What are the steps for managing burn injuries?

Management of Burn Injuries

Burn management requires immediate cooling with running water for 5-20 minutes, early fluid resuscitation with balanced crystalloids for severe burns, aggressive pain control with opioids or ketamine, and prompt referral to specialized burn centers for injuries meeting severity criteria. 1, 2

Initial Assessment and Severity Classification

Measure Total Body Surface Area (TBSA)

• Use the Lund-Browder chart (not the rule of nines) to accurately measure TBSA in both adults and children, as other methods significantly overestimate burn size in 70-94% of cases, leading to inappropriate fluid administration 1, 2
• The open hand method (palm plus fingers = 1% TBSA) can be used in prehospital settings or mass casualty situations 1
• Repeat TBSA assessment during initial management as accuracy improves with serial measurements 1

Define Severity Criteria Requiring Specialized Care

Adults - any of the following mandate burn center referral 1, 2:

• TBSA >20% or deep burns >5%
• Smoke inhalation injury
• Deep burns in function-sensitive areas (face, hands, feet, perineum, flexure lines)
• High-voltage electrical burns
• Age >75 years with TBSA <20% plus severe comorbidities
• Circular burns
• Chemical burns (e.g., hydrofluoric acid)

Children - any of the following mandate burn center referral 1, 2, 3:

• TBSA >10% or deep burns >5%
• Infants <1 year of age
• Smoke inhalation injuries
• Deep burns in function-sensitive areas
• Circular burns
• Any electrical or chemical burn

Immediate First Aid Management

Cooling the Burn

• Apply clean running water for 5-20 minutes immediately to limit tissue damage and reduce pain - this is the single most critical first intervention 2, 3
• Monitor children closely for hypothermia during cooling, especially with larger burns, due to their higher body surface area-to-weight ratio 1, 3
• If clean running water is unavailable, ice wrapped in cloth may be used for superficial burns, but never apply ice directly 2

Initial Wound Coverage

• After cooling, loosely cover the burn with a clean, non-adherent dressing while arranging transfer 2
• For minor superficial burns managed at home, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera after cooling 2
• Clean the wound with tap water or isotonic saline if transfer to a burn center is delayed 2

Airway Management

Intubation Criteria

• Intubate immediately if the patient has deep circular neck burns AND/OR symptoms of airway obstruction (voice change, stridor, laryngeal dyspnea) AND/OR very extensive burns (TBSA ≥40%) 3
• The only urgent indication for immediate escharotomy is compromised airway movement and/or ventilation 1

Carbon Monoxide Poisoning

• Administer 100% oxygen immediately starting at first aid stage for any suspected CO poisoning 3

Fluid Resuscitation for Severe Burns

Early Fluid Administration

• Administer 20 mL/kg of balanced crystalloid solution (Ringer's lactate or Hartmann's solution) within the first hour for adults with TBSA burned and children with TBSA >10% 1, 3
• Early fluid resuscitation (within 2 hours of burn) reduces morbidity and mortality, as the nadir of cardiac output occurs within the first 4 hours 1
• No TBSA adjustment is needed for this initial bolus due to difficulties in accurately assessing TBSA in the first minutes after injury 1

Ongoing Fluid Management

• Use Ringer's lactate solution as the first-line balanced fluid resuscitation solution, as 0.9% NaCl is associated with higher risk of hyperchloraemia, metabolic acidosis, and acute kidney injury 1
• Children require higher total fluid intake than adults: calculate daily basal fluid requirement using Holliday-Segar 4-2-1 rule PLUS modified Parkland formula (3-4 mL/kg/%TBSA) 3

Vascular Access

• Obtain intravenous access as soon as possible, preferably in unburned areas 1
• If IV access cannot be rapidly obtained, use intraosseous route 1
• Consider central femoral venous access only as a last resort 1

Pain Management

Severe Burn Pain

• Use titrated intravenous opioids or ketamine for severe burn pain, as burn pain is often intense and difficult to control 2, 3
• Ketamine is particularly effective and can limit morphine consumption 3

Minor Burn Pain

• Administer over-the-counter pain medications such as acetaminophen or NSAIDs for minor burns 2
• Acetaminophen is first-line treatment for pain associated with minor burns 4

Wound Management

Topical Antimicrobial Therapy

• Apply silver sulfadiazine cream 1% once to twice daily to a thickness of approximately one-sixteenth of an inch for partial-thickness burns 5, 4
• Continue treatment until satisfactory healing has occurred or until the burn site is ready for grafting 5
• Reapply immediately after hydrotherapy and to any areas from which it has been removed by patient activity 5
• Avoid prolonged use of silver sulfadiazine on superficial burns as it may delay healing 2

For Grafted Areas

• Mafenide acetate 5% topical solution may be used for grafted areas, keeping gauze dressing wet by irrigating every 4 hours or as necessary 6
• Treatment is usually continued until autograft vascularization occurs and healing is progressing (typically occurring in about 5 days) 6

Prophylactic Antibiotics

• Do not use systemic antibiotics prophylactically; reserve for clinically evident infections 2, 4

Escharotomy

Indications and Timing

• Perform escharotomy within 48 hours if patients exhibit intra-abdominal hypertension or circulatory impairment 1
• The only urgent indication for immediate escharotomy is compromised airway movement and/or ventilation 1
• Watch for signs of compartment syndrome: blue, purple, or pale extremities indicating poor perfusion 2, 3

Location of Procedure

• Escharotomy should be performed only at a Burns Centre, as poorly performed escharotomy is associated with increased morbidity, hemorrhage, and infection 1
• If immediate transfer is impossible, obtain specialist advice before performing escharotomy 1

Specialized Referral and Transfer

Mandatory Referral Criteria

• All burns meeting severity criteria listed above require immediate referral to a burn specialist or burn center 1, 2
• All hand burns with partial-thickness or full-thickness depth require immediate specialist referral to prevent permanent functional disability 2
• Burns involving face or eyes regardless of TBSA require referral 7, 3
• Direct admission to a burn center, rather than sequential transfers, improves survival and functional outcomes 2

Telemedicine Consultation

• Use telemedicine consultation if immediate specialist access is unavailable to guide initial management and determine transfer urgency 2, 7

Benefits of Specialized Care

• Specialist management improves survival and functional prognosis through multidisciplinary care 2
• Specialized burn centers improve survival rates through concentrated expertise in burn care techniques 2
• Specialist care reduces hospital length of stay and costs compared to non-specialized teams 2

Monitoring for Complications

Compartment Syndrome

• Monitor for blue, purple, or pale extremities indicating poor perfusion 2, 3
• Watch for increasing pressure with circumferential burns that may require emergency escharotomy 2, 3

Infection

• Monitor for increased pain, redness extending beyond burn margins, swelling, or purulent discharge 2, 3
• Do not break blisters, as this increases infection risk 2

Special Considerations for Burns Near the Eye

• Monitor for eyelid retraction or inability to close the eye completely, which can lead to corneal exposure and permanent visual impairment 7
• Perform ocular surface assessment using fluorescein eye drops to evaluate epithelial loss 7
• Apply white soft paraffin ointment to protect the cornea and prevent drying 7
• Arrange daily ophthalmology review during the acute phase 7

Critical Pitfalls to Avoid

• Do not delay referral for any partial-thickness or full-thickness hand burn, as this leads to permanent functional impairment 2
• Do not apply butter, oil, or other home remedies to burns 2
• Do not use the Wallace rule of nines for TBSA assessment, as it significantly overestimates TBSA and is not suitable for children 1
• Do not use hypertonic solutions for fluid resuscitation due to insufficient evidence 1
• Avoid prolonged cooling that may cause hypothermia, especially in children 1, 3