What are the initial steps in managing burn injuries?

Initial Management of Burn Injuries

Use the Lund-Browder chart to accurately measure total burned body surface area (TBSA), immediately cool appropriate burns with cold tap water (15-25°C) for 5-40 minutes, provide aggressive pain control with titrated opioids and ketamine, and urgently consult a burn specialist to determine need for transfer to a specialized burn center. 1, 2, 1

Immediate First Aid and Cooling

Cool burns with cold tap water (15-25°C) as soon as possible for 5-40 minutes to limit burn depth, reduce pain, and improve outcomes. 2, 3 This intervention is effective for up to three hours after injury and can significantly reduce the need for skin grafting when cooling times are 20-40 minutes. 1, 4

Critical cooling parameters:

• Adults with TBSA <20% and children with TBSA <10% should receive cooling in the absence of shock 1, 2
• Never cool large burns (>20% TBSA in adults, >10% in children) due to hypothermia risk 2
• Never apply ice directly to burns as this causes tissue ischemia and additional damage 2, 3
• Avoid prolonged use of external cooling devices (e.g., Water-Jel dressings) due to hypothermia risk 2

Accurate TBSA Assessment

Use the Lund-Browder chart as the gold standard method for measuring TBSA in both adults and children, as it is the most accurate method available. 1 The Wallace rule of nines significantly overestimates TBSA and is not suitable for children. 1

Practical assessment approaches:

• Smartphone applications (e.g., E-Burn) can facilitate accurate TBSA measurement 1
• The open hand method (palm and fingers = 1% TBSA) is simple and practical for field use 1
• Repeat TBSA measurements during initial management to prevent over- or undertriage 1
• Accurate TBSA measurement prevents fluid overresuscitation, which occurs in 70-94% of cases when TBSA is overestimated 1

Aggressive Pain Management

Provide titrated intravenous opioids and ketamine for severe burn-induced pain, using validated pain assessment scales to guide dosing. 1, 5 Burn pain is often extremely intense and difficult to treat, requiring multimodal analgesia. 1, 5

Pain management algorithm:

• Short-acting opioids and ketamine are the best drugs for burn-induced pain 1, 5
• Titrated intravenous ketamine can be combined with other analgesics to treat severe pain 1
• Inhaled nitrous oxide is useful when intravenous access is unavailable 2, 5
• General anesthesia is indicated for highly painful injuries or procedures like wound care 1
• Non-pharmacological techniques (cooling, appropriate dressings, virtual reality, hypnosis) should be combined with pharmacologic treatment when the patient is stable 1, 5

Urgent Specialist Consultation

Contact a burn specialist immediately to determine severity, guide fluid resuscitation, and decide on transfer to a burn center. 1 Specialist management is associated with better survival, reduced complications, shorter hospital stays, and lower costs. 1

Mandatory burn center referral criteria:

• TBSA >10% in adults or >5% in children 1, 2, 3
• Deep burns >5% TBSA 1
• Burns to face, hands, feet, perineum, or flexure lines 1, 2, 3
• Circular burns causing compartment syndrome 1
• Infants <1 year of age 1
• Smoke inhalation injuries 1
• All full-thickness burns 2, 3
• Severe comorbidities 1

Use telemedicine to improve initial assessment when direct specialist consultation is not immediately available. 1

Transfer directly to the burn center when indicated, avoiding intermediate stops that delay definitive care. 1

Initial Wound Care

Perform wound care only after adequate resuscitation in severe burns, as this is not an immediate priority. 1, 2 Wound care should be performed in a clean environment with adequate analgesia or general anesthesia. 1, 2, 3

Wound cleansing protocol:

• Clean wounds with tap water, isotonic saline, or antiseptic solution 1, 2, 3
• Thorough irrigation is essential to remove foreign matter and debris 2, 3
• Leave blisters intact and cover loosely with sterile dressing to improve healing and reduce pain 3
• Never completely unroof blisters as this significantly increases infection risk 3

Dressing application:

• Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the entire burn surface, including intact blisters, to reduce complications including hypertrophic scarring 3
• Cover with non-adherent dressings (Mepitel or Telfa) directly over the emollient 3
• Apply secondary foam or burn dressing to collect exudate 3
• Silver sulfadiazine should be applied to a thickness of approximately 1/16 inch once to twice daily if used, but avoid prolonged use on superficial burns as it may delay healing 2, 6

Infection Prevention

Reserve topical antibiotics for infected wounds only, not as routine prophylaxis, to prevent antimicrobial resistance. 2, 3 Systemic antibiotic prophylaxis should not be administered routinely. 2

Antimicrobial management:

• Apply topical antimicrobial agents only to sloughy or obviously infected areas 3
• Monitor for infection signs: increasing pain, redness, swelling, or purulent discharge 2
• Check tetanus immunization status as burns are tetanus-prone injuries 4

Critical Pitfalls to Avoid

• Never apply ice directly to burns—causes tissue damage 2, 3
• Never apply butter, oil, or home remedies—increases infection risk and delays healing 3
• Never use routine topical antibiotics on uninfected wounds—promotes antimicrobial resistance 2, 3
• Never delay specialist referral for high-risk anatomic locations or TBSA thresholds 2, 3
• Never cool large burns (>20% TBSA adults, >10% children)—causes hypothermia 2
• Never use prolonged external cooling devices—risk of hypothermia 2

Escharotomy Considerations

Perform escharotomy if deep circumferential burns induce compartment syndrome in limbs or trunk that compromises airways, respiration, or circulation. 1 Ideally, this should be performed in a burn center by an experienced provider. 1