A major burn is defined as a burn covering 25% or more of total body surface area, but any injury over

more than 10% should be treated similarly. Rapid assessment is vital. he general approach to a major burn can be e!trapolated to managing any burn. he most important points are to ta"e an accurate history and ma"e a detailed e!amination of the patient and the burn, to ensure that "ey information is not missed.

#istory ta"ing he history of a burn injury can give valuable information about the nature and e!tent of the burn, the li"elihood of inhalational injury, the depth of burn, and probability of other injuries. he e!act mechanism of injury and any prehospital treatment must be established. A patient$s history must be obtained on admission, as this may be the only time that a first hand history is obtainable. %&elling may develop around the air&ay in the hours after injury and re'uire intubation, ma"ing it impossible for the patient to give a verbal history. A brief medical history should be ta"en, outlining previous medical problems, medications, allergies, and vaccinations. (atients$ smo"ing habits should be determined as these may affect blood gas analyses.

(rimary survey he initial management of a severely burnt patient is similar to that of any trauma patient. A modified )advanced trauma life support* primary survey is performed, &ith particular emphasis on assessment of the air&ay and breathing. he burn injury must not distract from this se'uential assessment, other&ise serious associated injuries may be missed. A+Air&ay &ith cervical spine control An assessment must be made as to &hether the air&ay is compromised or is at ris" of compromise. he cervical spine should be protected unless it is definitely not injured. ,nhalation of hot gases &ill result in a burn above the vocal cords. his burn &ill become oedematous over the follo&ing hours, especially after fluid resuscitation has begun. his means that an air&ay that is patent on arrival at hospital may occlude after admission. his can be a particular problem in small children. -irect inspection of the oropharyn! should be done by a senior anaesthetist. ,f there is any concern about the patency of the air&ay then intubation is the safest policy. #o&ever, an unnecessary intubation and sedation could &orsen a patient$s condition, so the decision to intubate should be made carefully. .+.reathing All burn patients should receive 100% o!ygen through a humidified non/rebreathing mas" on presentation. .reathing problems are considered to be those that affect the respiratory system belo& the vocal cords. here are several &ays that a burn injury can compromise respiration. Mechanical restriction of breathing+-eep dermal or full thic"ness circumferential burns of the chest can limit chest e!cursion and prevent ade'uate ventilation. his may re'uire escharotomies 0see ne!t article1.

Blast injury+,f there has been an e!plosion, blast lung can complicate ventilation. (enetrating injuries can cause tension pneumothoraces, and the blast itself can cause lung contusions and alveolar trauma and lead to adult respiratory distress syndrome. Acute bronchoscopy being performed to assess amount of damage to the bronchial tree. (atient has been covered in a blan"et and a heat lamp placed overhead to prevent e!cessive cooling Smoke inhalation+ he products of combustion, though cooled by the time they reach the lungs, act as direct irritants to the lungs, leading to bronchospasm, inflammation, and bronchorrhoea. he ciliary action of pneumocytes is impaired, e!acerbating the situation. he inflammatory e!udate created is not cleared, and atelectasis or pneumonia follo&s. he situation can be particularly severe in asthmatic patients. 2on/invasive management can be attempted, &ith nebulisers and positive pressure ventilation &ith some positive end/e!piratory pressure. #o&ever, patients may need a period of ventilation, as this allo&s ade'uate o!ygenation and permits regular lung toileting. Carboxyhaemoglobin+3arbon mono!ide binds to deo!yhaemoglobin &ith 40 times the affinity of o!ygen. ,t also binds to intracellular proteins, particularly the cytochrome o!idase path&ay. hese t&o effects lead to intracellular and e!tracellular hypo!ia. (ulse o!imetry cannot differentiate bet&een o!yhaemoglobin and carbo!yhaemoglobin, and may therefore give normal results. #o&ever, blood gas analysis &ill reveal metabolic acidosis and raised carbo!yhaemoglobin levels but may not sho& hypo!ia. reatment is &ith 100% o!ygen, &hich displaces carbon mono!ide from bound proteins si! times faster than does atmospheric o!ygen. (atients &ith carbo!yhaemoglobin levels greater than 25/50% should be ventilated. #yperbaric therapy is rarely practical and has not been proved to be advantageous. ,t ta"es longer to shift the carbon mono!ide from the cytochrome o!idase path&ay than from his article outlines the structure of the initial assessment. he ne!t article &ill cover the detailed assessment of burn surface area and depth and ho& to calculate the fluid resuscitation formula. #istory ta"ing he history of a burn injury can give valuable information about the nature and e!tent of the burn, the li"elihood of inhalational injury, the depth of burn, and probability of other injuries. he e!act mechanism of injury and any prehospital treatment must be established. A patient$s history must be obtained on admission, as this may be the only time that a first hand history is obtainable. %&elling may develop around the air&ay in the hours after injury and re'uire intubation, ma"ing it impossible for the patient to give a verbal history. A brief medical history should be ta"en, outlining previous medical problems, medications, allergies, and vaccinations. (atients$ smo"ing habits should be determined as these may affect blood gas analyses. (rimary survey he initial management of a severely burnt patient is similar to that of any trauma patient. A modified )advanced trauma life support* primary survey is performed, &ith particular emphasis on assessment of the air&ay and breathing. he burn injury must not distract from this se'uential assessment, other&ise serious associated injuries may be missed. A+Air&ay &ith cervical spine control An assessment must be made as to &hether the air&ay is compromised or is at ris" of compromise. he cervical spine should be protected unless it is definitely not injured. ,nhalation of hot gases &ill result in a burn above the vocal cords. his burn &ill become oedematous over the follo&ing hours, especially after fluid resuscitation has begun. his means that an air&ay that is patent on arrival at hospital may occlude after admission. his can be a particular problem in small children.

-irect inspection of the oropharyn! should be done by a senior anaesthetist. ,f there is any concern about the patency of the air&ay then intubation is the safest policy. #o&ever, an unnecessary intubation and sedation could &orsen a patient$s condition, so the decision to intubate should be made carefully. BBreathing All burn patients should receive 100% o!ygen through a humidified non/rebreathing mas" on presentation. .reathing problems are considered to be those that affect the respiratory system belo& the vocal cords. here are several &ays that a burn injury can compromise respiration. Mechanical restriction of breathing+-eep dermal or full thic"ness circumferential burns of the chest can limit chest e!cursion and prevent ade'uate ventilation. his may re'uire escharotomies 0see ne!t article1. Blast injury+,f there has been an e!plosion, blast lung can complicate ventilation. (enetrating injuries can cause tension pneumothoraces, and the blast itself can cause lung contusions and alveolar trauma and lead to adult respiratory distress syndrome. Smoke inhalation+ he products of combustion, though cooled by the time they reach the lungs, act as direct irritants to the lungs, leading to bronchospasm, inflammation, and bronchorrhoea. he ciliary action of pneumocytes is impaired, e!acerbating the situation. he inflammatory e!udate created is not cleared, and atelectasis or pneumonia follo&s. he situation can be particularly severe in asthmatic patients. 2on/invasive management can be attempted, &ith nebulisers and positive pressure ventilation &ith some positive end/e!piratory pressure. #o&ever, patients may need a period of ventilation, as this allo&s ade'uate o!ygenation and permits regular lung toileting. Carboxyhaemoglobin+3arbon mono!ide binds to deo!yhaemoglobin &ith 40 times the affinity of o!ygen. ,t also binds to intracellular proteins, particularly the cytochrome o!idase path&ay. hese t&o effects lead to intracellular and e!tracellular hypo!ia. (ulse o!imetry cannot differentiate bet&een o!yhaemoglobin and carbo!yhaemoglobin, and may therefore give normal results. #o&ever, blood gas analysis &ill reveal metabolic acidosis and raised carbo!yhaemoglobin levels but may not sho& hypo!ia. reatment is &ith 100% o!ygen, &hich displaces carbon mono!ide from bound proteins si! times faster than does atmospheric o!ygen. (atients &ith carbo!yhaemoglobin levels greater than 25/50% should be ventilated. #yperbaric therapy is rarely practical and has not been proved to be advantageous. ,t ta"es longer to shift the carbon mono!ide from the cytochrome o!idase path&ay than from haemoglobin, so o!ygen therapy should be continued until the metabolic acidosis has cleared.

3+3irculation ,ntravenous access should be established &ith t&o large bore cannulas preferably placed through unburnt tissue. his is an opportunity to ta"e blood for chec"ing full blood count, urea and electrolytes, blood group, and clotting screen. (eripheral circulation must be chec"ed. Any deep or full thic"ness circumferential e!tremity burn can act as a tourni'uet, especially once oedema develops after fluid resuscitation. his may not occur until some hours after the burn. ,f there is any suspicion of decreased perfusion due to circumferential burn, the tissue must be released &ith escharotomies

(rofound hypovolaemia is not the normal initial response to a burn. ,f a patient is hypotensive then it is may be due to delayed presentation, cardiogenic dysfunction, or an occult source of blood loss 0chest, abdomen, or pelvis1. -+2eurological disability All patients should be assessed for responsiveness &ith the 6lasgo& coma scale7 they may be confused because of hypo!ia or hypovolaemia. 8+8!posure &ith environment control he &hole of a patient should be e!amined 0including the bac"1 to get an accurate estimate of the burn area 0see later1 and to chec" for any concomitant injuries. .urn patients, especially children, easily become hypothermic. his &ill lead to hypoperfusion and deepening of burn &ounds. (atients should be covered and &armed as soon as possible.

9+9luid resuscitation he resuscitation regimen should be determined and begun. his is based on the estimation of the burn area, and the detailed calculation is covered in the ne!t article. A urinary catheter is mandatory in all adults &ith injuries covering : 20% of total body surface area to monitor urine output. 3hildren$s urine output can be monitored &ith e!ternal catchment devices or by &eighing nappies provided the injury is ; 20% of total body area. ,n children the interosseous route can be used for fluid administration if intravenous access cannot be obtained, but should be replaced by intravenous lines as soon as possible.

Analgesia %uperficial burns can be e!tremely painful. All patients &ith large burns should receive intravenous morphine at a dose appropriate to body &eight. his can be easily titrated against pain and respiratory depression. he need for further doses should be assessed &ithin 50 minutes. ,nvestigations he amount of investigations &ill vary &ith the type of burn.burn. %econdary survey At the end of the primary survey and the start of emergency management, a secondary survey should be performed. his is a head to toe e!amination to loo" for any concomitant injuries. -ressing the &ound

<nce the surface area and depth of a burn have been estimated, the burn &ound should be &ashed and any loose s"in removed. .listers should be deroofed for ease of dressing, e!cept for palmar blisters 0painful1, unless these are large enough to restrict movement. he burn should then be dressed. 9or an acute burn &hich &ill be referred to a burn centre, cling film is an ideal dressing as it protects the &ound, reduces heat and evaporative losses, and does not alter the &ound appearance. his &ill permit accurate evaluation by the burn team later. 9lama=ine should not be used on a burn that is to be referred immediately, since it ma"es assessment of depth more difficult. Referral to a burns unit he 2ational .urn 3are Revie& has established referral guidelines to specialist units. .urns are divided into comple! burns 0those that re'uire specialist intervention1 and non/comple! burns 0those that do not re'uire immediate admission to a specialist unit1. 3omple! burns should be referred automatically. ,f you are not sure &hether a burn should be referred, discuss the case &ith your local burns unit. ,t is also important to discuss all burns that are not healed &ithin t&o &ee"s.