Comprehensive Summary of "Trauma Caused by External Agents: Burns" (Advanced Trauma Life Support - SVAT):

1. Introduction

• Severity Recognition: A burn-injured patient is to be considered a major trauma victim. Early and aggressive resuscitation is critical to reduce morbidity and mortality rates.

• Initial Assessment Framework: Following primary survey using the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) is paramount.

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2. Initial Management and Primary Survey

• Immediate Safety and Cessation of Injury:

  • Remove the patient from the source of heat.

  • Eliminate any causative chemical agent via copious irrigation.

  • Disconnect the electrical source in electrical injuries.

• Primary Survey (ABCDE):

  • A. Airway Management with C-Spine Control:

    • High Index of Suspicion for Inhalation Injury: Fire in an enclosed space, explosion history, loss of consciousness, extensive burns (especially face/neck), singed nasal hairs/eyebrows, carbonaceous sputum, hoarseness, stridor, or soot in the oropharynx.

    • Prophylactic Orotracheal Intubation is strongly indicated if inhalation injury is suspected, due to the rapid onset of life-threatening airway edema.

      

  • B. Breathing/Ventilation:

    • Administer High-Flow Oxygen (FiO2 1.0) to all fire victims.

    • Mechanisms of Injury: Thermal airway obstruction, systemic toxicity (CO, Cyanide), and irritant-induced bronchospasm.

    • Treat bronchospasm with nebulized Salbutamol (5mg).

    • Monitor for signs of Smoke Inhalation Syndrome.

  • C. Circulation and Hemodynamic Support:

    • Burns cause massive capillary leak, leading to significant fluid loss, tissue edema, and hypovolemic shock.

    • Immediate Fluid Resuscitation: Administer a 20-30 ml/kg bolus of crystalloid initially for hemodynamically unstable patients.

    • Formal Resuscitation Formulas:

      • Parkland Formula: 4 ml x kg body weight x % Total Body Surface Area (TBSA) burned. Half is given in the first 8 hours, the remainder over the next 16 hours.

      • Brooke Formula: 2 ml x kg x % TBSA, with the same time distribution.

    • Access: Establish large-bore (14-16G) peripheral IV lines, avoiding burned areas and lower extremities if possible.

    • Insert a urinary catheter for strict output monitoring (target: 0.5-1 ml/kg/hr in adults).

    • Colloids (e.g., Albumin): Use is controversial; may be considered after the first 8-12 hours (0.5-1 ml/kg/%TBSA) if needed.

  • D. Disability (Neurological Status): Perform a rapid neurological exam (AVPU/GCS). Altered mental status may indicate hypoxia, shock, or intoxication (CO/Cyanide).

  • E. Exposure/Environmental Control: Fully expose the patient to assess all injuries, then cover with warm, dry, sterile sheets to prevent hypothermia.

3. Pain Management and Adjuncts

• Analgesia: Administer IV opioids (e.g., Morphine 0.04-0.05 mg/kg or Fentanyl 1-2 µg/kg).

• Tetanus Prophylaxis: Administer if indicated based on vaccination history.

• Antibiotics: NOT indicated for prophylaxis; use only for proven infection.

• Gastric Protection: Consider Ranitidine (150 mg/12h IV) due to stress ulcer risk.

4. Secondary Survey and Burn Wound Care

• Identify Associated Injuries: Perform a thorough head-to-toe exam to rule out traumatic brain injury (TBI), spinal trauma, fractures, thoracic/abdominal injuries, and cardiac contusions.

• Burn-Specific Wound Management:

  • Stop the Burning Process:

    • Cool burns with tepid water or saline (15°C) for approximately 15 minutes ("Rule of 15s").

    • Remove all clothing, jewelry, and constrictive items.

  • Assess Burn:

    • Extent: Use the Rule of Nines to estimate TBSA. Note critical areas: face, hands, feet, perineum, and major joints.

    • Depth:

      • First-Degree (Superficial): Erythema, pain. Manage with analgesia.

      • Second-Degree (Partial Thickness): Blisters (flictenas), severe pain. Manage with cleaning, topical treatment (e.g., silver sulfadiazine), and sterile dressing.

      • Third-Degree (Full Thickness): Leathery, insensate eschar. Requires surgical evaluation for escharotomy/fasciotomy. Manage with cleaning and sterile dressings.

  • Wound Care: Cleanse with antiseptic (Povidone-iodine, Chlorhexidine), debride loose tissue, drain large blisters, apply topical antimicrobials (e.g., Flamazine/Silver sulfadiazine), and cover with sterile, non-adherent dressings.

  • Elevate burned extremities to reduce edema.

  

5. Special Considerations and Complications

• Hypothermia Prevention: Actively warm the patient (warm fluids, blankets, increased room temperature). Burned skin loses thermoregulatory function.

• Electrical Burns:

  • Can cause deep tissue necrosis (muscle, bone), compartment syndrome, rhabdomyolysis, cardiac arrhythmias, and late-onset neuropathies.

  • Assess for entrance/exit wounds. High suspicion for deep injury regardless of superficial appearance.

  • Monitor ECG and urine for myoglobin (dark tea-colored urine).

• Chemical Burns: Irrigate copiously with water for an extended period (minimum 20-30 minutes).

6. Smoke Inhalation and Toxic Gas Syndromes

• A leading cause of death in fires. Can cause hypoxia, thermal injury, and chemical poisoning.

• Key Toxic Products:

  • Carbon Monoxide (CO): Odorless, colorless. Binds to hemoglobin >200x more than oxygen, causing tissue hypoxia.

    • Symptoms: Headache, nausea, confusion, coma, cardiac ischemia.

    • Diagnosis: Elevated Carboxyhemoglobin (COHb). Note: Pulse oximetry readings (SpO2) are unreliable.

    • Treatment:

      • 100% Normobaric Oxygen until symptoms resolve and COHb normalizes.

      • Hyperbaric Oxygen (HBO) is indicated for severe cases (coma, neurological deficits, COHb >20-25%, pregnancy, cardiac instability).

  • Cyanide (CN): Produced from burning plastics, wool, silk. Causes cytotoxic hypoxia.

    • Symptoms: Anxiety, tachypnea, headache, seizures, coma, lactic acidosis, cardiovascular collapse.

    • Treatment:

      • 100% Oxygen.

      • Antidote: Hydroxocobalamin (Cyanokit) - 5g IV (70 mg/kg) over 15-30 minutes. May repeat if no response.

      • Sodium thiosulfate can be used as an adjunct.

• General Management for Inhalation: Early intubation if indicated, aggressive pulmonary toilet, and supportive care.

7. Indications for Transfer to a Burn Center

• Partial & full-thickness burns >10% TBSA in patients under 10 or over 50 years old.

• Burns >10% TBSA in any age group.

• Burns involving face, hands, feet, genitalia, perineum, or major joints.

• Full-thickness burns of any size.

• Significant electrical, chemical, or inhalation injuries.

• Burn patients with significant pre-existing medical conditions or associated major trauma.

8. Summary of Critical Actions

1. Secure the airway early if inhalation injury is suspected.

2. Start aggressive fluid resuscitation immediately using a standard formula.

3. Administer 100% oxygen to all smoke inhalation victims.

4. Provide adequate analgesia.

5. Perform a thorough secondary survey to identify associated injuries.

6. Cool the burn, remove constricting items, and cover with sterile dressings.

7. Prevent hypothermia.

8. Identify and treat toxic inhalations (CO, Cyanide).

9. Recognize when to transfer to a specialized burn unit.

This protocol emphasizes a systematic approach where airway management and shock resuscitation take precedence, followed by meticulous wound care and monitoring for systemic complications.