Frameworks of trauma such as Advancement Trauma Life Support (ATLS) or Emergency Management of Severe Burns (EMSB) provide the burns professional with treatment priority principles that emphasise the fact that timely resuscitation, assessment and recognition of life threatening injuries, together with early transfer to a definitive burns unit saves lives.

The recognised classic treatment algorithm of primary survey with the ABCDE (Airway, Breathing, Circulation, Disability and Environment/Hypothermia protection) approach, tip-to-toe secondary survey and continuous reassessment with definitive transfer to and expert facility displays a number of variations in the management of burn patients.

The potential for an impending airway compromise in major burns with an inhalational injury will require the early involvement of the Anaesthesia/Intensive Care teams in order to secure a definitive airway in the form of an endotracheal tube. Airway assessment and the possibility of an inhalational injury, especially if the injury has occurred in an enclosed space, need to be coupled with the careful assessment for potential injury of the cervical spine.

Potential inability or delay in weaning off burns patients from mechanical ventilation may require the insertion of a tracheostomy either through a percutaneous or open surgical method. Both methods are safe in expert hands with the choice of method depending on the state of the soft tissues of the neck affected by the burn, experience of the operator and the size of the burn and the body habitus of the patient. Tracheostomy is therefore a fundamental skill for both the burn surgeon and the intensive care specialist [10].

The adequacy of the oxygenation and ventilation may be compromised by the presence of full thickness burns of the chest wall and abdomen leading to decreased compliance and high inflation pressures (Fig. 10.2).

The full thickness skin eschar acts as a ventilation compliance-limiting factor. The presence of ventilation difficulties should prompt urgent assessment of the need for releasing escharotomy incisions performed under suitable theatre conditions and by professionals with adequate experience. Escharotomies will immediately improve ventilation and avert the possibility of abdominal compartment pressure [11, 12].

Escharotomies in the chest and abdomen are performed from unburned skin to unburned skin and along the anterior axillary lines and across the lower edge of the rib cage transversely. Occasionally there is a need to join these lines to provide a more definitive release that is ensured by direct visualisation of healthy bulging fat through the escharotomy incisions [13].

The adequacy of the circulation in the burns patient requires prompt insertion of Intravenous access in the form of two large cannulas preferably through unburned skin in order to promptly avert the hypovolemia that occurs as a consequence of the burns distributive shock.

In the case of full thickness circumferential burns to the limbs, the need for escharotomies in order to ensure adequate distal blood flow to the extremities is an urgent priority [14].

Upper limb escharotomies (Fig. 10.3) are performed along the lateral and medial axial lines with the arm in pronation applying the principles described above. Great care must be exerted to avoid damage to relevant neurovascular structures, especially around the medial epicondyle area, where the ulnar nerve is at great risk. When electrical injury is the cause of the soft tissue damage, the presence of muscle necrosis due to compartment syndrome may require the combination of escharotomies with fasciotomies in order to provide limb salvage and function preservation.

Lower limb escharotomies are performed also along lateral and medial axial lines down to healthy bulging fat avoiding damage to the common peroneal nerve at the level of the fibular neck laterally and proximally, and to the posterior tibial neurovascular bundle and the great saphenous vein distally.

Disability and neurological assessment of the critically ill major burned patient can be problematic and difficult to ascertain due to the fact that the patient may have been intubated onsite, In this case, obtaining a good burns and trauma history and performing a thorough physical examination will help to develop a high degree of suspicion and to exclude the possibility of a brain or spinal injury. Any lack of normalisation of neurological function following decrease of sedation and analgesia or a failed extubation should alert the burns professional about the possibility of neurological damage.

From the environmental point of view, hypothermia is often an overlooked risk factor in the management of the major burn, the importance of which cannot be overstated. Continuous reassessment is fundamental whilst resuscitating the patient in order to prevent the early onset of the lethal triad of hypothermia, acidosis and coagulopathy in burns, which is associated with significant mortality [15].

The importance of these complications cannot be underestimated taking into consideration the established practice of early excision of the burn wound that may involve severe blood loss potentially increased by a deranged clotting cascade and lack of platelet adhesion accentuated by hypothermia.

Keeping the patient warm at pre-hospital level and during transfer can therefore avert the delay in acute surgical debridement due to hypothermia. Temperature control can be achieved by the use of radiant heaters in the Emergency Department, and by keeping these patients in a warm room whilst in the burns unit. The infusion of warm intravenous fluids via new generation intravascular warming catheters and forced hot air technologies, such as such as the Bair Hugger^TM, are methods commonly used to avoid hypothermia [16].

Hypothermia can decrease the ability of the burn patient to withstand the stress of surgery and become less tolerant to the effect of anaesthetic drugs [17].

Adequate assessment of the burn wound in size and depth are performed in order to provide priorities of treatment.

Burns surgery is ultimately aimed at preserving the blood supply of the skin and all of the skin functions which include protection from environmental elements and pathological organisms, immunological surveillance, fluid and electrolyte homeostasis, maintenance of protein and electrolyte concentrations, thermoregulation and control of heat loss.