What are the different degrees of burn injuries and their corresponding treatments?

Burn Degrees and Treatment

Burns are classified by depth into superficial (first-degree), partial-thickness (second-degree), and full-thickness (third-degree) injuries, with treatment ranging from simple cooling and dressings for superficial burns to immediate burn center referral and surgical excision/grafting for deep burns.

Burn Classification by Depth

Superficial Burns (First-Degree)

• Involve only the epidermis with intact skin barrier function 1
• Present with erythema, pain, and no blistering 1
• Heal spontaneously without scarring within days 1

Partial-Thickness Burns (Second-Degree)

• Extend into the dermis but preserve some dermal elements necessary for re-epithelialization 1
• Characterized by blistering, severe pain (due to exposed nerve endings), and moist appearance 1, 2
• Superficial partial-thickness burns heal within 2-3 weeks with minimal scarring if properly managed 2
• Deep partial-thickness burns may require skin grafting and carry higher risk of hypertrophic scarring 2

Full-Thickness Burns (Third-Degree)

• Destroy the entire epidermis and dermis, including all skin appendages 1
• Appear white, brown, or charred with a leathery texture 1
• Paradoxically painless due to destruction of nerve endings 1
• Always require surgical excision and skin grafting as they cannot heal by re-epithelialization 1, 2

Treatment Algorithm by Burn Severity

Immediate First Aid (All Burns)

• Cool burns with clean running water for 5-20 minutes to limit tissue damage and reduce pain 3
• For adults: cool only if TBSA <20% and patient is not in shock 4
• For children: cool only if TBSA <10% and patient is not in shock 4
• Cooling for 20-39 minutes significantly reduces need for skin grafting (P<0.001) 4
• Cover with clean, non-adherent dressing after cooling 3

Pain Management

• Administer acetaminophen or NSAIDs for mild to moderate pain 5, 3
• Titrated intravenous ketamine combined with opioids for severe burn pain 4
• Short-acting opioids are preferred for dressing changes 4
• All analgesics must be titrated using validated pain assessment scales 4
• Consider general anesthesia for highly painful procedures 4

Criteria for Burn Center Referral

Adults require burn center referral if ANY of the following:

• TBSA >20% OR deep burns >5% 4
• Smoke inhalation 4
• Deep burns in function-sensitive areas (face, hands, feet, perineum) 4, 5
• High-voltage electrical burns 4, 6
• Chemical burns (e.g., hydrofluoric acid) 4, 5
• Age >75 years with TBSA >10% 4

Children require burn center referral if ANY of the following:

• TBSA >10% OR deep burns >5% 4
• Age <1 year 4
• Any electrical burn automatically qualifies as severe 6, 5
• Burns in function-sensitive areas 4
• Circular burns 4

Wound Care After Resuscitation

• Wound care is NOT a priority until after adequate resuscitation 4
• Clean wounds with tap water, isotonic saline, or antiseptic solution 4
• Avoid prolonged use of silver sulfadiazine on superficial burns as it delays healing 4
• Dressing type depends on TBSA, wound appearance, and patient condition 4
• Ideally consult burn specialist before applying dressings to determine optimal approach 4

Surgical Management

• Early excision and skin grafting (within 48 hours) reduces mortality, ventilator days, and hospital stay 6, 1, 2
• Escharotomy is indicated for circumferential full-thickness burns causing compartment syndrome, compromised circulation, or respiratory compromise 6, 5
• Escharotomy should ideally be performed by experienced providers in burn centers 6
• Irreversible damage occurs within 6-8 hours of compartment syndrome, so do not wait for pulse loss 5

Critical Pitfalls to Avoid

• Never underestimate electrical burns based on visible skin damage alone—internal tissue destruction often exceeds surface appearance 6
• Do not use silver sulfadiazine long-term on superficial burns—it prolongs healing time 4
• Avoid excessive cooling in large burns or shocked patients—this causes hypothermia 4
• Do not delay burn center transfer—direct admission improves survival compared to secondary transfer 6
• Never delay escharotomy when compartment syndrome is suspected—waiting for pulse loss results in irreversible tissue damage 5