What is the appropriate workup and management for a scald burn?

Workup and Management of Scald Burns

Immediately cool the scald burn with clean running water for 5-20 minutes, accurately assess total body surface area (TBSA) using the Lund-Browder chart, and refer to a burn specialist or burn center for any burn involving hands, feet, face, or genitals, or if TBSA >10% in adults or >5% in children. 1, 2

Initial Assessment and TBSA Measurement

Use the Lund-Browder chart exclusively to measure TBSA in both adults and children—the Wallace rule of nines significantly overestimates burn area in 70-94% of cases and is particularly unsuitable for children. 3, 2 This overestimation leads to excessive fluid administration and associated complications. 3

• In prehospital settings where the Lund-Browder method is impractical, use the patient's palm plus fingers (approximately 1% TBSA) or the serial halving method. 2, 4
• Smartphone applications like E-Burn can facilitate accurate TBSA assessment. 3, 2
• Repeat TBSA assessment during initial management to prevent both overtriage (which wastes resources) and undertriage (which increases morbidity and mortality). 3

Immediate First Aid Management

• Cool the scald burn immediately with clean running water for 5-20 minutes to limit tissue damage and reduce pain, which decreases the need for subsequent care. 1
• Monitor children closely for signs of hypothermia during active cooling, particularly with larger burns. 1, 2
• If clean running water is unavailable, cooling superficial burns with ice wrapped in cloth may be reasonable, but never apply ice directly to the burn. 1
• Remove jewelry before onset of swelling to prevent constriction and vascular ischemia. 2

Burn Severity Classification and Referral Criteria

Adults - Mandatory Burn Center Referral:

• TBSA >20% OR deep burns >5% 3
• Presence of smoke inhalation 3
• Deep burns in function-sensitive areas (face, hands, feet, perineum) regardless of size 3, 1
• Age >75 years with TBSA <20% 3
• Severe comorbidities with TBSA <20% 3
• TBSA >10% 3
• Deep burns 3-5% TBSA 3
• Circular burns 3

Children - Mandatory Burn Center Referral:

• TBSA >10% OR deep burns >5% 3
• Infants <1 year of age 3
• Severe comorbidities 3
• Smoke inhalation injuries 3
• Deep burns in function-sensitive areas (face, hands, feet, perineum, flexure lines) 3
• Circular burns 3

Contact a burn specialist immediately to determine need for burn center admission—do not delay this consultation. 1, 2 Use telemedicine when immediate specialist access is unavailable to guide initial management and determine transfer urgency. 1, 2 Transfer patients directly to burn centers rather than sequential transfers, as direct admission improves survival and functional outcomes. 1, 2

Fluid Resuscitation Protocol

Initiation Criteria:

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

Initial Resuscitation:

• Administer 20 mL/kg of Ringer's Lactate within the first hour for burns meeting criteria above. 2, 4
• Calculate 24-hour requirements using Parkland formula: 2-4 mL/kg/%TBSA 2, 4
• Administer half of calculated volume in first 8 hours post-burn, remaining half over next 16 hours 2, 4
• Use Ringer's Lactate, not normal saline—normal saline is associated with higher risk of hyperchloremic metabolic acidosis and acute kidney injury. 2, 4

Monitoring:

• Monitor urine output hourly, targeting 0.5-1 mL/kg/hour as the primary parameter for fluid adjustment. 2, 4
• Monitor arterial lactate concentration for adequacy of resuscitation. 4
• Use advanced hemodynamic monitoring (echocardiography, cardiac output monitoring) in patients with persistent oliguria or hemodynamic instability. 4

Albumin Administration (for severe burns):

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

Pain Management

• Administer titrated intravenous opioids or ketamine for severe burn pain, as scald burn pain is often intense and difficult to control. 1, 2
• Over-the-counter analgesics (acetaminophen or NSAIDs) are appropriate for minor burns. 1, 2

Wound Care

• After cooling, loosely cover the burn with a clean, non-adherent dressing while arranging transfer. 1, 2
• For superficial burns being managed at home, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera after cooling. 1
• Clean the wound with tap water or isotonic saline if transfer to a burn center is delayed. 1

Monitoring for Complications

Compartment Syndrome:

• Watch for signs of compartment syndrome: blue, purple, or pale extremities indicating poor perfusion. 1, 2
• Perform escharotomy emergently if deep circumferential burns compromise circulation, respiration, or airway movement. 1, 2
• Ideally perform escharotomy at a burn center by an experienced provider. 1

Infection:

• Monitor for signs of infection including increased pain, redness extending beyond burn margins, swelling, or purulent discharge. 1
• Do not use systemic antibiotics prophylactically; reserve for clinically evident infections. 1

Critical Pitfalls to Avoid

• Never delay specialist referral for any partial-thickness or full-thickness scald burn involving hands, feet, face, or genitals—this leads to permanent functional impairment. 1, 2
• Never use the Wallace rule of nines for TBSA calculation—it causes systematic overestimation and fluid overload. 3, 2
• Never break blisters—this increases infection risk. 1, 2
• Never apply butter, oil, or other home remedies to burns. 1, 2
• Never use normal saline as primary resuscitation fluid—use Ringer's Lactate. 2, 4
• Avoid "fluid creep" (excessive fluid administration) as it can lead to complications including compartment syndrome. 4
• Avoid prolonged use of silver sulfadiazine on superficial burns as it may delay healing. 1