Rapid Clinical Updates: Management of Burns and Carbon Monoxide Toxicity for Hospitalists-Slides

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This presentation by Drs. Gaby Frank and Scott Phillips provides hospitalists with key guidance on managing burns and carbon monoxide (CO) toxicity.<br /><br />Burn injuries affect over a million people annually in the U.S., mostly minor, but with around 486,000 seeking treatment. Burns are classified by depth—superficial (1st degree), partial thickness (2nd degree), and full thickness (3rd degree)—and total body surface area (TBSA) involvement. Accurate TBSA assessment (using Rule of 9, Lund-Browder chart) and burn depth evaluation are essential to guide fluid resuscitation (Parkland formula) and wound care. Non-surgical care includes oxygen, warming, Foley catheter placement, careful fluid management, wound cleaning, and topical antimicrobials (silver-based dressings preferred; silver sulfadiazine and mafenide acetate may worsen outcomes). Indications for transfer to specialized burn centers include >10% TBSA second-degree burns, any third-degree burn, burns involving face/hands/feet/genitalia, electrical/chemical burns, and inhalation injury.<br /><br />Smoke inhalation is a major contributor to fire-related mortality—accounting for 60-80% of deaths in U.S. fires—and increases mortality over burns alone. Smoke exposure is complex and involves thermal injury, particulate carbon soot, and cellular asphyxiants such as CO and cyanide. Inhalation injury ranges from mild to massive, graded bronchoscopically. CO is the predominant toxic gas causing hypoxia by binding hemoglobin (forming carboxyhemoglobin) and impairing cellular respiration via mitochondrial cytochrome oxidase inhibition, resulting in oxidative stress and inflammation. High-risk exposures often occur in confined spaces with synthetic materials.<br /><br />Management of CO toxicity includes high-flow oxygen and consideration for hyperbaric oxygen, especially in severe cases. Cyanide poisoning should be suspected with high lactate and treated with hydroxocobalamin. Multidisciplinary care involving critical care, toxicology, pulmonology, and burn specialists is recommended. Prevention strategies include smoke/CO detectors, fire suppression systems, and avoiding fuel-burning appliances in enclosed spaces.<br /><br />In summary, effective burn management requires prompt assessment of burn depth and extent, early fluid resuscitation, appropriate wound care, and timely transfer to burn centers as indicated. Concurrent smoke inhalation and CO poisoning necessitate high clinical suspicion and aggressive supportive care. Hospitalists should leverage available resources, including regional poison centers, to optimize outcomes in these complex injuries.

Keywords

burn injuries

carbon monoxide toxicity

burn depth classification

total body surface area

fluid resuscitation

smoke inhalation injury

hyperbaric oxygen therapy

cyanide poisoning

burn center transfer criteria

multidisciplinary burn care