What are the key components of medical management for burns?

Key Components of Medical Management for Burns

The medical management of burns should focus on prompt institution of appropriate care regimens, including control of shock and pain, followed by wound cleansing, debridement, and application of silver sulfadiazine cream to a thickness of approximately 1/16 inch under sterile conditions. 1

Initial Assessment and Management

Burn Assessment

• Use the Lund-Browder chart for accurate TBSA measurement (most accurate method) 2
• Alternative methods in prehospital settings:
  • Serial halving method for mass casualty situations
  • Open hand method (palm and fingers = 1% TBSA) to limit overestimation 2

Immediate Interventions

• Decontaminate chemical burns with running water for at least 15 minutes 3
• Remove contaminated clothing, jewelry, or materials 3
• Cool burns with cold (15-25°C) tap water until pain is relieved, but never apply ice directly 3
• For electrical burns, ensure scene safety by turning off power before approaching 3

Specialist Referral and Transfer

• Seek referral to a burn specialist to determine if the patient should be admitted to a burns center 2
• Consider telemedicine to improve initial assessment of severely burned patients 2
• Transfer directly to a burns center if indicated 2
• Indications for burn center referral:
  • Burns involving face, hands, feet, genitalia, or perineum
  • Full-thickness burns

  • 10% TBSA in children

  • 20% TBSA in adults 3

Fluid Resuscitation

Initial Fluid Management

• Adult burn patients with significant TBSA and pediatric burn patients with >10% TBSA should receive 20 mL/kg of intravenous crystalloid solution within the first hour 2
• Use balanced crystalloid solutions (e.g., Ringer's Lactate) as first-line 2
• Obtain intravenous access in unburned areas when possible; consider intraosseous route if IV access is difficult 2

Ongoing Fluid Management

• Adjust infusion rates based on clinical and hemodynamic parameters 2
• Target urine output of 0.5-1 mL/kg/h in adults 2
• Consider human albumin for severe burns with TBSA >30% after the first 6 hours 2
• Monitor for signs of both under-resuscitation and over-resuscitation ("fluid creep") 2

Wound Care

Initial Wound Management

• Leave burn blisters intact to improve healing and reduce pain 3
• Cover burns with sterile, non-adherent dressings 3

Topical Antimicrobial Therapy

• Apply silver sulfadiazine cream 1% to second and third-degree burns to a thickness of approximately 1/16 inch 3, 1
• Reapply once to twice daily and whenever necessary if removed by patient activity 1
• Continue treatment until satisfactory healing occurs or until the burn site is ready for grafting 1

Monitoring for Complications

• Watch for signs of compartment syndrome in extremity injuries (5 P's: pain, pallor, paresthesia, pulselessness, paralysis) 3
• Consider escharotomy if a deep burn induces compartment syndrome that compromises airways, respiration, and/or circulation 2
  • Ideally performed in a burns center by an experienced provider 2
• Monitor for transient leukopenia, particularly decreased neutrophil count, which typically occurs 2-4 days after starting silver sulfadiazine therapy 1

Pain Management

• Implement a multimodal approach:
  • First-line: Acetaminophen 1g every 4-6 hours
  • Second-line: Add NSAIDs for inflammatory pain
  • Third-line: Short-acting opioids and ketamine for severe pain 3
• Consider non-pharmacological techniques such as virtual reality or hypnosis to reduce pain intensity and anxiety 3

Rehabilitation and Follow-up

• Begin early range of motion exercises to prevent contractures 3
• Regular stretching exercises to improve flexibility 3
• Consider massage therapy to soften scar tissue and improve circulation 3
• Perform regular wound assessment for signs of healing or complications 2, 3

Nutritional Support

• Start nutritional support within 12 hours after burn injury, preferably via oral or enteral route 3

Pitfalls and Caveats

• TBSA is often overestimated (in 70-94% of cases), leading to excessive fluid administration 2
• Reduction in bacterial growth after topical antibacterial agents may cause delayed eschar separation, sometimes necessitating escharotomy to prevent contracture 1
• Mafenide acetate (an alternative topical agent) may cause metabolic acidosis through carbonic anhydrase inhibition, requiring close monitoring of acid-base balance, especially in patients with pulmonary or renal dysfunction 4
• Fungal colonization may occur with reduction of bacterial growth in burn wounds 4
• Monitor for signs of masked hyperventilation with respiratory alkalosis in patients treated with mafenide acetate 4