Title of Guideline

The management of patients with

Burns on Adult Critical Care
Contact Name and Job Dr Martin Levitt,
Title (author)
Consultant in Intensive Care, Critical Care, NUH
Dr Martin Beed
Consultant in Intensive Care, Critical Care, NUH
Directorate & Speciality Specialist Support
Adult Critical Care
Date of submission 1/12/2013
Date on which 1/12/2018
guideline must be
reviewed
Explicit definition of Applies to all adult patients requiring Critical Care admission
patient group to which it
applies (e.g. inclusion for management of Burns
and exclusion criteria, Excludes: All paediatric cases
diagnosis)
Abstract This guideline describes the procedures and management
plan associated with the Critical Care Management of the
above patients.
Management and care are shared between Burns Team
and the ICU Team
Key Words Burns, Adult critical care
Evidence base of the guideline:
Peer reviewed by: NUH critical care consultants; Critical care cross-town
guidelines group
Evidence base: (1-5)
4 expert committee reports or opinions and / or clinical experiences of respected authorities
5 recommended best practice based on the clinical experience of the guideline developer
Consultation Process Cross-town guidelines group
Burns and dermatology consultants
Target audience Medical and nursing staff all adult critical care areas
This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The
interpretation and application of clinical guidelines will remain the responsibility of the individual
clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines
after the review date.

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 1 of 24
 NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST
CRITICAL CARE GUIDELINES

Guidance for the management of patients with Burns in Adult Critical Care

Summary of Guidance
1. Referrals and Admission Criteria
All burns referrals will be discussed with a Burns Surgeon and an ICU consultant.
These are only a guide – some larger or more complex burns may have to remain in Nottingham (for example if
Birmingham cannot accommodate) – the final decision remains with the Burns Surgeon and ICU Consultant

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 2 of 24
2. Safe Transfer

It is the responsibility of the person accepting the admission to advise the referring Hospital on best
practice for safe transfer for the inured patient. It should not be assumed that this will happen
automatically.
A pre-transfer document is available on the Midlands Burn Operational Delivery Network website
http://www.midlandsburnnetwork.nhs.uk
Airway &  Patients at risk of airway compromise should have an endotracheal tube inserted.
Ventilation
If there is any doubt as to the risk of airway compromise then the patient must be
reviewed by a senior anaesthetist prior to transfer
 If airway protection is required then patients must be intubated with an uncut
oral ETT and tube secured with ties
 A chest X ray should confirm tube position 2-3 cm above carina
 Intubated patients will be sedated and mechanically ventilated during transfer
 If carboxyhaemoglobin levels are raised (>5%) or cannot be measured, the
patient should remain on 100% O2 during transfer
IV access &  IV access should include 2 x wide bore IV access
Circulation
 Patient must be stabilised and receiving appropriate resuscitation fluids which
will continue during transfer
 An arterial line should ideally be sited for transfer. CVC lines are desirable but
are not essential for transfer, and should not delay transfer (unless other IV
access is not possible)
Other If at all possible, prior to transfer
 A urinary catheter should be inserted
 A nasogastric tube should be inserted
Temperature  Efforts to prevent loss of core temperature should be instituted
control
 Core temperature should be monitored if possible
Safe Transfer  Transfers should be carried out according to the protocols of Mid Trent Critical
Care Network by a senior anaesthetist trained in inter- hospital transfer
 Formal handover from the transfer team will occur on City Critical Care,
including appropriate handover/transfer monitoring documentation

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 3 of 24
3. On Admission to Critical Care

On admission all burns admissions will be assessed by:

 An intensive care consultant (or senior trainee experienced in the management of burns patients)
 A burns consultant or senior plastic surgery trainee who is experienced in the management of
burns patients (Specialist burns anaesthetists may also be available to assess the patient)
Initial  The burns registrar or trainee will document the extent and type of burns
Assessment  The intensive care trainee will document a full assessment of the patient, including
a Tertiary Survey to exclude trauma or other injury (including ophthalmic injuries)
Airway  On admission the Critical Care team will verify the position and security of the
ETT, or of the safety of the airway should the patient not be intubated.
 Ensure the tube is uncut, if it is not the airway is at risk - inform the ICU consultant
 Once the ETT position has been confirmed as being appropriate the position at the
front teeth or gums should be documented, and the tube marked
 Decisions to extubate a patient transferred for burn management can only be made
by Consultant Critical Care or Burns anaesthetists and are unlikely to be made in
the first 24 hours after admission
Ventilation  All ventilated patients should be established on “lung protective strategy
ventilation” using tidal volumes of 5-7 ml/kg, high PEEP and avoiding high peak
airway pressures.
 Patients with elevated carboxyhaemoglobin (COHb) levels on initial blood gas
should be ventilated with an Fi02 of 100% until COHb levels fall to < 5%
Inhalational  Intubated patients at risk of direct thermal airway injury (or who have been
injury involved in enclosed space fires) should have fibre-optic bronchoscopy to confirm
the extent of the injury (and also perform therapeutic manoeuvres if required)
 In intubated patients with significant airway injury consider commencing nebulised
saline and also nebulised acetyl cysteine
Fluid Patients will have been commenced on the Baxter-Parklands fluid resuscitation by the
resuscitation transferring department
 Convert to Muir and Barclay fluid resuscitation using Human Albumin Solution
4.5%. This should be done at a suitable point (typically at 8 hours or at 24 hours
after injury). The burns doctor will assist in this calculation
 Commence maintenance crystalloids at a rate of 1 ml/kg/hour (Hartmann’s initially
or equivalent) alongside calculated resuscitation fluids – this is avoided prior to
transfer and should be reduced once enteral feeding has been established
 Commence cardiac output monitoring in most patients (using either trans-
oesophageal Doppler, LiDCO or Vigileo), target parameters include:
o MAP 70mmHg (or near normal BP if this is known)
o Urine output (UOP) 0.5ml/kg (averaged over 4 hours) - more if
rhabdomyolysis is present
o Stroke Volume Variation <10% (in patients who are not spontaneously
breathing) or cardiac index >4L/min/m2
o Lactate <2mmol/L
o Lactate and UOP are the prime indicators of resuscitation status, and if

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 4 of 24
 these are adequate moderate hypotension may be tolerated in order to
avoid vasopressors or excessive fluid resuscitation
 If extra fluid support is required to support the patient the boluses of 250 mls
Human Albumin Solution 4.5%. Each bolus should result in a 5-10% increase in
Stroke Volume (SV)
o If two sequential boluses do not result in a 10% increase in SV then discuss
with a consultant whether or not inotrope or vasopressor support is required –
do not commence these without discussion
o It is unusual to require vasopressors in the initial resuscitation period.
Noradrenaline should only be instituted once adequate volume resuscitation
and cardiac output have been assured
o Some burn patients have an unexpectedly low cardiac output at presentation
and my require inotropic support using dobutamine
Environment  The patient should be kept in a warm environment (>30oC), ideally in a room rather
than the open ward
 Core temperature measurement should be commenced using either an oesophageal
or catheter temperature probe
 Peripheral temperature measurement should also be commenced
Faecal wound  Patients with proximal lower extremity or perineal burns should have a faecal
contamination management system inserted and be commenced on stool softening agents (if in
doubt discuss with the burns team)
Nutrition  NG feeding tube position should be confirmed and enteral feeding commenced
 Ranitidine should be prescribed
Sedation and  Ventilated patients should be commenced on morphine and midazolam sedation
Analgesia  Awake patients should be prescribed adequate morphine analgesia
Investigations  Baseline investigations should include
o ABG, Lactate, COHb
o FBC, U&E, LFT, Mg2+, PO4
o G&S (cross match if early surgery anticipated)
o ECG if electrical injury suspected
o CXR
o Urine for Albumin Creatinine Ratio

Fluid resuscitation formulas

Parklands
Use IV Hartmann’s
1st 24 hrs requirement = (Body weight x BSA x 4ml)
Give ½ over 8 hrs and ½ over next 16 hrs
Muir and Barclay
Use IV colloid (human albumin solution 4.5%)
1st 4 hrs requirement = (Body weight x BSA x ½ml)
Give this fluid volume 6 times in the first 36 hours following the injury over the
following lengths of time 4,4,4,6,6 and 12 hours

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 5 of 24
4. Later management on Critical Care
All patients are under the shared care of the Burns team and the Intensive Care team. There will also
be regular input from the Burns Anaesthetists.
Airway  The position of endotracheal tubes at the front teeth (or gums) of the patients should
be checked and confirmed every day
 In patients at high risk of losing their airway discuss with the burns team the
possibility of wiring the tube to the teeth (alveolus) – Wire Cutters MUST be
available at the bedside
Ventilation  Lung protective ventilation guidelines should be followed if at all possible (TV
5ml/kg, Pinsp <30cmH2O)
 Ventilator care bundles should be used
Inhalational  Repeated therapeutic bronchoscopy may be required
injury o Nebulised acetyl cysteine, saline, salbutamol and/or heparin may be
prescribed at the request of a consultant
o Some consultants may use therapeutic lavage using aliquots of 1.4% sodium
bicarbonate solution
Temperature  Peripheral skin may require warming to maintain a core-peripheral temperature
Control gradient of ≤2ºC
o Peripheral warming should be stopped if the core temperature is >39ºC
 Pyrexia: the presence of a core body temperature >39.5ºC should prompt measures
to cool the patient (cooled IV fluids, peripheral cooling, paracetamol)
o NSAIDs as antipyretics may only be prescribed at the direction a consultant
(and must be stopped 12 hours prior to any surgery)
 A core temperature >40ºC that persists for longer than 1 hour is likely to require the
insertion of an intravascular cooling device (e.g. Coolguard)
Infections Pyrexia without infection is common, the following signs should trigger a septic
screen (blood, CVC, arterial line, sputum, and urine cultures)
 New fever (>38ºC, when the patient was previously apyrexial)
 Fever >39ºC; or Hypothermia (<36.5ºC)
 Pyrexia with any of the following:
o New tachycardia (>110 beats per minute)
o New tachypnoea (>25 breaths per minute); or increasing O2 requirement
o New thrombocytopaenia (<100x109)
o New hyperglycaemia
o New failure to absorb enteral feed; or New diarrhoea
Antimicrobials should be prescribed in the presence of suspected or proven infection
and on the advice of microbiology
Nutrition  Enteral feeding should be established as soon as possible
o If required prokinetics (metoclopramide and/or erythromycin) should be
prescribed as per ICU guidelines
o If NG feeding is unsuccessful consider early placement of an NJ tube
 Prescribe feed and supplementation as directed by the nutrition team (they may
request trace element serum measurements to aid this)
Sedation and  Morphine and midazolam sedation are used initially
Analgesia o Once patients are weaning enteral opiates may be prescribed
o Other analgesics (e.g. gabapentin) may be prescribed by consultants
Investigations  Regular FBC, U&E, PO4, Mg are required
o Hb should be maintained at >70g/L
o PO4 levels often drop acutely in the first few days after a burn
o Urine for Albumin Creatinine Ratio on Days 0, 1, 3 and 7

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 6 of 24
Contents

Summary of Guidelines 2
Referrals and Admission Criteria 2
Safe Transfer 3
On Admission to ICU 4
Fluid Resuscitation Formulas 5
Later Management on ICU 6

Introduction 8
Referrals 8
Admission Criteria 9
Safe Transfer 9
On Admission to Critical Care 10
Management 14

References 17
Appendix One
Appendix 1 Midlands Burn Operational Delivery Network: Burns
Management in the Emergency Department (Referral Proforma) 18
Appendix Two
Lund & Browder Chart 22
Equality impact assessment 23

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 7 of 24
Introduction:

Nottingham University Hospitals are part of a regional burns network consisting of:
University Hospital Birmingham Adult Burns Centre
Birmingham Childrens’ Hospital Paediatric Burns Centre
Nottingham University Hospital Adult and Paediatric Burns Unit
University Hospital Leicester Adult and Paediatric Burns Facility

What area does the Network cover?

The MBCN is involved in ensuring that anyone who

lives in the Midlands, whether this is Lincolnshire in
the East or Herefordshire in the West has access to
the level of care that they need.

This involves planning care for a population of

approximately 13.7 million; equating to
approximately 20% of the population of England. The
above map is an illustration of the area covered by
the MBCN.

http://www.midlandsburnnetwork.nhs.uk

The Adult Intensive Care units capable of providing ICU care to severely burned patients are
Birmingham and Nottingham. Both centres take referrals from throughout the region (and
sometimes beyond, depending upon national bed availability). Within Nottingham University
Hospitals it is currently the City Campus ICU that cares for adult patients with burns.
Nottingham is classed as a Burns Unit.

Referrals:
Referrals may be initially taken by the burns team, or by the ICU team. Each team MUST
liaise with the other before accepting the referral. As a Burns Unit Nottingham is capable of
accepting patients with major, up to 50% body surface area (BSA), burns. Nottingham is

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 8 of 24
currently NOT capable of accepting complex burns (i.e. burns with associated other injuries –
see criteria below), although there may be occasions where the unit is required to do so in
order to stabilise the patient until a more appropriate place becomes available elsewhere.

Admission Criteria:
At date of protocol CHN Critical Care will accept the following categories of acute burn
injuries:

 Patients over 18 years of age (patients between 16 and 18 may be admitted after
discussion)

 Patients who require intubation for airway security

 Patients with burns to face or neck

 Patients with proven or suspected inhalational injury

 Patients with burn injuries up to 50% body surface area

In addition the service will accept patients with acute dermatological conditions such as SJS /
TEN requiring the attention of the burns service (see separate protocol)

The following categories of patients should be transferred to more appropriate Units:

 Patients less than 18 years (see above)

 Patients with > 50% body surface area burns (unless palliative therapy is indicated)

 Patients with multiple-trauma which includes a burn injury

See also section 1. Referrals and Admission Criteria in the Summary Guidance at the start
of this document

Safe Transfer:
It is the responsibility of the person accepting the admission to advise the referring Hospital
on how to provide a safe transfer for the inured patient. It should not be assumed that this
will happen automatically.
Basic requirements for patients transferred to City Critical Care include:
 Patients must be stabilised and receiving appropriate resuscitation fluids which will
continue during transfer (according to the Regional Guidelines available in EDs)
 If intubation is required, patients must be intubated with an uncut oral ETT, ideally size
8 or above, and tube secured with ties. A chest X ray should confirm tube position 2-3
cm above carina. The length of the ET tube at the lips should be documented.

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 9 of 24
*Note that it is unusual for a patient fulfilling the criteria for Critical Care admission not to
require intubation for transfer. If in doubt insist that the patient is intubated.
 Intubated patients will be sedated and mechanically ventilated during transfer
 Patients with elevated carboxyhaemoglobin levels should be ventilated with 100%
during for transfer regardless of SaO2 or PaO2
 Lines should include 2 x wide bore IV access, urine catheter, naso-gastric tube and
ideally arterial line for transfer. Central venous access is desirable, but not essential
for transfer
 Transfer to be carried out according to the protocols of Mid Trent Critical Care Network
by a senior anaesthetist trained in inter- hospital transfer
 Efforts to prevent loss of core temperature should be instituted and core temperature
monitored
 Formal handover from the transfer team will occur on CHN Critical Care
See also section 2. Safe Transfer in the Summary Guidance at the start of this document

On Admission to Critical Care

General

All patients admitted to CHN Critical Care service following acute burn injury will be seen and
assessed by an experienced plastic surgeon and a senior member of the Critical Care
Medical team within one hour of admission.

The only exception to this will be those patients who have been seen and examined in QMC
A&E department by an experienced plastic surgeon prior to their transfer to this site.

Documentation will include:

 approximate burn surface area,

 location and depth of injury

 clinical photographs taken prior to dressings being applied (by the Medical
Photographer – not personal equipment)

 Note will be made of evidence of upper airway burn injury.

Responsibility for the prescription of resuscitation fluids will lie with the plastic surgical team
who have assessed and examined the patient. Failure of the patient to maintain acceptable
physiological parameters, despite apparently adequate volume resuscitation, is an indication
for institution of advanced cardiac monitoring.

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 10 of 24
On admission to Critical care an ATLS-style tertiary survey should be performed in order to
exclude any previously unrecognised trauma. Routine bloods should be performed (FBC,
U&E, LFT, Cross Match, Lactate, ABG, PO4, Mg) along with a chest X-ray. An ECG should
be performed if there is any evidence of electrical injury (if it is possible to attach ECG leads).
Urinary albumin/creatinine ratio should be sent.

Airway

On admission the Critical Care team will verify the position and security of the ETT, or of the
safety of the airway should the patient not be intubated. If there is a high risk of the ETT
becoming dislodged, or where the risk of losing the airway is considered to be particularly
high, the Burns team may chose to wire the ETT to the teeth (alveolus). Once the position of
the ETT has been confirmed as being appropriate the tube should be marked so that the
ideal position at the front teeth (or gums) is obvious. The length of the tube at the teeth
should e documented in the medical and nursing notes.

Decisions to extubate a patient transferred for burn management can only be made by
Consultant Critical Care or Burns anaesthetists and are unlikely to be made in the first 24
hours after admission

Ventilation

Most burn injured patients requiring Critical Care admission will require mechanical
ventilation. Specific attention should be paid to the following:

Patients who have been involved in enclosed space fires and those who have evidence of
airway burns are at particular risk of developing acute lung injury. All ventilated patients
should be established on “lung protective strategy ventilation” using tidal volumes of 5-7
ml/kg, high PEEP and avoiding high peak airway pressures.

Patients with elevated carboxyhaemoglobin (COHb) levels on initial blood gas assessment
must be ventilated with an Fi02 of 1.0 until COHb levels fall to below 5%.

Management of inhalational injury

Fibre-optic bronchoscopy is indicated as either a diagnostic tool or therapeutic manoeuvre in

all patients who are at risk of direct thermal airway injury or who have been involved in
enclosed space fires.

Diagnostic bronchoscopy is required to document the presence or absence of thermal burn

injury below the level of the vocal cords. This can occur in the presence of enclosed space

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 11 of 24
fires and when accelerants (e.g. petrol) or steam are involved and in explosions. Thermal
injury to the upper airway should be documented at initial assessment and intubation.

Therapeutic bronchoscopy is required in those patients in whom evidence of soot or

particulate contamination is found on bronchoscopy. Bronchoscopy should be repeated
within 24 hours and lavage repeated if required until clearance is obtained

Some consultants may take the presence of soot in the airway to be an indication for
therapeutic lavage using aliquots of 1.4% sodium bicarbonate solution to remove as much of
the contamination as possible. Mucosal sloughing can occur following thermal injury to the
airway. It is unusual on admission but may require repeated bronchoscopies, suction and
occasionally re-intubation.

All patients who have evidence of airway burn or contamination should be commenced on a
regime of nebulised salbutamol and saline. Consideration should be given to the use of
nebulised heparin (5,000 units 6 hrly) and the use of mucolytics such as nebulised n-acetyl
cysteine or enteral carbocysteine.

Fluid resuscitation

Patients transferred into City Critical Care should have been commenced on crystalloid
based resuscitation based on the Baxter – Parklands formula.

On admission, the extent of the burn injury should be re-evaluated.

Our current preferred resuscitation follows the Muir and Barclay protocol using 4.5% human
albumin solution. Following reassessment of the burn surface area, patients should be
converted to Muir and Barclay at 8 hours post burn injury. There will be a 50% drop in the
predicted infusion rate. Maintenance fluids may be commenced after transfer if there is a
delay in commencing enteral feeding.

Note that extra boluses of colloid may be required to correct any deficit caused by
underestimation of burn surface area. The preferred colloid is 4.5% human albumin solution.

Monitoring of resuscitation.

Reliance upon monitoring of CVP, urine output and haematocrit values is frequently
misleading. Advanced cardiac output monitoring should be considered for all burn patients to
facilitate adequate volume resuscitation and to reduce the risk of overloading. If in doubt,
use it.

Haemodynamic targets are dependent upon age and clinical response to therapy. As a
guide, a cardiac index of 4l/min/m2 and stroke volume variability of < 10% are desirable.

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 12 of 24
Some burn patients have an unexpectedly low cardiac output at presentation and may
require inotropic support using dobutamine to correct cardiac output and maintain renal
perfusion. Note that the presence of accelerants is associated with cardiac dysfunction.

It is unusual to require vasopressors in the initial resuscitation period. Noradrenaline should

only be instituted once adequate volume resuscitation and cardiac output have been
assured. The use of advanced cardiac monitoring is mandatory if you consider vasopressors
are required.

Adequacy of volume and cardiovascular resuscitation can be inferred by the maintenance of

a urine output of 1ml/kg/hr.

As a general rule mean arterial pressure (MAP) should be maintained at >70mmHg.

Alternatively, if the premorbid blood pressure is known, that may become the target MAP.

If boluses of fluid are required the change in stroke volume (SV) is used as a marker of fluid
responsiveness (if a 10% increase in SV does not occur then the patient is unresponsive).

Thermal environment

In the initial resuscitation period burn patients require active rewarming and elevated
environmental temperatures to prevent heat loss and risk of peripheral vasoconstriction.

Ideally patients should be nursed in a single room which is warmed with radiant heaters and
the patients warmed with a Bair Hugger®.

An oesophageal or catheter temperature probe should be inserted and core temperature

monitored. Hypothermia should be avoided and an initial core temperature of approximately
37-38oC should be attained if possible.

Eye Care

Where there is evidence of eye involvement and initial assessment should be performed by
the Critical Care team, and a formal Ophthalmology assessment arranged for as soon as is
practical. Topical eye lubricants (e.g. hypromellose) should be prescribed 1-2 hourly, in
combination with topical antibiotics (preservative free, e.g. chloramphenicol, preservative free
0.5%) if required.

Nutrition

Once the position of the nasogastric tube has been confirmed enteral feed should be
commenced.

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 13 of 24
Sedation

Morphine and midazolam sedation is the default sedation choice for major burns

See also section 3. On Admission to Critical Care in the Summary Guidance at the start of
this document

Management Issues

Feeding and Nutrition

The dieticians review burn patients daily. The preferred feeding route is via NG tube,
supplemented if required by prokinetic agents (erythromycin and/or metoclopramide). Start
feeding as soon as possible after admission. Failure to absorb feed adequately via the NG
route by 48 hours should prompt the placement of a naso-jejunal tube. Continue the
prokinetics if required. Parenteral nutrition is seldom required in burn patients.

Gastric protection with acid suppressants should be prescribed (e.g. intravenous ranitidine, or
equivalent).

Trace Elements and Blood Transfusion

Phosphate levels are known to drop rapidly early after severe burns and care should be
taken to monitor and replace this.

Dieticians may request blood tests for other trace element levels, and may order
supplementation according to the trust guidelines for major burn nutritional support (see
guidelines on the Trust intranet).

Blood should be transfused if required due to bleeding or symptomatic anaemia. In the

absence of these the target transfusion trigger is a haemoglobin of 70g/L. Blood products
may be required before or after major surgery to prevent/minimise blood loss associated with
surgery.

Faecal wound contamination.

Faecal contamination of wounds is a major sepsis risk for lower extremity and perineal burns.
Faecal management systems should be utilised inpatients at risk of contamination. Ensure
that appropriate faecal softeners are prescribed

Sedation & Analgesia

Patients with burn injuries require large amounts of sedation and analgesia. Morphine and
midazolam are commenced on admission. It is not unusual for patients to require in excess
of 50mg/hr of each. Supplementary analgesia can be provided with infusion of ketamine.

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 14 of 24
Burn patients will undergo regular dressing changes on the intensive care unit as well as in
theatre. It is essential to provide adequate anaesthesia and analgesia for these. The
baseline infusions of morphine and midazolam are inadequate for this purpose and should be
supplemented with infusions of remifentanil and propofol. Alternatively bolus IV ketamine
can be used during the procedure.

Cooling / management of pyrexia (including indications for blood cultures & line
changes)

Patients should initially be nursed in a warm environment to encourage cutaneous perfusion.

The ideal core – peripheral temperature gradient is < 2oC and peripheral warming may be
used to achieve this. However a core temperature of ≥39 oC is an indication to stop peripheral
warming and commence measures to encourage a decrease in core temperature (e.g. the
infusion of cooled fluids).

It is our policy to actively cool hyper-pyrexial burn patients using the Coolgard® intravenous
cooling device. This is normally inserted, via a femoral vein, when the patient’s temperature
reaches 39.5oC and continues to rise. It should always be used if the patient’s core
temperature is >40 oC for more than 1 hour. Once commenced, the Coolguard may need to
be continued for a considerable length of time to prevent rebound hyperpyrexia. In the
absence of an evidence base, we set the target temperature to 37.5 or 38oC. Note that the
Coolguard is very effective at preventing pyrexia and it can mask the development of sepsis
by preventing the patient from raising their temperature. In severe cases of hyperpyrexia
consider asking the nursing team to temporarily take down all burns dressings. Coolguard
insertion sites should be reviewed at least daily.

Physiological deterioration is common in the burn-injured patient and can occur at any time
during their hospital stay. Usually this is a consequence of developing infection and must be
addressed promptly. It is an indication for urgent review by senior members of the Critical
Care and Burns teams.

Indicators of sepsis include:

 New fever (>38ºC, when the patient was previously apyrexial)

 Fever >39ºC

 Hypothermia (<36.5ºC)

 Elevation of WBC

Especially where any of the above occurs in combination with any of:

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 15 of 24
  New tachycardia (>110 beats per minute), or Increasing inotrope or vasopressor
requirement

 Reducing SVR

 New tachypnoea (>25 breaths per minute); or increasing O2 requirement

 New thrombocytopaenia (<100x109)

 New hyperglycaemia

 New diarrhoea

 New failure to absorb enteral feed

If infection is suspected blood culture/ line cultures / MSU/ Wound swabs/ sputum
microbiology should be preformed. A full dressing change should be performed as soon as
possible.

If no other identified source of sepsis in a patient strongly suspected or demonstrated as

being septic then lines need changing even if this is an “over the wire” change. There is no
indication for line changes in the absence of sepsis unless the line passage through skin is
badly inflamed.

Antibiotics should be prescribed as guided by the microbiology team. There is no indication

for prophylactic antibiotics

Preparation for surgery

Following the Burns Multi-disciplinary meeting on Monday morning, burn patients are
normally scheduled for theatre on Tuesdays and Fridays. Urgent cases may need to be
fitted in between these days. It is essential that the ICU team liaise with the burns team and
Consultant burns anaesthetists to ensure that appropriate blood products are made available.
This is best done by speaking directly to blood transfusion services on the day prior to
surgery, who will be able to ensure that supplies of RBCs, FFP and platelets are prepared.

Fitness for theatre can only be confirmed by the MDT on the morning of surgery. Ensure that
a full set of bloods, including clotting and fibrinogen are requested at 06:00 so that they are
available for the 08:00 Burns ward round.

See also 4. Later management on Critical Care in the Summary Guidance at the start of
this document

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 16 of 24
References:
1. Bishop S, Maguire S. Anaesthesia and intensive care for major burns.
Continuing Education in Anaesthesia, Critical Care & Pain 2012;12(3):118-
22
2. Sheridan RL. Burns Crit Care Med 2002;30(11): (Suppl.)
3. Latenser BA. Critical care of the burn patient: The first 48 hours Crit Care
Med 2009;37:2819-26
4. Cochran C, Morris SE, Edelman LS, Saffle JR. Burn patient characteristics
and outcomes following resuscitation with albumin Burns (2007);33:25–30
5. Mlcak RP, Suman OE, Herndon DN. Respiratory management of inhalation
injury Burns (2007);33:2–13
6. Toon MH, Maybauer MO, Greenwood JE, Maybauer DM,John F Fraser JF,
Management of acute smoke inhalation injury Crit Care Resusc 2010;12:
53–61
7. Ipaktchi K, Arbabi S, Advances in burn critical care Crit Care Med 2006;
34[Suppl.]: S239 –S244
8. Dixon B, Santamaria JD, Campbell DJ. A phase 1 trial of nebulised heparin
in acute lung injury Critical Care 2008, 12:R64 (doi:10.1186/cc6894)
9. Mavrogordato AE, Wagstaff MJD, Fletcher AJP, Wilson DI, Jayamaha JEL.
A novel method to treat hyperthermia in a burns case: Use of a catheter-
based heat exchange system Burns (2009);35:141–145
10. The American Burn Association Consensus Conference on Burn Sepsis and
Infection Group; Greenhalgh DG, Saffle JR, Holmes JH, et al. American
Burn Association Consensus Conference to Define Sepsis and Infection in
Burns Journal of Burn Care & Research 2007;28(6): 776-90
11. Avni T, Levcovich A, Ad-El DD, Leibovici L, Paul M. Prophylactic antibiotics
for burns patients: systematic review and meta-analysis Br Med J
2010;340:c241
12. Yew WS, Pal SK. Correlation of microalbuminuria and outcome in patients
with extensive burns. Br J Anaesth 2006;97:499-502

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 17 of 24
Appendix 1 Midlands Burns Operational Delivery Network: Burns
Management in the Emergency Department (Referral Proforma)

Burns Management in the Emergency Department

(Referral Proforma)

Time/Date of injury (24hr)

Patient demographic data sticker

Please remember to protect C-spine until clinically cleared as stable

Airway
Administer high flow oxygen
Is there any suggestion this patient has an Airway injury?
Has this patient any of the following: (underline if present)
 Stridor
 Injury in an enclosed space
 Soot in airway Yes / No
 Singed nasal hair
 Facial burn If yes please seek senior anaesthetic
 Change in voice review immediately
 Brassy cough
 Carbonaceous sputum
If intubation is required use an uncut ETT to allow for facial oedema

URGENT AIRWAY MANAGEMENT MAY BE NECESSARY- DO NOT DELAY

Breathing
Is there any suggestion of Breathing impairment?
Has this patient any of the following: (underline if present)

 Circumferential chest burns: Needs immediate discussion with local burns service
 O2 saturation lower than expected
 Respiratory rate outside expected limits
 Any other evidence of broncho-pulmonary or chest wall injury
 Carbon Monoxide >10% (available with ABGs)
 Elevated lactate, arrhythmias, reduced GCS and reduced arterial-venous oxygen saturation
difference: Consider Cyanide poisoning. Use of antidote recommended

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 18 of 24
Circulation
Is there any suggestion of a Circulation problem?
Has the patient any of the following? (Underline if present)

 Tachycardia
 Tachypnoea
 Reduce level of consciousness
 Central and peripheral capillary refill time >2seconds
 Cool peripheries
 Circumferential limb burn. Absence of peripheral pulses requires immediate contact with
local burns service, as escharotomies may be required.

 IV fluid resuscitation should be commenced as per ATLS protocol. If this does not
improve parameters repeat primary survey looking for causes of shock.

All patients requiring fluid resuscitation should have two large-bore intravenous
cannulas through the burn if necessary, and an indwelling urinary catheter
attached to an hourly urine collection bag.

REMEMBER TO TAKE BLOOD FOR FBC, U&E, ABG, G&S, CK, BHCG

Disability
Does the patient have a GCS <9 and are pupils equal and reacting to light?
If so:
 Consider CO poisoning
 Exclude other injuries
 Contact AN ANAESTHETIST
 Ensure ABC normalised
GCS …./15
Pupils ….. reactive/unreactive

Exposure, Environment and Evaluation

Measure core temperature and maintain >36C

Assess total burn surface area (TBSA)

Use Lund and Browder Chart below to document findings. Ignore simple erythema. The
patient’s hand including fingers is 1% TBSA. This knowledge can be used to calculate the
total area of small burned or unburned areas.

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 19 of 24
Fluid resuscitation with Hartman’s solution

ADULT >15% OF TBSA burned require IV fluid resuscitation

Children >10% OF TBSA burned require IV fluid resuscitation

Use the Parkland Formula to calculate an estimate of the amount of fluid required in the form
of Hartman’s over the first 24 hrs from time of injury

4mls x %TBSA burn x weight(kg) = Total Fluid Volume TFV over 1st 24hrs from time of injury
Give half of fluid in first 8hrs from time of injury and half in next 16 hrs
 Fluid for 1st 8hrs TFV ÷ 2 =
Percentage TBSA Burned = times
 Fluid for 9 – 24hrs TFV ÷ 2 =
Weight in kg = times

Maintenance fluids Urine output target

Adults Adults 0.5 ml/ kg/hr Catheterise and attach an

No maintenance fluids hourly urine device
Children 1- 2 ml/ kg/hr
Children
Calculate as normal. give as Infants 2- 4 ml/ kg/ hr
Dextrose- Saline (0.45% Saline
+5% Dextrose)

FLUID RESUSITATION IS A GUIDE ONLY AND INFUSION RATE SHOULD BE

ADJUSTED TO DELIVER APPROPIRATE URINE OUTPUT

Wound Cover and Ambulance Transfer

Cover the burn wounds in loose cling film prior to transfer. If transfer is going to be delayed,
clean the burn wounds then cover with a non-adherent dressing e.g. Jelonet.

All ambulance transfers for resuscitation burns must be performed by crews who can and will
continue to provide on-going fluid resuscitation, and thermal regulation and monitoring
throughout transfer. Please attach any X-rays and blood results to the patient’s notes.

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 20 of 24
Management
M of Burns within Ad
dult Critical Care
e Dr M Beed 2011 Review datte 2018 Page 21 of 24
 Appendix 2 Lund & Browder Chart

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 22 of 24
Equality Impact Assessment Report

1. Name of Policy or Service

Response to external best practice policy

2. Responsible Manager
Owen Bennett (Clinical Quality, Risk and Safety Manager)

3. Name of person Completing EIA

Dr Martin Beed (Consultant in Intensive Care and Anaesthesia)

4. Date EIA Completed

1/4/2011

5. Description and Aims of Policy/Service

This clinical guideline has been written to inform adult critical care staff of how
to safely manage critically ill patients requiring a tracheostomy.

6. Brief Summary of Research and Relevant Data

There is no research or relevant data at the present time.

7. Methods and Outcome of Consultation

Consultations have been carried out with the following:

Adult critical care consultants and senior nurses

Comments from the above consultations have been received and

incorporated where appropriate.

8. Results of Initial Screening or Full Equality Impact Assessment:

Equality Group Assessment of Impact

Age No Impact Identified

Gender No Impact Identified

Race No Impact Identified

Sexual Orientation No Impact Identified

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 23 of 24
 Religion or belief No Impact Identified

Disability No Impact Identified

Dignity and Human Rights No Impact Identified

Working Patterns No Impact Identified

Social Deprivation No Impact Identified

9. Decisions and/or Recommendations (including supporting rationale)

From the information contained in the procedure, and following the initial
screening, it is my decision that a full assessment is not required at the
present time.

10. Equality Action Plan (if required)

N/A

11. Monitoring and Review Arrangements

1/12/2018

Management of Burns within Adult Critical Care Dr M Beed 2011 Review date 2018 Page 24 of 24