What are the steps for proper burn management?

Burn Management: A Systematic Approach

Immediate First Aid (First 20 Minutes)

Cool the burn immediately with clean running water (15-25°C) for 20 minutes, as this significantly reduces the need for skin grafting and limits burn depth progression. 1, 2

• Start cooling within 3 hours of injury for maximum benefit, though earlier is always better 3
• For adults with <20% total body surface area (TBSA) burns and children with <10% TBSA, cooling should be performed in the absence of shock 1, 2
• Monitor children closely for hypothermia during cooling, especially with larger burns 2
• Remove jewelry and non-adherent clothing before swelling occurs to prevent constriction 2, 4

Critical Pitfalls to Avoid:

• Never apply ice directly—this causes further tissue damage 2, 4
• Never apply butter, oil, or home remedies 2
• Do not use external cooling devices (Water-Jel dressings) for prolonged periods due to hypothermia risk 1

Initial Assessment and Triage

Evaluate burn severity using the rule of nines to determine TBSA 3:

Immediate referral to a burn center is required for: 2, 3

• Burns involving face, hands, feet, or genitals
• Partial-thickness burns >10% TBSA in adults (>5% in children)
• All full-thickness (third-degree) burns
• Chemical or electrical burns
• Signs of inhalation injury (soot around nose/mouth, difficulty breathing)

Wound Care and Dressing Selection

Burn wound care should be performed in a clean environment after adequate resuscitation, often requiring deep analgesia or general anesthesia. 1

Cleaning Protocol:

• Clean wounds with tap water, isotonic saline, or antiseptic solution 1, 2
• Perform in sterile conditions to minimize infection risk 1

Dressing Selection by Burn Depth:

Superficial (First-Degree) Burns: 2

• Apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera
• Cover with clean, non-adherent dressing
• Administer acetaminophen or NSAIDs for pain

Partial-Thickness (Second-Degree) Burns: 2, 4

• Apply thin layer of petrolatum-based antibiotic ointment
• Cover with non-adherent dressing (Xeroform, Mepitel, Allevyn, or Jelonet)
• Avoid prolonged use of silver sulfadiazine on superficial burns as it is associated with delayed healing 1, 5

Full-Thickness (Third-Degree) Burns: 2

• Cover with clean, dry, non-adherent dressing
• Immediate medical attention required

Dressing Management:

• When applying dressings on limbs, prevent tourniquet effect and monitor distal perfusion with circular dressings 1, 2
• Re-evaluate dressings daily 1, 2
• Dressing type depends on TBSA, wound appearance, and patient condition 1, 2

Antimicrobial Management

Topical antibiotics should not be used as first-line treatment but reserved for infected wounds only. 1, 2

• Routine systemic antibiotic prophylaxis is not recommended for burn patients 1, 2
• Antiseptic dressings may be appropriate for large or contaminated burns 1
• For skin grafts, mafenide acetate 5% solution may be used with specific irrigation protocols for up to 5 days 6

Pain Management Strategy

Use multimodal analgesia with all medications titrated based on validated comfort and analgesia assessment scales. 1, 7, 2

Pharmacological Approach:

For severe burn-induced pain: 1, 7

• Titrated IV ketamine combined with short-acting opioids (fentanyl) is the preferred regimen, as it reduces morphine consumption while maintaining spontaneous breathing
• Short-acting opioids are preferred due to hypermetabolism and tolerance in burn patients

For brief procedures/dressing changes: 1, 7

• Short-acting opioids plus ketamine
• Inhaled nitrous oxide when IV access unavailable
• General anesthesia for highly painful procedures

Critical Safety Considerations:

• Avoid alpha-2 receptor agonists (dexmedetomidine) in the acute phase due to hemodynamic effects 7
• Burn injuries trigger capillary leakage and hypovolemia, increasing risk of adverse effects from analgesics 1, 7
• Insufficient evidence exists for lidocaine use in burn patients 1, 7

Non-Pharmacological Adjuncts:

• Virtual reality or hypnosis techniques may reduce pain intensity and anxiety when patient is stable 1, 7
• Cooling limited burned surfaces improves pain control 1, 2
• Covering burns with fatty substances (Vaseline) may improve pain control 1

Supportive Care

Thromboprophylaxis should be routinely prescribed for severe burns patients in the initial phase. 1

Micronutrient supplementation: 1

• Supplement copper, zinc, selenium, and vitamins B, C, D, and E to meet high metabolic requirements

Tetanus prophylaxis: 3

• Check immunization status as burns are tetanus-prone wounds

Special Burn Types

Chemical burns: 8

• Immediate water lavage for 60 minutes (longer than thermal burns)
• Remove contaminated clothing if not adherent
• Early irrigation reduces hospital stay and scarring

Electrical burns: 9

• Require additional assessment for deep tissue injury
• Associated with increased morbidity

Follow-Up and Monitoring

• Burns often remain painful for extended periods after healing, requiring slow medication taper 7
• Burns that become infected or are slow to heal should be discussed with a burn unit 3
• Repetitive painful procedures can lead to central sensitization and chronic pain 7