What is the management of thermal burn injury?

From the Guidelines

Management of burn injuries should prioritize immediate removal from the burn source, assessment of airway, breathing, and circulation, and fluid resuscitation for extensive burns, with the primary goals being infection prevention, optimal healing, and minimizing scarring and functional impairment. The most recent and highest quality study, 1, recommends that patients with second- or third-degree burns involving the face, hands, feet, and genitals and those involving >10% body surface area (5% in children) be treated in a specialized burn center.

Key Considerations

• Ensure patient safety by removing them from the burn source and assessing airway, breathing, and circulation.
• For minor burns (first-degree and small second-degree), cool the area with room temperature water for 10-15 minutes, but never use ice as it can worsen tissue damage.
• Clean the wound gently with mild soap and water, apply an antibiotic ointment like bacitracin or silver sulfadiazine, and cover with a non-stick sterile dressing.
• Pain management typically includes acetaminophen or ibuprofen for mild burns, while more severe burns may require opioid analgesics.
• Severe burns (third-degree or burns covering large body areas) require immediate emergency care, with fluid resuscitation critical for extensive burns, often following the Parkland formula (4mL × patient's weight in kg × percentage of body surface area burned) administered over 24 hours, as suggested by 1.

Additional Recommendations

• Tetanus prophylaxis should be considered if the patient's immunization status is outdated.
• Nutritional support is essential during recovery, as burn patients have increased metabolic demands.
• Physical therapy should begin early to prevent contractures and maintain function.
• Psychological support is also crucial, as burn injuries can cause significant emotional trauma.
• The management approach varies based on burn depth, size, and location, with the primary goals being infection prevention, optimal healing, and minimizing scarring and functional impairment, as emphasized by 1 and 1.

From the FDA Drug Label

Prompt institution of appropriate regimens for care of the burned patient is of prime importance and includes the control of shock and pain. The burn wounds are then cleansed and debrided; silver sulfadiazine cream, USP 1% is then applied under sterile conditions. The burn areas should be covered with silver sulfadiazine cream, USP 1% at all times The cream should be applied once to twice daily to a thickness of approximately one sixteenth of an inch. Treatment with silver sulfadiazine cream, USP 1% should be continued until satisfactory healing has occurred or until the burn site is ready for grafting.

Management of burn injury involves:

• Control of shock and pain
• Cleansing and debridement of burn wounds
• Application of silver sulfadiazine cream, USP 1% under sterile conditions
• Coverage of burn areas with the cream at all times
• Reapplication of the cream once to twice daily
• Continuation of treatment until satisfactory healing or until the burn site is ready for grafting 2

The grafted area should be covered with one layer of fine mesh gauze. An eight-ply burn dressing should be cut to the size of the graft and wetted with Mafenide Acetate 5% Topical Solution Treatment is usually continued until autograft vascularization occurs and healing is progressing (typically occurring in about 5 days)

Alternatively, mafenide acetate 5% topical solution can be used for:

• Grafted areas, covered with one layer of fine mesh gauze and an eight-ply burn dressing wetted with the solution
• Treatment continuation until autograft vascularization and healing progression, typically around 5 days 3

From the Research

Assessment and Management of Burn Injuries

• Burn injuries vary in severity and early management is essential to reduce patient mortality and morbidity 4
• Immediate care involves accurate assessment of burn depth and appropriate fluid management 4
• The acute assessment and management of burn-injured patients is a critical part of their short-term and long-term outcomes and often benefit from specialty, multidisciplinary care 5

Local Wound Care and Topical Antimicrobial Agents

• Local wound care and appropriate excision and grafting are important parts of managing the functional, cosmetic, and physiologic derangements caused by burn injuries 5
• Topical antimicrobial agents are used to prevent burn-wound infection, with silver-containing dressings being recommended over antiseptics or antibiotics, regardless of the depth of the burn 6
• Silver sulfadiazine is the most recommended topical antimicrobial in low-resource settings 6

Emergency Department Management

• Thermal burn injuries are a significant cause of morbidity and mortality worldwide, and emergency clinicians must assess for inhalation injury, exposure to toxic gases, and related traumatic injuries 7
• Priorities for emergency resuscitation include stabilization of airway and breathing, intravenous fluid administration, pain control, and local wound care 7
• Special populations, including children and pregnant women, require additional treatment considerations 7

Use of Silver Sulfadiazine

• Silver sulfadiazine is an effective antibacterial agent for topical use in burns, with low toxicity and few side effects 8
• However, the emergence of resistant Gram negative bacilli, including Pseudomonas aeruginosa, is a concern 8