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Burn injury

What's new

Updated 2023 ABA guidelines for the management of burn shock.

Background

Overview

Definition
Burn injuries are defined as damage to the skin or other body tissues caused by heat, electricity, chemicals, or radiation.
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Pathophysiology
The pathophysiology of burn injuries involves the destruction of skin layers, which triggers an immune and inflammatory response, metabolic changes, and potentially distributive shock.
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Epidemiology
The incidence of burn injury in the US is estimated at 140 per 100,000 person-years.
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Disease course
Clinically, burn injuries present with redness, blistering, and skin damage. The severity of these symptoms can vary depending on the depth and extent of the burn. Superficial burns may only cause redness and pain, while deeper burns can lead to blistering, skin necrosis, and even systemic symptoms such as shock.
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Prognosis and risk of recurrence
The prognosis of burn injuries can vary widely, depending on factors such as the severity and extent of the burn, the patient's overall health, and the presence of complications. Burns involving a large percentage of the body surface area or those that result in inhalation injury can have a poor prognosis.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of burn injury are prepared by our editorial team based on guidelines from the American Burn Association (ABA 2024,2023,2020), the International Collaboration for Transfusion Medicine Guidelines (ICTMG 2024), the Surgical Infection Society Europe (SIS-E/GAIS/WSES/WSIS/AAST 2024), the Japanese Society for Burn Injuries (JSBI 2022), the International Symposium on Biomedical Imaging (ISBI 2018), ...
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Classification and risk stratification

Severity assessment: as per JSBI 2022 guidelines, use the following for measuring the burn area:
rule of nines
rule of fives
lund and Browder's law
palm method.
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  • Prognostic factors

Diagnostic investigations

Evaluation for inhalation injury: as per JSBI 2022 guidelines, consider obtaining chest CT and performing bronchoscopy for the diagnosis of inhalation injury.
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  • Evaluation for burn wound infection

  • Assessment of pain

  • Assessment of psychosocial factors

Respiratory support

Endotracheal intubation
As per JSBI 2022 guidelines:
Perform either prophylactic early intubation or intubation when symptoms of upper airway obstruction appear after careful monitoring, depending on the experience of the responding medical staff and the capacity of the treating facility.
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Prefer non-benzodiazepine over benzodiazepine sedative drugs during tracheal intubation.
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Medical management

Prehospital care: as per ISBI 2018 guidelines, recognize that first aid begins with the first responder at the accident site and ends when primary care commences at a healthcare facility. Provide public education to improve knowledge about first aid and to optimize first responder action, as knowledge regarding adequate first aid is globally deficient.
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  • Setting of care

  • Multidisciplinary care

  • Fluid resuscitation (indications)

  • Fluid resuscitation (crystalloids)

  • Fluid resuscitation (colloids)

  • Fluid resuscitation (albumin)

  • Fluid resuscitation (FFP)

  • Fluid resuscitation (infusion rate and monitoring)

  • Fluid resuscitation (vasopressors)

  • Fluid resuscitation (intravenous vitamin C)

  • Topical agents

  • Pain management (general principles)

  • Pain management (opioids)

  • Pain management (non-opioids)

  • Pain management (nonpharmacological)

  • Prevention of infection

  • Management of wound infection

  • Management of pneumonia

  • Management of sepsis

  • Management of HR

  • Management of body temperature

Inpatient care

Thromboprophylaxis: as per JSBI 2022 guidelines, insufficient evidence to recommend a specific method of risk assessment of DVT. Determine indications for prophylaxis against DVT in patients with burns according to the risk assessment of DVT in general inpatients and ICU patients. View the following as specific risks of DVT in patients with burns:
burn area
multiple surgeries
inhalation injury.
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  • Sedation

  • Considerations for vascular catheters

  • Considerations for urinary catheters

Nonpharmacologic interventions

Nutrition: as per JSBI 2022 guidelines, determine the amount of calories to be administered in each patient by measuring the amount of calories consumed at rest using an indirect calorimeter.
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  • Hydrotherapy

Therapeutic procedures

Blood transfusion: as per ISBI 2018 guidelines, administer blood transfusion in rare situations during burn resuscitation when associated traumatic injury causing significant blood loss is present. Administer blood transfusion during hospitalization based on clinical assessment and inform families of the risks of transfusion.
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  • Platelet transfusion

  • Regional anesthesia

  • Fecal diversion tube

  • RRT

Surgical interventions

Wound disinfection: as per JDA 2016 guidelines, consider disinfecting burns by evaluating the condition of the wound along with the causative bacteria and antibacterial spectra of various drugs.
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  • Dressing materials

  • Surgical excision

  • Epidermal grafts

Specific circumstances

Pediatric patients: as per JSBI 2022 guidelines, initiate initial fluid resuscitation in pediatric patients with burn area > 10% total body surface area.
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  • Patients with inhalation injury

  • Patients with chemical injury

  • Patients with electrical injury

Follow-up and surveillance

Rehabilitation: as per ABA 2023 guidelines, consider offering early mobilization and rehabilitation to reduce ICU-acquired weakness and delirium in critically ill adult patients with burns in an ICU setting. (Conditional.
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