What is the recommended management for an adult patient with burns and no significant medical history?

Management of Burns in Adults

Initial Assessment and Severity Determination

Immediately cool the burn with clean running water for 5-20 minutes to limit tissue damage, then accurately measure the total body surface area (TBSA) using the Lund-Browder chart—not the rule of nines—as this prevents the 70-94% overestimation that leads to excessive fluid resuscitation. 1, 2, 3

TBSA Measurement

• Use the standardized Lund-Browder chart for both adults and children, as it is the most accurate method available 1, 2, 3
• The Wallace rule of nines significantly overestimates TBSA and should be avoided, particularly in children 1, 3
• In prehospital settings where Lund-Browder is impractical, use the open hand method (palm plus fingers = 1% TBSA) or serial halving method 1, 2
• Smartphone applications like E-Burn can facilitate accurate assessment 1, 2
• Repeat TBSA assessment during initial management as burn appearance may evolve 3

Immediate Specialist Consultation

Contact a burn specialist urgently to determine whether the patient requires admission to a burn center, as specialist management improves survival, reduces morbidity, and facilitates rehabilitation. 1, 2, 4

When to Seek Specialist Opinion

• All burns requiring hospitalization should trigger specialist consultation 1
• Burns involving critical anatomical areas (face, hands, feet, flexure lines, genitals, perineum) require specialist input regardless of size 1, 2, 4
• Use telemedicine when immediate specialist access is unavailable, as it reliably improves TBSA measurement and prevents both overtriage and undertriage 1, 2, 4
• Telemedicine specifically limits inappropriate transfers, which are associated with increased mortality 1

Burn Center Referral Criteria (Adults)

• TBSA >20% 2
• Deep burns >5% TBSA 2
• Smoke inhalation injury 2
• Deep burns in function-sensitive areas (face, hands, feet, perineum) regardless of size 2
• High-voltage or low-voltage electrical burns 2
• Chemical burns (e.g., hydrofluoric acid) 2
• Age >75 years with any significant burn 2
• Severe comorbidities (including diabetes) with burns 2

Transfer and Admission Strategy

If hospitalization at a burn center is indicated, arrange direct admission rather than sequential transfers, as direct admission reduces time to surgical excision, duration of mechanical ventilation, and overall mortality. 1, 2, 4

• Burns centers provide better survival through concentrated expertise, specialized techniques, and high patient volumes 1, 4
• Early surgical excision and skin grafting at burn centers significantly reduce morbidity, mortality, and hospital length of stay 1, 2, 4
• Consider a transition phase at a nearby institution only if the patient exhibits hemodynamic or respiratory instability and transportation time is long 1

Fluid Resuscitation

Initiate aggressive fluid resuscitation with balanced crystalloid solutions (Ringer lactate) for adults with TBSA ≥15%, administering 20 mL/kg in the first hour. 4, 5

• Use balanced crystalloid solutions (Ringer lactate) rather than normal saline, as they reduce risk of hyperchloremia, metabolic acidosis, and acute kidney injury 4
• Base fluid calculations on accurate TBSA measurements to avoid the fluid overload that occurs in 70-94% of cases due to TBSA overestimation 1, 2, 3
• Titrate fluids to maintain tissue perfusion while avoiding excessive administration 2

Pain Management

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

• Over-the-counter medications (acetaminophen or NSAIDs) are appropriate only for minor burns managed at home 2
• Burn pain requires aggressive management with parenteral analgesics in moderate to severe cases 2

Wound Care

Initial Wound Management

• After cooling, loosely cover the burn with a clean, non-adherent dressing while arranging transfer 2
• Clean the wound with tap water or isotonic saline if transfer to a burn center is delayed 2
• For superficial burns managed at home, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera after cooling 2

Silver Sulfadiazine Application (When Appropriate)

• Apply silver sulfadiazine cream 1% once to twice daily to a thickness of approximately one-sixteenth of an inch under sterile conditions 6
• Cover burn areas with the cream at all times, reapplying to areas from which it has been removed by patient activity 6
• Continue treatment until satisfactory healing occurs or the burn site is ready for grafting 6
• Avoid prolonged use on superficial burns as it may delay healing 2

Emergency Escharotomy

Perform escharotomy emergently if circumferential third-degree burns induce compartment syndrome compromising airways, respiration, or circulation—but ideally perform this procedure at a burn center by an experienced provider. 1, 2, 4

Indications for Escharotomy

• Circumferential third-degree (and sometimes deep second-degree) burns causing compartment syndrome 1
• Acute limb ischemia with neurological disorders and downstream necrosis 1
• Thoracic or abdominal compartment syndrome with decreased cardiac output, pulmonary compliance, hypoxia, hypercapnia, acute renal failure, or mesenteric ischemia 1, 4

Timing and Location

• Rarely indicated immediately; the only urgent indication is compromised airway movement and/or ventilation 1
• Patients with intra-abdominal hypertension or circulatory impairment should undergo escharotomy within 48 hours 1
• Obtain specialist advice before performing escharotomy if rapid transfer to a burn center is impossible 1
• Escharotomy carries risks of hemorrhage and infection, and poorly performed procedures increase morbidity 1

Monitoring for Complications

• Watch for signs of compartment syndrome: blue, purple, or pale extremities indicating poor perfusion 2
• Monitor for infection: increased pain, redness extending beyond burn margins, swelling, or purulent discharge 2
• Assess for inhalation injury, which increases mortality risk non-linearly with transfer time 1

Critical Pitfalls to Avoid

• Do not delay specialist referral for any partial-thickness or full-thickness burn in critical areas, as undertriage increases morbidity and mortality 1, 2
• Do not use the rule of nines for TBSA calculation, as it overestimates in 70-94% of cases 1, 3
• Do not apply butter, oil, or other home remedies to burns 2
• Do not break blisters, as this increases infection risk 2
• Do not use systemic antibiotics prophylactically; reserve for clinically evident infections 2
• Do not perform escharotomy outside a burn center unless absolutely necessary and specialist consultation has been obtained 1