The standard "ABC' principles apply to managing patients with severe burns. Patients with severe burns should be stabilised and transferred to the nearest burns centre. The patient with a thermal injury to the respiratory tract may rapidly develop airway obstruction from the oedema. All patients suspected of having thermal or smoke injury to the respiratory tract should be given humidified high concentration oxygen. Arterial blood gas sampling and estimation of carboxyhaemoglobin level is necessary. The need for early intubation should be considered in the presence of any of the following features:
• Altered consciousness
• Direct burns to the face or oropharynx
• Hoarseness or stridor
• Soot in the nostrils or sputum
• Expiratory rhonchi
• Drooling and dribbling saliva
Having established intravenous access, fluid resuscitation should be started and burnt areas covered with cling film. The simple "rule of nine' (Figure TT.12) will produce an approximate calculation the surface area of the burn. This can be calculated more precisely later using a Lund and and Browder chart (Figure TT.13). The volume of colloid (gelatin, starch, or albumin) to be given over the first 4 hours (from the time of the burn) is: approximately = [weight of patient (kg) x % surface area burn]/2. This same volume can be given over subsequent periods of 4, 4, 6, 6 and 12 hours. The exact volume of fluid given depends on vital signs, central venous pressure and urine output. Patients with full thickness burns > 10% body surface area will probably require blood. Patients with severe burns require potent analgesia, best given as carefully titrated intravenous opioids.
Figure TT.12 Rule of 'nines'
Figure TT.13 Lund and Browder chart
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