What are the initial steps in managing burns?

Initial Management of Burns

Immediate Assessment and Burn Surface Area Measurement

Use the Lund-Browder chart to measure total body surface area (TBSA) burned—not the Rule of Nines, which overestimates TBSA in 70-94% of cases and leads to dangerous fluid overadministration. 1, 2

• The Lund-Browder chart is the gold standard for TBSA assessment in both adults and children, providing the most accurate quantification 1, 2
• In prehospital or mass casualty settings, use the patient's palm and fingers (approximately 1% TBSA) or the serial halving method as practical alternatives 1, 2
• Digital tools like smartphone applications (E-Burn) can facilitate accurate TBSA assessment 1
• Reassess TBSA repeatedly during initial management as burn appearance evolves, preventing both overtriage (wasting resources) and undertriage (increasing mortality) 1

Immediate Specialist Consultation and Transfer Decision

Contact a burn specialist immediately to determine whether the patient requires transfer to a burn center—this single intervention improves survival, reduces complications, and decreases length of stay. 1, 2

• Use telemedicine when specialists are not readily available to improve TBSA measurement accuracy and prevent inappropriate transfers 1, 2
• Transfer directly to the burn center when indicated, avoiding intermediate stops 1, 2, 3

Indications requiring specialist consultation: 1

• TBSA >10% in adults or >5% in children
• Deep burns >5% TBSA
• Burns involving face, hands, feet, genitals, perineum, or flexure lines
• Circumferential burns
• Infants <1 year of age
• Smoke inhalation injuries
• Severe comorbidities

Fluid Resuscitation Protocol

For adults with burns ≥10% TBSA and children with burns ≥5% TBSA, immediately administer 20 mL/kg of Ringer's Lactate within the first hour. 2, 3

• Calculate 24-hour fluid requirements using the Parkland formula: 2-4 mL/kg/%TBSA of balanced crystalloid solution (preferably Ringer's Lactate) 2
• Administer half of the calculated 24-hour volume in the first 8 hours post-burn, with the remaining half over the next 16 hours 2
• Children require higher volumes (approximately 6 mL/kg/%TBSA) due to higher surface area-to-weight ratio 2
• Do not use normal saline (0.9% NaCl) as primary resuscitation fluid—it increases risk of hyperchloremic metabolic acidosis and acute kidney injury 2

Fluid Resuscitation Monitoring:

• Titrate fluid rates hourly based on urine output: target 0.5-1 mL/kg/hour in adults 2, 3
• Monitor arterial lactate concentration for adequacy of resuscitation 3
• Use advanced hemodynamic monitoring (echocardiography, cardiac output monitoring) in patients with persistent oliguria or hemodynamic instability 3
• If hypotension persists despite adequate fluids, evaluate cardiac function with echocardiography before initiating vasopressors 3

Albumin Administration for Severe Burns:

• For TBSA >30%, initiate 5% human albumin between 6-12 hours post-burn to reduce crystalloid volumes and prevent "fluid creep" complications 2, 3
• Target serum albumin levels >30 g/L with doses of 1-2 g/kg/day 2, 3
• Albumin significantly reduces mortality (OR=0.34, P<0.001) and abdominal compartment syndrome (from 15.4% to 2.8%) 3
• Hydroxyethyl starches (HES) are contraindicated in severe burns; do not use gelatins or other synthetic starches 2

Airway and Inhalation Injury Assessment

Assess for inhalation injury immediately by checking for circumoral burns, oropharyngeal burns, and carbonaceous sputum—this significantly increases mortality. 2

• Establish intravenous access in unburned areas when possible; consider intraosseous access if IV access cannot be rapidly obtained 3
• Monitor for signs of hypovolemic shock due to inflammation, capillary leak syndrome, and microcirculation alterations 3

Wound Care and Pain Management

Provide adequate analgesia before wound cleaning and dressing application, as burn wound care typically requires deep analgesia or general anesthesia. 3

• Clean the burn wound with tap water, isotonic saline solution, or an antiseptic solution in a clean environment 3
• Apply appropriate dressings based on burn depth, TBSA, wound appearance, and patient's general condition 3
• When applying dressings to extremities, prevent bandages from causing a tourniquet effect and monitor distal perfusion regularly 3
• Silver sulfadiazine cream 1% should be applied once to twice daily to a thickness of approximately one-sixteenth of an inch, and continued until satisfactory healing occurs or the burn site is ready for grafting 4
• Do not routinely administer antibiotic prophylaxis unless specifically indicated for infected wounds 3

Escharotomy for Compartment Syndrome

Perform escharotomy immediately if deep circumferential burns cause compartment syndrome compromising circulation or respiration—ideally at a burn center by an experienced provider. 1, 2, 3

• Monitor for compartment syndrome in circumferential third-degree burns, which can lead to acute limb ischemia or thoracic/abdominal compartment syndrome 2
• Monitor intra-abdominal pressure as abdominal compartment syndrome risk is significantly reduced with albumin use 3
• Never delay escharotomy when indicated—poorly timed escharotomy is associated with increased morbidity 2

Critical Pitfalls to Avoid

• Avoid "fluid creep" (excessive fluid administration)—it leads to compartment syndrome and other complications 2
• Do not underestimate fluid requirements in electrical burns, which cause deeper tissue damage than apparent on the surface 2
• Avoid prolonged use of external cooling devices (e.g., Water-Jel dressings) to prevent hypothermia 3
• Do not use the Wallace Rule of Nines for TBSA assessment—it systematically overestimates and leads to excessive fluid administration 1, 2
• Avoid prolonged use of silver sulfadiazine on superficial burns, which may delay healing 3
• Do not perform escharotomy without proper training or consultation—this increases complications 3