What are the steps for proper burn management?

Burn Management: A Systematic Approach

Immediate First Aid (First Priority)

Cool the burn immediately with clean running water (15-25°C) for 5-20 minutes, starting as soon as possible and up to 3 hours post-injury, as this significantly reduces the need for skin grafting and limits burn depth. 1, 2, 3

• Remove jewelry and constrictive items before swelling occurs to prevent compartment syndrome 2, 4
• Cooling parameters by patient population:
  • Adults: Cool burns covering <20% total body surface area (TBSA) in absence of shock 1, 2
  • Children: Cool burns covering <10% TBSA with close monitoring for hypothermia 1, 2
• Do not apply ice directly, butter, oil, or home remedies as these cause further tissue damage 2, 4
• Do not use external cooling devices (Water-Jel dressings) for prolonged periods to prevent hypothermia 1

Pain Management (Concurrent with Initial Care)

Administer titrated intravenous ketamine combined with short-acting opioids (fentanyl) for severe burn pain, as this reduces morphine consumption while maintaining spontaneous breathing. 5, 2

• For minor burns: Over-the-counter acetaminophen or NSAIDs 2, 4
• For dressing changes: Short-acting opioids plus ketamine are optimal for brief procedures 1, 5
• Inhaled nitrous oxide can be used when IV access is unavailable 1, 5
• General anesthesia is indicated for highly painful procedures 1, 5
• All analgesics must be titrated using validated comfort scales to prevent under/overdosing due to burn-induced hypermetabolism and capillary leakage 1, 5

Wound Assessment and Cleaning

Clean the wound with tap water, isotonic saline, or antiseptic solution in a clean environment with adequate analgesia before applying dressings. 1, 2, 4

• Assess burn severity:
  • Superficial (first-degree): Epidermis only
  • Partial-thickness (second-degree): Into dermis with blisters
  • Full-thickness (third-degree): Through entire dermis 2
• Calculate TBSA using the rule of nines 3
• Do not break blisters as this increases infection risk 2, 4

Wound Dressing by Burn Depth

Superficial (First-Degree) Burns:

• Apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera 2
• Cover with clean, non-adherent dressing 2

Partial-Thickness (Second-Degree) Burns:

• Apply thin layer of petrolatum-based antibiotic ointment 2
• Cover with non-adherent dressing (Xeroform, Mepitel, Allevyn, or Jelonet) 2, 4
• Avoid prolonged silver sulfadiazine use on superficial burns as it is associated with delayed healing 1, 6
• Silver sulfadiazine should be applied 1-2 times daily at one-sixteenth inch thickness when used 6

Full-Thickness (Third-Degree) Burns:

• Cover with clean, dry, non-adherent dressing while awaiting immediate medical care 2
• All full-thickness burns require immediate medical attention 2, 4

Dressing Management Principles

Prevent tourniquet effect when applying limb dressings and monitor distal perfusion with circular dressings. 1, 2

• Re-evaluate dressings daily 1, 2
• Topical antibiotics should only be used for infected wounds, not as first-line prophylaxis 1, 2, 4
• Do not administer routine systemic antibiotic prophylaxis as evidence shows no reduction in infection risk 1

Thromboprophylaxis and Supportive Care

Administer thromboprophylaxis routinely for severe burns patients in the initial phase. 1

• Supplement micronutrients: copper, zinc, selenium, and vitamins B, C, D, and E for severe burns 1

Immediate Referral Criteria

Refer immediately to a burn unit for:

• Burns involving face, hands, feet, or genitals 2, 4, 3
• Partial-thickness burns >10% TBSA in adults or >5% in children 2, 4, 3
• All full-thickness burns 2, 4
• Chemical or electrical burns 3, 7
• Signs of inhalation injury (soot around nose/mouth, difficulty breathing) 2
• Burns showing signs of infection or slow healing 2, 3

Critical Pitfalls to Avoid

• Do not delay resuscitation for wound dressing - wound care is not a priority until after adequate resuscitation 1
• Avoid alpha-2 receptor agonists (dexmedetomidine) in acute phase due to hemodynamic effects 1, 5
• Insufficient evidence exists for lidocaine use in burn patients 1, 5
• Monitor for hypothermia during cooling, especially in children with larger burns 2, 4
• Check tetanus immunization status as burns are tetanus-prone 3