What is the appropriate treatment for burns in an urgent care setting?

Treatment of Burns in an Urgent Care Setting

In an urgent care setting, immediately cool the burn with clean running water for 5-20 minutes, provide titrated analgesia with opioids or ketamine, clean the wound with tap water or saline, apply a non-adherent dressing, and urgently refer any burn involving the hands, face, feet, genitals, or any partial/full-thickness burn >10% TBSA in adults (>5% in children) to a burn center. 1, 2

Immediate First Aid (First 20 Minutes)

Cooling is the priority intervention that limits tissue damage and reduces subsequent care needs:

• Cool the burn with clean running water for 5-20 minutes immediately upon presentation 1
• Monitor children closely for hypothermia during active cooling, especially with larger burns 1
• If clean water is unavailable, ice wrapped in cloth may be used for superficial burns only—never apply ice directly 1
• Cooling reduces burn depth progression and pain intensity 3

Pain Management

Burn pain is often severe and requires aggressive multimodal analgesia:

• Administer titrated intravenous opioids (short-acting preferred) or ketamine for severe burn pain 3
• Ketamine is particularly effective for burn-induced pain and limits morphine consumption 3
• For less severe burns, over-the-counter acetaminophen or NSAIDs are appropriate 1
• Titrate all analgesics based on validated pain assessment scales to avoid under- or overdosing in the context of burn-induced hypovolemia and capillary leakage 3
• Inhaled nitrous oxide can be useful when IV access is unavailable 3

Wound Assessment and Classification

Accurate assessment determines disposition and treatment:

• Use the Lund-Browder chart (not the Rule of Nines) to calculate total body surface area (TBSA), as the Rule of Nines overestimates TBSA in 70-94% of cases leading to fluid overadministration 2, 4
• For rapid field assessment, use the patient's palm and fingers (approximately 1% TBSA) 2, 4
• Classify burn depth: superficial, partial-thickness (blanched skin falling off indicates deep partial-thickness), or full-thickness 1, 2
• Reassess TBSA during initial management to prevent overtriage or undertriage 2

Wound Care and Dressing

After cooling and before transfer:

• Clean the wound with tap water or isotonic saline solution 3, 1
• Perform wound care in a clean environment with adequate analgesia or procedural sedation 3, 4
• Apply a non-adherent dressing or petrolatum-based ointment after cooling 1
• For superficial burns managed outpatient, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera 1
• Loosely cover the burn with a clean, non-adherent dressing while arranging transfer 1
• Avoid prolonged use of silver sulfadiazine on superficial burns as it delays healing 3, 1

Fluid Resuscitation (For Burns ≥10% TBSA in Adults, ≥5% in Children)

Initiate formal fluid resuscitation for larger burns:

• Administer 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate, not normal saline) within the first hour 2, 4
• Calculate 24-hour fluid requirements using the Parkland formula: 2-4 mL/kg/%TBSA 2
• Give half of the calculated volume in the first 8 hours post-burn, remaining half over next 16 hours 2
• Target urine output of 0.5-1 mL/kg/hour to guide fluid adjustment 2
• Avoid "fluid creep" (excessive fluid administration) as it causes compartment syndrome and other complications 2

Mandatory Referral Criteria to Burn Center

Contact a burn specialist immediately for:

• All hand, face, feet, genital, or perineum burns (regardless of size or depth) 1, 2, 4
• Partial-thickness or full-thickness burns >10% TBSA in adults 1, 2
• Partial-thickness or full-thickness burns >5% TBSA in children 1, 2
• Deep burns >5% TBSA in any patient 1, 2
• Circumferential burns of any extremity or torso 1, 2
• Any electrical or chemical burns 1, 2
• Smoke inhalation injury 1, 2
• Infants <1 year of age with any burn 1
• Adults >75 years with burns 1
• Patients with severe comorbidities (diabetes, etc.) 1

Use telemedicine consultation if immediate specialist access is unavailable to guide initial management and determine transfer urgency 3, 1, 2

Direct admission to a burn center is superior to sequential transfers and improves survival and functional outcomes 3, 1, 2

Monitoring for Complications

Watch for compartment syndrome in circumferential burns:

• Monitor for blue, purple, or pale extremities indicating poor perfusion 1
• Assess for decreased sensation, increased pain, or absent pulses 2
• Escharotomy should be performed within 48 hours if circulatory impairment develops, ideally at a burn center by an experienced provider 3, 2, 4
• The only urgent indication for immediate escharotomy is compromised airway movement or ventilation 3

Monitor for infection:

• Watch for increased pain, redness extending beyond burn margins, swelling, or purulent discharge 1
• Do not use systemic antibiotics prophylactically—reserve for clinically evident infections 1, 4

Critical Pitfalls to Avoid

• Do not delay referral for any hand, face, feet, or genital burn—undertriage increases morbidity and mortality 1, 2
• Do not use the Rule of Nines—it systematically overestimates TBSA 2, 4
• Do not use normal saline for resuscitation—it causes hyperchloremic metabolic acidosis and acute kidney injury 2
• Do not apply butter, oil, or other home remedies 1
• Do not break blisters—this increases infection risk 1
• Do not perform escharotomy without proper training or burn center consultation 3, 2, 4
• Do not use silver sulfadiazine on superficial burns for prolonged periods 3, 1
• Do not apply ice directly to burns 1

Special Considerations for Inhalation Injury

Suspect inhalation injury with:

• Circumoral burns, oropharyngeal burns, or carbonaceous sputum 2
• History of enclosed space fire exposure 2
• Provide 100% oxygen immediately via high-concentration mask or mechanical ventilation for 6-12 hours 3
• Early intubation is important if inhalation injury is suspected 3, 2