Burns: ISBI practice guidelines for burn care (2016)

Revised: April 05, 2019

About the Guidelines

These guidelines address the diagnosis and treatment of burns.
The International Society for Burn Injuries created these guidelines with consensus on managing the
various parts of burn management.
The guidelines were accepted in May 2016.

Key Clinical Considerations

Become familiar with the recommendations and best-practice statements provided in this guideline, especially if
you work in an acute care setting.

Assessment and Stabilization for the Initial Approach

The primary survey includes management of the airway; ventilation and breathing; circulation, including cardiac
status, deformity, or neurologic disability; and exposure.
Management of the airway with early intubation is indicated by the following signs of potential airway
compromise: soot around the mouth, singed facial hair, difficulty breathing, hoarseness, burns around the
neck, and stridor.
Interventions that can be used to manage/open the patient's airway:
Jaw-thrust maneuver
Chin lift
Oral airway
Intubation
Surgical airway
Ventilation, oxygenation, and breathing: Auscultate breath sounds and assess the chest wall, lungs, and
diaphragm, as well as the rate and depth of respirations.
Cardiac status and circulation: Utilize continuous pulse oximetry and cardiac monitoring, assess skin color
of the unburned skin, evaluate perfusion in all extremities, manage fluid status based on the patient's
weight and burn size, and evaluate the blood pressure to assess circulatory status.
Peripheral intravenous lines (IVs), central venous catheters, and intraosseus placement can be
used for access and can be placed through burn tissue if necessary.
Deformity or disability: Evaluate mental status using the Glasgow Coma Scale, a history of substance use,
an inhalation injury, hypoxia, or any other pre-existing condition.
Exposure: Remove any contaminants, heat, or chemical sources, and items such as contact lenses,
jewelry, and clothing. Maintain a warm environment, to prevent hypothermia.
Exposure injuries may be cooled for 3 to 5 minutes in cool water. Avoid applying cold water or ice, as
hypothermia may occur.
The secondary survey includes examining the patient for life-threatening non-burn injuries.
Evaluate problems that may cause death within the first 24 hours after the trauma.
Estimate total body surface area (TBSA). Use the rule of nines to divide the body of an adult into
anatomic areas, with each area representing 9%. A higher level of care for burn patients would include
second-degree burns that are >10% TBSA, third-degree burns of any size, and burns of any degree on
the perineum, genitals, face, feet, and hands.
Imaging, lab tests, and adjunctive measures such as nasogastric tubes and urethral catheters can be
placed during this time.
 Establish vaccination status: If the current status of vaccinations is unknown, patients should receive
tetanus toxoid along with a tetanus immune globulin (TIG) or an IV immune globulin if TIG is not
available.
Once they are stabilized, patients should be transferred to a higher level of care for second-degree burns
that are >10% of TBSA; burns to the face, genitals, hands, feet, or across any joint; and third-degree
burns of any size.

Smoke Inhalation Injury

Three components of inhalation injury, which may occur in combination or separately, include lower
respiratory system injury (from inhaling chemicals and particulates), upper airway obstruction (from heat
and edema), and poisoning from inhaling gases (hydrogen cyanide or carbon monoxide).
Initial assessment should include airway, breathing, and any trauma.
Signs and symptoms of smoke inhalation injuries include soot in the oral cavity, wheezing, and
hypoxemia.
Oropharyngeal and facial burns can quickly cause obstruction, respiratory failure, and coma.
Respiratory distress from inhaled toxins and progressive lung parenchyma damage will result in
pneumonia or death.
Burns to the face require assessment; symptoms include stridor or hoarseness, soot in the sputum, and
evidence of buccal cavity burns.
Treatment for upper airway burns will be determined by an inhalation injury diagnosis. Intubation and
ventilatory support may be indicated.
Edema of head and trunk may occur within the first 24 hours or later, post injury, causing upper
airway obstruction.
The head of the bed should be moderately elevated.
Carbon monoxide (CO) poisoning should be considered in patients with altered mental status who have
experienced a fire in a closed space.
Diagnosis is made from testing carboxyhemoglobin levels.
CO poisoning requires a high level of supplemental oxygen, administered continuously, for a
minimum of six hours.
Hydrogen cyanide is usually inhaled by fire victims, and patients present with the same signs and
symptoms as in CO poisoning.
Treatment includes high-flow oxygen and hydroxocobalamin.

Burn Shock Resuscitation

For burns covering >20% of TBSA, resuscitate with fluids containing salt, based on the percentage of the
burn and body weight. The Parkland formula can be used to calculate the amount of fluid needed for
resuscitation.
In the first 24 hours after an injury, IV fluids should be administered, if appropriate.
The amount of IV fluid is based on between 2 to 4 ml/kg of body weight/burn surface area
(percentage of TBSA).
For patients with burns <30% of their TBSA, and if oral fluid administration is appropriate, the optimal
amount for ingestion is determined by calculating 15% of body weight every 24 hours for 2 days.
When orally hydrating a patient, 50 mL or less of fluid should be given at a time.
For each liter of oral fluids ingested, 5-gm tablets of table salt (or equivalent) should be ingested.
One level teaspoon of table salt may be substituted for 1 tablet.
If tolerated, other fluids may be used, including chicken or vegetable soup with salt, fresh lime water with
sugar and salt, salted rice water, or sports drinks such as Gatorade, with the addition of 1/4 teaspoon
baking soda and 1/4 teaspoon salt for each quart.
Urine output should be monitored.
Output should be managed by titrating fluids containing salt to maintain a urine output of 0.3 to
0.5 mL/kg/hour.
Anuria may occur in the first three hours of burn resuscitation.
Escharotomy and Fasciotomy
Escharotomy should be performed when eschar on the neck or trunk is compromising breathing and
aeration, and when underlying tissue or circulation is compromised in the extremities from circumferential
eschar.
Even if there is doubt about the need for an escharotomy, the procedure should be performed.
Compartmental pressures above 40 mmHg require an escharotomy.
When signs of abdominal compartment syndrome (ACS) or intra-abdominal hypertension occur with near-
circumferential or circumferential eschar, abdominal escharotomy should be performed.
When unexplained oliguria, decreased minute ventilation, or both, are present, ACS should be suspected.
Escharotomy should be performed on the affected areas (longitudinal axis) near neurovascular bundles.
If this is not possible, the range would be from the joint above to the joint below.
The depth of the incision should be determined the depth of the cut that must be made before
healthy tissue is reached.
Patients will require general anesthesia.
A fasciotomy is often performed for compartment syndrome not relieved by escharotomy, especially when
very deep burns have been experienced. Fasciotomy requires general anesthesia, and wound care
postoperatively is more demanding.

Wound Care
Cleansing via irrigation with water or saline solution is a component of burn wound care.
Wound cleansing and care are used to remove debris, contaminants, foreign objects, slough,
microorganisms, dressing, excessive crust and exudate, and hyperkeratosis. Personal hygiene and
comfort are also part of the process.
The benefits of antimicrobial agents and antiseptics for cleansing are not clear.
Dressings help control bacteria and prevent viable tissue desiccation.
An optimal dressing has not yet been identified.
Characteristics of optimal dressings include:
Provides a setting for moist wound healing.
Allows the exchange of oxygen, carbon dioxide, and water vapor.
Provides thermal insulation and protection.
Is free of contamination from particulates.
Is non-adherent and sterile.
Is impermeable to microorganisms.
Is highly absorptive.
Allows monitoring of the wound and requires infrequent changes.
The type of dressing used is dependent on the wound exudate.
For low-exudate wounds, polyurethane, hydrocolloids, and hydrogels are used.
For moderate to high-exudate wounds, foams and alginates are used.
Treatment of blisters may include opening the vesicle and evacuating the contents, leaving a raw area
called a “biologic dressing.” An antimicrobial agent and a bandage or bulky dressing are then applied to
the raw area to complete the treatment.
Areas that are raw should have a closed-technique dressing.
Wound condition determines the frequency of the dressing change.
A closed dressing is often used for full-thickness burns and deep partial-thickness burns.
An open technique can be used until eschar separation occurs.

Surgical Management of the Burn Wound

A well-trained and well-prepared burn team is essential.
Early skin grafting and excision are associated with a higher survival rate in most patients.
A surgical plan should be created for each patient. The site, extent, and depth of the injury; physical
 state of the patient; and the resources of the treating team will determine what is contained in the plan.
A laser Doppler scanner can be used to differentiate deep partial-thickness burns from superficial burns.
To speed recovery for small to moderate-sized deep burns (<20 percent of TBSA), early surgery is
recommended. Small burns, especially burns on the face, hands, and feet, can still affect a patient's
ability to function.
For patients who have experienced electrical injuries from high voltage, early surgery or fasciotomy may
help save both their lives and their limbs.
Necrotic tissue should be removed; in some cases, amputation may be required for an extremity
that has been severely compromised.
High-voltage injuries require emergency surgical intervention. After 6 hours, ischemic muscle
damage becomes irreversible.
Surgical intervention for high-voltage injuries can cause reperfusion injury that can lead to
rhabdomyolysis, renal failure, hyperkalemia, and cardiac arrest; therefore, fasciotomy is the
preferred approach.
A standard method of wound excision from burns is tangential excision.
Subcutaneous fat and dead skin are removed and eschar is shaved.
The tangential method is done via a sequential approach.
Grafting and excision of the burn can be done by many methods, without the risk of blood loss.
Examples of blood-saving techniques include limb elevation and compression dressings,
tourniquets for limb surgery, and epinephrine solutions applied topically to the burn wound.
Preventing hypothermia is important.
After debridement or excision of a deep wound, the wound should be covered with an appropriate skin
substitute or autograft skin to prevent infection, fluid shifts, and protein loss.

Nonsurgical Management of Burn Scars

Burns that are superficial should heal in less than two weeks.
Sun protection, topical emollients, and humectants should be utilized.
The area(s) should be routinely massaged after healing begins.
Deeper dermal burns usually take more than three weeks to heal.
These areas should be monitored and aggressive scar-prevention therapies should be initiated.
Deep burns require pain relief, physiotherapy, and positioning regimens to decrease the risk of joint
contractures and hypertrophic scarring.
Sun protection, topical emollients, and humectants should be utilized.
The area(s) should be routinely massaged after healing begins.
Extensive burns with hypertrophic scars should be treated with pressure therapy using a silicone product
to help improve the characteristics of the scar.
Splinting, positioning, and physical therapy, including range-of-motion exercises, are
recommended.
Pressure garments, gel, and gel sheets can be used after wound healing to prevent scarring.
Non-ablative fractional lasers have been shown to improve the pliability and texture of thickened scar
tissue.
Intralesional administered therapies, such as calcium channel blockers, cryotherapy via micro-needling,
anti-tumor agents, and steroids have been shown to improve scarring.

Infection Prevention and Control

The hospital environment should be clean and maintained to a high standard of cleanliness.
Toilets, medical equipment, surfaces, etc., should be cleaned regularly.
Any contamination with body fluids (e.g., blood) should be immediately cleaned.
Isolation rooms should only be used for one patient.
The most important basic infection-control measure is hand hygiene. Hand hygiene includes using an
alcohol-based disinfectant, which is as effective as soap and water.
Guidelines for hand hygiene include teaching staff, implementing what is taught, and monitoring
 the results.
Personal protective equipment should be used for the prevention of health care-associated infections.

Antibiotic Stewardship
Prophylactic systemic antibiotics should be avoided.
An antibiotic stewardship program should be developed, implemented, and monitored.

Nutrition
Nutritional support and monitoring are important during the acute phase of injury.
Early support and monitoring help minimize the risk of needing aggressive intervention.
Metabolism increases after a burn injury. If not treated, moderate to severe malnutrition can occur,
resulting in death from protein loss. Malnutrition also weakens the immune response and the ability to
recover from infection.
If a patient needs nutritional support, enteral feeding is preferred over parenteral and should be started
as soon as possible; however, early enteral feedings after a burn injury may increase the risk for
aspiration pneumonia.
For burns over 20% of a patient's body surface, an adequate caloric intake and a high protein diet should
be initiated; 1.5 to 2 gm of protein/kg of body weight per day for adult intake is optimal.
Energy requirements for nutrition should be determined by the age and severity of the burn injury,
infection frequency, level of physical activity, and body weight. Burns that are >50% to 60% of TBSA will
necessitate a double basal metabolic rate.

Rehabilitation
Positioning affects the long-term outcomes of function by reducing contractures from scars. Splinting
devices may be used to help joints stretch and to promote movement.
The patient's head should be positioned above the heart level, with the neck in a neutral extension at
about 15 degrees, the shoulder/axilla in a 90-degree abduction, the forearm and elbow in full extension
below 5 degrees, the hand and wrist in a slight or neutral extension at about 10 degrees, the knee in a
full extension less than 5 degrees, and the ankle and foot in a neutral position. Hip position will depend
on the injury.

Pruritus Management
Routine care should include an assessment of the duration and intensity of pruritus and the impact on the
patient's daily living activities, such as work, sleep, and school.
Skin emollients with histamine blockers, proteolytic enzyme creams, and antidepressants that are
histamine blocking are recommended for use throughout the day.
Nonpharmacologic treatment may help with comfort. Massage with hydrating lotions, the use of silicone
gels, cool cloth applications, oatmeal preparations, transcutaneous electrical nerve stimulation, and
localized pressure may all be helpful.

Ethical Issues
Patients should be respected and participate in their treatment decisions. If they are unable to do this, a
surrogate should be appointed.

Reference
1. ISBI Practice Guidelines Committee (2016). ISBI practice guidelines for burn care. Burns (5), 953-1021.
doi:10.1016/j.burns.2016.05.013