What are the guidelines for burn management?

Guidelines for Burn Management

The management of severe thermal burns requires a structured approach including accurate assessment, prompt fluid resuscitation, appropriate wound care, and timely referral to specialized burn centers to optimize patient outcomes and reduce morbidity and mortality.

Assessment and Triage

• The Lund-Browder chart should be used as the standardized method to measure total burned body surface area (TBSA) in both adults and children, as it is the most accurate method for TBSA quantification 1, 2
• For quick estimation in the field, the palm and fingers of the patient's hand (approximately 1% TBSA) can be used as a reference 2
• TBSA is frequently overestimated (in 70-94% of cases), which can lead to excessive fluid administration 1, 2
• Burn depth should be determined (superficial, partial thickness, or full thickness) to guide further management 2

Criteria for Referral to Burn Centers

Adults:

• TBSA burned > 20%, deep burns > 5% 1
• Presence of smoke inhalation 1
• Deep burns in areas that might lead to functional sequelae (face, hands, feet, perineum) 1
• Burns from high-voltage electricity 1
• TBSA < 20% AND one or more of: age > 75 years, severe comorbidities, known or suspected smoke inhalation, deep circular burns, superficial burns in function-sensitive areas, TBSA > 10%, deep burn 3-5%, burns from low-voltage electricity, chemical burns 1

Children:

• TBSA > 10%, deep burns > 5% 1
• Infants (< 1 year of age) 1
• Severe comorbidities, smoke inhalation injuries 1
• Deep burns in function-sensitive areas (face, hands, feet, perineum, flexure lines) 1
• Circular burns, electrical or chemical burns 1

Initial Management

• Consult a burn specialist early, ideally through telemedicine if direct consultation is not available 1, 2
• 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, 2
• Establish intravenous access in unburned areas when possible; consider intraosseous access if IV access cannot be rapidly obtained 1, 2
• Monitor for signs of hypovolemic shock due to inflammation, capillary leak syndrome, and microcirculation alterations 1

Wound Care

• Clean the burn wound with tap water, isotonic saline solution, or an antiseptic solution 2
• Perform wound care in a clean environment 2, 3
• Consider whether blisters should be flattened or excised (ideally with burn specialist consultation) 2
• Apply appropriate dressings based on burn depth, TBSA, wound appearance, and patient's general condition 2, 3
• When applying dressings, be careful to prevent bandages from causing a tourniquet effect 2
• Monitor distal perfusion regularly when circular dressings are applied 2

Medication Management

• Silver sulfadiazine cream 1% is indicated as an adjunct for the prevention and treatment of wound sepsis in patients with second and third degree burns 4
• Apply silver sulfadiazine cream 1% once to twice daily to a thickness of approximately 1/16 inch 4
• Reapply cream to areas from which it has been removed by patient activity 4
• Continue treatment until satisfactory healing has occurred or until the burn site is ready for grafting 4
• Prophylactic systemic antibiotics are not indicated for outpatient management and may increase bacterial resistance 2, 3

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 1, 2
• Escharotomy carries risks of complications, particularly hemorrhage and infection, and should be performed only at a Burns Centre or after specialist advice if transfer is impossible 1
• Consider thromboprophylaxis for severe burns 2
• Avoid prolonged use of external cooling devices to prevent hypothermia 2
• Provide adequate analgesia before wound cleaning and dressing application 2

Common Pitfalls to Avoid

• Overestimation of TBSA, which can lead to excessive fluid administration 1, 2
• Delaying specialist consultation, which may increase morbidity and mortality 2
• Improper dressing application that restricts circulation 2
• Routine use of systemic antibiotics for prophylaxis 2, 3
• Prolonged use of silver sulfadiazine on superficial burns, which may delay healing 2
• Performing escharotomy without proper training or consultation 1, 2

Follow-up Care

• Monitor for long-term complications such as pruritus, hypertrophic scarring, and permanent hyperpigmentation, which are common with partial-thickness burns 3
• Patients with diabetes mellitus are at increased risk of complications and infection, and early referral to a burn center should be considered 3