What is the initial management and treatment guideline for burn injuries?

Initial Management and Treatment Guidelines for Burn Injuries

The initial management of burn injuries should focus on accurate assessment of burn severity followed by prompt fluid resuscitation with 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate) within the first hour for adults with burns >15% TBSA and children with burns >10% TBSA. 1, 2

Assessment and Triage

• Use the Lund-Browder chart 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 1
• Determine burn depth (superficial, partial thickness, or full thickness) to guide further management 1, 2
• Be aware that TBSA is frequently overestimated (in 70-94% of cases), which can lead to excessive fluid administration 1, 2

Criteria for Referral to Burn Centers

• Adults with TBSA burned > 20%, deep burns > 5%, presence of smoke inhalation, deep burns in areas that might lead to functional sequelae, or burns from high-voltage electricity should be referred to a burn center 2
• Children with TBSA > 10%, deep burns > 5%, infants (< 1 year of age), severe comorbidities, smoke inhalation injuries, deep burns in function-sensitive areas, circular burns, electrical or chemical burns should be referred to a burn center 2
• Consult a burn specialist early, ideally through telemedicine if direct consultation is not available 1, 2

Initial Fluid Resuscitation

• For adults with burns >15% TBSA and children with burns >10% TBSA, administer 20 mL/kg of balanced crystalloid solution within the first hour 1, 2
• Use Ringer's Lactate as the preferred balanced crystalloid solution 3
• Establish intravenous access in unburned areas when possible; if IV access cannot be rapidly obtained, an intraosseous route is recommended 3, 1
• Central femoral venous access should be considered as a last resort 3
• Monitor for signs of hypovolemic shock due to inflammation, capillary leak syndrome, and microcirculation alterations 3, 1

Wound Care

• Clean the burn wound with tap water, isotonic saline solution, or an antiseptic solution 1, 2
• Perform wound care in a clean environment 1
• Consider whether blisters should be flattened or excised (ideally with burn specialist consultation) 1, 2
• Apply appropriate dressings based on burn depth, TBSA, wound appearance, and patient's general condition 1, 2
• When applying dressings, be careful to prevent bandages from causing a tourniquet effect 1, 2
• Monitor distal perfusion regularly when circular dressings are applied 1, 2
• For topical treatment, silver sulfadiazine cream may be applied once to twice daily to a thickness of approximately one sixteenth of an inch, covering burn areas at all times 4
• Reapply silver sulfadiazine cream after hydrotherapy or when removed by patient activity 4

Escharotomy Considerations

• Evaluate the need for escharotomy if a deep burn induces compartment syndrome that compromises circulation 3, 1
• Escharotomy should ideally be performed only at a Burns Centre 3
• If transfer to a burn center is impossible, obtain specialist advice before performing an escharotomy 3
• Be aware that escharotomy carries risks of complications, particularly hemorrhage and infection 3
• A poorly performed escharotomy is associated with increased morbidity 3

Pain Management

• Provide adequate analgesia before wound cleaning and dressing application 1
• Consider the need for procedural sedation for extensive or painful burns 1

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 1, 2
• Improper dressing application that restricts circulation 1, 2
• Routine use of systemic antibiotics for prophylaxis unless specifically indicated for infected wounds 1, 2
• Prolonged use of silver sulfadiazine on superficial burns, which may delay healing 2
• Performing escharotomy without proper training or consultation 1, 2
• Prolonged use of external cooling devices to prevent hypothermia 2