What is the appropriate assessment and management of burns caused by hot liquids?

Assessment and Management of Burns from Hot Liquids

The Lund and Browder method should be used to measure the total burned body surface area (TBSA) in both adults and children, as it is the most accurate method for burn assessment and triage. 1, 2

Burn Assessment and Classification

Burn Depth Classification:

• First-degree (superficial): Involves only the epidermis; red, painful, no blisters
• Second-degree (partial thickness): Involves epidermis and part of dermis; blistered, painful, moist
• Third-degree (full thickness): Destroys all skin layers; appears dry, leathery, painless

Burn Severity Assessment Criteria:

Burns requiring immediate medical attention include:

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

• 10% TBSA in children

• 20% TBSA in adults 2

TBSA Measurement:

• Primary method: Lund and Browder chart (suitable for both adults and children)
• Alternative methods:
  • Serial halving method (useful in prehospital settings)
  • Open hand method (palm and fingers = 1% TBSA) 1

The Wallace rule of nines significantly overestimates TBSA and is not suitable for children. Accurate TBSA assessment is critical to prevent overtriage (wasting resources) or undertriage (increasing morbidity and mortality). 1

Immediate Management

First Aid (0-30 minutes post-burn):

1. Cool the burn immediately with running water at room temperature (15-25°C) for at least 10 minutes 2, 3

   • Immediate cooling reduces the progression from superficial to deep burns by approximately 32% 3
   • Cooling is most effective when started immediately after injury 4
   • Do NOT use ice or ice-cold water as this can increase tissue damage 2

2. Remove jewelry and non-adherent clothing from the burned area

3. Pain management: Begin with acetaminophen and add NSAIDs for more severe pain 2

Wound Care:

1. Clean and debride the wound gently
2. Leave blisters intact to improve healing and reduce pain in partial-thickness burns 2
3. Apply silver sulfadiazine cream (1%) to second and third-degree burns to a thickness of approximately 1/16 inch 2, 5
4. Cover with sterile, non-adherent dressing applied loosely 2

Triage and Referral Decision-Making

Criteria for Hospital Admission:

• Burns >20% TBSA in adults
• Burns >10% TBSA in children
• Deep burns >5% TBSA
• Burns in functional areas (face, hands, feet, perineum)
• High-voltage electrical burns
• Inhalation injury
• TBSA <20% with additional risk factors (age >75 years, severe comorbidities) 2

Referral to Burn Center:

Seek referral to a burn specialist to determine whether the patient should be admitted to a burns center. If indicated, the patient should be admitted directly to the center. 1

Telemedicine can be used to improve the initial assessment when burn specialist consultation is needed. 1

Ongoing Management

Pain Control:

• First-line: Acetaminophen 1g every 4-6 hours (maximum 4g/day)
• Second-line: Add NSAIDs for inflammatory pain
• Severe pain: Consider ketamine intravenous titration
• Breakthrough pain: Short-acting opioids at lowest effective dose 2

Monitoring:

• Assess distal circulation, sensation, and motor function every 15-30 minutes in circumferential burns
• Monitor for signs of compartment syndrome (especially in circumferential burns)
• Perform escharotomy if a deep burn induces compartment syndrome that compromises airways, respiration, or circulation 1, 2

Infection Prevention:

• Regularly evaluate the wound for signs of infection (increased redness, warmth, swelling, discharge, or fever)
• Continue silver sulfadiazine application until satisfactory healing has occurred or the burn site is ready for grafting 5
• Reapply silver sulfadiazine immediately after hydrotherapy 5

Common Pitfalls to Avoid

1. Delayed cooling: The most influential factor in reducing burn damage is immediate cooling 4
2. Inaccurate TBSA assessment: Overestimation leads to excessive fluid administration 1
3. Breaking blisters: Increases infection risk and delays healing 2
4. Using ice or very cold water: Can increase tissue damage 2, 4
5. Applying home remedies: Butter or homemade remedies can introduce infection 2
6. Neglecting to reassess burn depth: Burn depth can evolve over 24-48 hours

By following this structured approach to burn assessment and management, healthcare providers can optimize outcomes for patients with hot liquid burns, reducing morbidity and improving quality of life.