Management of Burn Scalding Wounds
Immediate First Aid: Cool with Running Water
Immediately cool the scald burn with clean running tap water (15-25°C) for 20 minutes as soon as possible after injury—this is the definitive first-line treatment that reduces burn depth, decreases the need for skin grafting, and minimizes pain. 1, 2, 3
Cooling Protocol Details:
- Duration: Cool for 20-40 minutes for optimal benefit; cooling is effective up to 3 hours post-injury 2
- Temperature: Use tap water at 15-25°C—never use ice water (1-8°C) as this causes additional tissue ischemia and increases necrosis 4, 3
- Population-specific limits:
- Remove jewelry immediately before swelling occurs to prevent vascular compromise 1, 3
Critical Pitfall:
Research demonstrates that ice water cooling (1-8°C) paradoxically causes more tissue necrosis than no cooling at all, while tap water (12-18°C) significantly reduces tissue damage 4. This is a common mistake that worsens outcomes.
Wound Cleaning and Assessment
After cooling, clean the wound in a clean environment using tap water, isotonic saline, or antiseptic solution 1, 2. Thorough irrigation removes foreign matter and prepares the wound for dressing 2.
Assess burn depth to guide treatment:
- Superficial (first-degree): Erythema only, no blisters
- Partial-thickness (second-degree): Blistering, painful
- Full-thickness (third-degree): White/charred, painless
Dressing Application Based on Burn Depth
Superficial Burns:
- Apply petrolatum, petrolatum-based antibiotic ointment, medical-grade honey, or aloe vera 1, 3
- Cover with clean, non-adherent dressing 1
- Administer acetaminophen or NSAIDs for pain 1, 3
Partial-Thickness Burns:
- Apply thin layer of petrolatum-based antibiotic ointment 1
- Cover with non-adherent dressing (Xeroform, Mepitel, or Allevyn) 1
- Avoid silver sulfadiazine for superficial burns as prolonged use delays healing 1, 2
- If silver sulfadiazine is used for deeper partial-thickness burns, apply to 1/16 inch thickness once to twice daily 5
Full-Thickness Burns:
- Cover with clean, dry, non-adherent dressing 1
- All full-thickness burns require immediate medical attention 1, 3
Key Dressing Principles:
- Do not break blisters—this increases infection risk 1, 3
- Prevent tourniquet effect when dressing limbs; monitor distal perfusion with circular dressings 1
- Re-evaluate dressings daily ideally 1
Pain Management Algorithm
- Mild pain (superficial burns): Acetaminophen or NSAIDs 1, 3
- Moderate to severe pain: Titrated intravenous short-acting opioids using validated pain scales 1, 2
- Severe burn-induced pain: Combine titrated IV ketamine with opioids 1, 2
- Highly painful procedures: General anesthesia may be necessary 1, 2
- Alternative when IV access unavailable: Inhaled nitrous oxide 2
Use multimodal analgesia with medications titrated based on validated comfort assessment scales 1.
Infection Prevention: Avoid Routine Antibiotics
Topical antibiotics should NOT be used as first-line treatment but reserved exclusively for infected wounds only. 1, 2, 3 This is a critical distinction from other traumatic wounds—burn wounds are initially sterile 6.
- No routine systemic antibiotic prophylaxis 1, 2
- Monitor for infection signs: increasing pain, redness, swelling, purulent discharge 2
- For infected burns only, use appropriate topical antimicrobial treatment after wound cleansing 2
The rationale: Routine antibiotic use promotes antimicrobial resistance without benefit in uninfected burns 2.
Critical Pitfalls to Avoid
- Never apply ice directly to burns—causes tissue ischemia 1, 3, 4
- Never apply butter, oil, or home remedies—these trap heat and worsen injury 1, 3
- Do not use external cooling devices (Water-Jel) for prolonged periods—hypothermia risk 1, 2, 3
- Do not break blisters—increases infection risk 1, 3
- Avoid prolonged silver sulfadiazine on superficial burns—delays healing 1, 2
Mandatory Immediate Medical Referral Criteria
Seek emergency care immediately for: 1, 2, 3
- Burns involving face, hands, feet, genitals, or perineum
- Partial-thickness burns >10% TBSA in adults or >5% in children
- All full-thickness (third-degree) burns
- Signs of inhalation injury (soot around nose/mouth, difficulty breathing, singed nasal hairs)
- Signs of infection or very painful burns
- Circumferential burns causing compartment syndrome
Specialist burn center management is associated with better survival, reduced complications, shorter hospital stays, and lower costs 2.