What is the treatment for fire burns?

Treatment for Fire Burns

For fire burns, immediately cool the burn with running water for at least 10-20 minutes, then apply petrolatum-based ointment or honey to small partial-thickness burns, cover with a clean nonadherent dressing, and transfer severe burns (>10% body surface area in adults, >5% in children, or involving face/hands/feet/genitals) directly to a specialized burn center. 1

Immediate First Aid Management

Cooling the Burn

• Remove all burning materials from the patient immediately using saline, water, or smothering techniques 1
• Cool the burn with running water for 10-20 minutes to stop the burning process and reduce tissue damage 1
• Remove jewelry before swelling develops to prevent vascular compromise 1

Wound Coverage

• For small partial-thickness burns managed at home: After cooling, apply petrolatum, petrolatum-based antibiotic ointment (such as polymyxin), honey, or aloe vera with a clean nonadherent dressing 1
• For burns with intact skin or blisters: Loosely cover with a clean cloth or nonadherent dry dressing while awaiting medical evaluation 1
• Covering burns protects the wound and reduces pain while avoiding heat entrapment 1

Pain Management

• Administer over-the-counter analgesics such as acetaminophen or NSAIDs (e.g., ibuprofen 800 mg every 6 hours) for burn pain 1

Criteria for Burn Center Transfer

Direct admission to a burn center is strongly preferred over secondary transfer, as it reduces time to surgical excision, decreases duration of mechanical ventilation, and improves overall morbidity and mortality. 1

Transfer Indications

• Second- or third-degree burns involving >10% body surface area in adults (>5% in children) 1
• Burns involving face, hands, feet, or genitals due to risk of permanent disability requiring surgical intervention 1
• Circumferential burns of extremities or torso 1
• Signs of inhalation injury: facial burns, difficulty breathing, singed nasal hairs, soot around nose/mouth, dysphonia, stridor, or carbonaceous sputum 1
• Full-thickness (third-degree) burns of any significant size 1

Airway Management for Inhalation Injury

Immediate Intubation Indications

Intubate immediately if the patient exhibits: 1

• Severe respiratory distress
• Severe hypoxia or hypercapnia
• Altered mental status or coma
• Signs of airway obstruction (voice modification, stridor, laryngeal dyspnea)

High-Risk Features Requiring Close Monitoring

For patients with face/neck burns, intubate if: 1

• Deep circular neck burn present, AND/OR
• Symptoms of airway obstruction exist, AND/OR
• Very extensive burn (TBSA ≥40%)

Critical pitfall: Patients exposed to smoke or vapors require close monitoring even with initially normal findings, as glottis edema and respiratory distress can develop progressively 1, 2

Airway Fire Management

If fire occurred in the airway: 1, 2

• Remove the tracheal tube immediately
• Stop flow of all airway gases
• Remove all flammable and burning materials from the airway
• Pour saline or water into the patient's airway to extinguish residual embers and cool tissues

Fluid Resuscitation for Severe Burns

Initial Fluid Administration

For adults with TBSA ≥20% and children with TBSA ≥10%: 1

• Administer 20 mL/kg of balanced crystalloid solution (Ringer's Lactate preferred) within the first hour of management
• Obtain intravenous access in unburned areas when possible; use intraosseous route if IV access cannot be rapidly obtained 1

Ongoing Fluid Management

• Use the Parkland formula: 4 mL/kg/% TBSA over first 24 hours (give half in first 8 hours, half in next 16 hours) 1
• Ringer's Lactate is the preferred balanced crystalloid as it reduces risk of hyperchloremic metabolic acidosis and acute kidney injury compared to 0.9% NaCl 1
• Children require higher total fluid intake (approximately 6 mL/kg/% TBSA) plus daily basal fluid requirements calculated by the 4-2-1 rule 1

Specialized Burn Center Interventions

Escharotomy

Perform escharotomy only at a burn center for: 1

• Circumferential third-degree burns causing compartment syndrome
• Compromised airway movement or ventilation (urgent indication)
• Circulatory impairment or intra-abdominal hypertension (within 48 hours)

Critical pitfall: Poorly performed escharotomy increases morbidity; obtain specialist advice before attempting if transfer is impossible 1

Topical Antimicrobial Therapy

Silver sulfadiazine cream 1% is the standard topical antimicrobial agent: 3

• Apply to thickness of approximately 1/16 inch once to twice daily under sterile conditions
• Keep burn areas covered with cream at all times
• Reapply after hydrotherapy or patient activity removes it
• Continue until satisfactory healing or burn site is ready for grafting

Surgical Management

Early surgical excision and skin grafting (performed at burn centers) significantly reduce morbidity, mortality, and hospital length of stay for severe burns 1

Common Pitfalls to Avoid

• Delaying intubation when signs of airway compromise are present, even subtle ones 2
• Performing bronchoscopy outside burn centers, which delays transfer without changing immediate management 1, 2
• Unnecessary prehospital intubation based solely on fear rather than objective criteria, which increases complications 1
• Using 0.9% NaCl instead of balanced crystalloids for fluid resuscitation, increasing risk of metabolic acidosis and renal injury 1
• Secondary transfer through non-specialized facilities rather than direct burn center admission, which delays definitive care 1

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