What is the appropriate treatment approach for a patient presenting with a burn injury, based on the burn grade?

Burn Grade and Treatment

Burn Classification and Initial Assessment

Burn treatment must be guided by accurate depth classification and total body surface area (TBSA) measurement using the Lund-Browder chart, as this prevents the 70-94% overestimation that occurs with the rule of nines and leads to dangerous fluid overload. 1, 2, 3

Burn Depth Classification

Burns are classified by depth, which determines treatment approach:

• Superficial (First-Degree): Involves epidermis only; managed with cooling, pain control, and topical agents like petrolatum or aloe vera 1, 3
• Partial-Thickness (Second-Degree): Extends into dermis; requires specialist evaluation if >10% TBSA in adults or >5% in children, or if involving critical areas (face, hands, feet, genitals, perineum, flexure lines) 1, 2, 3
• Full-Thickness (Third-Degree): Destroys entire dermis; always requires burn center referral and surgical management 1, 3

TBSA Measurement

• Use the Lund-Browder chart exclusively for accurate TBSA assessment in both adults and children 1, 2, 3
• The rule of nines overestimates TBSA in 70-94% of cases, causing excessive fluid administration and "fluid creep" complications 2, 3
• In prehospital settings, use the open hand method (palm plus fingers = 1% TBSA) or serial halving method only when Lund-Browder is impractical 1

Immediate First Aid Management

Cooling Protocol

Cool burns immediately with clean running water for 5-20 minutes to limit tissue damage and reduce pain. 1, 2, 3

• Apply cooling for adults with TBSA <20% and children with TBSA <10% in the absence of shock 4, 2
• Monitor children closely for hypothermia during cooling, particularly with larger burns 1
• Never apply ice directly to burns; if clean water unavailable, ice wrapped in cloth may be used for superficial burns only 1

Wound Coverage

• After cooling, loosely cover burns with clean, non-adherent dressing while arranging transfer 1, 3
• For superficial burns managed at home, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera after cooling 1, 3
• Clean wounds with tap water or isotonic saline if transfer is delayed 1, 3

Pain Management Algorithm

Burn pain is often intense and difficult to control, requiring aggressive multimodal analgesia with titrated medications based on validated assessment scales. 4

Pain Control by Severity

• Minor superficial burns (outpatient): Over-the-counter acetaminophen or NSAIDs 1, 3
• Moderate to severe burns (requiring hospitalization): Titrated intravenous opioids or ketamine 4, 2, 3
• Procedural pain (dressings): Short-acting opioids, ketamine, or inhaled nitrous oxide when IV access unavailable 4
• Highly painful injuries/procedures: General anesthesia is effective option 4

Multimodal Approach

• Combine titrated IV ketamine with other analgesics to treat severe burn pain and limit morphine consumption 4
• Add non-pharmacological techniques (virtual reality, hypnosis) when patient is stable 4
• Titrate all analgesics based on validated comfort scales to avoid under- and overdosing, as burns trigger hypovolemia increasing adverse drug effects 4

Mandatory Burn Center Referral Criteria

Contact a burn specialist immediately to determine burn center admission, as specialist management improves survival, reduces complications, and prevents permanent functional disability. 1, 2, 3

Adult Referral Criteria (Any of the Following)

• TBSA >10-20% (varies by source, use >10% threshold for safety) 1, 2
• Deep burns >3-5% TBSA 1
• Burns involving face, hands, feet, genitals, perineum, or flexure lines regardless of size or depth 1, 2, 3
• Circumferential burns 1
• Electrical burns (high or low voltage) or chemical burns 1, 2
• Smoke inhalation injury 1, 2
• Age >75 years with any significant burn 1
• Severe comorbidities (diabetes mellitus) 1

Pediatric Referral Criteria (Any of the Following)

• TBSA >5-10% 1, 2
• Deep burns >5% TBSA 1
• Infants <1 year of age with any burn 1
• Burns involving face, hands, feet, genitals, perineum, or flexure lines 1
• Circumferential burns 1
• Any electrical or chemical burn 1
• Smoke inhalation injury 1
• Severe comorbidities 1

Transfer Strategy

• Arrange direct admission to burn center rather than sequential transfers, as direct admission reduces time to surgical excision, duration of mechanical ventilation, and overall mortality 1, 2, 3
• Use telemedicine consultation if immediate specialist access unavailable to guide initial management and determine transfer urgency 1, 2

Fluid Resuscitation Protocol

For adults with TBSA ≥10-15% and children with TBSA ≥5%, initiate aggressive fluid resuscitation with 20 mL/kg balanced crystalloid solution (Ringer's Lactate) within the first hour. 2, 3

• Use Ringer's Lactate as first-line fluid, not normal saline, to reduce risk of hyperchloremic metabolic acidosis and acute kidney injury 2, 3
• Base resuscitation on accurate TBSA calculations using Lund-Browder chart to avoid fluid overload from TBSA overestimation 1, 2, 3

Topical Wound Management

Silver Sulfadiazine Application

• Apply silver sulfadiazine cream 1% to thickness of approximately 1/16 inch once to twice daily under sterile conditions 5
• Reapply immediately after hydrotherapy and to any 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 1

Critical Caveat

• Do not use systemic antibiotics prophylactically; reserve for clinically evident infections 1

Emergency Escharotomy Indications

Perform escharotomy emergently if deep circumferential burns cause compartment syndrome compromising airways, respiration, or circulation. 1, 2, 3

Signs Requiring Immediate Escharotomy

• Blue, purple, or pale extremities indicating poor perfusion 1, 2
• Acute limb ischemia with neurological deficits and downstream necrosis 3
• Thoracic compartment syndrome with decreased cardiac output, pulmonary compliance, hypoxia, hypercapnia 3
• Abdominal compartment syndrome with acute renal failure or mesenteric ischemia 3

Procedure Considerations

• Ideally perform at burn center by experienced provider 1, 3
• Indicated for circumferential third-degree and sometimes deep second-degree burns 3

Monitoring for Complications

Infection Surveillance

• Monitor for increased pain, redness extending beyond burn margins, swelling, or purulent discharge 1, 2
• Do not break blisters, as this increases infection risk 1

Inhalation Injury Assessment

• Check for circumoral burns, oropharyngeal burns, and carbonaceous sputum, as inhalation injury significantly increases mortality 2
• All patients with suspected CO poisoning should receive 100% oxygen via high concentration mask or FiO2 for 6-12 hours if mechanically ventilated 4

Critical Pitfalls to Avoid

• Never delay specialist referral for any partial-thickness or full-thickness burn in critical areas (hands, face, feet, genitals, perineum, flexure lines), as undertriage increases morbidity and mortality 1, 3
• Do not apply butter, oil, or other home remedies to burns 1, 3
• Do not use rule of nines for TBSA calculation due to 70-94% overestimation rate 2, 3
• Do not break blisters 1
• Avoid prophylactic systemic antibiotics 1