Guideline sources The following summarized guidelines for the evaluation and management of burn injury are prepared by our editorial team based on guidelines from the Japanese Society for Burn Injuries (JSBI 2022), the American Burn Association (ABA 2020), the International Symposium on Biomedical Imaging (ISBI 2018), the Japanese Dermatological Association (JDA 2016), and the Society of Critical Care Medicine (SCCM/ASPEN 2016). 1 2 3 4 5 Calculator Calculator Calculator ABA Criteria for Transfer to a Bu Hand Burn Severity HABS score Rule of nin https://web.pathway.md/diseases/recm1DDwtPmVxVHwt 1/12 6/29/23, 3:22 AM Burn injury Pathway Guidelines 1. Classification and risk stratification Severity assessment: As per JSBI 2022 guidelines, use the following for measuring the burn area: rule of nines rule of fives lund and Browder's law palm method. E Show 2 more As per JDA 2016 guidelines, use a classification based on clinical symptoms for estimating the depth of burns. B Show 4 more Prognostic factors: As per JSBI 2022 guidelines, use burn area (percentage of the total BSA) as the most basic prognostic factor. Consider using the following as additional prognostic factors: age inhalation injury third-degree burn area burn index suicide attempt injury revised Trauma Score prognostic burn index. E As per JDA 2016 guidelines, use the presence or absence of airway damage, area of third- degree burn, burned area (percentage relative to the total BSA), prognostic burn index and burn index as prognostic factors. B 2. Diagnostic investigations Evaluation for inhalation injury: As per JSBI 2022 guidelines, consider obtaining chest CT and performing bronchoscopy for the diagnosis of inhalation injury. E As per JDA 2016 guidelines, ask about the circumstances of injury (injury in a narrow space due to inhalation of hot vapor or liquid) and look for physical findings (soot in the mouth or sputum, burned ends of nasal hair, burns of the face) suggesting airway burns. B Show 2 more https://web.pathway.md/diseases/recm1DDwtPmVxVHwt 2/12 6/29/23, 3:22 AM Burn injury Pathway Evaluation for burn wound infection: obtain swabs from the burn wound surface for infection surveillance of the burn wound after dressing and topical antimicrobial agents are removed and the burn wound surface is cleaned. E Show 2 more Assessment of pain: As per JSBI 2022 guidelines, obtain pain assessment multiple times per day, depending on the timing of treatment and, protocolize for pain. Consider using the BSPAS to assess pain in the acute phase of burn injury. E As per ABA 2020 guidelines, obtain pain assessment several times a day and during various phases of care. A Show 4 more Assessment of psychosocial factors: Screen patients for psychiatric and social risk factors impacting safety and well-being. Obtain the following screenings: Situation Guidance Mechanism of injury (self-inflicted or abuse/neglect), social support resources, housing and food resources, blood alcohol level Upon admission Depression, acute stress disorder/posttraumatic stress disorder, anxiety, substance use disorder During inpatient hospitalization Depression, acute stress disorder/posttraumatic stress disorder, anxiety, substance use disorder. E Within the first month of hospital discharge, then as needed thereafter Offer treatment within a burn center via a hospital consultation/liaison service or by a community outpatient provider in patients screened positive for psychiatric disorders. Ensure that burn centers have access to a psychology/psychiatry hospital consultation service for their inpatients and a list of mental health providers in the community. E 3. Respiratory support Endotracheal intubation: As per JSBI 2022 guidelines: Perform either prophylactic early intubation or intubation when symptoms of upper airway obstruction appear after careful monitoring, depending on the experience of the responding medical staff and the capacity of the treating facility. E Prefer non-benzodiazepine over benzodiazepine sedative drugs during tracheal intubation. E https://web.pathway.md/diseases/recm1DDwtPmVxVHwt 3/12 6/29/23, 3:22 AM Burn injury Pathway As per JDA 2016 guidelines, perform preventive intubation, if possible, in patients with suspected inhalation injury. B 4. Medical management Prehospital care: recognize that first aid begins with the first responder at the accident site and ends when primary care commences at a healthcare facility. Provide public education to improve knowledge about first aid and to optimize first responder action, as knowledge regarding adequate first aid is globally deficient. E Show 5 more Setting of care: As per JSBI 2022 guidelines, use the Artz's or Moylan's criteria to determine the need of inpatient treatment at a burn specialty treatment facility with a second-degree burn of 30% total BSA. Treat patients with second-degree burns 10% of BSA at a specialized burn treatment facility according to the Advanced Burn Life Support course of the American Burn Association. E Show 3 more As per ISBI 2018 guidelines, provide outpatient care for smaller burn injuries and for follow-up of patients with larger burns after completing their hospital treatment by burn centers. E Multidisciplinary care: As per JSBI 2022 guidelines, consider ensuring burn care by a multidisciplinary burn team to improve prognosis during the entire process from the acute phase to the chronic phase. E Show 4 more As per ISBI 2018 guidelines: Establish multidisciplinary burn care outreach programs by burn centers to support providers where travel is difficult in their region. E Ensure outpatient burn programs are multidisciplinary and include wound care, scar management, functional activities, and psychosocial consultation as needed. E Fluid resuscitation: As per JSBI 2022 guidelines, initiate initial fluid resuscitation in adult patients with burn area > 15% total BSA. E Show 8 more As per JDA 2016 guidelines, initiate fluid resuscitation in adult patients with a burned area of 15% total BSA and pediatric patients with a burned area of 10% total BSA. Consider initiating early fluid resuscitation in patients with a smaller burned area depending on the general condition. B Show 5 more Topical agents: As per JSBI 2022 guidelines, insufficient evidence to support the use of topical corticosteroids for the treatment of epidermal burns and second-degree dermal burns within 1 week of injury. https://web.pathway.md/diseases/recm1DDwtPmVxVHwt 4/12 6/29/23, 3:22 AM Burn injury Pathway Consider applying topical corticosteroids in patients with signs of local inflammation. Apply topical corticosteroids in the early stage of injury (approximately 2 days) while paying close attention to the side effects when used for their anti-inflammatory effects. I Show 3 more As per ISBI 2018 guidelines, apply a topical antimicrobial agent to most burn wounds because a burn wound infection may have serious consequences including wound conversion, invasive infection including sepsis, skin graft failure, and prolonged hospitalization. E Show 7 more As per JDA 2016 guidelines, consider applying ointments with the following oleaginous bases for initial treatment of patients with second-degree burns: petrolatum zinc oxide dimethyl isopropylazulene. C Show 6 more Pain management (general principles): recognize that pain related to burns is a complex combination of distress, anxiety, delirium, and situational and emotional factors. Ensure management, monitoring, and treatment of pain to optimize outcomes following burn injury. E Show 4 more Pain management, opioids: As per JSBI 2022 guidelines, consider administering IV opioids, in combination with other analgesics to reduce the dose of opioids, as the first choice for analgesia and opioid analgesics. E Show 2 more As per ABA 2020 guidelines, choose pain medication based on physiology, pharmacology, and physician experience, given the limited amount of high-quality data available. B Show 4 more Pain management, non-opioids: As per JSBI 2022 guidelines, administer non-opioid analgesics to reduce the amount of IV opioids in patients in the recovery stage of severe burns in general wards where monitoring and observation are reduced. E As per ABA 2020 guidelines, initiate acetaminophen in all patients with burn injury, with care taken to monitor maximal daily dose. B Show 7 more As per ISBI 2018 guidelines, initiate non-opioid analgesics and nonsteroidal anti-inflammatory agents for the treatment of burn pain. Consider using an individualized multimodal approach to burn pain management including agents from different classes. E Pain management, nonpharmacological: As per ABA 2020 guidelines, offer a nonpharmacological pain control technique at least as an adjunctive measure to pain control regimen in all patients with burn injury. Offer CBT, hypnosis, https://web.pathway.md/diseases/recm1DDwtPmVxVHwt 5/12 6/29/23, 3:22 AM Burn injury Pathway and virtual reality when expertise and/or equipment is available, as those have the strongest evidence. A As per ISBI 2018 guidelines, consider including nonpharmacologic techniques as important additional elements in the comprehensive post-burn pain management plan. E Prevention of infection: As per JSBI 2022 guidelines, recognize that infection-related conditions have been reported to influence the mortality of patients with burn injuries, followed by early shock/organ failure. E Show 3 more As per ISBI 2018 guidelines, ensure diligent compliance with infection control practices (physical isolation in a private room, use of gowns and gloves during patient contact, and hand washing before and after each patient visit) and use a laminar airflow isolation room to reduce the risk of burn wound infection with nosocomial bacteria. E Show 5 more As per JDA 2016 guidelines, administer tetanus toxoid or human tetanus immunoglobulin in patients with contaminated burns. B Show 2 more Management of wound infection: Initiate topical and systemic antimicrobial agents for the initial treatment of burn wound infections. Perform urgent surgical excision/debridement when the clinical and/or laboratory evidence indicates invasive burn wound infections. E Perform aggressive wide debridement of the infected areas and administer systemic antifungal agents in patients with fungal wound infections. E Management of pneumonia: obtain close monitoring for signs of pneumonia in intubated patients with either inhalation injury or burns 15-20%, as they are at significant risk for pneumonia. E Show 3 more Management of sepsis: view sepsis in patients with burns differently than sepsis in the non-burn general population. E Show 5 more Management of heart rate: consider administering oral or enteral nonselective -blockers to reduce HR in patients with burns aged 18 years after burn resuscitation. Obtain HR monitoring (at least pulse oximetry) to accompany dosage titration to achieve 75% of the admission HR. E Management of body temperature: maintain core body temperature and attempt to avoid heat loss in the acute phase for burns involving 20% of the total BSA, absent contraindications. E 5. Inpatient care Thromboprophylaxis: https://web.pathway.md/diseases/recm1DDwtPmVxVHwt 6/12 6/29/23, 3:22 AM Burn injury Pathway As per JSBI 2022 guidelines, insufficient evidence to recommend a specific method of risk assessment of DVT. Determine indications for prophylaxis against DVT in patients with burns according to the risk assessment of DVT in general inpatients and ICU patients. View the following as specific risks of DVT in patients with burns: burn area multiple surgeries inhalation injury. I Show 2 more As per ISBI 2018 guidelines, evaluate adult patients for DVT risk after burn injury and initiate chemoprophylaxis in patients with moderate-to-high risk unless a medical contraindication exists. E Show 2 more Sedation: recognize that anxiety and agitation occur frequently in patients with burns and are associated with adverse clinical outcomes. Consider administering sedatives in patients with burns to treat agitation and anxiety. E Show 6 more Considerations for vascular catheters: select the most appropriate vascular access device for the intended use. Take into account therapeutic needs, monitoring requirements, and the characteristics of each vascular access device. E Show 12 more Considerations for urinary catheters: insert catheters only for appropriate indications and leave them in place only as long as needed. E Show 5 more 6. Nonpharmacologic interventions Nutrition: As per JSBI 2022 guidelines, determine the amount of calories to be administered in each patient by measuring the amount of calories consumed at rest using an indirect calorimeter. E Show 6 more Landmark trials: RE-ENERGIZE In patients with deep second or third degree burns within 72 hours after hospital admission, glutamine was not superior to placebo with respect to time to discharge alive from hospital. Daren K Heyland et al. N Engl J Med. 2022 Sep 15. As per ISBI 2018 guidelines: https://web.pathway.md/diseases/recm1DDwtPmVxVHwt 7/12 6/29/23, 3:22 AM Burn injury Pathway Provide caloric requirement in patients with burns > 20% total burn surface area predominantly with carbohydrate and protein, and in accordance with the accepted formulas. Consider using pre-injury nutritional status, weight trend, the WHO growth charts, and indirect calorimetry to personalize this estimate of post-burn caloric needs. E Administer supplemental insulin to maintain a target blood glucose of approximately 150 mg/dL in the setting of aggressive nutritional support of burns > 20% total burn surface area if blood glucose is > 180 mg/dL. E As per SCCM 2016 guidelines, consider initiating enteral nutrition very early, if possible, within 4-6 hours of injury, in patients with burn injury. Provide enteral nutrition in patients with functional gastrointestinal tracts if their volitional intake is inadequate to meet estimated energy needs. E Show 3 more Hydrotherapy: As per JSBI 2022 guidelines, perform hydrotherapy to remove residual tissue from burn wounds and improve blood flow to promote wound healing. E As per JDA 2016 guidelines: Advise hydrotherapy in patients with minor burns not requiring hospitalization. B Consider performing hydrotherapy with anti-infection measures in patients with a stable general condition and in patients expected to benefit from hydrotherapy, because using shared equipment for hydrotherapy may induce nosocomial infections, such as P. aeruginosa and MRSA infections, and exacerbate the survival rate in patients with extensive severe burns. C 7. Therapeutic procedures Blood transfusion: administer blood transfusion in rare situations during burn resuscitation when associated traumatic injury causing significant blood loss is present. Administer blood transfusion during hospitalization based on clinical assessment and inform families of the risks of transfusion. E Show 5 more Platelet transfusion: As per JSBI 2022 guidelines, consider targeting 7-8 g/dL Hgb level for RBC transfusion in patients with acute burns. C Show 3 more As per ISBI 2018 guidelines, consider administering plasma and platelets in a 1:1 ratio, if resources permit, during massive surgical blood loss. E Regional anesthesia: consider performing regional anesthesia for burn pain management to improve pain relief, patient satisfaction, and reduce opioid use without serious risks or complications. C Fecal diversion tube: As per JSBI 2022 guidelines, place intrarectal catheter for defecation management to prevent perianal wound infection in patients with extensive burns having perianal wounds. E https://web.pathway.md/diseases/recm1DDwtPmVxVHwt 8/12 6/29/23, 3:22 AM Burn injury Pathway As per JDA 2016 guidelines, consider inserting a fecal diversion tube in patients with perianal burns in consideration of the patient's general condition and the state of the wound because it may reduce the frequency of gauze changes due to contamination by stools and the incidence of wound or UTI. C 8. Surgical interventions Wound disinfection: consider disinfecting burns by evaluating the condition of the wound along with the causative bacteria and antibacterial spectra of various drugs. C Dressing materials: As per JSBI 2022 guidelines, apply silver-containing hydrofiber wound dressings for local treatment of partial-thickness burns within 1 week of injury. A Show 2 more As per JDA 2016 guidelines, consider applying dressing materials such as hydrocolloid, hydrogel, polyurethane film, chitin, polyurethane foam, alginate, or hydrofiber for topical treatment of patients with second-degree burns. C Surgical excision: perform early excision of necrotic tissue at the early stage of injury for extensive burns (> 30% total BSA). B Epidermal grafts: perform cryopreserved allogeneic skin grafting at the time of surgery for extensive burns. B Show 2 more 9. Specific circumstances Pediatric patients: initiate initial fluid resuscitation in pediatric patients with burn area > 10% total BSA. E Show 4 more Patients with inhalation injury: As per JSBI 2022 guidelines, insufficient evidence to recommend an appropriate initial infusion rate in patients with inhalation injury. Initiate infusion with the Parkland (Baxter) or Advanced Burn Life Support formula, but administer more infusions subsequently. I Show 2 more As per JDA 2016 guidelines, insufficient evidence to support the use of corticosteroids (systemic or topical) for the treatment of inhalation injury. I Patients with chemical injury: As per JSBI 2022 guidelines: Irrigate the wound with water as soon as possible after injury for the purpose of removing or diluting the attached chemical agent. B https://web.pathway.md/diseases/recm1DDwtPmVxVHwt 9/12 6/29/23, 3:22 AM Burn injury Pathway Apply local calcium gluconate for initial treatment of chemical injuries caused by hydrofluoric acid. B As per ISBI 2018 guidelines, remove the chemical agent immediately to mitigate ongoing injury to the skin and absorption of the chemical. E Show 3 more Patients with electrical injury: As per JSBI 2022 guidelines, obtain a 12-lead ECG in the initial evaluation of patients with electrical burns. B Show 2 more As per ISBI 2018 guidelines, obtain an ECG in patients with low-voltage electrical burns (< 1,000 volts), and otherwise, manage similarly to any other thermal injury adhering to admission criteria. E Show 3 more 10. Follow-up and surveillance Rehabilitation: As per JSBI 2022 guidelines, offer early rehabilitation, including respiratory physiotherapy, postural drainage, and early mobilization to prevent respiratory complications, in patients with burns. B Show 3 more As per ISBI 2018 guidelines, initiate early mobilization, including assisted ambulation, as soon as possible after burn injury. Initiate mobility and ambulation as early as possible with burn survivors regardless of the size of burn injury. E Show 11 more Clinical findings Symptoms Past medical history Confusion Sepsis Hoarseness Traumatic injury Hypoesthesia Neurological exam Pain Shortness of breath Altered mental status Vomiting Respiratory exam Vital signs Laryngeal edema Hypoxemia Soot in sputum Signs of shock Stridor Tachypnea https://web.pathway.md/diseases/recm1DDwtPmVxVHwt 10/12 6/29/23, 3:22 AM Burn injury Pathway Lab findings Head and neck exam Metabolic acidosis Oral mucosal erythema blood COHb Integument exam serum creatinine serum lactate Contractures urine myoglobin Cyanosis Skin blisters Skin erythema Studies 2022 RE-ENERGIZE In patients with deep second or third degree burns within 72 hours after hospital admission, glutamine was not superior to placebo with respect to time to discharge alive from hospital. Daren K Heyland et al. N Engl J Med. 2022 Sep 15. References 1. ISBI Practice Guidelines Committee, Advisory Subcommittee, Steering Subcommittee. ISBI Practice Guidelines for Burn Care, Part 2. Burns. 2018 Nov;44 7 1617 1706. Open 2. Junichi Sasaki, Asako Matsushima, Hiroto Ikeda et al. The Japanese Society for Burn Injuries JSBI Clinical Practice Guidelines for Management of Burn Care 3rd Edition). Acute Med Surg. 2022 Apr 27;9 1):e739. Open 3. Kathleen S Romanowski, Joshua Carson, Kate Pape et al. American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps. J Burn Care Res. 2020 Nov 30;41 6 1129 1151. Open 4. Yuichiro Yoshino, Mikio Ohtsuka, Masakazu Kawaguchi et al. The wound/burn guidelines 6 Guidelines for the management of burns. J Dermatol. 2016 Sep;43 9 989 1010. Open 5. McClave SA, Taylor BE, Martindale RG et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine SCCM and American Society for Parenteral and Enteral Nutrition A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016 Feb;40 2 159 211. Open 6. Brett Arnoldo, Matthew Klein, Nicole S Gibran. Practice guidelines for the management of electrical injuries. J Burn Care Res. Jul-Aug 2006;27 4 439 47. Open 7. C line G linas, Martine Fortier, Chantal Viens et al. Pain assessment and management in critically ill intubated patients: a retrospective study. Am J Crit Care. 2004 Mar;13 2 126 35. Open 8. Anand Padmanabhan, Laura Connelly-Smith, Nicole Aqui et al. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher. 2019 Jun;34 3 171 354. Open https://web.pathway.md/diseases/recm1DDwtPmVxVHwt 11/12 6/29/23, 3:22 AM Burn injury Pathway 9. Wallace AB. The exposure treatment of burns. Lancet. 1951 Mar 3;1 6653 501 4. Open 10. Sarah E Bache, Edmund Fitzgerald O'Connor, Evgenia Theodorakopoulou et al. The Hand Burn Severity HABS score: A simple tool for stratifying severity of hand burns. Burns. 2017 Feb;43 1 93 99. Open 11. American Burn Association/American College of Surgeons. Guidelines for the operation of burn centers. J Burn Care Res. Jan-Feb 2007;28 1 134 41. Open 12. ISBI Practice Guidelines Committee, Steering Subcommittee, Advisory Subcommittee. ISBI Practice Guidelines for Burn Care. Burns. 2016 Aug;42 5 953 1021. Open 13. Daren K Heyland, Lucy Wibbenmeyer, Jonathan A Pollack et al. A Randomized Trial of Enteral Glutamine for Treatment of Burn Injuries. N Engl J Med. 2022 Sep 15;387 11 1001 1010. Open 14. DAS Taskforce, Ralf Baron, Andreas Binder et al. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 DAS Guideline 2015 short version. Ger Med Sci. 2015 Nov 12;13 Doc19. Open https://web.pathway.md/diseases/recm1DDwtPmVxVHwt 12/12