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Essentials of Diagnosis
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- The ABC's
- Begin fluid resuscitation
- Obtain diagnostic information
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Establish an Adequate Airway
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When any patient enters the Emergency Department, the first steps to care involve evaluation of the ABC's—especially in burn patients. Severe burns to the lower face and neck may be associated with upper airway and laryngeal edema that cause airway obstruction. Inhalation of superheated air or steam in a confined space may also cause significant upper airway edema. Full-thickness chest wall burns, especially if they are circumferential, may limit chest wall movement and cause respiratory failure, requiring escharotomy on an emergency basis. Consider early endotracheal intubation in all patients with such injuries and in patients with stridor, hoarseness, or hypoxia.
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Airway obstruction may progress rapidly in these patients. When the burn size exceeds 60% total body surface area, early endotracheal intubation should be considered as these patients often deteriorate rapidly. If facial or airway involvement is noted, intubation is advisable. If endotracheal intubation is not successful, cricothyrotomy or tracheostomy may be necessary.
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Support Ventilation and Oxygenation
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Give oxygen by nasal cannula or face mask. If smoke inhalation may have occurred, give 100% oxygen by tight-fitting reservoir face mask or endotracheal tube. Monitor oxygen saturation by pulse oximetry, but be aware that pulse oximetry readings will be falsely elevated in patients with elevated carboxyhemoglobin levels. Simply subtract the measured carboxyhemoglobin level from the pulse oximetry value to determine the true oxygen saturation. Noninvasive co-oximetry is emerging as a useful tool to monitor the carboxyhemoglobin level in the ED.
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Begin Fluid Resuscitation
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Patients with deep burns covering more than 15% of body surface area require intravenous fluid resuscitation. Insert one or two large-bore (≥16-gauge) peripheral intravenous catheters, preferably inserted through unaffected skin, or a central venous catheter if peripheral lines cannot be established. Calculation of the percent of body surface burned can be performed using an age-adjusted burn chart displayed in Figure 45–2. Additionally, the “Rule of Nines” can be used to estimate total burned body surface area, with each of the following representing 9%: head, anterior chest, anterior abdomen, each arm, anterior of each leg, and posterior of each leg. The back and buttocks represent 18%, while the groin and each palm represent 1%. Adjustment of the rule of nines for children changes 9% to 5%, with the head encompassing 20% of the total.
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