What is the optimal management approach for a patient with severe burns?

Optimal Management of Severe Burns

For severe burns, immediately cool the wound with running water for 5-20 minutes, accurately measure TBSA using the Lund-Browder chart (not the rule of nines), contact a burn specialist urgently for direct transfer to a burn center, initiate aggressive fluid resuscitation with balanced crystalloids (Ringer's lactate) at 20 mL/kg in the first hour for TBSA ≥15%, and provide titrated IV opioids or ketamine for pain control. 1, 2

Immediate First Aid and Cooling

• Cool the burn immediately with clean running water for 5-20 minutes to limit tissue damage and reduce pain 1, 2
• Monitor children closely for hypothermia during cooling, particularly with larger burns 1
• Never apply ice directly to burns; if running water is unavailable, ice wrapped in cloth may be used for superficial burns only 1

Accurate TBSA Assessment

• Use the Lund-Browder chart exclusively for TBSA measurement in both adults and children, as it is the most accurate method available 1, 2
• The Wallace rule of nines overestimates TBSA in 70-94% of cases, leading to excessive fluid administration and complications 1, 2
• In prehospital or mass casualty settings where Lund-Browder is impractical, use the serial halving method or open hand method (palm plus fingers = 1% TBSA) 1
• Smartphone applications like E-Burn can facilitate accurate assessment 1

Immediate Specialist Consultation and Transfer Strategy

• Contact a burn specialist immediately upon identifying a severe burn to determine need for burn center admission 1, 2
• Use telemedicine for initial assessment when immediate specialist access is unavailable 1, 2
• Arrange direct admission to a burn center rather than sequential transfers, as this reduces time to surgical excision, duration of mechanical ventilation, and overall mortality 2
• Burn centers provide superior survival through concentrated expertise, specialized surgical techniques, and high patient volumes 2

Mandatory Burn Center Referral Criteria:

Adults:

• TBSA >20% 1
• Deep burns >5% TBSA 1
• Smoke inhalation injury 1
• Deep burns in function-sensitive areas (face, hands, feet, perineum) regardless of size 1
• High-voltage or low-voltage electrical burns 1
• Chemical burns (e.g., hydrofluoric acid) 1
• Age >75 years with TBSA <20% 1
• Severe comorbidities (diabetes mellitus) with TBSA <20% 1

Pediatric:

• TBSA >10% 1
• Deep burns >5% TBSA 1
• Infants <1 year of age with any burn 1
• Any electrical or chemical burn 1
• Circular burns 1
• Smoke inhalation 1

Fluid Resuscitation Protocol

• Initiate aggressive fluid resuscitation with balanced crystalloid solutions (Ringer's lactate) for adults with TBSA ≥15%, administering 20 mL/kg in the first hour 2
• Use balanced crystalloids (Ringer's lactate) rather than normal saline to reduce risk of hyperchloremia, metabolic acidosis, and acute kidney injury 2
• Base fluid calculations on accurate TBSA from Lund-Browder chart to avoid the fluid overload that occurs from TBSA overestimation 1, 2

Pain Management

• Administer titrated intravenous opioids or ketamine for severe burn pain, as burn pain is intense and difficult to control 1, 2
• Over-the-counter medications (acetaminophen or NSAIDs) are appropriate only for minor burns managed at home 1, 2
• Burn pain requires aggressive management with parenteral analgesics in moderate to severe cases 2

Wound Care During Initial Management

• After cooling, loosely cover the burn with a clean, non-adherent dressing while arranging immediate transfer 1, 2
• Clean the wound with tap water or isotonic saline if transfer to a burn center is delayed 1, 2
• For superficial burns managed at home, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera after cooling 1, 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 3
• Reapply immediately after hydrotherapy and to any areas from which it has been removed 3
• Continue treatment until satisfactory healing occurs or the burn site is ready for grafting 3
• Avoid prolonged use on superficial burns as it may delay healing 1

Emergency Escharotomy

• Perform escharotomy emergently if circumferential third-degree burns (and sometimes deep second-degree burns) induce compartment syndrome compromising airways, respiration, or circulation 1, 2
• Ideally perform at a burn center by an experienced provider 1, 2
• Indications include: acute limb ischemia with neurological disorders and downstream necrosis, thoracic or abdominal compartment syndrome with decreased cardiac output, pulmonary compliance issues, hypoxia, hypercapnia, acute renal failure, or mesenteric ischemia 2

Monitoring for Complications

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

Critical Pitfalls to Avoid

• Never 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, 2
• Do not apply butter, oil, or other home remedies to burns 1, 2
• Do not break blisters, as this increases infection risk 1
• Do not use systemic antibiotics prophylactically; reserve for clinically evident infections 1

Risk Stratification

• Calculate the revised Baux score after accurate TBSA assessment to objectively quantify injury severity and facilitate resource allocation 4
• Use the score to determine which patients require specialist consultation and potential transfer to burn centers 4
• Recalculate as needed during initial management as burn appearance may evolve 4