ATLS | Thermal Shock

Effective management of thermal injuries prioritizes airway control, stopping the burning process, and hemodynamic resuscitation to minimize morbidity and mortality. The primary survey begins by completely removing the patient's clothing to stop burning, brushing away dry chemicals, and covering the patient with warm linens to prevent hypothermia. Airway obstruction may be insidious due to progressive edema, particularly in patients with burns to the face, burns inside the mouth, or those involving more than 40% to 50% of the total body surface area (TBSA). Inhalation injury is a major concern in enclosed-space fires, requiring immediate administration of 100% oxygen to treat potential carbon monoxide poisoning, as standard pulse oximetry does not distinguish between oxyhemoglobin and carboxyhemoglobin.Burn shock differs from hemorrhagic shock as it results from capillary leak due to inflammation, necessitating fluid resuscitation for deep partial and full-thickness burns larger than 20% TBSA. The American Burn Association consensus formula recommends starting lactated Ringer’s solution at 2 mL/kg/%TBSA for adults and 3 mL/kg/%TBSA for children. Half of the calculated total volume is administered in the first eight hours post-injury, with the remainder given over the subsequent 16 hours. However, these formulas are merely starting points; fluid rates must be titrated hourly to maintain a urine output of 0.5 mL/kg/hr in adults and 1 mL/kg/hr in children weighing less than 30 kg. Over-resuscitation should be avoided to prevent complications such as compartment syndrome.Assessment of burn severity relies on estimating the surface area using the Rule of Nines or the patient's palm (representing 1% TBSA) and evaluating burn depth. Partial-thickness burns are painful and blistered, while full-thickness burns appear leathery, dry, and painless. Circumferential burns to the extremities or chest can lead to compartment syndrome by restricting circulation or ventilation; this may require escharotomy if compartment pressures exceed 30 mm Hg or clinical signs of compromise appear. Pain management should utilize small, frequent doses of intravenous narcotics, as intramuscular absorption is unreliable, and prophylactic antibiotics are not indicated.Unique injury types require specialized care. Chemical burns necessitate immediate, copious irrigation with water for 20 to 30 minutes, especially for alkali exposures which penetrate deeply. Electrical injuries often involve deep tissue damage not visible on the surface and can cause rhabdomyolysis; resuscitation for these patients starts at 4 mL/kg/%TBSA to maintain higher urine output and clear hemochromogens. Tar burns are treated by cooling and using mineral oil to dissolve the tar. Clinicians must also remain vigilant for burn patterns indicating abuse, such as circular burns or those with clear immersion lines.Cold injuries, such as frostbite, are managed by rapid rewarming in circulating water at 40°C (104°F) only when there is no risk of refreezing. Massage is contraindicated, and injured tissue should be protected from pressure. Patients meeting specific criteria, including partial-thickness burns >10% TBSA, burns to functional areas like hands or face, inhalation injuries, or electrical/chemical burns, should be stabilized and transferred to a burn center.