Name: Burns — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

In burns the surface area is the obvious part; the airway, the poisons, and the constricting eschar are what kill early. The defensible chart documents the airway/inhalation assessment, the TBSA and fluid plan, the CO/cyanide consideration, and — when the story doesn't fit — non-accidental injury.

01What's at stake

Inhalation injury and airway edema can progress fast — intubate early when the signs are there. Enclosed-space fires add carbon monoxide and cyanide. Circumferential burns threaten limb and chest, and electrical injury hides deep damage, arrhythmia, and rhabdomyolysis. And a burn whose pattern or history doesn't fit the child's development is a red flag for abuse.

02Can't-miss issues

Inhalation / airway injury — facial burns, singed nasal hair, soot, stridor, hoarseness → early intubation before edema closes the airway.
Carbon monoxide & cyanide — enclosed-space fire, altered mentation, lactate; 100% O₂ ± hydroxocobalamin.
Circumferential burns — chest (ventilation) or limb (perfusion) → escharotomy.
Electrical injury — cardiac monitoring, deep/occult tissue injury, rhabdomyolysis/AKI, compartment syndrome.
Chemical burns — immediate, prolonged irrigation.
Non-accidental injury — pattern (stocking/glove, immersion lines), mechanism inconsistent with development.

03Assessment

Airway signs (facial/oropharyngeal burns, soot, stridor, voice change)? → intubate early
Enclosed-space fire, altered mentation, high lactate? → CO / cyanide
Circumferential burn of chest/limb? → escharotomy
Electrical mechanism? → ECG/monitoring, CK, look deep
Estimate TBSA (Rule of Nines / Lund-Browder; palm ≈ 1%) for resuscitation and transfer; assess depth.

Skip the typing

Work the case in the Burns Workup — it records the TBSA, the ABA transfer criteria, and irrigation, and assembles an MDM that documents the airway/inhalation, CO/cyanide, and resuscitation reasoning.

04Management

Airway/breathing first — early intubation for inhalation injury; 100% O₂ for CO; hydroxocobalamin for suspected cyanide.
Fluids — titrate by a formula (e.g., Parkland/modified Brooke) and to urine output; avoid over-resuscitation ("fluid creep").
Wound care — cool/clean, cover; chemical burns get prolonged irrigation (eye → neutral pH); tetanus.
Escharotomy for circumferential chest/limb compromise.
Transfer per American Burn Association criteria (large TBSA, full-thickness, face/hands/feet/perineum/joints, inhalation, electrical/chemical, extremes of age, abuse concern).

05What to document

▼ weak

"Burn to arm, dressed, pain meds, discharged."

▲ defensible

"Scald to forearm, ~4% TBSA, partial thickness. House fire excluded (no enclosed-space exposure) — airway clear, no soot/stridor/facial burns; CO/cyanide not indicated. Not circumferential; distal neurovascular intact. Mechanism consistent with history (NAI considered — no concerning pattern). Cooled/dressed, tetanus updated, analgesia. ABA criteria reviewed; outpatient burn follow-up arranged with return precautions. (For inhalation: early intubation; large TBSA: Parkland to urine output and ABA transfer.)"

06Where charts fail

Waiting on a deteriorating airway instead of intubating early for inhalation injury.
Missing CO/cyanide after an enclosed-space fire.
Not recognizing a circumferential burn needing escharotomy.
Underestimating electrical injury (cardiac, deep tissue, rhabdo).
Not documenting TBSA/fluid plan, or missing the non-accidental-injury pattern.

07Sources

Greenhalgh DG. Management of burns. N Engl J Med. 2019;380(24):2349-2359.
ISBI Practice Guidelines Committee. ISBI practice guidelines for burn care. Burns. 2016;42(5):953-1021.
American Burn Association. Burn center referral criteria. Resources for Optimal Care of the Injured Patient (ACS).
Pham TN, Cancio LC, Gibran NS. American Burn Association practice guidelines: burn shock resuscitation. J Burn Care Res. 2008;29(1):257-266.

Burns: documentation that holds up