What are the guidelines for managing acute burns?

Management of Acute Burns

All acute burns require immediate cooling with clean running water for 5-20 minutes, accurate TBSA assessment using the Lund-Browder chart, early specialist consultation (ideally via telemedicine), and direct transfer to a burn center for patients meeting referral criteria. 1, 2

Initial Assessment and TBSA Measurement

Use the Lund-Browder chart as the standardized method for measuring total burned body surface area (TBSA) in both adults and children, as it is the most accurate quantification method. 1, 2

• The Wallace rule of nines significantly overestimates TBSA and is unsuitable for children 1
• TBSA is overestimated in 70-94% of cases with most methods, leading to excessive fluid administration 1, 2
• For rapid field assessment, use the patient's palm and fingers (approximately 1% TBSA) as a reference 1, 2
• Smartphone applications like E-Burn can facilitate accurate assessment 1
• Repeated TBSA evaluation during initial management prevents both overtriage (wasting resources) and undertriage (increasing morbidity and mortality) 1

Immediate First Aid Management

Cool the burn immediately with clean running water for 5-20 minutes to limit tissue damage and reduce pain. 3

• Monitor children closely for hypothermia during active cooling, particularly with larger burns 3
• If clean running water is unavailable, cooling superficial burns with ice wrapped in cloth may be reasonable, but never apply ice directly 3
• After cooling, loosely cover the burn with a clean, non-adherent dressing while arranging transfer 3
• Do not apply butter, oil, or other home remedies 3
• Do not break blisters, as this increases infection risk 3

Criteria for Burn Center Referral

Adults Requiring Mandatory Referral:

• TBSA burned >20%, deep burns >5%, smoke inhalation, deep burns in function-sensitive areas, or high-voltage electrical burns 2
• TBSA <20% with any of: age >75 years, severe comorbidities, known/suspected smoke inhalation, deep circular burns, superficial burns in function-sensitive areas, TBSA >10%, deep burn 3-5%, low-voltage electrical burns, or chemical burns 2

Children Requiring Mandatory Referral:

• TBSA >10%, deep burns >5%, infants (<1 year), severe comorbidities, smoke inhalation, deep burns in function-sensitive areas, circular burns, or electrical/chemical burns 2

Special Populations:

All hand burns involving partial-thickness or full-thickness depth require immediate referral to a burn specialist or burn center to prevent permanent functional disability. 3

Early Specialist Consultation

Contact a burn specialist immediately to determine admission to a burn center, using telemedicine if direct consultation is unavailable. 1, 2

• Telemedicine improves initial assessment of severely burned patients 1
• Direct admission to a burn center (rather than sequential transfers) improves survival and functional outcomes 1, 3
• Specialist management improves survival through concentrated expertise in burn care techniques 3
• Specialized centers reduce hospital length of stay and costs compared to non-specialized teams 3

Fluid Resuscitation

For adults with burns >15% TBSA and children with burns >10% TBSA, administer 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate) within the first hour. 2

• Establish intravenous access in unburned areas when possible 2
• Consider intraosseous access if IV access cannot be rapidly obtained 2
• Monitor for signs of hypovolemic shock due to inflammation, capillary leak syndrome, and microcirculation alterations 2
• Avoid fluid overload, as TBSA overestimation commonly leads to excessive administration 1, 2

Pain Management

Provide analgesia with titrated intravenous opioids or ketamine for severe burn pain, as burn pain is often intense and difficult to control. 3

• Administer over-the-counter pain medications such as acetaminophen or NSAIDs for less severe pain 3
• Provide adequate analgesia before wound cleaning and dressing application 2

Wound Care

Clean the burn wound with tap water, isotonic saline solution, or an antiseptic solution. 2

• For superficial burns managed at home, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera after cooling 3
• Consider whether blisters should be flattened or excised, ideally with burn specialist consultation 2
• Apply appropriate dressings based on burn depth, TBSA, wound appearance, and patient's general condition 2
• When applying dressings, prevent bandages from causing a tourniquet effect 2
• Monitor distal perfusion regularly when circular dressings are applied 2

Escharotomy Indications

Perform escharotomy if a deep burn induces compartment syndrome in the limbs or trunk that compromises airways, respiration, and/or circulation. 1, 2

• Ideally, escharotomy should be performed in a burn center by an experienced provider 1
• Watch for signs of compartment syndrome including blue, purple, or pale extremities indicating poor perfusion 3
• Escharotomy carries risks of hemorrhage and infection, and should only be performed at a burn center or after specialist advice if transfer is impossible 2

Critical Pitfalls to Avoid

• Do not delay specialist referral for any partial-thickness or full-thickness hand burn, as undertriage increases morbidity and mortality 3, 2
• Do not overestimate TBSA, which leads to excessive fluid administration 1, 2
• Do not use systemic antibiotics prophylactically; reserve for clinically evident infections 3, 2
• Avoid prolonged use of silver sulfadiazine on superficial burns, as it may delay healing 3, 2
• Do not perform escharotomy without proper training or consultation 2
• Avoid prolonged use of external cooling devices to prevent hypothermia 2

Monitoring for Complications

• Monitor for signs of infection including increased pain, redness extending beyond burn margins, swelling, or purulent discharge 3
• Consider thromboprophylaxis for severe burns 2
• Evaluate for smoke inhalation and consider early intubation when indicated 4