patients, delivery of the fetus may be considered in order to improve outcomes for both mother and fetus. There is no prospective evidence to guide this decision; it must be made in conjunction with obstetric consultation, taking into consideration gestational age, signs of fetal distress, and the severity of maternal injury.

http://www.ebmedicine.net/PedBurns

http://www.ebmedicine.net/PedNAT


from 2005 to 2007, were treated entirely at hospitals that were not burn centers, 48% of them met burn center referral criteria.98 Patients with large TBSA thermal burn involvement or inhalation injury should be transferred to a burn center for inpatient manage-ment. Prior to transfer, any concurrent traumatic in-juries must be stabilized. Patients with smaller burns but with high-risk comorbidities or at the extremes of age should also be transferred. Patients with burns to sensitive areas, such as the hand or face, should be referred to burn centers, but may follow up in an expedited manner as outpatients, depending on the depth of the burn, comorbidities, and the patient’s ability to comply with follow-up.

Summary

Emergency clinicians should apply evidence-based therapies and expert consensus guidelines to treat both the local and systemic effects of burns. Treat-ment of systemic effects includes airway stabiliza-tion, antidotes for toxic exposures, and intravenous fluid resuscitation. Treatment of local effects encom-passes wound cleaning, dressing, and tetanus pro-phylaxis. Clinicians should refer patients to special-ized burn centers based on ABA guidelines. Further research is needed to define the best therapies for burn wound care and pain control.

Time- and Cost-Effective Strategies

• Select the least-expensive appropriate dress-ing for partial-thickness burns. Dressings with widely varying costs have similar evidence of efficacy.

• Avoid prophylactic systemic antibiotics. There is no evidence that they prevent infection, and patients who have adverse reactions may incur additional healthcare costs.

• Avoid burn center referral for minor burns that do not meet ABA criteria. Risk Management Caveat: Ensure that patients who are not referred to a burn center have follow-up to evaluate for secondary infection or progression of their burn to a depth greater than that initially assessed.

Case Conclusions

After leaving the bedside of the 35-year-old chef with burns to his hand, you reviewed the ABA Burn Center Referral Criteria and noted the location of his burn was an indication for referral. Because his blisters were small and located in the thick palmar skin of the hand, you elected not to unroof them. You did not have a specialized occlusive burn dressing available in your ED, so you ir-rigated the wound, applied topical bacitracin, and covered it with nonadherent gauze. After updating the patient’s

Assessment of Burn Depth With Laser Doppler ImagingThe low accuracy of expert clinical estimates of burn depth—between 60% to 80% accuracy in distinguish-ing partial- from full-thickness burns—has led to a search for more advanced methods of burn classifica-tion. Laser Doppler imaging (LDI) is a noninvasive technique for estimating burn depth that was first described more than 20 years ago.93 The technique uses Doppler flow principles to estimate perfusion of burned tissue, with the underlying assumption that decreases in perfusion indicate greater wound depth.94 A systematic review and meta-analysis for the accuracy of LDI in predicting either delayed burn healing (> 3 weeks) or the need for operative intervention found a pooled sensitivity of 83% and specificity of 97% among 10 studies.95 However, there is lack of consensus on the cutoff value of perfusion units that should be used to predict need for surgical intervention.94,96 A randomized controlled trial of 202 patients found no difference in burn wound healing time or mean cost of care for patients assessed with LDI compared with those who received standard care.97 Currently, due to its limited availability outside burn specialty centers, LDI plays no role in the ED assessment of burn wounds.

Disposition

The ABA provides criteria for referral to a recognized burn center. (See Table 7.) A retrospective review of adherence to ABA referral criteria in the state of North Carolina found that, in general, clinicians are underreferring patients. Of 952 burn patients who,

Table 7. American Burn Association Burn Center Referral Criteria

• Partial-thickness burns > 10% total body surface area

• Burns that involve the face, hands, feet, genitalia, perineum, or

major joints

• Third-degree burns in any age group

• Electrical burns, including lightning injury

• Chemical burns

• Inhalation injury

• Burn injury in patients with pre-existing medical disorders that could

complicate management, prolong recovery, or affect mortality

• Any patient with burns and concomitant trauma (such as fractures)

in which the burn injury poses the greatest risk of morbidity or

mortality (may be stabilized at trauma center initially)

• Children with burns should be transferred to a burn center verified

to treat children.

• Burn injury in patients who will require special social, emotional, or

rehabilitative intervention

From: American Burn Association, American College of Surgeons

Committee on Trauma. Guidelines for the Operation of Burn Centers.

In: Resources for Optimal Care of the Injured Patient. Page 101.

©2014 American College of Surgeons. Used with permission.

https://www.facs.org/~/media/files/quality%20programs/trauma/vrc%20resources/resources%20for%20optimal%20care.ashx


1. “The patient had burns to his face and soot in his oropharynx, but had no respiratory distress prior to transfer. How did I know he was going to develop upper airway obstruction during transport?”Exercise caution and have a low threshold to establish a definitive airway in patients with clinical signs of inhalation injury prior to transfer. Upper airway edema or lower airway injury can cause decompensation during transport.

2. “I gave prophylactic oral antibiotics to a patient with a partial-thickness burn. The patient had an allergic reaction, and now my colleagues are saying that I should have never given the antibiotic in the first place.” Systemic prophylactic antibiotics do not benefit burn patients. Use topical dressings for local wound care. Treat with systemic antibiotics only if a clinically apparent infection develops.

3. “The patient had a deep partial-thickness burn to her hand that involved only 1% TBSA. I didn’t think she needed burn center referral for such a small burn.”TBSA is only one of several criteria for burn center referral. Remember to refer patients who have burns to sensitive functional areas such as the hand, major joints, face, and perineum.

4. “I gave my burn patient more than 20 mg of IV morphine, but she was still in severe pain. I was afraid that giving more might over-sedate her.” Burns are extremely painful and aggressive analgesia should be provided. Consider adjuncts such as ketamine or benzodiazepines in addition to IV opioid medications.

5. “I thought that fluid-resuscitating the patient according to the Parkland formula during the 8 hours he was awaiting transfer in my ED was enough. I didn’t realize he wasn’t making any urine.”Use clinical endpoints, such as urine output, to assess and guide IV fluid administration. Formulas are merely a guideline, and IV fluid administration may need to be decreased or increased depending on how the patient responds.

6. “I assumed the patient was hypotensive due to the extensive burns he sustained in the house fire. I didn’t consider that he might have intra-abdominal hemorrhage.” Burn patients are at risk for traumatic injuries and should undergo a comprehensive trauma survey and diagnostic testing per Advanced Trauma Life Support guidelines.

7. “My patient burned in an industrial fire re-mained hypotensive with elevated lactate level despite adequate fluid resuscitation. I should have considered toxic exposures.”Always consider exposures to toxic inhalants, cyanide and carbon monoxide, in patients who have unstable vital signs, altered mental status, elevated lactate level, or a history suggestive of a smoke inhalation. Treat empirically for cyanide exposure in these patients, as cyanide levels do not result in time to guide management in the ED.

8. “I used the rule of nines to estimate burn surface area in a 3-year-old child, and now the burn center is saying I gave the patient too much fluid.”The rule of nines does not accurately assess the TBSA of burn in pediatric patients. Lund and Browder charts are the preferred method for estimation in these patients. Remember to exclude superficial areas of burn from the calculation.

9. “I didn’t consider nonaccidental trauma in the 3-year-old who came in with scald burns to his buttocks.”Be alert for clinical features that are suspicious for nonaccidental trauma, such as well-demarcated even-thickness burns, delay in seeking care, or a mechanism inconsistent with injuries.

10. “The patient had a full-thickness circumferen-tial burn to his forearm, but I thought the burn center surgeon should perform the escha-rotomy. When he arrived at the burn center, his hand was ischemic.”The decision to perform escharotomy depends on clinical judgment, as there are no evidence-based criteria. Monitor perfusion clinically and have a low threshold to perform escharotomy prior to transport for signs of decreased perfusion or anticipated long transport time.

Risk Management Pitfalls for Management of Burn Patients in the Emergency Department


mental status.• Use Lund and Browder charts to assess burn size.• Do not include superficial (first-degree) burns in

the calculation of TBSA.• Initiate intravenous fluid resuscitation with crys-

talloid according to weight-based formulas, but use physiologic endpoints to dynamically guide treatment.

• Treat burn pain aggressively.• Initiate wound care according to depth of burn;

avoid silver sulfadiazine ointment.• Use ABA criteria to determine which patients

require referral to a burn center.

References

Evidence-based medicine requires a critical ap-praisal of the literature based upon study methodol-ogy and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report. To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative referenc-es cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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2. World Health Organization. Burns: fact sheet. 2016. Available at: http://www.who.int/mediacentre/factsheets/fs365/en/. Accessed January 10, 2018. (WHO website fact sheet)

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4. Evers LH, Bhavsar D, Mailander P. The biology of burn injury. Exp Dermatol. 2010;19(9):777-783. (Review)

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6. Monstrey S, Hoeksema H, Verbelen J, et al. Assessment of burn depth and burn wound healing potential. Burns. 2008;34(6):761-769. (Review)

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tetanus vaccination and dressing the wound, you gave him a prescription for oral pain medication and referral to a burn center for next-day follow-up. For the 22-year-old victim of the house fire, you performed endotracheal intubation because of the sus-pected inhalation injury based on oropharyngeal soot and her altered mental status. You placed the patient on 1.0 FiO2. You hypothesized that her shock might have been due either to hemorrhage from a traumatic injury or a toxic exposure. You initiated a bolus of 2 L IV lactated Ringer’s solution, sent labs, including a lactate and blood gas with CO-oximetry, and asked the nurse to place a Foley catheter to measure urine output. You noted that, despite circumfer-ential burns to her upper extremity, the distal perfusion of the extremity appeared normal. Her physical exam revealed no signs of traumatic injury. The COHb returned at 25% and lactate was 5.2 mmol/L. Based on these findings and the lack of traumatic explanation for the patient’s hypotension, you prepared to administer 5 g hydroxocobalamin IV for suspected cyanide poisoning. Just as you were about to give the medication, the nurse informed you that the patient’s urine pregnancy test was positive. Knowing that the benefits of treating cyanide exposure for both mother and fetus likely outweighed the potential risks of teratogenicity in this unsta-ble patient, you proceeded with medication administration. After 2 L of IV crystalloid fluid and treatment with 5 g IV hydroxocobalamin, the patient’s vital signs improved to heart rate, 120 beats/min; blood pressure, 115/60 mm Hg; and O2 saturation, 92%. You initiated transfer to a burn center and reassessed perfusion of her right upper extremity. Her radial pulse was now diminished, so you performed an escharotomy prior to transfer. You continued with IV crystalloid adminis-tration based on the Parkland formula, carefully monitoring urine output, until she left your ED. For your 3-year-old scald patient, after using a Lund and Browder chart to calculate the TBSA burn involve-ment, you determined that he had 3% TBSA involved and therefore did not require IV fluid resuscitation above maintenance fluids. You did, however, order oral opioids to treat his pain and planned for transfer to a burn center because of his age and the depth of the burn. Because the patient was up-to-date on his childhood vaccinations, you determined that he did not require additional prophylaxis for tetanus, per CDC guidelines. As you finished your orders, you remembered that pediatric scald burns of the extremities that are symmetric, of even thickness, and well-demarcated were concerning for abuse. You ordered a skeletal survey and social work consult. The survey revealed old rib fractures and you initiated reporting for suspected abuse.

Key Points

• Evidence-based methods for predicting inhala-tion injury are limited; use clinical judgment.

• Survey burn patients for concurrent trauma.• Treat empirically for toxic inhalation exposures

in patients who are unstable or who have altered

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http://www.ameriburn.org/resources_factsheet.php

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1. Which is the best method for initial cooling of a burn wound in the field?a. Application of iceb. Application of wet towelsc. Submersion in cool running waterd. Exposure to air

2. Which is the most accurate method for esti-mating total body surface area (TBSA) burn involvement for all age groups?a. Rule of ninesb. “Palm” methodc. Lund and Browder Chart

3. What is the TBSA burn involvement for a 5-year-old child who is burned on the entire left lower extremity and chest?a. 28% b. 36%c. 22% d. 50%

4. Which is NOT useful for guiding real-time empiric treatment of cyanide toxicity for a burn patient in the ED?a. Hemodynamic markersb. Lactatec. Cyanide leveld. History of burn in enclosed space

5. What is the treatment of choice for suspected cyanide poisoning?a. 100% inhaled FiO2

b. Hydroxocobalaminc. Sodium nitrited. Sodium thiosulfate

6. Which is the preferred choice for a resuscita-tion fluid, based on expert guidelines? a. Albuminb. Hetastarchc. Lactated Ringer's solutiond. Hypertonic saline

CME questions continued on page 24.

inhalation injury in a pregnant patient: a literature review of the evidence and current best practices in the setting of a classic case. J Burn Care Res. 2012;33(5):624-633. (Review and case report)

87. Wasiak J, Mahar PD, McGuinness SK, et al. Intravenous li-docaine for the treatment of background or procedural burn pain. Cochrane Database Syst Rev. 2014 Oct 16;(10):CD005622. (Cochrane review; 1 study, 45 patients)

88. Wasiak J, Spinks A, Costello V, et al. Adjuvant use of intrave-nous lidocaine for procedural burn pain relief: a randomized double-blind, placebo-controlled, cross-over trial. Burns. 2011;37(6):951-957. (Prospective double-blind randomized crossover study; 45 patients)

89. Asmussen S, Maybauer DM, Fraser JF, et al. A meta-analysis of analgesic and sedative effects of dexmedetomidine in burn patients. Burns. 2013;39(4):625-631. (Systematic review and meta-analysis; 4 randomized controlled trials; 266 patients)

90. Dat AD, Poon F, Pham KB, et al. Aloe vera for treating acute and chronic wounds. Cochrane Database Syst Rev. 2012 Feb 15;(2):CD008762. (Cochrane review; 7 randomized-con-trolled trials, 347 patients)

91. Jull AB, Cullum N, Dumville JC, et al. Honey as a topical treatment for wounds. Cochrane Database Syst Rev. 2015 Mar 6;(3):CD005083. (Cochrane review; 26 studies, 3011 patients)

92. Villanueva E, Bennett MH, Wasiak J, et al. Hyperbaric oxy-gen therapy for thermal burns. Cochrane Database Syst Rev. 2004;(3):CD004727. (Cochrane review; 2 randomized clinical trials)

93. Niazi ZB, Essex TJ, Papini R, et al. New laser Doppler scan-ner, a valuable adjunct in burn depth assessment. Burns. 1993;19(6):485-489. (Pilot study)

94. Jaskille AD, Ramella-Roman JC, Shupp JW, et al. Critical review of burn depth assessment techniques: part II. Review of laser Doppler technology. J Burn Care Res. 2010;31(1):151-157. (Review)

95. Shin JY, Yi HS. Diagnostic accuracy of laser Doppler imaging in burn depth assessment: systematic review and meta-analysis. Burns. 2016; 42(7):1369-1376. (Systematic review; 10 studies)

96. Khatib M, Jabir S, Fitzgerald O’Connor E, et al. A systematic review of the evolution of laser Doppler techniques in burn depth assessment. Plast Surg Int. 2014;2014:621792. (System-atic review; 26 studies)

97. Hop MJ, Stekelenburg CM, Hiddingh J, et al. Cost-effectiveness of laser Doppler imaging in burn care in the Netherlands: a ran-domized controlled trial. Plast Reconstr Surg. 2016;137(1):166e-176e. (Randomized controlled trial; 202 patients)

98. Carter JE, Neff LP, Holmes JH 4th. Adherence to burn center referral criteria: are patients appropriately being referred? J Burn Care Res. 2010;31(1):26-30. (Retrospective study; 2036 patients)

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CALCULATOR REVIEW AUTHOR

David Zodda, MD

Department of Emergency Medicine Hackensack University Medical Center, Hackensack, NJ

EB MEDICINE

Points & Pearls• The Parkland formula is a validated and effec-

tive approach to initial fluid resuscitation in the acutely burned patient.

• Overly aggressive fluid resuscitation, termed “fluid creep,” is well documented in critical care literature. Factors that may lead to fluid creep include lack of physician observation of endpoints (ie, urine output), increased opioid use, and the emergency nature of goal-directed resuscitation.

• Patients with inhalational and electrical burns, as well as children and the elderly, may require more or less fluid resuscitation than is predicted by the Parkland formula.

AdviceIt is important to remember that all resuscitation formulas should only be used as guides. Patients should be assessed frequently, with individual ad-justments made to maintain adequate organ perfu-sion.

Critical ActionsCritically ill burn patients are best cared for at a dedicated burn center, particularly those who have any of the following:

• Partial-thickness burns to > 10% of total body surface area

Click the thumbnail above to access the calculator.

Parkland Formula for Burns Introduction: The Parkland formula for burns calculates fluid requirements for burn patients in a 24-hour period.

• Any size full-thickness burn• Burns to hands or genitals• Inhalation injury• Serious chemical injury• Serious electrical injuries, including lightning

injury

Evidence AppraisalBlumetti et al (2008) conducted a retrospective study of patients resuscitated with the Parkland formula at a single institution over 15 years to determine the accuracy of the formula in guiding resuscitation. Using urine output as a guideline for adequate resuscitation, they found that patients commonly received fluid volumes higher than pre-dicted by the Parkland formula, and concluded that the formula should represent a resuscitation “start-ing point,” but urine output is the most important parameter to control resuscitation volume. Cartotto et al (2002) performed a retrospective study, and also found that the Parkland formula underestimated the volume requirements in most adults with burns, especially in those with large full-thickness burns. Thus, the Parkland formula is a validated and effective approach to initial fluid resuscitation in the acutely burned patient (Baxter 1974, Cartotto 2002, Blumetti 2008).

Use the Calculator NowClick here to access the calculator. Calculator CreatorCharles Baxter, MDClick here to read more about Dr. Baxter.

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Emergency Medicine Practice • February 2018 S2 Copyright © 2018 EB Medicine. All rights reserved.

Why to Use The Parkland formula has been endorsed by the American Burn Association. It has been shown to appropriately restore intravascular volume and limit the development of hypovolemic shock.

When to UseUse the Parkland formula for patients with acute burns.

Next Steps Resuscitation endpoints and monitoring:• Urine output: 0.5 mL/kg/hr in adults

(50-100 cc/hr) and 0.5 to 1.0 mL/kg/hr in children weighing < 30 kg.

• Heart rate: A heart rate of < 110 bpm in adults usually indicates adequate volume. Narrowed pulse pressure provides an earlier indication of shock than does systolic blood pressure alone.

• Monitoring blood pressure by arterial cath-eter is superior to cuff pressures because of the interference of tissue edema. The radial artery is the first choice, followed by the femoral artery.

• Serum lactate is a strong predictor of mor-tality, and trends can be utilized to deter-mine hemostatic status; however, it should not be used as an independent predictor of adequate fluid resuscitation.

Related Calculators• Click here to access the Arterial Blood Gas

(ABG) Analyzer.• Click here to access the Maintenance Fluids

Calculation.

ReferencesOriginal/Primary Reference• Baxter CR. Fluid volume and electrolyte changes in the early

post-burn period. Clin Plast Surg. 1974;1:693-703. Validation Reference• Cartotto RC, Innes M, Musgrave MA, et al. How well does

the Parkland formula estimate actual fluid resuscitation volumes? J Burn Care Rehabil. 2002; 23(4):258-265.

Other References• Blumetti J, Hunt JL, Arnoldo BD, et al. The Parkland for-

mula under fire: is the criticism justified? J Burn Care Res. 2008;29(1):180-186.

• American Burn Association Practice Guidelines. Available at: http://www.ameriburn.org. Accessed January 4, 2018.

• Ahrns KS. Trends in burn resuscitation: shifting the focus from fluids to adequate endpoint monitoring, edema con-trol, and adjuvant therapies. Crit Care Nurs Clin North Am. 2004;16(1):75-98.

• Ahrns KS, Harkins DR. Initial resuscitation after burn injury: therapies, strategies, and controversies. AACN Clin Issues. 1999;10(1):46-60.

• Jeng JC, Jablonski K, Bridgeman A, et al. Serum lactate, not base deficit, rapidly predicts survival after major burns. Burns. 2002;28(2):161-166.

Copyright © MDCalc • Reprinted with permission.

Emergency Medicine Practice (ISSN Print: 1524-1971, ISSN Online: 1559-3908, ACID-FREE) is published monthly (12 times per year) by EB Medicine (5550 Triangle Parkway, Suite 150, Norcross, GA 30092). Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Copyright © 2018 EB Medicine. All rights reserved. No part of this publication may be reproduced in any format without written consent of EB Medicine. This publication is intended for the use of the individual subscriber only

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for emergency medicine clinicians.

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Go online to www.ebmedicine.net/topics to see what's new!

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https://www.ncbi.nlm.nih.gov/pubmed/4609676





https://doi.org/10.1097/BCR.0b013e31815f5a62

https://doi.org/10.1097/BCR.0b013e31815f5a62

http://www.ameriburn.org

https://doi.org/10.1016/j.ccell.2003.09.007





http://dx.doi.org/10.1016/S0305-4179(01)00098-5

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Copyright © 2018 EB Medicine. All rights reserved. 24

Physician CME Information Date of Original Release: February 1, 2018. Date of most recent review: January 10, 2018.

Termination date: February 1, 2021.

Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.

Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.

AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of approval begins 07/01/2017. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Approved for 4 AAFP Prescribed credits.

AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.

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7. According to the Parkland formula, how much intravenous crystalloid should a 75-kg adult with 30% TBSA burns receive in the first 8 hours?a. 1200 mL b. 4500 mLc. 9000 mL d. None; oral hydration only

8. Which of the following is a mandatory in-dication for emergent burn escharotomy?a. Presence of circumferential burn to an

extremityb. Inability to ventilate patient due to

extensive burns of chestc. Pulse oximetry of < 90% in an

extremity affected by a circumferential burn

9. Which type of burn is the most common burn seen in nonaccidental trauma cases?a. Open flame b. Scaldc. Electrical d. Chemical

10. Which of the following patients does NOT meet burn center referral criteria?a. A 4-year-old with a superficial partial-

thickness thermal burn to the chest involving 15% TBSA

b. A 25-year-old with superficial partial-thickness thermal burn to the perineum involving 5% TBSA

c. A 60-year-old with a full-thickness thermal burn to the leg involving 3% TBSA

d. 20-year-old with a deep partial-thickness thermal burn to the anterior arm involving 9% TBSA

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