What are the initial steps and treatment options for burn management?

Initial Management of Burns

The initial management of burns should include cooling the burn with clean running water (15-25°C) for 5-20 minutes, removing contaminated clothing and jewelry, assessing burn severity, providing pain control with multimodal analgesia, and covering the burn with a clean, non-adherent dressing. 1, 2

Assessment and Triage

Burn Severity Assessment

1. Determine burn depth:

   • Superficial (first-degree): Involves only epidermis
   • Partial-thickness (second-degree): Extends into dermis
   • Full-thickness (third-degree): Involves entire dermal layer

2. Calculate Total Body Surface Area (TBSA):

   • Use the Lund-Browder chart for most accurate assessment (suitable for both adults and children) 1
   • Alternative methods in emergency settings:
     • Rule of nines (less accurate and not suitable for children)
     • Palm method: Patient's palm = approximately 1% TBSA

3. High-risk burns requiring immediate medical attention/transfer to burn center 1, 2:

   • Burns on face, hands, feet, or genitalia
   • Full-thickness burns

   • 10% TBSA in children

   • 20% TBSA in adults

   • Circumferential burns
   • Inhalation injury
   • Electrical or chemical burns

Initial Treatment Steps

1. Stop the Burning Process

• Remove contaminated clothing and jewelry before swelling occurs 2
• Cool the burn with clean running water (15-25°C) for 5-20 minutes 1, 2
• Monitor for hypothermia, especially in children and those with large TBSA burns

2. Pain Management

• Implement multimodal analgesia titrated based on validated pain assessment scales 1
• For severe burn pain:
  • Titrated intravenous ketamine can be combined with other analgesics 1
  • Consider non-pharmacological techniques when appropriate 1

3. Wound Care

• Clean the wound with tap water, isotonic saline, or antiseptic solution 1
• Cover with a clean, non-adherent dressing 2
• Do not:
  • Apply ice directly to burns
  • Use home remedies or butter
  • Apply topical antibiotics prophylactically 1, 2

4. Fluid Resuscitation

• For burns >10% TBSA in children or >20% in adults, start fluid resuscitation 1
• Start nutritional support within 12 hours after burn injury, preferably via oral or enteral routes 1

Special Considerations

Monitoring for Complications

• Assess distal circulation, sensation, and motor function every 15-30 minutes for circumferential burns 2
• Watch for signs of compartment syndrome requiring escharotomy (should only be performed at burn centers) 2
• Monitor for inhalation injury signs (difficulty breathing, soot around nose/mouth) 2

Medication Considerations

• Silver sulfadiazine is not recommended for routine use as it may prolong healing in superficial burns 1, 3
• If using silver sulfadiazine, apply once to twice daily to a thickness of approximately 1/16 inch 3
• For grafted areas, mafenide acetate 5% topical solution may be used with appropriate dressing technique 4

Thromboprophylaxis

• Thromboprophylaxis should be routinely prescribed for severe burns patients in the initial phase 1

Follow-up Care

• Continue treatment until satisfactory healing or until the burn site is ready for grafting 3
• For partial-thickness burns, monitor for long-term complications:
  • Pruritus
  • Hypertrophic scarring
  • Permanent hyperpigmentation 5

Prevention Strategies

• Patient education during primary care visits is an effective prevention strategy 5
• Special attention to prevention for high-risk groups (children and older adults) 5

Remember that direct admission to a burn center is preferred for severe burns as it reduces morbidity and mortality 2. Early excision and rapid wound coverage can decrease the hypermetabolic response and reduce the incidence of sepsis 6.