What is the initial management for burns?

Initial Management of Burns

The initial management of burns should include cooling the burn area with cold running water for 20-40 minutes, providing appropriate pain control, and determining burn severity to guide further treatment decisions. 1

Assessment and Classification

• Determine burn depth and total body surface area (TBSA) to guide treatment decisions 2
• Use the Lund-Browder chart for the most accurate TBSA measurement, especially for children 1
• For prehospital settings, the "palm method" (patient's palm equals approximately 1% TBSA) can be used for quick estimation 1
• Classify burns as:
  • Superficial (first-degree): involves only epidermis 2
  • Partial-thickness (second-degree): involves epidermis and part of dermis 2
  • Full-thickness (third-degree): complete destruction of epidermis and dermis 2

Immediate Interventions

• Cooling: Apply cold running water to burns for 20-40 minutes, which significantly reduces burn depth and need for skin grafting 1
• Pain management: Implement multimodal analgesia with titrated medications based on validated pain scales 1
  • Consider intravenous ketamine combined with other analgesics for severe burn pain 1
  • Short-acting opioids are effective for burn-induced pain 1
  • Non-pharmacological techniques (virtual reality, hypnosis) can be used when appropriate 1

Burn Wound Care

• Clean the wound with tap water, isotonic saline, or antiseptic solution 1
• Apply appropriate dressing after cleaning 1
• For minor burns, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera 2
• For larger burns requiring medical attention, silver sulfadiazine cream may be applied to a thickness of approximately 1/16 inch once to twice daily 3
• Note that silver sulfadiazine may be associated with prolonged healing if used for a long time on superficial burns 1

When to Refer to a Burn Center

• Seek referral to a burn specialist for:
  • Burns involving face, hands, feet, flexure lines, genitals, or perineum 1
  • Full-thickness burns of any size 2, 4
  • Partial-thickness burns >10% TBSA in adults or >5% in children 2, 5
  • Burns with signs of inhalation injury 2
• Consider using telemedicine to improve initial assessment when burn specialists are not readily available 1

Fluid Resuscitation

• For adults with burns ≥10% TBSA and children with burns ≥5% TBSA, initiate formal fluid resuscitation 6, 5
• Use the modified Parkland formula (3-4 mL/kg/%TBSA) with balanced crystalloid solution 6, 5
• Administer half of the calculated 24-hour fluid requirement in the first 8 hours post-burn 6, 5
• Monitor urine output (target: 0.5-1 mL/kg/hour) to guide fluid therapy 6, 5

Special Considerations

• Escharotomy should be performed if deep burns induce compartment syndrome compromising airways, respiration, or circulation 1
• Avoid routine antibiotic prophylaxis for burn patients 1
• Consider thromboprophylaxis for severe burns patients in the initial phase 1
• For electrical burns, monitor for deeper tissue damage and myoglobinuria 6

Common Pitfalls to Avoid

• Overestimating TBSA (occurs in 70-94% of cases), which leads to excessive fluid administration 1
• Delaying cooling, which can increase burn depth and complications 1
• Using external cooling devices (e.g., Water-Jel dressings) for prolonged periods, which increases risk of hypothermia 1
• Prioritizing wound care over resuscitation in severe burns 1
• Applying circular dressings without monitoring for tourniquet effect 1