Thermal, Electrical, Chemical & Inhalation Burns

Airway & Supraglottic Thermal Assessment (A):
• Apply 100% FiO₂ via High-Flow Non-Rebreather Mask (15 L/min) or HFNC (60 L/min at 100%) immediately [1].
• Inspect for High-Risk Intubation Triggers: Stridor, hoarseness, dysphagia, carbonaceous sputum, deep circumferential neck burns, or coma (GCS ≤ 8) [1,2].
• If intubating: Use video laryngoscopy with an uncut, large-bore ETT (≥ 7.5–8.0 mm ID in adults) [2].

RSI in Burn Shock / Inhalation Injury:
• Induction: Ketamine 1.5 mg/kg IV (or Etomidate 0.3 mg/kg IV).
• Paralysis: Rocuronium 1.2 mg/kg IV (Succinylcholine 1.5 mg/kg IV is safe ONLY within the first 24 hours of thermal burn; strictly contraindicated after 24–48 hours or in acute high-voltage crush hyperkalemia) [1,2].

• Poiseuille’s Law (R ∝ 1/r⁴): Supraglottic edema narrows airway radius (r), exponentially increasing airflow resistance (R).
• Large Uncut ETT (≥ 7.5–8.0 mm): Accommodates progression of facial/lip swelling (hence uncut) and allows passage of a flexible therapeutic bronchoscope for bronchial cast clearance [2].

Decontamination & Stopping the Burning Process (B-E):
• Remove all smoldering clothing, belts, watches, and rings immediately.
• Chemical Burns: Brush off dry powders (dry lime, elemental Na/K, phenol) BEFORE copious warm water irrigation (20–30 L until skin pH 7.0–7.5) [1,3].
• Cover thermal burns with clean dry sterile sheets and raise resuscitation bay ambient temperature to 30–32°C (86–90°F) [1,3].

Cyanide & Carbon Monoxide Antidote Rescue:
• If Enclosed-Space Fire + Coma, Arrest, Shock, or Lactate ≥ 10 mmol/L (90 mg/dL): Infuse Hydroxocobalamin (Cyanokit) 5 g IV (70 mg/kg peds) over 15 minutes [4,5].
• If Hydrofluoric Acid (HF) Exposure: Apply 2.5% Calcium Gluconate gel topically OR inject 10% Calcium Gluconate (0.5 mL/cm² intradermal or 10 mL in 40 mL D5W intra-arterial) + give systemic Calcium Chloride 10% 1 g (10 mL) IV [1].

• 100% O₂: Competitive mass action decreases carboxyhemoglobin (COHb) elimination half-life from 320 minutes (room air) to 60–80 minutes [1].
• Hydroxocobalamin: Cobalt ion (Co³⁺) directly chelates intracellular cyanide (CN⁻) with higher affinity than ferric cytochrome c oxidase (a₃), forming non-toxic cyanocobalamin (Vitamin B12) excreted renally without inducing methemoglobinemia [4,5].

Accurate TBSA Mapping (Exclude 1st-Degree Erythema):
• Calculate %TBSA of partial-thickness (2nd-degree) and full-thickness (3rd-degree) burns using the Lund-Browder Chart (gold standard) or Rule of Nines / Palmar Surface (patient’s palm + fingers = 1% TBSA) [1,6].
• Insert Foley catheter with temperature probe and 2 large-bore (14G–16G) IVs (prefer unburned skin; placing IV/IO through burned eschar is mandatory if no unburned access exists) [1].

2024 ABA Consensus Fluid Initiation (If TBSA ≥ 20%):
• Adult Thermal Burn (2–4 mL/kg/%TBSA, ABA Consensus 2 mL/kg/%TBSA): Infuse warmed Lactated Ringer’s (LR) (1st half over first 8 hours from time of burn, 2nd half over next 16 hours) [1,6].
• Pediatric Thermal Burn (< 14 yr or < 30 kg): 3 mL/kg/%TBSA LR + D5LR maintenance rate (4-2-1 rule) [1].
• High-Voltage Electrical (> 1,000 V): 4 mL/kg/%TBSA LR [1].

• Balanced Crystalloid (LR over 0.9% NaCl): Avoids hyperchloremic metabolic acidosis in massive resuscitation volumes.
• ABA 2 mL/kg/%TBSA Shift: Prevents “Fluid Creep” (secondary abdominal, orbital, and extremity compartment syndromes and pulmonary edema) while maintaining microvascular organ perfusion [6,7].

Baseline Diagnostics & ECG Screening:
• Co-oximetry VBG/ABG: Measure true COHb%, MetHb%, lactate, pH, and base deficit (standard 2-wavelength pulse oximetry cannot differentiate COHb from O₂Hb) [1].
• 12-Lead ECG + CK + Urine Myoglobin: Mandatory in all electrical injuries, crush/deep thermal burns, and CO/CN poisoning (screen for K⁺ surge, arrhythmias, and rhabdomyolysis) [1,3].

Titration to Physiological Urine Output Endpoints:
• Adult Thermal: Titrate hourly LR infusion by 20–30% increments to maintain UOP 0.5 mL/kg/hr (30–50 mL/hr) [1,6].
• Pediatric (< 30 kg): Target UOP 1.0 mL/kg/hr [1].
• Electrical / Myoglobinuria (Dark Red Urine): Titrate to UOP 1.0–1.5 mL/kg/hr (75–100 mL/hr) until urine clears [1].

• Hourly UOP Titration: Formulas are starting estimates only. Microvascular capillary leak peaks at 6–8 hours post-burn; real-time UOP titration prevents both acute tubular necrosis (under-resuscitation) and compartment syndromes (over-resuscitation) [6,7].

Circumferential Eschar & Compartment Decompression:
• Assess chest wall compliance / peak inspiratory pressures (Pplat > 30–35 cmH₂O), distal extremity Doppler pulses, compartment ΔP, and Intraocular Pressure (IOP > 30–40 mmHg) [1,6].

Emergent Bedside Escharotomy:
• Incise full-thickness leathery circumferential eschar down to subcutaneous fat using electrocautery/scalpel along mid-axial (medial and lateral) lines of extremities or anterior axillary lines + subcostal/clavicular “shield” on the chest wall [1,3].

• Escharotomy vs. Fasciotomy: Full-thickness eschar is inelastic coagulated dermal collagen that acts as a tourniquet as sub-eschar edema expands. Releasing the eschar down to subcutaneous fat restores venous outflow and chest wall excursion [1,3].