What is the recommended management for an adult with a thermal burn, including airway assessment, fluid resuscitation, analgesia, tetanus prophylaxis, wound care, antibiotics, nutrition, and grafting?

Management of Thermal Burns in Adults

Initial Assessment and Airway Management

Immediately assess for inhalation injury by examining for circumoral burns, oropharyngeal burns, and carbonaceous sputum, as these findings significantly increase mortality and require early intubation. 1

• Secure the airway early if inhalation injury is suspected—do not wait for respiratory distress to develop 1
• Look specifically for singed nasal hairs, facial burns, and hoarseness as additional indicators of airway compromise 2
• Consider fiberoptic bronchoscopy to confirm inhalation injury when clinical signs are present 3

Burn Assessment and Classification

Use the Lund-Browder chart, not the Rule of Nines, as the Rule of Nines overestimates TBSA in 70-94% of cases, leading to dangerous fluid over-administration. 4

• The Lund-Browder chart is the gold standard for measuring total body surface area (TBSA) burned 1, 4
• For rapid field assessment, use the patient's palm and fingers (approximately 1% TBSA) 1, 4
• Reassess TBSA during initial management to prevent both overtriage and undertriage 4
• Classify burns by depth: superficial, partial-thickness (superficial or deep), and full-thickness 4

Criteria Requiring Specialist Consultation

• Burns ≥10% TBSA in adults or ≥5% TBSA in children 4, 5
• Burns involving face, hands, feet, genitals, perineum, or flexure lines regardless of size 1, 4
• Full-thickness burns or circumferential burns 4
• Chemical or electrical burns 6
• Inhalation injury 1

Contact a burn specialist immediately and arrange direct transfer to a burn center when indicated—avoid intermediate stops, as direct admission improves survival and reduces complications. 1, 4

Fluid Resuscitation

Administer 20 mL/kg of Ringer's Lactate or Hartmann's solution intravenously within the first hour, regardless of precise burn size assessment. 4, 7

Parkland Formula for Adults (Burns ≥10% TBSA)

• Calculate 24-hour fluid requirement: 2-4 mL/kg × weight (kg) × %TBSA 4, 7, 5
• Use the upper end (4 mL/kg) for full-thickness burns or inhalation injury 7
• Administer 50% of calculated volume in first 8 hours from time of injury (not from time of presentation) 4, 7
• Administer remaining 50% over next 16 hours 4, 7

Fluid Choice

Use Ringer's Lactate or Hartmann's solution as first-line crystalloid—never use normal saline as primary resuscitation fluid, as it increases risk of hyperchloremic metabolic acidosis and acute kidney injury. 4, 7

Monitoring and Adjustment

• Target urine output: 0.5-1 mL/kg/hour 4, 7, 5
• Adjust fluid rates hourly based on urine output—this is the simplest and most reliable parameter 4, 7, 5
• Monitor arterial lactate concentration for adequacy of resuscitation 4, 5
• Use advanced hemodynamic monitoring (echocardiography, cardiac output monitoring, central venous pressure) if oliguria or hemodynamic instability persists despite adequate fluid administration 4, 5

Albumin Supplementation for Large Burns

For burns >30% TBSA, initiate 5% human albumin at 8-12 hours post-burn to reduce crystalloid volumes and prevent "fluid creep." 4, 7

• Target serum albumin levels >30 g/L with doses of 1-2 g/kg/day 4, 7
• Albumin reduces mortality (OR=0.34, P<0.001) and abdominal compartment syndrome from 15.4% to 2.8% 4
• Never use hydroxyethyl starches (HES)—they are contraindicated in burn patients 4, 7

Critical Pitfall: Avoiding "Fluid Creep"

Over-resuscitation occurs in 76% of cases and causes compartment syndrome, pulmonary edema, intestinal edema, and acute kidney injury—stop excessive fluid rates once adequate urine output is achieved. 4, 7

Analgesia

Use short-acting opioids and ketamine for burn-induced pain and dressing changes, as these are most effective for acute, short-lasting burn pain. 1

• Inhaled nitrous oxide is useful when intravenous access is unavailable 1
• General anesthesia is appropriate for highly painful procedures 1
• Avoid alpha-2 receptor agonists in the acute phase due to hemodynamic effects 1

Wound Cooling and Initial Care

Cool burns with TBSA <20% in adults (or <10% in children) for up to 40 minutes if no shock is present, as this reduces burn depth and need for grafting. 1

• Cooling is effective up to 3 hours after injury 6
• Remove external cooling devices before transport to prevent hypothermia 1
• Do not delay other resuscitation interventions for wound cooling 1

Wound Care and Dressings

Perform wound care only after adequate resuscitation—it is not a priority in the acute phase. 1

• Clean wounds with tap water, isotonic saline, or antiseptic solution 1
• Consult burn specialist to determine appropriate dressing type 1
• Avoid silver sulfadiazine for superficial burns, as prolonged use delays healing 1
• Use antiseptic dressings for large or contaminated burns 1
• Reserve topical antibiotics for infected wounds only—not first-line treatment 1
• Monitor distal perfusion with circumferential dressings to prevent tourniquet effect 1
• Re-evaluate dressings daily 1

Escharotomy

Perform escharotomy immediately if deep circumferential burns cause compartment syndrome compromising circulation or respiration—ideally at a burn center by an experienced provider. 1, 4

• Monitor for compartment syndrome in all circumferential third-degree burns 4
• Escharotomy should be performed within 48 hours if circulatory impairment develops 4
• The only urgent indication for immediate escharotomy is compromised airway movement or ventilation 4

Antibiotic Prophylaxis

Do not administer routine antibiotic prophylaxis to burn patients—reserve systemic antibiotics for documented infections only. 1

• Avoid oral antibiotics unless there are signs of infection 6
• Invasive sepsis (>10^5 organisms per gram of tissue with invasion of viable tissue) requires systemic antibiotic therapy 3

Tetanus Prophylaxis

Check tetanus immunization status and provide prophylaxis, as burns are tetanus-prone wounds. 6

Thromboprophylaxis

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

Nutrition

Supplement with copper, zinc, selenium, and vitamins B, C, D, and E, as burn patients have high micronutrient requirements that cannot be covered by enteral nutrition alone. 1

• Initiate early enteral nutrition as soon as feasible 7

Special Considerations

Electrical Burns

• Often cause deeper tissue damage than apparent on surface examination 4
• Require higher fluid volumes than thermal burns of similar surface appearance 4

Persistent Hypotension

• If hypotension persists despite adequate fluid resuscitation, evaluate cardiac function with echocardiography before initiating vasopressors 4, 5

Telemedicine

• Use telemedicine when burn specialists are not readily available to improve TBSA measurement and prevent inappropriate transfers 1