What is the initial approach to managing burns?

Initial Approach to Burns

The initial management of burns follows a systematic sequence: immediately cool the burn with clean running water for 5-20 minutes, assess total body surface area (TBSA) using the Lund-Browder chart, initiate early fluid resuscitation with 20 mL/kg of Ringer's Lactate within the first hour for severe burns (≥20% TBSA in adults, ≥10% in children), provide multimodal analgesia, clean and dress wounds appropriately, and urgently consult a burn specialist to determine need for burn center admission. 1, 2

Immediate First Aid (Within Minutes of Injury)

Stop the burning process and cool immediately:

• Cool the burn with clean running water (15-25°C) for 5-20 minutes to limit burn depth progression and reduce pain 3, 4, 2
• For adults with TBSA <20% and children with TBSA <10%, cooling should be performed in the absence of shock 2
• Never apply ice directly to burns as this causes tissue ischemia and increases damage 4, 2
• Monitor children closely for hypothermia during cooling, especially with larger burns 3, 2
• Remove jewelry and constrictive clothing before swelling occurs to prevent vascular compromise 3, 2

Critical timing: Cooling should ideally occur within 30 minutes of injury for maximum benefit 2. However, do not use external cooling devices (e.g., Water-Jel dressings) for prolonged periods due to hypothermia risk 1, 4.

Assessment of Burn Severity

Measure TBSA accurately:

• Use the Lund-Browder chart as the most accurate method for TBSA quantification 1
• The Wallace rule of nines significantly overestimates TBSA and is not suitable for children 1
• Alternative: use the open hand (palm and fingers) which equals 1% TBSA—this is simple and limits overestimation 1
• Smartphone applications (e.g., E-Burn) can facilitate assessment 1
• Repeat TBSA evaluation during initial management as initial assessments often overestimate by 70-94% 1

Identify high-risk features requiring specialist consultation:

• Burns involving face, hands, feet, flexure lines, genitals, or perineum 1, 3, 2
• TBSA >10% in adults or >5% in children 3, 4, 2
• All full-thickness (third-degree) burns 3, 4
• Signs of inhalation injury (soot around nose/mouth, difficulty breathing, singed nasal hairs) 3
• Age, TBSA, and smoke inhalation are the main risk factors for mortality 1

Early Fluid Resuscitation (Within First Hour)

Initiate aggressive fluid therapy for severe burns:

• Administer 20 mL/kg of balanced crystalloid solution within the first hour for adults with TBSA ≥20% and children with TBSA ≥10% 1, 2
• Ringer's Lactate is the first-line fluid as it reduces hyperchloremia, metabolic acidosis, and acute kidney injury compared to 0.9% NaCl 1, 2
• Obtain intravenous access as soon as possible, preferably in unburned areas 1, 2
• If IV access cannot be rapidly obtained, use the intraosseous route 1, 2
• Central femoral venous access should be considered as a last resort 1

Ongoing fluid management:

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

Pain Management

Implement multimodal analgesia immediately:

• Use short-acting opioids and ketamine as the best drugs for burn-induced pain 4, 2
• Titrated intravenous ketamine combined with other analgesics is effective for severe burn-induced pain and limits morphine consumption 2
• Consider over-the-counter pain medications (acetaminophen or NSAIDs) for minor burns 3
• Inhaled nitrous oxide is useful when no intravenous access is available 2
• General anesthesia is appropriate for highly painful injuries or procedures 2
• Cooling and covering burns with fatty substances (e.g., Vaseline) may improve pain control 2

Wound Care (After Resuscitation)

Wound care is not a priority and should only be performed after well-conducted resuscitation 2

Cleaning:

• Clean wounds with tap water, isotonic saline, or antiseptic solution in a clean environment 1, 3, 4, 2
• Wound care typically requires deep analgesia or general anesthesia 1, 2

Dressing selection:

• For small superficial burns managed at home: apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera, then cover with clean non-adherent dressing 3, 4, 2
• Leave burn blisters intact and cover loosely with sterile dressing—the intact blister acts as a natural biological barrier protecting against infection 2
• For larger burns, dressing type depends on TBSA, wound appearance, and patient condition 1, 3, 2
• Avoid prolonged silver sulfadiazine use on superficial burns as it is associated with prolonged healing 1, 4
• 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, 3, 4, 2

Dressing application technique:

• When applying dressings on limbs, prevent bandages from creating a tourniquet effect 3, 4, 2
• Monitor distal perfusion in case of circular dressings 3, 2
• Ideally, dressings should be re-evaluated daily 1, 3

Specialist Consultation and Transfer

Urgently seek burn specialist consultation:

• Referral to a burn specialist should be sought immediately to determine whether the patient should be admitted to a burns center 1, 2
• Use telemedicine when specialists are not readily available to improve TBSA assessment and prevent both overtriage and undertriage 1, 2
• Direct admission to burn centers is recommended when indicated, rather than secondary transfers 1, 2
• Specialist multidisciplinary burn center care is associated with better survival, reduced complications, shorter hospital stays, and lower costs 1, 2

Additional Supportive Measures

Nutritional support:

• Start nutritional support within 12 hours after burn injury via oral or enteral routes (preferred over parenteral) 1

Thromboprophylaxis:

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

Antibiotic prophylaxis:

• Routine antibiotic prophylaxis is not recommended for burn patients 1, 3, 4, 2

Escharotomy:

• Perform escharotomy if deep burns induce compartment syndrome compromising airways, respiration, or circulation 1, 2
• Ideally performed in burn centers by experienced providers 1, 2

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
• Do not delay cooling—it should be done within 30 minutes of injury when possible 2
• Do not use external cooling devices for prolonged periods due to hypothermia risk 1, 4
• Do not delay other resuscitation interventions for dressing application in severe burns 1, 4
• Avoid cooling large burns without ability to monitor core temperature, especially in children 2
• Do not underestimate the importance of early fluid resuscitation—children who receive early fluid resuscitation (within 2 hours) have reduced morbidity and mortality 1