What is the management approach for an adult patient with no significant medical history and an anterior abdominal wall burn wound?

Management of Anterior Abdominal Wall Burn Wounds

For an adult with an anterior abdominal wall burn, immediately cool the wound with clean running water (15-25°C) for 5-40 minutes if the total body surface area (TBSA) is <20%, provide aggressive pain control with titrated opioids and ketamine, clean the wound thoroughly, apply a moist dressing (petrolatum-based ointment or antibiotic cream), and refer to a burn center if the burn is >10% TBSA or full-thickness. 1, 2

Immediate Cooling and First Aid

• Cool the burn with clean running water (15-25°C) for 5-40 minutes as soon as possible to limit burn depth and reduce the need for skin grafting, but only if TBSA is <20% in adults. 1, 2
• Cooling is effective for up to 3 hours after injury and significantly reduces the need for skin grafting when performed for 20-40 minutes. 1
• Do not cool burns if the patient shows signs of shock or if TBSA exceeds 20%, as this increases the risk of hypothermia. 1, 2
• Remove all contaminated clothing immediately to prevent continued injury. 2
• Never apply ice directly to burns, as this causes tissue ischemia and additional damage. 1, 2, 3

Pain Management

• Provide titrated intravenous opioids and ketamine for severe burn-induced pain, using validated pain assessment scales to guide dosing. 4, 1
• Short-acting opioids and ketamine are the most effective drugs for burn-induced pain, with ketamine particularly useful for limiting morphine consumption. 4, 1
• Inhaled nitrous oxide can be used when intravenous access is unavailable. 4, 1
• For highly painful injuries or procedures, general anesthesia is an effective option. 4
• Non-pharmacological treatments such as covering burns with appropriate dressings may improve pain control. 4, 1

Wound Cleaning and Assessment

• Clean the burn wound in a clean environment with tap water, isotonic saline, or an antiseptic solution after proper pain control is established. 1, 2, 3
• Thorough irrigation is essential to remove foreign matter and debris. 1
• Wound care should be performed only after proper resuscitation in severe burns. 4, 1
• Assess burn depth, size (using the Lund-Browder chart for accurate TBSA measurement), and location to determine appropriate management. 1, 3

Wound Dressing Application

• Apply a moist dressing such as petrolatum-based ointment, petrolatum-based antibiotic ointment, medical-grade honey, or aloe vera with a clean nonadherent dressing. 1, 3
• Moist dressings significantly reduce complications including hypertrophic scarring compared to dry dressings. 1
• If using silver sulfadiazine cream, apply to a thickness of approximately 1/16 inch once to twice daily, but avoid prolonged use on superficial burns as it may delay healing. 1, 5
• Dressing selection should be based on TBSA, local wound appearance, and the patient's general condition. 1, 3
• Cover wounds to reduce pain, protect from external contamination, and limit heat loss. 1
• Reapply dressings immediately after hydrotherapy or whenever removed by patient activity. 5

Infection Prevention

• Topical antibiotics should not be used as first-line treatment but reserved for infected wounds only to prevent antimicrobial resistance. 1, 2, 3
• Systemic antibiotic prophylaxis should not be administered routinely to burn patients. 1
• Monitor for signs of infection including increasing pain, redness, swelling, or purulent discharge. 1, 2
• Burn wounds are sterile immediately following thermal injury but can be rapidly colonized by Gram-positive bacteria from endogenous skin flora, followed by Gram-negative bacteria within a week. 4
• Burn wound infections are typically polymicrobial and require appropriate antibiotic selection based on bacterial cultures, with dosing adjusted for altered pharmacokinetics in burn patients. 4

Burn Center Referral Criteria

• Refer to a burn center or emergency department if the burn covers >10% TBSA in adults or >5% in children. 1, 2, 3
• Refer all full-thickness (third-degree) burns regardless of size. 1, 2, 3
• Burns involving the face, hands, feet, genitals, or perineum require specialized burn center treatment. 1, 2, 3
• Refer burns to flexure lines, circular burns causing compartment syndrome, or any signs of respiratory involvement. 1
• Contact a burn specialist immediately to determine severity, guide fluid resuscitation, and decide on transfer, as specialist management is associated with better survival, reduced complications, shorter hospital stays, and lower costs. 1

Additional Supportive Care

• Initiate nutritional support within 12 hours after burn injury, preferably via oral or enteral routes. 1
• Routinely prescribe thromboprophylaxis for severe burn patients in the initial phase. 1
• Consider supplementation with trace elements (copper, zinc, selenium) and vitamins (B, C, D, E). 1
• Continue treatment until satisfactory healing has occurred or until the burn site is ready for grafting. 5

Critical Pitfalls to Avoid

• Do not use external cooling devices (e.g., Water-Jel dressings) for prolonged periods due to risk of hypothermia. 1
• Do not apply butter, oil, or other home remedies as they increase infection risk and delay healing. 3
• Do not break blisters, as this increases infection risk. 3
• Do not delay wound care in favor of imaging studies unless there is concern for deeper structural injury requiring surgical exploration. 4
• Avoid routine use of topical antibiotics for uninfected wounds to prevent antimicrobial resistance. 1, 2, 3