What is the initial management for a burn patient?

Initial Management of Burn Patients

The initial management of burn patients should include accurate assessment of burn severity, early specialist consultation, appropriate fluid resuscitation, pain control, wound care, and monitoring for complications to reduce morbidity and mortality. 1, 2

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, 2
• Determine burn depth (superficial, partial thickness, or full thickness) to guide further management 2, 3
• Early consultation with a burn specialist should be sought to determine whether the patient should be admitted to a burns center 1
• Telemedicine can be used to improve the initial assessment of severely burned patients when direct specialist consultation is not immediately available 1, 2

Fluid Resuscitation

• For adults with burns >15% TBSA and children with burns >10% TBSA, administer fluid resuscitation according to established protocols 2, 4
• Initial fluid resuscitation typically involves 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate) within the first hour 2, 5
• Establish intravenous access in unburned areas when possible; consider intraosseous access if IV access cannot be rapidly obtained 2, 6
• Monitor for signs of hypovolemic shock due to inflammation, capillary leak syndrome, and microcirculation alterations 2, 4

Pain Management

• Provide adequate analgesia through titrated intravenous medications based on validated comfort and analgesia assessment scales 1, 2
• Titrated intravenous ketamine can be combined with other analgesics to treat severe burn-induced pain 1, 2
• For stable patients, consider non-pharmacological techniques combined with analgesic drugs for dressing changes 1, 2

Wound Care

• Clean the burn wound with tap water, isotonic saline solution, or an antiseptic solution before applying dressings 1, 2
• Perform wound care in a clean environment after ensuring adequate resuscitation and pain control 1, 2
• Apply appropriate dressings based on burn depth, TBSA, wound appearance, and patient's general condition 1, 2
• Silver sulfadiazine cream should be applied to a thickness of approximately 1/16 inch once to twice daily, covering burn areas at all times 7, 2
• When applying dressings, be careful to prevent bandages from causing a tourniquet effect and monitor distal perfusion regularly 2, 6

Special Considerations

• Consider cooling burns in adults with TBSA < 20% and children with TBSA < 10% in the absence of shock to limit burn depth and reduce pain 1, 2
• Evaluate the need for escharotomy if a deep burn induces compartment syndrome that compromises airways, respiration, and/or circulation; this procedure should ideally be performed in a burn center by an experienced provider 1, 2
• Do not routinely administer antibiotic prophylaxis unless specifically indicated for infected wounds 2, 8

Transfer Considerations

• If transfer to a burn center is indicated, the patient should be admitted directly to the center when possible 1, 2
• Continue monitoring vital signs, urine output, and distal circulation during transfer, especially for circumferential burns 2, 3

Common Pitfalls to Avoid

• Overestimation of TBSA (occurs in 70-94% of cases), 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 2, 6
• Prolonged use of silver sulfadiazine on superficial burns, which may delay healing 1, 2
• Performing escharotomy without proper training or consultation 1, 2
• Neglecting to monitor for compartment syndrome in circumferential burns 1, 2