How should I assess and treat a burn injury, including cooling, analgesia, tetanus prophylaxis, wound care, fluid resuscitation, and criteria for referral to a burn center?

Burn Care: Assessment and Management

Immediate First Aid

Cool the burn immediately with clean running water for 5-20 minutes to limit tissue damage and reduce pain. 1 This intervention should be started as soon as possible and continued for at least 10 minutes, with evidence supporting up to 20 minutes of cooling. 1, 2 The optimal water temperature is approximately 15°C (cool tap water), as colder temperatures (2°C) or ice can cause additional tissue damage. 2

Critical Cooling Considerations:

• **Monitor children (especially <4 years) closely for hypothermia during cooling**, particularly with burns >10% TBSA. 1, 3 Avoid whole-body cooling methods like showers in young children. 3
• Only cool burns <20% TBSA in adults or <10% TBSA in children to prevent hypothermia. 4, 5
• Remove all jewelry and constrictive clothing before swelling occurs to prevent vascular compromise. 1, 6
• Never apply ice directly to burns, as this causes further tissue injury. 5, 2

Burn Assessment

Determine Burn Depth:

• Superficial (first-degree): Erythema, intact skin, painful
• Partial-thickness (second-degree): Blistering, moist, extremely painful
• Full-thickness (third-degree): White/charred, leathery, painless 4, 5

Calculate Total Body Surface Area (TBSA):

Use the Lund and Browder chart for accurate TBSA estimation in both adults and children. 5

Assess for Inhalation Injury:

Look for facial burns, singed nasal hairs, soot around nose/mouth, or difficulty breathing—these require immediate EMS activation. 1

Burn Center Referral Criteria

Immediate transfer to a specialized burn center is required for: 1, 4, 5

Adults:

• TBSA >10% (or >20% for specialized care)
• Deep burns >5% TBSA
• Burns to face, hands, feet, genitals, or major joints
• Circumferential burns
• Electrical or chemical burns
• Inhalation injury
• Age >75 with comorbidities

Children:

• TBSA >5-10%
• Deep burns >5% TBSA
• Age <1 year
• Burns to face, hands, feet, genitals, or major joints
• Any electrical or chemical burns
• Inhalation injury 4, 5, 3

All hand burns in children require specialist evaluation regardless of size due to functional concerns. 3

Wound Care Protocol

After Cooling:

For superficial and small partial-thickness burns being managed outpatient:

• Clean with tap water, isotonic saline, or antiseptic solution (chlorhexidine 1:5000). 4, 5
• Gently debride loose tissue; address tense blisters by sterile puncture while leaving blister roof intact as biological dressing. 4
• Apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera. 1, 4
• Cover with non-adherent dressing (Xeroform, Mepitel, Telfa). 4, 5
• Add secondary absorbent/foam dressing to collect exudate. 4

For full-thickness burns or burns with intact blisters awaiting evaluation:

• Loosely cover with clean, dry, non-adherent dressing. 1

Critical Wound Care Pitfalls:

• Avoid prolonged silver sulfadiazine on superficial burns—it delays healing and increases infection risk. 4, 5
• Do not use topical antibiotics as first-line prophylaxis; reserve only for infected wounds. 4, 5
• Never apply butter, oil, or home remedies. 5, 3
• Ensure limb dressings don't create tourniquet effect; monitor distal perfusion. 5
• Re-evaluate dressings daily ideally. 5

Pain Management

Administer over-the-counter acetaminophen or NSAIDs (e.g., ibuprofen 800mg) for mild-moderate pain. 1, 4 These are well-tolerated and generally recommended for burn pain. 1

For Severe Pain:

• Short-acting opioids for severe pain during initial dressing 4, 5
• Titrated IV ketamine combined with other analgesics for severe burn-induced pain 4, 5, 3
• Pre-medicate 30-60 minutes before dressing changes 4
• Use validated pain assessment scales to guide titration 5, 3
• General anesthesia may be necessary for highly painful procedures 5

Titrate analgesics carefully due to burn-induced inflammation and capillary leakage. 4

Tetanus Prophylaxis

Administer tetanus prophylaxis according to standard wound management protocols based on immunization history and burn severity. 4

Fluid Resuscitation

Initiate IV fluid resuscitation for burns ≥15% TBSA in adults: 4

• Use modified Parkland formula: Body weight (kg) × % TBSA = mL per hour for first 24 hours
• Avoid overly aggressive resuscitation to prevent pulmonary, cutaneous, and intestinal edema 4
• Anticipate fluid needs lower than classic Parkland formula predicts for thermal burns 4

Outpatient Management Criteria

Burns <10% TBSA in adults (<10% in children) without deep burns >5%, function-sensitive area involvement, or inhalation injury can be managed outpatient with proper wound care, pain control, and close follow-up. 4

Follow-up Requirements:

• Daily dressing changes initially
• Monitor for infection (increased pain, purulent drainage, erythema, fever)
• Assess healing progress
• Any clinical deterioration requires immediate medical attention 4

Post-Healing Management

For healed burns with hypopigmentation, dryness, or itching, apply petrolatum-based ointment with hydrocortisone 1% cream daily until symptoms resolve. 4 Avoid prolonged potent steroids as they can cause further hypopigmentation. 4