›Time critical priorities
›Cardiac monitoring for moderate to severe burns
›Pulse oximetry
›Noninvasive blood pressure cycling
›Two large bore IV lines for large TBSA
›IO access if IV access failure
›Active warming measures
›Remove constrictive clothing and jewelry
›Stop burning process
›Chemical decontamination
›Remove dry chemical with brushing
›Copious irrigation after brushing
›Cool thermal burns
›Cool running water
›Avoid ice
›100 percent oxygen for smoke exposure until CO excluded
›Early airway control if progressive airway risk
›Pain control regimen
›Fentanyl IV 25 mcg
›Repeat every 5 minutes as needed
›Typical total 50 to 200 mcg adult
›Morphine IV 0.05 mg per kg
›Repeat every 10 minutes as needed
›Hydromorphone IV 0.2 mg
›Repeat every 10 minutes as needed
›Ketamine IV 0.2 mg per kg
›For opioid sparing analgesia
›Acetaminophen PO 1000 mg
›Maximum 4000 mg per day adult
›Ibuprofen PO 400 mg
›Avoid in significant renal disease
›Antiemetic
›Ondansetron IV 4 mg
›Repeat every 8 hours as needed
›Fluid strategy by burn size
›Oral fluids for small burns with normal vitals
›IV fluids for
›Adults with TBSA 15 percent or higher
›Children with TBSA 10 percent or higher
›Any burn with shock
›Lactated Ringers preferred
›Parkland formula
›4 mL per kg per percent TBSA
›Half in first 8 hours from time of burn
›Half over next 16 hours
›Urine output targets
›Adults 0.5 mL per kg per hour
›Children 1 mL per kg per hour
›Electrical injury 1 mL per kg per hour
›Avoid over resuscitation
›Rising airway pressures
›Worsening extremity edema
Wound care and topical therapy
›Local care steps
›Gentle cleansing with soap and water
›Remove loose devitalized tissue
›Blister management local protocol dependent
›Nonadherent dressing
›Moist wound environment
›Elevation of burned extremities
›Topical agents for minor burns
›Bacitracin ointment
›Face friendly option
›Daily dressing changes
›Mupirocin ointment
›MRSA risk option
›Daily dressing changes
›Silver sulfadiazine
›Avoid on face
›Avoid in pregnancy near term
›Avoid in infants
›Avoid in sulfonamide allergy
›Systemic antibiotics
›Not routine for uncomplicated burns
›Use for clear cellulitis or sepsis
Tetanus and infection prevention
›Tetanus prophylaxis
›Tdap if immunization unknown or not up to date
›Tetanus immune globulin for incomplete primary series with dirty wound
Toxic smoke exposure management
›Carbon monoxide management
›100 percent oxygen via nonrebreather
›Consider hyperbaric oxygen local protocol dependent
›Loss of consciousness
›Neurologic deficits
›Pregnancy with elevated carboxyhemoglobin
›Cyanide toxicity management
›Hydroxocobalamin IV 5 g adult
›Repeat 5 g if refractory shock
Circumferential burn escalation
›Perfusion rescue
›Frequent neurovascular checks
›Doppler if pulses difficult
›Escharotomy local protocol dependent for
›Loss of Doppler signal
›Increasing pain with passive stretch
›Compartment pressure concern
›Reassessment timing
›Repeat vitals every 15 to 30 minutes for moderate to severe burns
›Repeat airway exam every 15 to 30 minutes if inhalation concern
›Repeat neurovascular checks every 30 minutes for circumferential burns
›Repeat urine output hourly during resuscitation