SFAR Recommendations for Management of Severe Thermal Burns During Acute Phase
In March 2020, the Société Française d'Anesthésie et de Réanimation (SFAR; French Society of Anesthesia and Intensive Care Medicine) published the following recommendations regarding the management of severe thermal burns during the acute phase in adults and children. [24]
Assessment, admission to specialized centers, and telemedicine
The standardized method of Lund and Browder (suitable for both adults and children) should be used to measure the total body surface area (TBSA) that is burned.
Referral to a burn specialist should be sought to determine whether the patient should be admitted to a burn center.
Telemedicine should be used to improve the initial assessment of severely burned patients.
If there is an indication for admission to a burn center, the patient should be admitted directly to the center.
If a deep burn induces compartment syndrome in the limbs or trunk that compromises the airways and respiration and/or circulation, an escharotomy should be performed. Ideally, the escharotomy should be performed in a burn center by an experienced provider.
Hemodynamic management
Adult burn patients with burn to ≥ 20% of TBSA and pediatric burn patients with a burn of ≥10% of TBSA should receive 20 mL/kg of an intravenous (IV) crystalloid solution within the first hour of management.
Balanced crystalloid solutions should be used.
To estimate the initial crystalloid infusion rate, a formula should be used that includes at least body weight and %TBSA burned.
In fluid resuscitation for severe burns, the infusion rate should be adjusted as soon as possible on the basis of clinical and hemodynamic parameters.
Human albumin should be administered to patients with severe burns involving >30% of TBSA after the first 6 hours of management.
Airway management and smoke inhalation
Patients with burns involving the face or neck should not be routinely intubated.
Intubation of patients with burns involving the entire face should be considered if one or more of the following features are also present:
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Deep and circular burn on the neck
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Symptoms of airway obstruction (ie, change in voice, stridor, laryngeal dyspnea)
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Very extensive burns (ie, ≥40% of TBSA)
If smoke inhalation is suspected, bronchial fibroscopy should not be performed outside burn centers, so as to avoid transfer delays.
Hydroxocobalamin should not be routinely administered after smoke inhalation.
Aadministration of hydroxocobalamin should be restricted to adult patients with smoke inhalation and a high suspicion of severe cyanide poisoning and to children with smoke intoxication and moderate intoxication from cyanide.
Hyperbaric oxygen therapy should not be routinely administered for cases of suspected carbon monoxide poisoning after smoke inhalation.
Anesthesia and analgesia
Multimodal analgesia can be used to control pain in patients with severe burns, but all analgesic medications must be titrated on the basis of validated comfort and analgesia assessment scales.
Titrated IV ketamine can be combined with other analgesics to treat severe burn-induced pain.
If the patient is stable, nonpharmacologic techniques should be combined with analgesic drugs for dressings, where appropriate.
Local treatment
In the absence of shock, cooling is appropriate for adults with burns involving < 20% of TBSA and for children with burns involving < 10% of TBSA.
Burn wounds should be covered in the initial phase to reduce the risk of hypothermia and microbial contamination. The dressing should be maintained until expert advice can be obtained.
Antibiotic prophylaxis should not be routinely administered to burn patients.
Other treatments
Nutritional support should be started within 12 hours after burn injury. The oral and enteral routes are preferred to the parenteral route.
Thromboprophylaxis should be routinely prescribed for severe burn patients in the initial phase.
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Skin histology diagram.
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Superficial partial-thickness burn.
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Deep partial-thickness burn.
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Full-thickness burn.
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Pediatric Rule of Nines.
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Lund and Browder Chart.
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Endotracheal tube immobilization in children. The figure demonstrates a method using umbilical tape to secure a pediatric endotracheal tube in patients with facial burns.
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Dental device to anchor the endotracheal tube.
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Application of Mepilex Ag foam dressing.
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Aquacel Ag adherent to burn wounds.
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Use of Aquacel Ag. Appearance of healed burns 10 days later.
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Escharotomy sites.
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Left, Arm escharotomy. Right, Leg escharotomy.
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Chest wall escharotomy.
