Initial Management
of Severe Burns
For burn injuries in adults >20% TBSA and children >10% TBSA or who meet the ANZBA transfer
criteria, consider early consultation with retrieval service and burn centre
Specific points to note in the primary survey with respect to burn injury:
PRIMARY SURVEY
Assess for history of burn in enclosed space, signs of upper airway oedema, sooty sputum, facial
burns, respiratory distress (dyspnoea, stridor, wheeze, hoarse voice).
If any of the above present, airway is at risk. Consider need for intubation and secure airway as
AIRWAY required. Maintain spinal precautions as required especially with explosion or electrical burns.
Assess breathing and support as required.
Assess adequacy of breathing where circumferential burns on chest wall -consider escharotomy.
BREATHING Administer humidified 100%FiO2.
Establish baseline ABGs and SaO2 (goal: >95%).
CIRCULATION Assess circulation: colour, refill, HR, BP.
Insert 2 large bore peripheral IV lines. If unable consider central or intraosseous access.
Specific points to note in the secondary survey and initial management of burn injury:
Guide fluid resuscitation with Parkland formula/Ambulance protocol
Insert urinary catheter. Titrate fluid resuscitation to urine output goals:
FLUID RESUSCITATION Adults: 0.5- 1.0 ml/kg/hr (30-50 mls/hr)
Paediatrics <30kgs: 1ml/kg/hr
Maintain accurate fluid balance chart
Assess pain score to determine analgesic requirements
Adults: 2-5mg Morphine IV repeat every 5 minute
ANALGESIA Paediatrics: IV Morphine 0.1mg/kg repeat every 5 minutes. Maximum 0.3mg/kg
Re-assess pain score (goal: Adult VAS pain score <4) and adjust analgesia accordingly.
Consider Morphine Infusion for ongoing pain relief
MANAGING WOUND Assess extent of burn using Rule of Nines
Clean then cover the wound (see below)
CIRCUMFERENTIAL Elevate limbs where circumferential burns present.
Assess perfusion distal to burn: capillary refill, pulse, warmth, colour.
BURNS Liaise with burn service if escharotomy required (cool to touch, weak or no pulse distally).
OTHER Cover the patient to prevent heat loss.
Insert nasogastric tube for burns >20% TBSA adults and 10%TBSA paediatrics. Keep nil
orally.
Administer tetanus immunoglobulin if required.
Investigative tests as indicated.
Wound care for transit Fluid resuscitation Transfer checklist
First aid: cool running H2O -≥20 mins Parkland formula: Airway secure
Clean the wound: Normal saline or 0.1% 3-4mls IV fluid X %TBSA X kg/24hrs O2 insitu
½ fluid in 8/24 post injury IV access established & secure
Chlorhexidine Fluid resuscitation commenced
Remove small loose dermis or blisters ½ fluid in 16/24 post injury
Urinary catheter inserted & secure
Hartmann’s solution Pain controlled
Assess: Extent and depth of burn injury
Paediatric maintenance fluids: Wounds are covered &Patient is warm
and for circumferential injury 5% Dextrose in ½ Normal Saline Elevate burnt area as appropriate
Cover: Cling wrap longitudinally if Up to 10kgs: 100mls/kg/day Tetoxid if indicated
immediate transfer (<8hrs). Paraffin 10-20kgs: 1000mls + 50mls/kg>10kgs/day Nasogastric insitu as necessary
gauze or silver dressing if T/F delayed 20-30kgs: 1500mls +20mls/kg >20kgs/day Retrieval Services aware
N.O.K. aware
Adapted from the Victorian Burn Service History & relevant documentation copied
