Comprehensive Guide to Trauma and Burn Management in the Emergency Department: From Primary Survey to IVR and Severe Burn Care

Step 0: Essential Knowledge and Current Trends in Trauma and Burns

🔹 Basic Concepts and Epidemiology of Trauma

Trauma refers to the sudden disruption of bodily structures due to external forces such as traffic accidents, falls, stab wounds, and blunt injuries.
It remains one of the leading causes of death among young people worldwide, particularly in the 10–40 age group, where trauma is often the top cause of mortality.
Public health interventions targeting prevention, early management, and rehabilitation are crucial across all stages of trauma care.

• 🌍 Estimated global trauma-related deaths: ~5 million per year
• 🇯🇵 Japan: Approximately 30,000 deaths annually due to trauma (based on 2020 statistics)

In the elderly, even low-energy trauma (e.g., minor falls) can be life-threatening. Comorbidities like osteoporosis and anticoagulant use must always be taken into consideration.

🔥 Basic Concepts and Epidemiology of Burns

Burns are injuries to the skin and deeper tissues caused by thermal, chemical, electrical, or radiation exposure.
In Japan, over 100,000 burn patients seek medical attention annually, with several thousand classified as severe burns (extensive, deep, or affecting critical areas).

Top 3 causes of burns:

1. Scalds from hot water or steam
2. Flame burns
3. Contact burns from hot surfaces

Elderly patients and children are especially vulnerable to severe outcomes. Early fluid resuscitation, infection prevention, and airway management are vital components of initial care.

❓ Why Is Initial Assessment So Critical?

• Silent killers such as internal bleeding, airway obstruction, tension pneumothorax, or inhalation injuries are not always visible at first glance.
• Without a structured ABCDE assessment, these life-threatening conditions may be missed.
• The speed and accuracy of initial evaluation and resuscitation directly impacts survival outcomes.

Now, let’s move on to the main content. We’ll start with the initial trauma assessment.

Part 1｜Trauma Section – Step 1: MIST and the Primary Survey (ABCDE, OMI, TAF3X)

1-1. Receiving MIST Report – Grasp the Big Picture in the First 3 Seconds

The MIST report from EMS or transferring facilities is the starting point of trauma care. Missing this can compromise the foundation for critical decisions.

MIST:

• M – Mechanism of injury
• I – Injuries found or suspected
• S – Signs (vital signs, consciousness)
• T – Treatment provided (on-site or during transport)

🚑 Example: “50-year-old male, traffic accident. Blunt chest trauma from steering wheel, GCS 14, BP 100/60, on 3L oxygen.”

This concise and focused report helps rapidly prioritize your initial actions.

1-2. 15-Second Initial Impression – ABCDE + Consciousness + Environment

Immediately upon arrival, perform a quick assessment within the first 15 seconds, focusing on these five elements:

• A (Airway): Can the patient speak? Any stridor?
• B (Breathing): Asymmetry, breath sounds, respiratory rate
• C (Circulation): Skin color, coldness, obvious bleeding
• D (Disability): Consciousness (JCS/GCS), pupils
• E (Environment/Exposure): Undress the patient, check body temperature and visible injuries

💡 Checkpoint:
Reduced breath sounds on one side / Cool skin and weak radial pulse → Consider tension pneumothorax or hemorrhagic shock.

1-3. Primary Survey – Life-Saving ABCDE with OMI

Conduct a detailed assessment of each component while simultaneously initiating appropriate interventions.

Component	Assessment & Intervention
A	Airway management (with cervical spine protection), suctioning, evaluate for intubation
B	Oxygen administration, SpO₂ monitoring, check chest movement and breath sounds
C	Check for bleeding, cold extremities, pulse and BP; secure two large-bore IVs; control bleeding
D	GCS, pupil size and reaction, check blood glucose
E	Full body examination (including back), temperature, undress and prevent hypothermia

OMI: Oxygen, Monitor, Infusion

• Oxygen: High-concentration oxygen via non-rebreather mask
• Monitor: ECG, SpO₂, blood pressure
• Infusion: Secure at least two large-bore IV lines and start rapid fluid resuscitation

1-4. Don’t Miss These! The 6 Deadly Chest Injuries (TAF3X)

Even if the patient appears stable, fatal chest injuries may be hidden. Always evaluate the following six conditions:

Abbreviation	Condition
T	Tamponade (Cardiac)
A	Airway Obstruction
F	Flail Chest
X1	Tension Pneumothorax
X2	Open Pneumothorax
X3	Massive Hemothorax

💡 Clinical Tips:

• Tamponade: Beck’s triad (JVD + hypotension + muffled heart sounds)
• Tension pneumothorax: Low SpO₂, decreased unilateral breath sounds, tracheal deviation
• Flail chest: Paradoxical movement of the chest wall during inspiration

At this point, the primary assessment for life-threatening trauma is complete. Next, move on to the Secondary Survey for a more detailed evaluation of the patient’s condition.

Step 2: Secondary Survey – Systematic Full-Body Assessment After Initial Stabilization

After addressing life-threatening issues during the primary survey, the next step is the secondary survey. This phase involves a thorough head-to-toe evaluation to identify missed injuries, concurrent medical conditions, and to guide further testing or treatment.

2-1. AMPLE History – Rapid Background Check in 5 Key Areas

If the patient is conscious, or if information can be obtained from family or EMS, gather the following:

• A: Allergies
• M: Medications (especially anticoagulants)
• P: Past medical history
• L: Last meal
• E: Events/Environment related to the injury

💡 Tips:

• Always ask about anticoagulant use (e.g., DOACs, warfarin).
• Last oral intake is important for aspiration risk and anesthesia decisions.

2-2. Head-to-Toe Physical Exam – Systematic Trauma Evaluation Framework

Conduct a systematic exam from head to toe. Commonly missed but important signs include:

• Head: Scalp hematomas, lacerations, ear bleeding, Battle’s sign
• Face: Nasal deformity, orbital fractures, visual disturbance
• Neck: Tracheal deviation, subcutaneous emphysema, JVD
• Chest: Breath sounds, deformities, flail segments
• Abdomen: Tenderness, guarding, distension (→ FAST recommended)
• Pelvis: Gently compress for instability or pain
• Limbs: Neurological function, deformities, wounds, distal pulses
• Back: Use log-roll technique to examine for spinal tenderness or injuries

📌 Column: What is Battle’s Sign?
A bluish discoloration behind the ear, indicating possible basilar skull fracture.

2-3. Cervical Spine Evaluation and Immobilization

Always suspect spinal cord injury in trauma patients. Cervical spine immobilization should be maintained until injury is definitively ruled out.

• Altered consciousness or head trauma: Prioritize cervical immobilization
• Posterior neck pain or limb numbness: Consider CT or MRI evaluation
• Until imaging clears C-spine: Keep cervical collar in place

💡 Tips:
Use the log-roll method for safe examination and transfer of trauma patients. A coordinated effort by 3–4 staff is ideal.

📌 Log-Roll Technique (4-Person Example)

1. Head Holder: Most crucial role – maintains C-spine neutrality and gives commands
2. Torso/Pelvis: Support and rotate torso on cue
3. Lower Limbs: Stabilize legs while turning
4. Examiner: Inspects back for wounds, spinal tenderness, or bleeding

💡 Important Points:

• Head holder must maintain cervical spine alignment throughout the entire process
• All members should move together on a unified count (“1-2-3”)
• Return to supine in the same coordinated manner after the back is examined

At the end of the secondary survey, you should have a comprehensive understanding of both life-threatening and occult injuries. Next, proceed to evaluating shock and fluid resuscitation strategies.

Step 3: Evaluating Shock and Initial Resuscitation – FAST, TXA, and Pelvic Injuries

One of the most critical aspects of trauma care is the early recognition and management of shock. Even without visible bleeding, significant internal hemorrhage can rapidly progress. This section covers key indicators, essential imaging, and initial resuscitation strategies, including TXA use and pelvic fracture care.

3-1. Definition and Clinical Signs of Shock

Shock is a life-threatening condition caused by inadequate tissue perfusion. In trauma, hemorrhagic shock is the most common type. Key physical findings include:

• Cold, pale, clammy skin
• Weak or impalpable radial pulse (SBP roughly ≤ 80 mmHg)
• Altered consciousness, tachycardia, decreased urine output

💡 Tips:
Vital signs may appear normal in young or elderly patients despite ongoing shock. Pay close attention to:

• Peripheral perfusion (cool extremities)
• Narrow pulse pressure
• Urine output

3-2. Localizing the Source – FAST and Pelvic X-ray

If shock is suspected, quickly search for internal bleeding. Two key tools are:

🔍 FAST (Focused Assessment with Sonography for Trauma)

• Check: pericardium, Morison’s pouch, splenorenal space, pelvis (Douglas pouch)
• Positive findings → consider emergent laparotomy or interventional radiology (IVR)

🦴 Pelvic X-ray

• Look for widening or asymmetry of pelvic ring → suggests pelvic bleeding
• Even with negative FAST, pelvic fracture may be the bleeding source

📌 Estimated Blood Loss by Fracture Type:

• Femoral fracture: 1.0–2.0 L
• Pelvic fracture: 1.0–4.0 L or more (can be fatal)
• Tibia/fibula fracture: 0.5–1.0 L
• Humerus fracture: ~0.5 L

3-3. Initial Resuscitation and Hemorrhage Control

Resuscitation should follow a stepwise approach:

1. Rapid fluid infusion using large-bore IV lines (preferably lactated Ringer’s)
2. Hemorrhage control: direct pressure → tourniquet → TXA → surgical or IVR intervention
3. Supplemental oxygen, temperature management, urine output monitoring

💡 Tips:
In suspected hemorrhagic shock, controlling bleeding may take priority over fluids. For pelvic fractures, immediate application of a pelvic binder is essential.

3-4. Use of TXA (Tranexamic Acid)

TXA has been shown to reduce mortality in traumatic bleeding, especially when administered early (within 3 hours). Based on the CRASH-2 trial:

• Initial dose: 1g IV over 10 minutes
• Maintenance: 1g IV over 8 hours
• Best efficacy: within 3 hours post-injury

📌 Column: What is the CRASH-2 Trial?
An international randomized controlled trial demonstrating that early TXA use significantly reduces mortality in trauma patients with bleeding.

With this knowledge, you should now be able to identify and respond to shock in trauma patients. Next, we’ll explore trauma classification, severity scoring, and predictive indices.

Step 4: Trauma Energy Classification and Severity Scoring – GCS, ISS, RTS, and More

Understanding the energy involved in trauma and applying appropriate severity scoring systems help determine triage priorities, the need for specialist referral, and prognosis. In this section, we cover essential frameworks like high- vs. low-energy trauma, GCS, ISS, and RTS.

4-1. High-Energy vs. Low-Energy Trauma

🔺 High-Energy Trauma:

• Causes: Motor vehicle accidents, falls from height, train or industrial accidents
• Often associated with multiple injuries → Full-body CT (head, neck, chest, abdomen) is usually indicated
• “Pick-up effect”: Early CT can identify life-threatening injuries not apparent initially

🔻 Low-Energy Trauma:

• Causes: Minor falls, low-impact injuries (especially common in the elderly)
• Risk: Significant injuries (e.g., pelvic fractures, intracranial hemorrhage) may be hidden
• CT is often warranted in elderly patients, even with seemingly minor trauma

💡 Tips:
Low-energy ≠ low-risk. For example, elderly patients on warfarin with minor head trauma may still require CT imaging due to high bleeding risk.

4-2. GCS (Glasgow Coma Scale)

The GCS is a standardized method to assess consciousness in trauma patients. Record both the initial and serial scores.

Component	Response	Score
E (Eye Opening)	Spontaneous	4
	To speech	3
	To pain	2
	None	1
V (Verbal Response)	Oriented	5
	Confused conversation	4
	Inappropriate words	3
	Incomprehensible sounds	2
	None	1
M (Motor Response)	Follows commands	6
	Localizes pain	5
	Withdraws from pain	4
	Flexion (decorticate)	3
	Extension (decerebrate)	2
	None	1

💡 Interpretation:
GCS 13–15: Mild
GCS 9–12: Moderate
GCS ≤ 8: Severe → Consider intubation

4-3. ISS (Injury Severity Score) and RTS (Revised Trauma Score)

📊 ISS – Anatomical Severity Score

The body is divided into six regions (head, face, chest, abdomen, extremities, external). The top 3 scores from the Abbreviated Injury Scale (AIS) are squared and summed:

ISS ≥ 16 = Major trauma

📈 RTS – Physiologic Severity Score

Combines 3 parameters to estimate physiologic derangement:

• GCS
• SBP (Systolic Blood Pressure)
• RR (Respiratory Rate)

Used for triage, transport decisions, and prognostic estimation in trauma systems.

📌 Which Score to Use?

• GCS: Standard for neurological assessment and monitoring trends
• ISS: Best for anatomical injury evaluation and trauma center transfer decisions
• RTS: Reflects physiological status; helpful for prognosis and triage

With this framework, you’re now equipped to evaluate trauma energy and severity. Next, let’s cover special populations and common fractures seen in the emergency department.

Step 5: Special Populations and Common Fractures in the Emergency Department

5-1. Special Populations: Elderly, Children, and Pregnant Patients

👵 Elderly Trauma

• Even minor trauma (e.g., falls) can result in serious injuries like femoral neck fractures.
• Anticoagulant use increases risk for intracranial or internal bleeding.
• Preexisting conditions (heart failure, COPD) require tailored oxygen and fluid management.

🧒 Pediatric Trauma

• Abdominal trauma (e.g., liver or spleen injuries) is common due to flexible ribs.
• Shock can progress quickly due to small blood volume—watch for hypoglycemia and hypothermia.

🤰 Trauma in Pregnancy

• After 20 weeks gestation, supine hypotensive syndrome is a risk → Position in left lateral decubitus.
• Monitor fetal heart rate and consult obstetrics early.
• Radiologic exams are safe when clinically necessary—maternal stability is the top priority.

5-2. Common Fractures Seen in the Emergency Department

🦴 ① Femoral Neck Fracture

• Classic in elderly fall patients → Limb shortened and externally rotated
• May be missed on X-ray → Consider CT or MRI if suspicion remains
• Early surgical intervention (within 24–48 hours) improves mobility and outcomes

🦴 ② Colles’ Fracture (Distal Radius)

• Caused by a fall onto an outstretched hand
• “Dinner fork” deformity on inspection
• Check for volar tilt and radial length on X-ray

🦴 ③ Proximal Humerus Fracture

• Common in elderly falls
• Cannot raise shoulder, swelling, pain with abduction
• Use Neer classification to guide treatment (conservative vs. surgical)

🦴 ④ Vertebral Compression Fracture

• Elderly women + low-energy fall → Sudden back pain, kyphosis
• X-ray may be inconclusive → MRI recommended for early detection
• Initial treatment includes pain control and rest; surgery for persistent or severe cases

💡 Tips: Suspect fracture when:

• Focal pain even with minimal trauma
• Inability to bear weight or walk without assistance
• Normal X-ray but persistent pain → Consider CT/MRI

📌 Ottawa Ankle Rules – When to X-ray Ankle Injuries

Use these criteria to reduce unnecessary X-rays in ankle trauma:

• Inability to bear weight immediately and in ED (4 steps)
• Tenderness at posterior edge or tip of lateral or medial malleolus (within 6 cm)
• Tenderness at base of 5th metatarsal or navicular bone (→ foot X-ray)

💡 Pelvic X-ray – How to Read It Systematically

• Check iliac wings: height and width symmetry
• Assess pubic symphysis: separation >1 cm is abnormal
• Inspect sacroiliac joints: widening or irregularity
• Follow the pelvic ring contour for step-offs or fractures
• Check the acetabulum for alignment and integrity

With these principles, you’re better prepared to handle common trauma in special populations and avoid common pitfalls in fracture diagnosis. Let’s now cover common diagnostic dilemmas and overlooked injuries in trauma care.

Step 5 Supplement: Overlooked Injuries, Diagnostic Dilemmas, and Legal/Insurance Tips in Trauma Care

🚗 Key Signs and Hidden Injuries in Traffic Trauma

• Seatbelt sign: Linear bruising across the abdomen → Suspect bowel injury or intra-abdominal bleeding → Order abdominal CT
• Chest contusion (steering wheel impact): Look for rib fractures, pulmonary contusion, cardiac tamponade
• Facial/neck trauma (airbag injury): Suspect cervical hyperextension → Consider C-spine X-ray or CT
• Lower extremity trauma (bike/pedestrian hit): Pelvic fracture, femoral fracture, hip dislocation

📌 Tip: Always perform CT in cases with seatbelt marks, localized pain, or suspected internal injury—even if vitals appear stable.

🧠 Diagnostic Dilemma #1: How Much Testing Is Enough?

Seemingly “minor trauma” can still hide serious injury. Combine mechanism of injury and clinical findings to justify imaging.

• CT is covered by insurance if clinically indicated—don’t hesitate to order when appropriate.
• “I wish I had done a CT” is more dangerous than being proactive.

💡 Tip: Injuries like bowel perforation, pancreatic or renal trauma often show minimal symptoms early—CT may be the only way to detect them.

🧾 Diagnostic Dilemma #2: Insurance and Documentation

Item	Clinical/Administrative Notes
Traffic Accident Billing	Initially self-pay → later billed to at-fault party’s auto insurance (liability insurance)
Medical Certificate	“Number of days” = estimated healing time, not actual disability
Continuing Care	Even for minor trauma, refer to orthopedics or document outpatient follow-up plan

💡 Tips for Writing Medical Certificates:

• Use specific terms like “contusion,” “sprain,” or “abrasion” rather than vague terms
• Example: “No fracture seen on X-ray” is better than “no fracture” → helps avoid legal disputes

🤔 Common Clinical Judgment Calls

• Patient says “I feel fine” → Still, CT may reveal serious injuries
• Bicycle vs. car accidents → Watch for facial trauma, dentition damage, and intracranial injuries even if ambulatory
• Minor rear-end collisions → Elderly patients with neck pain → Always evaluate cervical spine

📌 D-dimer Is NOT for Fracture Screening

D-dimer is used for thrombotic evaluation (e.g., DVT, PE) and is not appropriate to screen for fractures.

✅ Use D-dimer for:

• Suspected PE after lower limb trauma
• New-onset dyspnea in post-fracture patients

❌ Do NOT use D-dimer to rule out bone injury.

In the next section, we’ll shift focus to burn injuries, starting with pathophysiology, burn depth, and TBSA evaluation.

Burn Management – Step 1: Fundamentals and Severity Assessment

Burns are assessed based on two primary factors: burn depth and total body surface area (TBSA). Accurate assessment is essential for triage, referral decisions, and predicting the need for hospitalization or surgical intervention.

📌 Burn Depth Classification

• 1st-degree burn: Involves only the epidermis. Redness and pain without blisters (e.g., sunburn).
• 2nd-degree burn: Extends into the dermis. Blistering present. Further divided into superficial and deep partial-thickness burns.
• 3rd-degree burn: Full-thickness necrosis extending through dermis into subcutaneous tissue. Painless due to nerve damage. Often requires skin grafting.
• 4th-degree burn: Involves muscle, bone, or fat. Extremely severe with high morbidity.

👉 Burn depth can evolve over time. Avoid premature assessment—observe progression carefully in the first 24–48 hours.

📐 TBSA Assessment (Rule of 9s & Palm Method)

TBSA (Total Body Surface Area) is estimated to determine burn severity and guide fluid resuscitation.

• Rule of 9s (Adults):
  • Head and neck: 9%
  • Each upper limb: 9%
  • Each lower limb: 18%
  • Anterior trunk: 18%
  • Posterior trunk: 18%
  • Perineum: 1%
• Palm Method: Patient’s palm including fingers = approximately 1% of TBSA
  Useful for small or irregular burns.

📊 Epidemiology and Risk Factors

• 👶 Pediatrics: Most burns are caused by hot water or oil in household accidents.
• 👵 Elderly: Common causes include low-temperature burns from heaters or baths.
• 🏭 Adults: Work-related burns or fire injuries are more common.

⚠️ Children and the elderly are at higher risk of complications, even with apparently minor burns. Always assess carefully and manage aggressively.

🧪 Criteria for Severe Burns

Burns meeting any of the following criteria are considered severe and may require transfer to a burn center:

• ≥30% TBSA of 2nd-degree burns
• ≥10% TBSA of 3rd-degree burns
• Involvement of critical areas: face, hands, feet, perineum, or joints
• Inhalation injury, electrical burns, or chemical burns
• Special populations: infants, elderly, or patients with significant comorbidities

➡️ If any of the above are present, consider early referral to a burn center.

Burn Management – Step 2: Initial Assessment and Fluid Resuscitation

In severe burns, early and appropriate resuscitation is critical to improving survival. The initial approach follows the same ABCDE framework used in trauma, followed by burn-specific assessment and fluid management.

🩺 ABC Approach for Burn Patients

• A (Airway): Look for signs of inhalation injury: soot in mouth/nose, facial burns, hoarseness, or respiratory distress → Consider early intubation
• B (Breathing): Monitor respiratory rate, SpO₂, and listen for abnormal lung sounds
• C (Circulation): Extensive burns can lead to plasma volume loss → Monitor for hypovolemic shock

💡 Tips – Signs of Inhalation Injury:

• Soot in oral or nasal cavity
• Facial burns, singed nasal hair, eyebrows
• Hoarseness, wheezing, stridor
• Cough or respiratory distress

→ Inhalation injuries can rapidly worsen → Do not delay intubation if suspected.

💧 Fluid Resuscitation – Parkland Formula

Extensive burns cause capillary leakage and fluid loss → Prompt fluid replacement is essential.

Parkland Formula:

Fluid requirement (mL) = 4 × body weight (kg) × %TBSA burned

• Use lactated Ringer’s solution (LR)
• First 8 hours: Give half of the total volume
• Next 16 hours: Give the remaining half

💡 Start timing from the moment of burn injury, not arrival to hospital.
If patient presents 4 hours post-injury, administer remaining volume for the initial 8-hour period over the next 4 hours.

📌 When to Start Fluid Resuscitation

• Adults: ≥15–20% TBSA burns
• Children: ≥10% TBSA burns

📊 Monitoring Goals

• Urine output: Adults ≥0.5 mL/kg/hr; Children ≥1.0 mL/kg/hr
• Vital signs, weight, urine output, lactate, and mental status should be checked frequently

🧑‍⚕️ Special Considerations

👵 Elderly

• Often have comorbidities (e.g., heart failure, renal impairment) → Start with cautious fluid replacement

🧒 Pediatric Patients

• May require maintenance glucose-containing fluids in addition to resuscitation fluids

⚡ Electrical Injuries

• Surface burns may appear minor, but muscle necrosis and rhabdomyolysis can be extensive
• Monitor creatine kinase (CK) and potassium levels
• Ensure urine output of 1–2 mL/kg/hr to prevent renal failure

📘 Topic: Watch for Over-Resuscitation

Excessive fluid infusion can lead to “fluid creep,” pulmonary edema, or abdominal compartment syndrome.
→ Adjust based on urine output and clinical signs.

Burn Management – Step 3: Initial Wound Care – Cooling, Cleaning, Topicals, and Pain Control

🔹 1. Immediate First Aid: Cooling and Cleaning

• Cooling: Use cool running water (15–20°C) for 20 minutes as soon as possible after injury. Do not use ice or very cold water.
• Cleaning: Gently cleanse with saline or tap water to remove debris and necrotic tissue. Helps prevent infection.

🔹 2. Topical Treatments and Dressings

• Non-infected burns: Apply non-adherent dressings (e.g., Vaseline gauze, hydrocolloid dressings) to maintain a moist environment.
• Suspected infection: Use topical antimicrobials such as:
  • Silver sulfadiazine (SSD) ointment: Broad-spectrum but may delay epithelialization with prolonged use
  • Sofratulle (antibacterial tulle dressing): Good for reducing pain during dressing changes
  • Povidone-iodine: Avoid large-area use due to risk of thyroid suppression
• Other options: Consider epithelialization agents (e.g., fibroblast spray) or fibrin sprays for bleeding control—but avoid in infected wounds.

🔹 3. Blister (Bulla) Management

• Unbroken blisters: Leave intact when possible—they act as natural protection
• Large or tense blisters: May be drained or debrided if there are signs of infection or risk of rupture

🔹 4. Pain Control and Systemic Management

• Analgesia: Start with acetaminophen or NSAIDs; escalate to opioids if needed
• Extensive burns: Consider fluid resuscitation (as per Parkland formula), oxygen therapy, and frequent reassessment
• Inhalation injury suspected: Early airway management (intubation) is critical

🔹 5. Infection Prevention and Tetanus Prophylaxis

• Watch for signs of infection: increased redness, foul odor, worsening pain, or fever
• Systemic antibiotics: Indicated if there is evidence of infection or deep burns
• Common regimens: Ampicillin-sulbactam, or Clindamycin + Cephalosporin for anaerobic coverage
• Tetanus vaccination: Verify vaccination history. If unknown or >10 years, give Td. For dirty wounds and uncertain immunity, consider adding TIG (tetanus immune globulin)

🔹 6. Pediatric-Specific Considerations

• Use Lund-Browder chart for accurate TBSA estimation
• Watch for hypoglycemia and shock—especially in children under 2 years
• Fluid, nutrition, and emotional support are all essential

📌 Referral Tips: Consider early transfer for burns involving special areas (face, hands, perineum, joints) or in vulnerable populations (infants, elderly, patients with comorbidities).

Burn Management – Step 4: Burn Severity Classification and Criteria for Admission or Specialist Referral

🔸 1. When to Admit or Refer to a Burn Center

Some burns require specialized care, and timely referral is key. Consider inpatient care or burn center referral when any of the following criteria are met:

• ≥30% TBSA with second-degree (partial-thickness) burns
• ≥10% TBSA with third-degree (full-thickness) burns
• Burns involving:
  • Face
  • Hands or feet
  • Perineum
  • Major joints
• Inhalation injury (hoarseness, facial burns, soot, respiratory distress)
• Electrical or chemical burns (even if small)
• Vulnerable populations (infants, elderly, patients with comorbidities)

📌 Examples:
Even a small burn may justify admission if located on the face, fingers, or genitals, or if the patient has poor home care capacity (e.g., dementia, lives alone).

🔸 2. ABA (American Burn Association) Referral Criteria

These are widely used criteria for burn center referral:

• ≥10% TBSA second-degree burns
• Any third-degree burns
• Burns involving face, hands, feet, genitalia, perineum, or major joints
• Inhalation injury
• Electrical or chemical burns
• Burns in patients with preexisting medical disorders (e.g., heart failure, diabetes, mental illness)

🧮 Burn Index (BI) and Prognostic Burn Index (PBI)

• Burn Index (BI): BI = %TBSA (third-degree) + %TBSA (second-degree) ÷ 2
• Prognostic Burn Index (PBI): PBI = BI + patient’s age

📌 Interpretation: PBI > 100 → high risk of poor prognosis

🧠 Psychological Support Is Also Critical

• Facial burns and burns in young women can cause severe emotional trauma → Consider early mental health support
• Children are at risk of PTSD following severe burns → Family and psychological care are essential

With this, you now have a full understanding of initial burn management—from classification and resuscitation to wound care and referral. The final section will provide a summary and practical English phrases for use in clinical practice.

✉️ OET Writing Task – Sample Referral Letter

Today’s Date: 8 July 2025

Dr. Naomi Sato
Burn Center
Tokyo University Hospital

Re: Mr. Hiroshi Tanaka, 62 years old

Dear Dr. Sato,

I am writing to refer Mr. Hiroshi Tanaka, a 62-year-old man who sustained significant thermal injuries in a residential fire earlier today. He requires specialized burn care and close airway monitoring.

Mr. Tanaka presented with partial- and full-thickness burns involving approximately 18% of his total body surface area, affecting his anterior chest, right upper limb, and face. He exhibited signs of possible inhalation injury, including facial burns, soot in the oropharynx, and mild hoarseness.

Initial management in our department included oxygen administration via non-rebreather mask, fluid resuscitation using the Parkland formula, and intravenous analgesia. His wounds were cleansed and dressed, and tetanus prophylaxis was provided.

Due to the location and extent of his burns and the risk of airway compromise, we believe urgent transfer to your center is indicated for definitive evaluation and management.

Please do not hesitate to contact me if any additional information is required.

Yours sincerely,

Dr.[your name]
General Practinor
Department

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🗣️ OET Speaking Session – Burn Injury (Adult Female)

👥 Scenario

You are a doctor in the emergency department. A 35-year-old woman presents with a scald injury to her right forearm and hand after spilling boiling water while cooking. She is in considerable pain and highly anxious about the possibility of scarring and loss of hand function.

🎯 Your Task

• Assess and explain the severity of the burn
• Reassure the patient and discuss the dressing and recovery plan
• Manage her pain and provide advice on wound care at home
• Address emotional concerns about long-term function and appearance

💬 Common Patient Cues & Sample Doctor Responses

🧠 Challenging Questions & Sample Doctor Responses

🧾 Summary – Key Points from This Guide

Trauma and burns are among the most common, yet potentially life-threatening conditions encountered in emergency departments. Prompt assessment and appropriate intervention can dramatically influence patient outcomes.

• 🔍 Start with a structured ABCDE and MIST approach to prioritize life-threatening conditions such as bleeding, airway obstruction, and pneumothorax.
• 🩺 Use primary and secondary surveys to identify hidden injuries and comorbidities. Apply tools like FAST, GCS, ISS, and RTS when appropriate.
• 🚨 Early recognition of shock and appropriate fluid management, especially in bleeding or burn patients, is essential for survival.
• 🔥 Burn severity should be assessed by depth and TBSA. Use the Parkland formula for fluid resuscitation and monitor for inhalation injury.
• 🏥 Special populations (elderly, children, pregnant patients) require extra caution and often early referral.
• 📤 Refer to a burn center or trauma unit when criteria such as deep burns, critical area involvement, or inhalation injuries are met.
• 📘 Clear communication through structured referral letters and patient-centered dialogue is essential — especially in international or OET/USMLE contexts.

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🔗 Related Articles (Symptom-Based Approaches)

• Shock – ABC Approach and Fluid Strategy
• Dyspnea – Airway Burns and Inhalation Injury
• Syncope – Initial Evaluation and Red Flags
• Japanese version here:37症候別アプローチ　外傷・熱傷

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📚 References

• Complete Trauma & Burn Manual (2024 Edition)
• Japan Association for Acute Medicine (JAAM) – JATEC Guidelines
• American Burn Association (ABA) Referral Criteria
• CRASH-2 Trial, The Lancet, 2010
• PECARN Rule – Kuppermann N. et al., 2009
• Ottawa Ankle Rules – Stiell IG et al., 1992