What is the initial approach for a forearm burn in the Emergency Room (ER)?

Initial Management of Forearm Burns in the Emergency Room

The initial approach for a forearm burn in the emergency room should include prompt consultation with a burn specialist, cleaning the wound with tap water or isotonic saline, providing adequate pain control, and applying appropriate dressings while ensuring proper fluid resuscitation if the burn is severe. 1

Assessment and Triage

• Accurately assess the total body surface area (TBSA) affected using the Lund-Browder chart, which is the most accurate method for TBSA quantification 1
• For quick estimation in the field, the palm and fingers of the patient's hand (approximately 1% TBSA) can be used as a reference 1
• Determine burn depth (superficial, partial thickness, or full thickness) to guide further management 1
• Consult a burn specialist early, ideally through telemedicine if direct consultation is not available, to determine if transfer to a burn center is necessary 1

Initial Resuscitation

• For adults with burns >15% TBSA and children with burns >10% TBSA, administer 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate) within the first hour 1
• Establish intravenous access in unburned areas when possible; consider intraosseous access if IV access cannot be rapidly obtained 1
• Monitor for signs of hypovolemic shock due to inflammation, capillary leak syndrome, and microcirculation alterations 1
• Avoid over-resuscitation ("fluid creep") by carefully titrating fluid rates based on clinical endpoints 2

Pain Management

• Provide adequate analgesia before wound cleaning and dressing application, as burn wound care typically requires deep analgesia or general anesthesia 1
• Consider the need for procedural sedation for extensive or painful burns 1

Wound Care

• Clean the burn wound with tap water, isotonic saline solution, or an antiseptic solution 1
• Perform wound care in a clean environment 1
• Consider whether blisters should be flattened or excised (ideally with burn specialist consultation) 1
• Apply appropriate dressings based on burn depth, TBSA, wound appearance, and patient's general condition 1
• Silver sulfadiazine cream may be applied to a thickness of approximately 1/16 inch and reapplied once to twice daily as needed, though it may delay healing if used for prolonged periods on superficial burns 1, 3
• When applying dressings to the forearm, be careful to prevent bandages from causing a tourniquet effect 1
• Monitor distal perfusion regularly when circular dressings are applied 1

Special Considerations

• Evaluate the need for escharotomy if a deep burn induces compartment syndrome that compromises circulation; this procedure should ideally be performed in a burn center by an experienced provider 1
• Do not routinely administer antibiotic prophylaxis unless specifically indicated for infected wounds 1
• Consider thromboprophylaxis for severe burns 1
• Avoid prolonged use of external cooling devices (e.g., Water-Jel dressings) to prevent hypothermia 1

Transfer Considerations

• If transfer to a burn center is indicated, the patient should be admitted directly to the center when possible 1
• Ensure proper documentation of burn size, depth, and initial treatments provided 4
• Continue monitoring distal circulation, especially if the burn is circumferential 1

Common Pitfalls to Avoid

• Overestimation of TBSA (occurs in 70-94% of cases), which can lead to excessive fluid administration 1
• Delaying specialist consultation, which may increase morbidity and mortality 1
• Improper dressing application that restricts circulation 1
• Routine use of systemic antibiotics, which is not recommended for prophylaxis 1
• Prolonged use of silver sulfadiazine on superficial burns, which may delay healing 1
• Performing escharotomy without proper training or consultation, which can increase complications 1