What is the appropriate treatment for a patient with a burn?

Burn Treatment

Immediately cool the burn with clean running water for 5-20 minutes, then apply appropriate topical therapy and dressings based on burn depth, with pain management titrated to patient comfort. 1, 2

Immediate First Aid (Critical First Step)

Cool the burn immediately with clean running water for 5-20 minutes to limit tissue progression and reduce pain 1, 2, 3. This intervention has been shown to reduce the need for skin grafting by approximately 32% when applied promptly 4. The cooling window is critical—benefits are maximized when cooling occurs within the first 8-40 minutes after injury 5.

Key cooling parameters:

• Adults with <20% total body surface area (TBSA) burns should receive cooling 5, 1
• Children with <10% TBSA burns should receive cooling 5, 1
• Do not cool if the patient is in shock 5, 1
• Monitor children closely for hypothermia during cooling, especially with larger burns 1, 2
• Never apply ice directly to burns—this causes additional tissue damage 1, 3

Remove jewelry immediately before swelling occurs to prevent constriction and vascular ischemia 1, 2, 3.

Treatment Based on Burn Depth

Superficial (First-Degree) Burns

After cooling:

• Apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera 1, 2, 3
• Cover with a clean, non-adherent dressing 1, 2
• Administer acetaminophen or NSAIDs for pain control 1, 2, 3

Partial-Thickness (Second-Degree) Burns

After cooling:

• Clean the wound with tap water, isotonic saline, or antiseptic solution 5, 1, 3
• Leave blisters intact—the epidermis acts as a biological dressing 3
• Apply a thin layer of petrolatum-based antibiotic ointment (triple antibiotic containing bacitracin, neomycin, and polymyxin B) 1, 3
• Cover with non-adherent dressing such as Xeroform, Mepitel, or Allevyn 1
• Avoid prolonged use of silver sulfadiazine on superficial burns—it is associated with delayed healing 5, 1

Full-Thickness (Third-Degree) Burns

After cooling:

• Cover with clean, dry, non-adherent dressing 1
• All full-thickness burns require immediate medical attention 1
• Silver sulfadiazine 1% cream applied once to twice daily (approximately 1/16 inch thickness) is indicated for prevention and treatment of wound sepsis in second and third-degree burns 6

Pain Management Algorithm

Use multimodal analgesia titrated to validated pain scales 5, 1:

1. For mild to moderate pain: Acetaminophen or NSAIDs 1, 2, 3
2. For severe burn-induced pain: Short-acting opioids combined with titrated intravenous ketamine 5, 1
3. For dressing changes: Inhaled nitrous oxide when IV access unavailable 5
4. For highly painful procedures: General anesthesia 5, 1

Non-pharmacological techniques (virtual reality, hypnosis) should be combined with analgesics when the patient is stable 5.

Wound Care Principles

Perform wound care in a clean environment after adequate resuscitation, often requiring deep analgesia or general anesthesia 5, 1:

• Dressing type depends on TBSA, wound appearance, and patient condition 5, 1
• Reevaluate dressings daily 1, 3
• When applying limb dressings, prevent tourniquet effect and monitor distal perfusion 1
• Apply topical antimicrobials only to areas with necrotic tissue, not the entire burn surface 3
• Do not use routine antibiotic prophylaxis 1

Fluid Resuscitation for Extensive Burns

For adults with ≥20% TBSA burns or children with ≥10% TBSA burns:

• Administer 20 mL/kg of crystalloid solution IV within the first hour 3
• Use balanced crystalloid solutions, preferably Lactated Ringer's 3

Critical Pitfalls to Avoid

• Never apply ice directly—causes further tissue damage 1, 3
• Never apply butter, oil, or home remedies 1, 3
• Do not break blisters—increases infection risk 1, 3
• Avoid prolonged external cooling devices (e.g., Water-Jel dressings) to prevent hypothermia 1
• Do not use silver sulfadiazine long-term on superficial burns—delays healing 5, 1

Mandatory Immediate Medical Referral

Seek immediate medical care for:

• Burns involving face, hands, feet, or genitals 1, 2, 3
• Partial-thickness burns >10% TBSA in adults (>5% in children) 1, 2
• All full-thickness burns 1
• Signs of inhalation injury (soot around nose/mouth, difficulty breathing, singed nasal hairs) 1, 2, 3
• Signs of infection (increased pain, redness, swelling, discharge) 1, 3