Burn injuries, caused by thermal energy, chemicals, or electricity, represent a significant trauma requiring immediate and specialized medical attention. The emergency room (ER) focuses on stabilizing the patient’s condition and stopping the progression of the injury to prevent complications like infection and fluid loss. Acute care aims to halt the destructive process, manage pain, and determine the precise severity of the wound to guide subsequent treatment decisions. This systematic approach ensures patients receive the appropriate level of care from the moment they arrive.
Immediate Steps Upon Arrival
The first priority upon a burn patient’s arrival in the ER is to follow the standard trauma protocol of Airway, Breathing, and Circulation (ABCs). Airway assessment is rapid, especially if smoke inhalation is suspected, indicated by facial burns, soot in the mouth or nose, or a hoarse voice, which may necessitate immediate intubation to secure breathing.
The burning process must be stopped entirely; this means gently removing all clothing and jewelry from the affected area, as these items can retain heat or become constricting bands due to swelling. For chemical or electrical burns, the source of the agent must be removed or neutralized to stop the ongoing tissue damage. Chemical burns are aggressively flushed with copious amounts of water to dilute and wash away the corrosive substance. Intravenous access is established immediately, often using two large-bore catheters, in preparation for potential massive fluid administration.
Classifying the Injury
Once the patient is stabilized, the medical team conducts a thorough assessment to classify the injury based on burn depth and the total body surface area (TBSA) affected. Burn depth is categorized by degrees, reflecting the layers of skin and underlying tissue involved. A first-degree burn affects only the epidermis, causing redness and pain but no blistering, like a typical sunburn.
Second-degree burns extend into the dermis, resulting in fluid-filled blisters, significant pain, and a mottled red appearance. These are classified as superficial or deep partial-thickness based on the depth within the dermis. Third-degree, or full-thickness, burns destroy all layers of the skin, appearing white, leathery, or charred, and are often painless due to nerve ending destruction. Fourth-degree burns are the most severe, extending through the skin into fat, muscle, or bone.
The extent of the injury is calculated using a tool like the Rule of Nines for adults, which divides the body into sections representing 9% or multiples of 9% of the TBSA. For example, the entire head and neck account for 9%, each arm is 9%, and the entire front torso is 18%. For children, the Lund-Browder chart offers a more accurate assessment, as it accounts for the proportionally larger head size in pediatric patients. Only second-, third-, and fourth-degree burns are included in the TBSA calculation, as first-degree burns do not require fluid resuscitation calculations. This precise TBSA percentage is a critical factor used to determine the necessary amount of intravenous fluids required to prevent shock.
Acute Care and Pain Management
Pain management is a central component of acute burn care, typically starting with intravenous opioid medications due to their rapid onset and effectiveness for severe pain. Pain is treated before, during, and after any wound manipulation. The wound itself is then meticulously cleaned through debridement, which involves removing loose, non-viable, or dead tissue and ruptured blisters to reduce infection risk.
Following debridement, a topical antimicrobial agent, such as silver sulfadiazine, is applied to combat bacterial growth. This cream is effective against a broad spectrum of microbes and helps keep the burn wound moist. The wound is then covered with sterile, non-adherent dressings to protect the exposed tissue from contamination.
For patients with burns greater than 20% TBSA, fluid resuscitation is calculated using specialized protocols like the Parkland formula. This formula estimates the total volume of intravenous crystalloid solution needed over the first 24 hours based on the patient’s weight and the calculated TBSA. Half of the calculated fluid volume is administered during the first eight hours from the time of injury, with the remaining half delivered over the next sixteen hours. Tetanus prophylaxis is also addressed for all burn patients, as the injury constitutes a high-risk wound for bacterial contamination.
Determining Next Steps and Follow-Up
The final stage of ER management involves determining the patient’s disposition, dictated by the burn’s severity and location. Patients with minor burns, such as first-degree or small superficial second-degree burns, are discharged with detailed instructions for at-home wound care and pain control. They receive a clear plan for outpatient follow-up with a primary care provider or a specialized burn clinic.
Patients with moderate burns, such as deep second-degree burns or those covering a larger TBSA, may require admission to a general hospital bed for close observation, intravenous fluid management, and consistent wound care. Transfer to a specialized burn center is required for major burns, including third-degree burns or second-degree burns over 20% TBSA in adults (or 10% in children/elderly).
Transfer is also necessary for:
- Electrical burns.
- Chemical burns.
- Burns accompanied by a suspected inhalation injury or associated trauma.
- Burns involving the face, hands, feet, genitalia, perineum, or major joints due to potential functional impairment.
The ER team coordinates the transfer, ensuring stabilization and continuous monitoring throughout the transport process.