What are the latest treatment options for burns?

Latest Treatment Options for Burns

The latest evidence-based burn treatment prioritizes immediate cooling (5-20 minutes with running water), early specialist consultation for severe burns, balanced crystalloid fluid resuscitation (Ringer's Lactate), multimodal pain management with titrated ketamine and opioids, and early wound care with appropriate dressings while avoiding prolonged silver sulfadiazine use on superficial burns. 1, 2

Immediate First Aid and Initial Management

Cooling Protocol

• Cool burns immediately with clean running water for 5-20 minutes to limit tissue damage and reduce pain 2, 3
• For adults with TBSA <20% and children with TBSA <10%, cooling should be performed in the absence of shock 1, 2
• Monitor children closely for hypothermia during cooling, especially with larger burns 2, 4
• Never apply ice directly to burns as this causes tissue ischemia and increases damage 2, 4, 3
• Remove jewelry before swelling occurs to prevent vascular compromise 2, 4, 3

Assessment and Triage

• Seek specialist burn center consultation immediately for determining admission need and appropriate management 1
• Use telemedicine when specialists are not readily available to improve TBSA assessment and prevent both overtriage and undertriage 1
• Direct admission to burn centers is recommended when indicated, rather than secondary transfers 1
• Burns requiring specialist evaluation include: face, hands, feet, flexure lines, genitals, perineum, or TBSA >10% in adults (>5% in children) 1, 2, 3

Fluid Resuscitation (Severe Burns)

Early Phase

• Administer 20 mL/kg of balanced crystalloid solution within the first hour for adults with TBSA ≥20% and children with TBSA ≥10% 1
• Ringer's Lactate is the first-line fluid as it reduces hyperchloremia, metabolic acidosis, and acute kidney injury compared to 0.9% NaCl 1
• Obtain intravenous access as soon as possible, preferably in unburned areas; use intraosseous route if IV access cannot be rapidly obtained 1

Ongoing Resuscitation

• Multiple formulae exist (Parkland, Brooke, Rule of Tens) estimating 2-4 mL/kg/%TBSA over 24 hours, though none have been rigorously validated 1
• Children require higher total fluid intake (approximately 6 mL/kg/%TBSA over 48 hours) due to higher body surface area/weight ratio 1

Pain Management

Pharmacological Approach

• Use multimodal analgesia with medications titrated based on validated comfort and pain assessment scales 1, 2
• Titrated intravenous ketamine combined with other analgesics is effective for severe burn-induced pain and limits morphine consumption 1, 2
• Short-acting opioids and ketamine are the best drugs for burn-induced pain 1, 2
• Inhaled nitrous oxide is useful when no intravenous access is available 1
• General anesthesia is appropriate for highly painful injuries or procedures 1, 2

Non-Pharmacological Techniques

• Virtual reality or hypnosis techniques may reduce pain intensity and anxiety for stable patients 1
• Cooling and covering burns with fatty substances (e.g., Vaseline) may improve pain control 1

Wound Care

General Principles

• Wound care is not a priority and should only be performed after well-conducted resuscitation 1
• Perform wound care in a clean environment, typically requiring deep analgesia or general anesthesia 1, 2
• Clean wounds with tap water, isotonic saline, or antiseptic solution before dressing 1, 2

Dressing Selection

• No single dressing type has proven superiority, but choice depends on TBSA, wound appearance, and patient condition 1, 2
• Avoid prolonged silver sulfadiazine use on superficial burns as it is associated with prolonged healing 1, 2, 5
• Antiseptic dressings may be appropriate for large or contaminated burns 1
• Topical antibiotics should not be used as first-line treatment but reserved for infected wounds only 1, 2
• For superficial burns, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera with non-adherent dressing 2, 3

Blister Management

• Leave burn blisters intact and cover loosely with sterile dressing to improve healing and reduce pain 4
• The intact blister acts as a natural biological barrier protecting against infection 4

Application Technique

• When applying dressings on limbs, prevent tourniquet effect from bandages 1, 2
• Monitor distal perfusion with circular dressings 2
• Re-evaluate dressings daily when possible 2

Surgical Management

Escharotomy

• Perform escharotomy if deep burns induce compartment syndrome compromising airways, respiration, or circulation 1
• Ideally performed in burn centers by experienced providers 1

Definitive Surgical Treatment

• Early excision of eschar and wound coverage is critical to prevent infection 6
• Split-thickness skin grafts remain the standard for rapid permanent closure of full-thickness burns 6
• Continue treatment until satisfactory healing occurs or the burn site is ready for grafting 5

Common Pitfalls to Avoid

• Do not apply butter, oil, or other home remedies to burns 2
• Do not break blisters as this increases infection risk 2, 4
• Do not use external cooling devices (e.g., Water-Jel dressings) for prolonged periods due to hypothermia risk 2
• Routine antibiotic prophylaxis is not recommended for burn patients 2
• Do not delay cooling—it should be done within 30 minutes of injury when possible 4
• Avoid cooling large burns without ability to monitor core temperature, especially in children 4

Special Considerations

Mafenide Acetate

• May cause pain/burning sensation, metabolic acidosis, and tachypnea 7
• Rare but serious adverse effects include bone marrow depression and hemolytic anemia in G6PD deficiency 7

Multidisciplinary Approach

• Specialist multidisciplinary burn center care is associated with better survival, reduced complications, shorter hospital stays, and lower costs 1
• Written protocols for pain management and regular assessment should be encouraged 1