Triage 1 0 14 Ml

Triage 1 0 14 Ml

Impaled, 1 foot piece of shrapnel in right eye: Respirations 14: Female six months pregnant; broken left, lower leg: Respirations. Snap a photo to screen for thousands of skin conditions and symptoms using artificial intelligence. Procalcitonin, CRP and leucocyte count were slightly elevated or normal (PCT 0.06 ng/mL CRP 25 mg/L, leucocyte count 9.4 10 3 /microL). In addition to the laboratory data, a final diagnosis of Non‐COVID‐19 Viral was deemed clinically appropriate based on the patient's history of clinical improvement without antibiotics and discharge home. NCCT: 120kV, 280 to 340mA, 5.0 mm slice reconstruction, 1 mm increment; CTA: 100kV, 260 to 300mA, 5.0 mm slice reconstruction, 1 mm increment, 80 mL highly iodinated contrast medium and 50 mL NaCl flush at 4 mL/s; CTP: 80kV, 200 to 250mA, 5 mm slice reconstruction (maximum 10 mm), slice sampling rate 1.50 s (minimum 1.33 s), scan time 45 s.
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General InformationTriage 1 0 14 Ml =
After a chemical mass casualty incident, trauma with or without burns is expected to be common. 
Burn therapy adds significant logistical requirements and complexity to the medical response in a chemical mass casualty incident. 
Burns complicating physical injury and/or chemical injury decrease the likelihood of survival. 
Health care providers with burn expertise are needed to optimize burn care. 
Consultation with American Burn Association Verified Burn Centers is recommended 
Diagnosis of Burns
Definition: A burn is the partial or complete destruction of skin caused by some form of energy, usually thermal energy. 
Burn severity is dictated by: Percent total body surface area (TBSA) involvement Burns >20-25% TBSA require IV fluid resuscitation 
Burns >30-40% TBSA may be fatal without treatment 
In adults: 'Rule of Nines' is used as a rough indicator of % TBSA 
Rule of Nines for Establishing Extent of Body Surface BurnedAnatomic Surface% of total body surface
Head and neck9%
Anterior trunk18%
Posterior trunk18%
Arms, including hands9% each
Legs, including feet18% each
Genitalia1%

In children, adjust percents because they have proportionally larger heads (up to 20%) and smaller legs (13% in infants) than adults Lund-Browder diagrams improve the accuracy of the % TBSA for children. 
Palmar hand surface is approximately 1% TBSA 
Estimating Percent Total Body Surface Area in Children Affected by Burns
 (A) Rule of 'nines' 
 (B) Lund-Browder diagram for estimating extent of burns
 (Adapted from The Treatment of Burns, edition 2, Artz CP and Moncrief JA, Philadelphia, WB Saunders Company, 1969) 
Depth of burn injury (deeper burns are more severe) Superficial burns (first-degree and superficial second-degree burns) First-degree burns Damage above basal layer of epidermis 
Dry, red, painful ('sunburn') 
Second-degree burns Damage into dermis 
Skin adnexa (hair follicles, oil glands, etc,) remain 
Heal by re-epithelialization from skin adnexa 
The deeper the second-degree burn, the slower the healing (fewer adnexa for re-epithelialization) 
Moist, red, blanching, blisters, extremely painful 
Superficial burns heal by re-epithelialization and usually do not scar if healed within 2 weeks 
Deep burns (deep second-degree to fourth-degree burns) Deep second-degree burns (deep partial-thickness) Damage to deeper dermis 
Less moist, less blanching, less pain 
Heal by scar deposition, contraction and limited re-epithelialization 
Third-degree burns (full-thickness) Entire thickness of skin destroyed (into fat) 
Any color (white, black, red, brown), dry, less painful (dermal plexus of nerves destroyed) 
Heal by contraction and scar deposition (no epithelium left in middle of wound) 
Fourth-degree burns Burn into muscle, tendon, bone 
Need specialized care (grafts will not work) 
Deep burns usually need skin grafts to optimize results and lead to hypertrophic (raised) scars if not grafted 
Age Mortality for any given burn size increases with age Children/young adults can survive massive burns Children require more fluid per TBSA burns 
Elderly may die from small (<15% TBSA) burns 
Smoke inhalation injury Smoke inhalation injury doubles the mortality relative to burn size 
Associated injuries Other trauma increases severity of injury 
Delay in resuscitation Delay increases fluid requirements 
Need for escharotomies and fasciotomies Increases fluid requirements 
Use of alcohol or drugs (especially methamphetamine) Makes resuscitation more difficult 
American Burn Association Burn Unit Referral Criteria **Criteria not established for very large mass casualty incidents (MCI)
Summary of Burn Unit Referral Criteria (PDF - 7 KB) (American Burn Association)

Anatomic Surface	% of total body surface
Head and neck	9%
Anterior trunk	18%
Posterior trunk	18%
Arms, including hands	9% each
Legs, including feet	18% each
Genitalia	1%

Second- and third-degree burns greater than 10% TBSA in patients under 10 or over 50 years of age 
Second- and third-degree burns greater than 20% TBSA in other age groups 
Second- and third-degree burns that involve the face, hands, feet, genitalia, perineum, and major joints 
Third-degree burns greater than 5% TBSA in any age group 
Electrical burns, including lightning injury 
Chemical burns 
Inhalation injury 
Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality (e.g., significant chemical exposure) 
Any patients with burns and concomitant trauma (e.g., fractures, blast injury) where burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be treated initially in a trauma center until stable before being transferred to a burn center. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols appropriate for the incident 
Hospitals without qualified personnel or equipment for the care of children should transfer children with burns to a Verified Burn Center with these capabilities 
Burn injury in children who will require special social/emotional and/or long-term rehabilitative support, including cases involving suspected child abuse or substance abuse 
Treatment
General information All burn patients should initially be treated with the principles of Advanced Burn and/or Trauma Life Support The ABC's (airway, breathing, circulation) of trauma take precedent over caring for the burn 
Search for other signs of trauma 
Verified Burn Centers provide advanced support for complex cases Certified by the American College of Surgeons (ACS) Committee on Trauma and the American Burn Association (ABA) 
Resources will give advice or assist with care 
Burn Unit Referral Criteria (PDF - 7 KB) (American Burn Association) 
Airway Extensive burns may lead to massive edema 
Obstruction may result from upper airway swelling 
Risk of upper airway obstruction increases with Massive burns All patients with deep burns >35-40% TBSA should be endotracheally intubated 
Burns to the head 
Burns inside the mouth 
Intubate early if massive burn or signs of obstruction Intubate if patients require prolonged transport and any concern with potential for obstruction 
If any concerns about the airway, it is safer to intubate earlier than when the patient is decompensating 
Signs of airway obstruction Hoarseness or change in voice 
Use of accessory respiratory muscles 
High anxiety 
Tracheostomies not needed during resuscitation period 
Remember: Intubation can lead to complications, so do not intubate if not needed 
Breathing Hypoxia Fire consumes oxygen so people may suffer from hypoxia as a result of flame injuries 
Carbon monoxide (CO) Byproduct of incomplete combustion 
Binds hemoglobin with 200 times the affinity of oxygen 
Leads to inadequate oxygenation 
Diagnosis of CO poisoning Nondiagnostic PaO2 (partial pressure of O2 dissolved in serum) 
Oximeter (difference in oxy- and deoxyhemoglobin) 
Patient color ('cherry red' with poisoning) 
Diagnostic Carboxyhemoglobin levels <10% is normal 
>40% is severe intoxication 
Treatment Remove source 
100% oxygen until CO levels are <10% 
Smoke inhalation injury Pathophysiology Smoke particles settle in distal bronchioles 
Mucosal cells are die 
Sloughing and distal atelectasis 
Increase risk for pneumonia 
Diagnosis History of being in a smoke-filled enclosed space 
Bronchoscopy Soot beneath the glottis 
Airway edema, erythema, ulceration 
Nondiagnostic clinical tests Early chest x-ray 
Early blood gases 
Nondiagnostic clinical findings Soot in sputum or saliva 
Singed facial hair 
Treatment Supportive pulmonary management 
Aggressive respiratory therapy 
Circulation Obtain IV access anywhere possible Unburned areas preferred 
Burned areas acceptable 
Central access more reliable if proficient 
Cut-downs are last resort 
Resuscitation in burn shock (first 24 hours) Massive capillary leak occurs after major burns 
Fluids shift from intravascular space to interstitial space 
Fluid requirements increase with greater severity of burn (larger % TBSA, increase depth, inhalation injury, associate injuries - see above) 
Fluid requirements decrease with less severe burn (may be less than calculated rate) 
IV fluid rate dependent on physiologic response Place Foley catheter to monitor urine output 
Goal for adults: urine output of 0.5 ml/kg/hour 
Goal for children: urine output of 1 ml/kg/hour 
If urine output below these levels, increase fluid rate 
Preferred fluid: Lactated Ringer's Solution Isotonic 
Cheap 
Easily stored 
Resuscitation formulas are just a guide for initiating resuscitation 
Resuscitation formulas: Parkland formula most commonly used IV fluid - Lactated Ringer's Solution 
Fluid calculation 4 x weight in kg x %TBSA burn Give 1/2 of that volume in the first 8 hours 
Give other 1/2 in next 16 hours 
Warning: Despite the formula suggesting cutting the fluid rate in half at 8 hours, the fluid rate should be gradually reduced throughout the resuscitation to maintain the targeted urine output, i.e., do not follow the second part of the formula that says to reduce the rate at 8 hours, adjust the rate based on the urine output. 
Example of fluid calculation 100-kg man with 80% TBSA burn 
Parkland formula: 4 x 100 x 80 = 32,000 ml 
Give 1/2 in first 8 hours = 16,000 ml in first 8 hours 
Starting rate = 2,000 ml/hour 
Adjust fluid rate to maintain urine output of 50 ml/hr 
Albumin may be added toward end of 24 hours if not adequate response 
Resuscitation endpoint: maintenance rate When maintenance rate is reached (approximately 24 hours), change fluids to D50.5NS with 20 mEq KCl at maintenance level 
Maintenance fluid rate = basal requirements + evaporative losses Basal fluid rate Adult basal fluid rate = 1500 x body surface area (BSA) (for 24 hrs) 
Pediatric basal fluid rate (<20kg) = 2000 x BSA (for 24 hrs) May use 100 ml/kg for 1st 10 kg 
0 ml/kg for 2nd 10 kg 
20 ml/kg for remaining kg for 24 hrs 
Evaporative fluid loss Adult: (25 + % TBSA burn) x (BSA) = ml/hr 
Pediatric (<20kg): (35 + % TBSA burn) x (BSA) = ml/hr 
Complications of over-resuscitation Compartment syndromes Best dealt with at Verified Burn Centers
If unable to obtain assistance, compartment syndromes may require management 
Limb compartments Symptoms of severe pain (worse with movement), numbness, cool extremity, tight feeling compartments 
Distal pulses may remain palpable despite ongoing compartment syndrome (pulse is lost when pressure > systolic pressure) 
Compartment pressure >30 mmHg may compromise muscle/nerves 
Measure compartment pressures with arterial line monitor (place needle into compartment) 
Escharotomies may save limbs Performed laterally and medially throughout entire limb 
Performed with arms supinated 
Hemostasis is required 
Fasciotomies may be needed if pressure does not drop to <30 mmHg Requires surgical expertise 
Hemostasis is required 
Chest Compartment Syndrome Increased peak inspiratory pressure (PIP) due to circumferential trunk burns 
Escharotomies through mid-axillary line, horizontally across chest/abdominal junction 
Abdominal Compartment Syndrome Pressure in peritoneal cavity > 30 mmHg Measure through Foley catheter 
Signs: increased PIP, decreased urine output despite massive fluids, hemodynamic instability, tight abdomen 
Treatment Abdominal escharotomy 
NG tube 
Possible placement of peritoneal catheter to drain fluid 
Laparotomy as last resort 
Acute Respiratory Distress Syndrome (ARDS) Increased risk and severity if over-resuscitation 
Treatment supportive 
Wound Care During initial or emergent care, wound care is of secondary importance 
Advanced Burn Life Support recommendations Cover wound with clean, dry sheet or dressing. NO WET DRESSINGS. Simple dressing if being transported to burn center (they will need to see the wound) 
Sterile dressings are preferred but not necessary 
Covering wounds improves pain 
Elevate burned extremities 
Maintain patient's temperature (keep patient warm) While cooling may make a small wound more comfortable, cooling any wound >5% TBSA will cool the patient 
If providing prolonged care Wash wounds with soap and water (sterility is not necessary) 
Maintain temperature 
Topical antimicrobials help prevent infection but do not eliminate bacteria Silver sulfadiazine for deep burns 
Bacitracin and nonsticky dressings for more superficial burns 
Skin grafting Deep burns require skin grafting 
Grafting may not be necessary for days 
Preferable to refer patients with need for grafting to Verified Burn Centers or, if not available, others trained in surgical techniques Grafting of extensive areas may require significant amounts of blood 
Patient's temperature must be watched 
Anesthesia requires extra attention 
Medications All pain meds should be given IV 
Tetanus prophylaxis should be given as appropriate 
Prophylactic antibiotics are contraindicated Systemic antibiotics are only given to treat infections 
Special Burns
General information Often require specialized care 
Calling a Verified Burn Center is advised 
Electrical injuries Extent of injury may not be apparent Damage occurs deep within tissues 
Damage frequently progresses 
Electricity contracts muscles, so watch for associated injuries 
Cardiac arrhythmias may occur If arrhythmia present, patient needs monitoring 
CPR may be lifesaving 
Myoglobinuria may be present Color best indicator of severity 
If urine is dark (black, red), myoglobinuria needs to be treated Increase fluids to induce urine output of 75-100 ml/hr in adults 
In children, target urine output of 2 ml/kg/hour 
Alkalinize urine (give NaHCOi3) 
Check for compartment syndromes 
Mannitol as last resort 
Compartment syndromes are common 
Long-term neuro-psychiatric problems may result 
Chemical Burns Brush off powder 
Prolonged irrigation required 
Do not seek antidote Delays treatment 
May result in heat production 
Special chemical burns require contacting a Verified Burn Center, for example: Hydrofluoric acid burn 
American Burn Association Information
The American Burn Association (ABA) is an organization of burn caregivers who have set up a network to assist with management of burn disasters. 
The ABA has set up a system to verify burn centers (similar to Verified Trauma Centers) as meeting standards for managing patients with burns of all types of severity. 
Verified Burn Centers participate in disaster planning and have set up a network for transporting burn patients throughout the country. 
Verified Burn Centers are always available for advice and assistance in managing burn patients. 
To find the nearest Verified Burn Center near you, contact the ABA Web site: www.ameriburn.org or 
e-mail: info@ameriburn.org or 
call: 312-642-9260 
The ABA offers ABA Advanced Burn Life Support (ABLS), a Self-directed, Web-based Learning Program. 
Acknowledgement: This CHEMM Web page was adapted from REMM and prepared in consultation with Dr. David Greenhalgh, President of the American Burn Association, August 2006

Greenwood JE. Burn injury and explosions: an Australian perspective. Eplasty. 2009 Sep 16;9:e40. [PubMed Citation]
Orgill DP. Excision and skin grafting of thermal burns. N Engl J Med. 2009 Feb 26;360(9):893-901. [PubMed Citation]
Holmes JH 4th. Critical issues in burn care. J Burn Care Res. 2008 Nov-Dec;29(6 Suppl 2):S180-7. [PubMed Citation]
Singer AJ, Dagum AB. Current management of acute cutaneous wounds. N Engl J Med. 2008 Sep 4;359(10):1037-46. [PubMed Citation]
White CE, Renz EM. Advances in surgical care: management of severe burn injury. Crit Care Med. 2008 Jul;36(7 Suppl):S318-24. [PubMed Citation]
Yurt RW, Lazar EJ, Leahy NE, Cagliuso NV Sr, Rabbitts AC, Akkapeddi V, Cooper A, Dajer A, Delaney J, Mineo FP, Silber SH, Soloff L, Magbitang K, Mozingo DW. Burn disaster response planning: an urban region's approach. J Burn Care Res. 2008 Jan-Feb;29(1):158-65. [PubMed Citation]
Barillo DJ, Wolf S. Planning for burn disasters: lessons learned from one hundred years of history. J Burn Care Res. 2006 Sep-Oct;27(5):622-34. [PubMed Citation]
Saffle JR, Gibran N, Jordan M. Defining the ratio of outcomes to resources for triage of burn patients in mass casualties. J Burn Care Rehabil, 2005 Nov-Dec;26(6):478-82 [PubMed Citation]
Allison K, Porter K. Consensus on the pre-hospital approach to burns patient management. Injury. 2004 Aug;35(8):734-8. [PubMed Citation]
Ahuja RB, Bhattacharya S. Burns in the developing world and burn disasters. BMJ. 2004 Aug 21;329(7463):447-9. [PubMed Citation]
 Sheridan RL. Burns. Crit Care Med. 2002 Nov;30(11 Suppl):S500-14. [PubMed Citation]
Herndon DN, ed. Total Burn Care (2nd Ed), WB Saunders, London, 2002.
Leslie CL, Cushman M, McDonald GS, Joshi W, Maynard AM. Management of multiple burn casualties in a high volume ED without a verified burn unit. Am J Emerg Med. 2001 Oct;19(6):469-73. [PubMed Citation]
Mackie DP, Koning HM. Fate of mass burn casualties: implications for disaster planning. Burns. 1990 Jun;16(3):203-6. [PubMed Citation]
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Second- and third-degree burns greater than 10% TBSA in patients under 10 or over 50 years of age 
Second- and third-degree burns greater than 20% TBSA in other age groups 
Second- and third-degree burns that involve the face, hands, feet, genitalia, perineum, and major joints 
Third-degree burns greater than 5% TBSA in any age group 
Electrical burns, including lightning injury 
Chemical burns 
Inhalation injury 
Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality (e.g., significant chemical exposure) 
Any patients with burns and concomitant trauma (e.g., fractures, blast injury) where burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be treated initially in a trauma center until stable before being transferred to a burn center. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols appropriate for the incident 
Hospitals without qualified personnel or equipment for the care of children should transfer children with burns to a Verified Burn Center with these capabilities 
Burn injury in children who will require special social/emotional and/or long-term rehabilitative support, including cases involving suspected child abuse or substance abuse 
Treatment
General information All burn patients should initially be treated with the principles of Advanced Burn and/or Trauma Life Support The ABC's (airway, breathing, circulation) of trauma take precedent over caring for the burn 
Search for other signs of trauma 
Verified Burn Centers provide advanced support for complex cases Certified by the American College of Surgeons (ACS) Committee on Trauma and the American Burn Association (ABA) 
Resources will give advice or assist with care 
Burn Unit Referral Criteria (PDF - 7 KB) (American Burn Association) 
Airway Extensive burns may lead to massive edema 
Obstruction may result from upper airway swelling 
Risk of upper airway obstruction increases with Massive burns All patients with deep burns >35-40% TBSA should be endotracheally intubated 
Burns to the head 
Burns inside the mouth 
Intubate early if massive burn or signs of obstruction Intubate if patients require prolonged transport and any concern with potential for obstruction 
If any concerns about the airway, it is safer to intubate earlier than when the patient is decompensating 
Signs of airway obstruction Hoarseness or change in voice 
Use of accessory respiratory muscles 
High anxiety 
Tracheostomies not needed during resuscitation period 
Remember: Intubation can lead to complications, so do not intubate if not needed 
Breathing Hypoxia Fire consumes oxygen so people may suffer from hypoxia as a result of flame injuries 
Carbon monoxide (CO) Byproduct of incomplete combustion 
Binds hemoglobin with 200 times the affinity of oxygen 
Leads to inadequate oxygenation 
Diagnosis of CO poisoning Nondiagnostic PaO2 (partial pressure of O2 dissolved in serum) 
Oximeter (difference in oxy- and deoxyhemoglobin) 
Patient color ('cherry red' with poisoning) 
Diagnostic Carboxyhemoglobin levels <10% is normal 
>40% is severe intoxication 
Treatment Remove source 
100% oxygen until CO levels are <10% 
Smoke inhalation injury Pathophysiology Smoke particles settle in distal bronchioles 
Mucosal cells are die 
Sloughing and distal atelectasis 
Increase risk for pneumonia 
Diagnosis History of being in a smoke-filled enclosed space 
Bronchoscopy Soot beneath the glottis 
Airway edema, erythema, ulceration 
Nondiagnostic clinical tests Early chest x-ray 
Early blood gases 
Nondiagnostic clinical findings Soot in sputum or saliva 
Singed facial hair 
Treatment Supportive pulmonary management 
Aggressive respiratory therapy 
Circulation Obtain IV access anywhere possible Unburned areas preferred 
Burned areas acceptable 
Central access more reliable if proficient 
Cut-downs are last resort 
Resuscitation in burn shock (first 24 hours) Massive capillary leak occurs after major burns 
Fluids shift from intravascular space to interstitial space 
Fluid requirements increase with greater severity of burn (larger % TBSA, increase depth, inhalation injury, associate injuries - see above) 
Fluid requirements decrease with less severe burn (may be less than calculated rate) 
IV fluid rate dependent on physiologic response Place Foley catheter to monitor urine output 
Goal for adults: urine output of 0.5 ml/kg/hour 
Goal for children: urine output of 1 ml/kg/hour 
If urine output below these levels, increase fluid rate 
Preferred fluid: Lactated Ringer's Solution Isotonic 
Cheap 
Easily stored 
Resuscitation formulas are just a guide for initiating resuscitation 
Resuscitation formulas: Parkland formula most commonly used IV fluid - Lactated Ringer's Solution 
Fluid calculation 4 x weight in kg x %TBSA burn Give 1/2 of that volume in the first 8 hours 
Give other 1/2 in next 16 hours 
Warning: Despite the formula suggesting cutting the fluid rate in half at 8 hours, the fluid rate should be gradually reduced throughout the resuscitation to maintain the targeted urine output, i.e., do not follow the second part of the formula that says to reduce the rate at 8 hours, adjust the rate based on the urine output. 
Example of fluid calculation 100-kg man with 80% TBSA burn 
Parkland formula: 4 x 100 x 80 = 32,000 ml 
Give 1/2 in first 8 hours = 16,000 ml in first 8 hours 
Starting rate = 2,000 ml/hour 
Adjust fluid rate to maintain urine output of 50 ml/hr 
Albumin may be added toward end of 24 hours if not adequate response 
Resuscitation endpoint: maintenance rate When maintenance rate is reached (approximately 24 hours), change fluids to D50.5NS with 20 mEq KCl at maintenance level 
Maintenance fluid rate = basal requirements + evaporative losses Basal fluid rate Adult basal fluid rate = 1500 x body surface area (BSA) (for 24 hrs) 
Pediatric basal fluid rate (<20kg) = 2000 x BSA (for 24 hrs) May use 100 ml/kg for 1st 10 kg 
0 ml/kg for 2nd 10 kg 
20 ml/kg for remaining kg for 24 hrs 
Evaporative fluid loss Adult: (25 + % TBSA burn) x (BSA) = ml/hr 
Pediatric (<20kg): (35 + % TBSA burn) x (BSA) = ml/hr 
Complications of over-resuscitation Compartment syndromes Best dealt with at Verified Burn Centers
If unable to obtain assistance, compartment syndromes may require management 
Limb compartments Symptoms of severe pain (worse with movement), numbness, cool extremity, tight feeling compartments 
Distal pulses may remain palpable despite ongoing compartment syndrome (pulse is lost when pressure > systolic pressure) 
Compartment pressure >30 mmHg may compromise muscle/nerves 
Measure compartment pressures with arterial line monitor (place needle into compartment) 
Escharotomies may save limbs Performed laterally and medially throughout entire limb 
Performed with arms supinated 
Hemostasis is required 
Fasciotomies may be needed if pressure does not drop to <30 mmHg Requires surgical expertise 
Hemostasis is required 
Chest Compartment Syndrome Increased peak inspiratory pressure (PIP) due to circumferential trunk burns 
Escharotomies through mid-axillary line, horizontally across chest/abdominal junction 
Abdominal Compartment Syndrome Pressure in peritoneal cavity > 30 mmHg Measure through Foley catheter 
Signs: increased PIP, decreased urine output despite massive fluids, hemodynamic instability, tight abdomen 
Treatment Abdominal escharotomy 
NG tube 
Possible placement of peritoneal catheter to drain fluid 
Laparotomy as last resort 
Acute Respiratory Distress Syndrome (ARDS) Increased risk and severity if over-resuscitation 
Treatment supportive 
Wound Care During initial or emergent care, wound care is of secondary importance 
Advanced Burn Life Support recommendations Cover wound with clean, dry sheet or dressing. NO WET DRESSINGS. Simple dressing if being transported to burn center (they will need to see the wound) 
Sterile dressings are preferred but not necessary 
Covering wounds improves pain 
Elevate burned extremities 
Maintain patient's temperature (keep patient warm) While cooling may make a small wound more comfortable, cooling any wound >5% TBSA will cool the patient 
If providing prolonged care Wash wounds with soap and water (sterility is not necessary) 
Maintain temperature 
Topical antimicrobials help prevent infection but do not eliminate bacteria Silver sulfadiazine for deep burns 
Bacitracin and nonsticky dressings for more superficial burns 
Skin grafting Deep burns require skin grafting 
Grafting may not be necessary for days 
Preferable to refer patients with need for grafting to Verified Burn Centers or, if not available, others trained in surgical techniques Grafting of extensive areas may require significant amounts of blood 
Patient's temperature must be watched 
Anesthesia requires extra attention 
Medications All pain meds should be given IV 
Tetanus prophylaxis should be given as appropriate 
Prophylactic antibiotics are contraindicated Systemic antibiotics are only given to treat infections 
Special Burns
General information Often require specialized care 
Calling a Verified Burn Center is advised 
Electrical injuries Extent of injury may not be apparent Damage occurs deep within tissues 
Damage frequently progresses 
Electricity contracts muscles, so watch for associated injuries 
Cardiac arrhythmias may occur If arrhythmia present, patient needs monitoring 
CPR may be lifesaving 
Myoglobinuria may be present Color best indicator of severity 
If urine is dark (black, red), myoglobinuria needs to be treated Increase fluids to induce urine output of 75-100 ml/hr in adults 
In children, target urine output of 2 ml/kg/hour 
Alkalinize urine (give NaHCOi3) 
Check for compartment syndromes 
Mannitol as last resort 
Compartment syndromes are common 
Long-term neuro-psychiatric problems may result 
Chemical Burns Brush off powder 
Prolonged irrigation required 
Do not seek antidote Delays treatment 
May result in heat production 
Special chemical burns require contacting a Verified Burn Center, for example: Hydrofluoric acid burn 
American Burn Association Information
The American Burn Association (ABA) is an organization of burn caregivers who have set up a network to assist with management of burn disasters. 
The ABA has set up a system to verify burn centers (similar to Verified Trauma Centers) as meeting standards for managing patients with burns of all types of severity. 
Verified Burn Centers participate in disaster planning and have set up a network for transporting burn patients throughout the country. 
Verified Burn Centers are always available for advice and assistance in managing burn patients. 
To find the nearest Verified Burn Center near you, contact the ABA Web site: www.ameriburn.org or 
e-mail: info@ameriburn.org or 
call: 312-642-9260 
The ABA offers ABA Advanced Burn Life Support (ABLS), a Self-directed, Web-based Learning Program. 
Acknowledgement: This CHEMM Web page was adapted from REMM and prepared in consultation with Dr. David Greenhalgh, President of the American Burn Association, August 2006

Greenwood JE. Burn injury and explosions: an Australian perspective. Eplasty. 2009 Sep 16;9:e40. [PubMed Citation]
Orgill DP. Excision and skin grafting of thermal burns. N Engl J Med. 2009 Feb 26;360(9):893-901. [PubMed Citation]
Holmes JH 4th. Critical issues in burn care. J Burn Care Res. 2008 Nov-Dec;29(6 Suppl 2):S180-7. [PubMed Citation]
Singer AJ, Dagum AB. Current management of acute cutaneous wounds. N Engl J Med. 2008 Sep 4;359(10):1037-46. [PubMed Citation]
White CE, Renz EM. Advances in surgical care: management of severe burn injury. Crit Care Med. 2008 Jul;36(7 Suppl):S318-24. [PubMed Citation]
Yurt RW, Lazar EJ, Leahy NE, Cagliuso NV Sr, Rabbitts AC, Akkapeddi V, Cooper A, Dajer A, Delaney J, Mineo FP, Silber SH, Soloff L, Magbitang K, Mozingo DW. Burn disaster response planning: an urban region's approach. J Burn Care Res. 2008 Jan-Feb;29(1):158-65. [PubMed Citation]
Barillo DJ, Wolf S. Planning for burn disasters: lessons learned from one hundred years of history. J Burn Care Res. 2006 Sep-Oct;27(5):622-34. [PubMed Citation]
Saffle JR, Gibran N, Jordan M. Defining the ratio of outcomes to resources for triage of burn patients in mass casualties. J Burn Care Rehabil, 2005 Nov-Dec;26(6):478-82 [PubMed Citation]
Allison K, Porter K. Consensus on the pre-hospital approach to burns patient management. Injury. 2004 Aug;35(8):734-8. [PubMed Citation]
Ahuja RB, Bhattacharya S. Burns in the developing world and burn disasters. BMJ. 2004 Aug 21;329(7463):447-9. [PubMed Citation]
 Sheridan RL. Burns. Crit Care Med. 2002 Nov;30(11 Suppl):S500-14. [PubMed Citation]
Herndon DN, ed. Total Burn Care (2nd Ed), WB Saunders, London, 2002.
Leslie CL, Cushman M, McDonald GS, Joshi W, Maynard AM. Management of multiple burn casualties in a high volume ED without a verified burn unit. Am J Emerg Med. 2001 Oct;19(6):469-73. [PubMed Citation]
Mackie DP, Koning HM. Fate of mass burn casualties: implications for disaster planning. Burns. 1990 Jun;16(3):203-6. [PubMed Citation]
Screenflick 2 2 17 – capture screen movement to video. PDF documents can be viewed with the free Adobe® Reader™

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Letter from the Medical Director: Technological Advances with TriageLogicRavi K Raheja, M.D.
Technology in medicine is evolving faster than most people can keep up. Successful technology companies evolve and create new products that are intuitive and fit into the current infrastructure. Tooth fairy 2 4 4. This approach is known as interoperability, and it allows for progress without drastic change.
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