emergency

Major Burn

Airway first — inhalation injury means intubate early before oedema closes the airway. TBSA counts partial + full thickness only (palm ≈1%). Parkland: 4ml × kg × %TBSA Hartmann's, half in 8h FROM INJURY, titrated to urine output. Cool the burn, warm…

EMSB / Burns Resuscitation Pathway

The pathway

1 · Airway — intubate early

Soot, singed nasal hairs, hoarseness, facial burns, stridor
Oedema develops over hours → elective early intubation
Anaesthetics/ITU immediately

2 · Breathing & CO

100% O₂ via non-rebreather
SpO₂ is falsely normal in CO poisoning — send COHb
Cyanide if high lactate + collapse → hydroxocobalamin

3 · Estimate TBSA

Rule of Nines / Lund-Browder (children)
Count partial + full thickness only — NOT erythema
Palm incl. fingers ≈ 1%

4 · Parkland fluids

4ml × kg × %TBSA Hartmann's / 24h
Half in first 8h FROM TIME OF BURN
Titrate to urine output 0.5–1 ml/kg/hr — catheterise

5 · Cool burn, warm patient

Running water 20 min (within 3h of injury)
Then actively keep warm — hypothermia kills
Cling film lengthwise, never circumferential; never ice

6 · Circumferential burns

Chest → restricted ventilation → escharotomy
Limbs → ischaemia; check perfusion hourly, elevate

7 · Refer & complete

≥10% TBSA adults / ≥5% children, full thickness, face/hands/feet/perineum/joints, circumferential, electrical, chemical, inhalation
Analgesia (IV opioid), tetanus, no prophylactic antibiotics

Drugs

Drug	Dose	Route	Notes
Hartmann's solution	Parkland: 4ml × kg × %TBSA	IV	Half in 8h from time of burn. Titrate to urine output.
Morphine	Titrated IV	IV	Burns are extremely painful. IV route only — IM absorption unreliable.
Oxygen	15L NRB	INH	100% O₂ halves CO half-life. Give regardless of SpO₂.
Hydroxocobalamin	5g	IV	Cyanide antidote — enclosed-space fire with profound lactic acidosis.

When to escalate

Any inhalation injury feature — anaesthetics NOW for early intubation,≥10% TBSA adult / ≥5% child — burns service referral,Circumferential chest or limb burns — escharotomy,Rising airway pressures or falling limb perfusion

Reference: British Burn Association / EMSB referral criteria / NICE CKS Burns

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