TRAUMA
Critical care management
of patients with severe
burns and inhalational
injury
Matthew J Devine
Dominic M Trainor
Abstract
Anaesthetists and critical care physicians involved in emergency care
provision must be equipped with the adequate knowledge and skills
to accurately assess and manage patients with severe burns. This
summary aims to review the key principles in managing patients with
severe burns including airway management, fluid resuscitation, seda-
tion, burn care, analgesia and nutrition.
Keywords Critical care medicine; inhalational injury; resuscitation;
severe burns
Royal College of Anesthetists CPD Skills Framework: Trauma management
Introduction
In the UK, approximately 175,000 patients with burn injuries
present to emergency departments each year. In England, 12,375
patients required admission and inpatient management during
the financial year 2016/17.1 Burn injuries account for 180,000
deaths worldwide each year.2 A specialized multidisciplinary
team with a comprehensive understanding of severe burns
pathophysiology can ensure the delivery of safe and high quality
care to these patients.
There are multiple factors to consider when determining
prognosis, including gender, age, size and depth of burn. Up to
35% of burns patients suffer inhalational injury, which is asso-
ciated with significant complications.3 A coordinated approach
via a strategically developed burns network, is fundamental to
reducing morbidity and mortality, while promoting high-quality
specialist care.4
Pathophysiology
A severe burn injury is a significant and life-threatening physi-
ological insult. The resulting tissue trauma triggers local and
systemic effects, initiating a profound inflammatory, hypermet-
abolic and immunological response that can be more severe and
persistent than that seen with other types of insults such as
Matthew J Devine MB ChB FRCA FFICM is a Specialty Trainee in
Anaesthesia and Intensive Care Medicine at Royal Victoria Hospital,
Belfast, UK. Conflicts of interest: none declared.
Dominic M Trainor BSc MB MRCP FCARCSI DICM is a Consultant in
Anaesthesia and Intensive Care Medicine at Royal Victoria Hospital,
Belfast, UK. Conflicts of interest: none declared.
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Learning objectives
After reading this article, you should be able to:
C list clinical features that indicate the presence of an inhalational
injury
C identify risk factors for and signs of noxious agent involvement
in a severe burn
C outline the key aspects of severe burn pathophysiology
including burn shock
C describe evidence-based practice to commence resuscitation of
severe burns patients
C discuss the role of the multidisciplinary team in burns patient
care
trauma, surgery and sepsis. Concomitant inhalational injury can
result in direct thermal injury to supraglottic airway structures,
leading to mucosal oedema and stridor. Subglottic injury causes
chemical pneumonitis, pulmonary infection and acute respira-
tory distress syndrome (ARDS).
The effects on the cardiovascular system in response to burns
are divided into acute and hypermetabolic phases. Hypovolaemia
dominates the acute phase, generated by increased capillary
permeability resulting in fluid shifts. The hypermetabolic phase
results in hypoproteinaemia causing gross tissue oedema, while
excess catecholamine synthesis precipitates cardiac dysfunction
and acute kidney injury (AKI) secondary to ischaemia.5
Thermal injury can trigger multiple gastrointestinal tract
complications. Reduced nutritional intake, increased incidence of
gastric mucosal ulceration and bowel wall ischaemia may all
result in gastrointestinal haemorrhage. Bacterial translocation
across the mucosal wall may also result in sepsis.
Assessment and management
Assessment and management of any trauma patient should
follow the principles of Advanced Trauma Life Support teaching.
The approach to a burns patient should be no different. Basic
initial measures include high flow oxygen, basic monitoring and
intravenous access. Following stabilization, transfer to a regional
burns unit can be considered based upon locally agreed criteria
for referral (Table 1).
Airway
Cervical spine immobilization is essential if there is a significant
mechanism of injury to warrant concern until it can be cleared
clinically and/or radiologically. Immediate administration of
high-flow supplemental oxygen therapy to prevent tissue hyp-
oxia and treat smoke inhalation is vital. Mechanism and risk
factors for inhalational injury should be identified promptly
(Table 2).6
Patients with inhalational injury affecting the upper airway
are at risk of airway compromise due to supraglottic oedema.
Repeated assessment of the airway using clinical features and
flexible naseondoscopy (FNE) is essential. Patients with no signs
of significant airway oedema who are clinically stable do not
necessarily require emergent intubation.6 However, within this
stable group, it may be reasonable to intubate semi-electively if
397 Ó 2023 Published by Elsevier Ltd.
 TRAUMA

airway and rescue airway plans. The technique for intubation

British Burns Association referral criteria for patients will depend on patient factors, urgency, airway skills and
with burn injuries equipment availability. The modes of intubation in this scenario
Extremes of age <5 years or >60 years include rapid sequence induction, awake fibreoptic intubation
Site Face and inhalational induction. The use of a small endotracheal tube
Hands or feet may be required.
Perineum The use of suxamethonium should be limited to within the
Flexures first 24 hours, due to the risk of hyperkalaemia caused by the
Circumferential or full-thickness burns increase in extra-junctional nicotinic acetylcholine receptors.
Inhalation injury Excluding pure carbon monoxide poisoning Increased receptor numbers can also promote a resistance to
Mechanism of injury Chemical injury non-depolarizing agents, therefore requiring higher doses.
Radiation injury
Breathing
High-pressure steam injury
A lung protective ventilatory (LPV) strategy (Table 3) should be
Electrical injury
implemented in those who require intubation. Between 40% and
Suspicion of non-accidental injury
54% of patients requiring mechanical ventilation will develop
Size of skin injury <16 years with >5% TBSA
ARDS.3 Rescue interventions, including neuromuscular blocker
16 years or over with >10% total body surface
infusions, prone positioning and extracorporeal membrane
area (TBSA)
oxygenation (ECMO), may be required in cases of severe
Comorbidities Cardiorespiratory disease
hypoxaemia.
Diabetes mellitus
Progressive worsening of oxygenation and ventilation may
Pregnancy
occur for several reasons, including smoke inhalation injury,
Immunosuppression
ARDS, thoraco-abdominal circumferential burns and abdominal
Hepatic impairment
compartment syndrome. It is important to have a systematic
Associated injuries Crush injuries
approach to assessment and diagnosis of the underlying cause
Head injury
and direct management accordingly.
Penetrating injury
Intubated patients with smoke inhalation injury should un-
Table 1 dergo early bronchoscopy, clearance of particulate matter and
washout as this is associated with improve outcomes.6 Inhalation
inter-hospital transfer is necessary. Serial clinical and FNE as-
sessments can aid decision-making.7 If features of airway injury
are present accompanied by non-reassuring FNE assessment, Lung protective ventilation strategy criteria determined
intubation should be undertaken promptly by a senior clinician by the Acute Respiratory Distress Syndrome Network
with advanced airway skills. In addition to airway compromise, Tidal volume 6 ml/kg (range 4e8 ml/kg titrated against
patients may require intubation for respiratory failure, depressed plateau pressures and blood pH) predicted
consciousness and facilitation of radiological imaging. body weight
When undertaking emergency tracheal intubation, a clearly Plateau pressure 30 cmH2O
devised airway plan should be communicated to the team. In the FiO2 Wean as low as tolerated to achieve PaO2
setting of major burns and likely unfasted patient, it is important 55e80 mmHg (7.3e10.7 kPa)
to have high levels of preparedness, skilled assistance, equip-
ment, monitoring and clear communication regarding initial Table 3

Risk factors and clinical signs that indicate inhalational injury

Mechanisms Risk factors Clinical signs

Heat Exposure to smoke, flames or chemicals and Carbonaceous sputum

Particulate matter deposition and
respiratory irritants
Asphyxiation and systemic toxicity
whether these were either industrial or Evidence of burns to the face or neck
household Oropharyngeal burns (e.g. bulla and/or erythema)
Duration of time exposed and whether this Respiratory embarrassment
was in an enclosed space Singed facial or nasal hair
Burning substances such as plastics or fabrics Added sounds (wheeze or stridor)
Obtunded consciousness at scene Haemoptysis
At scene fatalities or cardiac arrests Altered voice
Odynophagia or dysphagia
Reduced Glasgow Coma Scale score

Table 2

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 TRAUMA
protocols administering nebulized b2-agonists, acetylcysteine
and heparin are used in some centres, however evidence for this
is limited.
Carbon monoxide (CO) poisoning should be assumed in all
fire victims. Standard pulse oximetry will overestimate oxygen
saturations. A carboxyhaemoglobinaemia (COHb) of >30% re-
quires rapid treatment; increasing the alveolar partial pressure of
oxygen by instigating high-flow oxygen therapy or a FiO2 of 1.0
in ventilated patients. This reduces the half-life of COHb from 4
hours to approximately 1 hour.
Fire involving synthetic materials increases the risk of
hydrogen cyanide (CN) toxicity from smoke inhalation. Clinical
features are non-specific and CN levels are not readily available.
A persistent hyperlactataemia, high anion gap metabolic acidosis
and reduced arterio-venous oxygen gradient suggests CN
toxicity. Treatment involves administration of the antidote
hydroxycobalamin which chelates cyanide to cyanocobalamin
(70 mg/kg or 5 g intravenously (IV) in intermediate to severe
cases, 10 g IV in cardio-respiratory arrest).6,8
Circulation
Large-bore IV cannula are essential to permit rapid fluid resusci-
tation and drug administration. Arterial and central venous cath-
eters, inserted through unburnt skin, should be considered early
to facilitate blood sampling, invasive pressure monitoring and
delivery of vasoactive medication when required. A urinary
catheter must be inserted and hourly urine output measurement
commenced as this is a useful measure perfusion.
The Parkland formula (4 ml per kg body weight  % of total
body surface area (TBSA) burned) %) is the most commonly
used formula to guide the initial resuscitation in burns trauma.
Military physicians applied a ‘rule of 10s’ (Table 4), which can be
used to calculate initial resuscitation fluid rate. In 88% of
simulated cases, the calculated volume was between 2 ml/kg and
4 ml/kg.3 Smoke inhalation patients may have significantly
increased fluid requirements for the same burn area. It is
essential that fluids are adjusted according to clinical response,
markers of fluid responsiveness and biochemical parameters
rather than blindly follow formulae recommendations.3
A balanced crystalloid solution is commonly used for initial
resuscitation; however, the optimal fluid remains debatable.
Transfusion of packed red cells and coagulation products may be
required due to bleeding from surgical sites, coagulopathy and
disseminated intravascular coagulation. Albumin may also have
a role, with a meta-analysis reporting reductions in both mor-
tality and the incidence of compartment syndrome.8
Resuscitation requires a balance between the prevention of
burn shock (caused by a combination of hypovolaemia,
Rule of 10s step-wise calculation for initial fluid rate in
adults weighing ‡40 kg
Step 1 Calculate the total body surface area (TBSA) to nearest
10%
Step 2 Calculate the fluid rate as 10 x TBSA in ml/hour
Step 3 If adult weighs >80 kg add an additional 100 ml/hour to
the fluid rate for every additional 10 kg
Table 4
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vasoplegia and myocardial dysfunction) and avoidance of the
effects of high-volume fluid resuscitation, which can result in
extravascular fluid loss leading to compartment syndrome.
Circumferential burns to limbs may lead to neurovascular
compromise. Rapid recognition will avoid delays in potentially
limb salvaging fasciotomies.
The incidence of venous thromboembolism in burn patents is
high. Venous thromboembolism prophylaxis (pharmacological
and mechanical) should be administered in all patients unless
there is a clear contraindication.
Disability
A Glasgow Coma Scale score of <8 or severe agitation are in-
dications for intubation. In an obtunded patient, especially when
the collateral history may be vague, consideration to the need for
further investigations, such as CT scan of the brain and investi-
gation of noxious substance exposure.
A blood glucose reading is essential given the hypermetabolic
state, as is the tracking of this parameter.
Acute and chronic pain associated with burns require detailed
and dynamic management. A non-verbal pain score should be
used to help assess and titrate analgesic requirements. From
basic nursing care to surgical procedures and dressing changes,
the nociceptive stimulation can be immense. Inadequate anal-
gesia has short- and long-term effects; increasing the inflamma-
tory response and risk of post-traumatic stress disorder.3
Multi-modal analgesia is required to manage background,
breakthrough and procedural pain sufficiently. Reliance on opioid
only protocols must be avoided. Agents with alternative mecha-
nisms of action modify different pain pathways, such as ketamine
(the N-methyl-D-aspartate receptor antagonist) and pregabalin (g-
aminobutyric acid analogue). Utilization of these drugs is associ-
ated with reduced opioid requirements. It is important to avoid
agents that may promote or worsen AKI, such as non-steroidal anti-
inflammatory drugs.
Exposure
The calculation of TBSA and assessment of burn depth requires a
methodical approach to ensure all areas, including the patient’s
back are reviewed without excessive total body exposure. Heat
loss can be rapid. Oesophageal, bladder or nasopharyngeal
probes can be used to measure core temperature. Mechanisms to
prevent hypothermia via both convection and evaporation
include warmed IV fluids, forced-air heating blankets and alter-
ation of the ambient temperature.
Chemical contamination must be safely, rapidly and thor-
oughly irrigated.
Burn depth has four categories each with their own charac-
teristic appearances (Table 5). TBSA is calculated by including
burns of superficial partial thickness and deeper. Wallace’s Rule
of Nines and Lund and Browder charts (age specific) are useful to
calculate TBSA.
Tissue contamination or devitalization require urgent surgical
debridement. Bullae may benefit from prompt de-roofing or fluid
evacuation. Liaising with the specialist burns surgical team is
paramount for effective management of these issues. During
exposure all clothing, contact lenses and jewellery must be
removed, specifically circumferential items such as rings or
necklaces.
399 Ó 2023 Published by Elsevier Ltd.
 TRAUMA

The appearance and features that differentiate various burn depths

Burn Depth Appearance Features

Epidermal C Painful
C Erythematous
C Blanching
C No blisters

Superficial partial thickness C Blanching erythema

C Blisters
C Pain with hyperalgesia

Deep partial thickness C White or yellow base

C Minimal to no blanching
C Reduced sensation
C Some blistering may be evident

Full thickness C Leathery appearance

C White, brown or black base
C No blanching
C No sensation

Table 5

Ongoing management issues Nutrition

Infection
There is no role for prophylactic antibiotics despite the increased
risk of infection.
Patients should be cared for in side-rooms to enable reverse
barrier nursing. Gloves and aprons are mandatory when
handling or moving the patient. Meticulous attention to hand
hygiene and usage of a faecal management system (especially
with burns to the buttocks and upper thighs) may reduce the risk
of wound contamination.
Systemic inflammatory response syndrome (SIRS) markers are
commonly seen in severe burns patients. Specific criteria have been
proposed to aid in the diagnosis of sepsis in burn patients; however,
they correlate poorly with positive blood cultures.3
A low threshold should exist for the administration of human
tetanus immunoglobulin (250 international units (IU) intramus-
cularly (IM), or 500 IU IM if >24 hours since burn occurred).
Burns induce a hypermetabolic state (basal metabolic rate rises
by approximately 170%) leading to protein catabolism and
lipolysis resulting in decreased muscle mass, poor wound healing
and reduced host defences. Enteral nutrition is the main route of
nutrition delivery with parenteral nutrition reserved for burn
patients who are unable to tolerate enteral feeds.9 Protein re-
quirements for adults are 1.5e2.0 g/kg/day and in children 3 g/
kg/day. Those with TBSA >20% a high-protein diet is required.
Use of a recognized formula to calculate energy requirements is
recommended, adjusting intake requirements based upon burn
TBSA, patient age and weight. Early engagement with the di-
etetics team is essential in this aspect of patient care.
Interruptions to feeding should be minimized, avoiding pe-
riods of fasting prior to a surgical procedure, unless airway
manipulation is planned. Unnecessary interruption or inadequate
calorific and protein provision predisposes the patient to sec-
ondary burn damage and increases infection risk and mortality.

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 TRAUMA
As with all intubated patients in intensive care units (ICU),
there should be consideration of gastric-ulcer prophylaxis.
Burns dressings
Multiple burn wound-related issues can occur after full-thickness
burns including wound closure, altered pigmentation, tissue
hypertrophy and contractures. The array of dressings available
for burns is vast. No single dressing is suitable for every burn;
there are several biological and anti-microbial dressings available
and the specialist surgical team will advise the optimum choice.4
Skin substitutes, a biomaterial or engineered tissue, include
cadaver allograft, dermal substitutes, neonatal derived produces,
amniotic membrane products and cultured epithelial autografts.
Further research is underway to investigate the use of allogenic
mesenchymal stem cells.10
Palliative care
Despite rapid assessment and advanced clinical management,
severe burns carry high mortality rates. There may be occasions
when treatment futility may need to be considered and discussed
with the multidisciplinary team. Should this occur then it is likely
these patients will die in ICU. High-quality end-of-life care,
involving palliative care specialists to ensure patient comfort and
dignity is a priority. A
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