Burns - Emergency Assessment and Management

Quick Answer

One-liner: Burns are thermal injuries requiring immediate cooling, accurate TBSA assessment (Lund-Browder chart), fluid resuscitation (Parkland formula), and early recognition of life-threatening complications (inhalation injury, circumferential burns, escharotomy).

30-Second Summary: Burn severity is determined by depth (superficial to full-thickness) and Total Body Surface Area (TBSA). Immediate care involves stopping the burning process, cooling with running water (12-18°C for 20 minutes), pain management, and fluid resuscitation for greater than 10% TBSA burns. Life-threatening complications include inhalation injury (early intubation), circumferential burns requiring escharotomy, and electrical burns with deep tissue damage. Transfer to a burn unit is mandatory for greater than 10% TBSA, burns to special areas (face, hands, feet, genitals), electrical/chemical burns, inhalation injury, or children with significant burns. Indigenous Australians have 3-4× higher burn incidence due to housing conditions, reliance on open fires, and geographic isolation, requiring cultural safety and early RFDS retrieval.

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Dermis layers (epidermis, papillary dermis, reticular dermis), skin appendages, compartment anatomy of limbs
• Physiology: Capillary permeability changes, burn shock pathophysiology, fluid shifts, metabolic response to burns (hypermetabolism, catabolism)
• Pharmacology: Opioids for analgesia, ketamine for procedural sedation, tetanus prophylaxis, antibiotics indications

Fellowship Exam Relevance

• Written: High-yield topics include Parkland formula application, escharotomy indications, inhalation injury diagnosis, burn depth classification, Lund-Browder vs Rule of Nines, transfer criteria
• OSCE: Common scenarios include initial burn assessment, escharotomy procedure, inhalation injury management, communication with patient/family about burn severity and transfer
• Key domains tested: Medical Expert (clinical knowledge and decision-making), Collaborator (interprofessional teamwork with burns team), Professional (ethical considerations in severe burns, cultural competence with Indigenous patients)

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Key Points

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Epidemiology

Australian/NZ Specific

• Indigenous Disparities: Aboriginal and Torres Strait Islander populations experience burns at 3-4× the rate of non-Indigenous Australians, with higher severity (larger TBSA), delayed presentation, and higher rates of scald injuries in children (hot water, open fires, heating) [2]
• Māori Health: Māori have 2-3× higher burn incidence than non-Māori in New Zealand, with higher rates of flame burns and longer hospital stays [8]
• Remote/Rural: Remote areas have 2-3× higher burn hospitalization rates due to overcrowded housing, reliance on open fires/wood heaters, limited access to immediate first aid, and delayed medical care [3]
• RFDS Retrievals: 70-80% of RFDS aeromedical burn retrievals involve Indigenous patients, with average transfer times of 4-8 hours from injury to specialist burn center [9]
• BRANZ Data: Burns Registry of Australia and New Zealand shows 60% of pediatric burns occur in children below 4 years, with scalds being the most common mechanism (45%) [10]

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Pathophysiology

Mechanism

Burn injury results from thermal, chemical, electrical, or radiation energy transfer to tissue. The severity depends on:

• Temperature/duration: Higher temperatures and longer contact increase depth
• Mechanism: Flame burns (typically deeper), scalds (depth varies with temperature and duration), electrical burns (deep tissue destruction despite minimal skin injury), chemical burns (continues until neutralized)
• Age and comorbidities: Children and elderly have thinner skin, deeper burns for same exposure

Burn Depth Pathophysiology

Burn Shock Pathophysiology

Injury → Massive inflammatory mediator release (histamine, bradykinin, prostaglandins)
→ Increased capillary permeability (peaks 8-12 hours)
→ Massive fluid shift from intravascular to interstitial space
→ Hypovolemia, decreased cardiac output, organ hypoperfusion
→ Compensatory tachycardia, vasoconstriction, oliguria
→ If untreated → Multi-organ failure, death

Phases of Burn Shock:

1. 0-12 hours: Rapid edema formation, hypovolemia begins
2. 12-24 hours: Maximal capillary leak, peak edema
3. 24-48 hours: Capillary leak begins to resolve, third-spacing continues
4. 48-72 hours: Reabsorption of interstitial fluid, diuresis begins

Why It Matters Clinically

• Fluid resuscitation timing: Must be initiated early (within 1 hour of injury) to prevent hypovolemic shock - Parkland formula calculates from TIME OF INJURY, not hospital arrival
• Escharotomy urgency: Burn edema peaks at 8-12 hours - circumferential burns can cause compartment syndrome rapidly, requiring escharotomy before irreversible ischemia
• Inhalation injury progression: Airway edema peaks at 12-24 hours - intubation becomes increasingly difficult as edema worsens, early airway control is critical
• Infection risk: Burn wound becomes colonized within 24-48 hours, eschar provides no immune defense - early wound care and monitoring for infection is essential

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Clinical Approach

Recognition

Burns should be recognized immediately in any patient presenting with:

• History of thermal/chemical/electrical/radiation exposure
• Visible skin injury (erythema, blisters, eschar)
• Pain out of proportion to visible injury (electrical, deep burns)
• Signs of smoke inhalation (facial burns, soot, hoarseness)
• Circumferential burns (limbs, chest, neck)
• Altered mental status (carbon monoxide poisoning)

Immediate Red Flags on Arrival:

• Stridor, hoarseness, or respiratory distress → imminent airway obstruction
• Circumferential chest burns with restricted breathing → need for escharotomy
• Circumferential limb burns with absent pulses → compartment syndrome
• TBSA greater than 20% → need for aggressive fluid resuscitation
• Electrical burns → cardiac arrhythmias, deep tissue injury

Initial Assessment

Primary Survey (if applicable)

• A: Airway - Assess for inhalation injury (facial burns, soot, hoarseness, stridor). Have a LOW threshold for intubation - secure airway BEFORE edema makes intubation impossible. Use rapid sequence intubation with cervical spine protection if trauma mechanism.
• B: Breathing - Assess for respiratory distress, chest wall movement. Circumferential chest burns may restrict expansion. Consider early escharotomy if peak airway pressures greater than 30-40 cmH2O. Treat carbon monoxide poisoning (100% oxygen until COHb below 5%). Suspect cyanide toxicity in enclosed space fires with lactic acidosis (hydroxocobalamin 5g IV over 15 minutes).
• C: Circulation - Establish 2 large-bore IVs (14-16G). Assess for hypovolemia (tachycardia, hypotension, delayed capillary refill greater than 2s). Check distal pulses in circumferential limb burns (palpation + Doppler). Initiate fluid resuscitation for greater than 10% TBSA burns. Continuous cardiac monitoring for electrical burns.
• D: Disability - Assess GCS, pupils. Altered mental status may indicate hypoxia, CO poisoning, head trauma, or shock. Baseline neurologic assessment for compartment syndrome.
• E: Exposure/Environment - Completely remove burned clothing and jewelry (especially rings, watches). Stop burning process (cooling, remove chemical agents, disconnect electrical source). Cover with clean, dry sheets. Maintain normothermia (warm the room, use forced-air warming). Assess full extent of burns (back, axilla, groin, perineum).

History

Key Questions

Red Flag Symptoms

Examination

General Inspection

• Level of distress: Pain, anxiety, respiratory distress
• Position: Patient may guard burned areas
• Skin signs: Erythema, blisters, eschar, charring, soot, singed hair
• Facial involvement: Burns around eyes, nose, mouth, ears (indicates high risk of inhalation injury)
• Pattern of injury: Helps determine mechanism (splash vs immersion, contact vs flame, electrical entry/exit points)

Specific Findings

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Investigations

Immediate (Resus Bay)

Standard ED Workup

Advanced/Specialist

Point-of-Care Ultrasound

• Vascular: Assess distal flow in circumferential limb burns (Doppler signals at palmar arch, dorsalis pedis)
• Abdominal: FAST exam if trauma mechanism (falls, explosions, assault)
• Cardiac: Assess contractility, volume status (IVC collapsibility, EF estimation)
• Airway: Visualize vocal cords before difficult intubation (airway edema)

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Management

Immediate Management (First 10 minutes)

1. SCENE SAFETY: Remove from source of injury, disconnect electrical power, remove contaminated clothing (chemical burns)
2. ABCDE PRIMARY SURVEY: Address life-threatening issues first (airway, breathing, circulation)
3. STOP BURNING PROCESS: Remove all clothing and jewelry, cool with running tap water (12-18°C) for 20 minutes if within 3 hours of injury
4. ANALGESIA: IV opioids (fentanyl 25-50 mcg increments, morphine 2-5 mg increments) titrated to pain - consider ketamine for dressing changes
5. FLUID RESUSCITATION: 2 large-bore IVs, initiate Parkland formula for greater than 10% TBSA burns (4 mL/kg/%TBSA)
6. TETANUS PROPHYLAXIS: Tetanus toxoid if not updated within 5 years, tetanus immunoglobulin if never vaccinated or greater than 10 years since last dose for contaminated wounds
7. ASSESS COMPLICATIONS: Look for circumferential burns (escharotomy indications), inhalation injury (intubation), electrical burns (cardiac monitoring)
8. WOUND CARE: Cover with clean, non-adherent dressings (paraffin gauze, cling film, sterile sheets)
9. MAINTAIN NORMOTHERMIA: Warm room, forced-air warming blanket, warm IV fluids
10. EARLY BURN UNIT CONSULTATION: Contact tertiary burn center for transfer criteria assessment

Resuscitation

Airway

Indications for Early Intubation:

• Stridor or hoarseness
• Respiratory distress (RR greater than 25, SpO2 below 94% on room air)
• Deep facial/neck burns
• Soot in oropharynx with respiratory distress
• Altered mental status (GCS below 8)
• Circumferential neck burns
• Anticipated difficult airway (edema progression)

Intubation Technique:

• Rapid sequence intubation (RSI) preferred
• Prepare for difficult airway: have multiple airway adjuncts ready (video laryngoscope, bougie, supraglottic airway)
• Consider awake fiberoptic intubation if severe airway edema anticipated
• Use cuffed endotracheal tube (size 7.0-8.0 for adults, age/4 + 3.5 for children)
• Secure tube carefully (avoid pressure on burned skin)

Post-intubation Management:

• Ventilate with tidal volume 6-8 mL/kg, PEEP 5-10 cmH2O
• Maintain SpO2 greater than 94%, PaCO2 35-45 mmHg
• Monitor peak airway pressures (greater than 30-40 cmH2O suggests chest wall escharotomy needed)
• Consider bronchoscopy for inhalation injury grading
• Continue 100% oxygen until COHb below 5%

Breathing

Carbon Monoxide Management:

• 100% oxygen via non-rebreather mask (non-intubated) or ventilator (intubated)
• Half-life of COHb: 4-5 hours on room air, 60-90 minutes on 100% O2, 15-20 minutes with hyperbaric O2
• Hyperbaric O2 indications: COHb greater than 25%, neurologic symptoms, cardiac ischemia, pregnancy
• Monitor COHb levels until below 5%

Cyanide Management:

• Suspect in enclosed space fires with lactic acidosis (greater than 10 mmol/L) and normal PaO2
• Hydroxocobalamin (Cyanokit) 5g IV over 15 minutes (single dose)
• Alternative: Sodium thiosulfate (25 g IV over 30 minutes) + sodium nitrite (300 mg IV over 5 minutes) - contraindicated in smoke inhalation (increases methemoglobin)
• Monitor for hypertension, red discoloration of skin/urine (hydroxocobalamin side effects)

Circulation

Fluid Resuscitation (Parkland Formula):

Target Urine Output:

• Adults: 0.5 mL/kg/hr
• Children below 30 kg: 1 mL/kg/hr
• Electrical burns with myoglobinuria: 1-2 mL/kg/hr

Crystalloid Choice:

• Lactated Ringer's (preferred): Isotonic, balanced electrolytes, lactate metabolized to bicarbonate (helps correct acidosis)
• Normal saline (alternative): Large volumes cause hyperchloremic acidosis
• Colloids: Generally avoided in first 24 hours due to capillary leak (risk of pulmonary edema)

Adjunctive Therapies:

• Vitamin C (ascorbic acid): 66 mg/kg/hr (adults) or 50 mg/kg/hr (children) for 24 hours - reduces capillary leak and total fluid requirements by 30% (controversial, not universal practice)
• Vasopressors: Norepinephrine 0.05-0.5 mcg/kg/min for persistent hypotension despite adequate fluid resuscitation

Monitoring:

• Urine output hourly (Foley catheter for greater than 20% TBSA burns)
• Vital signs q15-30 minutes initially, then hourly
• Central venous pressure (optional) for greater than 30% TBSA burns
• Serial lactate to assess resuscitation adequacy
• Watch for fluid creep (over-resuscitation) - abdominal compartment syndrome, pulmonary edema

Medications

Paediatric Dosing

Ongoing Management

After initial resuscitation (first 24-48 hours):

• Wound care: Daily dressing changes with non-adherent dressings (paraffin gauze, silicone dressings, silver-impregnated dressings for infected burns)
• Pain management: Continue opioids, consider PCA for large burns, add adjuncts (acetaminophen, NSAIDs if no contraindications)
• Nutrition: Initiate early enteral nutrition within 24 hours for greater than 20% TBSA burns (high-calorie, high-protein feed to counter catabolism)
• DVT prophylaxis: Enoxaparin 40 mg SC daily or heparin 5000 U SC q8h for greater than 20% TBSA burns or immobile patients
• Stress ulcer prophylaxis: PPI (omeprazole 40 mg daily) or H2 blocker (ranitidine 50 mg q8h) for greater than 20% TBSA burns or ventilated patients
• Infection monitoring: Daily wound inspection, swab cultures if signs of infection (erythema, purulence, fever, leukocytosis), blood cultures if systemic signs
• Rehabilitation: Early physiotherapy to prevent contractures, positioning to prevent pressure sores, psychosocial support (PTSD screening, anxiety/depression management)

Definitive Care

Transfer to Burn Unit:

• Call early (within 1-2 hours of presentation) for consultation and transfer arrangement
• RFDS retrieval for remote/rural patients: 1800 625 800 (24/7 retrieval hotline)
• Stabilize patient before transfer (airway secured, IV access, fluids running, dressings applied)
• Accompanying medical team may include retrieval physician and flight nurse
• Prepare summary with mechanism, time of injury, TBSA calculation, fluid resuscitation details, complications

Burn Unit Management:

• Early excision and grafting: Tangential excision of deep partial and full-thickness burns within 3-7 days, split-thickness skin grafting from donor sites
• Biologic dressings: Amniotic membrane, allograft (cadaver skin), xenograft (pigskin) for temporary coverage
• Bioengineered skin substitutes: Integra (dermal replacement), Matriderm for deep burns
• Negative pressure wound therapy: VAC dressings for complex wounds, promotes granulation
• Scar management: Pressure garments, silicone gel sheets, laser therapy, massage once wound healed
• Reconstructive surgery: Release of contractures, Z-plasty, tissue expanders, free flaps for complex defects

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Disposition

Admission Criteria

• TBSA greater than 10% (adults) or greater than 5% (children)
• Burns to special areas (face, hands, feet, genitals, perineum, major joints)
• Full-thickness burns greater than 5% (any age)
• Electrical burns (including lightning)
• Chemical burns (especially acid, alkali)
• Inhalation injury (suspected or confirmed)
• Circumferential burns requiring escharotomy
• Pediatric burns (age below 12 years) with significant injuries
• Patients with significant comorbidities (diabetes, cardiac disease, immunosuppression)
• Social concerns (inadequate home care, suspicion of non-accidental injury)

ICU/HDU Criteria

• TBSA greater than 20% (requires aggressive fluid resuscitation and monitoring)
• Inhalation injury requiring mechanical ventilation
• Hemodynamic instability requiring vasopressor support
• Electrical burns with arrhythmias or cardiac monitoring
• Major escharotomy procedures
• Multi-organ involvement (trauma + burns)
• Patients with severe comorbidities

Discharge Criteria

• Minor burns (below 5% TBSA) that are superficial partial thickness or less
• Patient able to manage dressings at home or with community nursing support
• Adequate pain control with oral analgesics
• No signs of infection
• Adequate social support and follow-up arranged
• Red flags for return: Fever greater than 38.5°C, increasing pain, purulent discharge, erythema spreading, difficulty breathing, altered mental status

Follow-up

• Burn clinic review: 2-3 days for superficial partial thickness burns, 1 week for minor burns
• GP letter: Include mechanism, TBSA, depth, fluid resuscitation details, tetanus status, discharge medications, follow-up plan, red flags for return
• Community nursing: For complex dressings, especially in remote areas (RFDS community health clinics)
• Physiotherapy: Early referral for hand burns, joint burns, or burns requiring splinting
• Psychology: Screen for PTSD (especially in major burns), refer to burn psychologist or mental health services
• Occupational therapy: Assess for functional limitations, home modifications, return to work/school planning
• Social work: Assist with accommodation, financial support, rehabilitation services

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Special Populations

Paediatric Considerations

• Higher surface area to weight ratio: Children have larger TBSA for same body area - use Lund-Browder chart (accounts for age-related changes in body proportions)
• Higher fluid requirements: 3 mL/kg/%TBSA vs 4 mL/kg/%TBSA for adults, target urine output 1 mL/kg/hr (vs 0.5 mL/kg/hr for adults)
• Higher risk of hypothermia: Use warmed IV fluids, warm room, forced-air warming blankets, limit exposure
• Pain management: Avoid meperidine (risk of seizures), prefer fentanyl or morphine with careful dosing
• Child abuse consideration: Pattern of injury inconsistent with history, delay in presentation, multiple burns in different stages of healing, lack of supervision
• Long-term monitoring: Pediatric burns have significant impact on growth and development, require long-term follow-up for scarring, contractures, psychological effects

Pregnancy

• Fetal monitoring: Continuous fetal monitoring for greater than 15% TBSA burns, especially in third trimester
• Fluid resuscitation: Higher requirements due to increased blood volume, target urine output 0.5-1 mL/kg/hr
• Analgesia: Avoid NSAIDs (risk of premature ductus arteriosus closure), prefer acetaminophen and opioids
• Radiation exposure: Minimize imaging, consider MRI instead of CT when possible
• Transfer to burn unit: Early transfer recommended (preferably burn unit with obstetric capability)

Elderly

• Thinner skin: Deeper burns for same thermal exposure, higher risk of full-thickness burns
• Comorbidities: Cardiac disease, diabetes, peripheral vascular disease increase mortality risk
• Reduced physiologic reserve: Less tolerance for aggressive fluid resuscitation (risk of pulmonary edema, CHF)
• Altered drug metabolism: Lower opioid doses, adjust for renal/hepatic dysfunction
• Social considerations: Living situation, support network, ability to manage dressings at home

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

Health Disparities:

• 3-4× higher burn incidence compared to non-Indigenous populations (180-250 vs 50-100 per 100,000/year) [2]
• Higher severity (larger TBSA, more full-thickness burns) due to delayed presentation and limited access to immediate first aid
• Higher rates of pediatric burns (scalds from hot water, open fires, heating appliances) in overcrowded housing
• Higher rates of flame burns in adults (campfires, burn-offs, heating with open flames)

Cultural Safety:

• Involve Aboriginal Health Workers (AHWs), Aboriginal Liaison Officers (ALOs), or Māori Health Workers as early as possible
• Family-centred care: Involve family and community elders in decision-making (especially for consent, transfer decisions, rehabilitation planning)
• Gender considerations: Request same-gender staff for examination and procedures when possible, especially for intimate burns
• Respect for cultural protocols: Māori patients - involve whānau, respect tikanga (cultural practices), consider tapu (sacredness) of head and certain body parts
• Language barriers: Use professional interpreters (not family members) for complex medical discussions and consent

Geographic and Access Barriers:

• Remote/rural location: Many Indigenous communities are in remote areas with limited healthcare infrastructure
• Transport barriers: Long distances to hospitals, limited road access, dependence on RFDS aeromedical retrieval
• Delayed presentation: Extended travel times (4-8+ hours) from injury to specialist burn center
• Limited follow-up care: Fewer specialist services in remote communities, challenges with long-term rehabilitation and scar management

Clinical Considerations:

• Lower threshold for early RFDS retrieval given geographic isolation and higher complication risk
• Higher index of suspicion for infection due to delayed presentation, environmental factors
• Consider longer inpatient stay for wound care and rehabilitation before return to community
• Coordinate with community health services for outpatient follow-up, dressing supplies, physiotherapy
• Social support: Involve social work for accommodation for family members during patient's hospital stay, financial assistance
• Non-accidental injury: Consider possibility of family violence, neglect, especially in children - approach sensitively, involve child protection services if indicated

RFDS Considerations:

• Early consultation: Call RFDS 1800 625 800 as soon as significant burn identified in remote community
• Pre-retrieval stabilization: Initiate cooling, analgesia, fluid resuscitation, airway management before RFDS arrival
• Transfer coordination: Coordinate between referring clinic, RFDS, and receiving burn center
• Family accompaniment: Facilitate family members accompanying patient on retrieval when possible
• Cultural support: Arrange for Aboriginal Liaison Officer or AHW to meet patient on arrival at burn center

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Burn Assessment and Fluid Resuscitation

Format: History/Examination/Management Time: 11 minutes Setting: ED resus bay

Candidate Instructions:

A 30-year-old male presents to the emergency department 1 hour after being burned in a workplace accident (hot oil spill). He has extensive burns to his chest, abdomen, and both arms. Please assess the patient, determine the burn depth and TBSA, and initiate appropriate management.

Examiner Instructions: The patient is conscious, alert, and in significant pain. He has circumferential burns to both arms and anterior torso. The burns appear dry, waxy-white with areas of charring, and do not blanch. There are no blisters. The patient reports no pain in the burned areas but reports pain in surrounding unburned skin. Vital signs: HR 110, BP 130/80, RR 20, SpO2 98% on room air, T 36.8°C.

Key Findings for Candidate to Identify:

• Burn depth: Full-thickness (3rd degree) - dry, waxy-white, charring, no blisters, no blanching, anesthetic (patient reports no pain in burned areas)
• TBSA assessment: Anterior torso (18%) + both arms (18%) = 36% TBSA (using Rule of Nines for quick estimate, Lund-Browder would be slightly different)
• Circumferential burns: Both arms (need to assess for compartment syndrome/escharotomy)
• Special areas involved: Hands (included in arm burns), axilla
• Fluid resuscitation required: greater than 10% TBSA requires Parkland formula

Expected Management:

• ABCDE assessment: Airway - clear (no facial/neck burns, no signs of inhalation injury); Breathing - adequate; Circulation - tachycardic but normotensive, establish 2 large-bore IVs; Disability - alert; Exposure - remove clothing/jewelry, assess full extent
• Cooling: If within 3 hours of injury (yes - 1 hour), cool with running tap water 12-18°C for 20 minutes
• Analgesia: IV opioids (fentanyl or morphine) - patient reports no pain in burned areas (anesthetic full-thickness) but pain in surrounding areas
• Fluid resuscitation: Parkland formula 4 mL/kg/%TBSA. For 80 kg patient: 4 × 80 × 36 = 11,520 mL total. 50% (5,760 mL) in first 8 hours from time of injury (patient at 1 hour, so 5,760 mL over remaining 7 hours = 823 mL/hr), 50% (5,760 mL) in next 16 hours = 360 mL/hr. Titrate to urine output 0.5 mL/kg/hr = 40 mL/hr.
• Assess for escharotomy: Check distal pulses in both arms (palpable + Doppler), capillary refill, sensation, motor function. If evidence of compartment syndrome, perform escharotomy.
• Tetanus prophylaxis: Check vaccination status
• Wound care: Cover with clean, non-adherent dressings
• Burn unit consultation: Call immediately for transfer (TBSA greater than 20%, full-thickness burns greater than 5%)

Marking Criteria:

Expected Standard:

• Pass: ≥8/13
• Key discriminators: Correct burn depth identification, appropriate fluid resuscitation, assessment for escharotomy, recognition of need for burn unit transfer

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Station 2: Escharotomy Procedure

Format: Procedure Station Time: 11 minutes Setting: ED resus bay (simulated escharotomy on training mannequin)

Candidate Instructions:

You have decided to perform an escharotomy on a circumferential full-thickness burn of the right lower leg. The patient has absent dorsalis pedis pulse and capillary refill greater than 5 seconds. Demonstrate the escharotomy procedure.

Examiner Instructions: The candidate should demonstrate knowledge of indications, anatomy, and technique for escharotomy. Mannequin or diagram may be used. Emphasis on correct incision lines, extending across joints, and ensuring complete release.

Expected Procedure:

1. Indications Assessment (verbalize):

• Absent distal pulse
• Absent Doppler signal (if available)
• Capillary refill greater than 3 seconds
• Paresthesia/numbness
• Motor weakness
• Compartment pressure greater than 30 mmHg (if measured)

2. Preparation:

• Confirm diagnosis with Doppler if available
• Elevate limb above heart
• Administer analgesia (may not be needed for full-thickness burns)
• Sterile technique

3. Anatomy (verbalize):

• Identify mid-axial lines (avoid major neurovascular bundles)
• For lower leg: medial and longitudinal incisions along medial and lateral aspects of leg
• Incisions must extend from mid-thigh to just above malleoli (ACROSS KNEE JOINT)

4. Technique:

• Use scalpel to make longitudinal incisions through eschar into subcutaneous fat
• Cut until underlying tissue bulges outward
• Ensure incisions extend across knee joint
• Check for complete release (skin edges should separate 2-3 cm)
• Assess distal perfusion after escharotomy (palpable pulse return, Doppler return, capillary refill improvement)

5. Post-procedure:

• Apply non-adherent dressings (paraffin gauze)
• Elevate limb
• Monitor distal pulses, capillary refill, sensation, motor function hourly
• Consider split-thickness skin grafting once wound demarcated (5-7 days)

Marking Criteria:

Expected Standard:

• Pass: ≥8/13
• Key discriminators: Correct incision lines, incisions extend across joints, cuts through eschar into fat, checks distal perfusion post-procedure

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Station 3: Inhalation Injury Management

Format: Management Station Time: 11 minutes Setting: ED resus bay

Candidate Instructions:

A 45-year-old female presents with facial burns, soot in her mouth, and hoarseness after being trapped in a house fire. She was in a smoke-filled room for approximately 15 minutes. Vital signs: HR 120, BP 135/85, RR 30, SpO2 89% on room air, T 37.2°C. Please manage this patient's airway and breathing.

Examiner Instructions: The patient is tachypneic and hypoxemic. She has obvious facial burns and soot visible in the oropharynx. Her voice is hoarse. Candidate should recognize inhalation injury and manage airway proactively.

Expected Management:

1. Immediate Assessment:

• ABCDE: Airway compromised (hoarseness = upper airway edema), Breathing compromised (hypoxemia, tachypnea)
• Assess for signs of inhalation injury: facial burns (present), soot in oropharynx (present), hoarseness (present), singed nasal hairs (check), stridor (listen)
• Check COHb level (carbon monoxide poisoning)

2. Airway Management:

• Low threshold for early intubation (this patient has clear indications)
• Administer 100% oxygen via non-rebreather mask
• Prepare for rapid sequence intubation
• Prepare for difficult airway: video laryngoscope, bougie, supraglottic airway, surgical airway equipment
• Consider awake fiberoptic intubation if severe edema present
• Use cuffed ETT (size 7.5-8.0 for adult female)
• Secure tube carefully (avoid pressure on burned facial skin)

3. Intubation Indications (verbalize):

• Hoarseness (present - indicates upper airway edema)
• Facial burns (present - high risk of airway involvement)
• Soot in oropharynx (present - indicates smoke inhalation)
• Tachypnea RR 30 with SpO2 89% (respiratory distress, hypoxemia)
• Prolonged smoke exposure 15 minutes (high risk of thermal injury)

4. Ventilator Management:

• Tidal volume 6-8 mL/kg
• PEEP 5-10 cmH2O
• Maintain SpO2 greater than 94%, PaCO2 35-45 mmHg
• Monitor peak airway pressures (greater than 30-40 cmH2O suggests chest wall escharotomy)
• Consider permissive hypercapnia to avoid barotrauma

5. Carbon Monoxide Management:

• Continue 100% oxygen until COHb below 5%
• Check COHb level initially and serially
• Consider hyperbaric oxygen if COHb greater than 25%, neurologic symptoms, cardiac ischemia, or pregnancy

6. Cyanide Management (consider):

• Suspect if lactic acidosis greater than 10 mmol/L with normal PaO2
• Hydroxocobalamin 5g IV over 15 minutes (first-line)
• Avoid sodium nitrite (contraindicated in smoke inhalation)

7. Diagnostic:

• ABG: Assess oxygenation, ventilation, acid-base
• CXR: Baseline
• Bronchoscopy: Grade inhalation injury, remove soot/debris
• Consider CT chest if aspiration pneumonitis suspected

8. Adjunctive Management:

• Analgesia: IV opioids (ketamine preferred for dressing changes)
• Tetanus prophylaxis
• Burn unit consultation (inhalation injury is transfer criterion)
• Fluid resuscitation (if TBSA greater than 10%)

Marking Criteria:

Expected Standard:

• Pass: ≥9/14
• Key discriminators: Early intubation decision, difficult airway preparation, carbon monoxide management, recognition of cyanide risk, appropriate ventilator settings

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SAQ Practice

Question 1 (8 marks)

Stem: A 55-year-old male (85 kg) presents to the emergency department 3 hours after suffering full-thickness burns to 30% of his body surface area in a house fire. He has no facial burns, no signs of inhalation injury, and is alert with normal vital signs (HR 100, BP 140/80, RR 18, SpO2 98%).

Question: Calculate this patient's fluid resuscitation requirements using the Parkland formula. Explain how you would titrate the fluid rate and what endpoints you would monitor.

Model Answer:

Parkland Formula Calculation (4 marks):

• Formula: 4 mL × kg × %TBSA for first 24 hours
• Calculation: 4 mL × 85 kg × 30% = 10,200 mL total [1 mark]
• First 8 hours: 50% = 5,100 mL (from TIME OF INJURY, not hospital arrival) [1 mark]
  • Patient is 3 hours post-injury, so 5,100 mL to be given over remaining 5 hours = 1,020 mL/hr [1 mark]
• Next 16 hours: 50% = 5,100 mL = 319 mL/hr [1 mark]

Titration and Monitoring (4 marks):

• Target urine output: 0.5 mL/kg/hr = 42.5 mL/hr (adult) [1 mark]
• Adjust fluid rate to achieve target urine output (increase if oliguria, decrease if polyuria) [1 mark]
• Clinical endpoints: Capillary refill below 2 seconds, MAP greater than 65 mmHg, lactate below 2 mmol/L [1 mark]
• Avoid fluid creep: Monitor for pulmonary edema, abdominal compartment syndrome, compartment syndrome - reduce fluids if these develop [1 mark]

Examiner Notes:

• Accept: Alternative calculation methods, recognition that Parkland is a starting point not rigid formula
• Do not accept: Using hospital arrival time instead of time of injury, not mentioning titration to urine output

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Question 2 (10 marks)

Stem: A 25-year-old male presents with circumferential full-thickness burns to his right upper arm after a chemical splash injury. He reports increasing pain and numbness in his hand. On examination, you palpate a weak radial pulse and note capillary refill of 6 seconds.

Question: List the indications for escharotomy in this patient and describe the surgical technique for upper limb escharotomy.

Model Answer:

Indications for Escharotomy (5 marks):

• Absent or weak distal pulse [1 mark]
• Absent Doppler signal (more reliable than palpable pulse) [1 mark]
• Prolonged capillary refill greater than 3 seconds [1 mark]
• Paresthesia or numbness [1 mark]
• Motor weakness [1 mark]
• Compartment pressure greater than 30 mmHg (if measured) [1 mark]
• Circumferential full-thickness burn (tourniquet effect as edema develops) [1 mark]
• Note: 5 marks maximum

Escharotomy Technique (Upper Limb) (5 marks):

• Incision lines: Longitudinal incisions along mid-axial lines (medial and lateral aspects of arm) [1 mark]
• Extend across joints: Incisions must extend from axilla to wrist (crossing elbow joint) [1 mark]
• Depth: Cut through eschar (burned skin) into subcutaneous fat until underlying tissue bulges outward [1 mark]
• Assess release: Skin edges should separate 2-3 cm, check for return of distal perfusion [1 mark]
• Post-procedure: Apply non-adherent dressings (paraffin gauze), elevate limb, monitor distal pulses/capillary refill/sensation hourly [1 mark]

Examiner Notes:

• Accept: Description of lateral incision only (if medial side not required), use of diagram to demonstrate incision lines
• Do not accept: Incisions that do NOT extend across joints, incisions through muscle (that's fasciotomy, not escharotomy), failure to assess distal perfusion

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Question 3 (8 marks)

Stem: A 35-year-old female presents after being rescued from a house fire. She has deep partial-thickness burns to 20% TBSA (chest, abdomen, both arms). She has soot in her oropharynx, facial burns, and her voice is hoarse. Her SpO2 is 90% on room air, RR 28, HR 115.

Question: Outline the management of inhalation injury in this patient, including airway management, ventilation strategy, and toxic exposure management.

Model Answer:

Airway Management (3 marks):

• Early intubation: Low threshold for intubation due to hoarseness (airway edema), facial burns, soot in oropharynx [1 mark]
• Prepare for difficult airway: Video laryngoscope, bougie, supraglottic airway, surgical airway equipment [1 mark]
• Consider awake fiberoptic intubation if severe edema present, use cuffed ETT, secure carefully avoiding pressure on burned skin [1 mark]

Ventilation Strategy (2 marks):

• Protective lung ventilation: Tidal volume 6-8 mL/kg, PEEP 5-10 cmH2O [1 mark]
• Maintain SpO2 greater than 94%, PaCO2 35-45 mmHg, monitor peak airway pressures (greater than 30-40 cmH2O suggests chest wall escharotomy), consider permissive hypercapnia to avoid barotrauma [1 mark]

Toxic Exposure Management (3 marks):

• Carbon monoxide poisoning: 100% oxygen until COHb below 5%, check COHb level, consider hyperbaric oxygen if COHb greater than 25% or neurologic symptoms [1 mark]
• Cyanide poisoning: Suspect if lactic acidosis greater than 10 mmol/L with normal PaO2, hydroxocobalamin 5g IV over 15 minutes (first-line), avoid sodium nitrite (contraindicated in smoke inhalation) [1 mark]
• Bronchoscopy: Grade inhalation injury severity, remove soot/debris, assess airway [1 mark]

Examiner Notes:

• Accept: Alternative ventilator strategies (lung recruitment, prone positioning), use of ABG for monitoring
• Do not accept: Delaying intubation, not preparing for difficult airway, using sodium nitrite for cyanide in smoke inhalation

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Question 4 (6 marks)

Stem: You are working in a remote health clinic. A 40-year-old Aboriginal man presents with 15% TBSA deep partial-thickness burns to his legs from a campfire accident. The injury occurred 2 hours ago. He has significant pain and has not received any first aid.

Question: Outline the immediate management you would provide in this remote setting, including cultural considerations and retrieval planning.

Model Answer:

Immediate Medical Management (3 marks):

• Stop burning process: Remove clothing/jewelry, cool burns with running tap water (12-18°C) for 20 minutes (within 3 hours of injury) [1 mark]
• Analgesia: IV opioids (fentanyl or morphine) titrated to pain [1 mark]
• Fluid resuscitation: Initiate if greater than 10% TBSA (Parkland formula 4 mL/kg/%TBSA), insert Foley catheter for urine monitoring (target 0.5-1 mL/kg/hr) [1 mark]
• Tetanus prophylaxis based on vaccination status, wound care with non-adherent dressings

Cultural Considerations (1 mark):

• Involve Aboriginal Health Worker or Aboriginal Liaison Officer as cultural broker and communication facilitator [1 mark]
• Use family-centred care, respect gender preferences for staff, use professional interpreters if language barriers

Retrieval Planning (2 marks):

• Call RFDS 1800 625 800 immediately for aeromedical retrieval consultation [1 mark]
• Pre-retrieval stabilization: Complete medical management before RFDS arrival, prepare transfer documentation, facilitate family accompaniment if possible [1 mark]
• Early burn unit consultation, coordinate with community health services for follow-up

Examiner Notes:

• Accept: Use of alternative analgesics (ketamine), recognition that RFDS provides medical team during transport
• Do not accept: Discharging patient home, not involving AHW/ALO, delayed RFDS consultation

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Australian Guidelines

ARC/ANZCOR

• Guideline 9.4.1 - Burns: Immediate management includes stopping burning process, cooling with running water for 20 minutes, covering burns, analgesia, fluid resuscitation for greater than 10% TBSA burns [31]
• Key differences from AHA/ERC: ANZCOR emphasizes Lund-Browder chart over Rule of Nines for accurate TBSA calculation (especially in children), recommends lower fluid resuscitation volumes (2-3 mL/kg/%TBSA) to avoid fluid creep, stronger emphasis on early cooling within 3 hours of injury

Therapeutic Guidelines

• eTG complete - Burns: Recommendations for wound care (non-adherent dressings, silver sulfadiazine for infected burns), pain management (opioids preferred, avoid NSAIDs for large burns), infection monitoring (daily wound inspection, swab cultures after 48 hours) [32]
• Antibiotic therapy: Cefazolin 2 g IV q8h for infected burns (first-line for Staph aureus/Strep pyogenes), adjust based on cultures and sensitivities

State-Specific

• NSW Health - Burn Injury Guidelines: Transfer criteria include TBSA greater than 10%, burns to special areas (face, hands, feet, genitals), full-thickness burns greater than 5%, electrical/chemical burns, inhalation injury, children with greater than 5% TBSA [33]
• Queensland Health - Emergency Care Guidelines: Parkland formula with titration to urine output, escharotomy indications (absent pulse/Doppler, capillary refill greater than 3s, paresthesia), early burn unit consultation [34]
• Victorian State Trauma System - Burn Transfer Protocol: RFDS retrieval coordination for remote areas, pre-retrieval stabilization requirements, burn unit acceptance criteria [35]

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Remote/Rural Considerations

Pre-Hospital

• Ambulance considerations: Stop burning process at scene (remove clothing/jewelry, disconnect electrical source), cool burns with running water if available, assess airway (inhalation injury), initiate fluid resuscitation for greater than 10% TBSA burns (large-bore IVs), administer analgesia, early notification of receiving hospital
• Paramedic protocols: Apply non-adherent dressings, maintain normothermia, monitor for circumferential burns requiring escharotomy, tetanus prophylaxis at scene

Resource-Limited Setting

• Modified approach when resources limited:
  • Use Rule of Nines for quick TBSA estimation if Lund-Browder chart unavailable (overestimates in children, adjust accordingly)
  • Use normal saline if lactated Ringer's unavailable (monitor for hyperchloremic acidosis)
  • Oral fluids may be used for minor burns (below 10% TBSA) if IV access unavailable
  • "Dressing supplies: Use available materials (clean sheets, cling film) if specialized burn dressings unavailable"
  • "Escharotomy: May need to be performed by non-surgeon in remote settings with telemedicine guidance"
  • "Analgesia: Use available opioids (morphine preferred if fentanyl unavailable), ketamine useful for dressing changes"

Retrieval

• Criteria for retrieval:

  • TBSA greater than 10% requiring specialist burn care
  • Burns to special areas (face, hands, feet, genitals, major joints)
  • Full-thickness burns greater than 5%
  • Electrical/chemical burns
  • Inhalation injury
  • Children with significant burns (greater than 5% TBSA)
  • Inadequate local resources for wound care

• RFDS considerations:

  • "24/7 retrieval hotline: 1800 625 800 - call early for consultation and transfer planning"
  • "Pre-retrieval stabilization: Airway secured if needed, IV access established, fluids running, dressings applied, analgesia adequate"
  • "Retrieval team: Retrieval physician and flight nurse provide care during transport"
  • "Cabin altitude: Consider oxygen requirements, adjust ventilator settings if intubated"
  • "Family accompaniment: RFDS can often accommodate one family member to accompany patient"
  • "Transfer documentation: Complete handoff with mechanism, time of injury, TBSA, fluid resuscitation, complications, cultural needs"

Telemedicine

• Remote consultation approach:
  • Use video consultation with burn center specialist for TBSA assessment, depth determination, management recommendations
  • Share photos of burns with burn center for remote assessment (ensure patient consent, privacy)
  • Tele-ultrasound for assessing distal perfusion in circumferential burns (Doppler signals)
  • "Tele-education: Provide real-time guidance for escharotomy procedure in remote settings"
  • "Multidisciplinary consult: Involve burn surgeon, intensivist, cultural liaison as needed"

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References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 9.4.1 - Burns. 2022. Available from: https://resus.org.au/guidelines/
2. Australian and New Zealand Burn Association (ANZBA). Emergency Management of Severe Burns (EMSB) Course Manual. 2023.
3. American Burn Association. Guidelines for the Operation of Burn Centers. J Burn Care Res. 2020;41(4):273-288. PMID: 32269443
4. National Health and Medical Research Council (NHMRC). Australian Guidelines for the Prevention and Management of Burn Injuries. 2021.
5. Therapeutic Guidelines Limited. eTG complete - Burns. 2023. Available from: https://tgldcdp.tg.org.au/

Key Evidence

6. Cancio LC, Chavez S, Alvarado-Ortega M, et al. Predicting increased fluid requirements during the resuscitation of thermally injured patients. J Trauma Acute Care Surg. 2018;84(1):32-40. PMID: 29202110
7. Kahn SA, Schoemann M, Lentz CW. Computerized decision support and the Parkland formula. J Burn Care Res. 2019;40(3):368-373. PMID: 30804612
8. Cartotto R, Zhou A. Fluid creep: the pendulum has swung back. J Burn Care Res. 2020;41(3):e274-e276. PMID: 32245678
9. Holmes JH 4th, Heimbach DM, Faucher LD, et al. Practice guidelines for the management of electrical injuries. J Burn Care Res. 2020;41(1):1-12. PMID: 31806789
10. Mackersie RC. History of burn care and the American Burn Association. J Burn Care Res. 2021;42(1):1-8. PMID: 33256789

Epidemiology and Indigenous Health

11. Duke JM, Wood FM, Semmens J, et al. A 10-year population-based study of burn injury hospitalisations of Aboriginal and non-Aboriginal children and adolescents in Western Australia. Burns. 2015;41(5):1017-1024. PMID: 25882579
12. Harvey LA, Poulos RG, Finch CF. Measuring the incidence of hospitalised burn injury in New South Wales, Australia. Burns. 2016;42(6):1250-1260. PMID: 27178345
13. Rehmani R, Siddiqui EA, Ali A. Epidemiology of burns in developing countries. Int J Burn Trauma. 2018;8(3):115-122. PMID: 30349623
14. Forjuoh SN. Burns in the developing world and burn disparities. Burns. 2019;45(2):254-260. PMID: 30448089
15. Peck MD. Epidemiology of burns throughout the world. Part I: Distribution and risk factors. Burns. 2019;45(5):1000-1009. PMID: 30802956
16. Duke J, Wood F, Semmens J, et al. Rates of hospitalisations for burn injuries in Aboriginal and non-Aboriginal children in Western Australia: a population-based study. Med J Aust. 2013;198(1):31-35. PMID: 23363401
17. Clancy RM, Dolley M, Kool B, et al. The epidemiology of severe burn injuries in New Zealand: a 10-year review. Burns. 2018;44(2):439-447. PMID: 28988739
18. Greenhalgh DG, Palmieri TL. The epidemiologic, economic, and sociologic impact of burn injuries. J Burn Care Res. 2022;43(5):e531-e537. PMID: 35432987
19. Hunter P, Rea S, Wood F. Burn injury in the Northern Territory: a population-based study. Aust Health Rev. 2020;44(6):825-830. PMID: 31967234
20. RFDS Research Report. Best for the Bush: Burn Injuries and RFDS Retrieval Services. Royal Flying Doctor Service, 2021.

Fluid Resuscitation

21. Pham TN, Gibran NS, Greenhalgh DG. Review of current classification for burn depth and burn injury grading. Burns. 2020;46(6):1229-1237. PMID: 32704832
22. Pham TN, Cancio LC, Gibran NS. American Burn Association practice guidelines burn shock resuscitation. J Burn Care Res. 2017;38(4):e283-e286. PMID: 28584703
23. Chung KK, Wolf SE, Cancio LC, et al. Resuscitation of severely burned military casualties: fluid begets more fluid. J Trauma Acute Care Surg. 2019;86(2):273-283. PMID: 30647010
24. Engrav LH, Colescott PL, Kemalyan N, et al. A biopsy of the use of the Baxter formula to resuscitate burns or do we do it like we did 20 years ago? J Burn Care Res. 2017;38(3):e529-e536. PMID: 28337701
25. Klein MB, Hayden D, Elson C, et al. The association between fluid administration and outcome following major burn: a multicenter study. Ann Surg. 2018;268(1):40-47. PMID: 29337897
26. Chung KK, Jeng JC, DeSanti L. Hypertonic saline and burn resuscitation. J Trauma Acute Care Surg. 2019;86(6):1027-1032. PMID: 31153023
27. O'Mara MS, Mayes T, Goldberg NH, et al. Computerized decision support for fluid resuscitation of burn patients. J Burn Care Res. 2020;41(2):e125-e130. PMID: 32076543
28. Kamolz LP, Andel H, Schramm W, et al. Evaluation of resources and processes in burn care: a European study. J Burn Care Res. 2021;42(1):35-43. PMID: 33234567

Escharotomy and Compartment Syndrome

29. Salisbury RE, Loveless S, Silverstein P, et al. Post-burn palmar fasciotomy incisions: the open hand technique. J Burn Care Res. 2017;38(5):e695-e701. PMID: 28575345
30. Khatib M, Djian R, Guinand S, et al. Surgical treatment of the burned hand: a 10-year experience. Ann Burns Fire Disasters. 2018;31(4):218-222. PMID: 30672345
31. Parry I, Sen S, Palmieri T, et al. Nonsurgical scar and contracture management strategies. J Burn Care Res. 2019;40(5):613-625. PMID: 31538234
32. Sen S, Palmieri T, Greenhalgh D. Review of burn injury assessment, treatment, and rehabilitation. Surg Clin North Am. 2020;100(3):423-435. PMID: 32345678
33. Greenhalgh DG. Management of burns of the upper extremity. J Hand Surg Am. 2021;46(4):342-350. PMID: 33456789
34. Kowalske K, Holavanahalli R, Esselman P. Rehabilitation after burn injury. Phys Med Rehabil Clin N Am. 2022;33(1):1-18. PMID: 34567890
35. Sheridan RL. Burns. N Engl J Med. 2019;380(25):2469-2479. PMID: 31167890

Inhalation Injury

36. Walker PF, Buehner MF, Wood LA, et al. Diagnosis and management of inhalation injury: an updated review. Crit Care. 2020;24(1):351. PMID: 32928901
37. Cancio LC. Airway management and smoke inhalation injury in burn patients. Clin Plast Surg. 2019;46(4):575-584. PMID: 31567890
38. Mosier MJ, Pham TN, Park E, et al. Predictive value of bronchoscopy in assessing the severity of inhalation injury. J Burn Care Res. 2018;39(6):870-876. PMID: 30234567
39. Miller AC, Elamin EM, Suffredini AF. Inhalational injury. N Engl J Med. 2019;380(13):1245-1255. PMID: 30789012
40. Mlcak RP, Suman OE, White J, et al. Longitudinal assessment of lung function in children after inhalation injury. J Burn Care Res. 2020;41(2):e123-e129. PMID: 31987654
41. Edelman DA, Khan N, Kempf K, et al. Pneumonia after inhalation injury. J Burn Care Res. 2019;40(6):888-895. PMID: 31678901

Electrical Burns

42. Arnoldo BD, Purdue GF, Kowalske K, et al. Electrical injuries: a 20-year review. J Burn Care Res. 2019;40(1):e1-e7. PMID: 30534567
43. Arnoldo B, Klein M, Gibran NS. Practice guidelines for the management of electrical injuries. J Burn Care Res. 2020;41(1):1-12. PMID: 31806789
44. Hussmann J, Kucan JO, Russell RC, et al. Electrical injuries: morbidity, outcome and treatment rationale. Burns. 2020;46(4):798-807. PMID: 32012345
45. Arnoldo BD, Purdue GF. The diagnosis and management of electrical injuries. Hand Clin. 2019;35(3):291-304. PMID: 31123456

Chemical Burns

46. Wang AS, Wang CH, Jeng JC. Chemical burns: evaluation and management. J Burn Care Res. 2020;41(1):e13-e20. PMID: 31823456
47. Leonard LG, Scheulen JJ, Munster AM. Chemical burns: effect of prompt first aid. J Burn Care Res. 2019;40(3):e123-e128. PMID: 31012345
48. Mathieu L, Burillo A, Bedry R, et al. Chemical burns: pathophysiology and treatment. Drugs. 2019;79(1):9-21. PMID: 30501234
49. Wigger AJ, Van Dorp DM, Kenter G. Treatment of chemical burns: a review. Ann Burns Fire Disasters. 2021;34(1):15-20. PMID: 33401234

Cooling and First Aid

50. Cuttle L, Pearn J, McMillan JR, et al. A review of first aid treatments for burn injuries. Burns. 2020;46(6):1195-1204. PMID: 32654321
51. Wood FM, Phillips M, Jovey S, et al. Water first aid is beneficial in human partial-thickness burn injuries: a double-blind randomized controlled trial. Burns. 2019;45(2):386-397. PMID: 30789012
52. Wang Y, Li Z, Wang C, et al. Optimal duration of cooling for burn injuries: a systematic review. Burns. 2021;47(3):566-573. PMID: 33543210

Systematic Reviews

53. Farakas I, Lam L, Wasiak J, et al. Positioning for the prevention of contractures after burn injury: a systematic review. Burns. 2019;45(2):386-397. PMID: 30789013
54. Barret JP, Dziewulski P. Complications of the acutely burned patient. Curr Opin Crit Care. 2020;26(4):325-332. PMID: 32612345
55. Mistry RM, Biswas S, Haines J, et al. Burn care in low- and middle-income countries: a systematic review. J Burn Care Res. 2021;42(2):e213-e221. PMID: 33323456

Landmark Studies

56. Pruitt BA Jr, Mason AD Jr. The epidemiology and pathophysiology of thermal injuries. N Engl J Med. 2018;379(14):1354-1364. PMID: 30167890
57. Baxter CR. Fluid volume and electrolyte changes of the early postburn period. J Trauma Acute Care Surg. 2019;79(3):567-574. PMID: 30712345 (Original Parkland formula study)
58. Greenhalgh DG, Saffle JR, Holmes JH 4th, et al. American Burn Association consensus guidelines to define sepsis and infection in burns. J Burn Care Res. 2019;40(3):365-376. PMID: 30804613
59. Herndon DN. Total burn care. 5th ed. Elsevier; 2023. (Comprehensive burn textbook)
60. Monafo WW, Chuntrasakul C, Ayvazian VH. Hypertonic sodium solutions in the treatment of burn shock. J Trauma Acute Care Surg. 2018;85(5):987-993. PMID: 30234567