Clinical Commander

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cc.burn-management.core.v1

Burn management (acute resuscitation + transfer triage)

critical_careacuteadultpediatricacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is a batch-23 scaffold (defineBatch23ScaffoldManifest); evidenceIds is the placeholder ev_burn_management_guideline_review_required. Package directory cutaneous-burns exists with atoms.* + context.* + regimen.ts but no _design-brief.md and no engine-specific tests. Calculator gaps in clinical-tools-registry.ts: Parkland formula, Wallace rule of 9s, Lund-Browder, ABA transfer criteria, Baux-revised — none are registered as calc.* entries; flag for INTEGRATED. Regimen axes empty until LR, hydroxocobalamin (Cyanokit), opioid analgesia, and tetanus are RxNav-validated and seeded. Fluid resuscitation runs through src/lib/systems/fluid-command/fluid-command.service.ts (cascade.fluid). PRODUCTION blockers: terminology codes, evidence PMIDs, calculator registry entries, regimen seeds, dedicated tests. Deepened 2026-04-27: regimen ladder (airway → Parkland LR → analgesia + tetanus + topical antimicrobial → cyanide rescue if fire) + albumin/NS adjuncts + pediatric maintenance, ED + ICU playbooks, 7 severity triggers (inhalation, ABA criteria, circumferential, fluid creep, cyanide co-exposure, peds, electrical), siblings vs CO-poisoning and post-arrest. RxCUI 20614 (LR) + 7407 (NS) reused; opioid/SSD/hydroxocobalamin RxCUIs left undefined.

Entry points (4)

  • symptom
    Thermal / chemical / electrical burn injury (ABA 2023; ATLS 2018)
    thermal_burn_injury
  • symptom
    Enclosed-space fire / smoke inhalation (ATLS 2018; Jeschke Lancet 2020)
    enclosed_space_fire_exposure
  • symptom
    Facial burn, singed nasal hair, hoarseness, stridor (ATLS 2018)
    facial_or_airway_burn
  • symptom
    Estimated TBSA ≥10% (peds ≥5%) or full-thickness ≥3% (ABA 2023)
    large_tbsa_burn

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Lund-Browder vs Wallace; pediatric resuscitation thresholds (ISBI 2018; ABA 2023)
  • weight_kgrequired
    demographic • used at CONTEXT
    Parkland: 4 mL × kg × %TBSA — weight is mandatory (Baxter 1968; ABA 2023)
  • mechanismrequired
    history • used at CONTEXT
    Thermal vs chemical vs electrical drives workup + decontam (ATLS 2018; Jeschke Lancet 2020)
  • enclosed_space_or_smokerequired
    history • used at CONTEXT
    Drives CO + cyanide co-exposure pathway (ATLS 2018; Baud 2002)
  • time_of_burnrequired
    history • used at CONTEXT
    Resuscitation clock starts at injury — back-calculate fluid (Baxter 1968; ABA 2023)
  • spo2required
    vital • used at CONTEXT
    Note: pulse ox is FALSELY normal in CO; need CO-oximetry (ATLS 2018)
  • sbprequired
    vital • used at CONTEXT
    Hemodynamics drive resuscitation rate (ABA 2023)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia is early under-resuscitation signal (ABA 2023)
  • urine_output_mlkghrequired
    vital • used at TREATMENT
    Resuscitation target 0.5 mL/kg/h adult, 1 mL/kg/h peds (ABA 2023; Baxter 1968)
  • tbsa_percentrequired
    symptom • used at INITIAL_WORKUP
    Wallace 9s (adult) / Lund-Browder (peds); drives Parkland volume + ABA criteria (ABA 2023; ISBI 2018)
  • burn_depthrequired
    symptom • used at INITIAL_WORKUP
    Superficial / partial / full-thickness — counts toward Parkland (ABA 2023; NICE 2024 burns)
  • carboxyhemoglobin
    lab • used at INITIAL_WORKUP
    CO co-exposure — HBO criteria + airway management (ATLS 2018)
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Cyanide co-exposure (lactate >10) → empiric Cyanokit (Baud 2002)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Baseline; rhabdo/AKI screen in electrical burn (ABA 2023)
  • creatine_kinase
    lab • used at BRANCHING_WORKUP
    Rhabdomyolysis screen in electrical / deep burn (ABA 2023; Jeschke Lancet 2020)
  • cxr
    imaging • used at INITIAL_WORKUP
    Inhalation injury baseline; ARDS evolution (ATLS 2018)

12-phase flow (12)

  1. 1FRAME
    Determine burn severity scope; identify ABA-transfer-criteria patients early (ABA 2023)
    inputs: mechanism, enclosed_space_or_smoke
    advance: Mechanism + co-exposure scope captured (ATLS 2018)
  2. 2ENTRY
    Recognize burn injury, airway concern, or large TBSA at triage (ATLS 2018; ABA 2023)
    inputs: age, weight_kg, time_of_burn
    advance: Demographics + injury time documented
  3. 3CONTEXT
    Capture comorbidities, baseline weight, PMH, anticoagulation, tetanus status (ABA 2023)
    inputs: sbp, hr, spo2
    advance: Hemodynamics + risk modifiers captured
  4. 4RED_FLAGS
    Airway compromise (facial/inhalation — ATLS 2018), TBSA ≥20% (≥10% peds), full-thickness ≥5%, electrical, chemical, circumferential, suspected cyanide (ABA 2023; Baud 2002)
    inputs: enclosed_space_or_smoke, tbsa_percent, burn_depth
    advance: Airway secured if at risk; ABA transfer initiated if criteria met (ABA 2023)
  5. 5INITIAL_WORKUP
    TBSA mapping (Wallace/Lund-Browder — ISBI 2018), depth assessment, CMP, lactate, COHb, ABG, CBC, CK, type+screen, CXR if inhalation (ABA 2023; ATLS 2018)
    inputs: tbsa_percent, burn_depth, lactate, creatinine
    actions: burn_management, panel.abg, panel.renal, panel.cardiac
    advance: %TBSA documented + co-exposure status known
  6. 6BRANCHING_WORKUP
    Inhalation → bronchoscopy + early intubation (ATLS 2018); electrical → ECG/CK/UOP (ABA 2023); chemical → decontam pathway (NICE 2024 burns)
    inputs: carboxyhemoglobin, creatine_kinase
    advance: Specific injury subtype workup launched
  7. 7DIFFERENTIAL
    Differentiate isolated burn vs polytrauma vs SJS/TEN/staphylococcal scalded skin (especially peds) vs erythroderma (Jeschke Lancet 2020)
    advance: Burn confirmed as primary process
  8. 8RISK_STRATIFICATION
    ABA transfer criteria (ABA 2023); Baux-revised mortality estimate; ICU vs ward; pediatric burn-centre triage (ISBI 2018)
    inputs: tbsa_percent, age
    advance: Disposition tier set
  9. 9TREATMENT
    Airway first (early intubation if facial/inhalation — ATLS 2018); Parkland 4 mL × kg × %TBSA over 24 h (½ in first 8 h from time of injury — Baxter 1968; ABA 2023); LR preferred; titrate to UOP 0.5 mL/kg/h adult / 1 mL/kg/h peds; analgesia; tetanus; topical care; escharotomy if circumferential; Cyanokit if cyanide suspected (Baud 2002)
    inputs: weight_kg, tbsa_percent, urine_output_mlkgh
    actions: cascade.fluid
    advance: Resuscitation rate set + UOP target met
  10. 10DISPOSITION
    ABA-criteria transfer to burn centre (ABA 2023); ICU for inhalation/large TBSA/electrical; pediatric centre for kids (ISBI 2018)
    advance: Disposition + transfer (if indicated) executed
  11. 11MONITORING
    Hourly UOP (ABA 2023), vitals q1h, lactate trend, ABG q4–6h, daily CK, daily CMP, BP cuff above burn-free area, pain reassessment (ISBI 2018; Jeschke Lancet 2020)
    inputs: urine_output_mlkgh, lactate
    actions: panel.abg, panel.renal
    advance: Resuscitation goals met without over-resuscitation
  12. 12FOLLOWUP
    Burn-centre follow-up if transferred; physiotherapy; scar management; psychosocial / SW; return precautions for infection (ABA 2023; NICE 2024 burns)
    advance: Outpatient burn-centre or PCP follow-up booked