Burn Patient Airway Management

• Major burns involving the face and neck suggest likely airway compromise, warranting anesthesia consultation.
• Circumferential burns can restrict blood supply to affected organs.
• Hypothermia is a significant concern; prepare a warm resuscitation room and use warmed IV fluids.
• Hypothermia can lead to coagulopathy.

Airway Management

• Loss of consciousness in burn patients is frequently due to suffocation/smoke inhalation, poisoning (e.g., cyanide), or head injury.
• Facial/upper airway swelling necessitates early intervention by an experienced anesthetist.
• Rapid sequence induction is required since awake intubation is usually not possible.
• Prophylactic intubation may be needed in cases of critical airways with anticipated deterioration, using proper emergency intubation setups and senior staff.
• Avoid cutting the tube due to potential further swelling.
• Smoke inhalation leads to chemical pneumonitis rather than direct swelling from the heat of the smoke.

Breathing Considerations

• Smoke inhalation causes inflammatory pneumonitis, especially in indoor burn incidents (e.g., house fires, car fires).
• Indicators of breathing difficulty include increased bagging resistance, rising airway pressures, and decreasing O2 saturation.
• Carbon monoxide (CO) poisoning should be suspected.
• Cherry red lips may not be visible due to soot and exudate.
• Measure CO levels to assess the severity of poisoning.
• Treat CO poisoning with 100% O2.
• Consider cyanide poisoning.
• Circumferential torso burns may require escharotomy to allow chest expansion by cutting through the burned dermis down to the underlying fat.
• Perform escharotomy in a warm theater to prevent bleeding.
• In limbs, avoid arteries and nerves during escharotomy.
• Tissue shrinkage and fluid loss from damaged capillaries reduces chest compliance.
• Opiate overdose can occur with repeated subcutaneous or intramuscular morphine doses; use small IV doses instead.
• Tension pneumothorax can occur due to direct injury, high-tension electrical injury, or iatrogenic causes (e.g., central line placement with positive pressure ventilation).
• Internal jugular or subclavian lines may cause lung injury if vessels are constricted.
• Intraosseous lines are an option for children.

Circulation Management

• Prioritize hemorrhage control.
• Burn shock develops hours after the injury due to plasma leakage (2-4 hours)
• Early aggressive fluid resuscitation is essential.
• Early shock may indicate accompanying injuries (e.g., ruptured spleen).
• Establish early peripheral venous or intraosseous access, even through burned skin if needed.
• Begin with warmed Hartmann's/Ringer's lactate boluses.
• Insert a urinary catheter for hourly output monitoring.
• Calculate resuscitation fluid requirements post-primary survey.
• The hierarchy of fluids is: blood > plasma > extracellular fluid (Hartmann’s).
• Fluid loss depends on the body surface area (BSA) affected by the burn, rather than burn depth.
• Hartmann's solution is effective and safer than plasma because plasma continues leaking out.

Disability/Neurological

• Airway/breathing problems caused by any condition
• Suffocation due to smoke
• Carbon monoxide
• Cyanide
• Opiate overdose
• Head injury

Exposure and Environmental Control

• Keep the resuscitation area and fluids warm.
• Acute burn patients are often hypothermic upon arrival.
• Fully expose the patient to assess burn extent using the Lund and Browder chart.
• Take photos for documentation and to aid in chart completion.
• Be cautious in chemical burn cases to avoid self-contamination.

Lund and Browder Chart

• More accurate than the "rule of nines" for estimating burn area.
• Differentiate between partial and full-thickness burns.
• Exclude simple erythema as it doesn't contribute to fluid loss.
• Document areas of circumferential burns.
• Make note of available unburned donor sites.

Burn Characteristics

• Partial Thickness: Painful, blistered/wet, blanch with refill. Scalds or flash burns.
• Full Thickness: Dry, waxy, charred, leathery, flame/electrical burns, prolonged hot water/radiator contact. Risk of circumferential shrinking.

Consequences of Skin Failure

• Management/prevention of shock and hypercatabolism.
• Skin’s temperature homeostasis disruption.
• Prevention of sepsis in burn wound, lung, urinary tract, IV lines.
• Gut translocation prevention: initiate early drip feeding.
• Repair of the burn wound and the prevention of contractures and secondary disability.

Fluid Resuscitation

• Adults: 3-4 mL/kg/%TBSA burn (Half in first 8 hours, half in the next 16 hours from time of injury).
• Children: 2-3 mL/kg/%TBSA burn + normal metabolic maintenance (100 mL/kg for the first 10 kg, 50 mL/kg for the second 10 kg, 20 mL/kg for each additional kg).
• Consider early FFP infusion for severe burns(>30% TBSA) to protect the endothelial glycocalyx.
• Target urine output of 0.5-1 mL/kg/hr. Exceeding that may mean over-resuscitation or renal failure.
• Consider replacing albumin losses after 24 hours once capillary leak subsides.
• Avoid over-resuscitation

Hypercatabolism Management

• Regulate environmental temperature to minimize heat loss.
• Initiate NG tube feeding.
• Perform early excision and wound treatment.

Management of Partial Thickness Burns

• Thorough cleaning/debridement ASAP (under GA in children).
• Apply antibacterial (silver-based) dressings or biological epidermal replacements.
• Avoid antibiotic-impregnated dressings to prevent resistance.
• Allow dressing to separate spontaneously as the wound heals.
• Graft areas that do not heal within 3 weeks.

Management of Full Thickness Burns

• Perform early complete excision before infection and SIRS set in.
• Prepare for significant blood loss (4% blood volume per 1% burn).
• Use subeschar dilute adrenaline.
• Close wound with dermal regeneration template.
• Wait 3-6 weeks for dermal regeneration.
• Peel off the silicone temporary epidermis and replace with split skin graft.

Dermal Regeneration Templates

• Integra: collagen-based dermal regeneration matrix.
• Polynovo: resorbable polyurethane foam (most commonly used).
• Body grows into the matrix, which then becomes vascularized.
• Creates a waterproof seal, much like a silicone membrane.
• Can be left in place for 16-18 weeks, then peeled off and replaced with a skin graft.