What is the initial approach for emergency management of burn injuries in primary care, particularly in vulnerable populations such as children, elderly, and individuals with pre-existing medical conditions like respiratory issues, cardiovascular disease, or previous trauma?

Emergency Management of Burn Injuries in Primary Care

Immediate First Aid (First 5-20 Minutes)

Cool the burn immediately with clean running water for 5-20 minutes to limit tissue damage and reduce pain, which is the single most important intervention in burn first aid. 1

• In children and elderly patients, monitor closely for hypothermia during active cooling, particularly with burns >10% TBSA 1
• If clean running water is unavailable, cooling superficial burns with ice wrapped in cloth may be reasonable, but never apply ice directly to the burn 1
• After cooling, loosely cover the burn with a clean, non-adherent dressing 1
• For superficial burns managed at home, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera after cooling 1

Pain Management

• Administer acetaminophen or NSAIDs for mild to moderate pain in superficial burns 1
• For severe burn pain requiring specialist referral, titrated intravenous opioids or ketamine should be administered, as burn pain is often intense and difficult to control 1

Burn Assessment and Classification

Use the Lund-Browder chart, not the Rule of Nines, for measuring total body surface area (TBSA) in all patients, as the Rule of Nines overestimates TBSA in 70-94% of cases leading to excessive fluid administration. 1, 2

• In prehospital settings, use the patient's palm plus fingers (approximately 1% TBSA) or serial halving method for rapid assessment 1, 2
• Classify burns by depth: superficial, partial-thickness, or full-thickness 2
• Reassess TBSA during initial management as burn appearance may evolve 3

Mandatory Immediate Referral Criteria

For All Patients:

• Deep burns in function-sensitive areas (face, hands, feet, genitals, perineum, flexure lines) regardless of size 1, 2
• Circumferential burns 1
• Smoke inhalation injury (check for circumoral burns, oropharyngeal burns, carbonaceous sputum) 1, 2
• Chemical or electrical burns 1

Age-Specific Criteria:

Children:

• TBSA >10% 1
• Deep burns >5% TBSA 1
• Infants <1 year of age with any burn 1
• Any child with severe comorbidities 1

Adults:

• TBSA >10-20% (lower threshold for elderly >75 years) 1, 2
• Deep burns >5% TBSA 1
• Age >75 years with TBSA <20% 1

Patients with Pre-existing Conditions:

• Diabetes mellitus, cardiovascular disease, or respiratory issues with any significant burn 1

Fluid Resuscitation (For Burns Requiring Specialist Care)

Adults with burns ≥10% TBSA and children with burns ≥5% TBSA require formal fluid resuscitation. 2

• Administer 20 mL/kg of Ringer's Lactate within the first hour 2
• Calculate 24-hour requirements using Parkland formula: 2-4 mL/kg/%TBSA 2
• Give half of calculated volume in first 8 hours post-burn, remaining half over next 16 hours 2
• Children require higher volumes (approximately 6 mL/kg/%TBSA) due to higher surface area-to-weight ratio 2
• Target urine output: 0.5-1 mL/kg/hour 2
• Do not use normal saline as primary resuscitation fluid due to risk of hyperchloremic metabolic acidosis and acute kidney injury 2

Monitoring for Life-Threatening Complications

Watch for compartment syndrome in circumferential burns, indicated by blue, purple, or pale extremities with poor perfusion—this requires emergency escharotomy within 48 hours. 1, 2

• Monitor for inhalation injury signs: circumoral burns, oropharyngeal burns, carbonaceous sputum, which significantly increases mortality 2
• Check for signs of infection: increased pain, redness extending beyond burn margins, swelling, purulent discharge 1
• In patients with cardiovascular disease, monitor for cardiac dysfunction if hypotension persists despite adequate fluid resuscitation 2

Wound Management Specific to Primary Care

• Clean the wound with tap water or isotonic saline if transfer is delayed 1
• Do not break blisters, as this increases infection risk 1
• Do not use systemic antibiotics prophylactically; reserve for clinically evident infections 1
• Avoid prolonged use of silver sulfadiazine on superficial burns as it may delay healing 1
• Silver sulfadiazine cream 1% should be applied once to twice daily to a thickness of approximately one-sixteenth inch for partial-thickness burns when specialist care is delayed 4

Critical Pitfalls to Avoid

• Never delay referral for any partial-thickness or full-thickness burn in function-sensitive areas, as this leads to permanent functional impairment 1
• Do not apply butter, oil, or other home remedies to burns 1
• Avoid "fluid creep" (excessive fluid administration) which can lead to compartment syndrome 2
• Never delay escharotomy when compartment syndrome is present 2
• Do not underestimate fluid requirements in electrical burns, which cause deeper tissue damage than apparent on surface 2

Specialist Consultation and Transfer

Contact a burn specialist immediately to determine need for transfer to a burn center, as direct admission (rather than sequential transfers) improves survival and functional outcomes. 1, 2

• Use telemedicine for initial assessment when immediate specialist access is unavailable 1, 2
• Specialized burn centers improve survival rates, reduce hospital length of stay, facilitate rehabilitation, and reduce long-term complications 1