What are the management steps for different degrees of burns?

Burn Degree Classification and Management

Burns are classified by depth and managed according to total body surface area (TBSA), with the Lund-Browder method being the most accurate assessment tool for both adults and children, and all severe burns requiring immediate specialist consultation to optimize survival and functional outcomes. 1

Burn Depth Classification

Burns are categorized by depth of tissue injury:

• Superficial (First-degree): Epidermis only, painful, red, no blisters
• Superficial partial-thickness (Second-degree superficial): Extends into superficial dermis, extremely painful, blistering, blanches with pressure
• Deep partial-thickness (Second-degree deep): Extends into deep dermis, less painful due to nerve damage, may not blanch
• Full-thickness (Third-degree): Extends through entire dermis, painless, white/charred appearance, leathery texture

Initial Assessment and TBSA Measurement

Use the Lund-Browder chart as the primary method for measuring TBSA burned, as it is the most accurate and prevents both overtriage and undertriage that increase morbidity and mortality. 1, 2, 3

• The Wallace rule of nines significantly overestimates TBSA and is not suitable for children 1, 3
• In prehospital or mass casualty settings, use the patient's open hand (palm and fingers), which represents approximately 1% TBSA 1, 2, 3
• Smartphone applications (e.g., E-Burn) can facilitate accurate TBSA assessment 1, 2
• Repeat TBSA measurement during initial management, as accuracy improves with serial assessments 1

Common pitfall: TBSA is overestimated in 70-94% of cases, leading to excessive fluid administration and complications including abdominal compartment syndrome, acute kidney injury, and acute respiratory distress syndrome 3

Criteria for Severe Burns Requiring Specialist Management

Adults (require burn center consultation):

• TBSA burned >20%, OR
• Deep burns >5%, OR
• Smoke inhalation, OR
• Deep burns in functional areas (face, hands, feet, perineum), OR
• High-voltage electrical burns 1, 3

Additional criteria for TBSA <20%:

• Age >75 years with severe comorbidities, OR
• Deep circular burns, OR
• TBSA >10% with deep burns 3-5% 1, 3

Children (require burn center consultation):

• TBSA >10%, OR
• Deep burns >5%, OR
• Age <1 year, OR
• Smoke inhalation, OR
• Deep burns in functional areas (face, hands, feet, perineum, flexure lines), OR
• Circular burns, OR
• Electrical or chemical burns 1

Management Algorithm by Burn Severity

Step 1: Immediate Actions (All Burns)

Stop the burning process immediately:

• Remove patient from heat source
• For thermal burns with TBSA <20% in adults or <10% in children without shock, cool the burn with running water for up to 40 minutes to limit burn depth and reduce pain 3
• Avoid prolonged cooling to prevent hypothermia 3
• For electrical burns, ensure scene safety by turning off power source before approaching the victim 2

Step 2: Specialist Consultation

Contact a burn specialist immediately for all severe burns to determine need for burn center admission. 1, 2

• Use telemedicine when specialists are not readily available to improve TBSA measurement and prevent inappropriate transfers 1, 2
• Direct admission to burn center (not secondary transfer) reduces time to excision, duration of mechanical ventilation, and improves survival 2, 3

Step 3: Airway Management

Do not routinely intubate patients with facial or cervical burns. 3

Specific intubation criteria:

• Deep and circular neck burns
• Symptoms of airway obstruction (stridor, hoarseness, respiratory distress)
• Extensive burns (TBSA ≥40%)
• Evidence of smoke inhalation with glottic edema 3

Pitfall: Unnecessary prehospital intubation occurs in almost one-third of patients and is associated with more complications 3

Step 4: Fluid Resuscitation (Severe Burns)

For adults with TBSA >20% or children with TBSA ≥5%, initiate formal fluid resuscitation using the Parkland formula:

• Adults: 2-4 mL/kg/%TBSA of Lactated Ringer's solution over 24 hours

  • Give half the volume in first 8 hours from time of injury
  • Target urine output: 0.5-1 mL/kg/hour 3

• Children: Approximately 6 mL/kg/%TBSA due to higher surface-to-weight ratio

  • Initiate formal resuscitation for TBSA ≥5% 3

Adjust fluid administration based on clinical response, not rigid formula adherence. 3

For severe burns (TBSA >30%):

• Start 5% human albumin between 8-12 hours post-burn to reduce crystalloid requirements and prevent fluid overload
• Maintain serum albumin >30 g/L with doses of 1-2 g/kg/day 3

For electrical burns:

• Use crystalloid isotonic fluids (0.9% saline) as first-line therapy
• Avoid hypotonic solutions like lactated Ringer's which can increase tissue edema
• Administer fluid boluses of 250-1000 mL with reevaluation after each bolus 2

Step 5: Pain Management

Administer short-acting opioid analgesics and titrated ketamine according to validated pain scales. 3

• Ketamine can be combined with other analgesics for severe burn-induced pain 3
• For highly painful lesions or procedures, general anesthesia is effective 3
• Inhaled nitrous oxide is useful when intravenous access is unavailable 3
• Combine non-pharmacological techniques with analgesic drugs for dressings in stable patients 3

Step 6: Wound Care

Perform wound care only after adequate resuscitation, in a clean environment, with deep analgesia or general anesthesia. 3

Wound cleaning:

• Cleanse with running water, isotonic saline, or antiseptic solution 3
• Consult burn specialist to determine appropriate dressing and whether blisters should be aspirated or debrided 3

Topical therapy:

• Apply silver sulfadiazine cream 1% once to twice daily to a thickness of approximately 1/16 inch 4
• Cover burn areas with cream at all times, reapplying as needed 4
• Avoid prolonged use of silver sulfadiazine in superficial burns, as it is associated with prolonged healing 3
• Continue treatment until satisfactory healing or burn site is ready for grafting 4

Step 7: Monitor for Compartment Syndrome

Perform escharotomy if deep circular burns cause compartment syndrome compromising airways, respiration, or circulation. 1, 2, 3

Indications for escharotomy:

• Circumferential third-degree burns causing:

  • Acute limb ischemia with neurological disorders
  • Thoracic/abdominal compartment syndrome with decreased cardiac output
  • Decreased pulmonary compliance, hypoxia, hypercapnia
  • Acute renal failure or mesenteric ischemia 2

• Ideally perform in burn center by experienced provider 1, 2

• If transfer not feasible, obtain specialized advice before performing 3

• Do not delay when indicated, as timely escharotomy reduces morbidity 3

Special Considerations

Electrical Burns

• Require close cardiac monitoring due to risk of arrhythmias (ventricular fibrillation, asystole, tachycardia) 2
• Assess for CPR and defibrillation needs 2
• Do not underestimate fluid requirements, as tissue damage is deeper than surface appearance 3
• Consider early intubation for extensive burns involving face, mouth, or anterior neck 2

Cardiac Monitoring

• Essential for electrical burns, as cardiopulmonary arrest is the primary cause of immediate death from electrocution 2
• Monitor for arrhythmias from both low and high-voltage current exposure 2

Key Pitfalls to Avoid

1. Overestimating TBSA leads to excessive fluid administration and complications 3
2. Underestimating electrical injury severity based on visible skin damage delays recognition of serious complications 2
3. Unnecessary intubation in facial burns increases complications 3
4. Prolonged silver sulfadiazine use in superficial burns delays healing 3
5. Delaying escharotomy when indicated increases morbidity 3
6. Secondary transfers instead of direct burn center admission worsen outcomes 2, 3