What is the appropriate initial management, analgesia, tetanus prophylaxis, and follow‑up for a scald burn?

Initial Management of Scald Burns

Immediately cool the scald burn with clean running water for 20 minutes within the first 3 hours of injury to reduce tissue damage, pain, and the need for subsequent medical care. 1

Immediate Cooling Protocol

• Apply clean running water to the burn for 20 minutes as soon as possible after injury—this is the single most effective first aid intervention with strong evidence showing decreased need for subsequent care 1
• Begin cooling within 3 hours of injury for maximum benefit in limiting tissue damage 2
• Monitor children for hypothermia during the cooling process, as prolonged water exposure can cause dangerous temperature drops in pediatric patients 3
• Remove all jewelry and constrictive items from the affected area before swelling begins to prevent vascular compromise 1, 3

Post-Cooling Wound Care

After completing the 20-minute cooling period, choose one of the following evidence-based topical treatments:

• Apply petrolatum (Vaseline) as a thin layer over the burn—this is the simplest, most accessible option 1, 3
• Petrolatum-based antibiotic ointment (polymyxin B or bacitracin) can be used for open burns or unroofed blisters 1, 3
• Medical-grade honey has demonstrated improved healing times for partial-thickness burns 1, 3
• Aloe vera gel applied directly to the burn is a reasonable alternative 1, 3

Cover the treated burn with a clean, non-adherent dressing to protect the wound and reduce pain 1, 3. For burns with intact skin or intact blisters, loosely cover with a clean cloth or non-adherent dry dressing while awaiting medical evaluation 1, 3.

Analgesia

Administer over-the-counter oral analgesics immediately for pain control:

• Acetaminophen or NSAIDs (ibuprofen) are well-tolerated and generally recommended for burn pain 1, 3
• Consider combining both acetaminophen and NSAIDs (multimodal analgesia) if pain is significant, as this approach provides superior pain relief 3
• A prospective randomized study of 61 patients with second- or third-degree burns found 800 mg IV ibuprofen every 6 hours had no significant serious adverse events 1

Tetanus Prophylaxis

Ensure tetanus immunization status is current, as burn injuries create a tetanus-prone wound environment. Case reports document tetanus developing 11 days post-burn in unimmunized patients who received inadequate prophylaxis 4. Follow standard tetanus prophylaxis guidelines based on immunization history and wound characteristics.

Immediate Medical Referral Criteria

Transfer immediately to emergency care or a specialized burn center if any of the following are present:

• Burns involving face, hands, feet, or genitals—these require surgical intervention to prevent permanent disability 1, 3
• Partial-thickness burns covering >10% body surface area in adults (>5% in children) due to risk of significant fluid loss and multisystem organ failure 1, 3
• Signs of inhalation injury: facial burns, difficulty breathing, singed nasal hairs, or soot around nose/mouth—these indicate potential airway compromise and carbon monoxide poisoning requiring immediate EMS activation 1, 3
• Full-thickness (third-degree) burns of any size 3

Follow-Up for Minor Burns Managed at Home

For small partial-thickness burns without the above referral criteria:

• Change dressings daily and reapply chosen topical agent (petrolatum, antibiotic ointment, honey, or aloe vera) until complete healing 1
• Monitor for signs of infection: increasing pain, redness spreading beyond burn margins, purulent drainage, fever, or worsening condition warrant immediate medical evaluation 3
• Reassess pain control: severe pain unresponsive to over-the-counter analgesics requires medical attention 3

Critical Pitfalls to Avoid

• Never apply ice directly to burns—this causes additional tissue damage through cold injury 5
• Do not apply butter, oil, or other home remedies—these trap heat and worsen tissue damage 5
• Do not break intact blisters—this significantly increases infection risk 5
• Do not delay cooling to search for specialized treatments—immediate water irrigation is the priority 5