How should I assess and treat an adult burn, including fluid resuscitation, analgesia, wound care, tetanus prophylaxis, and criteria for specialist referral?

Adult Burn Assessment and Management

Initial Assessment and TBSA Calculation

Use the Lund-Browder chart as the standardized method for measuring total body surface area (TBSA) in both adults and children, as it is the most accurate method and prevents the 70-94% overestimation that occurs with the Wallace rule of nines. 1

• The Wallace rule of nines significantly overestimates TBSA and leads to excessive fluid administration during acute resuscitation 1, 2
• In prehospital settings or when the Lund-Browder method is impractical, use the serial halving method or the open hand method (palm plus fingers = 1% TBSA) 1, 2
• Smartphone applications like EasyTBSA can facilitate accurate TBSA assessment 1

Immediate First Aid Management

Cool the burn immediately with clean running water for 5-20 minutes to limit tissue damage and reduce pain. 1

• 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
• Cool burns in adults with TBSA <20% and children with TBSA <10% in the absence of shock 3
• Monitor children closely for signs of hypothermia during active cooling, particularly with larger burns 1
• Remove jewelry from the affected area before edema occurs to prevent constriction 2

Wound Care

After cooling, clean the wound with tap water or isotonic saline, then apply a thin layer of petrolatum-based antibiotic ointment and cover with a clean, non-adherent dressing. 1, 2

• Do not break blisters, as this increases infection risk 1, 2
• Petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera may be applied after cooling for superficial burns 1
• Avoid prolonged use of silver sulfadiazine on superficial burns as it may delay healing 1, 2
• Do not apply butter, oil, or other home remedies to burns 1, 2
• Do not use systemic antibiotics prophylactically; reserve for clinically evident infections 1

Pain Management

Administer multimodal analgesia with all medications titrated based on validated pain assessment scales, combining titrated intravenous ketamine with short-acting opioids for severe burn-induced pain. 3, 4, 2

• For severe burn pain during wound care and dressing changes, administer ketamine at an initial dose of 1-2 mg/kg IV over 60 seconds, combined with a benzodiazepine and short-acting opioids as needed 4
• Continuous monitoring is required, including ECG, pulse oximetry, and blood pressure every 5 minutes during initial infusion, with emergency airway equipment immediately available 4
• Do not use ketamine within 4 hours of nerve blocks, fascial plane blocks, or local anesthetic infiltration 4
• For less severe pain, administer over-the-counter pain medications such as acetaminophen or NSAIDs 1
• Inhaled nitrous oxide is useful when IV access is unavailable 3, 4
• For highly painful injuries or extensive procedures, general anesthesia may be more appropriate 3, 4
• Avoid alpha-2 receptor agonists (such as dexmedetomidine) in the acute phase due to hemodynamic effects 3, 4

Fluid Resuscitation

Initiate aggressive fluid resuscitation with lactated Ringer's solution at 4 mL/kg/% TBSA based on accurate TBSA calculations to maintain tissue perfusion, but avoid fluid overload that commonly results from TBSA overestimation. 1, 5

• TBSA overestimation in 70-94% of cases leads to excessive fluid administration 1
• After the acute phase (48 hours), replacement of evaporative and hypermetabolic fluid loss is necessary, which may constitute 3-5 liters per day for a 40-70% TBSA burn 5

Tetanus Prophylaxis

For patients with unknown tetanus immunization status or fewer than three doses, administer tetanus and diphtheria toxoids (Td) 0.5 mL intramuscularly plus Tetanus Immune Globulin (TIG) for all wounds except clean, minor burns. 6

• For patients with three or more doses of tetanus toxoid: administer Td if >10 years since last dose for clean, minor wounds, or if >5 years since last dose for all other wounds 6
• Administer Td intramuscularly in the deltoid muscle; do not inject into the gluteal area or areas where there may be a major nerve trunk 6
• When indicated, TIG should be administered at a separate site, with a separate needle and syringe 6

Criteria for Specialist Referral and Burn Center Transfer

Contact a burn specialist immediately to determine whether the patient requires admission to a burn center, as specialist management improves survival, reduces complications, and facilitates rehabilitation. 1

Adult Referral Criteria:

• TBSA burned >20% 1
• Deep burns >5% TBSA 1
• Burns involving face, hands, feet, perineum, or major joints regardless of size 1, 7
• Smoke inhalation injury 1
• High-voltage or low-voltage electrical burns 1
• Chemical burns (such as hydrofluoric acid) 1
• Age >75 years with any significant burn 1
• Severe comorbidities (including diabetes mellitus) with burns 1
• Circumferential burns 1

Pediatric Referral Criteria:

• TBSA >10% 1
• Deep burns >5% TBSA 1
• Infants <1 year of age with any burn 1
• Burns involving face, hands, feet, perineum, or major joints 1
• Any electrical or chemical burn 1
• Smoke inhalation injuries 1
• Circumferential burns 1
• Severe comorbidities 1

Transfer Considerations:

• Transfer patients directly to burn centers rather than sequential transfers, as direct admission improves survival and functional outcomes 1
• Use telemedicine for initial assessment when immediate specialist access is unavailable 1
• Do not delay referral for any partial-thickness or full-thickness hand burn, as this leads to permanent functional impairment 1

Emergency Escharotomy

Perform escharotomy emergently if deep burns induce compartment syndrome in limbs or trunk that compromises airways, respiration, or circulation. 1

• Watch for signs of compartment syndrome including blue, purple, or pale extremities, which indicate poor perfusion 1
• Ideally perform escharotomy in a burn center by an experienced provider 1

Critical Pitfalls to Avoid

• Do not use the Wallace rule of nines for TBSA estimation, as it overestimates in 70-94% of cases 1
• Do not delay specialist consultation for burns meeting referral criteria 1
• Do not use systemic antibiotics prophylactically 1
• Do not apply ice directly to burns 1
• Do not break blisters 1, 2
• Do not use prolonged silver sulfadiazine on superficial burns 1, 2
• Do not cool burns for prolonged periods in children due to hypothermia risk 1