What is the recommended management for burns?

Management of Burns

For burn management, adult patients with burns ≥15% total body surface area (TBSA) and pediatric patients with burns ≥10% TBSA should receive 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate) within the first hour, followed by calculated fluid resuscitation based on the Parkland formula. 1, 2

Initial Assessment and Classification

• Burns should be classified by depth (superficial, partial-thickness, full-thickness) and total body surface area (TBSA) to determine appropriate management strategy 2
• Adults with burns ≥10% TBSA and children with burns ≥5% TBSA require formal fluid resuscitation 3, 2
• Burns involving the face, hands, feet, genitals, or those with full-thickness compromise require specialized care regardless of size 2
• Assess for inhalation injury, which significantly increases mortality, by checking for circumoral burns, oropharyngeal burns, and carbonaceous sputum 4

Fluid Resuscitation Protocol

• For initial resuscitation, administer 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate) within the first hour 3, 1
• Calculate 24-hour fluid requirements using the Parkland formula (2-4 mL/kg/%TBSA) 3, 2
• Administer half of the calculated 24-hour fluid requirement in the first 8 hours post-burn, with the remaining half over the next 16 hours 3, 2
• For children, higher fluid volumes may be required (approximately 6 mL/kg/%TBSA) due to their higher surface area-to-weight ratio 1, 2
• Monitor urine output (target: 0.5-1 mL/kg/hour) to guide fluid administration 3, 1
• Consider albumin administration for severe burns with TBSA >30% after the first 6 hours of management 1

Wound Care

• Clean and debride burn wounds before applying topical antimicrobial agents 5
• Apply silver sulfadiazine cream to a thickness of approximately 1/16 inch once to twice daily to prevent infection in partial and full-thickness burns 5
• Reapply silver sulfadiazine immediately after hydrotherapy 5
• For grafted areas, mafenide acetate 5% topical solution can be used with appropriate dressing technique 6
• Continue treatment with topical antimicrobials until satisfactory healing has occurred or until the burn site is ready for grafting 5

Management of Complications

• Monitor for compartment syndrome in circumferential third-degree burns, which can lead to acute limb ischemia or thoracic/abdominal compartment syndrome 4
• Consider escharotomy for third-degree circumferential burns causing constriction and increased compartmental pressure, ideally performed at a Burns Center 4, 1
• If hypotension persists despite adequate fluid resuscitation, evaluate cardiac function and consider vasopressors 1, 2
• Monitor for and manage acute kidney injury, which is a common complication in severe burns 1

Transfer Criteria to Burn Centers

• Major burns (≥25% TBSA or ≥10% full thickness) should be considered for treatment at a burn center 7
• Children or elderly patients with burns >10% TBSA should also be considered for transfer to specialized burn units 7
• Direct admission to a burn center is preferred, but a transition phase at a nearby institution should be considered if the patient exhibits hemodynamic or respiratory instability and transportation time is long 4

Common Pitfalls to Avoid

• Avoid "fluid creep" (excessive fluid administration) as it can lead to complications including compartment syndrome 3, 2
• Do not use normal saline (0.9% NaCl) as primary resuscitation fluid as it is associated with a higher risk of hyperchloremic metabolic acidosis and acute kidney injury 1
• Never delay escharotomy when indicated, as poorly timed or performed escharotomy is associated with increased morbidity 4
• Avoid underestimating fluid requirements in electrical burns, which often cause deeper tissue damage than is apparent on the surface 3