EM Command Center / Trauma & Orthopedics • 3 min read • 6 sections

Burns, Inhalation & Chemical Injuries

Comprehensive emergency protocol for major thermal burns, smoke inhalation, and hazardous chemical exposures. Details the Lund-Browder and Rule of Nines charts, American Burn Association consensus resuscitation formulas, early intubation triggers for upper airway thermal injury, escharotomy indications/techniques, and hydrofluoric acid neutralization.

Resuscitation Quick Ribbon (First 2 Minutes)

High-Acuity

Stop the burning process:Remove all smoldering clothing, jewelry, and belts; irrigate with room-temperature saline/water; NEVER apply ice.

Assess Airway:Immediate endotracheal intubation for stridor, hoarseness, extensive facial/neck burns, or oral soot.

TBSA calculation:Calculate % Total Body Surface Area using Rule of Nines (only count 2nd and 3rd degree burns; DO NOT count 1st degree erythema).

Fluid Resuscitation (ABA Consensus Formula):Adults: 2 mL * kg * %TBSA of Lactated Ringer's over 24 hours. Give 50% in first 8 hours (calculated from time of burn, not ED arrival), remaining 50% over next 16 hours.

Titrate fluid to urine output:Target 0.5 mL/kg/hr in adults (30-50 mL/hr) and 1 mL/kg/hr in children.

Circumferential full-thickness chest burns with ventilatory failure:Emergent bedside thoracic escharotomy.

Bottom-Line Clinical Pearl

Inhalation injury causes rapid, delayed laryngeal edema within 12-24 hours. Intubate EARLY if facial burns, soot in the oropharynx, hoarseness, stridor, or carbonaceous sputum are present, before progressive edema distorts landmarks and causes an impossible airway.

1. Burn Depth Classification & Rule of Nines

Depth Degree	Anatomic Layer	Clinical Appearance & Sensation	Healing & Scarring
Superficial (1st Degree)	Epidermis only (e.g., sunburn)	Red, dry, painful, blanches with pressure; NO blisters	Heals in 3-6 days; NO scarring; DO NOT count in %TBSA.
Superficial Partial-Thickness (2nd Degree)	Epidermis and superficial dermis (papillary dermis)	Blisters, moist, weeping, bright red, exquisitely tender/painful; blanches briskly	Heals in 7-21 days; minimal scar; COUNT in %TBSA.
Deep Partial-Thickness (2nd Degree Deep)	Epidermis into deep reticular dermis	Blisters unroofed, waxy white or mottled red, dry, reduced sensation; sluggish or absent blanching	Takes > 21 days; often requires excision and grafting; COUNT in %TBSA.
Full-Thickness (3rd Degree)	Entire epidermis and dermis destroyed into subcutaneous fat	Leathery, waxy white, brown, or charred black, dry, painless/anesthetic (nerve endings destroyed)	Requires excision and autografting; severe scarring; COUNT in %TBSA.
4th Degree	Extends through subcutaneous tissue into fascia, muscle, tendon, or bone	Charred, skeletonized appearance	Requires extensive surgical reconstruction/amputation; COUNT in %TBSA.

2. % TBSA Estimation (Adult Rule of Nines)

Rule of Nines for adults (for scattered small burns, the patient's entire palm including fingers represents ~1% TBSA):

Head and Neck: 9% total (anterior 4.5%, posterior 4.5%)
Anterior Trunk (Chest & Abdomen): 18%
Posterior Trunk (Upper & Lower Back): 18%
Each Upper Extremity: 9% each (anterior 4.5%, posterior 4.5%) -> Both arms = 18%
Each Lower Extremity: 18% each (anterior 9%, posterior 9%) -> Both legs = 36%
Perineum & Genitalia: 1%
Pediatric Adjustment: Infant head is 18% and each leg is 14%; use Lund-Browder chart for precise pediatric staging.

3. Fluid Resuscitation Formulas & Urine Output Targets

Updated American Burn Association (ABA) Consensus Guidelines supersede the older Parkland formula to avoid 'fluid creep' (abdominal compartment syndrome, pulmonary edema):

Patient Population	ABA Resuscitation Formula (Lactated Ringer's)	Target Urine Output (UOP)
Adults (Thermal/Chemical)	2 mL kg %TBSA given over 24 hours (1/2 in first 8 hours, 1/2 in next 16 hours)	0.5 mL/kg/hr (roughly 30-50 mL/hr)
Pediatrics (< 14 years / < 30 kg)	3 mL kg %TBSA + maintenance D5LR to prevent hypoglycemia	1.0 mL/kg/hr
High-Voltage Electrical Burns	4 mL kg %TBSA (massive deep muscle damage and myoglobinuria)	1.0 - 1.5 mL/kg/hr (until urine clears of pigment)

Clinical Caution

Time Zero Calculation: The 24-hour resuscitation timeline starts from the EXACT TIME OF THE INJURY, NOT the time of emergency department presentation. If a patient with 40% TBSA burns arrives 3 hours after injury, the first half of calculated fluid must be infused over the remaining 5 hours.

4. Inhalational Injury & Carbon Monoxide / Cyanide

Airway Triggers for Early RSI: Stridor, voice change/hoarseness, singed facial/nasal hairs, carbonaceous sputum, blistering of soft palate, or deep circular neck burns. Delaying intubation leads to complete upper airway obstruction requiring surgical cricothyroidotomy.
Carbon Monoxide (CO) Poisoning: SpO2 pulse oximetry is FALSELY NORMAL (cannot differentiate carboxyhemoglobin from oxyhemoglobin). Obtain co-oximetry blood gas. Treat with 100% High-Flow O2 via non-rebreather (reduces half-life from 300 min to 90 min). Hyperbaric O2 (HBO) indicated for COHb > 25% (> 15% in pregnancy), syncope, coma, or seizure.
Hydrogen Cyanide Poisoning: Suspect in all enclosed-space fires with persistent profound lactic acidosis (lactate > 8-10 mmol/L) and refractory hypotension. Administer Hydroxocobalamin 5 g IV over 15 minutes (binds cyanide to form cyanocobalamin / Vitamin B12).

5. Emergency Bedside Escharotomy

Circumferential full-thickness burns form an inelastic, rigid eschar that restricts perfusion and ventilation during fluid resuscitation:

Indications: (1) Thoracic eschar causing respiratory insufficiency, high peak inspiratory pressures (> 40 cmH2O on ventilator), or restricted chest excursion; (2) Extremity eschar causing loss of distal pulses, pallor, paresthesias, or compartment pressures > 30 mmHg.
Anesthesia: Full-thickness burned tissue is insensate, but adjacent tissue is sensitive; IV ketamine or fentanyl is recommended.
Thoracic Technique: Incise along the anterior axillary lines bilaterally from the 2nd rib down to the 12th rib, connected across the subcostal margin and superiorly across the upper chest (creating an 'H' or 'box' incision).
Extremity Technique: Incise longitudinally along the mid-medial or mid-lateral line of the limb, avoiding superficial nerves (ulnar nerve at medial epicondyle, common peroneal nerve at fibular head).
Depth: Cut through the rigid eschar down into the subcutaneous fat until the wound edges pop open and tissue compliance is restored. Do not incise muscle fascia unless a true fasciotomy is indicated.

6. Chemical Burns & Hydrofluoric (HF) Acid Protocol

Chemical Agent	Mechanism of Injury	Specific Emergency Intervention
Acids (Hydrochloric, Sulfuric)	Coagulative necrosis; forms protective eschar limiting penetration	Immediate copious water irrigation (minimum 30 minutes); check pH of skin/eyes.
Alkalis (Lye, Sodium Hydroxide, Lime)	Liquefactive necrosis; deep continuous tissue destruction and protein saponification	Prolonged copious water irrigation (minimum 1-2 hours) until tissue pH neutralizes to 7.0-7.5. Brush dry lime off skin BEFORE irrigating.
Hydrofluoric (HF) Acid	Weak acid but fluoride ions penetrate deeply, scavenging systemic calcium and magnesium -> lethal refractory ventricular fibrillation	1. Copious water irrigation. 2. Topical Calcium Gluconate Gel (mix 3.5 g calcium gluconate powder into 150 mL lubricating gel) applied to burned area. 3. Intradermal / Subcutaneous injection of 10% calcium gluconate (0.5 mL/cm2) for persistent pain. 4. Intravenous / Intra-arterial calcium gluconate infusion for digital or refractory burns. 5. Continuous cardiac telemetry for QTc prolongation and hyperkalemia.

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