What is the management of burns?

Management of Burns

Initial Assessment and Severity Classification

Use the Lund-Browder chart to accurately measure total body surface area (TBSA) burned, as this is the most accurate method and prevents both fluid overload from overestimation and undertriage from underestimation. 1, 2

• The Wallace rule of nines significantly overestimates TBSA and should not be used, especially in children 1
• In prehospital settings or mass casualty situations, use the open hand method (palm plus fingers = 1% TBSA) or serial halving method as practical alternatives 1, 2
• Repeat TBSA measurements during initial management as burn appearance evolves 1, 3

Criteria for Severe Burns Requiring Specialist Care

Adults: 1, 2

• TBSA >20%, OR
• Deep burns >5%, OR
• Smoke inhalation, OR
• Deep burns on face, hands, feet, perineum, OR
• High-voltage electrical burns, OR
• Age >75 years with TBSA <20% plus comorbidities, OR
• TBSA >10% with deep burns 3-5%

Children: 1, 2

• TBSA >10%, OR
• Deep burns >5%, OR
• Age <1 year, OR
• Smoke inhalation, OR
• Burns on face, hands, feet, perineum, flexure lines, OR
• Circular burns, OR
• Any electrical or chemical burn

Immediate First Aid (First 20 Minutes)

Cool the burn with clean running water for 5-20 minutes immediately to limit tissue damage and reduce pain. 2

• Monitor children for hypothermia during cooling, particularly with larger burns 2
• If clean water unavailable, ice wrapped in cloth may be used for superficial burns only—never apply ice directly 2
• After cooling, loosely cover with clean, non-adherent dressing 2
• Do not apply butter, oil, or other home remedies 2
• Do not break blisters as this increases infection risk 2

Pain Management

Administer titrated intravenous opioids or ketamine for severe burn pain, as burn pain is intense and difficult to control. 2

• For minor burns managed at home, use acetaminophen or NSAIDs 2

Specialist Consultation and Transfer

Contact a burn specialist immediately for any partial-thickness or full-thickness hand burn, or any burn meeting severity criteria above, as specialist management improves survival and functional outcomes. 1, 2

• Use telemedicine consultation when immediate specialist access is unavailable to guide initial management and determine transfer urgency 1, 2, 4
• Transfer directly to a burn center rather than sequential transfers, as direct admission reduces morbidity and mortality 1, 2, 4
• Specialist consultation is mandatory for burns involving face, hands, feet, flexure lines, genitals, or perineum regardless of size 1, 4

The evidence strongly supports that specialized burn centers improve survival through concentrated expertise, facilitate rehabilitation, reduce complications, and decrease hospital length of stay and costs compared to non-specialized teams 1, 2

Fluid Resuscitation

For adults with TBSA ≥15% and children with TBSA ≥10%, administer 20 mL/kg of balanced crystalloid solution (Ringer's lactate) intravenously in the first hour. 4

• Balanced crystalloid solutions are preferred over normal saline as they reduce risk of hyperchloremic acidosis, metabolic acidosis, and acute kidney injury 4
• Accurate TBSA measurement using Lund-Browder chart is critical to avoid fluid overload, which occurs in 70-94% of cases when TBSA is overestimated 1

Wound Management

Clean the wound with tap water or isotonic saline if transfer is delayed. 2

• For superficial burns managed at home, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera after cooling 2
• Avoid prolonged use of silver sulfadiazine on superficial burns as it may delay healing 2
• Apply silver sulfadiazine cream 1% once to twice daily to a thickness of 1/16 inch for deeper burns, continuing until satisfactory healing or readiness for grafting 5
• Do not use systemic antibiotics prophylactically; reserve for clinically evident infections 2

For mafenide acetate solution in grafted areas: reconstitute 50g powder in 1000mL sterile water, keep dressing wet by irrigating every 4 hours, continue for up to 5 days until graft vascularization occurs 6

Emergency Complications

Compartment Syndrome and Escharotomy

Perform escharotomy immediately if deep circumferential burns cause compartment syndrome compromising circulation, respiration, or airway. 1, 4

• Monitor for signs: blue, purple, or pale extremities indicating poor perfusion 2
• Deep third-degree circumferential burns increase pressure within anatomical compartments, leading to acute limb ischemia or thoracic/abdominal compartment syndrome 4
• Ideally perform escharotomy in a burn center by experienced provider 1

Infection Monitoring

Watch for increased pain, redness extending beyond burn margins, swelling, or purulent discharge 2

Definitive Surgical Management

Early surgical excision and skin grafting, performed routinely in burn centers, significantly reduce morbidity, mortality, and hospital length of stay. 4

This should be performed by specialized burn teams as part of comprehensive multidisciplinary care 1, 2

Critical Pitfalls to Avoid

• Never delay specialist referral for any partial-thickness or full-thickness hand burn or burns meeting severity criteria, as undertriage increases morbidity and mortality 1, 2
• Do not use Wallace rule of nines for TBSA estimation 1
• Do not apply ice directly to burns 2
• Do not break blisters 2
• Do not use topical home remedies 2
• Do not give prophylactic systemic antibiotics 2