What are the appropriate treatment options for burn injuries?

Treatment Options for Burns

Immediately cool all thermal burns with clean running water for 5-20 minutes, then apply petrolatum-based ointment and cover with non-adherent dressing, while monitoring for hypothermia in young children. 1

Immediate First Aid Management

Active cooling is the cornerstone of initial burn treatment and should be performed immediately:

• Apply clean running water to the burn for 5-20 minutes to limit tissue damage and reduce pain 2, 1
• Recent evidence suggests cooling within the first 3 hours post-burn mitigates injury extent, even if delayed beyond the immediate injury period 3
• Remove all jewelry and tight items from the affected area before swelling occurs to prevent vascular compromise 1, 4
• Critical caveat: Monitor young children (especially <4 years) closely for hypothermia during cooling, particularly with larger burns or whole-body cooling 2, 1
• Avoid cooling in patients with shock or burns covering >20% TBSA in adults or >10% TBSA in children 1

Common pitfalls to avoid during first aid:

• Never apply ice directly to burns as this causes further tissue damage 1, 5
• Do not apply butter, oil, or other home remedies 1, 5
• Do not break blisters as this significantly increases infection risk 1, 5
• External cooling devices (e.g., Water-Jel dressings) should not be used for prolonged periods due to hypothermia risk 1

Treatment by Burn Depth

Superficial (First-Degree) Burns

• After cooling, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera 1
• Cover with a clean, non-adherent dressing 1
• Administer acetaminophen or NSAIDs for pain control 1, 5

Partial-Thickness (Second-Degree) Burns

• Clean the wound with tap water, isotonic saline, or antiseptic solution in a clean environment 1, 5
• Apply a thin layer of petrolatum-based antibiotic ointment as first-line treatment 1, 4
• Cover with non-adherent dressing such as Xeroform, Mepitel, or Allevyn 1, 5
• Avoid silver sulfadiazine as first-line therapy as it may prolong healing time and worsen scarring in partial-thickness burns 1, 4
• Re-evaluate dressings daily for optimal monitoring 1, 5

Full-Thickness (Third-Degree) Burns

• After cooling, cover with a clean, dry, non-adherent dressing while awaiting medical care 1
• All full-thickness burns require immediate specialized medical attention 1

Topical Antimicrobial Agents

Silver sulfadiazine (when indicated):

• Apply once to twice daily to a thickness of approximately 1/16 inch 6
• Continue until satisfactory healing occurs or the burn site is ready for grafting 6
• Important limitation: Should not be used as first-line treatment for superficial partial-thickness burns due to prolonged healing times 1
• Reserved for deeper burns or infected wounds 1

Mafenide acetate solution (for grafted areas):

• Reconstitute 50g powder in 1000mL sterile water or normal saline 7
• Keep gauze dressing wet by irrigating every 4 hours or moistening every 6-8 hours 7
• Treatment typically continued for approximately 5 days until autograft vascularization occurs 7
• Monitor for acidosis, particularly in patients with pulmonary dysfunction 7

Pain Management

Use a multimodal approach with titrated medications:

• Start with over-the-counter acetaminophen or NSAIDs for mild to moderate pain 1, 5, 4
• For severe burn-induced pain, use short-acting opioids combined with titrated intravenous ketamine 1
• Titrate all medications based on validated comfort and analgesia assessment scales 1, 4
• For highly painful injuries or procedures, general anesthesia may be necessary 1

Wound Care Principles

Perform all burn wound care in a clean environment:

• Deep analgesia may be required for dressing changes 1
• Select dressing type based on TBSA, local wound appearance, and patient's general condition 1
• When applying dressings on limbs, prevent tourniquet effect and monitor distal perfusion with circular dressings 1
• Do not use routine antibiotic prophylaxis - reserve antibiotics for confirmed infected wounds only 1, 5

Burn Severity Assessment

Use the Lund and Browder method to measure TBSA (suitable for both adults and children): 2

Severe burns requiring specialized care include:

Adults:

• TBSA burned >20%, deep burns >5%, or smoke inhalation 2
• Deep burns in function-sensitive areas (face, hands, feet, perineum) 2
• High-voltage electrical burns 2
• Age >75 years with TBSA <20% plus comorbidities 2

Children:

• TBSA >10%, deep burns >5%, or infants <1 year of age 2
• Smoke inhalation injuries 2
• Deep burns in function-sensitive areas or circular burns 2
• Electrical or chemical burns 2

Mandatory Burn Center Referral Criteria

Immediate specialized burn center evaluation is required for:

• All partial-thickness burns involving the face, hands, feet, or genitals regardless of size 1, 5, 4
• Partial-thickness burns covering >10% body surface area in adults (>5% in children) 1, 4
• All full-thickness (third-degree) burns 1
• Burns with signs of inhalation injury (soot around nose/mouth, difficulty breathing) 1
• Circumferential burns with signs of vascular compromise 4
• Chemical burns to the genitalia (even if superficial) 1

The rationale for these strict referral criteria is the high risk of functional disability and permanent scarring in these anatomic locations, which mandates specialized multidisciplinary care regardless of initial burn size. 1, 5, 4