What are the guidelines for outpatient management of burns, including treatment and follow-up care for patients with varying severity of burns and underlying medical conditions?

Outpatient Burn Management

Determining Outpatient vs. Referral Eligibility

Most burn injuries can be managed outpatient by primary care physicians, but specific criteria mandate immediate burn center referral to prevent morbidity and mortality. 1

Mandatory Burn Center Referral Criteria

Adults - Refer immediately if ANY of the following: 1, 2

• TBSA >20% or deep burns >5%
• Smoke inhalation injury
• Deep burns in function-sensitive areas (face, hands, feet, perineum)
• High-voltage electrical burns
• Age >75 years with TBSA <20% AND severe comorbidities
• Deep circular burns
• Chemical burns (e.g., hydrofluoric acid)
• TBSA >10% with superficial burns in function-sensitive areas
• Deep burns 3-5% TBSA

Children - Refer immediately if ANY of the following: 1, 2

• TBSA >10% or deep burns >5%
• Age <1 year
• Smoke inhalation injury
• Deep burns in function-sensitive areas
• Any circular burns
• ANY electrical or chemical burn

Critical Pitfall: All hand burns with partial-thickness or full-thickness depth require immediate specialist referral regardless of size, as delayed referral causes permanent functional disability. 2, 3

Accurate Burn Assessment

Use the Lund-Browder chart for TBSA measurement in both adults and children, as the Wallace rule of nines overestimates TBSA in 70-94% of cases, leading to inappropriate fluid administration and overtriage. 1, 3

• Alternative: Use the open hand method (palm plus fingers = 1% TBSA) for quick assessment 1, 3
• Smartphone apps like E-Burn can facilitate accurate assessment 1, 2
• Repeat TBSA assessment during initial management as accuracy improves 3

Immediate First Aid (All Burns)

Cooling Phase

Apply clean running water for 5-20 minutes immediately - this is the single most critical first intervention to limit tissue damage and reduce pain. 2, 3

• Monitor children closely for hypothermia during cooling, especially with larger burns 2, 3
• If clean water unavailable, ice wrapped in cloth may be used for superficial burns only - never apply ice directly 2

Pain Management

Administer acetaminophen or NSAIDs for outpatient-appropriate burns. 2

• For severe burns requiring referral, use titrated IV opioids or ketamine 2, 3

Outpatient Wound Management

Superficial (First-Degree) Burns

Apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera after cooling. 2, 4

• These burns involve only the epidermis and heal with simple first-aid techniques 5
• Over-the-counter pain relievers are sufficient 5

Superficial Partial-Thickness (Second-Degree) Burns

Apply topical antimicrobial agent or absorptive occlusive dressing after cooling and cleaning. 4, 5

• Clean wound with tap water or isotonic saline 2
• Silver sulfadiazine 1% cream applied once to twice daily to thickness of 1/16 inch is the standard treatment 6, 4
• Reapply after hydrotherapy or patient activity removes cream 6
• Continue until satisfactory healing or wound ready for grafting 6
• Critical Pitfall: Avoid prolonged silver sulfadiazine use on superficial burns as it may delay healing 2

Alternative: Newer occlusive dressings provide faster healing and are often more cost-effective than silver sulfadiazine. 4

• These promote moist environment, reduce pain, and prevent wound desiccation 4, 5
• May take up to three weeks to heal 5

Deep Partial-Thickness Burns

Refer immediately to burn surgeon for possible early tangential excision - these burns are NOT appropriate for outpatient management. 5

Full-Thickness (Third-Degree) Burns

Automatic referral to burn center - these involve the entire dermal layer and require specialized surgical care. 5

Critical Management Principles

What NOT to Do

• Do not use prophylactic systemic antibiotics - reserve for clinically evident infections only 2, 7
• Do not apply butter, oil, or other home remedies 2
• Do not break blisters - this increases infection risk 2, 3
• Do not delay specialist referral for any partial-thickness or full-thickness hand burn 2

Monitoring for Complications

Watch for signs requiring immediate referral: 2, 3

• Blue, purple, or pale extremities indicating compartment syndrome
• Increased pain, redness extending beyond burn margins
• Swelling or purulent discharge indicating infection
• Circumferential burns with increasing pressure

Follow-Up Schedule

Reevaluate patients frequently after burn injury to assess healing progress and detect complications early. 4

• Superficial partial-thickness burns: Every 2-3 days initially 5
• Monitor for long-term complications: pruritus, hypertrophic scarring, permanent hyperpigmentation 5

Special Populations

Patients with Diabetes Mellitus

Consider early burn center referral - these patients are at increased risk of complications and infection. 5

Pediatric Patients

• Burns account for 25% of all pediatric hospitalizations 1
• Hot liquids are the most common cause 1
• Lower threshold for referral (TBSA >10% vs. >20% in adults) 1

Geriatric Patients

• Age >75 years with TBSA <20% plus severe comorbidities requires burn center referral 1

Telemedicine Consultation

Use telemedicine to improve initial assessment when immediate specialist access is unavailable, particularly to guide management and determine transfer urgency. 1, 2, 3