Chapter 36: Emergency Care – Burns: Site, Complications, Smoke Inhalation, Toxic Shock

Burn depth & site · Inhalational injury · Burn shock, infection, compartment syndrome · Toxic shock syndrome (staphylococcal / streptococcal) · Airway management & fluid resuscitation

🔥 Key principles: Burn depth (superficial, partial, full thickness). Site matters: face, hands, perineum, circumferential – high risk. Smoke inhalation → carbon monoxide, cyanide, upper airway edema. Complications: hypovolemia, sepsis, compartment syndrome. Toxic shock: fever, rash, hypotension; treat with IV fluids, clindamycin + immunoglobulin.

🔥 Summary: burn site, complications, smoke inhalation, toxic shock

🧴 Burn depth & site
Superficial (erythema), partial‑thickness (blisters), full‑thickness (leathery, painless). Critical sites: face/neck (airway), hands/feet (function), perineum, circumferential limbs (compartment syndrome).
💨 Smoke inhalation
Upper airway edema, carbon monoxide poisoning (headache, coma), cyanide toxicity. Signs: facial burns, singed nasal hairs, carbonaceous sputum, hoarseness. Early intubation key.
🩸 Burn complications
Hypovolemic shock (fluid loss), infection (burn wound sepsis, pneumonia), compartment syndrome (escharotomy), Curling’s ulcer (gastric stress ulcer), hypertrophic scarring.
⚠️ Toxic shock syndrome (TSS)
Staphylococcal or streptococcal. Fever >39°C, diffuse erythroderma, hypotension, desquamation (1-2 weeks). Multisystem involvement. Treatment: IV fluids, clindamycin + IVIG, source control.
💧 Fluid resuscitation (Parkland)
4 mL/kg/%TBSA crystalloid (LR) in first 24h (half in first 8h). Monitor urine output 0.5-1 mL/kg/h (infants 1-1.5 mL/kg/h).
🦠 Burn wound sepsis
Leading cause of late mortality. Topical antimicrobials (silver sulfadiazine), early excision, surveillance cultures.

📊 TBSA estimation (Lund-Browder, Rule of Nines – modified for children): Head 18% (infant), each leg 14%, arm 9%, anterior/posterior trunk 18%.

🔍 Approach to the burned child – site, airway, complications

Primary survey (ABC) – Airway: stridor, hoarseness → immediate intubation (smoke inhalation). Breathing: carbon monoxide, cyanide. Circulation: two large-bore IV, start resuscitation if >10% TBSA.

Burn depth & TBSA assessment – Rule of nines (adjust for age). Critical sites: face, perineum, hands, feet, circumferential burns (risk of compartment syndrome).

Smoke inhalation – specific signs – Carbonaceous sputum, facial burns, singed nasal hairs, altered mental status (CO poisoning). Measure carboxyhemoglobin, cyanide level if severe.

Burn shock & fluid resuscitation (Parkland) – Calculate 4 mL/kg/%TBSA crystalloid (LR) over 24h. Half in first 8h. Target urine output 0.5-1 mL/kg/h (infants 1-1.5).

Monitor for complications – Compartment syndrome (escharotomy), infection (topical antibiotics, early debridement), Curling’s ulcer (PPI prophylaxis). Toxic shock syndrome: fever, rash, hypotension → treat with clindamycin + IVIG.

📋 Stepwise management – burns, smoke inhalation, toxic shock

Airway management in inhalation injury – Early intubation if stridor, hoarseness, or facial/neck burns. Avoid delayed deterioration. 100% oxygen, consider bronchoscopy.

Carbon monoxide poisoning treatment – High‑flow O2 (100%) until COHb <5%. Hyperbaric oxygen for neurologic symptoms, COHb >25%.

Fluid resuscitation (Parkland formula) – Lactated Ringer’s 4 mL/kg/%TBSA burn (excluding superficial). Give half over first 8h from burn time. Adjust based on urine output.

Burn wound care & infection prevention – Clean with water/mild soap, topical silver sulfadiazine (or Acticoat for partial thickness). Tetanus prophylaxis. Surgical debridement for full‑thickness.

Toxic shock syndrome (TSS) management – IV fluids (20-40 mL/kg bolus), vasopressors if shock persists. Clindamycin 10-13 mg/kg IV q8h (toxin suppression) + IVIG 1-2 g/kg. Remove foreign body/tampon if present.

⚡ Key reminder: Smoke inhalation causes both upper airway edema and systemic poisoning (CO, cyanide). Circumferential burns → check peripheral pulses, compartment pressure; escharotomy may be limb‑saving.

🧠 Reflex prompts – burns, complications, TSS

🔥 First sign of smoke inhalation airway compromise?
Hoarseness, stridor, carbonaceous sputum → early intubation.
📏 Parkland formula – what fluid and rate?
Lactated Ringer’s 4 mL/kg/%TBSA over 24h. Half in first 8h.
🧪 Target urine output in pediatric burn resuscitation?
0.5-1 mL/kg/h (infants 1-1.5 mL/kg/h).
🦠 Most common cause of late death after major burns?
Burn wound sepsis (Pseudomonas, Staph, Candida).
⚠️ Toxic shock syndrome – toxin suppression antibiotic?
Clindamycin (reduces toxin production) + IVIG.
🩸 Indication for escharotomy in burn patient?
Circumferential burn with impaired distal perfusion, raised compartment pressures, or impending compartment syndrome.