Burn Assessment and Treatment Based on Depth and TBSA
Burns should be assessed using total body surface area (TBSA) and depth classification to guide immediate resuscitation, cooling, and wound management, with adults requiring fluid resuscitation at TBSA ≥10% and children at TBSA ≥10%, while cooling should be applied to burns <20% TBSA in adults and <10% TBSA in children in the absence of shock.
Initial Assessment and Resuscitation
TBSA Calculation
- Use the "rule of hand" where one hand (palm and fingers) represents approximately 1% of the patient's TBSA 1
- This method allows rapid bedside estimation to determine resuscitation needs
Immediate Fluid Resuscitation
For burns requiring fluid resuscitation (adults ≥10% TBSA, children ≥10% TBSA), administer 20 mL/kg of balanced crystalloid solution within the first hour of management 1. This addresses the early hypovolemic phase caused by inflammation, capillary leak syndrome, and microcirculation alterations.
- Use Ringer's Lactate or balanced crystalloid solutions as first-line 1
- Avoid 0.9% NaCl due to increased risk of hyperchloremia, metabolic acidosis, and acute kidney injury 1
- Obtain IV access in unburned areas when possible; use intraosseous route if IV access cannot be rapidly obtained 1
- Early fluid resuscitation (within 2 hours) reduces morbidity and mortality 1
Critical pitfall: The initial 20 mL/kg bolus is not adjusted for TBSA due to difficulties in accurate assessment during the first minutes after injury 1. Subsequent fluid management should follow established formulas based on accurate TBSA calculation.
Burn Depth Classification
Second-Degree Burns
- Characterized by blister formation (phlyctena)
- Epidermis and varying depths of dermis affected
- Retain some sensation
Third-Degree Burns
- Appear as adherent necrosis without sensibility
- Complete destruction of epidermis and skin appendages
- Healing only occurs with severe scarring without intervention
- Require necrectomy and skin grafting 2
The deep burn index (DBI)—defined as the proportion of third and fourth-degree burns in total TBSA—is a critical prognostic factor, with DBI >0.38 indicating significantly worse outcomes in patients with burns ≥70% TBSA 3.
Cooling Protocol
Cool burns in adults with TBSA <20% and children with TBSA <10% in the absence of shock 1. This intervention:
- Limits burn deepening and progression
- Reduces need for skin grafting when applied for 20-40 minutes 1
- Provides pain relief 1
Critical caveats:
- Do not cool if patient is in shock (risk of hypothermia)
- Do not use external cooling devices (e.g., Water-Jel dressings) for prolonged periods or during transport 1
- Cooling beyond these TBSA thresholds risks hypothermia
Wound Management
Timing and Priority
Wound care is NOT a priority and should only be performed after well-conducted resuscitation 1. If transfer to a burns center cannot occur within a few hours, dressing becomes necessary.
Wound Cleaning and Dressing
- Clean wounds with tap water, isotonic saline, or antiseptic solution 1
- Perform in clean environment with deep analgesia or general anesthesia 1
- Avoid prolonged use of silver sulfadiazine on superficial burns as it prolongs healing 1
- Use antiseptic dressings for large or contaminated burns 1
- Do not use topical antibiotics as first-line; reserve for infected wounds only 1
Blister Management
- Consult burns specialist to determine whether blisters should be flattened or excised 1
- Removal of all blisters facilitates accurate assessment of burn size and depth 4
Dressing Application
- Prevent tourniquet effect, especially on limbs 1
- Monitor distal perfusion with circular dressings 1
- Re-evaluate dressings daily 1
Pain Management
Use titrated short-acting opioids and ketamine as first-line agents for burn-induced pain 1. The pain from burns and dressing changes is often intense and short-lasting.
Pharmacological Approach
- Titrate analgesics using validated comfort and analgesia assessment scales 1
- Combine titrated IV ketamine with other analgesics for severe burn pain 1
- Ketamine is particularly effective and limits morphine consumption 1
- Inhaled nitrous oxide useful when IV access unavailable 1
- General anesthesia for highly painful injuries or procedures 1
Non-Pharmacological Adjuncts
- Combine with pharmacological treatment when patient is stable 1
- Cooling (within parameters above) 1
- Covering burns with fatty substances (e.g., Vaseline) 1
- Virtual reality or hypnosis techniques may reduce pain intensity and anxiety 1
Important consideration: Burn injuries cause hypermetabolism and capillary leakage leading to hypovolemia, increasing risk of adverse effects from analgesics and sedatives—hence the emphasis on titration 1.
Escharotomy Considerations
Escharotomy should be performed only at a burns center; if impossible to transfer quickly, obtain specialist advice before proceeding 1.
Indications and Timing
- Rarely indicated immediately
- Urgent indication: Compromised airway movement and/or ventilation
- Within 48 hours: Intra-abdominal hypertension or circulatory impairment 1
- Decreases intra-compartmental pressure and improves functional outcomes 1
Risk: Poorly performed escharotomy increases morbidity, with complications including hemorrhage and infection 1.
Antibiotic Prophylaxis
Do not administer routine antibiotic prophylaxis to burns patients 1. Prevention of infection should rely on good wound care, including proper wound cleaning and topical antimicrobial dressings 4.