Burns and Wound Management
Assessment
Estimate surface area with the Rule of Nines (head 9, each arm 9, each leg 18, anterior trunk 18, posterior trunk 18, perineum 1), but the patient palm including fingers is roughly 1% and is better for patchy burns. In children use Lund–Browder charts, because the head is proportionally larger and the legs smaller; applying adult percentages to an infant is a classic error.
Airway: suspect inhalation injury with hoarseness, stridor, soot in the oropharynx, singed nasal hair, facial burns or a fire in an enclosed space. Intubate early rather than waiting for oedema to make it impossible. Give 100% oxygen and measure carboxyhaemoglobin; suspect cyanide toxicity in enclosed-space fires with persistent lactic acidosis.
Fluids: Parkland 2–4 mL/kg/%TBSA crystalloid in the first 24 hours from the time of injury, half in the first 8 hours, titrated to urine output 0.5–1 mL/kg/h in adults (1–2 in children). The formula is a starting point, not a prescription - over-resuscitation causes compartment syndromes.
Circumferential full-thickness burns and deep limb burns need escharotomy for vascular compromise. Chemical burns need prolonged irrigation (brush dry powder off first); hydrofluoric acid needs calcium gluconate.
Never apply ice, butter or toothpaste. Refer: above 10% TBSA, face, hands, perineum, circumferential, inhalation, electrical, and extremes of age.
Rule of thumb: a burn of the palms, face or perineum, or one crossing a joint circumferentially, needs a burns centre.