1. Perform primary and secondary surveys for any trauma patient. Acute injuries found in the primary and secondary survey should be addressed as per standard trauma protocols. Avoid becoming distracted by the appearance of burned tissues.
2. Assess and protect the airway, if needed. Immediate intubation may not be necessary in less severely burned casualties, thereby allowing time to complete the primary survey and prepare for controlled intubation.
3. Indications for endotracheal intubation include a comatose patient, symptomatic inhalation injury, deep facial burns, and burns over 40% Total Body Surface Area (TBSA).
NOTE: Edema after burn injury causes most Supraglottic airway devices such as laryngeal mask airways (LMAs) to be inadequate.
4. Use a large-bore endotracheal tube (ETT), especially if inhalation injury is suspected. Size 8 ETT or larger is preferred for adults. The larger ETT tube facilitates subsequent bronchoscopy and pulmonary toilet, and decreases the risk of later airway occlusion due to casts comprised of blood, mucus and debris.
5. Secure ETT with cotton umbilical ties which can be adjusted as edema develops during resuscitation; standard adhesive ETT holders do not work around burned skin. Consider securing ETT with stainless steel wire secured around a pre-molar tooth prior to long-range transport, particularly in patients with extensive facial burns. Frequently reassess position of the ETT during the acute resuscitation period as edema waxes and wanes.
6. Keep the patient warm. Burns increase insensible heat loss. Burn casualties with injuries >20% TBSA are at high risk of hypothermia.
NOTE: Do not debride blisters until the patient has reached a facility with surgical capability. Cover burns with loose, dry gauze wraps or a clean sheet.