What is the initial management for a patient with burns?

Initial Management of Burns

The immediate management of burn patients begins with cooling the burn with clean running water for 5-20 minutes (avoiding hypothermia in children), followed by aggressive fluid resuscitation using the Parkland formula for burns ≥10% TBSA in adults or ≥5% TBSA in children, while simultaneously providing titrated intravenous opioids or ketamine for pain control. 1, 2

Primary Survey and Airway Assessment

Airway management takes absolute priority in burn patients, as burned tissue swells rapidly and can compromise the airway within hours 2:

• Assess immediately for inhalation injury by examining for facial burns, singed nasal hairs, soot around nose/mouth, difficulty breathing, or altered consciousness 2
• Administer 100% oxygen via high-concentration mask or mechanical ventilation for 6-12 hours in suspected inhalation injury 2
• Consider early endotracheal intubation if airway compromise is actual or impending, as delay can make intubation impossible 2
• Children with CO intoxication exhibiting impaired consciousness and/or neurological, cardiac, respiratory, or psychological symptoms should receive hyperbaric oxygen therapy (HBOT) regardless of carboxyhaemoglobin level 1

Immediate Wound Cooling

Cool burns immediately with clean running water for 5-20 minutes to limit tissue damage, reduce pain, and decrease need for subsequent care 3, 2:

• For adults: Cool burns with TBSA <20% in absence of shock 1
• For children: Cool burns with TBSA <10% in absence of shock, but monitor closely for hypothermia 1, 3
• Cooling duration: Less than 40 minutes significantly reduces need for skin grafting 1
• Never apply ice directly to burns; if clean water unavailable, ice wrapped in cloth may be reasonable for superficial burns only 3
• Stop cooling immediately if patient develops hypothermia or shock 1

Burn Assessment and Classification

Use the Lund-Browder chart, not the Rule of Nines, for measuring total body surface area (TBSA) in both adults and children, as the Rule of Nines overestimates TBSA in 70-94% of cases leading to dangerous fluid overload 3, 4:

• Reassess TBSA during initial management to prevent overtriage and undertriage 4
• In prehospital settings: Use serial halving method or palm method (open hand = 1% TBSA) 3, 4
• Classify burn depth: Superficial, partial-thickness (second-degree), or full-thickness (third-degree) 4

Fluid Resuscitation Protocol

Initiate aggressive fluid resuscitation immediately for burns meeting threshold criteria 2, 4:

Thresholds for IV Fluid Resuscitation:

• Adults: TBSA ≥10-15% 2, 4
• Children: TBSA ≥5-10% 2, 4

Initial Bolus:

• Administer 20 mL/kg of Ringer's Lactate (preferred over normal saline) within the first hour 2, 4
• Ringer's Lactate is superior to normal saline as it prevents hyperchloremic metabolic acidosis and acute kidney injury 4

24-Hour Fluid Calculation (Parkland Formula):

• Adults: 2-4 mL/kg/%TBSA burned 2, 4
• Children: Approximately 6 mL/kg/%TBSA due to higher surface area-to-weight ratio 4
• Administer half of calculated 24-hour volume in first 8 hours post-burn, remaining half over next 16 hours 4

Monitoring Targets:

• Urine output: 0.5-1 mL/kg/hour in adults 1, 4
• Adjust fluid rates hourly based on urine output 4
• Monitor arterial lactate for adequacy of resuscitation 2, 4
• Use advanced hemodynamic monitoring (echocardiography, cardiac output monitoring) in patients with persistent oliguria or hemodynamic instability 2, 4

Albumin Administration:

• For burns >30% TBSA: Initiate 5% human albumin between 6-12 hours post-burn to reduce crystalloid volumes and prevent complications 2, 4
• Target serum albumin >30 g/L with doses of 1-2 g/kg/day 4
• Albumin reduces mortality (OR=0.34, P<0.001) and abdominal compartment syndrome from 15.4% to 2.8% 4

Pain Management

Provide titrated intravenous opioids or ketamine for severe burn pain, as burn pain is often intense and difficult to control 1, 2:

• Multimodal analgesia should be used with all medications titrated based on validated comfort and analgesia assessment scales 1
• Titrated IV ketamine can be combined with other analgesics to treat severe burn-induced pain and limit morphine consumption 1
• Short-acting opioids and ketamine are the best drugs for burn-induced pain 1
• Inhaled nitrous oxide can be useful when no IV access is available 1
• For highly painful procedures: General anaesthesia is an effective option 1
• Non-pharmacological techniques (virtual reality, hypnosis) may reduce pain intensity and anxiety in stable patients 1

Wound Care and Dressing

Wound care is not a priority and should be performed only after well-conducted resuscitation 1:

• After cooling: Loosely cover burn with clean, non-adherent dressing while arranging transfer 3
• If transfer delayed: Clean wound with tap water or isotonic saline 1, 3
• For superficial burns managed at home: Apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera after cooling 3
• Burn wound dressings reduce pain, protect from contamination, and limit heat loss 1
• Consult burn specialist to define appropriate dressing and whether blisters should be flattened or excised 1
• Never apply butter, oil, or other home remedies 3
• Do not break blisters as this increases infection risk 3

Silver Sulfadiazine Application (if appropriate):

• Apply once to twice daily to thickness of approximately 1/16 inch under sterile conditions 5
• Cover burn areas at all times with cream; reapply to areas removed by patient activity 5
• Continue treatment until satisfactory healing or burn site ready for grafting 5
• Avoid prolonged use on superficial burns as it may delay healing 3

Antibiotic Prophylaxis

Do not administer routine antibiotic prophylaxis to burn patients 1:

• Systemic antibiotic prophylaxis does not reduce infection risk and increases selection of multidrug-resistant bacteria 1
• Reserve antibiotics for clinically evident infections only 1, 3

Monitoring for Compartment Syndrome

Monitor for compartment syndrome in circumferential burns, which can lead to acute limb ischemia or thoracic/abdominal compartment syndrome 3, 2, 4:

• Signs include: Blue, purple, or pale extremities indicating poor perfusion 3, 2
• Evaluate for circumferential chest burns that may restrict respiratory excursion 2
• Perform escharotomy emergently if deep circumferential burns induce compartment syndrome compromising circulation or respiration 3, 2, 4
• Ideally perform at burn center by experienced provider within 48 hours if circulatory impairment develops 3, 4

Specialist Consultation and Transfer Criteria

Contact a burn specialist immediately to determine need for burn center admission, as specialist management improves survival, reduces complications, and facilitates rehabilitation 3, 2, 4:

Adult Referral Criteria:

• TBSA >10-20% 3, 2, 4
• Deep burns >5% TBSA 3
• Burns involving face, hands, feet, genitals, perineum, or flexure lines regardless of size 3, 2, 4
• Smoke inhalation injury 3
• Electrical or chemical burns 3
• Age >75 years with any significant burn 3
• Severe comorbidities (diabetes mellitus) 3

Pediatric Referral Criteria:

• TBSA >10% 3
• Deep burns >5% TBSA 3
• Infants <1 year of age 3
• Any electrical or chemical burn 3
• Circular burns 3
• Burns involving face, hands, feet, genitals, or perineum 3

Transfer Considerations:

• Transfer directly to burn center rather than sequential transfers, as direct admission improves survival and functional outcomes 3, 4
• Use telemedicine for initial assessment when immediate specialist access unavailable 3, 4

Nutritional Support

Start nutritional support within 12 hours after burn injury, preferring oral or enteral routes over parenteral 1:

• Early nutrition (within 6-12 hours) attenuates neuro-hormonal stress response, increases immunoglobulin production, and reduces stress ulcer incidence 1
• Protein requirements: 1.5-2 g/kg/day for adults, up to 3 g/kg/day for children 1
• Glutamine supplementation reduces gram-negative bacteremia, shortens hospital stay, and decreases mortality 1
• Micronutrient supplementation (copper, zinc, selenium, vitamins B, C, D, E) should be given early 1

Thromboprophylaxis

Routinely prescribe thromboprophylaxis for severe burn patients in the initial phase 1

Critical Pitfalls to Avoid

• Never delay specialist referral for partial-thickness or full-thickness hand burns or burns meeting transfer criteria, as undertriage increases morbidity and mortality 3
• Avoid "fluid creep" (excessive fluid administration) as it leads to compartment syndrome, ARDS, and acute kidney injury 2, 4
• Do not use normal saline as primary resuscitation fluid due to hyperchloremic acidosis risk 4
• Never delay escharotomy when indicated, as poorly timed escharotomy increases morbidity 4
• Do not use external cooling devices (e.g., Water-Jel dressings) for prolonged periods during transport to prevent hypothermia 1
• Do not underestimate fluid requirements in electrical burns, which cause deeper tissue damage than apparent 4