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cc.burn-management.core.v1PRODUCTION
cc.burn-management.core.v1

Burn management (acute resuscitation + transfer triage)

critical_careacuteadultpediatric
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Determine burn severity scope; identify ABA-transfer-criteria patients early (ABA 2023)

Inputs
2
Actions
0
Advance rule
Set
Advance when

Mechanism + co-exposure scope captured (ATLS 2018)

Patient inputs (16)

Lund-Browder vs Wallace; pediatric resuscitation thresholds (ISBI 2018; ABA 2023)

Parkland: 4 mL × kg × %TBSA — weight is mandatory (Baxter 1968; ABA 2023)

Thermal vs chemical vs electrical drives workup + decontam (ATLS 2018; Jeschke Lancet 2020)

Drives CO + cyanide co-exposure pathway (ATLS 2018; Baud 2002)

Resuscitation clock starts at injury — back-calculate fluid (Baxter 1968; ABA 2023)

Note: pulse ox is FALSELY normal in CO; need CO-oximetry (ATLS 2018)

Hemodynamics drive resuscitation rate (ABA 2023)

Tachycardia is early under-resuscitation signal (ABA 2023)

Wallace 9s (adult) / Lund-Browder (peds); drives Parkland volume + ABA criteria (ABA 2023; ISBI 2018)

Superficial / partial / full-thickness — counts toward Parkland (ABA 2023; NICE 2024 burns)

Cyanide co-exposure (lactate >10) → empiric Cyanokit (Baud 2002)

Baseline; rhabdo/AKI screen in electrical burn (ABA 2023)

Resuscitation target 0.5 mL/kg/h adult, 1 mL/kg/h peds (ABA 2023; Baxter 1968)

Rhabdomyolysis screen in electrical / deep burn (ABA 2023; Jeschke Lancet 2020)

CO co-exposure — HBO criteria + airway management (ATLS 2018)

Inhalation injury baseline; ARDS evolution (ATLS 2018)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateninginhalation_injury_or_facial_burn
    Facial burn, singed nasal hair, hoarseness, stridor, soot in oropharynx, enclosed-space fire (ATLS 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcircumferential_burn_compartment
    Circumferential burn (extremity, chest, neck) with signs of vascular/respiratory compromise (ABA 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcyanide_co_exposure_fire_lactate_high
    Fire victim + lactate >10 OR cardiac arrest OR severe unexplained acidosis (Baud 2002)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaba_transfer_criteria_met
    Partial-thickness >10% TBSA OR full-thickness >5% OR face/hands/feet/genitalia/joints OR electrical OR chemical OR inhalation OR comorbid trauma OR pediatric burn (ABA 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefluid_creep_over_6ml_kg_tbsa
    Resuscitation requirement exceeds 6 mL/kg/%TBSA (Ivy Index — ISBI 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepediatric_burn_special_thresholds
    Pediatric burn (<5 years): TBSA ≥10% OR any partial-thickness >5% OR full-thickness >2% (ABA 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereelectrical_burn_arrhythmia_rhabdo
    Electrical burn (especially high-voltage) with ECG abnormality, arrhythmia, or CK >5000 (ABA 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

Burn resuscitation — Parkland fluids + airway + analgesia + topical care + tetanus + cyanide rescue
axis: burn_resuscitation_and_supportivestep 1 - Step 1 — Airway first (early intubation if inhalation injury)
Selected step "Step 1 — Airway first (early intubation if inhalation injury)" — Facial burn, singed nasal hair, hoarseness, stridor, soot in airway, enclosed-space exposure, or AMS

ed playbook — drug actions (5)

  1. 1. lactated_ringers_parkland
    rxcui 20614
    Parkland: 4 mL × kg × %TBSA — half in first 8 h from time of injury (Baxter 1968) • IV • continuous
    trigger: TBSA ≥15% adult / ≥10% peds-elderly / full-thickness ≥5% (ABA 2023)
    ABA 2023 standard fluid resuscitation
  2. 2. opioid_analgesia
    Morphine 0.05-0.1 mg/kg IV OR fentanyl 1-2 mcg/kg IV • IV • q1-2h PRN
    trigger: Burn pain
    IV only (not IM — unpredictable in shock — ABA 2023)
  3. 3. tetanus_prophylaxis
    Td/Tdap 0.5 mL IM; TIG 250 IU IM if non-immunised • IM • once
    trigger: Beyond superficial burn + uncertain tetanus status
    CDC ACIP tetanus prophylaxis (ABA 2023)
  4. 4. hydroxocobalamin_if_fire
    5 g IV (70 mg/kg peds) • IV • over 15 min; can repeat once
    trigger: Enclosed-space fire + lactate >10 OR cardiac arrest (Baud 2002)
    Cyanide empiric in fire victim (Baud 2002; ABA 2023)
  5. 5. silver_sulfadiazine_topical
    1/16-inch layer • topical • BID after wound cleansing
    trigger: Partial-thickness burns, awaiting transfer or admission
    First-line topical antimicrobial (NICE 2024 burns; ABA 2023)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Thermal / chemical / electrical burn injury (ABA 2023; ATLS 2018); Enclosed-space fire / smoke inhalation (ATLS 2018; Jeschke Lancet 2020); Facial burn, singed nasal hair, hoarseness, stridor (ATLS 2018).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Burn management (acute resuscitation + transfer triage)** (cc.burn-management.core.v1).
Phenotype framing: Differentiate isolated burn vs polytrauma vs SJS/TEN/staphylococcal scalded skin (especially peds) vs erythroderma (Jeschke Lancet 2020)
Scope: Determine burn severity scope; identify ABA-transfer-criteria patients early (ABA 2023)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Burn resuscitation — Parkland fluids + airway + analgesia + topical care + tetanus + cyanide rescue** — step "Step 1 — Airway first (early intubation if inhalation injury)".

Setting playbook (ed) — Secure airway, calculate TBSA + Parkland, initiate fluid resuscitation, screen for inhalation/CO/cyanide, transfer to burn centre per ABA 2023
1. lactated_ringers_parkland Parkland: 4 mL × kg × %TBSA — half in first 8 h from time of injury (Baxter 1968) IV continuous — TBSA ≥15% adult / ≥10% peds-elderly / full-thickness ≥5% (ABA 2023) (ABA 2023 standard fluid resuscitation)
2. opioid_analgesia Morphine 0.05-0.1 mg/kg IV OR fentanyl 1-2 mcg/kg IV IV q1-2h PRN — Burn pain (IV only (not IM — unpredictable in shock — ABA 2023))
3. tetanus_prophylaxis Td/Tdap 0.5 mL IM; TIG 250 IU IM if non-immunised IM once — Beyond superficial burn + uncertain tetanus status (CDC ACIP tetanus prophylaxis (ABA 2023))
4. hydroxocobalamin_if_fire 5 g IV (70 mg/kg peds) IV over 15 min; can repeat once — Enclosed-space fire + lactate >10 OR cardiac arrest (Baud 2002) (Cyanide empiric in fire victim (Baud 2002; ABA 2023))
5. silver_sulfadiazine_topical 1/16-inch layer topical BID after wound cleansing — Partial-thickness burns, awaiting transfer or admission (First-line topical antimicrobial (NICE 2024 burns; ABA 2023))

Non-pharmacologic actions:
- Early intubation if facial/inhalation/airway compromise — DO NOT WAIT for stridor (rapid airway oedema — ATLS 2018)
- Use ketamine + rocuronium for induction (ketamine bronchodilator — ABA 2023)
- Cool burn briefly with running water (5-10 min) within first hour; AVOID prolonged cooling (hypothermia — NICE 2024 burns)
- Wrap burns in clean dry dressings after cooling (NICE 2024 burns)
- NG tube for large burns / paralytic ileus prevention (ABA 2023)
- Foley catheter for hourly UOP (ABA 2023; Baxter 1968)
- Stop the burning (remove clothes, irrigation for chemical, electrical secondary survey — ATLS 2018)
- Compartment syndrome assessment if circumferential — escharotomy by surgeon (ABA 2023; Jeschke Lancet 2020)
- ABA criteria check: partial >10%, full >5%, face/hands/feet/genitalia/joints, electrical, chemical, inhalation, comorbid trauma, peds (<5y or >65y) — TRANSFER to burn centre (ABA 2023)
- Avoid hypothermia (ambient 28°C, warm blankets, warmed fluids — ISBI 2018)

AVOID / contraindication checks:
- No_silver_sulfadiazine_on_face_or_in_G6PD_or_late_pregnancy (ABA 2023; NICE 2024 burns)
- LR_preferred_over_NS_to_avoid_hyperchloremic_acidosis (ABA 2023)
- Fluid_creep_avoid_more_than_6mL_kg_TBSA_consider_colloid (ISBI 2018)
- Circumferential_burn_check_for_compartment_syndrome_escharotomy (ABA 2023)
- No_IM_meds_in_shock_state_unpredictable_absorption (ABA 2023)

Monitoring

Regimen monitoring:
- hourly UOP target 0.5 adult 1.0 peds mL kg h (ABA 2023; Baxter 1968)
- BP q15min initially then q1h (ATLS 2018)
- continuous cardiac SpO2 (ABA 2023)
- lactate q4-6h until clearing (ABA 2023)
- ABG q4-6h (ABA 2023)
- daily CMP CK INR (ABA 2023)
- temperature continuous avoid hypothermia (ISBI 2018)
- compartment pressure if circumferential (ABA 2023; Jeschke Lancet 2020)
- wound inspection q12h (NICE 2024 burns)

Setting (ed) monitoring:
- UOP hourly (0.5 mL/kg/h adult, 1 mL/kg/h peds — ABA 2023; Baxter 1968)
- BP, HR, SpO2 q15min initially (ATLS 2018)
- Lactate q4-6h (ABA 2023)
- ABG q4-6h (ABA 2023)
- Temperature continuous (ISBI 2018)

Follow-up plan: Burn-centre follow-up if transferred; physiotherapy; scar management; psychosocial / SW; return precautions for infection (ABA 2023; NICE 2024 burns)
- Close-out criterion: Outpatient burn-centre or PCP follow-up booked

Monitoring phase: 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)

Disposition

Current setting: ed — Secure airway, calculate TBSA + Parkland, initiate fluid resuscitation, screen for inhalation/CO/cyanide, transfer to burn centre per ABA 2023

Disposition criteria:
- Discharge home: superficial / minor partial-thickness <10%, no airway / inhalation, no comorbidity, follow-up arranged, tetanus updated (ABA 2023; NICE 2024 burns)
- Admit ward: 10-20% TBSA partial-thickness, no inhalation/co-exposure, no ABA criteria (ABA 2023)
- Admit ICU: ≥20% TBSA, inhalation, electrical, AMS, comorbid trauma (ABA 2023)
- Transfer to burn centre per ABA criteria (ABA 2023)

Escalation triggers (move to higher acuity):
- Airway concern → intubate now (ATLS 2018)
- TBSA ≥20% (≥10% peds) → ICU + burn centre (ABA 2023)
- Inhalation injury → ICU + bronchoscopy + ABA transfer (ABA 2023)
- Cyanide suspected (fire + lactate >10) → hydroxocobalamin + ICU (Baud 2002)
- Compartment syndrome → escharotomy + surgical consult (ABA 2023; Jeschke Lancet 2020)
- Electrical burn → ECG + CK + cardiac monitor + UOP target 1-2 mL/kg/h (ABA 2023)
- Hemodynamically unstable despite Parkland → reassess for hidden trauma, cyanide, CO (ATLS 2018)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Facial burn, singed nasal hair, hoarseness, stridor, soot in oropharynx, enclosed-space fire (ATLS 2018)
- [LIFE_THREATENING] Circumferential burn (extremity, chest, neck) with signs of vascular/respiratory compromise (ABA 2023)
- [LIFE_THREATENING] Fire victim + lactate >10 OR cardiac arrest OR severe unexplained acidosis (Baud 2002)

Citations

- ABA Clinical Practice Guidelines on Burn Shock Resuscitation 2024 + evidence-based inhalation-injury management review + hydroxocobalamin smoke-inhalation cyanide evidence + initial major-burn evaluation/transfer review [PMID:38051821](https://pubmed.ncbi.nlm.nih.gov/38051821/)
- Cited evidence (PMID 29398078) [PMID:29398078](https://pubmed.ncbi.nlm.nih.gov/29398078/)
- Cited evidence (PMID 17481777) [PMID:17481777](https://pubmed.ncbi.nlm.nih.gov/17481777/)
- Cited evidence (PMID 14699814) [PMID:14699814](https://pubmed.ncbi.nlm.nih.gov/14699814/)

Last reconciled with current guidelines: 2026-05-22.
References
  • ABA Clinical Practice Guidelines on Burn Shock Resuscitation 2024 + evidence-based inhalation-injury management review + hydroxocobalamin smoke-inhalation cyanide evidence + initial major-burn evaluation/transfer review — PMID:38051821
  • Cited evidence (PMID 29398078) — PMID:29398078
  • Cited evidence (PMID 17481777) — PMID:17481777
  • Cited evidence (PMID 14699814) — PMID:14699814